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Sample records for stratified care approach

  1. General Practitioners' and patients' perceptions towards stratified care: a theory informed investigation.

    Science.gov (United States)

    Saunders, Benjamin; Bartlam, Bernadette; Foster, Nadine E; Hill, Jonathan C; Cooper, Vince; Protheroe, Joanne

    2016-08-31

    Stratified primary care involves changing General Practitioners' (GPs) clinical behaviour in treating patients, away from the current stepped care approach to instead identifying early treatment options that are matched to patients' risk of persistent disabling pain. This article explores the perspectives of UK-based GPs and patients about a prognostic stratified care model being developed for patients with the five most common primary care musculoskeletal pain presentations. The focus was on views about acceptability, and anticipated barriers and facilitators to the use of stratified care in routine practice. Four focus groups and six semi-structured telephone interviews were conducted with GPs (n = 23), and three focus groups with patients (n = 20). Data were analysed thematically; and identified themes examined in relation to the Theoretical Domains Framework (TDF), which facilitates comprehensive identification of behaviour change determinants. A critical approach was taken in using the TDF, examining the nuanced interrelationships between theoretical domains. Four key themes were identified: Acceptability of clinical decision-making guided by stratified care; impact on the therapeutic relationship; embedding a prognostic approach within a biomedical model; and practical issues in using stratified care. Whilst within each theme specific findings are reported, common across themes was the identified relationships between the theoretical domains of knowledge, skills, professional role and identity, environmental context and resources, and goals. Through analysis of these identified relationships it was found that, for GPs and patients to perceive stratified care as being acceptable, it must be seen to enhance GPs' knowledge and skills, not undermine GPs' and patients' respective identities and be integrated within the environmental context of the consultation with minimal disruption. Findings highlight the importance of taking into account the context of

  2. General Practitioners Views of Implementing a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study.

    Directory of Open Access Journals (Sweden)

    Sven Karstens

    Full Text Available The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs. However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP.A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach.For the three deductively developed main themes, 15 subthemes emerged: (1 application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2 psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3 the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues.The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be

  3. A statistical mechanics approach to mixing in stratified fluids

    OpenAIRE

    Venaille , Antoine; Gostiaux , Louis; Sommeria , Joël

    2016-01-01

    Accepted for the Journal of Fluid Mechanics; Predicting how much mixing occurs when a given amount of energy is injected into a Boussinesq fluid is a longstanding problem in stratified turbulence. The huge number of degrees of freedom involved in these processes renders extremely difficult a deterministic approach to the problem. Here we present a statistical mechanics approach yielding a prediction for a cumulative, global mixing efficiency as a function of a global Richard-son number and th...

  4. The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581).

    Science.gov (United States)

    Foster, Nadine E; Konstantinou, Kika; Lewis, Martyn; Ogollah, Reuben; Dunn, Kate M; van der Windt, Danielle; Beardmore, Ruth; Artus, Majid; Bartlam, Bernadette; Hill, Jonathan C; Jowett, Sue; Kigozi, Jesse; Mallen, Christian; Saunders, Benjamin; Hay, Elaine M

    2017-04-26

    Sciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of 'wait and see' for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care. Multicentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the

  5. Interactive Fuzzy Goal Programming approach in multi-response stratified sample surveys

    Directory of Open Access Journals (Sweden)

    Gupta Neha

    2016-01-01

    Full Text Available In this paper, we applied an Interactive Fuzzy Goal Programming (IFGP approach with linear, exponential and hyperbolic membership functions, which focuses on maximizing the minimum membership values to determine the preferred compromise solution for the multi-response stratified surveys problem, formulated as a Multi- Objective Non Linear Programming Problem (MONLPP, and by linearizing the nonlinear objective functions at their individual optimum solution, the problem is approximated to an Integer Linear Programming Problem (ILPP. A numerical example based on real data is given, and comparison with some existing allocations viz. Cochran’s compromise allocation, Chatterjee’s compromise allocation and Khowaja’s compromise allocation is made to demonstrate the utility of the approach.

  6. Implementing the Keele stratified care model for patients with low back pain: an observational impact study.

    Science.gov (United States)

    Bamford, Adrian; Nation, Andy; Durrell, Susie; Andronis, Lazaros; Rule, Ellen; McLeod, Hugh

    2017-02-03

    The Keele stratified care model for management of low back pain comprises use of the prognostic STarT Back Screening Tool to allocate patients into one of three risk-defined categories leading to associated risk-specific treatment pathways, such that high-risk patients receive enhanced treatment and more sessions than medium- and low-risk patients. The Keele model is associated with economic benefits and is being widely implemented. The objective was to assess the use of the stratified model following its introduction in an acute hospital physiotherapy department setting in Gloucestershire, England. Physiotherapists recorded data on 201 patients treated using the Keele model in two audits in 2013 and 2014. To assess whether implementation of the stratified model was associated with the anticipated range of treatment sessions, regression analysis of the audit data was used to determine whether high- or medium-risk patients received significantly more treatment sessions than low-risk patients. The analysis controlled for patient characteristics, year, physiotherapists' seniority and physiotherapist. To assess the physiotherapists' views on the usefulness of the stratified model, audit data on this were analysed using framework methods. To assess the potential economic consequences of introducing the stratified care model in Gloucestershire, published economic evaluation findings on back-related National Health Service (NHS) costs, quality-adjusted life years (QALYs) and societal productivity losses were applied to audit data on the proportion of patients by risk classification and estimates of local incidence. When the Keele model was implemented, patients received significantly more treatment sessions as the risk-rating increased, in line with the anticipated impact of targeted treatment pathways. Physiotherapists were largely positive about using the model. The potential annual impact of rolling out the model across Gloucestershire is a gain in approximately 30

  7. Spatial Analysis of Geothermal Resource Potential in New York and Pennsylvania: A Stratified Kriging Approach

    Science.gov (United States)

    Smith, J. D.; Whealton, C. A.; Stedinger, J. R.

    2014-12-01

    Resource assessments for low-grade geothermal applications employ available well temperature measurements to determine if the resource potential is sufficient for supporting district heating opportunities. This study used a compilation of bottomhole temperature (BHT) data from recent unconventional shale oil and gas wells, along with legacy oil, gas, and storage wells, in Pennsylvania (PA) and New York (NY). Our study's goal was to predict the geothermal resource potential and associated uncertainty for the NY-PA region using kriging interpolation. The dataset was scanned for outliers, and some observations were removed. Because these wells were drilled for reasons other than geothermal resource assessment, their spatial density varied widely. An exploratory spatial statistical analysis revealed differences in the spatial structure of the geothermal gradient data (the kriging semi-variogram and its nugget variance, shape, sill, and the degree of anisotropy). As a result, a stratified kriging procedure was adopted to better capture the statistical structure of the data, to generate an interpolated surface, and to quantify the uncertainty of the computed surface. The area was stratified reflecting different physiographic provinces in NY and PA that have geologic properties likely related to variations in the value of the geothermal gradient. The kriging prediction and the variance-of-prediction were determined for each province by the generation of a semi-variogram using only the wells that were located within that province. A leave-one-out cross validation (LOOCV) was conducted as a diagnostic tool. The results of stratified kriging were compared to kriging using the whole region to determine the impact of stratification. The two approaches provided similar predictions of the geothermal gradient. However, the variance-of-prediction was different. The stratified approach is recommended because it gave a more appropriate site-specific characterization of uncertainty

  8. Background stratified Poisson regression analysis of cohort data.

    Science.gov (United States)

    Richardson, David B; Langholz, Bryan

    2012-03-01

    Background stratified Poisson regression is an approach that has been used in the analysis of data derived from a variety of epidemiologically important studies of radiation-exposed populations, including uranium miners, nuclear industry workers, and atomic bomb survivors. We describe a novel approach to fit Poisson regression models that adjust for a set of covariates through background stratification while directly estimating the radiation-disease association of primary interest. The approach makes use of an expression for the Poisson likelihood that treats the coefficients for stratum-specific indicator variables as 'nuisance' variables and avoids the need to explicitly estimate the coefficients for these stratum-specific parameters. Log-linear models, as well as other general relative rate models, are accommodated. This approach is illustrated using data from the Life Span Study of Japanese atomic bomb survivors and data from a study of underground uranium miners. The point estimate and confidence interval obtained from this 'conditional' regression approach are identical to the values obtained using unconditional Poisson regression with model terms for each background stratum. Moreover, it is shown that the proposed approach allows estimation of background stratified Poisson regression models of non-standard form, such as models that parameterize latency effects, as well as regression models in which the number of strata is large, thereby overcoming the limitations of previously available statistical software for fitting background stratified Poisson regression models.

  9. The Stratified Legitimacy of Abortions.

    Science.gov (United States)

    Kimport, Katrina; Weitz, Tracy A; Freedman, Lori

    2016-12-01

    Roe v. Wade was heralded as an end to unequal access to abortion care in the United States. However, today, despite being common and safe, abortion is performed only selectively in hospitals and private practices. Drawing on 61 interviews with obstetrician-gynecologists in these settings, we examine how they determine which abortions to perform. We find that they distinguish between more and less legitimate abortions, producing a narrative of stratified legitimacy that privileges abortions for intended pregnancies, when the fetus is unhealthy, and when women perform normative gendered sexuality, including distress about the abortion, guilt about failure to contracept, and desire for motherhood. This stratified legitimacy can perpetuate socially-inflected inequality of access and normative gendered sexuality. Additionally, we argue that the practice by physicians of distinguishing among abortions can legitimate legislative practices that regulate and restrict some kinds of abortion, further constraining abortion access. © American Sociological Association 2016.

  10. RADIAL STABILITY IN STRATIFIED STARS

    International Nuclear Information System (INIS)

    Pereira, Jonas P.; Rueda, Jorge A.

    2015-01-01

    We formulate within a generalized distributional approach the treatment of the stability against radial perturbations for both neutral and charged stratified stars in Newtonian and Einstein's gravity. We obtain from this approach the boundary conditions connecting any two phases within a star and underline its relevance for realistic models of compact stars with phase transitions, owing to the modification of the star's set of eigenmodes with respect to the continuous case

  11. Implementing content constraints in alpha-stratified adaptive testing using a shadow test approach

    NARCIS (Netherlands)

    van der Linden, Willem J.; Chang, Hua-Hua

    2001-01-01

    The methods of alpha-stratified adaptive testing and constrained adaptive testing with shadow tests are combined in this study. The advantages are twofold. First, application of the shadow test allows the researcher to implement any type of constraint on item selection in alpha-stratified adaptive

  12. Background stratified Poisson regression analysis of cohort data

    International Nuclear Information System (INIS)

    Richardson, David B.; Langholz, Bryan

    2012-01-01

    Background stratified Poisson regression is an approach that has been used in the analysis of data derived from a variety of epidemiologically important studies of radiation-exposed populations, including uranium miners, nuclear industry workers, and atomic bomb survivors. We describe a novel approach to fit Poisson regression models that adjust for a set of covariates through background stratification while directly estimating the radiation-disease association of primary interest. The approach makes use of an expression for the Poisson likelihood that treats the coefficients for stratum-specific indicator variables as 'nuisance' variables and avoids the need to explicitly estimate the coefficients for these stratum-specific parameters. Log-linear models, as well as other general relative rate models, are accommodated. This approach is illustrated using data from the Life Span Study of Japanese atomic bomb survivors and data from a study of underground uranium miners. The point estimate and confidence interval obtained from this 'conditional' regression approach are identical to the values obtained using unconditional Poisson regression with model terms for each background stratum. Moreover, it is shown that the proposed approach allows estimation of background stratified Poisson regression models of non-standard form, such as models that parameterize latency effects, as well as regression models in which the number of strata is large, thereby overcoming the limitations of previously available statistical software for fitting background stratified Poisson regression models. (orig.)

  13. Physiotherapists' views of implementing a stratified treatment approach for patients with low back pain in Germany: a qualitative study

    NARCIS (Netherlands)

    Karstens, S.; Kuithan, P.; Joos, S.; Hill, J.C.; Wensing, M.; Steinhauser, J.; Krug, K.; Szecsenyi, J.

    2018-01-01

    BACKGROUND: The STarT-Back-Approach (STarT: Subgroups for Targeted Treatment) was developed in the UK and has demonstrated clinical and cost effectiveness. Based on the results of a brief questionnaire, patients with low back pain are stratified into three treatment groups. Since the organisation of

  14. Turbulent fluxes in stably stratified boundary layers

    International Nuclear Information System (INIS)

    L'vov, Victor S; Procaccia, Itamar; Rudenko, Oleksii

    2008-01-01

    We present here an extended version of an invited talk we gave at the international conference 'Turbulent Mixing and Beyond'. The dynamical and statistical description of stably stratified turbulent boundary layers with the important example of the stable atmospheric boundary layer in mind is addressed. Traditional approaches to this problem, based on the profiles of mean quantities, velocity second-order correlations and dimensional estimates of the turbulent thermal flux, run into a well-known difficulty, predicting the suppression of turbulence at a small critical value of the Richardson number, in contradiction to observations. Phenomenological attempts to overcome this problem suffer from various theoretical inconsistencies. Here, we present an approach taking into full account all the second-order statistics, which allows us to respect the conservation of total mechanical energy. The analysis culminates in an analytic solution of the profiles of all mean quantities and all second-order correlations, removing the unphysical predictions of previous theories. We propose that the approach taken here is sufficient to describe the lower parts of the atmospheric boundary layer, as long as the Richardson number does not exceed an order of unity. For much higher Richardson numbers, the physics may change qualitatively, requiring careful consideration of the potential Kelvin-Helmoholtz waves and their interaction with the vortical turbulence.

  15. Random forcing of geostrophic motion in rotating stratified turbulence

    Science.gov (United States)

    Waite, Michael L.

    2017-12-01

    Random forcing of geostrophic motion is a common approach in idealized simulations of rotating stratified turbulence. Such forcing represents the injection of energy into large-scale balanced motion, and the resulting breakdown of quasi-geostrophic turbulence into inertia-gravity waves and stratified turbulence can shed light on the turbulent cascade processes of the atmospheric mesoscale. White noise forcing is commonly employed, which excites all frequencies equally, including frequencies much higher than the natural frequencies of large-scale vortices. In this paper, the effects of these high frequencies in the forcing are investigated. Geostrophic motion is randomly forced with red noise over a range of decorrelation time scales τ, from a few time steps to twice the large-scale vortex time scale. It is found that short τ (i.e., nearly white noise) results in about 46% more gravity wave energy than longer τ, despite the fact that waves are not directly forced. We argue that this effect is due to wave-vortex interactions, through which the high frequencies in the forcing are able to excite waves at their natural frequencies. It is concluded that white noise forcing should be avoided, even if it is only applied to the geostrophic motion, when a careful investigation of spontaneous wave generation is needed.

  16. Stratified Medicine and Reimbursement Issues

    Directory of Open Access Journals (Sweden)

    Hans-Joerg eFugel

    2012-10-01

    Full Text Available Stratified Medicine (SM has the potential to target patient populations who will most benefit from a therapy while reducing unnecessary health interventions associated with side effects. The link between clinical biomarkers/diagnostics and therapies provides new opportunities for value creation to strengthen the value proposition to pricing and reimbursement (P&R authorities. However, the introduction of SM challenges current reimbursement schemes in many EU countries and the US as different P&R policies have been adopted for drugs and diagnostics. Also, there is a lack of a consistent process for value assessment of more complex diagnostics in these markets. New, innovative approaches and more flexible P&R systems are needed to reflect the added value of diagnostic tests and to stimulate investments in new technologies. Yet, the framework for access of diagnostic–based therapies still requires further development while setting the right incentives and appropriate align stakeholders interests when realizing long- term patient benefits. This article addresses the reimbursement challenges of SM approaches in several EU countries and the US outlining some options to overcome existing reimbursement barriers for stratified medicine.

  17. Comparison of exact, efron and breslow parameter approach method on hazard ratio and stratified cox regression model

    Science.gov (United States)

    Fatekurohman, Mohamat; Nurmala, Nita; Anggraeni, Dian

    2018-04-01

    Lungs are the most important organ, in the case of respiratory system. Problems related to disorder of the lungs are various, i.e. pneumonia, emphysema, tuberculosis and lung cancer. Comparing all those problems, lung cancer is the most harmful. Considering about that, the aim of this research applies survival analysis and factors affecting the endurance of the lung cancer patient using comparison of exact, Efron and Breslow parameter approach method on hazard ratio and stratified cox regression model. The data applied are based on the medical records of lung cancer patients in Jember Paru-paru hospital on 2016, east java, Indonesia. The factors affecting the endurance of the lung cancer patients can be classified into several criteria, i.e. sex, age, hemoglobin, leukocytes, erythrocytes, sedimentation rate of blood, therapy status, general condition, body weight. The result shows that exact method of stratified cox regression model is better than other. On the other hand, the endurance of the patients is affected by their age and the general conditions.

  18. Economic viability of Stratified Medicine concepts: An investor perspective on drivers and conditions that favour using Stratified Medicine approaches in a cost-contained healthcare environment.

    Science.gov (United States)

    Fugel, Hans-Joerg; Nuijten, Mark; Postma, Maarten

    2016-12-25

    Stratified Medicine (SM) is becoming a natural result of advances in biomedical science and a promising path for the innovation-based biopharmaceutical industry to create new investment opportunities. While the use of biomarkers to improve R&D efficiency and productivity is very much acknowledged by industry, much work remains to be done to understand the drivers and conditions that favour using a stratified approach to create economically viable products and to justify the investment in SM interventions as a stratification option. In this paper we apply a decision analytical methodology to address the economic attractiveness of different SM development options in a cost-contained healthcare environment. For this purpose, a hypothetical business case in the oncology market has been developed considering four feasible development scenarios. The article outlines the effects of development time and time to peak sales as key economic value drivers influencing profitability of SM interventions under specific conditions. If regulatory and reimbursement challenges can be solved, decreasing development time and enhancing early market penetration would most directly improve the economic attractiveness of SM interventions. Appropriate tailoring of highly differentiated patient subgroups is the prerequisite to leverage potential efficiency gains in the R&D process. Also, offering a better targeted and hence ultimately more cost-effective therapy at reimbursable prices will facilitate time to market access and allow increasing market share gains within the targeted populations. Copyright © 2016 Elsevier B.V. All rights reserved.

  19. A robust and accurate approach to computing compressible multiphase flow: Stratified flow model and AUSM+-up scheme

    International Nuclear Information System (INIS)

    Chang, Chih-Hao; Liou, Meng-Sing

    2007-01-01

    In this paper, we propose a new approach to compute compressible multifluid equations. Firstly, a single-pressure compressible multifluid model based on the stratified flow model is proposed. The stratified flow model, which defines different fluids in separated regions, is shown to be amenable to the finite volume method. We can apply the conservation law to each subregion and obtain a set of balance equations. Secondly, the AUSM + scheme, which is originally designed for the compressible gas flow, is extended to solve compressible liquid flows. By introducing additional dissipation terms into the numerical flux, the new scheme, called AUSM + -up, can be applied to both liquid and gas flows. Thirdly, the contribution to the numerical flux due to interactions between different phases is taken into account and solved by the exact Riemann solver. We will show that the proposed approach yields an accurate and robust method for computing compressible multiphase flows involving discontinuities, such as shock waves and fluid interfaces. Several one-dimensional test problems are used to demonstrate the capability of our method, including the Ransom's water faucet problem and the air-water shock tube problem. Finally, several two dimensional problems will show the capability to capture enormous details and complicated wave patterns in flows having large disparities in the fluid density and velocities, such as interactions between water shock wave and air bubble, between air shock wave and water column(s), and underwater explosion

  20. Turbulent circulation above the surface heat source in stably stratified atmosphere

    Science.gov (United States)

    Kurbatskii, A. F.; Kurbatskaya, L. I.

    2016-10-01

    The 3-level RANS approach for simulating a turbulent circulation over the heat island in a stably stratified environment under nearly calm conditions is formulated. The turbulent kinetic energy its spectral consumption (dissipation) and the dispersion of turbulent fluctuations of temperature are found from differential equations, thus the correct modeling of transport processes in the interface layer with the counter-gradient heat flux is assured. The three-parameter turbulence RANS approach minimizes difficulties in simulating the turbulent transport in a stably stratified environment and reduces efforts needed for the numerical implementation of the 3-level RANS approach. Numerical simulation of the turbulent structure of the penetrative convection over the heat island under conditions of stably stratified atmosphere demonstrates that the three-equation model is able to predict the thermal circulation induced by the heat island. The temperature distribution, root-mean-square fluctuations of the turbulent velocity and temperature fields and spectral turbulent kinetic energy flux are in good agreement with the experimental data. The model describes such thin physical effects, as a crossing of vertical profiles of temperature of a thermal plume with the formation of the negative buoyancy area testifying to development of the dome-shaped form at the top part of a plume in the form of "hat".

  1. New numerical approaches for modeling thermochemical convection in a compositionally stratified fluid

    Science.gov (United States)

    Puckett, Elbridge Gerry; Turcotte, Donald L.; He, Ying; Lokavarapu, Harsha; Robey, Jonathan M.; Kellogg, Louise H.

    2018-03-01

    Geochemical observations of mantle-derived rocks favor a nearly homogeneous upper mantle, the source of mid-ocean ridge basalts (MORB), and heterogeneous lower mantle regions. Plumes that generate ocean island basalts are thought to sample the lower mantle regions and exhibit more heterogeneity than MORB. These regions have been associated with lower mantle structures known as large low shear velocity provinces (LLSVPS) below Africa and the South Pacific. The isolation of these regions is attributed to compositional differences and density stratification that, consequently, have been the subject of computational and laboratory modeling designed to determine the parameter regime in which layering is stable and understanding how layering evolves. Mathematical models of persistent compositional interfaces in the Earth's mantle may be inherently unstable, at least in some regions of the parameter space relevant to the mantle. Computing approximations to solutions of such problems presents severe challenges, even to state-of-the-art numerical methods. Some numerical algorithms for modeling the interface between distinct compositions smear the interface at the boundary between compositions, such as methods that add numerical diffusion or 'artificial viscosity' in order to stabilize the algorithm. We present two new algorithms for maintaining high-resolution and sharp computational boundaries in computations of these types of problems: a discontinuous Galerkin method with a bound preserving limiter and a Volume-of-Fluid interface tracking algorithm. We compare these new methods with two approaches widely used for modeling the advection of two distinct thermally driven compositional fields in mantle convection computations: a high-order accurate finite element advection algorithm with entropy viscosity and a particle method that carries a scalar quantity representing the location of each compositional field. All four algorithms are implemented in the open source finite

  2. Analysis of photonic band-gap structures in stratified medium

    DEFF Research Database (Denmark)

    Tong, Ming-Sze; Yinchao, Chen; Lu, Yilong

    2005-01-01

    in electromagnetic and microwave applications once the Maxwell's equations are appropriately modeled. Originality/value - The method validates its values and properties through extensive studies on regular and defective 1D PBG structures in stratified medium, and it can be further extended to solving more......Purpose - To demonstrate the flexibility and advantages of a non-uniform pseudo-spectral time domain (nu-PSTD) method through studies of the wave propagation characteristics on photonic band-gap (PBG) structures in stratified medium Design/methodology/approach - A nu-PSTD method is proposed...... in solving the Maxwell's equations numerically. It expands the temporal derivatives using the finite differences, while it adopts the Fourier transform (FT) properties to expand the spatial derivatives in Maxwell's equations. In addition, the method makes use of the chain-rule property in calculus together...

  3. Economic viability of Stratified Medicine concepts : An investor perspective on drivers and conditions that favour using Stratified Medicine approaches in a cost-contained healthcare environment

    NARCIS (Netherlands)

    Fugel, Hans-Joerg; Nuijten, Mark; Postma, Maarten

    2016-01-01

    RATIONALE: Stratified Medicine (SM) is becoming a natural result of advances in biomedical science and a promising path for the innovation-based biopharmaceutical industry to create new investment opportunities. While the use of biomarkers to improve R&D efficiency and productivity is very much

  4. Design of dry sand soil stratified sampler

    Science.gov (United States)

    Li, Erkang; Chen, Wei; Feng, Xiao; Liao, Hongbo; Liang, Xiaodong

    2018-04-01

    This paper presents a design of a stratified sampler for dry sand soil, which can be used for stratified sampling of loose sand under certain conditions. Our group designed the mechanical structure of a portable, single - person, dry sandy soil stratified sampler. We have set up a mathematical model for the sampler. It lays the foundation for further development of design research.

  5. Maternal factors influencing late entry into prenatal care: a stratified analysis by race or ethnicity and insurance status.

    Science.gov (United States)

    Baer, Rebecca J; Altman, Molly R; Oltman, Scott P; Ryckman, Kelli K; Chambers, Christina D; Rand, Larry; Jelliffe-Pawlowski, Laura L

    2018-04-09

    Examine factors influencing late (> sixth month of gestation) entry into prenatal care by race/ethnicity and insurance payer. The study population was drawn from singleton live births in California from 2007-2012 in the birth cohort file maintained by the California Office of Statewide Health Planning and Development, which includes linked birth certificate and mother and infant hospital discharge records. The sample was restricted to infants delivered between 20 and 44 weeks gestation. Logistic regression was used to calculate relative risks (RR) and 95% confidence intervals (CI) for factors influencing late entry into prenatal care. Maternal age, education, smoking, drug or alcohol abuse/dependence, mental illness, participation in the Women, Infants and Children's program and rural residence were evaluated for women entering prenatal care > sixth month of gestation compared with women entering prenatal care entry for each race or ethnicity and insurance payer. The sample included 2 963 888 women. The percent of women with late entry into prenatal care was consistently higher among women with public versus private insurance. Less than 1% of white non-Hispanic and Asian women with private insurance entered prenatal care late versus more than 4% of white non-Hispanic and black women with public insurance. After stratifying by race or ethnicity and insurance status, women less than 18 years of age were more likely to enter prenatal care late, with young Asian women with private insurance at the highest risk (15.6%; adjusted RR 7.4, 95% CI 5.3-10.5). Among all women with private insurance, > 12-year education or age > 34 years at term reduced the likelihood of late prenatal care entry (adjusted RRs 0.5-0.7). Drugs and alcohol abuse/dependence and residing in a rural county were associated with increased risk of late prenatal care across all subgroups (adjusted RRs 1.3-3.8). Participation in the Women, Infants and Children's program was associated with decreased

  6. Stratified Simulations of Collisionless Accretion Disks

    Energy Technology Data Exchange (ETDEWEB)

    Hirabayashi, Kota; Hoshino, Masahiro, E-mail: hirabayashi-k@eps.s.u-tokyo.ac.jp [Department of Earth and Planetary Science, The University of Tokyo, Tokyo, 113-0033 (Japan)

    2017-06-10

    This paper presents a series of stratified-shearing-box simulations of collisionless accretion disks in the recently developed framework of kinetic magnetohydrodynamics (MHD), which can handle finite non-gyrotropy of a pressure tensor. Although a fully kinetic simulation predicted a more efficient angular-momentum transport in collisionless disks than in the standard MHD regime, the enhanced transport has not been observed in past kinetic-MHD approaches to gyrotropic pressure anisotropy. For the purpose of investigating this missing link between the fully kinetic and MHD treatments, this paper explores the role of non-gyrotropic pressure and makes the first attempt to incorporate certain collisionless effects into disk-scale, stratified disk simulations. When the timescale of gyrotropization was longer than, or comparable to, the disk-rotation frequency of the orbit, we found that the finite non-gyrotropy selectively remaining in the vicinity of current sheets contributes to suppressing magnetic reconnection in the shearing-box system. This leads to increases both in the saturated amplitude of the MHD turbulence driven by magnetorotational instabilities and in the resultant efficiency of angular-momentum transport. Our results seem to favor the fast advection of magnetic fields toward the rotation axis of a central object, which is required to launch an ultra-relativistic jet from a black hole accretion system in, for example, a magnetically arrested disk state.

  7. Quantum image pseudocolor coding based on the density-stratified method

    Science.gov (United States)

    Jiang, Nan; Wu, Wenya; Wang, Luo; Zhao, Na

    2015-05-01

    Pseudocolor processing is a branch of image enhancement. It dyes grayscale images to color images to make the images more beautiful or to highlight some parts on the images. This paper proposes a quantum image pseudocolor coding scheme based on the density-stratified method which defines a colormap and changes the density value from gray to color parallel according to the colormap. Firstly, two data structures: quantum image GQIR and quantum colormap QCR are reviewed or proposed. Then, the quantum density-stratified algorithm is presented. Based on them, the quantum realization in the form of circuits is given. The main advantages of the quantum version for pseudocolor processing over the classical approach are that it needs less memory and can speed up the computation. Two kinds of examples help us to describe the scheme further. Finally, the future work are analyzed.

  8. The effect of surfactant on stratified and stratifying gas-liquid flows

    Science.gov (United States)

    Heiles, Baptiste; Zadrazil, Ivan; Matar, Omar

    2013-11-01

    We consider the dynamics of a stratified/stratifying gas-liquid flow in horizontal tubes. This flow regime is characterised by the thin liquid films that drain under gravity along the pipe interior, forming a pool at the bottom of the tube, and the formation of large-amplitude waves at the gas-liquid interface. This regime is also accompanied by the detachment of droplets from the interface and their entrainment into the gas phase. We carry out an experimental study involving axial- and radial-view photography of the flow, in the presence and absence of surfactant. We show that the effect of surfactant is to reduce significantly the average diameter of the entrained droplets, through a tip-streaming mechanism. We also highlight the influence of surfactant on the characteristics of the interfacial waves, and the pressure gradient that drives the flow. EPSRC Programme Grant EP/K003976/1.

  9. Electromagnetic waves in stratified media

    CERN Document Server

    Wait, James R; Fock, V A; Wait, J R

    2013-01-01

    International Series of Monographs in Electromagnetic Waves, Volume 3: Electromagnetic Waves in Stratified Media provides information pertinent to the electromagnetic waves in media whose properties differ in one particular direction. This book discusses the important feature of the waves that enables communications at global distances. Organized into 13 chapters, this volume begins with an overview of the general analysis for the electromagnetic response of a plane stratified medium comprising of any number of parallel homogeneous layers. This text then explains the reflection of electromagne

  10. Impacts of light shading and nutrient enrichment geo-engineering approaches on the productivity of a stratified, oligotrophic ocean ecosystem.

    Science.gov (United States)

    Hardman-Mountford, Nick J; Polimene, Luca; Hirata, Takafumi; Brewin, Robert J W; Aiken, Jim

    2013-12-06

    Geo-engineering proposals to mitigate global warming have focused either on methods of carbon dioxide removal, particularly nutrient fertilization of plant growth, or on cooling the Earth's surface by reducing incoming solar radiation (shading). Marine phytoplankton contribute half the Earth's biological carbon fixation and carbon export in the ocean is modulated by the actions of microbes and grazing communities in recycling nutrients. Both nutrients and light are essential for photosynthesis, so understanding the relative influence of both these geo-engineering approaches on ocean ecosystem production and processes is critical to the evaluation of their effectiveness. In this paper, we investigate the relationship between light and nutrient availability on productivity in a stratified, oligotrophic subtropical ocean ecosystem using a one-dimensional water column model coupled to a multi-plankton ecosystem model, with the goal of elucidating potential impacts of these geo-engineering approaches on ecosystem production. We find that solar shading approaches can redistribute productivity in the water column but do not change total production. Macronutrient enrichment is able to enhance the export of carbon, although heterotrophic recycling reduces the efficiency of carbon export substantially over time. Our results highlight the requirement for a fuller consideration of marine ecosystem interactions and feedbacks, beyond simply the stimulation of surface blooms, in the evaluation of putative geo-engineering approaches.

  11. Health care managers' views on and approaches to implementing models for improving care processes.

    Science.gov (United States)

    Andreasson, Jörgen; Eriksson, Andrea; Dellve, Lotta

    2016-03-01

    To develop a deeper understanding of health-care managers' views on and approaches to the implementation of models for improving care processes. In health care, there are difficulties in implementing models for improving care processes that have been decided on by upper management. Leadership approaches to this implementation can affect the outcome. In-depth interviews with first- and second-line managers in Swedish hospitals were conducted and analysed using grounded theory. 'Coaching for participation' emerged as a central theme for managers in handling top-down initiated process development. The vertical approach in this coaching addresses how managers attempt to sustain unit integrity through adapting and translating orders from top management. The horizontal approach in the coaching refers to managers' strategies for motivating and engaging their employees in implementation work. Implementation models for improving care processes require a coaching leadership built on close manager-employee interaction, mindfulness regarding the pace of change at the unit level, managers with the competence to share responsibility with their teams and engaged employees with the competence to share responsibility for improving the care processes, and organisational structures that support process-oriented work. Implications for nursing management are the importance of giving nurse managers knowledge of change management. © 2015 John Wiley & Sons Ltd.

  12. Data splitting for artificial neural networks using SOM-based stratified sampling.

    Science.gov (United States)

    May, R J; Maier, H R; Dandy, G C

    2010-03-01

    Data splitting is an important consideration during artificial neural network (ANN) development where hold-out cross-validation is commonly employed to ensure generalization. Even for a moderate sample size, the sampling methodology used for data splitting can have a significant effect on the quality of the subsets used for training, testing and validating an ANN. Poor data splitting can result in inaccurate and highly variable model performance; however, the choice of sampling methodology is rarely given due consideration by ANN modellers. Increased confidence in the sampling is of paramount importance, since the hold-out sampling is generally performed only once during ANN development. This paper considers the variability in the quality of subsets that are obtained using different data splitting approaches. A novel approach to stratified sampling, based on Neyman sampling of the self-organizing map (SOM), is developed, with several guidelines identified for setting the SOM size and sample allocation in order to minimize the bias and variance in the datasets. Using an example ANN function approximation task, the SOM-based approach is evaluated in comparison to random sampling, DUPLEX, systematic stratified sampling, and trial-and-error sampling to minimize the statistical differences between data sets. Of these approaches, DUPLEX is found to provide benchmark performance with good model performance, with no variability. The results show that the SOM-based approach also reliably generates high-quality samples and can therefore be used with greater confidence than other approaches, especially in the case of non-uniform datasets, with the benefit of scalability to perform data splitting on large datasets. Copyright 2009 Elsevier Ltd. All rights reserved.

  13. Analysis of Turbulent Combustion in Simplified Stratified Charge Conditions

    Science.gov (United States)

    Moriyoshi, Yasuo; Morikawa, Hideaki; Komatsu, Eiji

    The stratified charge combustion system has been widely studied due to the significant potentials for low fuel consumption rate and low exhaust gas emissions. The fuel-air mixture formation process in a direct-injection stratified charge engine is influenced by various parameters, such as atomization, evaporation, and in-cylinder gas motion at high temperature and high pressure conditions. It is difficult to observe the in-cylinder phenomena in such conditions and also challenging to analyze the following stratified charge combustion. Therefore, the combustion phenomena in simplified stratified charge conditions aiming to analyze the fundamental stratified charge combustion are examined. That is, an experimental apparatus which can control the mixture distribution and the gas motion at ignition timing was developed, and the effects of turbulence intensity, mixture concentration distribution, and mixture composition on stratified charge combustion were examined. As a result, the effects of fuel, charge stratification, and turbulence on combustion characteristics were clarified.

  14. Risk Factors Associated with Very Low Birth Weight in a Large Urban Area, Stratified by Adequacy of Prenatal Care.

    Science.gov (United States)

    Xaverius, Pamela; Alman, Cameron; Holtz, Lori; Yarber, Laura

    2016-03-01

    This study examined risk and protective factors associated with very low birth weight (VLBW) for babies born to women receiving adequate or inadequate prenatal care. Birth records from St. Louis City and County from 2000 to 2009 were used (n = 152,590). Data was categorized across risk factors and stratified by adequacy of prenatal care (PNC). Multivariate logistic regression and population attributable risk (PAR) was used to explore risk factors for VLBW infants. Women receiving inadequate prenatal care had a higher prevalence of delivering a VLBW infant than those receiving adequate PNC (4.11 vs. 1.44 %, p < .0001). The distribution of risk factors differed between adequate and inadequate PNC regarding Black race (36.4 vs. 79.0 %, p < .0001), age under 20 (13.0 vs. 33.6 %, p < .0001), <13 years of education (35.9 vs. 77.9 %, p < .0001), Medicaid status (35.7 vs. 74.9, p < .0001), primiparity (41.6 vs. 31.4 %, p < .0001), smoking (9.7 vs. 24.5 %, p < .0001), and diabetes (4.0 vs. 2.4 %, p < .0001), respectively. Black race, advanced maternal age, primiparity and gestational hypertension were significant predictors of VLBW, regardless of adequate or inadequate PNC. Among women with inadequate PNC, Medicaid was protective against (aOR 0.671, 95 % CI 0.563-0.803; PAR -32.6 %) and smoking a risk factor for (aOR 1.23, 95 % CI 1.01, 1.49; PAR 40.1 %) VLBW. When prematurity was added to the adjusted models, the largest PAR shifts to education (44.3 %) among women with inadequate PNC. Community actions around broader issues of racism and social determinants of health are needed to prevent VLBW in a large urban area.

  15. Analysing stratified medicine business models and value systems: innovation-regulation interactions.

    Science.gov (United States)

    Mittra, James; Tait, Joyce

    2012-09-15

    Stratified medicine offers both opportunities and challenges to the conventional business models that drive pharmaceutical R&D. Given the increasingly unsustainable blockbuster model of drug development, due in part to maturing product pipelines, alongside increasing demands from regulators, healthcare providers and patients for higher standards of safety, efficacy and cost-effectiveness of new therapies, stratified medicine promises a range of benefits to pharmaceutical and diagnostic firms as well as healthcare providers and patients. However, the transition from 'blockbusters' to what might now be termed 'niche-busters' will require the adoption of new, innovative business models, the identification of different and perhaps novel types of value along the R&D pathway, and a smarter approach to regulation to facilitate innovation in this area. In this paper we apply the Innogen Centre's interdisciplinary ALSIS methodology, which we have developed for the analysis of life science innovation systems in contexts where the value creation process is lengthy, expensive and highly uncertain, to this emerging field of stratified medicine. In doing so, we consider the complex collaboration, timing, coordination and regulatory interactions that shape business models, value chains and value systems relevant to stratified medicine. More specifically, we explore in some depth two convergence models for co-development of a therapy and diagnostic before market authorisation, highlighting the regulatory requirements and policy initiatives within the broader value system environment that have a key role in determining the probable success and sustainability of these models. Copyright © 2012 Elsevier B.V. All rights reserved.

  16. Grain distinct stratified nanolayers in aluminium alloys

    Energy Technology Data Exchange (ETDEWEB)

    Donatus, U., E-mail: uyimedonatus@yahoo.com [School of Materials, The University of Manchester, Manchester, M13 9PL, England (United Kingdom); Thompson, G.E.; Zhou, X.; Alias, J. [School of Materials, The University of Manchester, Manchester, M13 9PL, England (United Kingdom); Tsai, I.-L. [Oxford Instruments NanoAnalysis, HP12 2SE, High Wycombe (United Kingdom)

    2017-02-15

    The grains of aluminium alloys have stratified nanolayers which determine their mechanical and chemical responses. In this study, the nanolayers were revealed in the grains of AA6082 (T6 and T7 conditions), AA5083-O and AA2024-T3 alloys by etching the alloys in a solution comprising 20 g Cr{sub 2}O{sub 3} + 30 ml HPO{sub 3} in 1 L H{sub 2}O. Microstructural examination was conducted on selected grains of interest using scanning electron microscopy and electron backscatter diffraction technique. It was observed that the nanolayers are orientation dependent and are parallel to the {100} planes. They have ordered and repeated tunnel squares that are flawed at the sides which are aligned in the <100> directions. These flawed tunnel squares dictate the tunnelling corrosion morphology as well as appearing to have an affect on the arrangement and sizes of the precipitation hardening particles. The inclination of the stratified nanolayers, their interpacing, and the groove sizes have significant influence on the corrosion behaviour and seeming influence on the strengthening mechanism of the investigated aluminium alloys. - Highlights: • Stratified nanolayers in aluminium alloy grains. • Relationship of the stratified nanolayers with grain orientation. • Influence of the inclinations of the stratified nanolayers on corrosion. • Influence of the nanolayers interspacing and groove sizes on hardness and corrosion.

  17. Emerging Techniques in Stratified Designs and Continuous Gradients for Tissue Engineering of Interfaces

    Science.gov (United States)

    Dormer, Nathan H.; Berkland, Cory J.; Detamore, Michael S.

    2013-01-01

    Interfacial tissue engineering is an emerging branch of regenerative medicine, where engineers are faced with developing methods for the repair of one or many functional tissue systems simultaneously. Early and recent solutions for complex tissue formation have utilized stratified designs, where scaffold formulations are segregated into two or more layers, with discrete changes in physical or chemical properties, mimicking a corresponding number of interfacing tissue types. This method has brought forth promising results, along with a myriad of regenerative techniques. The latest designs, however, are employing “continuous gradients” in properties, where there is no discrete segregation between scaffold layers. This review compares the methods and applications of recent stratified approaches to emerging continuously graded methods. PMID:20411333

  18. The stratified H-index makes scientific impact transparent

    DEFF Research Database (Denmark)

    Würtz, Morten; Schmidt, Morten

    2017-01-01

    The H-index is widely used to quantify and standardize researchers' scientific impact. However, the H-index does not account for the fact that co-authors rarely contribute equally to a paper. Accordingly, we propose the use of a stratified H-index to measure scientific impact. The stratified H......-index supplements the conventional H-index with three separate H-indices: one for first authorships, one for second authorships and one for last authorships. The stratified H-index takes scientific output, quality and individual author contribution into account....

  19. Implementing a stepped-care approach in primary care: results of a qualitative study

    Directory of Open Access Journals (Sweden)

    Franx Gerdien

    2012-01-01

    Full Text Available Abstract Background Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC was initiated in the Netherlands. Methods Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT. Results The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring, were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method, and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT

  20. A study on the instability criterion for the stratified flow in horizontal pipe at cocurrent flow conditions

    Energy Technology Data Exchange (ETDEWEB)

    Sung, Chang Kyung [Korea Electric Power Research Institute, Taejon (Korea, Republic of)

    1998-12-31

    This paper presents a theoretical approach of the instability criterion from stratified to nonstratified flow in horizontal pipe at cocurrent flow conditions. The new theoretical instability criterion for the stratified and nonstratified flow transition in horizontal pipe has been developed by hyperbolic equations in two-phase flow. Critical flow condition criterion and onset of slugging at cocurrent flow condition correspond to zero and imaginary characteristics which occur when the hyperbolicity of a stratified two-phase flow is broken, respectively. Through comparison between results predicted by the present flow is broken, respectively. Through comparison between results predicted by the present theory and the Kukita et al. [1] experimental data of pipes, it is shown that they are in good agreement with data. 4 refs., 2 figs. (Author)

  1. A study on the instability criterion for the stratified flow in horizontal pipe at cocurrent flow conditions

    Energy Technology Data Exchange (ETDEWEB)

    Sung, Chang Kyung [Korea Electric Power Research Institute, Taejon (Korea, Republic of)

    1997-12-31

    This paper presents a theoretical approach of the instability criterion from stratified to nonstratified flow in horizontal pipe at cocurrent flow conditions. The new theoretical instability criterion for the stratified and nonstratified flow transition in horizontal pipe has been developed by hyperbolic equations in two-phase flow. Critical flow condition criterion and onset of slugging at cocurrent flow condition correspond to zero and imaginary characteristics which occur when the hyperbolicity of a stratified two-phase flow is broken, respectively. Through comparison between results predicted by the present flow is broken, respectively. Through comparison between results predicted by the present theory and the Kukita et al. [1] experimental data of pipes, it is shown that they are in good agreement with data. 4 refs., 2 figs. (Author)

  2. Integrating lifestyle approaches into osteoarthritis care

    Directory of Open Access Journals (Sweden)

    Garver MJ

    2015-09-01

    Full Text Available Matthew J Garver,1 Brian C Focht,2 Sarah J Taylor3 1Department of Kinesiology and Nutrition, Abilene Christian University, Abilene, TX, 2Department of Human Sciences, Ohio State University, Columbus, OH, 3School of Occupational Therapy, Texas Woman's University, Dallas, TX, USA Abstract: As the lifetime risk, societal cost, and overall functional impact of osteoarthritis (OA is imposing, it is imperative that clinicians provide an individualized care model for patients. Patients must be offered a multiplicity of care strategies and encouraged to embrace lifestyle approaches for self-managing the effects and symptoms of OA. Certainly, the attitude of the clinician and patient will directly influence receptivity and implementation of lifestyle approaches. This work proposes how the use of structured and routine assessments and cognitive therapy ideologies may complement a comprehensive treatment plan. Assessments described herein include objective and/or self-report measures of physical function, pain, attitude about social support, and sleep quality. Baseline assessments followed by systematic monitoring of the results may give patients and clinicians valuable insight into the effectiveness of the care plan. Empirical evidence from randomized trials with OA patients highlights the effectiveness of cognitive behavioral change strategies for addressing salient concerns for OA (pain control, mobility performance, and sleep quality. Cognitive restructuring can provide patients with renewed power in managing their disease. Cognitive therapy topics discussed presently include: 1 what is OA?, 2 effectiveness of exercise and FITT (frequency, intensity, time, and type principles for OA patients, 3 goal-setting and barriers, and 4 translating to independent care. Woven within the discussion about cognitive therapy are ideas about how the results from baseline assessments and group-mediated dynamics might assist more favorable outcomes. There are a plethora

  3. Risk Factors for Emergency Department Short Time Readmission in Stratified Population

    Directory of Open Access Journals (Sweden)

    Ariadna Besga

    2015-01-01

    Full Text Available Background. Emergency department (ED readmissions are considered an indicator of healthcare quality that is particularly relevant in older adults. The primary objective of this study was to identify key factors for predicting patients returning to the ED within 30 days of being discharged. Methods. We analysed patients who attended our ED in June 2014, stratified into four groups based on the Kaiser pyramid. We collected data on more than 100 variables per case including demographic and clinical characteristics and drug treatments. We identified the variables with the highest discriminating power to predict ED readmission and constructed classifiers using machine learning methods to provide predictions. Results. Classifier performance distinguishing between patients who were and were not readmitted (within 30 days, in terms of average accuracy (AC. The variables with the greatest discriminating power were age, comorbidity, reasons for consultation, social factors, and drug treatments. Conclusions. It is possible to predict readmissions in stratified groups with high accuracy and to identify the most important factors influencing the event. Therefore, it will be possible to develop interventions to improve the quality of care provided to ED patients.

  4. A holistic approach to pastoral care and poverty

    Directory of Open Access Journals (Sweden)

    Johan Janse van Rensburg

    2010-03-01

    Full Text Available The previous approaches to pastoral care are no longer adequate or effective for addressing the many issues related to poverty. The church has done wonderful work in terms of Christian charity. However, more needs to be done to improve the worsening situation of the poor significantly. The clear distinction between pastoral care and Christian charity is a luxury that is no longer affordable. Once we have a holistic understanding of pastoral care and counselling, we will find that we cannot possibly restrict our pastoral attention to encouraging the poor, to giving random advice and to praying. A holistic pastoral theology could lead to empowerment and should be a key concept in pastoral care with poor people and societies. The article offers a theological theory for a holistic approach and some implications of the praxis of counselling.

  5. Funding intensive care - approaches in systems using diagnosis-related groups.

    OpenAIRE

    Ettelt, S; Nolte, E

    2010-01-01

    This report reviews approaches to funding intensive care in health systems that use activitybased payment mechanisms based on diagnosis-related groups (DRGs) to reimburse hospital care. The report aims to inform the current debate about options for funding intensive care services for adults, children and newborns in England. Funding mechanisms reviewed here include those in Australia (Victoria), Denmark, France, Germany, Italy, Spain, Sweden and the United States (Medicare). Approaches to org...

  6. Integrated care: wellness-oriented peer approaches: a key ingredient for integrated care.

    Science.gov (United States)

    Swarbrick, Margaret A

    2013-08-01

    People with lived experience of mental illness have become leaders of an influential movement to help the mental health system embrace the notion of whole health and wellness in the areas of advocacy, policy, and care delivery. Wellness-oriented peer approaches delivered by peer-support whole-health specialists and wellness coaches can play an important role in integrated care models. This column examines the wellness definitions and peer models and some specific benefits and tensions between the peer-oriented wellness approach and the medical model. These models can work in unison to improve health and wellness among people with mental and substance use disorders.

  7. Integrated Care for Older Adults Improves Perceived Quality of Care : Results of a Randomized Controlled Trial of Embrace

    NARCIS (Netherlands)

    Uittenbroek, Ronald J; Kremer, Hubertus P H; Spoorenberg, Sophie L W; Reijneveld, Sijmen A; Wynia, Klaske

    BACKGROUND: All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care. To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care. Stratified

  8. Critical interactionism: an upstream-downstream approach to health care reform.

    Science.gov (United States)

    Martins, Diane Cocozza; Burbank, Patricia M

    2011-01-01

    Currently, per capita health care expenditures in the United States are more than 20% higher than any other country in the world and more than twice the average expenditure for European countries, yet the United States ranks 37th in life expectancy. Clearly, the health care system is not succeeding in improving the health of the US population with its focus on illness care for individuals. A new theoretical approach, critical interactionism, combines symbolic interactionism and critical social theory to provide a guide for addressing health care problems from both an upstream and downstream approach. Concepts of meaning from symbolic interactionism and emancipation from critical perspective move across system levels to inform and reform health care for individuals, organizations, and societies. This provides a powerful approach for health care reform, moving back and forth between the micro and macro levels. Areas of application to nursing practice with several examples (patients with obesity; patients who are lesbian, gay, bisexual, and transgender; workplace bullying and errors), nursing education, and research are also discussed.

  9. Doubly stratified mixed convection flow of Maxwell nanofluid with heat generation/absorption

    Energy Technology Data Exchange (ETDEWEB)

    Abbasi, F.M., E-mail: abbasisarkar@gmail.com [Department of Mathematics, Comsats Institute of Information Technology, Islamabad 44000 (Pakistan); Shehzad, S.A. [Department of Mathematics, Comsats Institute of Information Technology, Sahiwal 57000 (Pakistan); Hayat, T. [Department of Mathematics, Quaid-i-Azam University, 45320, Islamabad 44000 (Pakistan); NAAM Research Group, Department of Mathematics, Faculty of Science, King Abdulaziz University, Jeddah 21589 (Saudi Arabia); Ahmad, B. [NAAM Research Group, Department of Mathematics, Faculty of Science, King Abdulaziz University, Jeddah 21589 (Saudi Arabia)

    2016-04-15

    Magnetohydrodynamic (MHD) doubly stratified flow of Maxwell nanofluid in presence of mixed convection is analyzed in this article. Effects of thermophoresis, Brownian motion and heat generation/absorption are present. The flow is induced due to linear stretching of sheet. Mathematical formulation is made under boundary layer approach. Expressions of velocity, temperature and nanoparticles concentration are developed. The obtained results are plotted and discussed to examine the variations in temperature and nanoparticles concentration due to different physical parameters. Numerical computations are made to obtain the values of local Nusselt and Sherwood numbers. Impact of sundry parameters on the flow quantities is analyzed graphically. - Highlights: • Double stratified flow of Maxwell nanofluid with mixed convection is modeled. • Thermophoresis and Brownian motion effects are encountered. • Computations are made to obtain the solution expressions. • Numerical values of local Nusselt and Sherwood numbers are computed and examined.

  10. Exploring the role of wave drag in the stable stratified oceanic and atmospheric bottom boundary layer in the cnrs-toulouse (cnrm-game) large stratified water flume

    NARCIS (Netherlands)

    Kleczek, M.; Steeneveld, G.J.; Paci, A.; Calmer, R.; Belleudy, A.; Canonici, J.C.; Murguet, F.; Valette, V.

    2014-01-01

    This paper reports on a laboratory experiment in the CNRM-GAME (Toulouse) stratified water flume of a stably stratified boundary layer, in order to quantify the momentum transfer due to orographically induced gravity waves by gently undulating hills in a boundary layer flow. In a stratified fluid, a

  11. Cross-cultural adaptation of the STRATIFY tool in detecting and predicting risk of falling.

    Science.gov (United States)

    Enríquez de Luna-Rodríguez, Margarita; Aranda-Gallardo, Marta; Canca-Sánchez, José Carlos; Vazquez-Blanco, M José; Moya-Suárez, Ana Belén; Morales-Asencio, José Miguel

    To adapt to Spanish language the STRATIFY tool for clinical use in the Spanish-speaking World. A multicenter, 2 care settings cross-sectional study cultural adaptation study in acute care hospitals and nursing homes was performed in Andalusia during 2014. The adaptation process was divided into 4 stages: translation, back-translation, equivalence between the 2 back-translations and piloting of the Spanish version, thus obtaining the final version. The validity of appearance, content validity and the time required to complete the scale were taken into account. For analysis, the median, central tendency and dispersion of scores, the interquartile range, and the interquartile deviation for the possible variability in responses it was calculated. Content validity measured by content validity index reached a profit of 1. For the validity aspect the clarity and comprehensibility of the questions were taken into account. Of the 5 questions of the instrument, 2 had a small disagreement solved with the introduction of an explanatory phrase to achieve conceptual equivalence. Median both questions were equal or superior to 5. The average time for completion of the scale was less than 3 minutes. The process of adaptation to Spanish of STRATIFY has led to a semantic version and culturally equivalent to the original for easy filling and understanding for use in the Spanish-speaking world. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

  12. Aligning the Economic Value of Companion Diagnostics and Stratified Medicines

    Directory of Open Access Journals (Sweden)

    Edward D. Blair

    2012-11-01

    Full Text Available The twin forces of payors seeking fair pricing and the rising costs of developing new medicines has driven a closer relationship between pharmaceutical companies and diagnostics companies, because stratified medicines, guided by companion diagnostics, offer better commercial, as well as clinical, outcomes. Stratified medicines have created clinical success and provided rapid product approvals, particularly in oncology, and indeed have changed the dynamic between drug and diagnostic developers. The commercial payback for such partnerships offered by stratified medicines has been less well articulated, but this has shifted as the benefits in risk management, pricing and value creation for all stakeholders become clearer. In this larger healthcare setting, stratified medicine provides both physicians and patients with greater insight on the disease and provides rationale for providers to understand cost-effectiveness of treatment. This article considers how the economic value of stratified medicine relationships can be recognized and translated into better outcomes for all healthcare stakeholders.

  13. Large eddy simulation of stably stratified turbulence

    International Nuclear Information System (INIS)

    Shen Zhi; Zhang Zhaoshun; Cui Guixiang; Xu Chunxiao

    2011-01-01

    Stably stratified turbulence is a common phenomenon in atmosphere and ocean. In this paper the large eddy simulation is utilized for investigating homogeneous stably stratified turbulence numerically at Reynolds number Re = uL/v = 10 2 ∼10 3 and Froude number Fr = u/NL = 10 −2 ∼10 0 in which u is root mean square of velocity fluctuations, L is integral scale and N is Brunt-Vaïsälä frequency. Three sets of computation cases are designed with different initial conditions, namely isotropic turbulence, Taylor Green vortex and internal waves, to investigate the statistical properties from different origins. The computed horizontal and vertical energy spectra are consistent with observation in atmosphere and ocean when the composite parameter ReFr 2 is greater than O(1). It has also been found in this paper that the stratification turbulence can be developed under different initial velocity conditions and the internal wave energy is dominated in the developed stably stratified turbulence.

  14. Stratified medicine and reimbursement issues

    NARCIS (Netherlands)

    Fugel, Hans-Joerg; Nuijten, Mark; Postma, Maarten

    2012-01-01

    Stratified Medicine (SM) has the potential to target patient populations who will most benefit from a therapy while reducing unnecessary health interventions associated with side effects. The link between clinical biomarkers/diagnostics and therapies provides new opportunities for value creation to

  15. Simulation modeling for stratified breast cancer screening - a systematic review of cost and quality of life assumptions.

    Science.gov (United States)

    Arnold, Matthias

    2017-12-02

    The economic evaluation of stratified breast cancer screening gains momentum, but produces also very diverse results. Systematic reviews so far focused on modeling techniques and epidemiologic assumptions. However, cost and utility parameters received only little attention. This systematic review assesses simulation models for stratified breast cancer screening based on their cost and utility parameters in each phase of breast cancer screening and care. A literature review was conducted to compare economic evaluations with simulation models of personalized breast cancer screening. Study quality was assessed using reporting guidelines. Cost and utility inputs were extracted, standardized and structured using a care delivery framework. Studies were then clustered according to their study aim and parameters were compared within the clusters. Eighteen studies were identified within three study clusters. Reporting quality was very diverse in all three clusters. Only two studies in cluster 1, four studies in cluster 2 and one study in cluster 3 scored high in the quality appraisal. In addition to the quality appraisal, this review assessed if the simulation models were consistent in integrating all relevant phases of care, if utility parameters were consistent and methodological sound and if cost were compatible and consistent in the actual parameters used for screening, diagnostic work up and treatment. Of 18 studies, only three studies did not show signs of potential bias. This systematic review shows that a closer look into the cost and utility parameter can help to identify potential bias. Future simulation models should focus on integrating all relevant phases of care, using methodologically sound utility parameters and avoiding inconsistent cost parameters.

  16. [Heart failure in primary care: Attitudes, knowledge and self-care].

    Science.gov (United States)

    Salvadó-Hernández, Cristina; Cosculluela-Torres, Pilar; Blanes-Monllor, Carmen; Parellada-Esquius, Neus; Méndez-Galeano, Carmen; Maroto-Villanova, Neus; García-Cerdán, Rosa Maria; Núñez-Manrique, M Pilar; Barrio-Ruiz, Carmen; Salvador-González, Betlem

    2018-04-01

    To determine the attitudes, knowledge, and self-care practices in patients with heart failure (HF) in Primary Care, as well as to identify factors associated with better self-care. Cross-sectional and multicentre study. Primary Care. Subjects over 18 years old with HF diagnosis, attended in 10 Primary Health Care Centres in the Metropolitan Area of Barcelona. Self-care was measured using the European Heart Failure Self-Care Behaviour Scale. Sociodemographic and clinical characteristics, tests on attitudes (Self-efficacy Managing Chronic Disease Scale), knowledge (Patient Knowledge Questionnaire), level of autonomy (Barthel), and anxiety and depression screening (Goldberg Test), were also gathered in an interview. A multivariate mixed model stratified by centre was used to analyse the adjusted association of covariates with self-care. A total of 295 subjects (77.6%) agreed to participate, with a mean age of 75.6 years (SD: 11), 56.6% women, and 62% with no primary education. The mean self-care score was 28.65 (SD: 8.22), with 25% of patients scoring lower than 21 points. In the final stratified multivariate model (n=282; R 2 conditional=0.3382), better self-care was associated with higher knowledge (coefficient, 95% confidence interval: -1.37; -1.85 to -0.90), and coronary heart disease diagnosis (-2.41; -4.36: -0.46). Self-care was moderate. The correlation of better self-care with higher knowledge highlights the opportunity to implement strategies to improve self-care, which should consider the characteristics of heart failure patients attended in Primary Care. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

  17. Predictors of depressive symptoms in older Japanese primiparas at 1 month post-partum: A risk-stratified analysis.

    Science.gov (United States)

    Iwata, Hiroko; Mori, Emi; Tsuchiya, Miyako; Sakajo, Akiko; Maehara, Kunie; Ozawa, Harumi; Morita, Akiko; Maekawa, Tomoko; Aoki, Kyoko; Tamakoshi, Koji

    2016-01-01

    Older maternal age has become more common in Japan. Studies suggest that older maternal age and primiparity are associated with post-partum depression. The present study aimed to identify predictors of post-partum depression in older Japanese primiparas at 1 month post-partum. Participants were 479 primiparas aged 35 years and over, drawn from a prospective cohort study. Data were collected using self-report questionnaires. Depression was measured with the Japanese version of the Edinburgh Postnatal Depression Scale. Stepwise logistic regression analysis was conducted on binary outcome variables of depression at 1 month post-partum, along with a stratified analysis based on the risk status of depression. Five predictors were identified: (i) the depression score during hospital stay; (ii) financial burden; (iii) dissatisfaction with appraisal support; (iv) physical burden in daily life; and (v) concerns about infant caretaking. Stratified analysis identified dissatisfaction with instrumental support in the low-risk group, and the Child-care Value Scale score as unique predictors in the high-risk group. These results highlight the importance of early assessment of depressive symptoms and the provision of continuous care. © 2015 Japan Academy of Nursing Science.

  18. Cost approach of health care entity intangible asset valuation.

    Science.gov (United States)

    Reilly, Robert F

    2012-01-01

    degree of marketability; and The degree of variation in the range of value indications. Valuation analysts value health care intangible assets for a number of reasons. In addition to regulatory compliance reasons, these reasons include various transaction, taxation, financing, litigation, accounting, bankruptcy, and planning purposes. The valuation analyst should consider all generally accepted intangible asset valuation approaches, methods, and procedures. Many valuation analysts are more familiar with market approach and income approach valuation methods. However, there are numerous instances when cost approach valuation methods are also applicable to the health care intangible asset valuation. This discussion summarized the analyst's procedures and considerations with regard to the cost approach. The cost approach is often applicable to the valuation of intangible assets in the health care industry. However, the cost approach is only applicable if the valuation analyst (1) appropriately considers all of the cost components and (2) appropriately identifies and quantifies all obsolescence allowances. Regardless of the health care intangible asset or the reason for the valuation, the analyst should be familiar with all generally accepted valuation approaches and methods. And, the valuation analyst should have a clear, convincing, and cogent rationale for (1) accepting each approach and method applied and (2) rejecting each approach and method not applied. That way, the valuation analyst will best achieve the purpose and objective of the health care intangible asset valuation.

  19. Treating alcoholism as a chronic disease: approaches to long-term continuing care.

    Science.gov (United States)

    McKay, James R; Hiller-Sturmhofel, Susanne

    2011-01-01

    For many patients, alcohol and other drug (AOD) use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. To disrupt this cycle, treatment can include continuing care to reduce the risk of relapse. The most commonly used treatment approach is initial intensive inpatient or outpatient care based on 12-step principles, followed by continuing care involving self-help groups, 12-step group counseling, or individual therapy. Although these programs can be effective, many patients drop out of initial treatment or do not complete continuing care. Thus, researchers and clinicians have begun to develop alternative approaches to enhance treatment retention in both initial and continuing care. One focus of these efforts has been the design of extended treatment models. These approaches increasingly blur the distinction between initial and continuing care and aim to prolong treatment participation by providing a continuum of care. Other researchers have focused on developing alternative treatment strategies (e.g., telephone-based interventions) that go beyond traditional settings and adaptive treatment algorithms that may improve outcomes for clients who do not respond well to traditional approaches.

  20. Implementing risk-stratified screening for common cancers: a review of potential ethical, legal and social issues.

    Science.gov (United States)

    Hall, A E; Chowdhury, S; Hallowell, N; Pashayan, N; Dent, T; Pharoah, P; Burton, H

    2014-06-01

    The identification of common genetic variants associated with common cancers including breast, prostate and ovarian cancers would allow population stratification by genotype to effectively target screening and treatment. As scientific, clinical and economic evidence mounts there will be increasing pressure for risk-stratified screening programmes to be implemented. This paper reviews some of the main ethical, legal and social issues (ELSI) raised by the introduction of genotyping into risk-stratified screening programmes, in terms of Beauchamp and Childress's four principles of biomedical ethics--respect for autonomy, non-maleficence, beneficence and justice. Two alternative approaches to data collection, storage, communication and consent are used to exemplify the ELSI issues that are likely to be raised. Ultimately, the provision of risk-stratified screening using genotyping raises fundamental questions about respective roles of individuals, healthcare providers and the state in organizing or mandating such programmes, and the principles, which underpin their provision, particularly the requirement for distributive justice. The scope and breadth of these issues suggest that ELSI relating to risk-stratified screening will become increasingly important for policy-makers, healthcare professionals and a wide diversity of stakeholders. © The Author 2013. Published by Oxford University Press on behalf of Faculty of Public Health.

  1. Design of Helical Capacitance Sensor for Holdup Measurement in Two-Phase Stratified Flow: A Sinusoidal Function Approach

    Science.gov (United States)

    Lim, Lam Ghai; Pao, William K. S.; Hamid, Nor Hisham; Tang, Tong Boon

    2016-01-01

    A 360° twisted helical capacitance sensor was developed for holdup measurement in horizontal two-phase stratified flow. Instead of suppressing nonlinear response, the sensor was optimized in such a way that a ‘sine-like’ function was displayed on top of the linear function. This concept of design had been implemented and verified in both software and hardware. A good agreement was achieved between the finite element model of proposed design and the approximation model (pure sinusoidal function), with a maximum difference of ±1.2%. In addition, the design parameters of the sensor were analysed and investigated. It was found that the error in symmetry of the sinusoidal function could be minimized by adjusting the pitch of helix. The experiments of air-water and oil-water stratified flows were carried out and validated the sinusoidal relationship with a maximum difference of ±1.2% and ±1.3% for the range of water holdup from 0.15 to 0.85. The proposed design concept therefore may pose a promising alternative for the optimization of capacitance sensor design. PMID:27384567

  2. Design of Helical Capacitance Sensor for Holdup Measurement in Two-Phase Stratified Flow: A Sinusoidal Function Approach

    Directory of Open Access Journals (Sweden)

    Lam Ghai Lim

    2016-07-01

    Full Text Available A 360° twisted helical capacitance sensor was developed for holdup measurement in horizontal two-phase stratified flow. Instead of suppressing nonlinear response, the sensor was optimized in such a way that a ‘sine-like’ function was displayed on top of the linear function. This concept of design had been implemented and verified in both software and hardware. A good agreement was achieved between the finite element model of proposed design and the approximation model (pure sinusoidal function, with a maximum difference of ±1.2%. In addition, the design parameters of the sensor were analysed and investigated. It was found that the error in symmetry of the sinusoidal function could be minimized by adjusting the pitch of helix. The experiments of air-water and oil-water stratified flows were carried out and validated the sinusoidal relationship with a maximum difference of ±1.2% and ±1.3% for the range of water holdup from 0.15 to 0.85. The proposed design concept therefore may pose a promising alternative for the optimization of capacitance sensor design.

  3. Design of Helical Capacitance Sensor for Holdup Measurement in Two-Phase Stratified Flow: A Sinusoidal Function Approach.

    Science.gov (United States)

    Lim, Lam Ghai; Pao, William K S; Hamid, Nor Hisham; Tang, Tong Boon

    2016-07-04

    A 360° twisted helical capacitance sensor was developed for holdup measurement in horizontal two-phase stratified flow. Instead of suppressing nonlinear response, the sensor was optimized in such a way that a 'sine-like' function was displayed on top of the linear function. This concept of design had been implemented and verified in both software and hardware. A good agreement was achieved between the finite element model of proposed design and the approximation model (pure sinusoidal function), with a maximum difference of ±1.2%. In addition, the design parameters of the sensor were analysed and investigated. It was found that the error in symmetry of the sinusoidal function could be minimized by adjusting the pitch of helix. The experiments of air-water and oil-water stratified flows were carried out and validated the sinusoidal relationship with a maximum difference of ±1.2% and ±1.3% for the range of water holdup from 0.15 to 0.85. The proposed design concept therefore may pose a promising alternative for the optimization of capacitance sensor design.

  4. Stratified charge rotary engine for general aviation

    Science.gov (United States)

    Mount, R. E.; Parente, A. M.; Hady, W. F.

    1986-01-01

    A development history, a current development status assessment, and a design feature and performance capabilities account are given for stratified-charge rotary engines applicable to aircraft propulsion. Such engines are capable of operating on Jet-A fuel with substantial cost savings, improved altitude capability, and lower fuel consumption by comparison with gas turbine powerplants. Attention is given to the current development program of a 400-hp engine scheduled for initial operations in early 1990. Stratified charge rotary engines are also applicable to ground power units, airborne APUs, shipboard generators, and vehicular engines.

  5. A discussion of approaches to transforming care: contemporary strategies to improve patient safety.

    Science.gov (United States)

    Burston, Sarah; Chaboyer, Wendy; Wallis, Marianne; Stanfield, Jane

    2011-11-01

    This article presents a discussion of three contemporary approaches to transforming care: Transforming Care at the Bedside, Releasing Time to Care: the Productive Ward and the work of the Studer Group(®). International studies of adverse events in hospitals have highlighted the need to focus on patient safety. The case for transformational change was identified and recently several approaches have been developed to effect this change. Despite limited evaluation, these approaches have spread and have been adopted outside their country of origin and contextual settings. Medline and CINAHL databases were searched for the years 1999-2009. Search terms included derivatives of 'transformation' combined with 'care', 'nursing', 'patient safety', 'Transforming Care at the Bedside', 'the Productive Ward' and 'Studer Group'. A comparison of the three approaches revealed similarities including: the foci of the approaches; interventions employed; and the outcomes measured. Key differences identified are the implementation models used, spread strategies and sustainability of the approaches. The approaches appear to be complementary and a hybrid of the approaches such as a blend of a top-down and bottom-up leadership strategy may offer more sustainable behavioural change. These approaches transform the way nurses do their work, how they work with others and how they view the care they provide to promote patient safety. All the approaches involve the implementation of multiple interventions occurring simultaneously to affect improvements in patient safety. The approaches are complementary and a hybrid approach may offer more sustainable outcomes. © 2011 Blackwell Publishing Ltd.

  6. When Should We Use Care Robots? The Nature-of-Activities Approach.

    Science.gov (United States)

    Santoni de Sio, Filippo; van Wynsberghe, Aimee

    2016-12-01

    When should we use care robots? In this paper we endorse the shift from a simple normative approach to care robots ethics to a complex one: we think that one main task of a care robot ethics is that of analysing the different ways in which different care robots may affect the different values at stake in different care practices. We start filling a gap in the literature by showing how the philosophical analysis of the nature of healthcare activities can contribute to (care) robot ethics. We rely on the nature-of-activities approach recently proposed in the debate on human enhancement, and we apply it to the ethics of care robots. The nature-of-activities approach will help us to understand why certain practice-oriented activities in healthcare should arguably be left to humans, but certain (predominantly) goal-directed activities in healthcare can be fulfilled (sometimes even more ethically) with the assistance of a robot. In relation to the latter, we aim to show that even though all healthcare activities can be considered as practice-oriented, when we understand the activity in terms of different legitimate 'fine-grained' descriptions, the same activities or at least certain components of them can be seen as clearly goal-directed. Insofar as it allows us to ethically assess specific functionalities of specific robots to be deployed in well-defined circumstances, we hold the nature-of-activities approach to be particularly helpful also from a design perspective, i.e. to realize the Value Sensitive Design approach.

  7. Design and simulation of stratified probability digital receiver with application to the multipath communication

    Science.gov (United States)

    Deal, J. H.

    1975-01-01

    One approach to the problem of simplifying complex nonlinear filtering algorithms is through using stratified probability approximations where the continuous probability density functions of certain random variables are represented by discrete mass approximations. This technique is developed in this paper and used to simplify the filtering algorithms developed for the optimum receiver for signals corrupted by both additive and multiplicative noise.

  8. Nitrogen transformations in stratified aquatic microbial ecosystems

    DEFF Research Database (Denmark)

    Revsbech, Niels Peter; Risgaard-Petersen, N.; Schramm, Andreas

    2006-01-01

    Abstract  New analytical methods such as advanced molecular techniques and microsensors have resulted in new insights about how nitrogen transformations in stratified microbial systems such as sediments and biofilms are regulated at a µm-mm scale. A large and ever-expanding knowledge base about n...... performing dissimilatory reduction of nitrate to ammonium have given new dimensions to the understanding of nitrogen cycling in nature, and the occurrence of these organisms and processes in stratified microbial communities will be described in detail.......Abstract  New analytical methods such as advanced molecular techniques and microsensors have resulted in new insights about how nitrogen transformations in stratified microbial systems such as sediments and biofilms are regulated at a µm-mm scale. A large and ever-expanding knowledge base about...... nitrogen fixation, nitrification, denitrification, and dissimilatory reduction of nitrate to ammonium, and about the microorganisms performing the processes, has been produced by use of these techniques. During the last decade the discovery of anammmox bacteria and migrating, nitrate accumulating bacteria...

  9. Using a strengths-based approach to build caring work environments.

    Science.gov (United States)

    Henry, Linda S; Henry, James D

    2007-12-01

    The current health care environment has a growing shortage of nurses and other health care professionals. Health care organizations face the twofold task of retaining employees and preventing "brain drain". A caring work environment can be instrumental in attracting and retaining productive and loyal employees, leading to increased employee and patient satisfaction and a positively impacted bottom line. A strengths-based approach powerfully and effectively promotes and nurtures a caring work environment in all health care specialties and organizations.

  10. A study of stratified gas-liquid pipe flow

    Energy Technology Data Exchange (ETDEWEB)

    Johnson, George W.

    2005-07-01

    This work includes both theoretical modelling and experimental observations which are relevant to the design of gas condensate transport lines. Multicomponent hydrocarbon gas mixtures are transported in pipes over long distances and at various inclinations. Under certain circumstances, the heavier hydrocarbon components and/or water vapour condense to form one or more liquid phases. Near the desired capacity, the liquid condensate and water is efficiently transported in the form of a stratified flow with a droplet field. During operating conditions however, the flow rate may be reduced allowing liquid accumulation which can create serious operational problems due to large amounts of excess liquid being expelled into the receiving facilities during production ramp-up or even in steady production in severe cases. In particular, liquid tends to accumulate in upward inclined sections due to insufficient drag on the liquid from the gas. To optimize the transport of gas condensates, a pipe diameters should be carefully chosen to account for varying flow rates and pressure levels which are determined through the knowledge of the multiphase flow present. It is desirable to have a reliable numerical simulation tool to predict liquid accumulation for various flow rates, pipe diameters and pressure levels which is not presently accounted for by industrial flow codes. A critical feature of the simulation code would include the ability to predict the transition from small liquid accumulation at high flow rates to large liquid accumulation at low flow rates. A semi-intermittent flow regime of roll waves alternating with a partly backward flowing liquid film has been observed experimentally to occur for a range of gas flow rates. Most of the liquid is transported in the roll waves. The roll wave regime is not well understood and requires fundamental modelling and experimental research. The lack of reliable models for this regime leads to inaccurate prediction of the onset of

  11. Friendship Repertoires and Care Arrangement: A Praxeological Approach.

    Science.gov (United States)

    Hahmann, Julia

    2017-01-01

    Friends are important companions and serve as sources for diverse dimensions of social support, including elderly care. Rather than researching populations that have already established care arrangements including friends, the author seeks to understand relationship systems with a focus on the inner logic friendship to consequently describe and understand involved care arrangements, be it with family members or friends. To illustrate the diversity of friendship repertoires, qualitative interviews with older adult Germans are analyzed regarding cognitive concepts of friendships in contrast to familiar ties as well as social practices around relationship systems. While some repertoires successfully include chosen ties in their care arrangements, others not only focus on family, they do not wish to receive care from friends. The article's praxeological approach highlights the need to reflect habitual differences when thinking about elderly informal care arrangements. © The Author(s) 2016.

  12. Transthoracic approach for lesions involving the anterior dorsal spine: A multidisciplinary approach with good outcomes

    Directory of Open Access Journals (Sweden)

    Srikant Balasubramaniam

    2016-01-01

    Materials and Methods: A total of 16 patients were operated for varying lesions of body of dorsal vertebra by the transthoracic approach. The study was for a period of 5 years from January 2011 to December 2015. Patients age ranged from 25 to 61 years with an average of 36.4 yrs. There were 7 males and 9 females. In our series 9 patients had Kochs spine, 4 patients were traumatic fracture spine and 3 had neoplastic lesion. Majority of patients had multiple symptoms with backache being present in all patients. Results: There was one post operative mortality which was unrelated to surgery. One patient had post operative delayed kyphosis. Remaining patients improved in their symptoms following surgery. Conclusion: With careful coordination by thoracic surgeons, neurospinal surgeons and anaesthetists, the anterior spine approach for dorsal spine is safe and effective. Adequate preoperative evaluation should stratify the risk and institute measures to reduce it. Accurate surgical planning and careful surgical technique are the key to yield a good outcome and to reduce the risk of complications.

  13. Erosion of a confined stratified layer by a vertical jet – Detailed assessment of a CFD approach against the OECD/NEA PSI benchmark

    Energy Technology Data Exchange (ETDEWEB)

    Kelm, S., E-mail: s.kelm@fz-juelich.de [Forschungszentrum Jülich GmbH, 52425 Jülich (Germany); Kapulla, R., E-mail: ralf.kapulla@psi.ch [Paul Scherrer Institute, 5232 Villigen PSI (Switzerland); Allelein, H.-J., E-mail: allelein@lrst.rwth-aachen.de [Forschungszentrum Jülich GmbH, 52425 Jülich (Germany); RWTH Aachen University, 52080 Aachen (Germany)

    2017-02-15

    Highlights: • Systematic of a U-RANS approach, capable to be applied at containment scale. • Validation against measured and derived point-wise and field data. • Validation by means of transported quantities (concentration) but also underlying flow field and turbulent kinetic energy. • U-RANS approach yields in overall consistent and plausible results. • But unexpected difference in SST and k–ε identified for free-stream flow. - Abstract: Recently, a blind CFD benchmark exercise was conducted by the OECD/NEA (2013–2014) based on an experiment in the PANDA facility at the Paul Scherrer Institute (PSI) in Switzerland, investigating the turbulent erosion of a stratified helium rich layer in the upper region of the test vessel by means of a vertical air-helium jet impinging from below. In addition to the ‘classical’ pointwise measurements available for similar experiments conducted in the past, significant additional efforts were spent on the experimental characterization of the underlying flow field and turbulent quantities by means of particle image velocimetry (PIV) for the benchmark. This data is well suited for a detailed assessment of the driving jet flow and its interaction with the stratified layer. Both are essential in order to avoid elimination of different errors, which is possible if validation is performed in a global manner. Different impacts on the simulation results, in particular on the jet profile and on the mixing progress, are discussed in this paper. A systematic validation is carried out based on measured and derived quantities. It is identified that e.g. the mesh resolution in the jet and mixing zone has only a minor impact, while small changes in turbulence modeling strategy or the chosen model constants, like Sc{sub t}, significantly affect the simulation results. Finally, the chosen unsteady RANS model represents mixing process consistently in the transient progression and instantaneous flow variables, while an unexpected

  14. Simulation model of stratified thermal energy storage tank using finite difference method

    Science.gov (United States)

    Waluyo, Joko

    2016-06-01

    Stratified TES tank is normally used in the cogeneration plant. The stratified TES tanks are simple, low cost, and equal or superior in thermal performance. The advantage of TES tank is that it enables shifting of energy usage from off-peak demand for on-peak demand requirement. To increase energy utilization in a stratified TES tank, it is required to build a simulation model which capable to simulate the charging phenomenon in the stratified TES tank precisely. This paper is aimed to develop a novel model in addressing the aforementioned problem. The model incorporated chiller into the charging of stratified TES tank system in a closed system. The model was developed in one-dimensional type involve with heat transfer aspect. The model covers the main factors affect to degradation of temperature distribution namely conduction through the tank wall, conduction between cool and warm water, mixing effect on the initial flow of the charging as well as heat loss to surrounding. The simulation model is developed based on finite difference method utilizing buffer concept theory and solved in explicit method. Validation of the simulation model is carried out using observed data obtained from operating stratified TES tank in cogeneration plant. The temperature distribution of the model capable of representing S-curve pattern as well as simulating decreased charging temperature after reaching full condition. The coefficient of determination values between the observed data and model obtained higher than 0.88. Meaning that the model has capability in simulating the charging phenomenon in the stratified TES tank. The model is not only capable of generating temperature distribution but also can be enhanced for representing transient condition during the charging of stratified TES tank. This successful model can be addressed for solving the limitation temperature occurs in charging of the stratified TES tank with the absorption chiller. Further, the stratified TES tank can be

  15. Changing the lens: widening the approach to primary care research.

    Science.gov (United States)

    Checkland, Kath

    2003-10-01

    After years of being shielded from most of the managerial and organisational changes in health care, primary care is going through a period of change in many countries. Much of the research that has been done in primary care, in common with that in secondary care, puts at the centre of its methodology the concept of professionalism. However, there are other ways of theorising medical work, and using a wider range of theoretical 'lenses' when planning research into the impact of change will enhance and enrich that research. Viewing primary care physicians as 'workers', concerned, like other workers, with constructing understanding of what they do that helps them cope with pressures and uncertainties, shifts the focus of research questions away from issues of professional status towards the practical ways in which they deal with change in their local contexts. Research using this theoretical approach may be able to explain phenomena that other, more broad-brush approaches cannot.

  16. Free Falling in Stratified Fluids

    Science.gov (United States)

    Lam, Try; Vincent, Lionel; Kanso, Eva

    2017-11-01

    Leaves falling in air and discs falling in water are examples of unsteady descents due to complex interaction between gravitational and aerodynamic forces. Understanding these descent modes is relevant to many branches of engineering and science such as estimating the behavior of re-entry space vehicles to studying biomechanics of seed dispersion. For regularly shaped objects falling in homogenous fluids, the motion is relatively well understood. However, less is known about how density stratification of the fluid medium affects the falling behavior. Here, we experimentally investigate the descent of discs in both pure water and in stable linearly stratified fluids for Froude numbers Fr 1 and Reynolds numbers Re between 1000 -2000. We found that stable stratification (1) enhances the radial dispersion of the disc at landing, (2) increases the descent time, (3) decreases the inclination (or nutation) angle, and (4) decreases the fluttering amplitude while falling. We conclude by commenting on how the corresponding information can be used as a predictive model for objects free falling in stratified fluids.

  17. Prototypic Features of Loneliness in a Stratified Sample of Adolescents

    Directory of Open Access Journals (Sweden)

    Mathias Lasgaard

    2009-06-01

    Full Text Available Dominant theoretical approaches in loneliness research emphasize the value of personality characteristics in explaining loneliness. The present study examines whether dysfunctional social strategies and attributions in lonely adolescents can be explained by personality characteristics. A questionnaire survey was conducted with 379 Danish Grade 8 students (M = 14.1 years, SD = 0.4 from 22 geographically stratified and randomly selected schools. Hierarchical linear regression analysis showed that network orientation, success expectation and avoidance in affiliative situations predicted loneliness independent of personality characteristics, demographics and social desirability. The study indicates that dysfunctional strategies and attributions in affiliative situations are directly related to loneliness in adolescence. These strategies and attributions may preclude lonely adolescents from guidance and intervention. Thus, professionals need to be knowledgeable about prototypic features of loneliness in addition to employing a pro-active approach when assisting adolescents who display prototypic features.

  18. Evaluation of a Stratified National Breast Screening Program in the United Kingdom: An Early Model-Based Cost-Effectiveness Analysis.

    Science.gov (United States)

    Gray, Ewan; Donten, Anna; Karssemeijer, Nico; van Gils, Carla; Evans, D Gareth; Astley, Sue; Payne, Katherine

    2017-09-01

    To identify the incremental costs and consequences of stratified national breast screening programs (stratified NBSPs) and drivers of relative cost-effectiveness. A decision-analytic model (discrete event simulation) was conceptualized to represent four stratified NBSPs (risk 1, risk 2, masking [supplemental screening for women with higher breast density], and masking and risk 1) compared with the current UK NBSP and no screening. The model assumed a lifetime horizon, the health service perspective to identify costs (£, 2015), and measured consequences in quality-adjusted life-years (QALYs). Multiple data sources were used: systematic reviews of effectiveness and utility, published studies reporting costs, and cohort studies embedded in existing NBSPs. Model parameter uncertainty was assessed using probabilistic sensitivity analysis and one-way sensitivity analysis. The base-case analysis, supported by probabilistic sensitivity analysis, suggested that the risk stratified NBSPs (risk 1 and risk-2) were relatively cost-effective when compared with the current UK NBSP, with incremental cost-effectiveness ratios of £16,689 per QALY and £23,924 per QALY, respectively. Stratified NBSP including masking approaches (supplemental screening for women with higher breast density) was not a cost-effective alternative, with incremental cost-effectiveness ratios of £212,947 per QALY (masking) and £75,254 per QALY (risk 1 and masking). When compared with no screening, all stratified NBSPs could be considered cost-effective. Key drivers of cost-effectiveness were discount rate, natural history model parameters, mammographic sensitivity, and biopsy rates for recalled cases. A key assumption was that the risk model used in the stratification process was perfectly calibrated to the population. This early model-based cost-effectiveness analysis provides indicative evidence for decision makers to understand the key drivers of costs and QALYs for exemplar stratified NBSP. Copyright

  19. Stratified turbulent Bunsen flames: flame surface analysis and flame surface density modelling

    Science.gov (United States)

    Ramaekers, W. J. S.; van Oijen, J. A.; de Goey, L. P. H.

    2012-12-01

    In this paper it is investigated whether the Flame Surface Density (FSD) model, developed for turbulent premixed combustion, is also applicable to stratified flames. Direct Numerical Simulations (DNS) of turbulent stratified Bunsen flames have been carried out, using the Flamelet Generated Manifold (FGM) reduction method for reaction kinetics. Before examining the suitability of the FSD model, flame surfaces are characterized in terms of thickness, curvature and stratification. All flames are in the Thin Reaction Zones regime, and the maximum equivalence ratio range covers 0.1⩽φ⩽1.3. For all flames, local flame thicknesses correspond very well to those observed in stretchless, steady premixed flamelets. Extracted curvature radii and mixing length scales are significantly larger than the flame thickness, implying that the stratified flames all burn in a premixed mode. The remaining challenge is accounting for the large variation in (subfilter) mass burning rate. In this contribution, the FSD model is proven to be applicable for Large Eddy Simulations (LES) of stratified flames for the equivalence ratio range 0.1⩽φ⩽1.3. Subfilter mass burning rate variations are taken into account by a subfilter Probability Density Function (PDF) for the mixture fraction, on which the mass burning rate directly depends. A priori analysis point out that for small stratifications (0.4⩽φ⩽1.0), the replacement of the subfilter PDF (obtained from DNS data) by the corresponding Dirac function is appropriate. Integration of the Dirac function with the mass burning rate m=m(φ), can then adequately model the filtered mass burning rate obtained from filtered DNS data. For a larger stratification (0.1⩽φ⩽1.3), and filter widths up to ten flame thicknesses, a β-function for the subfilter PDF yields substantially better predictions than a Dirac function. Finally, inclusion of a simple algebraic model for the FSD resulted only in small additional deviations from DNS data

  20. When Should We Use Care Robots? The Nature-of-Activities Approach

    NARCIS (Netherlands)

    Santoni de Sio, F.; Van Wynsberghe, A.

    2015-01-01

    When should we use care robots? In this paper we endorse the shift from a simple normative approach to care robots ethics to a complex one: we think that one main task of a care robot ethics is that of analysing the different ways in which different care robots may affect the different values at

  1. When Should We Use Care Robots? The Nature-of-Activities Approach

    NARCIS (Netherlands)

    Santoni de Sio, Filippo; van Wynsberghe, Amy Louise

    2016-01-01

    When should we use care robots? In this paper we endorse the shift from a simple normative approach to care robots ethics to a complex one: we think that one main task of a care robot ethics is that of analysing the different ways in which different care robots may affect the different values at

  2. Arts-based and creative approaches to dementia care.

    Science.gov (United States)

    McGreevy, Jessica

    2016-02-01

    This article presents a review of arts-based and creative approaches to dementia care as an alternative to antipsychotic medications. While use of antipsychotics may be appropriate for some people, the literature highlights the success of creative approaches and the benefits of their lack of negative side effects associated with antipsychotics. The focus is the use of biographical approaches, music, dance and movement to improve wellbeing, enhance social networks, support inclusive practice and enable participation. Staff must be trained to use these approaches. A case study is presented to demonstrate how creative approaches can be implemented in practice and the outcomes that can be expected when used appropriately.

  3. Approaches to capturing the financial cost of family care-giving within a palliative care context: a systematic review.

    Science.gov (United States)

    Gardiner, Clare; Brereton, Louise; Frey, Rosemary; Wilkinson-Meyers, Laura; Gott, Merryn

    2016-09-01

    The economic burden faced by family caregivers of people at the end of life is well recognised. Financial burden has a significant impact on the provision of family care-giving in the community setting, but has seen limited research attention. A systematic review with realist review synthesis and thematic analysis was undertaken to identify literature relating to the financial costs and impact of family care-giving at the end of life. This paper reports findings relating to previously developed approaches which capture the financial costs and implications of caring for family members receiving palliative/end-of-life care. Seven electronic databases were searched from inception to April 2012, for original research studies relating to the financial impact of care-giving at the end of life. Studies were independently screened to identify those which met the study inclusion criteria, and the methodological quality of included studies was appraised using realist review criteria of relevance and rigour. A descriptive thematic approach was used to synthesise data. Twelve articles met the inclusion criteria for the review. Various approaches to capturing data on the financial costs of care-giving at the end of life were noted; however, no single tool was identified with the sole purpose of exploring these costs. The majority of approaches used structured questionnaires and were administered by personal interview, with most studies using longitudinal designs. Calculation of costs was most often based on recall by patients and family caregivers, in some studies combined with objective measures of resource use. While the studies in this review provide useful data on approaches to capturing costs of care-giving, more work is needed to develop methods which accurately and sensitively capture the financial costs of caring at the end of life. Methodological considerations include study design and method of administration, contextual and cultural relevance, and accuracy of cost

  4. Fixed-location hydroacoustic monitoring designs for estimating fish passage using stratified random and systematic sampling

    International Nuclear Information System (INIS)

    Skalski, J.R.; Hoffman, A.; Ransom, B.H.; Steig, T.W.

    1993-01-01

    Five alternate sampling designs are compared using 15 d of 24-h continuous hydroacoustic data to identify the most favorable approach to fixed-location hydroacoustic monitoring of salmonid outmigrants. Four alternative aproaches to systematic sampling are compared among themselves and with stratified random sampling (STRS). Stratifying systematic sampling (STSYS) on a daily basis is found to reduce sampling error in multiday monitoring studies. Although sampling precision was predictable with varying levels of effort in STRS, neither magnitude nor direction of change in precision was predictable when effort was varied in systematic sampling (SYS). Furthermore, modifying systematic sampling to include replicated (e.g., nested) sampling (RSYS) is further shown to provide unbiased point and variance estimates as does STRS. Numerous short sampling intervals (e.g., 12 samples of 1-min duration per hour) must be monitored hourly using RSYS to provide efficient, unbiased point and interval estimates. For equal levels of effort, STRS outperformed all variations of SYS examined. Parametric approaches to confidence interval estimates are found to be superior to nonparametric interval estimates (i.e., bootstrap and jackknife) in estimating total fish passage. 10 refs., 1 fig., 8 tabs

  5. Public health approaches to end-of-life care in the UK: an online survey of palliative care services.

    Science.gov (United States)

    Paul, Sally; Sallnow, Libby

    2013-06-01

    The public health approach to end-of-life care has gained recognition over the past decade regarding its contribution to palliative care services. Terms, such as health-promoting palliative care, and compassionate communities, have entered the discourse of palliative care and practice; examples exist in the UK and globally. This scoping study aimed to determine if such initiatives were priorities for hospices in the UK and, if so, provide baseline data on the types of initiatives undertaken. An online survey was designed, piloted and emailed to 220 palliative care providers across the four UK countries. It included a total of six questions. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically. There was a 66% response rate. Of those providers, 60% indicated that public health approaches to death, dying and loss were a current priority for their organisation. Respondents identified a range of work being undertaken currently in this area. The most successful were felt to be working with schools and working directly with local community groups. The findings demonstrate the relevance of a public health approach for palliative care services and how they are currently engaging with the communities they serve. Although the approach was endorsed by the majority of respondents, various challenges were highlighted. These related to the need to balance this against service provision, and the need for more training and resources to support these initiatives, at both national and community levels.

  6. Estimation of Finite Population Mean in Multivariate Stratified Sampling under Cost Function Using Goal Programming

    Directory of Open Access Journals (Sweden)

    Atta Ullah

    2014-01-01

    Full Text Available In practical utilization of stratified random sampling scheme, the investigator meets a problem to select a sample that maximizes the precision of a finite population mean under cost constraint. An allocation of sample size becomes complicated when more than one characteristic is observed from each selected unit in a sample. In many real life situations, a linear cost function of a sample size nh is not a good approximation to actual cost of sample survey when traveling cost between selected units in a stratum is significant. In this paper, sample allocation problem in multivariate stratified random sampling with proposed cost function is formulated in integer nonlinear multiobjective mathematical programming. A solution procedure is proposed using extended lexicographic goal programming approach. A numerical example is presented to illustrate the computational details and to compare the efficiency of proposed compromise allocation.

  7. A community based interventional approach to intranatal And neonatal health care

    Directory of Open Access Journals (Sweden)

    Bhupendra Tripathi

    2003-12-01

    Full Text Available Objective : To assess the contribution of the interventions through the local change agent (Bal Parivar Mitra towards achievement of health awareness among rural women regarding maternal child health through improvement and change in health practices. Study design: Stratified multistage random sampling technique. Study unit : Within the selected households lactating mothers were selected as study units. Study area : The study was conducted in Jasra and Saidabad blocks of Allahabad district wherein MCHN Project is going on since July 2000. Study variable : Maternal care. Intervention, Impact. Statistical analysis : Ztesl for testing significance of differences between two proportions (Z - test. Results: Deliveries assisted by trained persons increased from 22.4%to 36.7%. Follow-up of'5-cleans’ during pregnancy was among 43.3%. Birth registration increased from 19.2% in baseline to 35%. feeding of colostrum from 27,4% to 40.0%. Breastfeeding within half an hour after birth was among 23.3% followed by 16.7% within 1/2-12 hours. Proper warmth was given to 68.3% newborns and 58.3% babies were bathed after one day of birth. Conclusions : The suggested intervention package through BPM seems to be a sustainable effort and several parameters of intranatal and neonatal health care arc expected to be attained as long-term achievements.

  8. Thermal stratification built up in hot water tank with different inlet stratifiers

    DEFF Research Database (Denmark)

    Dragsted, Janne; Furbo, Simon; Dannemand, Mark

    2017-01-01

    Thermal stratification in a water storage tank can strongly increase the thermal performance of solar heating systems. Thermal stratification can be built up in a storage tank during charge, if the heated water enters through an inlet stratifier. Experiments with a test tank have been carried out...... in order to elucidate how well thermal stratification is established in the tank with differently designed inlet stratifiers under different controlled laboratory conditions. The investigated inlet stratifiers are from Solvis GmbH & Co KG and EyeCular Technologies ApS. The inlet stratifier from Solvis Gmb...... for Solvis GmbH & Co KG had a better performance at 4 l/min. In the intermediate charge test the stratifier from EyeCular Technologies ApS had a better performance in terms of maintaining the thermal stratification in the storage tank while charging with a relative low temperature. [All rights reserved...

  9. Investigating the "inverse care law" in dental care: A comparative analysis of Canadian jurisdictions.

    Science.gov (United States)

    Dehmoobadsharifabadi, Armita; Singhal, Sonica; Quiñonez, Carlos

    2017-03-01

    To compare physician and dentist visits nationally and at the provincial/territorial level and to assess the extent of the "inverse care law" in dental care among different age groups in the same way. Publicly available data from the 2007 to 2008 Canadian Community Health Survey were utilized to investigate physician and dentist visits in the past 12 months in relation to self-perceived general and oral health by performing descriptive statistics and binary logistic regression, controlling for age, sex, education, income, and physician/dentist population ratios. Analysis was conducted for all participants and stratified by age groups - children (12-17 years), adults (18-64 years) and seniors (65 years and over). Nationally and provincially/territorially, it appears that the "inverse care law" persists for dental care but is not present for physician care. Specifically, when comparing to those with excellent general/oral health, individuals with poor general health were 2.71 (95% confidence interval [CI]: 2.70-2.72) times more likely to visit physicians, and individuals with poor oral health were 2.16 (95% CI: 2.16-2.17) times less likely to visit dentists. Stratified analyses by age showed more variability in the extent of the "inverse care law" in children and seniors compared to adults. The "inverse care law" in dental care exists both nationally and provincially/territorially among different age groups. Given this, it is important to assess the government's role in improving access to, and utilization of, dental care in Canada.

  10. Large eddy simulation of turbulent and stably-stratified flows

    International Nuclear Information System (INIS)

    Fallon, Benoit

    1994-01-01

    The unsteady turbulent flow over a backward-facing step is studied by mean of Large Eddy Simulations with structure function sub grid model, both in isothermal and stably-stratified configurations. Without stratification, the flow develops highly-distorted Kelvin-Helmholtz billows, undergoing to helical pairing, with A-shaped vortices shed downstream. We show that forcing injected by recirculation fluctuations governs this oblique mode instabilities development. The statistical results show good agreements with the experimental measurements. For stably-stratified configurations, the flow remains more bi-dimensional. We show with increasing stratification, how the shear layer growth is frozen by inhibition of pairing process then of Kelvin-Helmholtz instabilities, and the development of gravity waves or stable density interfaces. Eddy structures of the flow present striking analogies with the stratified mixing layer. Additional computations show the development of secondary Kelvin-Helmholtz instabilities on the vorticity layers between two primary structures. This important mechanism based on baroclinic effects (horizontal density gradients) constitutes an additional part of the turbulent mixing process. Finally, the feasibility of Large Eddy Simulation is demonstrated for industrial flows, by studying a complex stratified cavity. Temperature fluctuations are compared to experimental measurements. We also develop three-dimensional un-stationary animations, in order to understand and visualize turbulent interactions. (author) [fr

  11. Transition of Gas-Liquid Stratified Flow in Oil Transport Pipes

    Directory of Open Access Journals (Sweden)

    D. Lakehal

    2011-12-01

    Full Text Available Large-Scale Simulation results of the transition of a gas-liquid stratified flow to slug flow regime in circular 3D oil transport pipes under turbulent flow conditions expressed. Free surface flow in the pipe is treated using the Level Set method. Turbulence is approached via the LES and VLES methodologies extended to interfacial two-phase flows. It is shown that only with the Level Set method the flow transition can be accurately predicted, better than with the two-fluid phase-average model. The transition from stratified to slug flow is found to be subsequent to the merging of the secondary wave modes created by the action of gas shear (short waves with the first wave mode (high amplitude long wave. The model is capable of predicting global flow features like the onset of slugging and slug speed. In the second test case, the model predicts different kinds of slugs, the so-called operating slugs formed upstream that fill entirely the pipe with water slugs of length scales of the order of 2-4 D, and lower size (1-1.5 D disturbance slugs, featuring lower hold-up (0.8-0.9. The model predicts well the frequency of slugs. The simulations revealed important parameter effects on the results, such as two-dimensionality, pipe length, and water holdup.

  12. Closing the Health Care Gap in Communities: A Safety Net System Approach.

    Science.gov (United States)

    Gabow, Patricia A

    2016-10-01

    The goal of U.S. health care should be good health for every American. This daunting goal will require closing the health care gap in communities with a particular focus on the most vulnerable populations and the safety net institutions that disproportionately serve these communities. This Commentary describes Denver Health's (DH's) two-pronged approach to achieving this goal: (1) creating an integrated system that focuses on the needs of vulnerable populations, and (2) creating an approach for financial viability, quality of care, and employee engagement. The implementation and outcomes of this approach at DH are described to provide a replicable model. An integrated delivery system serving vulnerable populations should go beyond the traditional components found in most integrated health systems and include components such as mental health services, school-based clinics, and correctional health care, which address the unique and important needs of, and points of access for, vulnerable populations. In addition, the demands that a safety net system experiences from an open-door policy on access and revenue require a disciplined approach to cost, quality of care, and employee engagement. For this, DH chose Lean, which focuses on reducing waste to respect the patients and employees within its health system, as well as all citizens. DH's Lean effort produced almost $195 million of financial benefit, impressive clinical outcomes, and high employee engagement. If this two-pronged approach were widely adopted, health systems across the United States would improve their chances of giving better care at costs they can afford for every person in society.

  13. Child and Youth Care Approaches to Management

    Science.gov (United States)

    Gharabaghi, Kiaras

    2008-01-01

    This article explores the themes and issues related to child and youth care approaches to management. The profession is significantly underrepresented at the management level. To some extent, this reflects the challenges of being recognized in the broader human services sector as a profession, but perhaps more so, it reflects an underdevelopment…

  14. Monitoring and identification of spatiotemporal landscape changes in multiple remote sensing images by using a stratified conditional Latin hypercube sampling approach and geostatistical simulation.

    Science.gov (United States)

    Lin, Yu-Pin; Chu, Hone-Jay; Huang, Yu-Long; Tang, Chia-Hsi; Rouhani, Shahrokh

    2011-06-01

    This study develops a stratified conditional Latin hypercube sampling (scLHS) approach for multiple, remotely sensed, normalized difference vegetation index (NDVI) images. The objective is to sample, monitor, and delineate spatiotemporal landscape changes, including spatial heterogeneity and variability, in a given area. The scLHS approach, which is based on the variance quadtree technique (VQT) and the conditional Latin hypercube sampling (cLHS) method, selects samples in order to delineate landscape changes from multiple NDVI images. The images are then mapped for calibration and validation by using sequential Gaussian simulation (SGS) with the scLHS selected samples. Spatial statistical results indicate that in terms of their statistical distribution, spatial distribution, and spatial variation, the statistics and variograms of the scLHS samples resemble those of multiple NDVI images more closely than those of cLHS and VQT samples. Moreover, the accuracy of simulated NDVI images based on SGS with scLHS samples is significantly better than that of simulated NDVI images based on SGS with cLHS samples and VQT samples, respectively. However, the proposed approach efficiently monitors the spatial characteristics of landscape changes, including the statistics, spatial variability, and heterogeneity of NDVI images. In addition, SGS with the scLHS samples effectively reproduces spatial patterns and landscape changes in multiple NDVI images.

  15. Numerical simulation of stratified flows with different k-ε turbulence models

    International Nuclear Information System (INIS)

    Dagestad, S.

    1991-01-01

    The thesis comprises the numerical simulation of stratified flows with different k-ε models. When using the k-ε model, two equations are solved to describe the turbulence. The k-equation represents the turbulent kinetic energy of the turbulence and the ε-equation is the turbulent dissipation. Different k-ε models predict stratified flows differently. The standard k-ε model leads to higher turbulent mixing than the low-Reynolds model does. For lower Froude numbers, F 0 , this effect becomes enhanced. Buoyancy extension of the k-ε model also leads to less vertical mixing in cases with strong stratification. When the stratification increases, buoyancy-extension becomes larger influence. The turbulent Prandtl number effects have large impact on the transport of heat and the development of the flow. Two different formulae which express the turbulent Prandtl effects have been tested. For unstably stratified flows, the rapid mixing and three-dimensionality of the flow can in fact be computed using a k-ε model when buoyancy-extended is employed. The turbulent heat transfer and thus turbulent production in unstable stratified flows depends strongly upon the turbulent Prandtl number effect. The main conclusions are: Stable stratified flows should be computed with a buoyancy-extended low-Reynolds k-ε model; Unstable stratified flows should be computed with a buoyancy-extended standard k-ε model; The turbulent Prandtl number effects should be included in the computations; Buoyancy-extension has lead to more correct description of the physics for all of the investigated flows. 78 refs., 128 figs., 17 tabs

  16. Stratified prevention: opportunities and limitations. Report on the 1st interdisciplinary cardiovascular workshop in Augsburg.

    Science.gov (United States)

    Kirchhof, Gregor; Lindner, Josef Franz; Achenbach, Stephan; Berger, Klaus; Blankenberg, Stefan; Fangerau, Heiner; Gimpel, Henner; Gassner, Ulrich M; Kersten, Jens; Magnus, Dorothea; Rebscher, Herbert; Schunkert, Heribert; Rixen, Stephan; Kirchhof, Paulus

    2018-03-01

    Sufficient exercise and sleep, a balanced diet, moderate alcohol consumption and a good approach to handle stress have been known as lifestyles that protect health and longevity since the Middle Age. This traditional prevention quintet, turned into a sextet by smoking cessation, has been the basis of the "preventive personality" that formed in the twentieth century. Recent analyses of big data sets including genomic and physiological measurements have unleashed novel opportunities to estimate individual health risks with unprecedented accuracy, allowing to target preventive interventions to persons at high risk and at the same time to spare those in whom preventive measures may not be needed or even be harmful. To fully grasp these opportunities for modern preventive medicine, the established healthy life styles require supplementation by stratified prevention. The opportunities of these developments for life and health contrast with justified concerns: A "surveillance society", able to predict individual behaviour based on big data, threatens individual freedom and jeopardises equality. Social insurance law and the new German Disease Prevention Act (Präventionsgesetz) rightly stress the need for research to underpin stratified prevention which is accessible to all, ethical, effective, and evidence based. An ethical and acceptable development of stratified prevention needs to start with autonomous individuals who control and understand all information pertaining to their health. This creates a mandate for lifelong health education, enabled in an individualised form by digital technology. Stratified prevention furthermore requires the evidence-based development of a new taxonomy of cardiovascular diseases that reflects disease mechanisms. Such interdisciplinary research needs broad support from society and a better use of biosamples and data sets within an updated research governance framework.

  17. Resident challenges with daily life in Chinese long-term care facilities: A qualitative pilot study.

    Science.gov (United States)

    Song, Yuting; Scales, Kezia; Anderson, Ruth A; Wu, Bei; Corazzini, Kirsten N

    As traditional family-based care in China declines, the demand for residential care increases. Knowledge of residents' experiences with long-term care (LTC) facilities is essential to improving quality of care. This pilot study aimed to describe residents' experiences in LTC facilities, particularly as it related to physical function. Semi-structured open-ended interviews were conducted in two facilities with residents stratified by three functional levels (n = 5). Directed content analysis was guided by the Adaptive Leadership Framework. A two-cycle coding approach was used with a first-cycle descriptive coding and second-cycle dramaturgical coding. Interviews provided examples of challenges faced by residents in meeting their daily care needs. Five themes emerged: staff care, care from family members, physical environment, other residents in the facility, and personal strategies. Findings demonstrate the significance of organizational context for care quality and reveal foci for future research. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. China's community-based strategy of universal preconception care in rural areas at a population level using a novel risk classification system for stratifying couples´ preconception health status.

    Science.gov (United States)

    Zhou, Qiongjie; Zhang, Shikun; Wang, Qiaomei; Shen, Haiping; Tian, Weidong; Chen, Jingqi; Acharya, Ganesh; Li, Xiaotian

    2016-12-28

    Preconception care (PCC) is recommended for optimizing a woman's health prior to pregnancy to minimize the risk of adverse pregnancy and birth outcomes. We aimed to evaluate the impact of strategy and a novel risk classification model of China´s "National Preconception Health Care Project" (NPHCP) in identifying risk factors and stratifying couples' preconception health status. We performed a secondary analysis of data collected by NPHCP during April 2010 to December 2012 in 220 selected counties in China. All couples enrolled in the project accepted free preconception health examination, risk evaluation, health education and medical advice. Risk factors were categorized into five preconception risk classes based on their amenability to prevention and treatment: A-avoidable risk factors, B- benefiting from targeted medical intervention, C-controllable but requiring close monitoring and treatment during pregnancy, D-diagnosable prenatally but not modifiable preconceptionally, X-pregnancy not advisable. Information on each couple´s socio-demographic and health status was recorded and further analyzed. Among the 2,142,849 couples who were enrolled to this study, the majority (92.36%) were from rural areas with low education levels (89.2% women and 88.3% men had education below university level). A total of 1463266 (68.29%) couples had one or more preconception risk factors mainly of category A, B and C, among which 46.25% were women and 51.92% were men. Category A risk factors were more common among men compared with women (38.13% versus 11.24%; P = 0.000). This project provided new insights into preconception health of Chinese couples of reproductive age. More than half of the male partners planning to father a child, were exposed to risk factors during the preconception period, suggesting that an integrated approach to PCC including both women and men is justified. Stratification based on the new risk classification model demonstrated that a majority of the

  19. Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic.

    Science.gov (United States)

    Tapp, Hazel; Phillips, Shay E; Waxman, Dael; Alexander, Matthew; Brown, Rhett; Hall, Mary

    2012-01-01

    Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

  20. MC3D modelling of stratified explosion

    International Nuclear Information System (INIS)

    Picchi, S.; Berthoud, G.

    1999-01-01

    It is known that a steam explosion can occur in a stratified geometry and that the observed yields are lower than in the case of explosion in a premixture configuration. However, very few models are available to quantify the amount of melt which can be involved and the pressure peak that can be developed. In the stratified application of the MC3D code, mixing and fragmentation of the melt are explained by the growth of Kelvin Helmholtz instabilities due to the shear flow of the two phase coolant above the melt. Such a model is then used to recalculate the Frost-Ciccarelli tin-water experiment. Pressure peak, speed of propagation, bubble shape and erosion height are well reproduced as well as the influence of the inertial constraint (height of the water pool). (author)

  1. MC3D modelling of stratified explosion

    Energy Technology Data Exchange (ETDEWEB)

    Picchi, S.; Berthoud, G. [DTP/SMTH/LM2, CEA, 38 - Grenoble (France)

    1999-07-01

    It is known that a steam explosion can occur in a stratified geometry and that the observed yields are lower than in the case of explosion in a premixture configuration. However, very few models are available to quantify the amount of melt which can be involved and the pressure peak that can be developed. In the stratified application of the MC3D code, mixing and fragmentation of the melt are explained by the growth of Kelvin Helmholtz instabilities due to the shear flow of the two phase coolant above the melt. Such a model is then used to recalculate the Frost-Ciccarelli tin-water experiment. Pressure peak, speed of propagation, bubble shape and erosion height are well reproduced as well as the influence of the inertial constraint (height of the water pool). (author)

  2. The effect of existing turbulence on stratified shear instability

    Science.gov (United States)

    Kaminski, Alexis; Smyth, William

    2017-11-01

    Ocean turbulence is an essential process governing, for example, heat uptake by the ocean. In the stably-stratified ocean interior, this turbulence occurs in discrete events driven by vertical variations of the horizontal velocity. Typically, these events have been modelled by assuming an initially laminar stratified shear flow which develops wavelike instabilities, becomes fully turbulent, and then relaminarizes into a stable state. However, in the real ocean there is always some level of turbulence left over from previous events, and it is not yet understood how this turbulence impacts the evolution of future mixing events. Here, we perform a series of direct numerical simulations of turbulent events developing in stratified shear flows that are already at least weakly turbulent. We do so by varying the amplitude of the initial perturbations, and examine the subsequent development of the instability and the impact on the resulting turbulent fluxes. This work is supported by NSF Grant OCE1537173.

  3. Stratified source-sampling techniques for Monte Carlo eigenvalue analysis

    International Nuclear Information System (INIS)

    Mohamed, A.

    1998-01-01

    In 1995, at a conference on criticality safety, a special session was devoted to the Monte Carlo ''Eigenvalue of the World'' problem. Argonne presented a paper, at that session, in which the anomalies originally observed in that problem were reproduced in a much simplified model-problem configuration, and removed by a version of stratified source-sampling. In this paper, stratified source-sampling techniques are generalized and applied to three different Eigenvalue of the World configurations which take into account real-world statistical noise sources not included in the model problem, but which differ in the amount of neutronic coupling among the constituents of each configuration. It is concluded that, in Monte Carlo eigenvalue analysis of loosely-coupled arrays, the use of stratified source-sampling reduces the probability of encountering an anomalous result over that if conventional source-sampling methods are used. However, this gain in reliability is substantially less than that observed in the model-problem results

  4. Understanding care in the past to develop caring science of the future: a historical methodological approach.

    Science.gov (United States)

    Nyborg, Vibeke N; Hvalvik, Sigrun; McCormack, Brendan

    2018-05-31

    In this paper, we explore how the development of historical research methodologies during the last centuries can contribute to more diverse and interdisciplinary research in future caring science, especially towards a care focus that is more person-centred. The adding of a historical approach by professional historians to the theory of person-centredness and person-centred care can develop knowledge that enables a more holistic understanding of the patient and the development of the patient perspective from the past until today. Thus, the aim was to show how developments within historical methodology can help us to understand elements of care in the past to further develop caring science in future. Historical research methodologies have advocated a "history from below" perspective, and this has enabled the evolution of systematic approaches to historical research that can be explored and critically analysed. Linked with this, the development of a more social and cultural oriented understanding of historical research has enabled historians to explore and add knowledge from a broader societal perspective. By focusing on the life of ordinary people and taking social and cultural aspects into account when trying to reconstruct the past, we can get a deeper understanding of health, care and medical development. However, an interdisciplinary research focus on person-centredness and person-centred care that includes professional historians can be challenging. In this paper, we argue that a historical perspective is necessary to meet the challenges we face in future delivery of health care to all people, in all parts of society in an ever more global world. © 2018 Nordic College of Caring Science.

  5. Turbulent circulation above the surface heat source in a stably stratified environment

    Science.gov (United States)

    Kurbatskii, A. F.; Kurbatskaya, L. I.

    2016-09-01

    The results of the numerical modeling of turbulent structure of the penetrating convection above the urban heat island with a small aspect ratio in a stably stratified medium at rest are presented. The gradient diffusion representations for turbulent momentum and heat fluxes are used, which depend on three parameters — the turbulence kinetic energy, the velocity of its spectral expenditure, and the dispersion of temperature fluctuations. These parameters are found from the closed differential equations of balance in the RANS approach of turbulence description. The distributions of averaged velocity and temperature fields as well as turbulent characteristics agree well with measurement data.

  6. Exploring the concept of a team approach to wound care: Managing wounds as a team.

    Science.gov (United States)

    Moore, Zena; Butcher, Gillian; Corbett, Lisa Q; McGuiness, William; Snyder, Robert J; van Acker, Kristien

    2014-05-01

    Background - The growing prevalence and incidence of nonhealing acute and chronic wounds is a worrying concern. A major challenge is the lack of united services aimed at addressing the complex needs of individuals with wounds. However, the WHO argues that interprofessional collaboration in education and practice is key to providing the best patient care, enhancing clinical and health-related outcomes and strengthening the health system. It is based on this background that the team approach to wound care project was conceptualised. The project was jointly initiated and realised by the Association for the Advancement of Wound Care (AAWC-USA), the Australian Wound Management Association (AWMA) and the European Wound Management Association (EWMA). Aim - The aim of this project was to develop a universal model for the adoption of a team approach to wound care. Objective The overarching objective of this project was to provide recommendations for implementing a team approach to wound care within all clinical settings and through this to develop a model for advocating the team approach toward decision makers in national government levels. Method An integrative literature review was conducted. Using this knowledge, the authors arrived at a consensus on the most appropriate model to adopt and realise a team approach to wound care. Results - Eighty four articles met the inclusion criteria. Following data extraction, it was evident that none of the articles provided a definition for the terms multidisciplinary, interdisciplinary or transdisciplinary in the context of wound care. Given this lack of clarity within the wound care literature, the authors have here developed a Universal Model for the Team Approach to Wound Care to fill this gap in our current understanding. Conclusion - We advocate that the patient should be at the heart of all decision-making, as working with the Universal Model for the Team Approach to Wound Care begins with the needs of the patient. To

  7. Keeping all options open: Parents' approaches to advance care planning.

    Science.gov (United States)

    Beecham, Emma; Oostendorp, Linda; Crocker, Joanna; Kelly, Paula; Dinsdale, Andrew; Hemsley, June; Russell, Jessica; Jones, Louise; Bluebond-Langner, Myra

    2017-08-01

    Early engagement in advance care planning (ACP) is seen as fundamental for ensuring the highest standard of care for children and young people with a life-limiting condition (LLC). However, most families have little knowledge or experience of ACP. To investigate how parents of children and young people with LLCs approach and experience ACP. Open-ended, semi-structured interviews were conducted with parents of 18 children; nine children who were currently receiving palliative care services, and nine children who had received palliative care and died. Verbatim transcripts of audiotaped interviews were analysed following principles of grounded theory while acknowledging the use of deductive strategies, taking account of both the child's condition, and the timing and nature of decisions made. Parents reported having discussions and making decisions about the place of care, place of death and the limitation of treatment. Most decisions were made relatively late in the illness and by parents who wished to keep their options open. Parents reported different levels of involvement in a range of decisions; many wished to be involved in decision making but did not always feel able to do so. This study highlights that parents' approaches to decision making vary by the type of decision required. Their views may change over time, and it is important to allow them to keep their options open. We recommend that clinicians have regular discussions over the course of the illness in an effort to understand parents' approaches to particular decisions rather than to drive to closure prematurely. © 2016 The Authors Health Expectations Published by John Wiley & Sons Ltd.

  8. Visualization of mole fraction distribution of slow jet forming stably stratified field

    International Nuclear Information System (INIS)

    Fumizawa, Motoo; Hishida, Makoto

    1990-01-01

    An experimental study has been performed to investigate the behavior of flow and mass transfer in gaseous slow jet in which buoyancy force opposed the flow forming stably stratified field. The study has been performed to understand the basic features of air ingress phenomena at pipe rupture accident of the high temperature gas-cooled reactor. A displacement fringe technique was adopted in Mach-Zehnder interferometer to visualize the mole fraction distribution. As the result, the followings were obtained: (1) The stably stratified fields were formed in the vicinity of the outlet of the slow jet. The penetration distance of the stably stratified fields increased with Froude number. (2) Mass fraction distributions in the stably stratified fields were well correlated with the present model using the ramp mole velocity profile. (author)

  9. A comprehensive approach to quality management of intensive care services.

    Science.gov (United States)

    Hariharan, Seetharaman; Dey, Prasanta Kumar

    2010-01-01

    The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. The paper focuses on a uniform model that can be applied to most intensive care units.

  10. Simulation of steam explosion in stratified melt-coolant configuration

    International Nuclear Information System (INIS)

    Leskovar, Matjaž; Centrih, Vasilij; Uršič, Mitja

    2016-01-01

    Highlights: • Strong steam explosions may develop spontaneously in stratified configurations. • Considerable melt-coolant premixed layer formed in subcooled water with hot melts. • Analysis with MC3D code provided insight into stratified steam explosion phenomenon. • Up to 25% of poured melt was mixed with water and available for steam explosion. • Better instrumented experiments needed to determine dominant mixing process. - Abstract: A steam explosion is an energetic fuel coolant interaction process, which may occur during a severe reactor accident when the molten core comes into contact with the coolant water. In nuclear reactor safety analyses steam explosions are primarily considered in melt jet-coolant pool configurations where sufficiently deep coolant pool conditions provide complete jet breakup and efficient premixture formation. Stratified melt-coolant configurations, i.e. a molten melt layer below a coolant layer, were up to now believed as being unable to generate strong explosive interactions. Based on the hypothesis that there are no interfacial instabilities in a stratified configuration it was assumed that the amount of melt in the premixture is insufficient to produce strong explosions. However, the recently performed experiments in the PULiMS and SES (KTH, Sweden) facilities with oxidic corium simulants revealed that strong steam explosions may develop spontaneously also in stratified melt-coolant configurations, where with high temperature melts and subcooled water conditions a considerable melt-coolant premixed layer is formed. In the article, the performed study of steam explosions in a stratified melt-coolant configuration in PULiMS like conditions is presented. The goal of this analytical work is to supplement the experimental activities within the PULiMS research program by addressing the key questions, especially regarding the explosivity of the formed premixed layer and the mechanisms responsible for the melt-water mixing. To

  11. A three musketeering approach to pastoral care: Reflections on collaboration between pastoral care, narrative therapy and positive psychology

    Directory of Open Access Journals (Sweden)

    Alfred R. Brunsdon

    2014-01-01

    Full Text Available In the current times of change, deconstruction and ever-growing relativisation, pastoral praxis finds itself in methodological limbo. Pastoral practitioners currently face the challenge of effectively reaching postmodern people through the pastoral process. This challenge is intensified by the innate tension between revelation and experience in pastoral theology as well as the philosophical migration from modernism to postmodernism, which necessitates an on-going rethinking of pastoral praxis. This research investigates a collaborative approach between pastoral care, narrative therapy and positive psychology as a possible method for dispensing pastoral care. A broad outline of these approaches as well as their underlying philosophical frameworks is contemplated in order to evaluate their suitability for a pastoral collaboration. Markers for a collaborative model are suggested where the narrative and positive psychology are employed as strategies in a so-called three- musketeering approach to pastoral care.

  12. Condensation heat transfer coefficient in horizontal stratified cocurrent flow of steam and cold water

    International Nuclear Information System (INIS)

    Kim, Kap; Kim, Hho Jung

    1986-01-01

    Some studies on direct-contact condensation in cocurrent stratified flow of steam and subcooled water were reviewed. Several approaches have been performed to develop the condensation heat transfer coefficient relationship. The local Nusselt number is correlated in terms of the local water Reynolds and Prandtl numbers as well as the steam Froude number. In addition, a turbulence-centered model, developed principally for gas absorption in several geometries, is modified by using calculated interfacial parameters for the turbulent velocity and length scales. These approaches result in a fairly good agreement with the data, whereas, the turbulence-centered model is here recommended since it is based on the turbulent properties which may be closely related to the condensation phenomena. (Author)

  13. A novel approach for evaluating the risk of health care failure modes.

    Science.gov (United States)

    Chang, Dong Shang; Chung, Jenq Hann; Sun, Kuo Lung; Yang, Fu Chiang

    2012-12-01

    Failure mode and effects analysis (FMEA) can be employed to reduce medical errors by identifying the risk ranking of the health care failure modes and taking priority action for safety improvement. The purpose of this paper is to propose a novel approach of data analysis. The approach is to integrate FMEA and a mathematical tool-Data envelopment analysis (DEA) with "slack-based measure" (SBM), in the field of data analysis. The risk indexes (severity, occurrence, and detection) of FMEA are viewed as multiple inputs of DEA. The practicality and usefulness of the proposed approach is illustrated by one case of health care. Being a systematic approach for improving the service quality of health care, the approach can offer quantitative corrective information of risk indexes that thereafter reduce failure possibility. For safety improvement, these new targets of the risk indexes could be used for management by objectives. But FMEA cannot provide quantitative corrective information of risk indexes. The novel approach can surely overcome this chief shortcoming of FMEA. After combining DEA SBM model with FMEA, the two goals-increase of patient safety, medical cost reduction-can be together achieved.

  14. A diagnostic approach to understanding entrepreneurship in health care.

    Science.gov (United States)

    McCleary, Karl J; Rivers, Patrick A; Schneller, Eugene S

    2006-01-01

    Health care is quite different from other industries because of its organizational structure, service delivery, and financing of health services. Balancing costs, quality, and access presents unique challenges for each stakeholder group committed to promoting the health and healing of its citizens. Using the diagnostic approach to health care entrepreneurship, we created a framework from research in the field to understand the predisposing, enabling, and reinforcing factors most relevant to successful entrepreneurship.

  15. Advanced stratified charge rotary aircraft engine design study

    Science.gov (United States)

    Badgley, P.; Berkowitz, M.; Jones, C.; Myers, D.; Norwood, E.; Pratt, W. B.; Ellis, D. R.; Huggins, G.; Mueller, A.; Hembrey, J. H.

    1982-01-01

    A technology base of new developments which offered potential benefits to a general aviation engine was compiled and ranked. Using design approaches selected from the ranked list, conceptual design studies were performed of an advanced and a highly advanced engine sized to provide 186/250 shaft Kw/HP under cruise conditions at 7620/25,000 m/ft altitude. These are turbocharged, direct-injected stratified charge engines intended for commercial introduction in the early 1990's. The engine descriptive data includes tables, curves, and drawings depicting configuration, performance, weights and sizes, heat rejection, ignition and fuel injection system descriptions, maintenance requirements, and scaling data for varying power. An engine-airframe integration study of the resulting engines in advanced airframes was performed on a comparative basis with current production type engines. The results show airplane performance, costs, noise & installation factors. The rotary-engined airplanes display substantial improvements over the baseline, including 30 to 35% lower fuel usage.

  16. Staff satisfaction and its components in residential aged care.

    Science.gov (United States)

    Chou, Shu-Chiung; Boldy, Duncan P; Lee, Andy H

    2002-06-01

    The purpose of this study was to assess the direction and magnitude of the effects among the components of staff satisfaction in residential aged care and to examine whether the relationships among satisfaction components vary according to facility type (i.e. nursing homes and hostels). A hostel is a low care facility in which residents are more independent, have a lower level of care needs, and receive personal but not nursing care. A cross-sectional survey design was adopted to collect the required information, and a stratified random sampling approach was utilized to select facilities. Structural equation modeling was used to examine relationships among satisfaction components. Seventy residential aged care facilities in Western Australia. The sample includes 610 nursing home and 373 hostel care staff. The relationships among satisfaction components are different for nursing home and hostel staff. Professional support is found to have a strong and positive effect on all other aspects of staff satisfaction. The findings lead to an improved understanding of the interrelationship among staff satisfaction components, which has important implications through enhancing professional support. This needs to be recognized and emphasized by managers, care providers, and policy makers so as to maintain stable personnel and continuity of care.

  17. Soil mixing of stratified contaminated sands.

    Science.gov (United States)

    Al-Tabba, A; Ayotamuno, M J; Martin, R J

    2000-02-01

    Validation of soil mixing for the treatment of contaminated ground is needed in a wide range of site conditions to widen the application of the technology and to understand the mechanisms involved. Since very limited work has been carried out in heterogeneous ground conditions, this paper investigates the effectiveness of soil mixing in stratified sands using laboratory-scale augers. This enabled a low cost investigation of factors such as grout type and form, auger design, installation procedure, mixing mode, curing period, thickness of soil layers and natural moisture content on the unconfined compressive strength, leachability and leachate pH of the soil-grout mixes. The results showed that the auger design plays a very important part in the mixing process in heterogeneous sands. The variability of the properties measured in the stratified soils and the measurable variations caused by the various factors considered, highlighted the importance of duplicating appropriate in situ conditions, the usefulness of laboratory-scale modelling of in situ conditions and the importance of modelling soil and contaminant heterogeneities at the treatability study stage.

  18. Stratified charge rotary aircraft engine technology enablement program

    Science.gov (United States)

    Badgley, P. R.; Irion, C. E.; Myers, D. M.

    1985-01-01

    The multifuel stratified charge rotary engine is discussed. A single rotor, 0.7L/40 cu in displacement, research rig engine was tested. The research rig engine was designed for operation at high speeds and pressures, combustion chamber peak pressure providing margin for speed and load excursions above the design requirement for a high is advanced aircraft engine. It is indicated that the single rotor research rig engine is capable of meeting the established design requirements of 120 kW, 8,000 RPM, 1,379 KPA BMEP. The research rig engine, when fully developed, will be a valuable tool for investigating, advanced and highly advanced technology components, and provide an understanding of the stratified charge rotary engine combustion process.

  19. Transformational leadership in primary care: Clinicians' patterned approaches to care predict patient satisfaction and health expectations.

    Science.gov (United States)

    Huynh, Ho Phi; Sweeny, Kate; Miller, Tricia

    2018-04-01

    Clinicians face the complex challenge of motivating their patients to achieve optimal health while also ensuring their satisfaction. Inspired by transformational leadership theory, we proposed that clinicians' motivational behaviors can be organized into three patient care styles (transformational, transactional, and passive-avoidant) and that these styles differentially predict patient health outcomes. In two studies using patient-reported data and observer ratings, we found that transformational patient care style positively predicted patients' satisfaction and health expectations above and beyond transactional and passive-avoidant patient care style. These findings provide initial support for the patient care style approach and suggest novel directions for the study of clinicians' motivational behaviors.

  20. Forensic nursing and the palliative approach to care: an empirical nursing ethics analysis.

    Science.gov (United States)

    Wright, David Kenneth; Vanderspank-Wright, Brandi; Holmes, Dave; Skinner, Elise

    2017-08-02

    A movement is underway to promote a palliative approach to care in all contexts where people age and live with life-limiting conditions, including psychiatric settings. Forensic psychiatry nursing-a subfield of mental health nursing- focuses on individuals who are in conflict with the criminal justice system. We know little about the values of nurses working in forensic psychiatry, and how these values might influence a palliative approach to care for frail and aging patients. Interviews with four nurses working on one of two forensic units of a university-affiliated mental health hospital in an urban area of eastern Canada. Three specific values were found to guide forensic nurses in their care of aging patients that are commensurate with a palliative approach: hope, inclusivity, and quality of life. When we started this project, we wondered whether the culture of forensic nursing practice was antithetical to the values of a palliative approach. Instead, we found several parallels between forensic nurses' moral identities and palliative philosophy. These findings have implications for how we think about the palliative approach in contexts not typically associated with palliative care, but in which patients will increasingly age and die.

  1. A review of recent developments on turbulent entrainment in stratified flows

    International Nuclear Information System (INIS)

    Cotel, Aline J

    2010-01-01

    Stratified interfaces are present in many geophysical flow situations, and transport across such an interface is an essential factor for correctly evaluating the physical processes taking place at many spatial and temporal scales in such flows. In order to accurately evaluate vertical and lateral transport occurring when a turbulent flow impinges on a stratified interface, the turbulent entrainment and vorticity generation mechanisms near the interface must be understood and quantified. Laboratory experiments were performed for three flow configurations: a vertical thermal, a sloping gravity current and a vertical turbulent jet with various tilt angles and precession speeds. All three flows impinged on an interface separating a two-layer stably stratified environment. The entrainment rate is quantified for each flow using laser-induced fluorescence and compared to predictions of Cotel and Breidenthal (1997 Appl. Sci. Res. 57 349-66). The possible applications of transport across stratified interfaces include the contribution of hydrothermal plumes to the global ocean energy budget, turbidity currents on the ocean floor, the design of lake de-stratification systems, modeling gas leaks from storage reservoirs, weather forecasting and global climate change.

  2. Stratified turbulent Bunsen flames : flame surface analysis and flame surface density modelling

    NARCIS (Netherlands)

    Ramaekers, W.J.S.; Oijen, van J.A.; Goey, de L.P.H.

    2012-01-01

    In this paper it is investigated whether the Flame Surface Density (FSD) model, developed for turbulent premixed combustion, is also applicable to stratified flames. Direct Numerical Simulations (DNS) of turbulent stratified Bunsen flames have been carried out, using the Flamelet Generated Manifold

  3. Two-phase air-water stratified flow measurement using ultrasonic techniques

    International Nuclear Information System (INIS)

    Fan, Shiwei; Yan, Tinghu; Yeung, Hoi

    2014-01-01

    In this paper, a time resolved ultrasound system was developed for investigating two-phase air-water stratified flow. The hardware of the system includes a pulsed wave transducer, a pulser/receiver, and a digital oscilloscope. The time domain cross correlation method is used to calculate the velocity profile along ultrasonic beam. The system is able to provide velocities with spatial resolution of around 1mm and the temporal resolution of 200μs. Experiments were carried out on single phase water flow and two-phase air-water stratified flow. For single phase water flow, the flow rates from ultrasound system were compared with those from electromagnetic flow (EM) meter, which showed good agreement. Then, the experiments were conducted on two-phase air-water stratified flow and the results were given. Compared with liquid height measurement from conductance probe, it indicated that the measured velocities were explainable

  4. Integrating neurocritical care approaches into neonatology: should all infants be treated equitably?

    Science.gov (United States)

    Mann, P C; Gospe, S M; Steinman, K J; Wilfond, B S

    2015-12-01

    To improve the neurologic outcomes for infants with brain injury, neonatal providers are increasingly implementing neurocritical care approaches into clinical practice. Term infants with brain injury have been principal beneficiaries of neurologically-integrated care models to date, as evidenced by the widespread adoption of therapeutic hypothermia protocols for hypoxic-ischemic encephalopathy. Innovative therapeutic and diagnostic support for very low birth weight infants with brain injury has lagged behind. Given that concern for significant future neurodevelopmental impairment can lead to decisions to withdraw life supportive care at any gestational age, providing families with accurate prognostic information is essential for all infants. Current variable application of multidisciplinary neurocritical care approaches to infants at different gestational ages may be ethically problematic and reflect distinct perceptions of brain injury for infants born extremely premature.

  5. Spinning phenomena and energetics of spherically pulsating patterns in stratified fluids

    International Nuclear Information System (INIS)

    Ibragimov, Ranis N; Dameron, Michael

    2011-01-01

    The nonlinear solutions of the two-dimensional Boussinesq equations describing internal waves in rotating stratified fluids were obtained as group invariant solutions. The latter nonlinear solutions correspond to the rotation transformation preserving the form of the original nonlinear equations of motion. It is shown that the obtained class of exact solutions can be associated with the spherically pulsating patterns observed in uniformly stratified fluids. It is also shown that the obtained rotationally symmetric solutions are bounded functions that can be visualized as spinning patterns in stratified fluids. It is also shown that the rotational transformation provides the energy conservation law together with other conservation laws for which the spinning phenomena is observed. The effects of nonlinearity and the Earth's rotation on such a phenomenon are also discussed.

  6. Modeling the Conducting Stably-Stratified Layer of the Earth's Core

    Science.gov (United States)

    Petitdemange, L.; Philidet, J.; Gissinger, C.

    2017-12-01

    Observations of the Earth magnetic field as well as recent theoretical works tend to show that the Earth's outer liquid core is mostly comprised of a convective zone in which the Earth's magnetic field is generated - likely by dynamo action -, but also features a thin, stably stratified layer at the top of the core.We carry out direct numerical simulations by modeling this thin layer as an axisymmetric spherical Couette flow for a stably stratified fluid embedded in a dipolar magnetic field. The dynamo region is modeled by a conducting inner core rotating slightly faster than the insulating mantle due to magnetic torques acting on it, such that a weak differential rotation (low Rossby limit) can develop in the stably stratified layer.In the case of a non-stratified fluid, the combined action of the differential rotation and the magnetic field leads to the well known regime of `super-rotation', in which the fluid rotates faster than the inner core. Whereas in the classical case, this super-rotation is known to vanish in the magnetostrophic limit, we show here that the fluid stratification significantly extends the magnitude of the super-rotation, keeping this phenomenon relevant for the Earth core. Finally, we study how the shear layers generated by this new state might give birth to magnetohydrodynamic instabilities or waves impacting the secular variations or jerks of the Earth's magnetic field.

  7. Needs assessments in palliative care: an appraisal of definitions and approaches used.

    Science.gov (United States)

    Higginson, Irene J; Hart, Sam; Koffman, Jonathan; Selman, Lucy; Harding, Richard

    2007-05-01

    We report a systematic appraisal of definitions and approaches to needs assessment in palliative care. Electronic databases were searched, and relevant individuals and organizations were contacted to identify needs assessments in palliative care. Over 200 articles were identified giving general information on needs assessment, and 77 articles comprised palliative care-related needs assessment reports. The reports originated from Africa (37), Australia (1), Europe (including former central/eastern European states) (35), USA (1), Latin America (5), and Asia (7). Two underpinning definitions of need were identified, that of Maslow from the field of psychology, and that of Bradshaw from sociology. However, in conducting needs assessments, these definitions were operationalized, and here the National Health Service Executive definition of need as "the ability to benefit from health care" is helpful. We identified three main categories of approach to needs assessment--epidemiological, corporate, and comparative--that can be used in combination. Careful consideration must be paid to any needs assessment data to ensure that the assessment is implemented.

  8. Application of radial basis function in densitometry of stratified regime of liquid-gas two phase flows

    International Nuclear Information System (INIS)

    Roshani, G.H.; Nazemi, E.; Roshani, M.M.

    2017-01-01

    In this paper, a novel method is proposed for predicting the density of liquid phase in stratified regime of liquid-gas two phase flows by utilizing dual modality densitometry technique and artificial neural network (ANN) model of radial basis function (RBF). The detection system includes a 137 Cs radioactive source and two NaI(Tl) detectors for registering transmitted and scattered photons. At the first step, a Monte Carlo simulation model was utilized to obtain the optimum position for the scattering detector in dual modality densitometry configuration. At the next step, an experimental setup was designed based on obtained optimum position for detectors from simulation in order to generate the required data for training and testing the ANN. The results show that the proposed approach could be successfully applied for predicting the density of liquid phase in stratified regime of gas-liquid two phase flows with mean relative error (MRE) of less than 0.701. - Highlights: • Density of liquid phase in stratified regime of two phase flows was predicted. • Combination of dual modality densitometry technique and ANN was utilized. • Detection system includes a 137 Cs radioactive source and two NaI(Tl) detectors. • MCNP simulation was done to obtain the optimum position for the scattering detector. • An experimental setup was designed to generate the required data for training the ANN.

  9. US approaches to physician payment: the deconstruction of primary care.

    Science.gov (United States)

    Berenson, Robert A; Rich, Eugene C

    2010-06-01

    The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients' best interests. Most payers don't employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, "time is money;" extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.

  10. What can a participatory approach to evaluation contribute to the field of integrated care?

    Science.gov (United States)

    Eyre, Laura; Farrelly, Michael; Marshall, Martin

    2017-07-01

    Better integration of care within the health sector and between health and social care is seen in many countries as an essential way of addressing the enduring problems of dwindling resources, changing demographics and unacceptable variation in quality of care. Current research evidence about the effectiveness of integration efforts supports neither the enthusiasm of those promoting and designing integrated care programmes nor the growing efforts of practitioners attempting to integrate care on the ground. In this paper we present a methodological approach, based on the principles of participatory research, that attempts to address this challenge. Participatory approaches are characterised by a desire to use social science methods to solve practical problems and a commitment on the part of researchers to substantive and sustained collaboration with relevant stakeholders. We describe how we applied an emerging practical model of participatory research, the researcher-in-residence model, to evaluate a large-scale integrated care programme in the UK. We propose that the approach added value to the programme in a number of ways: by engaging stakeholders in using established evidence and with the benefits of rigorously evaluating their work, by providing insights for local stakeholders that they were either not familiar with or had not fully considered in relation to the development and implementation of the programme and by challenging established mindsets and norms. While there is still much to learn about the benefits and challenges of applying participatory approaches in the health sector, we demonstrate how using such approaches have the potential to help practitioners integrate care more effectively in their daily practice and help progress the academic study of integrated care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  11. Adaptive leadership and person-centered care: a new approach to solving problems.

    Science.gov (United States)

    Corazzini, Kirsten N; Anderson, Ruth A

    2014-01-01

    Successfully transitioning to person-centered care in nursing homes requires a new approach to solving care issues. The adaptive leadership framework suggests that expert providers must support frontline caregivers in their efforts to develop high-quality, person-centered solutions.

  12. Nitrogen transformations in stratified aquatic microbial ecosystems

    DEFF Research Database (Denmark)

    Revsbech, N. P.; Risgaard-Petersen, N.; Schramm, A.

    2006-01-01

    Abstract  New analytical methods such as advanced molecular techniques and microsensors have resulted in new insights about how nitrogen transformations in stratified microbial systems such as sediments and biofilms are regulated at a µm-mm scale. A large and ever-expanding knowledge base about n...

  13. [Causes of emergency dizziness stratified by etiology].

    Science.gov (United States)

    Qiao, Wenying; Liu, Jianguo; Zeng, Hong; Liu, Yugeng; Jia, Weihua; Wang, Honghong; Liu, Bo; Tan, Jing; Li, Changqing

    2014-06-03

    To explore the causes of emergency dizziness stratified to improve the diagnostic efficiency. A total of 1 857 cases of dizziness at our emergency department were collected and their etiologies stratified by age and gender. The top three diagnoses were benign paroxysmal positional vertigo (BPPV, 31.7%), hypertension (24.0%) and posterior circulation ischemia (PCI, 20.5%). Stratified by age, the main causes of dizziness included BPPV (n = 6), migraine-associated vertigo (n = 2), unknown cause (n = 1) for the group of vertigo (14.5%) and neurosis (7.3%) for 18-44 years; BPPV (36.8%), hypertension (22.4%) and migraine-associated vertigo (11.2%) for 45-59 years; hypertension (30.8%), PCI (29.8%) and BPPV (22.9%) for 60-74 years; PCI (30.7%), hypertension (28.6%) and BPPV (25.5%) for 75-92 years. BPPV, migraine and neurosis were more common in females while hypertension and PCI predominated in males (all P hypertension, neurosis and migraine showed the following significant demographic features: BPPV, PCI, hypertension, neurosis and migraine may be the main causes of dizziness. BPPV should be considered initially when vertigo was triggered repeatedly by positional change, especially for young and middle-aged women. And the other common causes of dizziness were migraine-associated vertigo, neurosis and Meniere's disease.Hypertension should be screened firstly in middle-aged and elderly patients presenting mainly with head heaviness and stretching. In elders with dizziness, BPPV is second in constituent ratio to PCI and hypertension.In middle-aged and elderly patients with dizziness, psychological factors should be considered and diagnosis and treatment should be offered timely.

  14. Identification and Management of Chronic Pain in Primary Care: a Review.

    Science.gov (United States)

    Mills, Sarah; Torrance, Nicola; Smith, Blair H

    2016-02-01

    Chronic pain is a common, complex, and challenging condition, where understanding the biological, social, physical and psychological contexts is vital to successful outcomes in primary care. In managing chronic pain the focus is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. Recent screening tools and brief intervention techniques can be effective in helping clinicians identify, stratify and manage both patients already living with chronic pain and those who are at risk of developing chronic pain from acute pain. Frequent assessment and re-assessment are key to ensuring treatment is appropriate and safe, as well as minimizing and addressing side effects. Primary care management should be holistic and evidence-based (where possible) and incorporates both pharmacological and non-pharmacological approaches, including psychology, self-management, physiotherapy, peripheral nervous system stimulation, complementary therapies and comprehensive pain-management programmes. These may either be based wholly in primary care or supported by appropriate specialist referral.

  15. A Human-Centered Approach to CV Care: Infrastructure Development in Uganda.

    Science.gov (United States)

    Longenecker, Christopher T; Kalra, Ankur; Okello, Emmy; Lwabi, Peter; Omagino, John O; Kityo, Cissy; Kamya, Moses R; Webel, Allison R; Simon, Daniel I; Salata, Robert A; Costa, Marco A

    2018-04-20

    In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

  16. Monitoring oil persistence on beaches : SCAT versus stratified random sampling designs

    International Nuclear Information System (INIS)

    Short, J.W.; Lindeberg, M.R.; Harris, P.M.; Maselko, J.M.; Pella, J.J.; Rice, S.D.

    2003-01-01

    In the event of a coastal oil spill, shoreline clean-up assessment teams (SCAT) commonly rely on visual inspection of the entire affected area to monitor the persistence of the oil on beaches. Occasionally, pits are excavated to evaluate the persistence of subsurface oil. This approach is practical for directing clean-up efforts directly following a spill. However, sampling of the 1989 Exxon Valdez oil spill in Prince William Sound 12 years later has shown that visual inspection combined with pit excavation does not offer estimates of contaminated beach area of stranded oil volumes. This information is needed to statistically evaluate the significance of change with time. Assumptions regarding the correlation of visually-evident surface oil and cryptic subsurface oil are usually not evaluated as part of the SCAT mandate. Stratified random sampling can avoid such problems and could produce precise estimates of oiled area and volume that allow for statistical assessment of major temporal trends and the extent of the impact. The 2001 sampling of the shoreline of Prince William Sound showed that 15 per cent of surface oil occurrences were associated with subsurface oil. This study demonstrates the usefulness of the stratified random sampling method and shows how sampling design parameters impact statistical outcome. Power analysis based on the study results, indicate that optimum power is derived when unnecessary stratification is avoided. It was emphasized that sampling effort should be balanced between choosing sufficient beaches for sampling and the intensity of sampling

  17. A Powerful Approach to Estimating Annotation-Stratified Genetic Covariance via GWAS Summary Statistics.

    Science.gov (United States)

    Lu, Qiongshi; Li, Boyang; Ou, Derek; Erlendsdottir, Margret; Powles, Ryan L; Jiang, Tony; Hu, Yiming; Chang, David; Jin, Chentian; Dai, Wei; He, Qidu; Liu, Zefeng; Mukherjee, Shubhabrata; Crane, Paul K; Zhao, Hongyu

    2017-12-07

    Despite the success of large-scale genome-wide association studies (GWASs) on complex traits, our understanding of their genetic architecture is far from complete. Jointly modeling multiple traits' genetic profiles has provided insights into the shared genetic basis of many complex traits. However, large-scale inference sets a high bar for both statistical power and biological interpretability. Here we introduce a principled framework to estimate annotation-stratified genetic covariance between traits using GWAS summary statistics. Through theoretical and numerical analyses, we demonstrate that our method provides accurate covariance estimates, thereby enabling researchers to dissect both the shared and distinct genetic architecture across traits to better understand their etiologies. Among 50 complex traits with publicly accessible GWAS summary statistics (N total ≈ 4.5 million), we identified more than 170 pairs with statistically significant genetic covariance. In particular, we found strong genetic covariance between late-onset Alzheimer disease (LOAD) and amyotrophic lateral sclerosis (ALS), two major neurodegenerative diseases, in single-nucleotide polymorphisms (SNPs) with high minor allele frequencies and in SNPs located in the predicted functional genome. Joint analysis of LOAD, ALS, and other traits highlights LOAD's correlation with cognitive traits and hints at an autoimmune component for ALS. Copyright © 2017 American Society of Human Genetics. Published by Elsevier Inc. All rights reserved.

  18. How can primary care providers manage pediatric obesity in the real world?

    Science.gov (United States)

    Hopkins, Kristy F; Decristofaro, Claire; Elliott, Lydia

    2011-06-01

    To provide information regarding evidence-based interventions and clinical practice guidelines as a basis for a clinical toolkit utilizing a step management approach for the primary care provider in managing childhood obesity. Evidence-based literature including original clinical trials, literature reviews, and clinical practice guidelines. Interventions can be stratified based on initial screening of children and adolescents so that selection of treatment options is optimized. For all treatments, lifestyle modifications include attention to diet and activity level. Levels of initial success, as well as maintenance of target body mass index, may be related to the intensity and duration of interventions; involvement of family may increase success rates. For failed lifestyle interventions, or for patients with extreme obesity and/or certain comorbidities, pharmacologic or surgical options should be considered. Many intensive programs have shown success, but the resources required for these approaches may be unavailable to the typical community provider and family. However, using current guidelines, the primary care provider can initiate and manage ongoing interventions in pediatric obesity. A toolkit for primary care implementation and maintenance interventions is provided. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.

  19. Molecular polymorphism of a cell surface proteoglycan: distinct structures on simple and stratified epithelia.

    Science.gov (United States)

    Sanderson, R D; Bernfield, M

    1988-12-01

    Epithelial cells are organized into either a single layer (simple epithelia) or multiple layers (stratified epithelia). Maintenance of these cellular organizations requires distinct adhesive mechanisms involving many cell surface molecules. One such molecule is a cell surface proteoglycan, named syndecan, that contains both heparan sulfate and chondroitin sulfate chains. This proteoglycan binds cells to fibrillar collagens and fibronectin and thus acts as a receptor for interstitial matrix. The proteoglycan is restricted to the basolateral surface of simple epithelial cells, but is located over the entire surface of stratified epithelial cells, even those surfaces not contacting matrix. We now show that the distinct localization in simple and stratified epithelia correlates with a distinct proteoglycan structure. The proteoglycan from simple epithelia (modal molecular size, 160 kDa) is larger than that from stratified epithelia (modal molecular size, 92 kDa), but their core proteins are identical in size and immunoreactivity. The proteoglycan from simple epithelia has more and larger heparan sulfate and chondroitin sulfate chains than the proteoglycan from stratified epithelia. Thus, the cell surface proteoglycan shows a tissue-specific structural polymorphism due to distinct posttranslational modifications. This polymorphism likely reflects distinct proteoglycan functions in simple and stratified epithelia, potentially meeting the different adhesive requirements of the cells in these different organizations.

  20. Effects of unstratified and centre-stratified randomization in multi-centre clinical trials.

    Science.gov (United States)

    Anisimov, Vladimir V

    2011-01-01

    This paper deals with the analysis of randomization effects in multi-centre clinical trials. The two randomization schemes most often used in clinical trials are considered: unstratified and centre-stratified block-permuted randomization. The prediction of the number of patients randomized to different treatment arms in different regions during the recruitment period accounting for the stochastic nature of the recruitment and effects of multiple centres is investigated. A new analytic approach using a Poisson-gamma patient recruitment model (patients arrive at different centres according to Poisson processes with rates sampled from a gamma distributed population) and its further extensions is proposed. Closed-form expressions for corresponding distributions of the predicted number of the patients randomized in different regions are derived. In the case of two treatments, the properties of the total imbalance in the number of patients on treatment arms caused by using centre-stratified randomization are investigated and for a large number of centres a normal approximation of imbalance is proved. The impact of imbalance on the power of the study is considered. It is shown that the loss of statistical power is practically negligible and can be compensated by a minor increase in sample size. The influence of patient dropout is also investigated. The impact of randomization on predicted drug supply overage is discussed. Copyright © 2010 John Wiley & Sons, Ltd.

  1. International Vision Care: Issues and Approaches.

    Science.gov (United States)

    Khanna, Rohit C; Marmamula, Srinivas; Rao, Gullapalli N

    2017-09-15

    Globally, 32.4 million individuals are blind and 191 million have moderate or severe visual impairment (MSVI); 80% of cases of blindness and MSVI are avoidable. However, great efforts are needed to tackle blindness and MSVI, as eye care in most places is delivered in isolation from and without significant integration with general health sectors. Success stories, including control of vitamin A deficiency, onchocerciasis, and trachoma, showed that global partnerships, multisectoral collaboration, public-private partnerships, corporate philanthropy, support from nongovernmental organizations-both local and international-and governments are responsible for the success of these programs. Hence, the World Health Organization's universal eye health global action plan for 2014-2019 has a goal of reducing the public health problem of blindness and ensuring access to comprehensive eye care; the plan aims to integrate eye health into health systems, thus providing universal eye health coverage (UEHC). This article discusses the challenges faced by low- and middle-income countries in strengthening the six building blocks of the health system. It discusses how the health systems in these countries need to be geared toward tackling the issues of emerging noncommunicable eye diseases, existing infectious diseases, and the common causes of blindness and visual impairment, such as cataract and refractive error. It also discusses how some of the comprehensive eye care models in the developing world have addressed these challenges. Moving ahead, if we are to achieve UEHC, we need to develop robust, sustainable, good-quality, comprehensive eye care programs throughout the world, focusing on the areas of greatest need. We also need to develop public health approaches for more complex problems such as diabetic retinopathy, glaucoma, childhood blindness, corneal blindness, and low vision. There is also a great need to train high-level human resources of all cadres in adequate numbers and

  2. New approaches of organizing care and work: giving way to participation, mobilization, and innovation.

    Science.gov (United States)

    Viens, Chantal; Lavoie-Tremblay, Mélanie; Leclerc, Martine Mayrand; Brabant, Louise Hamelin

    2005-01-01

    Quebec's health network has undertaken large-scale organizational changes to ensure the continuity, accessibility, and quality of health care and services for the population. This article describes the optimal approach for making changes to the organization of care and work for patients, health care workers, and organizations. This participative action research was carried out by means of interviews and document analysis. One hundred participants were involved, describing a total of 34 projects for significant organizational change. Results include an optimal approach broken down into 4 phases, each of which includes steps, facilitating factors, and potential difficulties. The phases of this approach are: (1) sharing the vision, mission, and values of the organization and identifying the purpose and need underlying the change; (2) building alliances and validating the involvement of the various players; (3) conceptualizing and planning the project; and (4) implementing changes and continuing evaluation. It is possible to rise to the challenge of finding new approaches to organize care and work by giving way to participation, mobilization, and innovation.

  3. Approach to Peripheral Neuropathy for the Primary Care Clinician.

    Science.gov (United States)

    Doughty, Christopher T; Seyedsadjadi, Reza

    2018-02-02

    Peripheral neuropathy is commonly encountered in the primary care setting and is associated with significant morbidity, including neuropathic pain, falls, and disability. The clinical presentation of neuropathy is diverse, with possible symptoms including weakness, sensory abnormalities, and autonomic dysfunction. Accordingly, the primary care clinician must be comfortable using the neurologic examination-including the assessment of motor function, multiple sensory modalities, and deep tendon reflexes-to recognize and characterize neuropathy. Although the causes of peripheral neuropathy are numerous and diverse, careful review of the medical and family history coupled with limited, select laboratory testing can often efficiently lead to an etiologic diagnosis. This review offers an approach for evaluating suspected neuropathy in the primary care setting. It will describe the most common causes, suggest an evidence-based workup to aid in diagnosis, and highlight recent evidence that allows for selection of symptomatic treatment of patients with neuropathy. Copyright © 2018 Elsevier Inc. All rights reserved.

  4. Theoretical study of evaporation heat transfer in horizontal microfin tubes: stratified flow model

    Energy Technology Data Exchange (ETDEWEB)

    Honda, H; Wang, Y S [Kyushu Univ., Inst. for Materials Chemistry and Engineering, Kasuga, Fukuoka (Japan)

    2004-08-01

    The stratified flow model of evaporation heat transfer in helically grooved, horizontal microfin tubes has been developed. The profile of stratified liquid was determined by a theoretical model previously developed for condensation in horizontal microfin tubes. For the region above the stratified liquid, the meniscus profile in the groove between adjacent fins was determined by a force balance between the gravity and surface tension forces. The thin film evaporation model was applied to predict heat transfer in the thin film region of the meniscus. Heat transfer through the stratified liquid was estimated by using an empirical correlation proposed by Mori et al. The theoretical predictions of the circumferential average heat transfer coefficient were compared with available experimental data for four tubes and three refrigerants. A good agreement was obtained for the region of Fr{sub 0}<2.5 as long as partial dry out of tube surface did not occur. (Author)

  5. Employing a Qualitative Description Approach in Health Care Research.

    Science.gov (United States)

    Bradshaw, Carmel; Atkinson, Sandra; Doody, Owen

    2017-01-01

    A qualitative description design is particularly relevant where information is required directly from those experiencing the phenomenon under investigation and where time and resources are limited. Nurses and midwives often have clinical questions suitable to a qualitative approach but little time to develop an exhaustive comprehension of qualitative methodological approaches. Qualitative description research is sometimes considered a less sophisticated approach for epistemological reasons. Another challenge when considering qualitative description design is differentiating qualitative description from other qualitative approaches. This article provides a systematic and robust journey through the philosophical, ontological, and epistemological perspectives, which evidences the purpose of qualitative description research. Methods and rigor issues underpinning qualitative description research are also appraised to provide the researcher with a systematic approach to conduct research utilizing this approach. The key attributes and value of qualitative description research in the health care professions will be highlighted with the aim of extending its usage.

  6. Promoting self-management in diabetes: efficacy of a collaborative care approach.

    Science.gov (United States)

    Sieber, William; Newsome, Alita; Lillie, Dustin

    2012-12-01

    Diabetes is a leading cause of death and is estimated to cost the United States 90 billion dollars annually. Increasing patient self-management skills has been shown to improve outcomes in patients with Type II diabetes. Promotion of shared decision-making between patient and provider is a core element of collaborative care and is especially well suited for increasing patient self-management. Research trials to date have been limited in demonstrating how self-management promotion can be fully integrated into primary care practices. Demonstration of the impact of this approach is needed. This study involves 22 randomly assigned physicians across three family medicine clinics to either provide usual care or work with a part-time collaborative care therapist in their clinic serving as an outreach health coach for their diabetic patients. Each outreach health coach met with each physician in the intervention group to identify patients most in need of intervention, sent identified patients a video on diabetes management, and called to encourage video viewing and discuss any patient-perceived barriers to self-management. Initial markers of patient activation in self-management, patients' video-viewing behavior, and health care encounters in the subsequent 6 months were compared between groups. Results showed that patients targeted by an outreach health coach were more likely to view the video, be seen by their primary care physician (PCP) within 6 months, and have disease-relevant laboratory tests performed than patients receiving usual care from their PCP (p < .05). This approach, linking PCPs with collaborative care staff, is viewed as expanding the engagement of PCPs with the collaborative team for superior patient health outcomes.

  7. Does the Planetree patient-centered approach to care pay off?: a cost-benefit analysis.

    Science.gov (United States)

    Coulmont, Michel; Roy, Chantale; Dumas, Lucie

    2013-01-01

    Although the Planetree patient-centered approach to care is being implemented in many institutions around the world, its impact is still the subject of some debate. On the one hand, it is viewed as the most cost-effective way to provide care and create a positive work environment that reduces staff burnout. On the other hand, it is argued that it requires higher staffing ratios and a substantial infusion of financial resources and is time consuming, which in turn results in more work. The present study addresses the economic agenda of the Planetree patient-centered approach to care and has been designed to answer the following question: do the advantages of the Planetree patient-centered approach outweigh its costs? This question is of considerable interest for health care administrators and managers because the relevant authorities the world over have limited resources to allocate to health care organizations. Using a trend analysis approach to cost-benefit in a rehabilitation center, this study shows that the revenues the model generates are greater than the costs of implementing it. Fewer grievances and vacant positions, an improved employee retention rate, a better working atmosphere, and a high level of employee satisfaction (higher than in similar establishments) were also noted.

  8. An experimental investigation of stratified two-phase pipe flow at small inclinations

    Energy Technology Data Exchange (ETDEWEB)

    Espedal, Mikal

    1998-12-31

    The prediction of stratified flow is important for several industrial applications. Stratified flow experiments were carefully performed in order to investigate the performance of a typical model which uses wall friction factors based on single phase pipe flow as described above. The test facility has a 18.5 m long and 60 mm i.d. (L/D=300) acrylic test section which can be inclined between -10 {sup o} and +10 {sup o}. The liquid holdup was measured by using fast closing valves and the pressure gradients by using three differential pressure transducers. Interfacial waves were measured by thin wire conductance probes mounted in a plane perpendicular to the main flow. The experiments were performed using water and air at atmospheric pressure. The selected test section inclinations were between -3 {sup o} and +0.5 {sup o} to the horizontal plane. A large number of experiments were performed for different combinations of air and water flow rates and the rates were limited to avoid slug flow and stratified flow with liquid droplets. The pressure gradient and the liquid holdup were measured. In addition the wave probes were used to find the wave heights and the wave power spectra. The results show that the predicted pressure gradient using the standard models is approximately 30% lower than the measured value when large amplitude waves are present. When the flow is driven by the interfacial force the test section inclination has minor influence on the deviation between predicted and measured pressure gradients. Similar trends are apparent in data from the literature, although they seem to have gone unnoticed. For several data sets large spread in the predictions are observed when the model described above was used. Gas wall shear stress experiments indicate that the main cause of the deviation between measured and predicted pressure gradient and holdup resides in the modelling of the liquid wall friction term. Measurements of the liquid wall shear stress distribution

  9. Dual Spark Plugs For Stratified-Charge Rotary Engine

    Science.gov (United States)

    Abraham, John; Bracco, Frediano V.

    1996-01-01

    Fuel efficiency of stratified-charge, rotary, internal-combustion engine increased by improved design featuring dual spark plugs. Second spark plug ignites fuel on upstream side of main fuel injector; enabling faster burning and more nearly complete utilization of fuel.

  10. Integration of the primary health care approach into a community nursing science curriculum.

    Science.gov (United States)

    Vilakazi, S S; Chabeli, M M; Roos, S D

    2000-12-01

    The purpose of this article is to explore and describe guidelines for integration of the primary health care approach into a Community Nursing Science Curriculum in a Nursing College in Gauteng. A qualitative, exploratory, descriptive and contextual research design was utilized. The focus group interviews were conducted with community nurses and nurse educators as respondents. Data were analysed by a qualitative descriptive method of analysis as described in Creswell (1994: 155). Respondents in both groups held similar perceptions regarding integration of primary health care approach into a Community Nursing Science Curriculum. Five categories, which are in line with the curriculum cycle, were identified as follows: situation analysis, selection and organisation of objectives/goals, content, teaching methods and evaluation. Guidelines and recommendations for the integration of the primary health care approach into a Community Nursing Science Curriculum were described.

  11. Integration of the primary health care approach into a community nursing science curriculum

    Directory of Open Access Journals (Sweden)

    SS Vilakazi

    2000-09-01

    Full Text Available The purpose of this article is to explore and describe guidelines for integration of the primary health care approach into a Community Nursing Science Curriculum in a Nursing College in Gauteng. A qualitative, exploratory, descriptive and contextual research design was utilized. The focus group interviews were conducted with community nurses and nurse educators as respondents. Data were analysed by a qualitative descriptive method of analysis as described in Creswell (1994:155. Respondents in both groups held similar perceptions regarding integration of primary health care approach into a Community Nursing Science Curriculum. Five categories, which are in line with the curriculum cycle, were identified as follows: situation analysis, selection and organisation of objectives/ goals, content, teaching methods and evaluation. Guidelines and recommendations for the integration of the primary health care approach into a Community Nursing Science Curriculum were described.

  12. Impact of Anterior vs Posterior Approach for Total Hip Arthroplasty on Post-Acute Care Service Utilization.

    Science.gov (United States)

    L'Hommedieu, Coles E; Gera, James J; Rupp, Gerald; Salin, Jeffery W; Cox, John S; Duwelius, Paul J

    2016-09-01

    Controversy exists as to which surgical approach is best for total hip arthroplasty (THA). Previous studies suggested that the tissue-sparing anterior approach should result in a more rapid recovery requiring fewer postacute services, ultimately decreasing overall episodic cost. The purpose of this cross-sectional study was to determine if any significant differences exist between the anterior vs posterior approaches on postacute care service utilization, readmissions, or episodic cost. Claims data from 26,773 Medicare fee-for-service beneficiaries receiving elective THAs (Medical Severity-Diagnosis Related Groups (MS-DRGs) 469/470) were analyzed. Claims data were collected from the 2-year period, January 2013 through December 2014. The posterior surgical approach was performed on 23,653 patients while 3120 patients received the anterior approach. Data analysis showed negligible effect sizes in postacute care service utilization, readmission rate, and cost between the surgical approaches for elective THA (MS-DRG 469 and 470). Average THA total episode cost was negligibly higher for procedures using the anterior approach compared to the posterior approach ($22,517 and $22,068, respectively). Statistically significant differences were observed in inpatient rehab and home health cost and service utilization. However, the effect sizes of these comparisons are negligible when accounting for the large sample size. All other comparisons showed minimal and statistically insignificant variation. The results indicate that surgical approach alone is not the primary driver of postacute care service utilization, quality outcomes, or cost. Other factors such as physician-led patient-focused care pathways, care coordination, rapid rehabilitation protocols, perioperative pain management protocols, and patient education are integral for effective patient care. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Chronic care coordination by integrating care through a team-based, population-driven approach: a case study.

    Science.gov (United States)

    van Eeghen, Constance O; Littenberg, Benjamin; Kessler, Rodger

    2018-05-23

    Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team's use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.

  14. US Approaches to Physician Payment: The Deconstruction of Primary Care

    OpenAIRE

    Berenson, Robert A.; Rich, Eugene C.

    2010-01-01

    The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary ...

  15. Guidelines for a palliative approach for aged care in the community setting: a suite of resources

    Directory of Open Access Journals (Sweden)

    David C. Currow

    2012-11-01

    Full Text Available AbstractIn Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary. The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers. The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations

  16. Guidelines for a palliative approach for aged care in the community setting: A suite of resources.

    Science.gov (United States)

    Toye, Christine; Blackwell, Scott; Maher, Sean; Currow, David C; Holloway, Kristi; Tieman, Jennifer; Hegarty, Meg

    2012-01-01

    In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two 'plain English' booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.The resources are intended to facilitate home care that acknowledges and plans for the client's deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and

  17. Stratified coastal ocean interactions with tropical cyclones

    Science.gov (United States)

    Glenn, S. M.; Miles, T. N.; Seroka, G. N.; Xu, Y.; Forney, R. K.; Yu, F.; Roarty, H.; Schofield, O.; Kohut, J.

    2016-01-01

    Hurricane-intensity forecast improvements currently lag the progress achieved for hurricane tracks. Integrated ocean observations and simulations during hurricane Irene (2011) reveal that the wind-forced two-layer circulation of the stratified coastal ocean, and resultant shear-induced mixing, led to significant and rapid ahead-of-eye-centre cooling (at least 6 °C and up to 11 °C) over a wide swath of the continental shelf. Atmospheric simulations establish this cooling as the missing contribution required to reproduce Irene's accelerated intensity reduction. Historical buoys from 1985 to 2015 show that ahead-of-eye-centre cooling occurred beneath all 11 tropical cyclones that traversed the Mid-Atlantic Bight continental shelf during stratified summer conditions. A Yellow Sea buoy similarly revealed significant and rapid ahead-of-eye-centre cooling during Typhoon Muifa (2011). These findings establish that including realistic coastal baroclinic processes in forecasts of storm intensity and impacts will be increasingly critical to mid-latitude population centres as sea levels rise and tropical cyclone maximum intensities migrate poleward. PMID:26953963

  18. Properties of the endogenous post-stratified estimator using a random forests model

    Science.gov (United States)

    John Tipton; Jean Opsomer; Gretchen G. Moisen

    2012-01-01

    Post-stratification is used in survey statistics as a method to improve variance estimates. In traditional post-stratification methods, the variable on which the data is being stratified must be known at the population level. In many cases this is not possible, but it is possible to use a model to predict values using covariates, and then stratify on these predicted...

  19. Stratified steady and unsteady two-phase flows between two parallel plates

    International Nuclear Information System (INIS)

    Sim, Woo Gun

    2006-01-01

    To understand fluid dynamic forces acting on a structure subjected to two-phase flow, it is essential to get detailed information about the characteristics of two-phase flow. Stratified steady and unsteady two-phase flows between two parallel plates have been studied to investigate the general characteristics of the flow related to flow-induced vibration. Based on the spectral collocation method, a numerical approach has been developed for the unsteady two-phase flow. The method is validated by comparing numerical result to analytical one given for a simple harmonic two-phase flow. The flow parameters for the steady two-phase flow, such as void fraction and two-phase frictional multiplier, are evaluated. The dynamic characteristics of the unsteady two-phase flow, including the void fraction effect on the complex unsteady pressure, are illustrated

  20. Employing a Qualitative Description Approach in Health Care Research

    Science.gov (United States)

    Bradshaw, Carmel; Atkinson, Sandra; Doody, Owen

    2017-01-01

    A qualitative description design is particularly relevant where information is required directly from those experiencing the phenomenon under investigation and where time and resources are limited. Nurses and midwives often have clinical questions suitable to a qualitative approach but little time to develop an exhaustive comprehension of qualitative methodological approaches. Qualitative description research is sometimes considered a less sophisticated approach for epistemological reasons. Another challenge when considering qualitative description design is differentiating qualitative description from other qualitative approaches. This article provides a systematic and robust journey through the philosophical, ontological, and epistemological perspectives, which evidences the purpose of qualitative description research. Methods and rigor issues underpinning qualitative description research are also appraised to provide the researcher with a systematic approach to conduct research utilizing this approach. The key attributes and value of qualitative description research in the health care professions will be highlighted with the aim of extending its usage. PMID:29204457

  1. Resource-stratified implementation of a community-based breast cancer management programme in Peru.

    Science.gov (United States)

    Duggan, Catherine; Dvaladze, Allison L; Tsu, Vivien; Jeronimo, Jose; Constant, Tara K Hayes; Romanoff, Anya; Scheel, John R; Patel, Shilpen; Gralow, Julie R; Anderson, Benjamin O

    2017-10-01

    Breast cancer incidence and mortality rates continue to rise in Peru, with related deaths projected to increase from 1208 in 2012, to 2054 in 2030. Despite improvements in national cancer control plans, various barriers to positive breast cancer outcomes remain. Multiorganisational stakeholder collaboration is needed for the development of functional, sustainable early diagnosis, treatment and supportive care programmes with the potential to achieve measurable outcomes. In 2011, PATH, the Peruvian Ministry of Health, the National Cancer Institute in Lima, and the Regional Cancer Institute in Trujillo collaborated to establish the Community-based Program for Breast Health, the aim of which was to improve breast health-care delivery in Peru. A four-step, resource-stratified implementation strategy was used to establish an effective community-based triage programme and a practical early diagnosis scheme within existing multilevel health-care infrastructure. The phased implementation model was initially developed by the Breast Cancer Initiative 2·5: a group of health and non-governmental organisations who collaborate to improve breast cancer outcomes. To date, the Community-based Program for Breast Health has successfully implemented steps 1, 2, and 3 of the Breast Cancer Initiative 2·5 model in Peru, with reports of increased awareness of breast cancer among women, improved capacity for early diagnosis among health workers, and the creation of stronger and more functional linkages between the primary levels (ie, local or community) and higher levels (ie, district, region, and national) of health care. The Community-based Program for Breast Health is a successful example of stakeholder and collaborator involvement-both internal and external to Peru-in the design and implementation of resource-appropriate interventions to increase breast health-care capacity in a middle-income Latin American country. Copyright © 2017 Elsevier Ltd. All rights reserved.

  2. Study of MRI in stratified viscous plasma configuration

    Science.gov (United States)

    Carlevaro, Nakia; Montani, Giovanni; Renzi, Fabrizio

    2017-02-01

    We analyze the morphology of the magneto-rotational instability (MRI) for a stratified viscous plasma disk configuration in differential rotation, taking into account the so-called corotation theorem for the background profile. In order to select the intrinsic Alfvénic nature of MRI, we deal with an incompressible plasma and we adopt a formulation of the local perturbation analysis based on the use of the magnetic flux function as a dynamical variable. Our study outlines, as consequence of the corotation condition, a marked asymmetry of the MRI with respect to the equatorial plane, particularly evident in a complete damping of the instability over a positive critical height on the equatorial plane. We also emphasize how such a feature is already present (although less pronounced) even in the ideal case, restoring a dependence of the MRI on the stratified morphology of the gravitational field.

  3. Creating patient value in glaucoma care : applying quality costing and care delivery value chain approaches

    NARCIS (Netherlands)

    D.F. de Korne (Dirk); J.C.A. Sol (Kees); T. Custers (Thomas); E. van Sprundel (Esther); B.M. van Ineveld (Martin); H.G. Lemij (Hans); N.S. Klazinga (Niek)

    2009-01-01

    textabstractPurpose: The purpose of this paper is to explore in a specific hospital care process the applicability in practice of the theories of quality costing and value chains. Design/methodology/approach: In a retrospective case study an in-depth evaluation of the use of a quality cost model

  4. The Counseling, Self-Care, Adherence Approach to Person-Centered Care and Shared Decision Making: Moral Psychology, Executive Autonomy, and Ethics in Multi-Dimensional Care Decisions.

    Science.gov (United States)

    Herlitz, Anders; Munthe, Christian; Törner, Marianne; Forsander, Gun

    2016-08-01

    This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.

  5. On Internal Waves in a Density-Stratified Estuary

    NARCIS (Netherlands)

    Kranenburg, C.

    1991-01-01

    In this article some field observations, made in recent years, of internal wave motions in a density-stratified estuary are presented, In order to facilitate the appreciation of the results, and to make some quantitative comparisons, the relevant theory is also summarized. Furthermore, the origins

  6. Prognosis research strategy (PROGRESS) 4: Stratified medicine research

    NARCIS (Netherlands)

    A. Hingorani (Aroon); D.A.W.M. van der Windt (Daniëlle); R.D. Riley (Richard); D. Abrams; K.G.M. Moons (Karel); E.W. Steyerberg (Ewout); S. Schroter (Sara); W. Sauerbrei (Willi); D.G. Altman (Douglas); H. Hemingway; A. Briggs (Andrew); N. Brunner; P. Croft (Peter); J. Hayden (Jill); P.A. Kyzas (Panayiotis); N. Malats (Núria); G. Peat; P. Perel (Pablo); I. Roberts (Ian); A. Timmis (Adam)

    2013-01-01

    textabstractIn patients with a particular disease or health condition, stratified medicine seeks to identify thosewho will have the most clinical benefit or least harm from a specific treatment. In this article, thefourth in the PROGRESS series, the authors discuss why prognosis research should form

  7. Approaches to long-term conditions management and care for older people: similarities or differences?

    Science.gov (United States)

    Tullett, Michael; Neno, Rebecca

    2008-03-01

    In the past few years, there has been an increased emphasis both on the care for older people and the management of long-term conditions within the United Kingdom. Currently, the Department of Health and the Scottish Executive identify and manage these two areas as separate entities. The aim of this article is to examine the current approaches to both of these areas of care and identify commonalities and articulate differences. The population across the world and particularly within the United Kingdom is ageing at an unprecedented rate. The numbers suffering long-term illness conditions has also risen sharply in recent years. As such, nurses need to be engaged at a strategic level in the design of robust and appropriate services for this increasing population group. A comprehensive literature review on long-term conditions and the care of older people was undertaken in an attempt to identify commonalities and differences in strategic and organizational approaches. A policy analysis was conducted to support the paper and establish links that may inform local service development. Proposing service development based on identified needs rather than organizational boundaries after the establishment of clear links between health and social care for those with long-term conditions and the ageing population. Nurse Managers need to be aware of the similarities and differences in political and theoretical approaches to the care for older people and the management of long-term conditions. By adopting this view, creativity in the service redesign and service provision can be fostered and nurtured as well as achieving a renewed focus on partnership working across organizational boundaries. With the current renewed political focus on health and social care, there is an opportunity in the UK to redefine the structure of care. This paper proposes similarities between caring for older people and for those with long-term conditions, and it is proposed these encapsulate the wider

  8. Implications of the modelling of stratified hot water storage tanks in the simulation of CHP plants

    Energy Technology Data Exchange (ETDEWEB)

    Campos Celador, A., E-mail: alvaro.campos@ehu.es [ENEDI Research Group-University of the Basque Country, Departamento de Maquinas y Motores Termicos, E.T.S.I. de Bilbao Alameda de Urquijo, s/n 48013 Bilbao, Bizkaia (Spain); Odriozola, M.; Sala, J.M. [ENEDI Research Group-University of the Basque Country, Departamento de Maquinas y Motores Termicos, E.T.S.I. de Bilbao Alameda de Urquijo, s/n 48013 Bilbao, Bizkaia (Spain)

    2011-08-15

    Highlights: {yields} Three different modelling approaches for simulation of hot water tanks are presented. {yields} The three models are simulated within a residential cogeneration plant. {yields} Small differences in the results are found by an energy and exergy analysis. {yields} Big differences between the results are found by an advanced exergy analysis. {yields} Results on the feasibility study are explained by the advanced exergy analysis. - Abstract: This paper considers the effect that different hot water storage tank modelling approaches have on the global simulation of residential CHP plants as well as their impact on their economic feasibility. While a simplified assessment of the heat storage is usually considered in the feasibility studies of CHP plants in buildings, this paper deals with three different levels of modelling of the hot water tank: actual stratified model, ideal stratified model and fully mixed model. These three approaches are presented and comparatively evaluated under the same case of study, a cogeneration plant with thermal storage meeting the loads of an urbanisation located in the Bilbao metropolitan area (Spain). The case of study is simulated by TRNSYS for each one of the three modelling cases and the so obtained annual results are analysed from both a First and Second-Law-based viewpoint. While the global energy and exergy efficiencies of the plant for the three modelling cases agree quite well, important differences are found between the economic results of the feasibility study. These results can be predicted by means of an advanced exergy analysis of the storage tank considering the endogenous and exogenous exergy destruction terms caused by the hot water storage tank.

  9. Dispersion of (light) inertial particles in stratified turbulence

    NARCIS (Netherlands)

    van Aartrijk, M.; Clercx, H.J.H.; Armenio, Vincenzo; Geurts, Bernardus J.; Fröhlich, Jochen

    2010-01-01

    We present a brief overview of a numerical study of the dispersion of particles in stably stratified turbulence. Three types of particles arc examined: fluid particles, light inertial particles ($\\rho_p/\\rho_f = \\mathcal{O}(1)$) and heavy inertial particles ($\\rho_p/\\rho_f \\gg 1$). Stratification

  10. Use of Electronic Health Records in Residential Care Communities

    Science.gov (United States)

    ... The 2010 NSRCF used a stratified two-stage probability sampling design. The first stage was the selection ... 3,605 residential care communities were sampled with probability proportional to size. Interviews were completed with 2, ...

  11. Internal circle uplifts, transversality and stratified G-structures

    Energy Technology Data Exchange (ETDEWEB)

    Babalic, Elena Mirela [Department of Theoretical Physics, National Institute of Physics and Nuclear Engineering,Str. Reactorului no.30, P.O.BOX MG-6, Postcode 077125, Bucharest-Magurele (Romania); Department of Physics, University of Craiova,13 Al. I. Cuza Str., Craiova 200585 (Romania); Lazaroiu, Calin Iuliu [Center for Geometry and Physics, Institute for Basic Science,Pohang 790-784 (Korea, Republic of)

    2015-11-24

    We study stratified G-structures in N=2 compactifications of M-theory on eight-manifolds M using the uplift to the auxiliary nine-manifold M̂=M×S{sup 1}. We show that the cosmooth generalized distribution D̂ on M̂ which arises in this formalism may have pointwise transverse or non-transverse intersection with the pull-back of the tangent bundle of M, a fact which is responsible for the subtle relation between the spinor stabilizers arising on M and M̂ and for the complicated stratified G-structure on M which we uncovered in previous work. We give a direct explanation of the latter in terms of the former and relate explicitly the defining forms of the SU(2) structure which exists on the generic locus U of M to the defining forms of the SU(3) structure which exists on an open subset Û of M̂, thus providing a dictionary between the eight- and nine-dimensional formalisms.

  12. Dyadic Green's function of an eccentrically stratified sphere.

    Science.gov (United States)

    Moneda, Angela P; Chrissoulidis, Dimitrios P

    2014-03-01

    The electric dyadic Green's function (dGf) of an eccentrically stratified sphere is built by use of the superposition principle, dyadic algebra, and the addition theorem of vector spherical harmonics. The end result of the analytical formulation is a set of linear equations for the unknown vector wave amplitudes of the dGf. The unknowns are calculated by truncation of the infinite sums and matrix inversion. The theory is exact, as no simplifying assumptions are required in any one of the analytical steps leading to the dGf, and it is general in the sense that any number, position, size, and electrical properties can be considered for the layers of the sphere. The point source can be placed outside of or in any lossless part of the sphere. Energy conservation, reciprocity, and other checks verify that the dGf is correct. A numerical application is made to a stratified sphere made of gold and glass, which operates as a lens.

  13. A Strategic Approach to Medical Care for Exploration Missions

    Science.gov (United States)

    Canga, Michael A.; Shah, Ronak V.; Mindock, Jennifer A.; Antonsen, Erik L.

    2016-01-01

    Exploration missions will present significant new challenges to crew health, including effects of variable gravity environments, limited communication with Earth-based personnel for diagnosis and consultation for medical events, limited resupply, and limited ability for crew return. Providing health care capabilities for exploration class missions will require system trades be performed to identify a minimum set of requirements and crosscutting capabilities, which can be used in design of exploration medical systems. Medical data, information, and knowledge collected during current space missions must be catalogued and put in formats that facilitate querying and analysis. These data are used to inform the medical research and development program through analysis of risk trade studies between medical care capabilities and system constraints such as mass, power, volume, and training. Medical capability as a quantifiable variable is proposed as a surrogate risk metric and explored for trade space analysis that can improve communication between the medical and engineering approaches to mission design. The resulting medical system design approach selected will inform NASA mission architecture, vehicle, and subsystem design for the next generation of spacecraft.

  14. Stratified B-trees and versioning dictionaries

    OpenAIRE

    Twigg, Andy; Byde, Andrew; Milos, Grzegorz; Moreton, Tim; Wilkes, John; Wilkie, Tom

    2011-01-01

    A classic versioned data structure in storage and computer science is the copy-on-write (CoW) B-tree -- it underlies many of today's file systems and databases, including WAFL, ZFS, Btrfs and more. Unfortunately, it doesn't inherit the B-tree's optimality properties; it has poor space utilization, cannot offer fast updates, and relies on random IO to scale. Yet, nothing better has been developed since. We describe the `stratified B-tree', which beats all known semi-external memory versioned B...

  15. Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department.

    Science.gov (United States)

    Wong, Ambrose H; Ruppel, Halley; Crispino, Lauren J; Rosenberg, Alana; Iennaco, Joanne D; Vaca, Federico E

    2018-05-01

    The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy. Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.

  16. The Values of Combined and Sub-Stratified Imaging Scores with Ultrasonography and Mammography in Breast Cancer Subtypes.

    Directory of Open Access Journals (Sweden)

    Tsun-Hou Chang

    Full Text Available The Breast Imaging Reporting and Data System (BI-RADS of Mammography (MG and Ultrasonography (US were equivalent to the "5-point score" and applied for combined and sub-stratified imaging assessments. This study evaluated the value of combined and sub-stratified imaging assessments with MG and US over breast cancer subtypes (BCS.Medical records of 5,037 cases having imaging-guided core biopsy, performed from 2009 to 2012, were retrospectively reviewed. This study selected 1,995 cases (1,457 benign and 538 invasive cancer having both MG and US before biopsy. These cases were categorized with the "5-point score" for their MG and US, and applied for combined and sub-stratified imaging assessments. Invasive cancers were classified on the basis of BCS, and correlated with combined and sub-stratified imaging assessments.These selected cases were evaluated by the "5-point score." MG, US, and combined and sub-stratified imaging assessments all revealed statistically significant (P < 0.001 incidence of malignancy. The sensitivity was increased in the combined imaging score (99.8%, and the specificity was increased in the sub-stratified combined score (75.4%. In the sub-stratified combined imaging assessment, all BCS can be classified with higher scores (abnormality hierarchy, and luminal B subtype showed the most salient result (hierarchy: higher, 95%; lower, 5%.Combined and sub-stratified imaging assessments can increase sensitivity and specificity of breast cancer diagnosis, respectively, and Luminal B subtype shows the best identification by sub-stratified combined imaging scoring.

  17. Classroom quality and academic skills: Approaches to learning as a moderator.

    Science.gov (United States)

    Meng, Christine

    2015-12-01

    The purpose of this study was to examine whether approaches to learning moderated the association between child care classroom environment and Head Start children's academic skills. The data came from the Head Start Family and Child Experiences Survey (FACES-2003 Cohort). The dataset is a nationally representative longitudinal study of Head Start children. The sample was selected using the stratified 4-stage sampling procedure. Data was collected in fall 2003, spring 2004, spring 2005, and spring 2006 in the first year of kindergarten. Participants included 3- and 4-year-old Head Start children (n = 786; 387 boys, 399 girls; 119 Hispanic children, 280 African American children, 312 Caucasian children). Head Start children's academic skills in letter-word identification, dictation/spelling, and mathematics at the 4 time points were measured by the Woodcock-Johnson Achievement Battery tests. Approaches to learning in fall 2003 was measured by the teacher report of the Preschool Learning Behaviors Scale. Child care classroom quality in fall 2003 was measured by the revised Early Childhood Environment Rating Scale. Results of the linear mixed effects models demonstrated that approaches to learning significantly moderated the effect of child care classroom quality on Head Start children's writing and spelling. Specifically, positive approaches to learning mitigated the negative effect of lower levels of classroom quality on dictation/spelling. Results underscore the important role of approaches to learning as a protective factor. Implications for early childhood educators with an emphasis on learning goals for disengaged children are discussed. (c) 2015 APA, all rights reserved).

  18. A blended learning approach to teaching CVAD care and maintenance.

    Science.gov (United States)

    Hainey, Karen; Kelly, Linda J; Green, Audrey

    2017-01-26

    Nurses working within both acute and primary care settings are required to care for and maintain central venous access devices (CVADs). To support these nurses in practice, a higher education institution and local health board developed and delivered CVAD workshops, which were supported by a workbook and competency portfolio. Following positive evaluation of the workshops, an electronic learning (e-learning) package was also introduced to further support this clinical skill in practice. To ascertain whether this blended learning approach to teaching CVAD care and maintenance prepared nurses for practice, the learning package was evaluated through the use of electronic questionnaires. Results highlighted that the introduction of the e-learning package supported nurses' practice, and increased their confidence around correct clinical procedures.

  19. Social-Professional Networks in Long-Term Care Settings With People With Dementia: An Approach to Better Care? A Systematic Review.

    Science.gov (United States)

    Mitchell, Janet I; Long, Janet C; Braithwaite, Jeffrey; Brodaty, Henry

    2016-02-01

    Dementia is a syndrome associated with stigma and social isolation. Forty-two percent of people with dementia in the United States and almost 40% in the United Kingdom live in assisted living and residential care facilities. Up to 90% of residents with dementia experience behavioral and psychological symptoms of dementia (BPSD). Currently psychotropic drugs are often used to manage BPSD, despite the drugs' limited efficacy and adverse effects. Even though psychosocial approaches are as effective as medical ones without side effects, their uptake has been slow. Social networks that investigate the structure of relationships among residents and staff may represent an important resource to increase the uptake of psychosocial approaches and facilitate improvements in care. To conduct a systematic review of social network studies set in long-term care (LTC), including residents with dementia, and identify network factors influencing the care available to residents. Peer-reviewed articles across CINAHL, EMBASE, IBSS, Medline, PsychInfo, Scopus, and Web of Science were searched from January 1994 to December 2014 inclusive, using PRISMA guidelines. Studies included those examining social networks of residents or staff in LTC. Nine articles from studies in the United States, Europe, Asia, and Australia met search criteria. Resident networks had few social connections. One study proposed that residents with high centrality be encouraged to welcome new residents and disseminate information. The high density in 2 staff network studies was associated with the cooperation needed to provide care to residents with dementia. Staff's boundary-spanning led to higher-status nurses becoming more involved in decision-making and problem-solving in one study. In another, the outcome was staff treating residents with more respect and actively caring for them. These studies suggest interventions using a network approach may improve care services in LTC. Copyright © 2016 AMDA – The

  20. Mean-field theory of differential rotation in density stratified turbulent convection

    Science.gov (United States)

    Rogachevskii, I.

    2018-04-01

    A mean-field theory of differential rotation in a density stratified turbulent convection has been developed. This theory is based on the combined effects of the turbulent heat flux and anisotropy of turbulent convection on the Reynolds stress. A coupled system of dynamical budget equations consisting in the equations for the Reynolds stress, the entropy fluctuations and the turbulent heat flux has been solved. To close the system of these equations, the spectral approach, which is valid for large Reynolds and Péclet numbers, has been applied. The adopted model of the background turbulent convection takes into account an increase of the turbulence anisotropy and a decrease of the turbulent correlation time with the rotation rate. This theory yields the radial profile of the differential rotation which is in agreement with that for the solar differential rotation.

  1. Alberta's systems approach to chronic disease management and prevention utilizing the expanded chronic care model.

    Science.gov (United States)

    Delon, Sandra; Mackinnon, Blair

    2009-01-01

    Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.

  2. Futures of elderly care in Iran: A protocol with scenario approach.

    Science.gov (United States)

    Goharinezhad, Salime; Maleki, Mohammadreza; Baradaran, Hamid Reza; Ravaghi, Hamid

    2016-01-01

    Background: The number of people aged 60 and older is increasing faster than other age groups worldwide. Iran will experience a sharp aging population increase in the next decades, and this will pose new challenges to the healthcare system. Since providing high quality aged-care services would be the major concern of the policymakers, this question arises that what types of aged care services should be organized in the coming 10 years? This protocol has been designed to develop a set of scenarios for the future of elderly care in Iran. Methods: In this study, intuitive logics approach and Global Business Network (GBN) model were used to develop scenarios for elderly care in Iran. In terms of perspective, the scenarios in this approach are normative, qualitative with respect to methodology and deductive in constructing the process of scenarios. The three phases of GBN model are as follows: 1) Orientation: Identifying strategic levels, stakeholders, participants and time horizon; 2) Exploration: Identifying the driving forces and key uncertainties; 3) Synthesis: Defining the scenario logics and constructing scenario storyline. Results: Presently, two phases are completed and the results will be published in mid-2016. Conclusion: This study delivers a comprehensive framework for taking appropriate actions in providing care for the elderly in the future. Moreover, policy makers should specify and provide the full range of services for the elderly, and in doing so, the scenarios and key findings of this study could be of valuable help.

  3. Translating Pressure Ulcer Prevention Into Intensive Care Nursing Practice: Overlaying a Care Bundle Approach With a Model for Research Implementation.

    Science.gov (United States)

    Tayyib, Nahla; Coyer, Fiona

    This article reports on the development and implementation process used to integrate a care bundle approach (a pressure ulcer [PU] prevention bundle to improve patients' skin integrity in intensive care) and the Ottawa Model of Research Use (OMRU). The PU prevention care bundle demonstrated significant reduction in PU incidence, with the OMRU model providing a consolidated framework for the implementation of bundled evidence in an effective and consistent manner into daily clinical nursing practice.

  4. Shifts in care approaches and attitudes at the end of life of people with intellectual disabilities: from activating towards caring and letting go.

    NARCIS (Netherlands)

    Veer, A.J.E. de; Bekkema, N.; Hertogh, C.M.P.M.; Francke, A.L.

    2015-01-01

    Background: The focus in the care for people with intellectual disabilities (ID) is predominantly on self-reliance and participation. An increasing number of them will have life-limiting illnesses and will need palliative care, that requires another care approach. Aims: The aim is to describe

  5. A multidisciplinary approach to therapeutic risk management of the suicidal patient

    Directory of Open Access Journals (Sweden)

    Grant CL

    2015-06-01

    Full Text Available Cynthia L Grant,1,2 Jaimie L Lusk3 1Arapahoe/Douglas Mental Health Network, Englewood, CO, 2School of Education and Human Development, University of Colorado Denver, Denver, CO, 3Mental Health Service, VA Portland Health Care System, Portland, OR, USA Abstract: As health care trends toward a system of care approach, providers from various disciplines strive to collaborate to provide optimal care for their patients. While a multidisciplinary approach to suicide risk assessment and management has been identified as important for reducing suicidality, standardized clinical guidelines for such an approach do not yet exist. In this article, the authors propose the adoption of the therapeutic risk management of the suicidal patient (TRMSP to improve suicide risk assessment and management within multidisciplinary systems of care. The TRMSP, which has been fully articulated in previous articles, involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. Augmenting clinical risk assessments with reliable and valid structured instruments serves several functions, including ensuring important aspects of suicide are addressed, establishing a baseline for suicidal thoughts and behaviors, facilitating interprofessional communication, and mitigating risk. Similarly, a two-dimensional risk stratification qualifying suicide risk in terms of both severity and temporality can enhance communication across providers and settings and improve understanding of acute crises in the context of chronic risk. Finally, safety planning interventions allow providers and patients to collaboratively create a personally meaningful plan for managing a suicidal crisis that can be continually modified across time with multiple providers in different care settings. In a busy care environment, the TRMSP can provide concrete guidance on conducting clinically and

  6. Diagnostic accuracy of the STRATIFY clinical prediction rule for falls: A systematic review and meta-analysis

    LENUS (Irish Health Repository)

    Billington, Jennifer

    2012-08-07

    AbstractBackgroundThe STRATIFY score is a clinical prediction rule (CPR) derived to assist clinicians to identify patients at risk of falling. The purpose of this systematic review and meta-analysis is to determine the overall diagnostic accuracy of the STRATIFY rule across a variety of clinical settings.MethodsA literature search was performed to identify all studies that validated the STRATIFY rule. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. A STRATIFY score of ≥2 points was used to identify individuals at higher risk of falling. All included studies were combined using a bivariate random effects model to generate pooled sensitivity and specificity of STRATIFY at ≥2 points. Heterogeneity was assessed using the variance of logit transformed sensitivity and specificity.ResultsSeventeen studies were included in our meta-analysis, incorporating 11,378 patients. At a score ≥2 points, the STRATIFY rule is more useful at ruling out falls in those classified as low risk, with a greater pooled sensitivity estimate (0.67, 95% CI 0.52–0.80) than specificity (0.57, 95% CI 0.45 – 0.69). The sensitivity analysis which examined the performance of the rule in different settings and subgroups also showed broadly comparable results, indicating that the STRATIFY rule performs in a similar manner across a variety of different ‘at risk’ patient groups in different clinical settings.ConclusionThis systematic review shows that the diagnostic accuracy of the STRATIFY rule is limited and should not be used in isolation for identifying individuals at high risk of falls in clinical practice.

  7. Development of a practice tool for community-based nurses: the Heart Failure Palliative Approach to Care (HeFPAC).

    Science.gov (United States)

    Strachan, Patricia H; Joy, Cathy; Costigan, Jeannine; Carter, Nancy

    2014-04-01

    Patients living with advanced heart failure (HF) require a palliative approach to reduce suffering. Nurses have described significant knowledge gaps about the disease-specific palliative care (PC) needs of these patients. An intervention is required to facilitate appropriate end-of-life care for HF patients. The purpose of this study was to develop a user-friendly, evidence-informed HF-specific practice tool for community-based nurses to facilitate care and communication regarding a palliative approach to HF care. Guided by the Knowledge to Action framework, we identified key HF-specific issues related to advanced HF care provision within the context of a palliative approach to care. Informed by current evidence and subsequent iterative consultation with community-based and specialist PC and HF nurses, a pocket guide tool for community-based nurses was created. We developed the Heart Failure Palliative Approach to Care (HeFPAC) pocket guide to promote communication and a palliative approach to care for HF patients. The HeFPAC has potential to improve the quality of care and experiences for patients with advanced HF. It will be piloted in community-based practice and in a continuing education program for nurses. The HeFPAC pocket guide offers PC nurses a concise, evidence-informed and practical point-of care tool to communicate with other clinicians and patients about key HF issues that are associated with improving disease-specific HF palliative care and the quality of life of patients and their families. Pilot testing will offer insight as to its utility and potential for modification for national and international use.

  8. 'From activating towards caring': shifts in care approaches at the end of life of people with intellectual disabilities; a qualitative study of the perspectives of relatives, care-staff and physicians.

    Science.gov (United States)

    Bekkema, Nienke; de Veer, Anke J E; Hertogh, Cees M P M; Francke, Anneke L

    2015-07-25

    Professionals and relatives increasingly have to deal with people with intellectual disabilities (ID) who are in need of end-of-life care. This is a specific type of care that may require a different approach to the focus on participation that currently characterizes the care for people with ID. This paper describes the shifts in care approaches and attitudes that relatives and professionals perceive as the death of a person with ID approaches, as well as the values underlying these shifts. A qualitative design was used to reconstruct the cases of twelve recently deceased people with ID. Relatives and professionals who were closest to the person at the end of their life were interviewed. Interviews were transcribed verbatim and data were analyzed inductively, using elements of thematic analysis. Five shifts were found: 1) adapting to a new strategy of comforting care, taking over tasks and symptom relief, 2) interweaving of emotional and professional involvement, 3) stronger reliance on the joint interpretation of signals expressing distress and pain, 4) magnified feeling of responsibility in medical decisions, 5) intensified caring relationship between 'two families': relatives and care staff. Six relational values were behind these shifts: 'being there' for the person with ID, 'being responsive' to the person's needs, 'reflection' on their own emotions and caring relationships, 'attentiveness' to the ID person's wishes and expressions of distress, 'responsibility' for taking joint decisions in the best interests of the person, and 'openness to cooperation and sharing' the care with others. End-of-life care for people with ID involves curtailing expectations of participation and skill acquirement, and an increase in teamwork featuring intensified comforting care, symptom management and medical decision making. Three caring relationships need to be fostered: the relationship with the person with ID, relationships among professionals and the relationship between

  9. SMART DOCS: a new patient-centered outcomes and coordinated-care management approach for the future practice of sleep medicine.

    Science.gov (United States)

    Kushida, Clete A; Nichols, Deborah A; Holmes, Tyson H; Miller, Ric; Griffin, Kara; Cardell, Chia-Yu; Hyde, Pamela R; Cohen, Elyse; Manber, Rachel; Walsh, James K

    2015-02-01

    The practice of medicine is currently undergoing a transformation to become more efficient, cost-effective, and patient centered in its delivery of care. The aim of this article is to stimulate discussion within the sleep medicine community in addressing these needs by our approach as well as other approaches to sleep medicine care. The primary goals of the Sustainable Methods, Algorithms, and Research Tools for Delivering Optimal Care Study (SMART DOCS) are: (1) to introduce a new Patient-Centered Outcomes and Coordinated-Care Management (PCCM) approach for the future practice of sleep medicine, and (2) to test the PCCM approach against a Conventional Diagnostic and Treatment Outpatient Medical Care (CONV) approach in a randomized, two-arm, single-center, long-term, comparative effectiveness trial. The PCCM approach is integrated into a novel outpatient care delivery model for patients with sleep disorders that includes the latest technology, allowing providers to obtain more accurate and rapid diagnoses and to make evidence-based treatment recommendations, while simultaneously enabling patients to have access to personalized medical information and reports regarding their diagnosis and treatment so that they can make more informed health care decisions. Additionally, the PCCM approach facilitates better communication between patients, referring primary care physicians, sleep specialists, and allied health professionals so that providers can better assist patients in achieving their preferred outcomes. A total of 1,506 patients 18 y or older will be randomized to either the PCCM or CONV approach and will be followed for at least 1 y with endpoints of improved health care performance, better health, and cost control. http://www.clinicaltrials.gov, NCT02037438. © 2015 Associated Professional Sleep Societies, LLC.

  10. Ethanol dehydration to ethylene in a stratified autothermal millisecond reactor.

    Science.gov (United States)

    Skinner, Michael J; Michor, Edward L; Fan, Wei; Tsapatsis, Michael; Bhan, Aditya; Schmidt, Lanny D

    2011-08-22

    The concurrent decomposition and deoxygenation of ethanol was accomplished in a stratified reactor with 50-80 ms contact times. The stratified reactor comprised an upstream oxidation zone that contained Pt-coated Al(2)O(3) beads and a downstream dehydration zone consisting of H-ZSM-5 zeolite films deposited on Al(2)O(3) monoliths. Ethanol conversion, product selectivity, and reactor temperature profiles were measured for a range of fuel:oxygen ratios for two autothermal reactor configurations using two different sacrificial fuel mixtures: a parallel hydrogen-ethanol feed system and a series methane-ethanol feed system. Increasing the amount of oxygen relative to the fuel resulted in a monotonic increase in ethanol conversion in both reaction zones. The majority of the converted carbon was in the form of ethylene, where the ethanol carbon-carbon bonds stayed intact while the oxygen was removed. Over 90% yield of ethylene was achieved by using methane as a sacrificial fuel. These results demonstrate that noble metals can be successfully paired with zeolites to create a stratified autothermal reactor capable of removing oxygen from biomass model compounds in a compact, continuous flow system that can be configured to have multiple feed inputs, depending on process restrictions. Copyright © 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

  11. Art, Objects, and Beautiful Stories: A "New" Approach to Spiritual Care.

    Science.gov (United States)

    Smith, Aaron P B; Read, Julia E

    2017-06-01

    The use of story, and the use of art or various arts-based techniques have become popular in a number of helping professions, including spiritual care. There remains a gap in the literature, however, in which an approach comprised of both story and art or objects is explored. This paper addresses this gap by discussing the experience, theory, benefits, and technique of combining story and art or object-based techniques for the provision of spiritual care.

  12. Inviscid incompressible limits of strongly stratified fluids

    Czech Academy of Sciences Publication Activity Database

    Feireisl, Eduard; Jin, B.J.; Novotný, A.

    2014-01-01

    Roč. 89, 3-4 (2014), s. 307-329 ISSN 0921-7134 R&D Projects: GA ČR GA201/09/0917 Institutional support: RVO:67985840 Keywords : compressible Navier-Stokes system * anelastic approximation * stratified fluid Subject RIV: BA - General Mathematics Impact factor: 0.528, year: 2014 http://iospress.metapress.com/content/d71255745tl50125/?p=969b60ae82634854ab8bd25505ce1f71&pi=3

  13. Quality and effectiveness of different approaches to primary care delivery in Brazil

    Directory of Open Access Journals (Sweden)

    Trindade Thiago G

    2006-12-01

    Full Text Available Abstract Background Since 1994, Brazil has developed a primary care system based on multidisciplinary teams which include not only a physician and a nurse, but also 4–6 lay community health workers. This system now consists of 26,650 teams, covering 46% of the Brazilian population. Yet relatively few investigations have examined its effectiveness, especially in contrast with that of the traditional multi-specialty physician team approach it is replacing, or that of other existing family medicine approaches placing less emphasis on lay community health workers. Primary health care can be defined through its domains of access to first contact, continuity, coordination, comprehensiveness, community orientation and family orientation. These attributes can be ascertained via instruments such as the Primary Care Assessment Tool (PCATool, and correlated with the effectiveness of care. The objectives of our study are to validate the adult version of this instrument in Portuguese, identify the extent (quality of primary care present in different models of primary care services, and correlate this extent with measures of process and outcomes in patients with diabetes, hypertension and coronary heart disease (CHD. Methods/Design We are conducting a population-based cross-sectional study of primary care in the municipality of Porto Alegre. We will interview a random sample totaling 3000 adults residing in geographic areas covered by four distinct models of primary care of the Brazilian national health system or, alternatively, by one nationally prominent complementary health care service, as well as the physicians and nurses of the health teams of these services. Interviews query perceived quality of care (PCATool-Adult Version, patient satisfaction, and process indicators of management of diabetes, hypertension and known CHD. We are measuring blood pressure, anthropometrics and, in adults with known diabetes, glycated hemoglobin. Discussion We hope to

  14. SMART DOCS: A New Patient-Centered Outcomes and Coordinated-Care Management Approach for the Future Practice of Sleep Medicine

    Science.gov (United States)

    Kushida, Clete A.; Nichols, Deborah A.; Holmes, Tyson H.; Miller, Ric; Griffin, Kara; Cardell, Chia-Yu; Hyde, Pamela R.; Cohen, Elyse; Manber, Rachel; Walsh, James K.

    2015-01-01

    The practice of medicine is currently undergoing a transformation to become more efficient, cost-effective, and patient centered in its delivery of care. The aim of this article is to stimulate discussion within the sleep medicine community in addressing these needs by our approach as well as other approaches to sleep medicine care. The primary goals of the Sustainable Methods, Algorithms, and Research Tools for Delivering Optimal Care Study (SMART DOCS) are: (1) to introduce a new Patient-Centered Outcomes and Coordinated-Care Management (PCCM) approach for the future practice of sleep medicine, and (2) to test the PCCM approach against a Conventional Diagnostic and Treatment Outpatient Medical Care (CONV) approach in a randomized, two-arm, single-center, long-term, comparative effectiveness trial. The PCCM approach is integrated into a novel outpatient care delivery model for patients with sleep disorders that includes the latest technology, allowing providers to obtain more accurate and rapid diagnoses and to make evidence-based treatment recommendations, while simultaneously enabling patients to have access to personalized medical information and reports regarding their diagnosis and treatment so that they can make more informed health care decisions. Additionally, the PCCM approach facilitates better communication between patients, referring primary care physicians, sleep specialists, and allied health professionals so that providers can better assist patients in achieving their preferred outcomes. A total of 1,506 patients 18 y or older will be randomized to either the PCCM or CONV approach and will be followed for at least 1 y with endpoints of improved health care performance, better health, and cost control. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT02037438. Citation: Kushida CA, Nichols DA, Holmes TH, Miller R, Griffin K, Cardell CY, Hyde PR, Cohen E, Manber R, Walsh JK. SMART DOCS: a new patient-centered outcomes and coordinated-care

  15. 'From activating towards caring': shifts in care approaches at the end of life of people with intellectual disabilities; a qualitative study of the perspectives of relatives, care-staff and physicians.

    NARCIS (Netherlands)

    Bekkema, N.; Veer, A.J.E. de; Hertogh, C.M.P.M.; Francke, A.L.

    2015-01-01

    Background: Professionals and relatives increasingly have to deal with people with intellectual disabilities (ID) who are in need of end-of-life care. This is a specific type of care that may require a different approach to the focus on participation that currently characterizes the care for people

  16. 'From activating towards caring': shifts in care approaches at the end of life of people with intellectual disabilities; a qualitative study of the perspectives of relatives, care-staff and physicians

    NARCIS (Netherlands)

    Bekkema, N.; de Veer, A.J.E.; Hertogh, C.M.P.M.; Francke, A.L.

    2015-01-01

    Background: Professionals and relatives increasingly have to deal with people with intellectual disabilities (ID) who are in need of end-of-life care. This is a specific type of care that may require a different approach to the focus on participation that currently characterizes the care for people

  17. Integrating care for people with mental illness: the Care Programme Approach in England and its implications for long-term conditions management

    Directory of Open Access Journals (Sweden)

    Nick Goodwin

    2010-03-01

    Full Text Available Introduction: This policy paper considers what the long-term conditions policies in England and other countries could learn from the experience of the Care Programme Approach (CPA. The CPA was introduced in England in April 1991 as the statutory framework for people requiring support in the community for more severe and enduring mental health problems. The CPA approach is an example of a long-standing 'care co-ordination' model that seeks to develop individualised care plans and then attempt to integrate care for patients from a range of providers.Policy description: The CPA experience is highly relevant to both the English and international debates on the future of long-term conditions management where the agenda has focused on developing co-ordinated care planning and delivery between health and social care; to prioritise upstream interventions that promote health and wellbeing; and to provide for a more personalised service.Conclusion: This review of the CPA experience suggests that there is the potential for better care integration for those patients with multiple or complex needs where a strategy of personalised care planning and pro-active care co-ordination is provided. However, such models will not reach their full potential unless a number of preconditions are met including: clear eligibility criteria; standardised measures of service quality; a mix of governance and incentives to hold providers accountable for such quality; and genuine patient involvement in their own care plans.Implications: Investment and professional support to the role of the care co-ordinator is particularly crucial. Care co-ordinators require the requisite skills and competencies to act as a  care professional  to the patient as well as to have the power to exert authority among other care professionals to ensure multidisciplinary care plans are implemented successfully. Attention to inter-professional practice, culture, leadership and organisational

  18. Integrating care for people with mental illness: the Care Programme Approach in England and its implications for long-term conditions management

    Directory of Open Access Journals (Sweden)

    Nick Goodwin

    2010-03-01

    Full Text Available Introduction: This policy paper considers what the long-term conditions policies in England and other countries could learn from the experience of the Care Programme Approach (CPA. The CPA was introduced in England in April 1991 as the statutory framework for people requiring support in the community for more severe and enduring mental health problems. The CPA approach is an example of a long-standing 'care co-ordination' model that seeks to develop individualised care plans and then attempt to integrate care for patients from a range of providers. Policy description: The CPA experience is highly relevant to both the English and international debates on the future of long-term conditions management where the agenda has focused on developing co-ordinated care planning and delivery between health and social care; to prioritise upstream interventions that promote health and wellbeing; and to provide for a more personalised service. Conclusion: This review of the CPA experience suggests that there is the potential for better care integration for those patients with multiple or complex needs where a strategy of personalised care planning and pro-active care co-ordination is provided. However, such models will not reach their full potential unless a number of preconditions are met including: clear eligibility criteria; standardised measures of service quality; a mix of governance and incentives to hold providers accountable for such quality; and genuine patient involvement in their own care plans. Implications: Investment and professional support to the role of the care co-ordinator is particularly crucial. Care co-ordinators require the requisite skills and competencies to act as a  care professional  to the patient as well as to have the power to exert authority among other care professionals to ensure multidisciplinary care plans are implemented successfully. Attention to inter-professional practice, culture, leadership and organisational

  19. Toward a Holistic Approach to Spiritual Health Care for People With Schizophrenia.

    Science.gov (United States)

    Ho, Rainbow T H; Wan, Adrian H Y; Chan, Caitlin K P

    2016-01-01

    Medical and behavioral treatments are the predominant types of rehabilitation services for people with schizophrenia. Spirituality in people with schizophrenia remains poorly conceptualized, thereby limiting knowledge advancement in the area of spiritual health care services. To provide a framework for better clinical and research practices, we advocate a holistic approach to investigating spirituality and its application in spiritual health care services of people with schizophrenia.

  20. Elements of integrated care approaches for older people: a review of reviews.

    Science.gov (United States)

    Briggs, Andrew M; Valentijn, Pim P; Thiyagarajan, Jotheeswaran A; Araujo de Carvalho, Islene

    2018-04-07

    The World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge gap remains in the key elements of integrated care approaches used in health and social care delivery systems for older populations. The objective of this review was to identify and describe the key elements of integrated care models for elderly people reported in the literature. Review of reviews using a systematic search method. A systematic search was performed in MEDLINE and the Cochrane database in June 2017. Reviews of interventions aimed at care integration at the clinical (micro), organisational/service (meso) or health system (macro) levels for people aged ≥60 years were included. Non-Cochrane reviews published before 2015 were excluded. Reviews were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) 1 tool. Fifteen reviews (11 systematic reviews, of which six were Cochrane reviews) were included, representing 219 primary studies. Three reviews (20%) included only randomised controlled trials (RCT), while 10 reviews (65%) included both RCTs and non-RCTs. The region where the largest number of primary studies originated was North America (n=89, 47.6%), followed by Europe (n=60, 32.1%) and Oceania (n=31, 16.6%). Eleven (73%) reviews focused on clinical 'micro' and organisational 'meso' care integration strategies. The most commonly reported elements of integrated care models were multidisciplinary teams, comprehensive assessment and case management. Nurses, physiotherapists, general practitioners and social workers were the most commonly reported service providers. Methodological quality was variable (AMSTAR scores: 1-11). Seven (47%) reviews were scored as high quality (AMSTAR score ≥8). Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there

  1. Behaviour of a pressure vessel nozzle with thermo-sleeve under thermal loading induced by stratified flow

    International Nuclear Information System (INIS)

    Kussmaul, K.; Mayinger, W.; Diem, H.; Katzenmeier, G.

    1993-01-01

    Startup at low reactor power may give rise to stratified flow conditions in pipes of boiling water and pressurized water reactors. Stratified flow regimes cause a steep temperature gradient between the cold and the hot fluid layer. This temperature gradient produces high axial stresses which, in the case of intermittent feeding of cold water and an appropriate number of repetitions, in principle may initiate cracking in the feedwater pipe and close to the feeding nozzle. Thermosleeves have been installed in a number of reactors to mitigate thermally induced stresses; they reduce the intensity of thermal transients by means of an insulating fluid annulus developing between the sleeve and the nozzle, in order to measure the temperature and stress gradients occurring in the region of the nozzle edge, the so-called TEMS experiments were carried out under realistic operating conditions, and with different cold water levels within the framework of German research activities in the field of reactor safety at the HDR test facility. The experiments served to simulate the physics phenomena by means of a FE-program and to verify the computational approach by comparisons of measurements and calculations

  2. When homogeneity meets heterogeneity: the geographically weighted regression with spatial lag approach to prenatal care utilization

    Science.gov (United States)

    Shoff, Carla; Chen, Vivian Yi-Ju; Yang, Tse-Chuan

    2014-01-01

    Using geographically weighted regression (GWR), a recent study by Shoff and colleagues (2012) investigated the place-specific risk factors for prenatal care utilization in the US and found that most of the relationships between late or not prenatal care and its determinants are spatially heterogeneous. However, the GWR approach may be subject to the confounding effect of spatial homogeneity. The goal of this study is to address this concern by including both spatial homogeneity and heterogeneity into the analysis. Specifically, we employ an analytic framework where a spatially lagged (SL) effect of the dependent variable is incorporated into the GWR model, which is called GWR-SL. Using this innovative framework, we found evidence to argue that spatial homogeneity is neglected in the study by Shoff et al. (2012) and the results are changed after considering the spatially lagged effect of prenatal care utilization. The GWR-SL approach allows us to gain a place-specific understanding of prenatal care utilization in US counties. In addition, we compared the GWR-SL results with the results of conventional approaches (i.e., OLS and spatial lag models) and found that GWR-SL is the preferred modeling approach. The new findings help us to better estimate how the predictors are associated with prenatal care utilization across space, and determine whether and how the level of prenatal care utilization in neighboring counties matters. PMID:24893033

  3. RANS Modeling of Stably Stratified Turbulent Boundary Layer Flows in OpenFOAM®

    Directory of Open Access Journals (Sweden)

    Wilson Jordan M.

    2015-01-01

    Full Text Available Quantifying mixing processes relating to the transport of heat, momentum, and scalar quantities of stably stratified turbulent geophysical flows remains a substantial task. In a stably stratified flow, such as the stable atmospheric boundary layer (SABL, buoyancy forces have a significant impact on the flow characteristics. This study investigates constant and stability-dependent turbulent Prandtl number (Prt formulations linking the turbulent viscosity (νt and diffusivity (κt for modeling applications of boundary layer flows. Numerical simulations of plane Couette flow and pressure-driven channel flow are performed using the Reynolds-averaged Navier-Stokes (RANS framework with the standard k-ε turbulence model. Results are compared with DNS data to evaluate model efficacy for predicting mean velocity and density fields. In channel flow simulations, a Prandtl number formulation for wall-bounded flows is introduced to alleviate overmixing of the mean density field. This research reveals that appropriate specification of Prt can improve predictions of stably stratified turbulent boundary layer flows.

  4. A systems approach to accepted standards of care: Shifting the blame

    Directory of Open Access Journals (Sweden)

    David G. Glance

    2011-09-01

    Full Text Available In healthcare, from a legal perspective, the standard ofacceptable practice has been generally set by the courts anddefined as healthcare professionals acting in a manner thatis widely accepted by their peers as meeting an acceptablestandard of care. This view, however, reflects the state ofhow practice “is” rather than what it “ought to be”. What isought to be depends on whether you take a “person” or“system” oriented approach to practice.The increasing pressures of lack of money and resources,and an ever-increasing need for care are bringing pressureon the health services to move to a system approach andthis is gaining acceptance both with clinicians and thuseventually the courts.A systems-type approach to healthcare will, by necessity,embrace clinical protocols and guidelines supported byclinical information systems. It will also see blame for errorsshifting from clinicians to the organisations that employthem.This paper argues that a continued use of a person-basedapproach to healthcare, developed through an historicalrecord of practice by individual clinicians, is no longeradequate defence in a case of supposed negligence.When the healthcare system has codified clinical guidelinesand digital data gathered across thousands of clinicians andtheir patients, it is possible to compute adequate levels ofcare and expect clinicians and the healthcare system ingeneral to meet these minimum standards.Future negligence decisions will rely on a systems-basedbest practice standard of care determined through evidencerather than opinion

  5. Cancer Care and Control as a Human Right: Recognizing Global Oncology as an Academic Field.

    Science.gov (United States)

    Eniu, Alexandru E; Martei, Yehoda M; Trimble, Edward L; Shulman, Lawrence N

    2017-01-01

    The global burden of cancer incidence and mortality is on the rise. There are major differences in cancer fatality rates due to profound disparities in the burden and resource allocation for cancer care and control in developed compared with developing countries. The right to cancer care and control should be a human right accessible to all patients with cancer, regardless of geographic or economic region, to avoid unnecessary deaths and suffering from cancer. National cancer planning should include an integrated approach that incorporates a continuum of education, prevention, cancer diagnostics, treatment, survivorship, and palliative care. Global oncology as an academic field should offer the knowledge and skills needed to efficiently assess situations and work on solutions, in close partnership. We need medical oncologists, surgical oncologists, pediatric oncologists, gynecologic oncologists, radiologists, and pathologists trained to think about well-tailored resource-stratified solutions to cancer care in the developing world. Moreover, the multidisciplinary fundamental team approach needed to treat most neoplastic diseases requires coordinated investment in several areas. Current innovative approaches have relied on partnerships between academic institutions in developed countries and local governments and ministries of health in developing countries to provide the expertise needed to implement effective cancer control programs. Global oncology is a viable and necessary field that needs to be emphasized because of its critical role in proposing not only solutions in developing countries, but also solutions that can be applied to similar challenges of access to cancer care and control faced by underserved populations in developed countries.

  6. Why health care corruption needs a new approach.

    Science.gov (United States)

    Radin, Dagmar

    2016-07-01

    While corruption has been at the center of academic studies and on the agenda of international organizations for a couple of decades, in the health care sector corruption has not generated much interest or progress. At the centre of this issue is the lack of an interdisciplinary approach, which is warranted given the complexity of the issue and the lack of cooperation between STET scientifically rigorous academics and policy-makers, leaving room for more cooperation and progress. © The Author(s) 2015.

  7. Where the Mind Meets the Mouth – an integrated and collaborative health care approach

    OpenAIRE

    Martin, Rachel Ellen; Calache, Hanny; Richardson, Jessie; Krouskos, Demos; Hall, Martin; Bettega, Alyson; Chalmers-Robinson, Emily; Christian, Bradley

    2018-01-01

    Background: The majority of the cost of oral health care in Australia is borne by individuals, hence many miss out on early, cost-effective care. 63,000 Australians are hospitalised annually for preventable oral conditions. Current approaches separate the provision of oral from general health care. Australia’s National Oral Health Plan recognises oral health as everyone’s business and a role for health care workers and carers to intervene early in oral disease.Objectives: To present an innova...

  8. Stability of Miscible Displacements Across Stratified Porous Media

    Energy Technology Data Exchange (ETDEWEB)

    Shariati, Maryam; Yortsos, Yanis C.

    2000-09-11

    This report studied macro-scale heterogeneity effects. Reflecting on their importance, current simulation practices of flow and displacement in porous media were invariably based on heterogeneous permeability fields. Here, it was focused on a specific aspect of such problems, namely the stability of miscible displacements in stratified porous media, where the displacement is perpendicular to the direction of stratification.

  9. Stratifying the Risk of Venous Thromboembolism in Otolaryngology

    Science.gov (United States)

    Shuman, Andrew G.; Hu, Hsou Mei; Pannucci, Christopher J.; Jackson, Christopher R.; Bradford, Carol R.; Bahl, Vinita

    2015-01-01

    Objective The consequences of perioperative venous thromboembolism (VTE) are devastating; identifying patients at risk is an essential step in reducing morbidity and mortality. The utility of perioperative VTE risk assessment in otolaryngology is unknown. This study was designed to risk-stratify a diverse population of otolaryngology patients for VTE events. Study Design Retrospective cohort study. Setting Single-institution academic tertiary care medical center. Subjects and Methods Adult patients presenting for otolaryngologic surgery requiring hospital admission from 2003 to 2010 who did not receive VTE chemoprophylaxis were included. The Caprini risk assessment was retrospectively scored via a validated method of electronic chart abstraction. Primary study variables were Caprini risk scores and the incidence of perioperative venous thromboembolic outcomes. Results A total of 2016 patients were identified. The overall 30-day rate of VTE was 1.3%. The incidence of VTE in patients with a Caprini risk score of 6 or less was 0.5%. For patients with scores of 7 or 8, the incidence was 2.4%. Patients with a Caprini risk score greater than 8 had an 18.3% incidence of VTE and were significantly more likely to develop a VTE when compared to patients with a Caprini risk score less than 8 (P otolaryngology patients for 30-day VTE events and allows otolaryngologists to identify patient subgroups who have a higher risk of VTE in the absence of chemoprophylaxis. PMID:22261490

  10. Reproductive health care strategy -- a gender-sensitive approach to family welfare.

    Science.gov (United States)

    Anita

    1996-01-01

    The author advocates a reproductive health care strategy to revitalize India's family welfare program. A major shift in focus is needed in population policy and programs to incorporate a gender-sensitive approach. That shift should help to clear the path toward improved health status for women and female children. Consensus reached at the UN's 1994 International Conference on Population and Development supported a change in population and development policies, affording women's empowerment, gender equality, and equity greater priority for a meaningful policy of human-centered sustainable development. Reproductive health care, reproductive health in practice, the quality of care in reproductive health, gender equality as a human right, and empowering women are discussed.

  11. Mechanisms and Variability of Salt Transport in Partially-Stratified Estuaries

    National Research Council Canada - National Science Library

    Bowen, Melissa

    2000-01-01

    .... Analysis of salt transport from observations in the Hudson Estuary show that stratified periods with elevated estuarine salt transport occur in five-day intervals once a month during apogean neap tides...

  12. Unit Stratified Sampling as a Tool for Approximation of Stochastic Optimization Problems

    Czech Academy of Sciences Publication Activity Database

    Šmíd, Martin

    2012-01-01

    Roč. 19, č. 30 (2012), s. 153-169 ISSN 1212-074X R&D Projects: GA ČR GAP402/11/0150; GA ČR GAP402/10/0956; GA ČR GA402/09/0965 Institutional research plan: CEZ:AV0Z10750506 Institutional support: RVO:67985556 Keywords : Stochastic programming * approximation * stratified sampling Subject RIV: BB - Applied Statistics, Operational Research http://library.utia.cas.cz/separaty/2013/E/smid-unit stratified sampling as a tool for approximation of stochastic optimization problems.pdf

  13. Evaluation of complex integrated care programmes: the approach in North West London

    Science.gov (United States)

    Greaves, Felix; Pappas, Yannis; Bardsley, Martin; Harris, Matthew; Curry, Natasha; Holder, Holly; Blunt, Ian; Soljak, Michael; Gunn, Laura; Majeed, Azeem; Car, Josip

    2013-01-01

    Background Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important. PMID:23687478

  14. Evaluation of complex integrated care programmes: the approach in North West London

    Directory of Open Access Journals (Sweden)

    Felix Greaves

    2013-03-01

    Full Text Available Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

  15. Evaluation of complex integrated care programmes: the approach in North West London

    Directory of Open Access Journals (Sweden)

    Felix Greaves

    2013-03-01

    Full Text Available Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect.Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context.Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them.Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

  16. Exploring a model-driven architecture (MDA) approach to health care information systems development.

    Science.gov (United States)

    Raghupathi, Wullianallur; Umar, Amjad

    2008-05-01

    To explore the potential of the model-driven architecture (MDA) in health care information systems development. An MDA is conceptualized and developed for a health clinic system to track patient information. A prototype of the MDA is implemented using an advanced MDA tool. The UML provides the underlying modeling support in the form of the class diagram. The PIM to PSM transformation rules are applied to generate the prototype application from the model. The result of the research is a complete MDA methodology to developing health care information systems. Additional insights gained include development of transformation rules and documentation of the challenges in the application of MDA to health care. Design guidelines for future MDA applications are described. The model has the potential for generalizability. The overall approach supports limited interoperability and portability. The research demonstrates the applicability of the MDA approach to health care information systems development. When properly implemented, it has the potential to overcome the challenges of platform (vendor) dependency, lack of open standards, interoperability, portability, scalability, and the high cost of implementation.

  17. Inhibition of Rho-associated kinases disturbs the collective cell migration of stratified TE-10 cells

    Directory of Open Access Journals (Sweden)

    Taro Mikami

    2015-01-01

    Full Text Available BACKGROUND: The collective cell migration of stratified epithelial cells is considered to be an important phenomenon in wound healing, development, and cancer invasion; however, little is known about the mechanisms involved. Furthermore, whereas Rho family proteins, including RhoA, play important roles in cell migration, the exact role of Rho-associated coiled coil-containing protein kinases (ROCKs in cell migration is controversial and might be cell-type dependent. Here, we report the development of a novel modified scratch assay that was used to observe the collective cell migration of stratified TE-10 cells derived from a human esophageal cancer specimen. RESULTS: Desmosomes were found between the TE-10 cells and microvilli of the surface of the cell sheet. The leading edge of cells in the cell sheet formed a simple layer and moved forward regularly; these rows were followed by the stratified epithelium. ROCK inhibitors and ROCK small interfering RNAs (siRNAs disturbed not only the collective migration of the leading edge of this cell sheet, but also the stratified layer in the rear. In contrast, RhoA siRNA treatment resulted in more rapid migration of the leading rows and disturbed movement of the stratified portion. CONCLUSIONS: The data presented in this study suggest that ROCKs play an important role in mediating the collective migration of TE-10 cell sheets. In addition, differences between the effects of siRNAs targeting either RhoA or ROCKs suggested that distinct mechanisms regulate the collective cell migration in the simple epithelium of the wound edge versus the stratified layer of the epithelium.

  18. Should care homes adopt a static-led approach to pressure ulcer prevention?

    Science.gov (United States)

    Keen, Delia Catherine

    A static-led approach refers to the provision of high-specification foam mattresses for the whole of a population at risk of pressure damage. Such mattresses have been found to reduce the risk of pressure ulceration and cost less overall than standard mattresses, even in populations where only 1 in 100 patients develops a pressure ulcer. Reduced pressure ulcer prevalence and reduced costs resulting from decreased expenditure on dynamic mattresses following the implementation of a static-led approach have been reported. Pressure ulcers cause pain, a reduced quality of life, loss of independence, depression and social isolation for those in whom they develop. Organizations are increasingly having to pay out large sums of money following litigation surrounding pressure ulcers. This article explains why NHS healthcare providers and private care organizations need to work together to consider implementing a static-led approach to pressure ulcer prevention within care homes in order to reduce pressure ulcer incidence cost-effectively within their local populations.

  19. Stereo imaging and random array stratified imaging for cargo radiation inspecting

    International Nuclear Information System (INIS)

    Wang Jingjin; Zeng Yu

    2003-01-01

    This paper presents a Stereo Imaging and Random Array Stratified Imaging for cargo container radiation Inspecting. By using dual-line vertical detector array scan, a stereo image of inspected cargo can be obtained and watched with virtual reality view. The random detector array has only one-row of detectors but distributed in a certain horizontal dimension randomly. To scan a cargo container with this random array detector, a 'defocused' image is obtained. By using 'anti-random focusing', one layer of the image can be focused on the background of all defocused images from other layers. A stratified X-ray image of overlapped bike wheels is presented

  20. Studying integrated health care systems with a structurationist approach

    Science.gov (United States)

    Demers, Louis; Arseneault, Stéphane; Couturier, Yves

    2010-01-01

    Introduction To implement an integrated health care system is not an easy task and to ensure its sustainability is yet more difficult. Aim Discuss how a structurationist approach can shed light on the stakes of these processes and guide the managers of such endeavours. Theory and method Structuration theory [1] has been used by numerous authors to cast new light on complex organizational phenomena. One of the central tenets of this theory is that social systems, such as integrated health care systems, are recurrent social practices across time-space and are characterized by structural properties which simultaneously constrain and enable the constitutive social actors who reproduce and transform the system through their practices. We will illustrate our theoretical standpoint with empirical material gathered during the study of an integrated health care system for the frail elderly in Quebec, Canada. This system has been implemented in 1997 and is still working well in 2010. Results and conclusion To implement an integrated health care system that is both effective and sustainable, its managers must shrewdly allow for the existing system and progressively introduce changes in the way managers and practitioners at work in the system view their role and act on a daily basis.

  1. Stratified charge rotary engine combustion studies

    Science.gov (United States)

    Shock, H.; Hamady, F.; Somerton, C.; Stuecken, T.; Chouinard, E.; Rachal, T.; Kosterman, J.; Lambeth, M.; Olbrich, C.

    1989-07-01

    Analytical and experimental studies of the combustion process in a stratified charge rotary engine (SCRE) continue to be the subject of active research in recent years. Specifically to meet the demand for more sophisticated products, a detailed understanding of the engine system of interest is warranted. With this in mind the objective of this work is to develop an understanding of the controlling factors that affect the SCRE combustion process so that an efficient power dense rotary engine can be designed. The influence of the induction-exhaust systems and the rotor geometry are believed to have a significant effect on combustion chamber flow characteristics. In this report, emphasis is centered on Laser Doppler Velocimetry (LDV) measurements and on qualitative flow visualizations in the combustion chamber of the motored rotary engine assembly. This will provide a basic understanding of the flow process in the RCE and serve as a data base for verification of numerical simulations. Understanding fuel injection provisions is also important to the successful operation of the stratified charge rotary engine. Toward this end, flow visualizations depicting the development of high speed, high pressure fuel jets are described. Friction is an important consideration in an engine from the standpoint of lost work, durability and reliability. MSU Engine Research Laboratory efforts in accessing the frictional losses associated with the rotary engine are described. This includes work which describes losses in bearing, seal and auxillary components. Finally, a computer controlled mapping system under development is described. This system can be used to map shapes such as combustion chamber, intake manifolds or turbine blades accurately.

  2. Equipment for extracting and conveying stratified minerals

    Energy Technology Data Exchange (ETDEWEB)

    Blumenthal, G.; Kunzer, H.; Plaga, K.

    1991-08-14

    This invention relates to equipment for extracting stratified minerals and conveying the said minerals along the working face, comprising a trough shaped conveyor run assembled from lengths, a troughed extraction run in lengths matching the lengths of conveyor troughing, which is linked to the top edge of the working face side of the conveyor troughing with freedom to swivel vertically, and a positively guided chain carrying extraction tools and scrapers along the conveyor and extraction runs.

  3. A mechanically enhanced hybrid nano-stratified barrier with a defect suppression mechanism for highly reliable flexible OLEDs.

    Science.gov (United States)

    Jeong, Eun Gyo; Kwon, Seonil; Han, Jun Hee; Im, Hyeon-Gyun; Bae, Byeong-Soo; Choi, Kyung Cheol

    2017-05-18

    Understanding the mechanical behaviors of encapsulation barriers under bending stress is important when fabricating flexible organic light-emitting diodes (FOLEDs). The enhanced mechanical characteristics of a nano-stratified barrier were analyzed based on a defect suppression mechanism, and then experimentally demonstrated. Following the Griffith model, naturally-occurring cracks, which were caused by Zn etching at the interface of the nano-stratified structure, can curb the propagation of defects. Cross-section images after bending tests provided remarkable evidence to support the existence of a defect suppression mechanism. Many visible cracks were found in a single Al 2 O 3 layer, but not in the nano-stratified structure, due to the mechanism. The nano-stratified structure also enhanced the barrier's physical properties by changing the crystalline phase of ZnO. In addition, experimental results demonstrated the effect of the mechanism in various ways. The nano-stratified barrier maintained a low water vapor transmission rate after 1000 iterations of a 1 cm bending radius test. Using this mechanically enhanced hybrid nano-stratified barrier, FOLEDs were successfully encapsulated without losing mechanical or electrical performance. Finally, comparative lifetime measurements were conducted to determine reliability. After 2000 hours of constant current driving and 1000 iterations with a 1 cm bending radius, the FOLEDs retained 52.37% of their initial luminance, which is comparable to glass-lid encapsulation, with 55.96% retention. Herein, we report a mechanically enhanced encapsulation technology for FOLEDs using a nano-stratified structure with a defect suppression mechanism.

  4. Experimental investigation and physical description of stratified flow in horizontal channels

    International Nuclear Information System (INIS)

    Staebler, T.

    2007-05-01

    The interaction between a liquid film and turbulent gas flows plays an important role in many technical applications (e.g. in hydraulic engineering, process engineering and nuclear engineering). The local kinematic and turbulent time-averaged flow quantities for counter-current stratified flows (supercritical and subcritical flows with and without flow reversal) have been measured for the first time. Therefore, the method of Particle Image Velocimetry was applied. By using fluorescent particles in combination with an optical filter it was possible to determine the flow quantities of the liquid phase up to the free surface. Additionally, the gaseous phase was investigated by using the scattering of light of conventional particles. With a further measurement technique the void fraction distribution along the channel height has been determined. For this purpose, a single-tip conductivity probe was developed. Furthermore, water delivery rates and pressure losses along the test section were measured over a wide range of parameters. The measurements also revealed new details on the hysteresis effect after the occurrence of flow reversal. The experimental findings were used to develop and validate a statistical model in which the liquid phase is considered to be an agglomeration of interacting particles. The statistical consideration of the particle interactions delivers a differential equation which can be used to predict the local void fraction distribution with the local turbulent kinematic energies of the liquid phase. Beyond that, an additional statistical description is presented in which the probability density functions of the local void fraction are described by beta-functions. Both theoretical approaches can be used for numerical modelling whereas the statistical model can be used to describe the phase interactions and the statistical description to describe the turbulent fluctuations of the local void fraction. Thus, this work has made available all necessary

  5. Evaluation of a Stratified National Breast Screening Program in the United Kingdom : An Early Model-Based Cost-Effectiveness Analysis

    NARCIS (Netherlands)

    Gray, Ewan; Donten, Anna; Karssemeijer, Nico; van Gils, Carla; Evans, D. Gareth R.; Astley, Sue; Payne, Katherine

    Objectives: To identify the incremental costs and consequences of stratified national breast screening programs (stratified NBSPs) and drivers of relative cost-effectiveness. Methods: A decision-analytic model (discrete event simulation) was conceptualized to represent four stratified NBSPs (risk 1,

  6. Evaluation of a Stratified National Breast Screening Program in the United Kingdom: An Early Model-Based Cost-Effectiveness Analysis

    NARCIS (Netherlands)

    Gray, E.; Donten, A.; Karssemeijer, N.; Gils, C. van; Evans, D.G.; Astley, S.; Payne, K.

    2017-01-01

    OBJECTIVES: To identify the incremental costs and consequences of stratified national breast screening programs (stratified NBSPs) and drivers of relative cost-effectiveness. METHODS: A decision-analytic model (discrete event simulation) was conceptualized to represent four stratified NBSPs (risk 1,

  7. Integrating housing and long-term care services for the elderly: a social marketing approach.

    Science.gov (United States)

    Moore, S T

    1991-01-01

    Subsidized senior high-rise apartments have tended to neglect the needs of an increasingly aged and frail resident population. Research demonstrates that this population has greater unmet needs than elderly who reside in traditional community housing. This paper makes the case for a vertically integrated marketing approach to serving the elderly. Such an approach would combine housing and community based long-term care services into a single system of care. Enriched senior high-rise apartments are a viable alternative for elders who need assistance in order to maintain an independent lifestyle.

  8. Project INTEGRATE - a common methodological approach to understand integrated health care in Europe

    Directory of Open Access Journals (Sweden)

    Lucinda Cash-Gibson

    2014-12-01

    Full Text Available Background: The use of case studies in health services research has proven to be an excellent methodology for gaining in-depth understanding of the organisation and delivery of health care. This is particularly relevant when looking at the complexity of integrated healthcare programmes, where multifaceted interactions occur at the different levels of care and often without a clear link between the interventions (new and/or existing and their impact on outcomes (in terms of patients health, both patient and professional satisfaction and cost-effectiveness. Still, integrated care is seen as a core strategy in the sustainability of health and care provision in most societies in Europe and beyond. More specifically, at present, there is neither clear evidence on transferable factors of integrated care success nor a method for determining how to establish these specific success factors. The drawback of case methodology in this case, however, is that the in-depth results or lessons generated are usually highly context-specific and thus brings the challenge of transferability of findings to other settings, as different health care systems and different indications are often not comparable. Project INTEGRATE, a European Commission-funded project, has been designed to overcome these problems; it looks into four chronic conditions in different European settings, under a common methodology framework (taking a mixed-methods approach to try to overcome the issue of context specificity and limited transferability. The common methodological framework described in this paper seeks to bring together the different case study findings in a way that key lessons may be derived and transferred between countries, contexts and patient-groups, where integrated care is delivered in order to provide insight into generalisability and build on existing evidence in this field.Methodology: To compare the different integrated care experiences, a mixed-methods approach has

  9. The meaning of integrated care: a systems approach

    Directory of Open Access Journals (Sweden)

    Lars Edgren

    2008-10-01

    Full Text Available Introduction: Organizations can be regarded as systems. The traditional model of systems views them as machines. This seems to be insufficient when it comes to understanding and organizing complex tasks. To better understand integrated care we should approach organizations as constantly changing living organisms, where many agents are interconnected in so-called Complex Adaptive Systems (CAS. Theory and discussion: The term “complex” emphasizes that the necessary competence to perform a task is not owned by any one part, but comes as a result of co-operation within the system. “Adaptive” means that system change occurs through successive adaptations. A CAS consists of several subsystems called agents, which act in dependence of one another. Examples would be the ant-hill, the human immune defence, the financial market and the surgical operating theatre team. Studying a CAS, the focus is on the interaction and communication between agents. Although these thoughts are not new, the CAS-approach has not yet been widely applied to the management of integrated care. This helps the management to understand why the traditional top down way of managing, following the machine model thinking, may meet with problems in interdependent organizations with complex tasks. Conclusion: When we perceive health and social services as CASs we should gain more insight into the processes that go on within and between organizations and how top management, for example within a hospital, in fact executes its steering function.

  10. How Health Care Organizations Are Using Data on Patients' Race and Ethnicity to Improve Quality of Care

    Science.gov (United States)

    Thorlby, Ruth; Jorgensen, Selena; Siegel, Bruce; Ayanian, John Z

    2011-01-01

    Context: Racial and ethnic disparities in the quality of health care are well documented in the U.S. health care system. Reducing these disparities requires action by health care organizations. Collecting accurate data from patients about their race and ethnicity is an essential first step for health care organizations to take such action, but these data are not systematically collected and used for quality improvement purposes in the United States. This study explores the challenges encountered by health care organizations that attempted to collect and use these data to reduce disparities. Methods: Purposive sampling was used to identify eight health care organizations that collected race and ethnicity data to measure and reduce disparities in the quality and outcomes of health care. Staff, including senior managers and data analysts, were interviewed at each site, using a semi-structured interview format about the following themes: the challenges of collecting and collating accurate data from patients, how organizations defined a disparity and analyzed data, and the impact and uses of their findings. Findings: To collect accurate self-reported data on race and ethnicity from patients, most organizations had upgraded or modified their IT systems to capture data and trained staff to collect and input these data from patients. By stratifying nationally validated indicators of quality for hospitals and ambulatory care by race and ethnicity, most organizations had then used these data to identify disparities in the quality of care. In this process, organizations were taking different approaches to defining and measuring disparities. Through these various methods, all organizations had found some disparities, and some had invested in interventions designed to address them, such as extra staff, extended hours, or services in new locations. Conclusion: If policymakers wish to hold health care organizations accountable for disparities in the quality of the care they

  11. A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model

    Science.gov (United States)

    2009-01-01

    Abstract Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models. TIDES social marketing approach The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan. Results Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy. Discussion and conclusion Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems. PMID:19785754

  12. Using prognostic models in CLL to personalize approach to clinical care: Are we there yet?

    Science.gov (United States)

    Mina, Alain; Sandoval Sus, Jose; Sleiman, Elsa; Pinilla-Ibarz, Javier; Awan, Farrukh T; Kharfan-Dabaja, Mohamed A

    2018-03-01

    Four decades ago, two staging systems were developed to help stratify CLL into different prognostic categories. These systems, the Rai and the Binet staging, depended entirely on abnormal exam findings and evidence of anemia and thrombocytopenia. Better understanding of biologic, genetic, and molecular characteristics of CLL have contributed to better appreciating its clinical heterogeneity. New prognostic models, the GCLLSG prognostic index and the CLL-IPI, emerged. They incorporate biologic and genetic information related to CLL and are capable of predicting survival outcomes and cases anticipated to need therapy earlier in the disease course. Accordingly, these newer models are helping develop better informed surveillance strategies and ultimately tailor treatment intensity according to presence (or lack thereof) of certain prognostic markers. This represents a step towards personalizing care of CLL patients. We anticipate that as more prognostic factors continue to be identified, the GCLLSG prognostic index and CLL-IPI models will undergo further revisions. Copyright © 2017 Elsevier Ltd. All rights reserved.

  13. Crenothrix are major methane consumers in stratified lakes.

    Science.gov (United States)

    Oswald, Kirsten; Graf, Jon S; Littmann, Sten; Tienken, Daniela; Brand, Andreas; Wehrli, Bernhard; Albertsen, Mads; Daims, Holger; Wagner, Michael; Kuypers, Marcel Mm; Schubert, Carsten J; Milucka, Jana

    2017-09-01

    Methane-oxidizing bacteria represent a major biological sink for methane and are thus Earth's natural protection against this potent greenhouse gas. Here we show that in two stratified freshwater lakes a substantial part of upward-diffusing methane was oxidized by filamentous gamma-proteobacteria related to Crenothrix polyspora. These filamentous bacteria have been known as contaminants of drinking water supplies since 1870, but their role in the environmental methane removal has remained unclear. While oxidizing methane, these organisms were assigned an 'unusual' methane monooxygenase (MMO), which was only distantly related to 'classical' MMO of gamma-proteobacterial methanotrophs. We now correct this assignment and show that Crenothrix encode a typical gamma-proteobacterial PmoA. Stable isotope labeling in combination swith single-cell imaging mass spectrometry revealed methane-dependent growth of the lacustrine Crenothrix with oxygen as well as under oxygen-deficient conditions. Crenothrix genomes encoded pathways for the respiration of oxygen as well as for the reduction of nitrate to N 2 O. The observed abundance and planktonic growth of Crenothrix suggest that these methanotrophs can act as a relevant biological sink for methane in stratified lakes and should be considered in the context of environmental removal of methane.

  14. Crystallization of a compositionally stratified basal magma ocean

    Science.gov (United States)

    Laneuville, Matthieu; Hernlund, John; Labrosse, Stéphane; Guttenberg, Nicholas

    2018-03-01

    Earth's ∼3.45 billion year old magnetic field is regenerated by dynamo action in its convecting liquid metal outer core. However, convection induces an isentropic thermal gradient which, coupled with a high core thermal conductivity, results in rapid conducted heat loss. In the absence of implausibly high radioactivity or alternate sources of motion to drive the geodynamo, the Earth's early core had to be significantly hotter than the melting point of the lower mantle. While the existence of a dense convecting basal magma ocean (BMO) has been proposed to account for high early core temperatures, the requisite physical and chemical properties for a BMO remain controversial. Here we relax the assumption of a well-mixed convecting BMO and instead consider a BMO that is initially gravitationally stratified owing to processes such as mixing between metals and silicates at high temperatures in the core-mantle boundary region during Earth's accretion. Using coupled models of crystallization and heat transfer through a stratified BMO, we show that very high temperatures could have been trapped inside the early core, sequestering enough heat energy to run an ancient geodynamo on cooling power alone.

  15. Family members' involvement in psychiatric care: experiences of the healthcare professionals' approach and feeling of alienation.

    Science.gov (United States)

    Ewertzon, M; Lützén, K; Svensson, E; Andershed, B

    2010-06-01

    The involvement of family members in psychiatric care is important for the recovery of persons with psychotic disorders and subsequently reduces the burden on the family. Earlier qualitative studies suggest that the participation of family members can be limited by how they experience the professionals' approach, which suggests a connection to the concept of alienation. Thus, the aim of this study was in a national sample investigate family members' experiences of the psychiatric health care professionals' approach. Data were collected by the Family Involvement and Alienation Questionnaire. The median level and quartiles were used to describe the distributions and data were analysed with non-parametric statistical methods. Seventy family members of persons receiving psychiatric care participated in the study. The results indicate that a majority of the participants respond that they have experiencing a negative approach from the professionals, indicating lack of confirmation and cooperation. The results also indicate that a majority of the participants felt powerlessness and social isolation in the care being provided, indicating feelings of alienation. A significant but weak association was found between the family members' experiences of the professionals' approach and their feelings of alienation.

  16. Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study.

    Science.gov (United States)

    Braithwaite, Jeffrey; Greenfield, David; Westbrook, Johanna; Pawsey, Marjorie; Westbrook, Mary; Gibberd, Robert; Naylor, Justine; Nathan, Sally; Robinson, Maureen; Runciman, Bill; Jackson, Margaret; Travaglia, Joanne; Johnston, Brian; Yen, Desmond; McDonald, Heather; Low, Lena; Redman, Sally; Johnson, Betty; Corbett, Angus; Hennessy, Darlene; Clark, John; Lancaster, Judie

    2010-02-01

    Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

  17. Patient Care Planning: An Interdisciplinary Approach

    OpenAIRE

    Prophet, Colleen M.

    1989-01-01

    The INFORMM Patient Care Planning System provides interdepartmental communication and individualized patient care plans based upon current standards of care. This interdisciplinary system facilitates the identification of patient problems and nursing diagnoses as well as patient care orders. The selected nurses' and physicians' orders are integrated and organized by care plan categories in printouts. As a system by-product, Patient Care Planning automatically generates and calculates patient ...

  18. Helping families improve: an evaluation of two primary care approaches to parenting support in the Netherlands

    NARCIS (Netherlands)

    Graaf, I.M. de; Onrust, S.A.; Haverman, M.C.C.; Janssens, J.M.A.M.

    2009-01-01

    The present study evaluated two primary care parenting interventions. First, we evaluated the most widely used Dutch practices for primary care parenting support. Second, we assessed the applicability of the Primary Care Triple P approach, which is now being utilized in a wide variety of primary

  19. Iranian nurses' professional competence in spiritual care in 2014.

    Science.gov (United States)

    Adib-Hajbaghery, Mohsen; Zehtabchi, Samira; Fini, Ismail Azizi

    2017-06-01

    The holistic approach views the human as a bio-psycho-socio-spiritual being. Evidence suggests that among these dimensions, the spiritual one is largely ignored in healthcare settings. This study aimed to evaluate Iranian nurses' perceived professional competence in spiritual care, the relationship between perceived competence and nurses' personal characteristics, and barriers to provide spiritual care. A cross-sectional study was conducted in the year 2014. Participants and research context: The study population consisted of nurses working in teaching hospitals in Kashan city. Using a stratified, systematic random method, 250 samples were selected from a total of 1400 nurses. An indigenous instrument was used to assess the nurses' competencies in spiritual care. Ethical considerations: A research ethics committee approved the study. All the participants were briefed on the study aims, were assured of the confidentiality of their personal information, and signed a written informed consent. Among a total of 250 nurses, 239 answered the questionnaire completely, and in total, 23%, 51%, and 26% had poor, moderate, and favorable competence in spiritual care, respectively. No significant differences were found between the mean competence scores of spiritual care in terms of gender, marital status, employment status, and level of qualification. Significant difference was found between nurses' overall score of competence in spiritual care and receiving training on spiritual care, nurses' position, and the ward they worked in. Confirming the findings of the international literature, this study puts light on the situation of nurses' perceived competence and barriers to providing spiritual care in Iran as an eastern and Islamic context. Three-quarters of the nurses had moderate or unfavorable competence in spiritual care. Due to the crucial role of spiritual care in quality of care and patient satisfaction, nurses should be trained and supported to provide spiritual care.

  20. Degradation of organic dyes using spray deposited nanocrystalline stratified WO3/TiO2 photoelectrodes under sunlight illumination

    Science.gov (United States)

    Hunge, Y. M.; Yadav, A. A.; Mahadik, M. A.; Bulakhe, R. N.; Shim, J. J.; Mathe, V. L.; Bhosale, C. H.

    2018-02-01

    The need to utilize TiO2 based metal oxide hetero nanostructures for the degradation of environmental pollutants like Rhodamine B and reactive red 152 from the wastewater using stratified WO3/TiO2 catalyst under sunlight illumination. WO3, TiO2 and stratified WO3/TiO2 catalysts were prepared by a spray pyrolysis method. It was found that the stratified WO3/TiO2 heterostructure has high crystallinity, no mixed phase formation occurs, strong optical absorption in the visible region of the solar spectrum, and large surface area. The photocatalytic activity was tested for degradation of Rhodamine B (Rh B) and reactive red 152 in an aqueous medium. TiO2 layer in stratified WO3/TiO2 catalyst helps to extend its absorption spectrum in the solar light region. Rh B and Reactive red 152is eliminated up to 98 and 94% within the 30 and 40 min respectively at optimum experimental condition by stratified WO3/TiO2. Moreover, stratified WO3/TiO2 photoelectrode has good stability and reusability than individual TiO2 and WO3 thin film in the degradation of Rh B and reactive red 152. The photoelectrocatalytic experimental results indicate that stratified WO3/TiO2 photoelectrode is a promising material for dye removal.

  1. The organisational context of nursing care in stroke units: a case study approach.

    Science.gov (United States)

    Burton, Christopher R; Fisher, Andrea; Green, Theresa L

    2009-01-01

    Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing

  2. Identification of major planktonic sulfur oxidizers in stratified freshwater lake.

    Directory of Open Access Journals (Sweden)

    Hisaya Kojima

    Full Text Available Planktonic sulfur oxidizers are important constituents of ecosystems in stratified water bodies, and contribute to sulfide detoxification. In contrast to marine environments, taxonomic identities of major planktonic sulfur oxidizers in freshwater lakes still remain largely unknown. Bacterioplankton community structure was analyzed in a stratified freshwater lake, Lake Mizugaki in Japan. In the clone libraries of 16S rRNA gene, clones very closely related to a sulfur oxidizer isolated from this lake, Sulfuritalea hydrogenivorans, were detected in deep anoxic water, and occupied up to 12.5% in each library of different water depth. Assemblages of planktonic sulfur oxidizers were specifically analyzed by constructing clone libraries of genes involved in sulfur oxidation, aprA, dsrA, soxB and sqr. In the libraries, clones related to betaproteobacteria were detected with high frequencies, including the close relatives of Sulfuritalea hydrogenivorans.

  3. Mixing of stratified flow around bridge piers in steady current

    DEFF Research Database (Denmark)

    Jensen, Bjarne; Carstensen, Stefan; Christensen, Erik Damgaard

    2018-01-01

    This paper presents the results of an experimental and numerical investigation of the mixing of stratified flow around bridge pier structures. In this study, which was carried out in connection with the Fehmarnbelt Fixed Link environmental impact assessment, the mixing processes of two-layer stra......This paper presents the results of an experimental and numerical investigation of the mixing of stratified flow around bridge pier structures. In this study, which was carried out in connection with the Fehmarnbelt Fixed Link environmental impact assessment, the mixing processes of two......-layer stratification was studied in which the lower level had a higher salinity than the upper layer. The physical experiments investigated two different pier designs. A general study was made regarding forces on the piers in which the effect of the current angle relative to the structure was also included...

  4. Rheumatic heart disease: infectious disease origin, chronic care approach.

    Science.gov (United States)

    Katzenellenbogen, Judith M; Ralph, Anna P; Wyber, Rosemary; Carapetis, Jonathan R

    2017-11-29

    Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.

  5. Stepped Skills: A team approach towards communication about sexuality and intimacy in cancer and palliative care

    Directory of Open Access Journals (Sweden)

    Hilde de Vocht

    2011-11-01

    Full Text Available BackgroundCancer often has a profound and enduring impact on sexuality, affecting both patients and their partners. Most healthcare professionals in cancer and palliative care are struggling to address intimate issues with the patients in their care.MethodsStudy 1: An Australian study using semi-structured interviews and documentary data analysis.Study 2: Building on this Australian study, using a hermeneutic phenomenological approach, data were collected in the Netherlands through interviewing 15 cancer patients, 13 partners and 20 healthcare professionals working in cancer and palliative care. The hermeneutic analysis was supported by ATLAS.ti and enhanced by peer debriefing and expert consultation.ResultsFor patients and partners a person-oriented approach is a prerequisite for discussing the whole of their experience regarding the impact of cancer treatment on their sexuality and intimacy. Not all healthcare professionals are willing or capable of adopting such a person-oriented approach.ConclusionA complementary team approach, with clearly defined roles for different team members and clear referral pathways, is required to enhance communication about sexuality and intimacy in cancer and palliative care. This approach, that includes the acknowledgement of the importance of patients’ and partners’ sexuality and intimacy by all team members, is captured in the Stepped Skills model that was developed as an outcome of the Dutch study.

  6. Suppression of stratified explosive interactions

    Energy Technology Data Exchange (ETDEWEB)

    Meeks, M.K.; Shamoun, B.I.; Bonazza, R.; Corradini, M.L. [Wisconsin Univ., Madison, WI (United States). Dept. of Nuclear Engineering and Engineering Physics

    1998-01-01

    Stratified Fuel-Coolant Interaction (FCI) experiments with Refrigerant-134a and water were performed in a large-scale system. Air was uniformly injected into the coolant pool to establish a pre-existing void which could suppress the explosion. Two competing effects due to the variation of the air flow rate seem to influence the intensity of the explosion in this geometrical configuration. At low flow rates, although the injected air increases the void fraction, the concurrent agitation and mixing increases the intensity of the interaction. At higher flow rates, the increase in void fraction tends to attenuate the propagated pressure wave generated by the explosion. Experimental results show a complete suppression of the vapor explosion at high rates of air injection, corresponding to an average void fraction of larger than 30%. (author)

  7. Monte Carlo stratified source-sampling

    International Nuclear Information System (INIS)

    Blomquist, R.N.; Gelbard, E.M.

    1997-01-01

    In 1995, at a conference on criticality safety, a special session was devoted to the Monte Carlo open-quotes eigenvalue of the worldclose quotes problem. Argonne presented a paper, at that session, in which the anomalies originally observed in that problem were reproduced in a much simplified model-problem configuration, and removed by a version of stratified source-sampling. The original test-problem was treated by a special code designed specifically for that purpose. Recently ANL started work on a method for dealing with more realistic eigenvalue of the world configurations, and has been incorporating this method into VIM. The original method has been modified to take into account real-world statistical noise sources not included in the model problem. This paper constitutes a status report on work still in progress

  8. A pragmatist approach to the hope discourse in health care research.

    Science.gov (United States)

    Herrestad, Henning; Biong, Stian; McCormack, Brendan; Borg, Marit; Karlsson, Bengt

    2014-07-01

    Hope is a central concept in nursing and other fields of health care. However, there is no consensus about the concept of hope. We argue that seeking consensus is futile given the multifaceted and multidimensional nature of the concept, but instead we encourage in-depth studies of the assumptions behind talk about hope in specific contexts. Our approach to the 'science of hope' is inspired by philosophical pragmatism. We argue that hope is a concept that opens different rooms for action in different contexts and that accordingly, all hope interventions are contextually sensitive. Careful attention to how the relative positions and power of nurses and patients influence what can be inferred from their different ways of talking about hope may make hopeful conversations more meaningful in health care relationships. © 2014 John Wiley & Sons Ltd.

  9. Controls on Turbulent Mixing in a Strongly Stratified and Sheared Tidal River Plume

    Energy Technology Data Exchange (ETDEWEB)

    Jurisa, Joseph T.; Nash, Jonathan D.; Moum, James N.; Kilcher, Levi F.

    2016-08-01

    Considerable effort has been made to parameterize turbulent kinetic energy (TKE) dissipation rate ..epsilon.. and mixing in buoyant plumes and stratified shear flows. Here, a parameterization based on Kunze et al. is examined, which estimates ..epsilon.. as the amount of energy contained in an unstable shear layer (Ri < Ric) that must be dissipated to increase the Richardson number Ri = N2/S2 to a critical value Ric within a turbulent decay time scale. Observations from the tidal Columbia River plume are used to quantitatively assess the relevant parameters controlling ..epsilon.. over a range of tidal and river discharge forcings. Observed ..epsilon.. is found to be characterized by Kunze et al.'s form within a factor of 2, while exhibiting slightly decreased skill near Ri = Ric. Observed dissipation rates are compared to estimates from a constant interfacial drag formulation that neglects the direct effects of stratification. This is found to be appropriate in energetic regimes when the bulk-averaged Richardson number Rib is less than Ric/4. However, when Rib > Ric/4, the effects of stratification must be included. Similarly, ..epsilon.. scaled by the bulk velocity and density differences over the plume displays a clear dependence on Rib, decreasing as Rib approaches Ric. The Kunze et al. ..epsilon.. parameterization is modified to form an expression for the nondimensional dissipation rate that is solely a function of Rib, displaying good agreement with the observations. It is suggested that this formulation is broadly applicable for unstable to marginally unstable stratified shear flows.

  10. The productivity of mental health care: an instrumental variable approach.

    Science.gov (United States)

    Lu, Mingshan

    1999-06-01

    BACKGROUND: Like many other medical technologies and treatments, there is a lack of reliable evidence on treatment effectiveness of mental health care. Increasingly, data from non-experimental settings are being used to study the effect of treatment. However, as in a number of studies using non-experimental data, a simple regression of outcome on treatment shows a puzzling negative and significant impact of mental health care on the improvement of mental health status, even after including a large number of potential control variables. The central problem in interpreting evidence from real-world or non-experimental settings is, therefore, the potential "selection bias" problem in observational data set. In other words, the choice/quantity of mental health care may be correlated with other variables, particularly unobserved variables, that influence outcome and this may lead to a bias in the estimate of the effect of care in conventional models. AIMS OF THE STUDY: This paper addresses the issue of estimating treatment effects using an observational data set. The information in a mental health data set obtained from two waves of data in Puerto Rico is explored. The results using conventional models - in which the potential selection bias is not controlled - and that from instrumental variable (IV) models - which is what was proposed in this study to correct for the contaminated estimation from conventional models - are compared. METHODS: Treatment effectiveness is estimated in a production function framework. Effectiveness is measured as the improvement in mental health status. To control for the potential selection bias problem, IV approaches are employed. The essence of the IV method is to use one or more instruments, which are observable factors that influence treatment but do not directly affect patient outcomes, to isolate the effect of treatment variation that is independent of unobserved patient characteristics. The data used in this study are the first (1992

  11. Developing a mental health care plan in a low resource setting: the theory of change approach.

    Science.gov (United States)

    Hailemariam, Maji; Fekadu, Abebaw; Selamu, Medhin; Alem, Atalay; Medhin, Girmay; Giorgis, Tedla Wolde; DeSilva, Mary; Breuer, Erica

    2015-09-28

    Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care. An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan. A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later

  12. Multi-agent systems: effective approach for cancer care information management.

    Science.gov (United States)

    Mohammadzadeh, Niloofar; Safdari, Reza; Rahimi, Azin

    2013-01-01

    Physicians, in order to study the causes of cancer, detect cancer earlier, prevent or determine the effectiveness of treatment, and specify the reasons for the treatment ineffectiveness, need to access accurate, comprehensive, and timely cancer data. The cancer care environment has become more complex because of the need for coordination and communication among health care professionals with different skills in a variety of roles and the existence of large amounts of data with various formats. The goals of health care systems in such a complex environment are correct health data management, providing appropriate information needs of users to enhance the integrity and quality of health care, timely access to accurate information and reducing medical errors. These roles in new systems with use of agents efficiently perform well. Because of the potential capability of agent systems to solve complex and dynamic health problems, health care system, in order to gain full advantage of E- health, steps must be taken to make use of this technology. Multi-agent systems have effective roles in health service quality improvement especially in telemedicine, emergency situations and management of chronic diseases such as cancer. In the design and implementation of agent based systems, planning items such as information confidentiality and privacy, architecture, communication standards, ethical and legal aspects, identification opportunities and barriers should be considered. It should be noted that usage of agent systems only with a technical view is associated with many problems such as lack of user acceptance. The aim of this commentary is to survey applications, opportunities and barriers of this new artificial intelligence tool for cancer care information as an approach to improve cancer care management.

  13. [Challenges of an integrative and personalised health care for health economics and the insurance system].

    Science.gov (United States)

    Schoch, Goentje-Gesine; Würdemann, E

    2014-11-01

    "Stratifying medicine" is a topic of increasing importance in the public health system. There are several questions related to "stratifying medicine". This paper reconsiders definitions, opportunities and risks related to "stratifying medicine" as well as the main challenges of "stratifying medicine" from the perspective of a public health insurance. The application of the term and the definition are important points to discuss. Terms such as "stratified medicine", "personalised medicine" or "individualised medicine" are used. The Techniker Krankenkasse prefers "stratifying medicine", because it usually means a medicine that tailors therapy to specific groups of patients by biomarkers. OPPORTUNITIES AND RISKS: "Stratifying medicine" is associated with various hopes, e. g., the avoidance of ineffective therapies and early detection of diseases. But "stratifying medicine" also carries risks, such as an increase in the number of cases by treatment of disease risks, a duty for health and the weakening of the criteria of evidence-based medicine. The complexity of "stratifying medicine" is a big challenge for all involved parties in the health system. A lot of interrelations are still not completely understood. So the statutory health insurance faces the challenge of making innovative therapy concepts accessible in a timely manner to all insured on the one hand but on the other hand also to protect the community from harmful therapies. Information and advice to patients related to "stratifying medicine" is of particular importance. The equitable distribution of fees for diagnosis and counselling presents a particular challenge. The solidarity principle of public health insurance may be challenged by social and ethical issues of "stratifying medicine". "Stratifying medicine" offers great potential to improve medical care. However, false hopes must be avoided. Providers and payers should measure chances and risks of "stratifying medicine" together for the welfare of the

  14. The value of informal care in the context of option B+ in Malawi: a contingent valuation approach.

    Science.gov (United States)

    Chiwaula, Levison Stanely; Chirwa, Gowokani Chijere; Cataldo, Fabian; Kapito-Tembo, Atupele; Hosseinipour, Mina C; van Lettow, Monique; Tweya, Hannock; Kayoyo, Virginia; Khangamwa-Kaunda, Blessings; Kasende, Florence; Trapence, Clement; Gugsa, Salem; Rosenberg, Nora E; Eliya, Michael; Phiri, Sam

    2016-04-19

    Informal care, the health care provided by the patient's social network is important in low income settings although its monetary value is rarely estimated. The lack of estimates of the value of informal care has led to its omission in economic evaluations but this can result in incorrect decisions about cost effectiveness of an intervention. We explore the use of contingent valuation methods of willingness to pay (WTP) and willingness to accept (WTA) to estimate the value of informal care provided to HIV infected women that are accessing antiretroviral therapy (ART) under the Option B+ approach to prevention of mother-to-child transmission (PMTCT) of HIV in Malawi. We collected cross sectional data from 93 caregivers of women that received ART care from six health facilities in Malawi. Caregivers of women that reported for ART care on the survey day and consented to participate in the survey were included until the targeted sample size for the facility was reached. We estimated the value of informal care by using the willingness to accept (WTA) and willingness to pay (WTP) approaches. Medians were used to summarize the values and these were compared by the Wilcoxon signed-rank test. The median WTA to provide informal care in a month was US$30 and the median WTP for informal care was US$13 and the two were statistically different (p lower quintile (US$15 vs. US$13, p < 0.0462). Informal caregivers place substantial value on informal care giving. In low income settings where most caregivers are not formally employed, WTP and WTA approaches can be used to value informal care. NCT02005835.

  15. Bacterial production, protozoan grazing, and mineralization in stratified Lake Vechten

    NARCIS (Netherlands)

    Bloem, J.

    1989-01-01

    The role of heterotrophic nanoflagellates (HNAN, size 2-20 μm) in grazing on bacteria and mineralization of organic matter in stratified Lake Vechten was studied.

    Quantitative effects of manipulation and fixation on HNAN were checked. Considerable losses were caused by

  16. Internal wave patterns in enclosed density-stratified and rotating fluids

    NARCIS (Netherlands)

    Manders, A.M.A.

    2003-01-01

    Stratified fluids support internal waves, which propagate obliquely through the fluid. The angle with respectto the stratification direction is contrained: it is purely determined by the wave frequency and the strength of the density stratification (internal gravity waves) or the rotation rate

  17. Computational Fluid Dynamics model of stratified atmospheric boundary-layer flow

    DEFF Research Database (Denmark)

    Koblitz, Tilman; Bechmann, Andreas; Sogachev, Andrey

    2015-01-01

    For wind resource assessment, the wind industry is increasingly relying on computational fluid dynamics models of the neutrally stratified surface-layer. So far, physical processes that are important to the whole atmospheric boundary-layer, such as the Coriolis effect, buoyancy forces and heat...

  18. The nature, characteristics and associations of care home staff stress and wellbeing: a national survey.

    Science.gov (United States)

    Islam, Muhammad Saiful; Baker, Christine; Huxley, Peter; Russell, Ian T; Dennis, Michael S

    2017-01-01

    The majority of residents in care homes in the United Kingdom are living with dementia or significant memory problems. Caring in this setting can be difficult and stressful for care staff who work long hours, have little opportunity for training, are poorly paid and yet subject to high expectation. This may affect their mental and physical wellbeing, cause high rates of staff turnover and absenteeism, and affect the quality of care they provide. The main objective of this survey was to explore the nature, characteristics and associations of stress in care home staff. Staff working in a stratified random sample of care homes within Wales completed measures covering: general health and wellbeing (SF-12); stress (Work Stress Inventory); job content (Karasek Job Content); approach to, and experience of, working with people living with dementia (Approaches to Dementia Questionnaire; and Experience of Working with Dementia Patients); and Productivity and Health Status (SPS-6). Multiple linear regressions explored the effects of home and staff characteristics on carers. 212 staff from 72 care homes completed questionnaires. Staff from nursing homes experienced more work stress than those from residential homes (difference 0.30; 95% confidence interval (CI) from 0.10 to 0.51; P  work (difference -4.77; CI -7.80 to -1.73; P  working in local authority homes than in the private sector (difference 7.75; CI 2.56 to 12.94; P  < 0.01). Our study highlights the importance of dementia training in care homes, with a particular need in the private sector. An effective intervention to reduce stress in health and social care staff is required, especially in nursing and larger care homes, and for nursing staff. ISRCTN registry: ISRCTN80487202. Registered 24 July 2013.

  19. Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach.

    Science.gov (United States)

    Birkhead, Guthrie S; Klein, Susan J; Candelas, Alma R; O'Connell, Daniel A; Rothman, Jeffrey R; Feldman, Ira S; Tsui, Dennis S; Cotroneo, Richard A; Flanigan, Colleen A

    2007-10-01

    New York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs' needs are required. A HCV strategic plan has stressed integration. HCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development. IDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain. A comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV-HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.

  20. A criterion for the onset of slugging in horizontal stratified air-water countercurrent flow

    International Nuclear Information System (INIS)

    Chun, Moon-Hyun; Lee, Byung-Ryung; Kim, Yang-Seok

    1995-01-01

    This paper presents an experimental and theoretical investigation of wave height and transition criterion from wavy to slug flow in horizontal air-water countercurrent stratified flow conditions. A theoretical formula for the wave height in a stratified wavy flow regime has been developed using the concept of total energy balance over a wave crest to consider the shear stress acting on the interface of two fluids. From the limiting condition of the formula for the wave height, a necessary criterion for transition from a stratified wavy flow to a slug flow has been derived. A series of experiments have been conducted changing the non-dimensional water depth and the flow rates of air in a horizontal pipe and a duct. Comparisons between the measured data and the predictions of the present theory show that the agreement is within ±8%

  1. A criterion for the onset of slugging in horizontal stratified air-water countercurrent flow

    Energy Technology Data Exchange (ETDEWEB)

    Chun, Moon-Hyun; Lee, Byung-Ryung; Kim, Yang-Seok [Korea Advanced Institute of Science and Technology, Taejon (Korea, Republic of)] [and others

    1995-09-01

    This paper presents an experimental and theoretical investigation of wave height and transition criterion from wavy to slug flow in horizontal air-water countercurrent stratified flow conditions. A theoretical formula for the wave height in a stratified wavy flow regime has been developed using the concept of total energy balance over a wave crest to consider the shear stress acting on the interface of two fluids. From the limiting condition of the formula for the wave height, a necessary criterion for transition from a stratified wavy flow to a slug flow has been derived. A series of experiments have been conducted changing the non-dimensional water depth and the flow rates of air in a horizontal pipe and a duct. Comparisons between the measured data and the predictions of the present theory show that the agreement is within {plus_minus}8%.

  2. Generation of stratified squamous epithelial progenitor cells from mouse induced pluripotent stem cells.

    Directory of Open Access Journals (Sweden)

    Satoru Yoshida

    Full Text Available BACKGROUND: Application of induced pluripotent stem (iPS cells in regenerative medicine will bypass ethical issues associated with use of embryonic stem cells. In addition, patient-specific IPS cells can be useful to elucidate the pathophysiology of genetic disorders, drug screening, and tailor-made medicine. However, in order to apply iPS cells to mitotic tissue, induction of tissue stem cells that give rise to progeny of the target organ is required. METHODOLOGY/PRINCIPAL FINDINGS: We induced stratified epithelial cells from mouse iPS cells by co-culture with PA6 feeder cells (SDIA-method with use of BMP4. Clusters of cells positive for the differentiation markers KRT1 or KRT12 were observed in KRT14-positive colonies. We successfully cloned KRT14 and p63 double-positive stratified epithelial progenitor cells from iPS-derived epithelial cells, which formed stratified epithelial sheets consisting of five- to six-polarized epithelial cells in vitro. When these clonal cells were cultured on denuded mouse corneas, a robust stratified epithelial layer was observed with physiological cell polarity including high levels of E-cadherin, p63 and K15 expression in the basal layer and ZO-1 in the superficial layer, recapitulating the apico-basal polarity of the epithelium in vivo. CONCLUSIONS/SIGNIFICANCE: These results suggest that KRT14 and p63 double-positive epithelial progenitor cells can be cloned from iPS cells in order to produce polarized multilayer epithelial cell sheets.

  3. Experimental Validation of a Domestic Stratified Hot Water Tank Model in Modelica for Annual Performance Assessment

    DEFF Research Database (Denmark)

    Carmo, Carolina; Dumont, Olivier; Nielsen, Mads Pagh

    2015-01-01

    The use of stratified hot water tanks in solar energy systems - including ORC systems - as well as heat pump systems is paramount for a better performance of these systems. However, the availability of effective and reliable models to predict the annual performance of stratified hot water tanks...

  4. Interprofessional primary care protocols: a strategy to promote an evidence-based approach to teamwork and the delivery of care.

    Science.gov (United States)

    Goldman, Joanne; Meuser, Jamie; Lawrie, Lynne; Rogers, Jess; Reeves, Scott

    2010-11-01

    Primary care reform involving interprofessional team-based care is a global phenomenon. In Ontario, Canada, 150 Family Health Teams (FHTs) have been approved in the past few years. The transition to a FHT is complex involving many changes and the processes for collaborative teamwork are not clearly delineated. To support the transition to team-based care in FHTs, a project was undertaken to develop and implement a series of interprofessional protocols in four clinical areas. These interprofessional protocols would contain relevant and evidence-based resources to support both a team and evidence-based approach to care. This paper reports on a qualitative study to examine the process of interprofessional protocol development and pilot implementation. Adopting an exploratory case study approach (Robson, 2002 ), 36 interviews were conducted with health professionals and community group members who participated in the creation and piloting of the protocols, and with project managers. In addition, observational and documentary data were gathered on the protocol development and implementation processes. The findings from the protocol development stage demonstrate the value of the focus on evidence and team, the process of assessing and targeting FHT needs, inter-organizational and interprofessional sharing, the importance of facilitation and support, and expectations for implementation. The findings from the pilot implementation stage report on the importance of champions and leaders, the implementation strategies used, FHT and organizational factors affecting implementation, and outcomes achieved. Findings are discussed in relation to the knowledge translation and interprofessional literature. Research is ongoing to examine the effectiveness of dissemination of the protocols to FHTs across the province of Ontario and its impact on health care outcomes.

  5. Theory of hyperbolic stratified nanostructures for surface-enhanced Raman scattering

    Science.gov (United States)

    Wong, Herman M. K.; Dezfouli, Mohsen Kamandar; Axelrod, Simon; Hughes, Stephen; Helmy, Amr S.

    2017-11-01

    We theoretically investigate the enhancement of surface enhanced Raman spectroscopy (SERS) using hyperbolic stratified nanostructures and compare to metal nanoresonators. The photon Green function of each nanostructure within its environment is first obtained from a semianalytical modal theory, which is used in a quantum optics formalism of the molecule-nanostructure interaction to model the SERS spectrum. An intuitive methodology is presented for calculating the single-molecule enhancement factor (SMEF), which is also able to predict known experimental SERS enhancement factors of a gold nanodimer. We elucidate the important figures-of-merit of the enhancement and explore these for different designs. We find that the use of hyperbolic stratified materials can enhance the photonic local density of states (LDOS) by close to two times in comparison to pure metal nanostructures, when both designed to work at the same operating wavelengths. However, the increased LDOS is accompanied by higher electric field concentration within the lossy hyperbolic material, which leads to increased quenching that serves to reduce the overall detected SERS enhancement in the far field. For nanoresonators with resonant localized surface plasmon wavelengths in the near-infrared, the SMEF for the hyperbolic stratified nanostructure is approximately one order of magnitude lower than the pure metal counterpart. Conversely, we show that by detecting the Raman signal using a near-field probe, hyperbolic materials can provide an improvement in SERS enhancement compared to using pure metal nanostructures when the probe is sufficiently close (<50 nm ) to the Raman active molecule at the plasmonic hotspot.

  6. Information content of household-stratified epidemics

    Directory of Open Access Journals (Sweden)

    T.M. Kinyanjui

    2016-09-01

    Full Text Available Household structure is a key driver of many infectious diseases, as well as a natural target for interventions such as vaccination programs. Many theoretical and conceptual advances on household-stratified epidemic models are relatively recent, but have successfully managed to increase the applicability of such models to practical problems. To be of maximum realism and hence benefit, they require parameterisation from epidemiological data, and while household-stratified final size data has been the traditional source, increasingly time-series infection data from households are becoming available. This paper is concerned with the design of studies aimed at collecting time-series epidemic data in order to maximize the amount of information available to calibrate household models. A design decision involves a trade-off between the number of households to enrol and the sampling frequency. Two commonly used epidemiological study designs are considered: cross-sectional, where different households are sampled at every time point, and cohort, where the same households are followed over the course of the study period. The search for an optimal design uses Bayesian computationally intensive methods to explore the joint parameter-design space combined with the Shannon entropy of the posteriors to estimate the amount of information in each design. For the cross-sectional design, the amount of information increases with the sampling intensity, i.e., the designs with the highest number of time points have the most information. On the other hand, the cohort design often exhibits a trade-off between the number of households sampled and the intensity of follow-up. Our results broadly support the choices made in existing epidemiological data collection studies. Prospective problem-specific use of our computational methods can bring significant benefits in guiding future study designs.

  7. Information content of household-stratified epidemics.

    Science.gov (United States)

    Kinyanjui, T M; Pellis, L; House, T

    2016-09-01

    Household structure is a key driver of many infectious diseases, as well as a natural target for interventions such as vaccination programs. Many theoretical and conceptual advances on household-stratified epidemic models are relatively recent, but have successfully managed to increase the applicability of such models to practical problems. To be of maximum realism and hence benefit, they require parameterisation from epidemiological data, and while household-stratified final size data has been the traditional source, increasingly time-series infection data from households are becoming available. This paper is concerned with the design of studies aimed at collecting time-series epidemic data in order to maximize the amount of information available to calibrate household models. A design decision involves a trade-off between the number of households to enrol and the sampling frequency. Two commonly used epidemiological study designs are considered: cross-sectional, where different households are sampled at every time point, and cohort, where the same households are followed over the course of the study period. The search for an optimal design uses Bayesian computationally intensive methods to explore the joint parameter-design space combined with the Shannon entropy of the posteriors to estimate the amount of information in each design. For the cross-sectional design, the amount of information increases with the sampling intensity, i.e., the designs with the highest number of time points have the most information. On the other hand, the cohort design often exhibits a trade-off between the number of households sampled and the intensity of follow-up. Our results broadly support the choices made in existing epidemiological data collection studies. Prospective problem-specific use of our computational methods can bring significant benefits in guiding future study designs. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

  8. Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning.

    Science.gov (United States)

    Tucker, Sue; Brand, Christian; Wilberforce, Mark; Abendstern, Michele; Challis, David

    2015-07-17

    Mental health problems in older people are common and costly, posing multiple challenges for commissioners. Against this backdrop, a series of initiatives have sought to shift resources from institutional to community care in the belief that this will save money and concurs with user preferences. However, most of this work has focused on the use of care home beds and general hospital admissions, and relatively little attention has been given to reducing the use of mental health inpatient beds, despite their very high cost. The study employed a 'Balance of Care approach' in three areas of North-West England. This long-standing strategic planning framework identifies people whose needs can be met in more than one setting, and compares the costs and consequences of the possible alternatives in a simulation modelling exercise. Information was collected about a six-month cohort of admissions in 2010/11 (n = 216). The sample was divided into groups of people with similar needs for care, and vignettes were formulated to represent the most prevalent groups. A range of key staff judged the appropriateness of these admissions and suggested alternative care for those considered least appropriate for hospital. A public sector costing approach was used to compare the estimated costs of the recommended care with that people currently receive. The findings suggest that more than a sixth of old age psychiatry inpatient admissions could be more appropriately supported in other settings if enhanced community services were available. Such restructuring could involve the provision of intensive support from Care Home Outreach and Community Mental Health Teams, rather than the development of crisis intervention and home treatment teams as currently advocated. Estimated savings were considerable, suggesting local agencies might release up to £1,300,000 per annum. No obvious trade-off between health and social care costs was predicted. There is considerable potential to change the

  9. Psychosocial Distress in Bladder Cancer Stratified by Gender, Age, Treatment, and Tumour Stage.

    Science.gov (United States)

    Draeger, Désirée Louise; Sievert, Karl-Dietrich; Hakenberg, Oliver W

    2018-05-14

    Cancer patients have to cope with anxieties -concerning their prognosis, potential recurrence/progression, and treatment-associated sequelae. Stress-related psychosocial factors influence survival and disease-related mortality in cancer patients. Despite improvements in diagnosis and treatment, bladder cancer (BC) remains characterized by high rates of recurrence and progression. We screened -pre-therapeutically the stress level of BC patients stratified by gender, disease state, treatment, and other factors by -self-administered validated questionnaires to integrate them into psychosocial support as needed. A cross-sectional analysis of distress and need of psychosocial care was done in 301 patients undergoing treatment for BC by 2 questionnaires (Distress Thermometer [DT] and Hornheider Screening Instrument). Of the 301 patients, 230 patients underwent transurethral resection for a first -diagnosis, 63 for recurrent disease, 37 had progressive disease, and 25 had advanced metastatic disease and eventually died of BC. The mean stress level in all patients was 4.6. Twenty-eight percent of the patients expressed a need for psychosocial support. In patients with progressive disease, significantly higher stress scores were seen as well as a higher need of psychosocial care (5.4 and 41%). The median DT-level of 4.6 indicates moderate psychosocial stress in BC patients. From a stress level of 5, the recommendations of a psycho-oncological supervision are pronounced, so that our study showed that early systematic evaluation of psychosocial needs in BC patients is important. © 2018 S. Karger AG, Basel.

  10. [Health care innovation from a territorial perspective: a call for a new approach].

    Science.gov (United States)

    Costa, Laís Silveira; Gadelha, Carlos Augusto Grabois; Maldonado, José

    2012-12-01

    Innovation plays an increasingly important role in health care, partly because it is responsible for a significant share of national investment in research and development, and partly because of its industrial and service provision base, which provides a conduit to future technology. The relationship between health care and development is also strengthened as a result of the leading role of health care in generating innovation. Nevertheless, Brazil's health care production base is persistently weak, hindering both universal provision of health care services and international competitiveness. This article, based on the theoretical framework of Political Economy and innovation systems, has sought to identify variables in subnational contexts that influence the dynamic of innovation generation in health care. To this end, the theoretical approach used lies on the assumption that innovation is a contextualized social process and that the production base in healthcare will remain weak if new variables involved in the dynamic of innovation are not taken into account.

  11. Psychiatry's Role in the Management of Human Trafficking Victims: An Integrated Care Approach.

    Science.gov (United States)

    Gordon, Mollie; Salami, Temilola; Coverdale, John; Nguyen, Phuong T

    2018-03-01

    Human trafficking is an outrageous human rights violation with potentially devastating consequences to individuals and the public health. Victims are often underrecognized and there are few guidelines for how best to identify, care for, and safely reintegrate victims back into the community. The purpose of this paper is to propose a multifaceted, interdisciplinary, and interprofessional guideline for providing care and services to human trafficking victims. Databases such as PubMed and PsycINFO were searched for papers outlining human trafficking programs with a primary psychiatric focus. No integrated care models that provide decisional guidelines at different points of intervention for human trafficking patients and that highlight the important role of psychiatric consultation were found. Psychiatrists and psychologists are pivotal to an integrated care approach in health care settings. The provision of such a comprehensive and integrated model of care should facilitate the identification of victims, promote their recovery, and reduce the possibility of retraumatization.

  12. Large Eddy Simulation of stratified flows over structures

    OpenAIRE

    Brechler J.; Fuka V.

    2013-01-01

    We tested the ability of the LES model CLMM (Charles University Large-Eddy Microscale Model) to model the stratified flow around three dimensional hills. We compared the quantities, as the height of the dividing streamline, recirculation zone length or length of the lee waves with experiments by Hunt and Snyder[3] and numerical computations by Ding, Calhoun and Street[5]. The results mostly agreed with the references, but some important differences are present.

  13. Large Eddy Simulation of stratified flows over structures

    Science.gov (United States)

    Fuka, V.; Brechler, J.

    2013-04-01

    We tested the ability of the LES model CLMM (Charles University Large-Eddy Microscale Model) to model the stratified flow around three dimensional hills. We compared the quantities, as the height of the dividing streamline, recirculation zone length or length of the lee waves with experiments by Hunt and Snyder[3] and numerical computations by Ding, Calhoun and Street[5]. The results mostly agreed with the references, but some important differences are present.

  14. Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study.

    Science.gov (United States)

    Smekal, Michelle D; Tam-Tham, Helen; Finlay, Juli; Donald, Maoliosa; Benterud, Eleanor; Thomas, Chandra; Quinn, Robert R; Tam, Kin; Manns, Braden J; Tonelli, Marcello; Bello, Aminu; Tangri, Navdeep; Hemmelgarn, Brenda R

    2018-01-01

    The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care. We aimed to describe patient, family, and health care provider's perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input. We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey. Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants' feedback. We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.

  15. Nurses' knowledge and barriers regarding pain management in intensive care units.

    Science.gov (United States)

    Wang, Hsiang-Ling; Tsai, Yun-Fang

    2010-11-01

    To explore nurses' knowledge and barriers regarding pain management in intensive care units. Pain is a common and treatable condition among intensive care patients. Quality care of these patients depends on the pain knowledge and pain management skills of critical care nurses. However, no single study has explored these nurses' knowledge of and perceived barriers to pain management in Taiwan. A cross-sectional study. Intensive care unit nurses (n = 370) were recruited from 16 hospitals chosen by stratified sampling across Taipei County in Taiwan. Data were collected on nurses' knowledge of pain management using the Nurses' Knowledge and Attitudes Survey-Taiwanese version, on perceived barriers to pain management using a researcher-developed scale and on background information. The overall average correct response rate for the knowledge scale was 53.4%, indicating poor knowledge of pain management. The top barrier to managing pain identified by these nurses was 'giving proper pain prescription needs doctor's approval; can't depend on me'. Knowledge of pain management was significantly and negatively related to perceived barriers to pain management. In addition, scores for knowledge and perceived barriers differed significantly by specific intensive care unit. Knowledge also differed significantly by nurses' education level, clinical competence level (nursing ladder) and hospital accreditation category. Our results indicate an urgent need to strengthen pain education by including case analysis for intensive care nurses in Taiwan. Pain education should target knowledge deficits and barriers to changing pain management approaches for Taiwanese nurses in intensive care units. © 2010 Blackwell Publishing Ltd.

  16. Ecosystem metabolism in a stratified lake

    DEFF Research Database (Denmark)

    Stæhr, Peter Anton; Christensen, Jesper Philip Aagaard; Batt, Ryan D.

    2012-01-01

    , differences were not significant. During stratification, daily variability in epilimnetic DO was dominated by metabolism (46%) and air-water gas exchange (44%). Fluxes related to mixed-layer deepening dominated in meta- and hypolimnic waters (49% and 64%), while eddy diffusion (1% and 14%) was less important....... Although air-water gas exchange rates differed among the three formulations of gas-transfer velocity, this had no significant effect on metabolic rates....... that integrates rates across the entire depth profile and includes DO exchange between depth layers driven by mixed-layer deepening and eddy diffusivity. During full mixing, NEP was close to zero throughout the water column, and GPP and R were reduced 2-10 times compared to stratified periods. When present...

  17. An Expanded Conceptual Framework of Medical Students' Primary Care Career Choice.

    Science.gov (United States)

    Pfarrwaller, Eva; Audétat, Marie-Claude; Sommer, Johanna; Maisonneuve, Hubert; Bischoff, Thomas; Nendaz, Mathieu; Baroffio, Anne; Junod Perron, Noëlle; Haller, Dagmar M

    2017-11-01

    In many countries, the number of graduating medical students pursuing a primary care career does not meet demand. These countries face primary care physician shortages. Students' career choices have been widely studied, yet many aspects of this process remain unclear. Conceptual models are useful to plan research and educational interventions in such complex systems.The authors developed a framework of primary care career choice in undergraduate medical education, which expands on previously published models. They used a group-based, iterative approach to find the best way to represent the vast array of influences identified in previous studies, including in a recent systematic review of the literature on interventions to increase the proportion of students choosing a primary care career. In their framework, students enter medical school with their personal characteristics and initial interest in primary care. They complete a process of career decision making, which is subject to multiple interacting influences, both within and outside medical school, throughout their medical education. These influences are stratified into four systems-microsystem, mesosystem, exosystem, and macrosystem-which represent different levels of interaction with students' career choices.This expanded framework provides an updated model to help understand the multiple factors that influence medical students' career choices. It offers a guide for the development of new interventions to increase the proportion of students choosing primary care careers and for further research to better understand the variety of processes involved in this decision.

  18. A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

    Science.gov (United States)

    Benvenuti, Michael A; An, Thomas J; Mignemi, Megan E; Martus, Jeffrey E; Mencio, Gregory A; Lovejoy, Stephen A; Thomsen, Isaac P; Schoenecker, Jonathan G; Williams, Derek J

    2016-01-01

    Objective There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department. Methods An IRB-approved retrospective review was conducted to identify patients aged 0–18 who presented to the pediatric emergency department at a tertiary care children’s hospital with concern for acute MSKI over a five-year period (2008–2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a three-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein, and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a p-value ≤ 0.2). Discriminatory power of the models was assessed using the concordance (c)-index. Results Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83, 95% CI [0.79–0.88]; reduced model 0.83, 95% CI [0.78–0.87]). Model fit was also similar, indicating preference for the reduced model. Variables in this model included C-reactive protein, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10-unit increase in C-reactive protein. Conclusions Clinical and laboratory data obtained in the emergency department may be used to accurately

  19. Approaches to Sustainable Capacity Building for Cardiovascular Disease Care in Kenya.

    Science.gov (United States)

    Barasa, Felix A; Vedanthan, Rajesh; Pastakia, Sonak D; Crowe, Susie J; Aruasa, Wilson; Sugut, Wilson K; White, Russ; Ogola, Elijah S; Bloomfield, Gerald S; Velazquez, Eric J

    2017-02-01

    Cardiovascular diseases are approaching epidemic levels in Kenya and other low- and middle-income countries without accompanying effective preventive and therapeutic strategies. This is happening in the background of residual and emerging infections and other diseases of poverty, and increasing physical injuries from traffic accidents and noncommunicable diseases. Investments to create a skilled workforce and health care infrastructure are needed. Improving diagnostic capacity, access to high-quality medications, health care, appropriate legislation, and proper coordination are key components to ensuring the reversal of the epidemic and a healthy citizenry. Strong partnerships with the developed countries also crucial. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. Stratifying Parkinson's Patients With STN-DBS Into High-Frequency or 60 Hz-Frequency Modulation Using a Computational Model.

    Science.gov (United States)

    Khojandi, Anahita; Shylo, Oleg; Mannini, Lucia; Kopell, Brian H; Ramdhani, Ritesh A

    2017-07-01

    High frequency stimulation (HFS) of the subthalamic nucleus (STN) is a well-established therapy for Parkinson's disease (PD), particularly the cardinal motor symptoms and levodopa induced motor complications. Recent studies have suggested the possible role of 60 Hz stimulation in STN-deep brain stimulation (DBS) for patients with gait disorder. The objective of this study was to develop a computational model, which stratifies patients a priori based on symptomatology into different frequency settings (i.e., high frequency or 60 Hz). We retrospectively analyzed preoperative MDS-Unified Parkinson's Disease Rating Scale III scores (32 indicators) collected from 20 PD patients implanted with STN-DBS at Mount Sinai Medical Center on either 60 Hz stimulation (ten patients) or HFS (130-185 Hz) (ten patients) for an average of 12 months. Predictive models using the Random Forest classification algorithm were built to associate patient/disease characteristics at surgery to the stimulation frequency. These models were evaluated objectively using leave-one-out cross-validation approach. The computational models produced, stratified patients into 60 Hz or HFS (130-185 Hz) with 95% accuracy. The best models relied on two or three predictors out of the 32 analyzed for classification. Across all predictors, gait and rest tremor of the right hand were consistently the most important. Computational models were developed using preoperative clinical indicators in PD patients treated with STN-DBS. These models were able to accurately stratify PD patients into 60 Hz stimulation or HFS (130-185 Hz) groups a priori, offering a unique potential to enhance the utilization of this therapy based on clinical subtypes. © 2017 International Neuromodulation Society.

  1. Experimental analysis of an oblique turbulent flame front propagating in a stratified flow

    Energy Technology Data Exchange (ETDEWEB)

    Galizzi, C.; Escudie, D. [Universite de Lyon, CNRS, CETHIL, INSA-Lyon, UMR5008, F-69621 Cedex (France)

    2010-12-15

    This paper details the experimental study of a turbulent V-shaped flame expanding in a nonhomogeneous premixed flow. Its aim is to characterize the effects of stratification on turbulent flame characteristics. The setup consists of a stationary V-shaped flame stabilized on a rod and expanding freely in a lean premixed methane-air flow. One of the two oblique fronts interacts with a stratified slice, which has an equivalence ratio close to one and a thickness greater than that of the flame front. Several techniques such as PIV and CH{sup *} chemiluminescence are used to investigate the instantaneous fields, while laser Doppler anemometry and thermocouples are combined with a concentration probe to provide information on the mean fields. First, in order to provide a reference, the homogeneous turbulent case is studied. Next, the stratified turbulent premixed flame is investigated. Results show significant modifications of the whole flame and of the velocity field upstream of the flame front. The analysis of the geometric properties of the stratified flame indicates an increase in flame brush thickness, closely related to the local equivalence ratio. (author)

  2. Improvements to TRAC models of condensing stratified flow. Pt. 1

    International Nuclear Information System (INIS)

    Zhang, Q.; Leslie, D.C.

    1991-12-01

    Direct contact condensation in stratified flow is an important phenomenon in LOCA analyses. In this report, the TRAC interfacial heat transfer model for stratified condensing flow has been assessed against the Bankoff experiments. A rectangular channel option has been added to the code to represent the experimental geometry. In almost all cases the TRAC heat transfer coefficient (HTC) over-predicts the condensation rates and in some cases it is so high that the predicted steam is sucked in from the normal outlet in order to conserve mass. Based on their cocurrent and countercurrent condensing flow experiments, Bankoff and his students (Lim 1981, Kim 1985) developed HTC models from the two cases. The replacement of the TRAC HTC with either of Bankoff's models greatly improves the predictions of condensation rates in the experiment with cocurrent condensing flow. However, the Bankoff HTC for countercurrent flow is preferable because it is based only on the local quantities rather than on the quantities averaged from the inlet. (author)

  3. A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model.

    Science.gov (United States)

    Luck, Jeff; Hagigi, Fred; Parker, Louise E; Yano, Elizabeth M; Rubenstein, Lisa V; Kirchner, JoAnn E

    2009-09-28

    Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models. The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan. Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy. Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.

  4. The balanced scorecard: an incremental approach model to health care management.

    Science.gov (United States)

    Pineno, Charles J

    2002-01-01

    The balanced scorecard represents a technique used in strategic management to translate an organization's mission and strategy into a comprehensive set of performance measures that provide the framework for implementation of strategic management. This article develops an incremental approach for decision making by formulating a specific balanced scorecard model with an index of nonfinancial as well as financial measures. The incremental approach to costs, including profit contribution analysis and probabilities, allows decisionmakers to assess, for example, how their desire to meet different health care needs will cause changes in service design. This incremental approach to the balanced scorecard may prove to be useful in evaluating the existence of causality relationships between different objective and subjective measures to be included within the balanced scorecard.

  5. Large Eddy Simulation of stratified flows over structures

    Directory of Open Access Journals (Sweden)

    Brechler J.

    2013-04-01

    Full Text Available We tested the ability of the LES model CLMM (Charles University Large-Eddy Microscale Model to model the stratified flow around three dimensional hills. We compared the quantities, as the height of the dividing streamline, recirculation zone length or length of the lee waves with experiments by Hunt and Snyder[3] and numerical computations by Ding, Calhoun and Street[5]. The results mostly agreed with the references, but some important differences are present.

  6. Experimental investigation of droplet separation in a horizontal counter-current air/water stratified flow

    International Nuclear Information System (INIS)

    Gabriel, Stephan Gerhard

    2015-01-01

    A stratified counter-current two-phase gas/liquid flow can occur in various technical systems. In the past investigations have mainly been motivated by the possible occurrence of these flows in accident scenarios of nuclear light water-reactors and in numerous applications in process engineering. However, the precise forecast of flow parameters, is still challenging, for instance due to their strong dependency on the geometric boundary conditions. A new approach which uses CFD methods (Computational Fluid Dynamics) promises a better understanding of the flow phenomena and simultaneously a higher scalability of the findings. RANS methods (Reynolds Averaged Navier Stokes) are preferred in order to compute industrial processes and geometries. A very deep understanding of the flow behavior and equation systems based on real physics are necessary preconditions to develop the equation system for a reliable RANS approach with predictive power. Therefore, local highly resolved, experimental data is needed in order to provide and validate the required turbulence and phase interaction models. The central objective of this work is to provide the data needed for the code development for these unsteady, turbulent and three-dimensional flows. Experiments were carried out at the WENKA facility (Water Entrainment Channel Karlsruhe) at the Karlsruhe Institute of Technology (KIT). The work consists of a detailed description of the test-facility including a new bended channel, the measurement techniques and the experimental results. The characterization of the new channel was done by flow maps. A high-speed imaging study gives an impression of the occurring flow regimes, and different flow phenomena like droplet separation. The velocity distributions as well as various turbulence values were investigated by particle image velocimetry (PIV). In the liquid phase fluorescent tracer-particles were used to suppress optical reflections from the phase surface (fluorescent PIV, FPIV

  7. Layer contributions to the nonlinear acoustic radiation from stratified media.

    Science.gov (United States)

    Vander Meulen, François; Haumesser, Lionel

    2016-12-01

    This study presents the thorough investigation of the second harmonic generation scenario in a three fluid layer system. An emphasis is on the evaluation of the nonlinear parameter B/A in each layer from remote measurements. A theoretical approach of the propagation of a finite amplitude acoustic wave in a multilayered medium is developed. In the frame of the KZK equation, the weak nonlinearity of the media, attenuation and diffraction effects are computed for the fundamental and second harmonic waves propagating back and forth in each of the layers of the system. The model uses a gaussian expansion to describe the beam propagation in order to quantitatively evaluate the contribution of each part of the system (layers and interfaces) to its nonlinearity. The model is validated through measurements on a water/aluminum/water system. Transmission as well as reflection configurations are studied. Good agreement is found between the theoretical results and the experimental data. The analysis of the second harmonic field sources measured by the transducers from outside the stratified medium highlights the factors that favor the cumulative effects. Copyright © 2016 Elsevier B.V. All rights reserved.

  8. Mixed Convection Flow along a Stretching Cylinder in a Thermally Stratified Medium

    Directory of Open Access Journals (Sweden)

    Swati Mukhopadhyay

    2012-01-01

    Full Text Available An analysis for the axisymmetric laminar boundary layer mixed convection flow of a viscous and incompressible fluid towards a stretching cylinder immersed in a thermally stratified medium is presented in this paper. Similarity transformation is employed to convert the governing partial differential equations into highly nonlinear ordinary differential equations. Numerical solutions of these equations are obtained by a shooting method. It is found that the heat transfer rate at the surface is lower for flow in a thermally stratified medium compared to that of an unstratified medium. Moreover, both the skin friction coefficient and the heat transfer rate at the surface are larger for a cylinder compared to that for a flat plate.

  9. Improving patient-centeredness of fertility care using a multifaceted approach: study protocol for a randomized controlled trial

    Directory of Open Access Journals (Sweden)

    Huppelschoten Aleida G

    2012-09-01

    Full Text Available Abstract Background Beside traditional outcomes of safety and (cost-effectiveness, the Institute of Medicine states patient-centeredness as an independent outcome indicator to evaluate the quality of healthcare. Providing patient-centered care is important because patients want to be heard for their ideas and concerns. Healthcare areas associated with high emotions and intensive treatment periods could especially benefit from patient-centered care. How care can become optimally improved in patient-centeredness is unknown. Therefore, we will conduct a study in the context of Dutch fertility care to determine the effects of a multifaceted approach on patient-centeredness, patients’ quality of life (QoL and levels of distress. Our aims are to investigate the effectiveness of a multifaceted approach and to identify determinants of a change in the level of patient-centeredness, patients’ QoL and distress levels. This paper presents the study protocol. Methods/Design In a cluster-randomized trial in 32 Dutch fertility clinics the effects of a multifaceted approach will be determined on the level of patient-centeredness (Patient-centredness Questionnaire – Infertility, patients’ QoL (FertiQoL and levels of distress (SCREENIVF. The multifaceted approach includes audit and feedback, educational outreach visits and patient-mediated interventions. Potential determinants of a change in patient-centeredness, patients’ QoL and levels of distress will be collected by an addendum to the patients’ questionnaire and a professionals’ questionnaire. The latter includes the Organizational Culture Assessment Instrument about the clinic’s culture as a possible determinant of an increase in patient-centered care. Discussion The study is expected to yield important new evidence about the effects of a multifaceted approach on levels of patient-centeredness, patients’ QoL and distress in fertility care. Furthermore, determinants associated with a change

  10. A Randomized Effectiveness Trial of a Systems-Level Approach to Stepped Care for War-Related PTSD

    Science.gov (United States)

    2015-09-01

    Assessment” [1] emphasized an urgent need to expand Department of Defense (DoD) and Department of Veterans Affairs (VA) capacity for integrated ...involve elements of collaborative care. Collaborative care is a service delivery package that accommodates empirically validated psychotherapies and...evidence-based pharmacologic approaches. Collaborative care is not a type of psychotherapy per se. Three or four basic strategies are used to increase

  11. Plane Stratified Flow in a Room Ventilated by Displacement Ventilation

    DEFF Research Database (Denmark)

    Nielsen, Peter Vilhelm; Nickel, J.; Baron, D. J. G.

    2004-01-01

    The air movement in the occupied zone of a room ventilated by displacement ventilation exists as a stratified flow along the floor. This flow can be radial or plane according to the number of wall-mounted diffusers and the room geometry. The paper addresses the situations where plane flow...

  12. Equity in health care financing in Palestine: the value-added of the disaggregate approach.

    Science.gov (United States)

    Abu-Zaineh, Mohammad; Mataria, Awad; Luchini, Stéphane; Moatti, Jean-Paul

    2008-06-01

    This paper analyzes the redistributive effect and progressivity associated with the current health care financing schemes in the Occupied Palestinian Territory, using data from the first Palestinian Household Health Expenditure Survey conducted in 2004. The paper goes beyond the commonly used "aggregate summary index approach" to apply a more detailed "disaggregate approach". Such an approach is borrowed from the general economic literature on taxation, and examines redistributive and vertical effects over specific parts of the income distribution, using the dominance criterion. In addition, the paper employs a bootstrap method to test for the statistical significance of the inequality measures. While both the aggregate and disaggregate approaches confirm the pro-rich and regressive character of out-of-pocket payments, the aggregate approach does not ascertain the potential progressive feature of any of the available insurance schemes. The disaggregate approach, however, significantly reveals a progressive aspect, for over half of the population, of the government health insurance scheme, and demonstrates that the regressivity of the out-of-pocket payments is most pronounced among the worst-off classes of the population. Recommendations are advanced to improve the performance of the government insurance schemes to enhance its capacity in limiting inequalities in health care financing in the Occupied Palestinian Territory.

  13. Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review.

    Science.gov (United States)

    Hoeft, Theresa J; Fortney, John C; Patel, Vikram; Unützer, Jürgen

    2018-12-01

    Rural areas persistently face a shortage of mental health specialists. Task shifting, or task sharing, is an approach in global mental health that may help address unmet mental health needs in rural and other low-resource areas. This review focuses on task-shifting approaches and highlights future directions for research in this area. Systematic review on task sharing of mental health care in rural areas of high-income countries included: (1) PubMed, (2) gray literature for innovations not yet published in peer-reviewed journals, and (3) outreach to experts for additional articles. We included English language articles published before August 31, 2013, on interventions sharing mental health care tasks across a team in rural settings. We excluded literature: (1) from low- and middle-income countries, (2) involving direct transfer of care to another provider, and (3) describing clinical guidelines and shared decision-making tools. The review identified approaches to task sharing focused mainly on community health workers and primary care providers. Technology was identified as a way to leverage mental health specialists to support care across settings both within primary care and out in the community. The review also highlighted how provider education, supervision, and partnerships with local communities can support task sharing. Challenges, such as confidentiality, are often not addressed in the literature. Approaches to task sharing may improve reach and effectiveness of mental health care in rural and other low-resource settings, though important questions remain. We recommend promising research directions to address these questions. © 2017 National Rural Health Association.

  14. Young siblings of children with cancer deserve care and a personalized approach.

    Science.gov (United States)

    Massimo, Luisa M; Wiley, Thomas J

    2008-03-01

    The youngest siblings may be both emotionally vulnerable and often neglected members of the family of a childhood cancer patient. The prompt identification of signs of distress in these subjects allows trained caregivers to intervene with personalized, age-appropriate, attention, and care. A narrative approach, based on personalized listening, writings, and spontaneous drawings, can provide the means to elicit markers of psychological maladjustment in even the youngest of siblings. Two exemplary cases are reported to illustrate this approach. (c) 2007 Wiley-Liss, Inc.

  15. Primary health care in rural Malawi - a qualitative assessment exploring the relevance of the community-directed interventions approach

    DEFF Research Database (Denmark)

    Makaula, Peter; Bloch, Paul; Banda, Hastings T.

    2012-01-01

    Primary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions...... is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated...

  16. White dwarf stars with chemically stratified atmospheres

    Science.gov (United States)

    Muchmore, D.

    1982-01-01

    Recent observations and theory suggest that some white dwarfs may have chemically stratified atmospheres - thin layers of hydrogen lying above helium-rich envelopes. Models of such atmospheres show that a discontinuous temperature inversion can occur at the boundary between the layers. Model spectra for layered atmospheres at 30,000 K and 50,000 K tend to have smaller decrements at 912 A, 504 A, and 228 A than uniform atmospheres would have. On the basis of their continuous extreme ultraviolet spectra, it is possible to distinguish observationally between uniform and layered atmospheres for hot white dwarfs.

  17. Measuring mixing efficiency in experiments of strongly stratified turbulence

    Science.gov (United States)

    Augier, P.; Campagne, A.; Valran, T.; Calpe Linares, M.; Mohanan, A. V.; Micard, D.; Viboud, S.; Segalini, A.; Mordant, N.; Sommeria, J.; Lindborg, E.

    2017-12-01

    Oceanic and atmospheric models need better parameterization of the mixing efficiency. Therefore, we need to measure this quantity for flows representative of geophysical flows, both in terms of types of flows (with vortices and/or waves) and of dynamical regimes. In order to reach sufficiently large Reynolds number for strongly stratified flows, experiments for which salt is used to produce the stratification have to be carried out in a large rotating platform of at least 10-meter diameter.We present new experiments done in summer 2017 to study experimentally strongly stratified turbulence and mixing efficiency in the Coriolis platform. The flow is forced by a slow periodic movement of an array of large vertical or horizontal cylinders. The velocity field is measured by 3D-2C scanned horizontal particles image velocimetry (PIV) and 2D vertical PIV. Six density-temperature probes are used to measure vertical and horizontal profiles and signals at fixed positions.We will show how we rely heavily on open-science methods for this study. Our new results on the mixing efficiency will be presented and discussed in terms of mixing parameterization.

  18. Interdisciplinary collaboration in gerontology and geriatrics in Latin America: conceptual approaches and health care teams.

    Science.gov (United States)

    Gomez, Fernando; Curcio, Carmen Lucia

    2013-01-01

    The underlying rationale to support interdisciplinary collaboration in geriatrics and gerontology is based on the complexity of elderly care. The most important characteristic about interdisciplinary health care teams for older people in Latin America is their subjective-basis framework. In other regions, teams are organized according to a theoretical knowledge basis with well-justified priorities, functions, and long-term goals, in Latin America teams are arranged according to subjective interests on solving their problems. Three distinct approaches of interdisciplinary collaboration in gerontology are proposed. The first approach is grounded in the scientific rationalism of European origin. Denominated "logical-rational approach," its core is to identify the significance of knowledge. The second approach is grounded in pragmatism and is more associated with a North American tradition. The core of this approach consists in enhancing the skills and competences of each participant; denominated "logical-instrumental approach." The third approach denominated "logical-subjective approach" has a Latin America origin. Its core consists in taking into account the internal and emotional dimensions of the team. These conceptual frameworks based in geographical contexts will permit establishing the differences and shared characteristics of interdisciplinary collaboration in geriatrics and gerontology to look for operational answers to solve the "complex problems" of older adults.

  19. Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings: one size may not fit all.

    Science.gov (United States)

    Van Rie, Annelies; Patel, Monita R; Nana, Mbonze; Vanden Driessche, Koen; Tabala, Martine; Yotebieng, Marcel; Behets, Frieda

    2014-03-01

    A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed. Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is 350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007). ART uptake increased (17%-69%, P vs 9.8%, P decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6% vs 6.3%, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8%). Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.

  20. Social network approaches to recruitment, HIV prevention, medical care, and medication adherence.

    Science.gov (United States)

    Latkin, Carl A; Davey-Rothwell, Melissa A; Knowlton, Amy R; Alexander, Kamila A; Williams, Chyvette T; Boodram, Basmattee

    2013-06-01

    This article reviews the current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates, treatment access, and outcomes. Social network analysis is a valuable tool to link social structural factors to individual behaviors. Social networks provide an avenue for low-cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social networks can be utilized as a viable approach to recruitment for HIV testing and counseling, HIV prevention interventions, optimizing HIV medical care, and medication adherence. Social network interventions may be face-to-face or through social media. Key issues in designing social network interventions are contamination due to social diffusion, network stability, density, and the choice and training of network members. There are also ethical issues involved in the development and implementation of social network interventions. Social network analyses can also be used to understand HIV transmission dynamics.

  1. The dynamics of small inertial particles in weakly stratified turbulence

    NARCIS (Netherlands)

    van Aartrijk, M.; Clercx, H.J.H.

    We present an overview of a numerical study on the small-scale dynamics and the large-scale dispersion of small inertial particles in stably stratified turbulence. Three types of particles are examined: fluid particles, light inertial particles (with particle-to-fluid density ratio 1Ͽp/Ͽf25) and

  2. Patients' Care Needs: Documentation Analysis in General Hospitals.

    Science.gov (United States)

    Paans, Wolter; Müller-Staub, Maria

    2015-10-01

    The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs. A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards. The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity. Most care needs were determined in physiological health patterns and few in psychosocial patterns. To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns. © 2014 NANDA International, Inc.

  3. [A population-targeted approach to connect prevention, care and welfare: visualising the trend].

    Science.gov (United States)

    Lemmens, L C; Drewes, H W; Lette, M; Baan, C A

    2017-01-01

    To map initiatives in the Netherlands using a population-targeted approach to link prevention, care and welfare. Descriptive investigation, based on conversations and structured interviews. We searched for initiatives in which providers in the areas of prevention, care and welfare together with health insurers and/or local authorities attempted to provide the 'triple aim': improving the health of the population and the quality of care, and managing costs. We found potential initiatives on the basis of interviews with key figures, project databases and congress programmes. We looked for additional information on websites and via contact persons to gather additional information to determine whether the initiative met the inclusion criteria. An initiative should link prevention, care and welfare with a minimum of three players actively pursuing a population-targeted goal through multiple interventions for a non-disease specific and district-transcending population. We described the goal, organisational structure, parties involved, activities and funding on the basis of interviews conducted in the period August-December 2015 with the managers of the initiatives included. We found 19 initiatives which met the criteria where there was experimentation with organisational forms, levels of participation, interventions and funding. It was noticeable that the interventions mostly concerned medical care. There was a lack of insight into the 'triple aim', mostly because data exchange between parties is generally difficult. There is an increasing number of initiatives that follow a population-targeted approach. Although the different parties strive to connect the three domains, they are still searching for an optimal collaboration, organisational form, data exchange and financing.

  4. Management of kidney cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2012.

    Science.gov (United States)

    Chiong, Edmund; Tay, Miah Hiang; Tan, Min Han; Kumar, Santosh; Sim, Hong Gee; Teh, Bin Tean; Umbas, Rainy; Chau, Noan Minh

    2012-11-01

    Treatment of renal-cell carcinoma has progressed over the past decade, in terms of surgical and systemic therapy. Current treatment guidelines are based on clinical evidence, but do not take into account resource limitations among different countries. These limitations, which include financial and logistical challenges and lack of skilled health-care professionals, have the greatest effect in low-income countries. This consolidated statement gives treatment recommendations for renal-cell carcinoma that are based on clinical evidence and stratified according to extent of resource availability. The statement was formulated by a panel of urologists, medical oncologists, and clinical oncologists from Asian countries, at a consensus session on kidney cancer that was held as part of the 2012 Asian Oncology Summit in Singapore. Resource levels are defined according to a four-tier system (basic, limited, enhanced, and maximum), and treatment recommendations are specified based on availability of financial, skill, and logistical resources. Copyright © 2012 Elsevier Ltd. All rights reserved.

  5. Model-Based Prediction of Pulsed Eddy Current Testing Signals from Stratified Conductive Structures

    International Nuclear Information System (INIS)

    Zhang, Jian Hai; Song, Sung Jin; Kim, Woong Ji; Kim, Hak Joon; Chung, Jong Duk

    2011-01-01

    Excitation and propagation of electromagnetic field of a cylindrical coil above an arbitrary number of conductive plates for pulsed eddy current testing(PECT) are very complex problems due to their complicated physical properties. In this paper, analytical modeling of PECT is established by Fourier series based on truncated region eigenfunction expansion(TREE) method for a single air-cored coil above stratified conductive structures(SCS) to investigate their integrity. From the presented expression of PECT, the coil impedance due to SCS is calculated based on analytical approach using the generalized reflection coefficient in series form. Then the multilayered structures manufactured by non-ferromagnetic (STS301L) and ferromagnetic materials (SS400) are investigated by the developed PECT model. Good prediction of analytical model of PECT not only contributes to the development of an efficient solver but also can be applied to optimize the conditions of experimental setup in PECT

  6. Dipole formation by two interacting shielded monopoles in a stratified fluid

    NARCIS (Netherlands)

    Beckers, M.; Clercx, H.J.H.; Heijst, van G.J.F.; Verzicco, R.

    2002-01-01

    The interaction between two shielded monopolar vortices has been investigated experimentally in a nonrotating linearly stratified fluid and by full three-dimensional (3D) numerical simulations. The characteristic Reynolds and Froude numbers in the experiments are approximately Re [[approximate

  7. Stratified flows with variable density: mathematical modelling and numerical challenges.

    Science.gov (United States)

    Murillo, Javier; Navas-Montilla, Adrian

    2017-04-01

    Stratified flows appear in a wide variety of fundamental problems in hydrological and geophysical sciences. They may involve from hyperconcentrated floods carrying sediment causing collapse, landslides and debris flows, to suspended material in turbidity currents where turbulence is a key process. Also, in stratified flows variable horizontal density is present. Depending on the case, density varies according to the volumetric concentration of different components or species that can represent transported or suspended materials or soluble substances. Multilayer approaches based on the shallow water equations provide suitable models but are not free from difficulties when moving to the numerical resolution of the governing equations. Considering the variety of temporal and spatial scales, transfer of mass and energy among layers may strongly differ from one case to another. As a consequence, in order to provide accurate solutions, very high order methods of proved quality are demanded. Under these complex scenarios it is necessary to observe that the numerical solution provides the expected order of accuracy but also converges to the physically based solution, which is not an easy task. To this purpose, this work will focus in the use of Energy balanced augmented solvers, in particular, the Augmented Roe Flux ADER scheme. References: J. Murillo , P. García-Navarro, Wave Riemann description of friction terms in unsteady shallow flows: Application to water and mud/debris floods. J. Comput. Phys. 231 (2012) 1963-2001. J. Murillo B. Latorre, P. García-Navarro. A Riemann solver for unsteady computation of 2D shallow flows with variable density. J. Comput. Phys.231 (2012) 4775-4807. A. Navas-Montilla, J. Murillo, Energy balanced numerical schemes with very high order. The Augmented Roe Flux ADER scheme. Application to the shallow water equations, J. Comput. Phys. 290 (2015) 188-218. A. Navas-Montilla, J. Murillo, Asymptotically and exactly energy balanced augmented flux

  8. Numerical simulations of the stratified oceanic bottom boundary layer

    Science.gov (United States)

    Taylor, John R.

    Numerical simulations are used to consider several problems relevant to the turbulent oceanic bottom boundary layer. In the first study, stratified open channel flow is considered with thermal boundary conditions chosen to approximate a shallow sea. Specifically, a constant heat flux is applied at the free surface and the lower wall is assumed to be adiabatic. When the surface heat flux is strong, turbulent upwellings of low speed fluid from near the lower wall are inhibited by the stable stratification. Subsequent studies consider a stratified bottom Ekman layer over a non-sloping lower wall. The influence of the free surface is removed by using an open boundary condition at the top of the computational domain. Particular attention is paid to the influence of the outer layer stratification on the boundary layer structure. When the density field is initialized with a linear profile, a turbulent mixed layer forms near the wall, which is separated from the outer layer by a strongly stable pycnocline. It is found that the bottom stress is not strongly affected by the outer layer stratification. However, stratification reduces turbulent transport to the outer layer and strongly limits the boundary layer height. The mean shear at the top of the boundary layer is enhanced when the outer layer is stratified, and this shear is strong enough to cause intermittent instabilities above the pycnocline. Turbulence-generated internal gravity waves are observed in the outer layer with a relatively narrow frequency range. An explanation for frequency content of these waves is proposed, starting with an observed broad-banded turbulent spectrum and invoking linear viscous decay to explain the preferential damping of low and high frequency waves. During the course of this work, an open-source computational fluid dynamics code has been developed with a number of advanced features including scalar advection, subgrid-scale models for large-eddy simulation, and distributed memory

  9. Promise and problems with supply chain management approaches to health care purchasing.

    Science.gov (United States)

    Ford, Eric W; Scanlon, Dennis P

    2007-01-01

    Double-digit health care inflation, coupled with widespread reports of poor care quality and deadly medical errors, has caused private sector employers to reevaluate their health benefits purchasing strategies, with a focus on supply chain management approaches. In other industries, this strategy has proven to be an effective method for simultaneously reducing costs and increasing quality. This article describes four current applications of supply chain management network methodologies to health care systems and identifies potential ways to improve purchasers' return on investment. In particular, information exchanges, purchase decision, and payment agreement components of integrated supply chains are described. First, visual depictions of the health care supply chain are developed from a purchaser's perspective. Next, five nationwide programs designed to realign incentives and rewards across the health care supply chain are described. Although several nationwide efforts are gaining traction in the marketplace, at this time, no cost reduction and quality improvement program initiative appears to systematically align the entire health care supply chain from providers to purchasers, raising doubt about the ability of supply chain management network techniques to significantly impact the health care marketplace in the short run. Current individual efforts to coordinate the health care supply chain do not act on all of the actors necessary to improve outcomes, promote safety, and control costs. Nevertheless, there are indications that several of the individual efforts are coming together. If national efforts touching on all critical elements can coordinate with purchasers, then the health care supply chain's performance may improve significantly.

  10. Cost-effectiveness of collaborative care including PST and an antidepressant treatment algorithm for the treatment of major depressive disorder in primary care; a randomised clinical trial

    Directory of Open Access Journals (Sweden)

    Beekman Aartjan TF

    2007-03-01

    Full Text Available Abstract Background Depressive disorder is currently one of the most burdensome disorders worldwide. Evidence-based treatments for depressive disorder are already available, but these are used insufficiently, and with less positive results than possible. Earlier research in the USA has shown good results in the treatment of depressive disorder based on a collaborative care approach with Problem Solving Treatment and an antidepressant treatment algorithm, and research in the UK has also shown good results with Problem Solving Treatment. These treatment strategies may also work very well in the Netherlands too, even though health care systems differ between countries. Methods/design This study is a two-armed randomised clinical trial, with randomization on patient-level. The aim of the trial is to evaluate the treatment of depressive disorder in primary care in the Netherlands by means of an adapted collaborative care framework, including contracting and adherence-improving strategies, combined with Problem Solving Treatment and antidepressant medication according to a treatment algorithm. Forty general practices will be randomised to either the intervention group or the control group. Included will be patients who are diagnosed with moderate to severe depression, based on DSM-IV criteria, and stratified according to comorbid chronic physical illness. Patients in the intervention group will receive treatment based on the collaborative care approach, and patients in the control group will receive care as usual. Baseline measurements and follow up measures (3, 6, 9 and 12 months are assessed using questionnaires and an interview. The primary outcome measure is severity of depressive symptoms, according to the PHQ9. Secondary outcome measures are remission as measured with the PHQ9 and the IDS-SR, and cost-effectiveness measured with the TiC-P, the EQ-5D and the SF-36. Discussion In this study, an American model to enhance care for patients with a

  11. Examining leadership as a strategy to enhance health care service delivery in regional hospitals in South Africa.

    Science.gov (United States)

    Govender, Sagaren; Gerwel Proches, Cecile N; Kader, Abdulla

    2018-01-01

    Four public hospitals in South Africa, which render both specialized and nonspecialized services to thousands of patients, were examined to determine the impact of leadership on health care service delivery. These hospitals were inundated by various problems that were impacting negatively on health care service delivery. This research study aimed to gain a comprehensive understanding of the challenges, complexities and constraints facing public health care in KwaZulu-Natal (KZN) and to examine leadership as a strategy to enhance healthcare service delivery with a particular focus on four regional hospitals in the KZN Province. The mixed-method research approach was utilized. Purposive sampling and stratified random sampling were employed in the research setting, and in-depth, semistructured interviews and questionnaires were used to collect data. Data were analyzed using the Nvivo computer software package for in-depth interviews and the Statistical Package for the Social Sciences (SPSS) software for the quantitative analysis. The research findings showed that the current leadership framework adopted by the health care leaders in regional hospitals in KZN is weak and is contributing to poor health care service delivery. This study, therefore, aimed to address the current challenges and weaknesses that are impacting negatively on health care service delivery in regional hospitals in the KZN Province and made recommendations for improvement.

  12. The feasibility of a train-the-trainer approach to end of life care training in care homes: an evaluation.

    Science.gov (United States)

    Mayrhofer, Andrea; Goodman, Claire; Smeeton, Nigel; Handley, Melanie; Amador, Sarah; Davies, Sue

    2016-01-22

    there is organisational stability, peer to peer approaches to skills training in end of life care can, with expert facilitation, cascade and sustain learning in care homes.

  13. Reflections on using biographical approaches in end-of-life care: dignity therapy as example.

    Science.gov (United States)

    Lindqvist, Olav; Threlkeld, Guinever; Street, Annette F; Tishelman, Carol

    2015-01-01

    The therapeutic potential of nonpharmacologic interventions using biographical approaches at the end of life (EoL) is being increasingly recognized, but less attention is paid to processes impeding realization of this potential. In this article, Swedish and Australian researchers reflect on and problematize experiences using one biographical approach, dignity therapy (DT), in EoL care in Sweden. We use this as an example, focusing on critical examination of the process of applying DT in practice, examining frictions experienced in recruiting participants, collecting the data, and creating a biography. We discuss issues regarding agency, which became evident in the recruitment process and choices made about participation, and the power differentials manifested in the interactive process of eliciting stories and crafting them into a final product. We also raise salient questions about how research and practice with biographical approaches in EoL care might better build on and further existing knowledge to better reflect the complexities of everyday life. © The Author(s) 2014.

  14. Stratified sampling design based on data mining.

    Science.gov (United States)

    Kim, Yeonkook J; Oh, Yoonhwan; Park, Sunghoon; Cho, Sungzoon; Park, Hayoung

    2013-09-01

    To explore classification rules based on data mining methodologies which are to be used in defining strata in stratified sampling of healthcare providers with improved sampling efficiency. We performed k-means clustering to group providers with similar characteristics, then, constructed decision trees on cluster labels to generate stratification rules. We assessed the variance explained by the stratification proposed in this study and by conventional stratification to evaluate the performance of the sampling design. We constructed a study database from health insurance claims data and providers' profile data made available to this study by the Health Insurance Review and Assessment Service of South Korea, and population data from Statistics Korea. From our database, we used the data for single specialty clinics or hospitals in two specialties, general surgery and ophthalmology, for the year 2011 in this study. Data mining resulted in five strata in general surgery with two stratification variables, the number of inpatients per specialist and population density of provider location, and five strata in ophthalmology with two stratification variables, the number of inpatients per specialist and number of beds. The percentages of variance in annual changes in the productivity of specialists explained by the stratification in general surgery and ophthalmology were 22% and 8%, respectively, whereas conventional stratification by the type of provider location and number of beds explained 2% and 0.2% of variance, respectively. This study demonstrated that data mining methods can be used in designing efficient stratified sampling with variables readily available to the insurer and government; it offers an alternative to the existing stratification method that is widely used in healthcare provider surveys in South Korea.

  15. Direct contact condensation induced transition from stratified to slug flow

    International Nuclear Information System (INIS)

    Strubelj, Luka; Ezsoel, Gyoergy; Tiselj, Iztok

    2010-01-01

    Selected condensation-induced water hammer experiments performed on PMK-2 device were numerically modelled with three-dimensional two-fluid models of computer codes NEPTUNE C FD and CFX. Experimental setup consists of the horizontal pipe filled with the hot steam that is being slowly flooded with cold water. In most of the experimental cases, slow flooding of the pipe was abruptly interrupted by a strong slugging and water hammer, while in the selected experimental runs performed at higher initial pressures and temperatures that are analysed in the present work, the transition from the stratified into the slug flow was not accompanied by the water hammer pressure peak. That makes these cases more suitable tests for evaluation of the various condensation models in the horizontally stratified flows and puts them in the range of the available CFD (Computational Fluid Dynamics) codes. The key models for successful simulation appear to be the condensation model of the hot vapour on the cold liquid and the interfacial momentum transfer model. The surface renewal types of condensation correlations, developed for condensation in the stratified flows, were used in the simulations and were applied also in the regions of the slug flow. The 'large interface' model for inter-phase momentum transfer model was compared to the bubble drag model. The CFD simulations quantitatively captured the main phenomena of the experiments, while the stochastic nature of the particular condensation-induced water hammer experiments did not allow detailed prediction of the time and position of the slug formation in the pipe. We have clearly shown that even the selected experiments without water hammer present a tough test for the applied CFD codes, while modelling of the water hammer pressure peaks in two-phase flow, being a strongly compressible flow phenomena, is beyond the capability of the current CFD codes.

  16. Proposed catalog of the neuroanatomy and the stratified anatomy for the 361 acupuncture points of 14 channels.

    Science.gov (United States)

    Chapple, Will

    2013-10-01

    In spite of the extensive research on acupuncture mechanisms, no comprehensive and systematic peer-reviewed reference list of the stratified anatomical and the neuroanatomical features of all 361 acupuncture points exists. This study creates a reference list of the neuroanatomy and the stratified anatomy for each of the 361 acupuncture points on the 14 classical channels and for 34 extra points. Each acupuncture point was individually assessed to relate the point's location to anatomical and neuroanatomical features. The design of the catalogue is intended to be useful for any style of acupuncture or Oriental medicine treatment modality. The stratified anatomy was divided into shallow, intermediate and deep insertion. A separate stratified anatomy was presented for different needle angles and directions. The following are identified for each point: additional specifications for point location, the stratified anatomy, motor innervation, cutaneous nerve and sensory innervation, dermatomes, Langer's lines, and somatotopic organization in the primary sensory and motor cortices. Acupuncture points for each muscle, dermatome and myotome are also reported. This reference list can aid clinicians, practitioners and researchers in furthering the understanding and accurate practice of acupuncture. Additional research on the anatomical variability around acupuncture points, the frequency of needle contact with an anatomical structure in a clinical setting, and conformational imaging should be done to verify this catalogue. Copyright © 2013. Published by Elsevier B.V.

  17. Statement on gender-affirmative approach to care from the pediatric endocrine society special interest group on transgender health.

    Science.gov (United States)

    Lopez, Ximena; Marinkovic, Maja; Eimicke, Toni; Rosenthal, Stephen M; Olshan, Jerrold S

    2017-08-01

    The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth. Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender nonconforming/transgender youth, as well as adequate mental health and medical care. This document provides a summary of relevant definitions, information and current literature on which the medical management and affirmative approach to care of transgender youth are based.

  18. Bayesian stratified sampling to assess corpus utility

    Energy Technology Data Exchange (ETDEWEB)

    Hochberg, J.; Scovel, C.; Thomas, T.; Hall, S.

    1998-12-01

    This paper describes a method for asking statistical questions about a large text corpus. The authors exemplify the method by addressing the question, ``What percentage of Federal Register documents are real documents, of possible interest to a text researcher or analyst?`` They estimate an answer to this question by evaluating 200 documents selected from a corpus of 45,820 Federal Register documents. Bayesian analysis and stratified sampling are used to reduce the sampling uncertainty of the estimate from over 3,100 documents to fewer than 1,000. A possible application of the method is to establish baseline statistics used to estimate recall rates for information retrieval systems.

  19. A direct observation method for auditing large urban centers using stratified sampling, mobile GIS technology and virtual environments.

    Science.gov (United States)

    Lafontaine, Sean J V; Sawada, M; Kristjansson, Elizabeth

    2017-02-16

    With the expansion and growth of research on neighbourhood characteristics, there is an increased need for direct observational field audits. Herein, we introduce a novel direct observational audit method and systematic social observation instrument (SSOI) for efficiently assessing neighbourhood aesthetics over large urban areas. Our audit method uses spatial random sampling stratified by residential zoning and incorporates both mobile geographic information systems technology and virtual environments. The reliability of our method was tested in two ways: first, in 15 Ottawa neighbourhoods, we compared results at audited locations over two subsequent years, and second; we audited every residential block (167 blocks) in one neighbourhood and compared the distribution of SSOI aesthetics index scores with results from the randomly audited locations. Finally, we present interrater reliability and consistency results on all observed items. The observed neighbourhood average aesthetics index score estimated from four or five stratified random audit locations is sufficient to characterize the average neighbourhood aesthetics. The SSOI was internally consistent and demonstrated good to excellent interrater reliability. At the neighbourhood level, aesthetics is positively related to SES and physical activity and negatively correlated with BMI. The proposed approach to direct neighbourhood auditing performs sufficiently and has the advantage of financial and temporal efficiency when auditing a large city.

  20. Clinical features and multidisciplinary approaches to dementia care

    Directory of Open Access Journals (Sweden)

    Gr

    2011-05-01

    Full Text Available Jacob HG Grand¹, Sienna Caspar², Stuart WS MacDonald11Department of Psychology, University of Victoria, Victoria, BC, Canada; 2Interdisciplinary Graduate Studies, University of British Columbia, Vancouver, BC, CanadaAbstract: Dementia is a clinical syndrome of widespread progressive deterioration of cognitive abilities and normal daily functioning. These cognitive and behavioral impairments pose considerable challenges to individuals with dementia, along with their family members and caregivers. Four primary dementia classifications have been defined according to clinical and research criteria: 1 Alzheimer’s disease; 2 vascular dementias; 3 frontotemporal dementias; and 4 dementia with Lewy bodies/Parkinson’s disease dementia. The cumulative efforts of multidisciplinary healthcare teams have advanced our understanding of dementia beyond basic descriptions, towards a more complete elucidation of risk factors, clinical symptoms, and neuropathological correlates. The characterization of disease subtypes has facilitated targeted management strategies, advanced treatments, and symptomatic care for individuals affected by dementia. This review briefly summarizes the current state of knowledge and directions of dementia research and clinical practice. We provide a description of the risk factors, clinical presentation, and differential diagnosis of dementia. A summary of multidisciplinary team approaches to dementia care is outlined, including management strategies for the treatment of cognitive impairments, functional deficits, and behavioral and psychological symptoms of dementia. The needs of individuals with dementia are extensive, often requiring care beyond traditional bounds of medical practice, including pharmacologic and non-pharmacologic management interventions. Finally, advanced research on the early prodromal phase of dementia is reviewed, with a focus on change-point models, trajectories of cognitive change, and threshold models of

  1. Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach.

    Science.gov (United States)

    Timpel, P; Lang, C; Wens, J; Contel, J C; Gilis-Januszewska, A; Kemple, K; Schwarz, P E

    2017-11-13

    Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and

  2. Training Physicians toward a Dignifying Approach in Adolescents' Health Care: A Promising Simulation-Based Medical Education Program.

    Science.gov (United States)

    Hardoff, Daniel; Gefen, Assaf; Sagi, Doron; Ziv, Amitai

    2016-08-01

    Human dignity has a pivotal role within the health care system. There is little experience using simulation-based medical education (SBME) programs that focus on human dignity issues in doctor-patient relationships. To describe and assess a SBME program aimed at improving physicians' competence in a dignifying approach when encountering adolescents and their parents. A total of 97 physicians participated in 8 one-day SMBE workshops that included 7 scenarios of typical adolescent health care dilemmas. These issues could be resolved if the physician used an appropriate dignifying approach toward the patient and the parents. Debriefing discussions were based on video recordings of the scenarios. The effect of the workshops on participants' approach to adolescent health care was assessed by a feedback questionnaire and on 5-point Likert score questionnaires administered before the workshop and 3 months after. All participants completed both the pre-workshop and the feedback questionnaires and 41 (42%) completed the post-workshop questionnaire 3 months later. Practice and competence topics received significantly higher scores in post-workshop questionnaires (P simulation-based workshop may improve physicians' communication skills and sense of competence in addressing adolescents' health care issues which require a dignifying approach toward both the adolescent patients and their parents. This dignity-focused methodology may be expanded to improve communication skills of physicians from various disciplines.

  3. Approaches and challenges to optimising primary care teams’ electronic health record usage

    Directory of Open Access Journals (Sweden)

    Nancy Pandhi

    2014-07-01

    Full Text Available Background Although the presence of an electronic health record (EHR alone does not ensure high quality, efficient care, few studies have focused on the work of those charged with optimising use of existing EHR functionality.Objective To examine the approaches used and challenges perceived by analysts supporting the optimisation of primary care teams’ EHR use at a large U.S. academic health care system.Methods A qualitative study was conducted. Optimisation analysts and their supervisor were interviewed and data were analysed for themes.Results Analysts needed to reconcile the tension created by organisational mandates focused on the standardisation of EHR processes with the primary care teams’ demand for EHR customisation. They gained an understanding of health information technology (HIT leadership’s and primary care team’s goals through attending meetings, reading meeting minutes and visiting with clinical teams. Within what was organisationally possible, EHR education could then be tailored to fit team needs. Major challenges were related to organisational attempts to standardise EHR use despite varied clinic contexts, personnel readiness and technical issues with the EHR platform. Forcing standardisation upon clinical needs that current EHR functionality could not satisfy was difficult.Conclusions Dedicated optimisation analysts can add value to health systems through playing a mediating role between HIT leadership and care teams. Our findings imply that EHR optimisation should be performed with an in-depth understanding of the workflow, cognitive and interactional activities in primary care.

  4. A theory-informed approach to mental health care capacity building for pharmacists.

    Science.gov (United States)

    Murphy, Andrea L; Gardner, David M; Kutcher, Stan P; Martin-Misener, Ruth

    2014-01-01

    Pharmacists are knowledgeable, accessible health care professionals who can provide services that improve outcomes in mental health care. Various challenges and opportunities can exist in pharmacy practice to hinder or support pharmacists' efforts. We used a theory-informed approach to development and implementation of a capacity-building program to enhance pharmacists' roles in mental health care. Theories and frameworks including the Consolidated Framework for Implementation Research, the Theoretical Domains Framework, and the Behaviour Change Wheel were used to inform the conceptualization, development, and implementation of a capacity-building program to enhance pharmacists' roles in mental health care. The More Than Meds program was developed and implemented through an iterative process. The main program components included: an education and training day; use of a train-the-trainer approach from partnerships with pharmacists and people with lived experience of mental illness; development of a community of practice through email communications, a website, and a newsletter; and use of educational outreach delivered by pharmacists. Theories and frameworks used throughout the program's development and implementation facilitated a means to conceptualize the component parts of the program as well as its overall presence as a whole from inception through evolution in implementation. Using theoretical foundations for the program enabled critical consideration and understanding of issues related to trialability and adaptability of the program. Theory was essential to the underlying development and implementation of a capacity-building program for enhancing services by pharmacists for people with lived experience of mental illness. Lessons learned from the development and implementation of this program are informing current research and evolution of the program.

  5. Interfacial transport characteristics in a gas-liquid or an immiscible liquid-liquid stratified flow

    International Nuclear Information System (INIS)

    Inoue, A.; Aoki, S.; Aritomi, M.; Kozawa, Y.

    1982-01-01

    This paper is a review for an interfacial transport characteristics of mass, momentum and energy in a gas-liquid or a immiscible liquid-liquid stratified flow with wavy interface which have been studied in our division. In the experiment, a characteristic of wave motion and its effect to the turbulence near the interface as well as overall flow characteristics like pressure drop, position of the interface were investigated in an air-water, an air-mercury and a water-liquid metal stratified flow. On the other hand, several models based on the mixing length model and a two-equation model of turbulence, with special interfacial boundary conditions in which the wavy surface was regarded as a rough surface correspond to the wavy height, a source of turbulent energy equal to the wave energy and a damped-turbulence due to the surface tension, were proposed to predict the flow characteristics and the interfacial heat transfer in a fully developed and an undeveloped stratified flow and examined by the experimental data. (author)

  6. LONGITUDINAL OSCILLATIONS IN DENSITY STRATIFIED AND EXPANDING SOLAR WAVEGUIDES

    Energy Technology Data Exchange (ETDEWEB)

    Luna-Cardozo, M. [Instituto de Astronomia y Fisica del Espacio, CONICET-UBA, CC. 67, Suc. 28, 1428 Buenos Aires (Argentina); Verth, G. [School of Computing, Engineering and Information Sciences, Northumbria University, Newcastle Upon Tyne NE1 8ST (United Kingdom); Erdelyi, R., E-mail: mluna@iafe.uba.ar, E-mail: robertus@sheffield.ac.uk, E-mail: gary.verth@northumbria.ac.uk [Solar Physics and Space Plasma Research Centre (SP2RC), University of Sheffield, Hicks Building, Hounsfield Road, Sheffield S3 7RH (United Kingdom)

    2012-04-01

    Waves and oscillations can provide vital information about the internal structure of waveguides in which they propagate. Here, we analytically investigate the effects of density and magnetic stratification on linear longitudinal magnetohydrodynamic (MHD) waves. The focus of this paper is to study the eigenmodes of these oscillations. It is our specific aim to understand what happens to these MHD waves generated in flux tubes with non-constant (e.g., expanding or magnetic bottle) cross-sectional area and density variations. The governing equation of the longitudinal mode is derived and solved analytically and numerically. In particular, the limit of the thin flux tube approximation is examined. The general solution describing the slow longitudinal MHD waves in an expanding magnetic flux tube with constant density is found. Longitudinal MHD waves in density stratified loops with constant magnetic field are also analyzed. From analytical solutions, the frequency ratio of the first overtone and fundamental mode is investigated in stratified waveguides. For small expansion, a linear dependence between the frequency ratio and the expansion factor is found. From numerical calculations it was found that the frequency ratio strongly depends on the density profile chosen and, in general, the numerical results are in agreement with the analytical results. The relevance of these results for solar magneto-seismology is discussed.

  7. Optimal energy growth in a stably stratified shear flow

    Science.gov (United States)

    Jose, Sharath; Roy, Anubhab; Bale, Rahul; Iyer, Krithika; Govindarajan, Rama

    2018-02-01

    Transient growth of perturbations by a linear non-modal evolution is studied here in a stably stratified bounded Couette flow. The density stratification is linear. Classical inviscid stability theory states that a parallel shear flow is stable to exponentially growing disturbances if the Richardson number (Ri) is greater than 1/4 everywhere in the flow. Experiments and numerical simulations at higher Ri show however that algebraically growing disturbances can lead to transient amplification. The complexity of a stably stratified shear flow stems from its ability to combine this transient amplification with propagating internal gravity waves (IGWs). The optimal perturbations associated with maximum energy amplification are numerically obtained at intermediate Reynolds numbers. It is shown that in this wall-bounded flow, the three-dimensional optimal perturbations are oblique, unlike in unstratified flow. A partitioning of energy into kinetic and potential helps in understanding the exchange of energies and how it modifies the transient growth. We show that the apportionment between potential and kinetic energy depends, in an interesting manner, on the Richardson number, and on time, as the transient growth proceeds from an optimal perturbation. The oft-quoted stabilizing role of stratification is also probed in the non-diffusive limit in the context of disturbance energy amplification.

  8. An integrated approach to health care costs: the case of American Can.

    Science.gov (United States)

    Silvers, J B; Haslinger, J

    1984-01-01

    Faced with numerous health care options, corporations are searching for plans which provide necessary benefits while containing costs. This article examines the case of the American Can Company where, since 1978, a new approach has produced mutual economic gains and employee satisfaction. American Can's efforts involved differential pricing and encouraged responsible selection by employees. The company was one of several studied by the Health Systems Management Center at Case Western Reserve University under contract with the Business Roundtable Health Initiatives Task Force. Such studies provide insight for other companies seeking ways to attack burgeoning corporate health care costs. This article is one of a series reporting the results of these studies.

  9. Technetium reduction and removal in a stratified fjord

    International Nuclear Information System (INIS)

    Keith-Roach, M.; Roos, P.

    2002-01-01

    The distribution of Tc in the water columns of a stratified fjord has been measured to investigate the behaviour and fate of Tc on reaching reducing waters. Slow mixing in the water column of the fjord results in vertical transport of the dissolved Tc to the oxic/anoxic interface. Tc is reduced just below the interface and at 21 m 60% is sorbed to particulate and colloidal material. Tc is carried to the sediments sorbed to the particulate material, where there is a current inventory of approximately 3 Bq m -2 . (LN)

  10. Technetium reduction and removal in a stratified fjord

    Energy Technology Data Exchange (ETDEWEB)

    Keith-Roach, M.; Roos, P. [Risoe National Lab., Roskilde (Denmark)

    2002-04-01

    The distribution of Tc in the water columns of a stratified fjord has been measured to investigate the behaviour and fate of Tc on reaching reducing waters. Slow mixing in the water column of the fjord results in vertical transport of the dissolved Tc to the oxic/anoxic interface. Tc is reduced just below the interface and at 21 m 60% is sorbed to particulate and colloidal material. Tc is carried to the sediments sorbed to the particulate material, where there is a current inventory of approximately 3 Bq m{sup -2}. (LN)

  11. Sensitivity of the Geomagnetic Octupole to a Stably Stratified Layer in the Earth's Core

    Science.gov (United States)

    Yan, C.; Stanley, S.

    2017-12-01

    The presence of a stably stratified layer at the top of the core has long been proposed for Earth, based on evidence from seismology and geomagnetic secular variation. Geodynamo modeling offers a unique window to inspect the properties and dynamics in Earth's core. For example, numerical simulations have shown that magnetic field morphology is sensitive to the presence of stably stratified layers in a planet's core. Here we use the mMoSST numerical dynamo model to investigate the effects of a thin stably stratified layer at the top of the fluid outer core in Earth on the resulting large-scale geomagnetic field morphology. We find that the existence of a stable layer has significant influence on the octupolar component of the magnetic field in our models, whereas the quadrupole doesn't show an obvious trend. This suggests that observations of the geomagnetic field can be applied to provide information of the properties of this plausible stable layer, such as how thick and how stable this layer could be. Furthermore, we have examined whether the dominant thermal signature from mantle tomography at the core-mantle boundary (CMB) (a degree & order 2 spherical harmonic) can influence our results. We found that this heat flux pattern at the CMB has no outstanding effects on the quadrupole and octupole magnetic field components. Our studies suggest that if there is a stably stratified layer at the top of the Earth's core, it must be limited in terms of stability and thickness, in order to be compatible with the observed paleomagnetic record.

  12. Blood component therapy in anesthesia and intensive care: Adoption of evidence based approaches

    Directory of Open Access Journals (Sweden)

    Sukhminder Jit Singh Bajwa

    2014-01-01

    Full Text Available Transfusion of blood and its components has undergone technological advancement, and its use is increasing both perioperatively as well as in the Intensive Care Unit. The separation of blood into its various components has made it very economical as blood donated from a single donor can be utilized for many recipients at the same time. However, the transfusion of blood and its components do carry the inherent risk of various transfusion reactions as well as transmission of infections. The indications for transfusion should be strictly adhered to for preventing nonjudicious use. The health care persons involved in transfusion should be well aware of implications of the mismatched transfusion and should be able to provide treatment if such mishaps do occur. A health care professional should carefully weigh the benefits of blood transfusion against the risks involved before subjecting the patients to the transfusion. This manuscript aims to comprehensively review the current evidence based approaches in blood and component transfusion which are being followed in anesthesiology and intensive care practice.

  13. Propagation of acoustic waves in a stratified atmosphere, 1

    Science.gov (United States)

    Kalkofen, W.; Rossi, P.; Bodo, G.; Massaglia, S.

    1994-01-01

    This work is motivated by the chromospheric 3 minute oscillations observed in the K(sub 2v) bright points. We study acoustic gravity waves in a one-dimensional, gravitationally stratified, isothermal atmosphere. The oscillations are excited either by a velocity pulse imparted to a layer in an atmosphere of infinite vertical extent, or by a piston forming the lower boundary of a semi-infinite medium. We consider both linear and non-linear waves.

  14. The Fokker-Planck equation for ray dispersion in gyrotropic stratified media

    NARCIS (Netherlands)

    Golynski, S.M.

    1984-01-01

    The Hamilton equations of geometrical optics determine the rays of the relevant wave field in the short wavelength. We give a systematic derivation of the Fokker-Planck equation for the joint probability density of the position and unit direction vector of rays propagating in a gyrotropic stratified

  15. Stratified polymer brushes from microcontact printing of polydopamine initiator on polymer brush surfaces.

    Science.gov (United States)

    Wei, Qiangbing; Yu, Bo; Wang, Xiaolong; Zhou, Feng

    2014-06-01

    Stratified polymer brushes are fabricated using microcontact printing (μCP) of initiator integrated polydopamine (PDOPBr) on polymer brush surfaces and the following surface initiated atom transfer radical polymerization (SI-ATRP). It is found that the surface energy, chemically active groups, and the antifouling ability of the polymer brushes affect transfer efficiency and adhesive stability of the polydopamine film. The stickiness of the PDOPBr pattern on polymer brush surfaces is stable enough to perform continuous μCP and SI-ATRP to prepare stratified polymer brushes with a 3D topography, which have broad applications in cell and protein patterning, biosensors, and hybrid surfaces. © 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

  16. Development and evaluation of a teaching and learning approach in cross-cultural care and antidiscrimination in university nursing students.

    Science.gov (United States)

    Allen, Jacqui; Brown, Lucinda; Duff, Carmel; Nesbitt, Pat; Hepner, Anne

    2013-12-01

    Cross-cultural care and antidiscrimination are vital to ethical effective health systems. Nurses require quality educational preparation in cross-cultural care and antidiscrimination. Limited evidence-based research is available to guide teachers. To develop, implement and evaluate an evidence-based teaching and learning approach in cross-cultural care and antidiscrimination for undergraduate nursing students. A quantitative design using pre- and post-survey measures was used to evaluate the teaching and learning approach. The Bachelor of Nursing program in an Australian university. Academics and second year undergraduate nursing students. A literature review and consultation with academics informed the development of the teaching and learning approach. Thirty-three students completed a survey at pre-measures and following participation in the teaching and learning approach at post-measures about their confidence to practice cross-cultural nursing (Transcultural Self-efficacy Tool) and about their discriminatory attitudes (Quick Discrimination Index). The literature review found that educational approaches that solely focus on culture might not be sufficient in addressing discrimination and racism. During consultation, academics emphasised the importance of situating cross-cultural nursing and antidiscrimination as social determinants of health. Therefore, cross-cultural nursing was contextualised within primary health care and emphasised care for culturally diverse communities. Survey findings supported the effectiveness of this strategy in promoting students' confidence regarding knowledge about cross-cultural nursing. There was no reported change in discriminatory attitudes. The teaching and learning approach was modified to include stronger experiential learning and role playing. Nursing education should emphasise cross-cultural nursing and antidiscrimination. The study describes an evaluated teaching and learning approach and demonstrates how evaluation

  17. Multi-Instrument Observations of Prolonged Stratified Wind Layers at Iqaluit, Nunavut

    Science.gov (United States)

    Mariani, Zen; Dehghan, Armin; Gascon, Gabrielle; Joe, Paul; Hudak, David; Strawbridge, Kevin; Corriveau, Julien

    2018-02-01

    Data collected between October 2015 and May 2016 at Environment and Climate Change Canada's Iqaluit research site (64°N, 69°W) have revealed a high frequency (40% of all days for which observations were available) of stratified wind layer events that occur from near the surface up to about 7.2 km above sea level. These stratified wind layers are clearly visible as wind shifts (90 to 180°) with height in range-height indicator scans from the Doppler lidar and Ka-band radar and in wind direction profiles from the Doppler lidar and radiosonde. During these events, the vertical structure of the flow appears to be a stack of 4 to 10 layers ranging in vertical width from 0.1 to 4.4 km. The stratification events that were observed occurred predominantly (81%) during light precipitation and lasted up to 27.5 h. The integrated measurement platforms at Iqaluit permitted continuous observations of the evolution of stratification events in different meteorological conditions.

  18. Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

    NARCIS (Netherlands)

    J.B.M. Vos; J.M. Cramm (Jane); J.D.H. van Wijngaarden (Jeroen); T.J.E.M. Bakker (Ton); J.P. Mackenbach (Johan); A.P. Nieboer (Anna)

    2017-01-01

    textabstractBackground: The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older

  19. An efficient non hydrostatic dynamical care far high-resolution simulations down to the urban scale

    International Nuclear Information System (INIS)

    Bonaventura, L.; Cesari, D.

    2005-01-01

    Numerical simulations of idealized stratified flows aver obstacles at different spatial scales demonstrate the very general applicability and the parallel efficiency of a new non hydrostatic dynamical care far simulation of mesoscale flows aver complex terrain

  20. The stratified Boycott effect

    Science.gov (United States)

    Peacock, Tom; Blanchette, Francois; Bush, John W. M.

    2005-04-01

    We present the results of an experimental investigation of the flows generated by monodisperse particles settling at low Reynolds number in a stably stratified ambient with an inclined sidewall. In this configuration, upwelling beneath the inclined wall associated with the Boycott effect is opposed by the ambient density stratification. The evolution of the system is determined by the relative magnitudes of the container depth, h, and the neutral buoyancy height, hn = c0(ρp-ρf)/|dρ/dz|, where c0 is the particle concentration, ρp the particle density, ρf the mean fluid density and dρ/dz Boycott layer transports dense fluid from the bottom to the top of the system; subsequently, the upper clear layer of dense saline fluid is mixed by convection. For sufficiently strong stratification, h > hn, layering occurs. The lowermost layer is created by clear fluid transported from the base to its neutral buoyancy height, and has a vertical extent hn; subsequently, smaller overlying layers develop. Within each layer, convection erodes the initially linear density gradient, generating a step-like density profile throughout the system that persists after all the particles have settled. Particles are transported across the discrete density jumps between layers by plumes of particle-laden fluid.

  1. P05.03. Integrative Primary Care Approach to Irritable Bowel Syndrome

    OpenAIRE

    Locke, Amy

    2013-01-01

    Focus Area: Integrative Approaches to Care Irritable bowel syndrome (IBS) is thought to affect 5% to 10% of the population and is likely a constellation of disorders resulting in abdominal pain, diarrhea, and/or constipation. This presentation will review the scientific evidence for common integrative treatments. A comprehensive integrative history often elucidates underlying factors contributing to symptoms. Assessment of the foundations of health, as with most conditions, is important for I...

  2. Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach.

    Science.gov (United States)

    Krishna, Lalit Kumar Radha

    2015-09-01

    The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.

  3. FDTD scattered field formulation for scatterers in stratified dispersive media.

    Science.gov (United States)

    Olkkonen, Juuso

    2010-03-01

    We introduce a simple scattered field (SF) technique that enables finite difference time domain (FDTD) modeling of light scattering from dispersive objects residing in stratified dispersive media. The introduced SF technique is verified against the total field scattered field (TFSF) technique. As an application example, we study surface plasmon polariton enhanced light transmission through a 100 nm wide slit in a silver film.

  4. Health care providers' perceived barriers to and need for the implementation of a national integrated health care standard on childhood obesity in the Netherlands - a mixed methods approach.

    Science.gov (United States)

    Schalkwijk, Annemarie A H; Nijpels, Giel; Bot, Sandra D M; Elders, Petra J M

    2016-03-08

    In 2010, a national integrated health care standard for (childhood) obesity was published and disseminated in the Netherlands. The aim of this study is to gain insight into the needs of health care providers and the barriers they face in terms of implementing this integrated health care standard. A mixed-methods approach was applied using focus groups, semi-structured, face-to-face interviews and an e-mail-based internet survey. The study's participants included: general practitioners (GPs) (focus groups); health care providers in different professions (face-to-face interviews) and health care providers, including GPs; youth health care workers; pediatricians; dieticians; psychologists and physiotherapists (survey). First, the transcripts from the focus groups were analyzed thematically. The themes identified in this process were then used to analyze the interviews. The results of the analysis of the qualitative data were used to construct the statements used in the e-mail-based internet survey. Responses to items were measured on a 5-point Likert scale and were categorized into three outcomes: 'agree' or 'important' (response categories 1 and 2), 'disagree' or 'not important'. Twenty-seven of the GPs that were invited (51 %) participated in four focus groups. Seven of the nine health care professionals that were invited (78 %) participated in the interviews and 222 questionnaires (17 %) were returned and included in the analysis. The following key barriers were identified with regard to the implementation of the integrated health care standard: reluctance to raise the subject; perceived lack of motivation and knowledge on the part of the parents; previous negative experiences with lifestyle programs; financial constraints and the lack of a structured multidisciplinary approach. The main needs identified were: increased knowledge and awareness on the part of both health care providers and parents/children; a social map of effective intervention; structural

  5. Preventive child health care at elementary school age: The costs of routine assessments with a triage approach.

    Directory of Open Access Journals (Sweden)

    Janine Bezem

    Full Text Available Triage in Preventive Child Health Care (PCH assessments could further the efficient use of human resources and budgets and therefore make extra care possible for children with specific needs. We assessed the costs of routine PCH assessments with and without triage for children aged 5/6 years and 10/11 years. In a triage approach, PCH assistants conduct pre-assessments to identify children requiring follow-up assessments by a physician or nurse. In the usual approach, all children are assessed by a physician and an assistant (children aged 5/6 years or a nurse (children aged 10/11 years.All the direct costs of conducting routine PCH assessments with the triage and usual approach were assessed using a bottom-up micro-costing approach. In four PCH services in the Netherlands, two using triage and two the usual approach, professionals completed questionnaires about time spent on assessments, including time related to non-attendance at assessments, the referral of children and administration.The projected costs for PCH professionals working on PCH assessments amounted to €5.2 million per cohort of 100,000 children aged 5/6 years in the triage approach, and €7.6 million in the usual approach. The projected costs in both approaches for children aged 10/11 years were about €4 million per 100,000 children.The triage approach to PCH resulted in a projected cost reduction of about one-third, compared with usual practice, for routine assessments by physicians of children aged 5/6 years. There are minimal cost savings in the group of children aged 10/11 years when nurses are involved and so other considerations such as workforce shortages would be required to justify a change to a triage approach. Further research is needed to investigate the differences in costs of care after the completion of the routine assessments.

  6. Stratified growth in Pseudomonas aeruginosa biofilms

    DEFF Research Database (Denmark)

    Werner, E.; Roe, F.; Bugnicourt, A.

    2004-01-01

    In this study, stratified patterns of protein synthesis and growth were demonstrated in Pseudomonas aeruginosa biofilms. Spatial patterns of protein synthetic activity inside biofilms were characterized by the use of two green fluorescent protein (GFP) reporter gene constructs. One construct...... synthesis was restricted to a narrow band in the part of the biofilm adjacent to the source of oxygen. The zone of active GFP expression was approximately 60 Am wide in colony biofilms and 30 Am wide in flow cell biofilms. The region of the biofilm in which cells were capable of elongation was mapped...... by treating colony biofilms with carbenicillin, which blocks cell division, and then measuring individual cell lengths by transmission electron microscopy. Cell elongation was localized at the air interface of the biofilm. The heterogeneous anabolic patterns measured inside these biofilms were likely a result...

  7. Thermal instability in a stratified plasma

    International Nuclear Information System (INIS)

    Hermanns, D.F.M.; Priest, E.R.

    1989-01-01

    The thermal instability mechansism has been studied in connection to observed coronal features, like, e.g. prominences or cool cores in loops. Although these features show a lot of structure, most studies concern the thermal instability in an uniform medium. In this paper, we investigate the thermal instability and the interaction between thermal modes and the slow magneto-acoustic subspectrum for a stratified plasma slab. We fomulate the relevant system of equations and give some straightforward properties of the linear spectrum of a non-uniform plasma slab, i.e. the existence of continuous parts in the spectrum. We present a numerical scheme with which we can investigate the linear spectrum for equilibrium states with stratification. The slow and thermal subspectra of a crude coronal model are given as a preliminary result. (author). 6 refs.; 1 fig

  8. Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization.

    Science.gov (United States)

    Kumar, Nitin; Conwell, Darwin L; Thompson, Christopher C

    2014-11-01

    Infected walled-off pancreatic necrosis (WOPN) is a complication of acute pancreatitis requiring intervention. Surgery is associated with considerable morbidity. Percutaneous catheter drainage (PCD), initial therapy in the step-up approach, minimizes complications. Direct endoscopic necrosectomy (DEN) has demonstrated safety and efficacy. We compared outcome and health care utilization of DEN versus step-up approach. This was a matched cohort study using a prospective registry. Twelve consecutive DEN patients were matched with 12 step-up approach patients. Outcomes were clinical resolution after primary therapeutic modality, new organ failure, mortality, endocrine or exocrine insufficiency, length of stay, and health care utilization. Clinical resolution in 11 of 12 patients after DEN versus 3 of 12 step-up approach patients after PCD (P endocrine insufficiency, and shorter length of stay (P < 0.05). Health care utilization was lower after DEN by 5.2:1 (P < 0.01). Direct endoscopic necrosectomy may be superior to step-up approach for WOPN with suspected or established infection. Primary PCD generally delayed definitive therapy. Given the higher efficacy, shorter length of stay, and lower health care utilization, DEN could be the first-line therapy for WOPN, with primary PCD for inaccessible or immature collections.

  9. Clinical and medication profiles stratified by household income in patients referred for diabetes care

    Directory of Open Access Journals (Sweden)

    Svenson Lawrence W

    2007-03-01

    Full Text Available Abstract Background Low income individuals with diabetes are at particularly high risk for poor health outcomes. While specialized diabetes care may help reduce this risk, it is not currently known whether there are significant clinical differences across income groups at the time of referral. The objective of this study is to determine if the clinical profiles and medication use of patients referred for diabetes care differ across income quintiles. Methods This cross-sectional study was conducted using a Canadian, urban, Diabetes Education Centre (DEC database. Clinical information on the 4687 patients referred to the DEC from May 2000 – January 2002 was examined. These data were merged with 2001 Canadian census data on income. Potential differences in continuous clinical parameters across income quintiles were examined using regression models. Differences in medication use were examined using Chi square analyses. Results Multivariate regression analysis indicated that income was negatively associated with BMI (p Conclusion Our findings demonstrate that low income patients present to diabetes clinic older, heavier and with a more atherogenic lipid profile than do high income patients. Overall medication use was higher among the lower income group suggesting that differences in clinical profiles are not the result of under-treatment, thus invoking lifestyle factors as potential contributors to these findings.

  10. Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract

    Directory of Open Access Journals (Sweden)

    H. Hildebrandt

    2010-06-01

    Full Text Available Introduction: Integrated care solutions need supportive financial incentives. In this paper we describe the financial architecture and operative details of the integrated pilot Gesundes Kinzigtal.Description of integrated care case: Located in Southwest Germany, Gesundes Kinzigtal is one of the few population-based integrated care approaches in Germany, organising care across all health service sectors and indications. The system serving around half of the population of the region is run by a regional health management company (Gesundes Kinzigtal GmbH in coope­ration with the physicians' network in the region (MQNK, a German health care management company with a background in medical sociology and health economics (OptiMedis AG and with two statutory health insurers (among them is the biggest health insurer in Southwest Germany: AOK Baden-Württemberg.Discussion and (preliminary conclusion: The shared savings contract between Gesundes Kinzigtal GmbH and the two health insurers, providing financial incentives for managers and health care providers to realize a sub­stantial efficiency gain, could be an appropriate contractual base of Gesundes Kinzigtal's population health gain approach. This approach is based on the assumption that a more effective trans-sector organisation of Germany's health care system and increased investments in well-designed preventive programmes will lead to a reduction in  morbidity, and in particular to a reduced incidence and prevalence of chronic diseases. This, in turn, is to lead to a comparative reduction in health care cost. Although the comparative cost in the Kinzigtal region has been reduced from the onset of Gesundes Kinzigtal Integrated Care, only future research will have to demonstrate whether - and to what extent - cost reduction may be attributed to a real population health gain.

  11. Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract

    Directory of Open Access Journals (Sweden)

    H. Hildebrandt

    2010-06-01

    Full Text Available Introduction: Integrated care solutions need supportive financial incentives. In this paper we describe the financial architecture and operative details of the integrated pilot 'Gesundes Kinzigtal'. Description of integrated care case: Located in Southwest Germany, 'Gesundes Kinzigtal' is one of the few population-based integrated care approaches in Germany, organising care across all health service sectors and indications. The system serving around half of the population of the region is run by a regional health management company (Gesundes Kinzigtal GmbH in coope­ration with the physicians' network in the region (MQNK, a German health care management company with a background in medical sociology and health economics (OptiMedis AG and with two statutory health insurers (among them is the biggest health insurer in Southwest Germany: AOK Baden-Württemberg. Discussion and (preliminary conclusion: The shared savings contract between Gesundes Kinzigtal GmbH and the two health insurers, providing financial incentives for managers and health care providers to realize a sub­stantial efficiency gain, could be an appropriate contractual base of Gesundes Kinzigtal's population health gain approach. This approach is based on the assumption that a more effective trans-sector organisation of Germany's health care system and increased investments in well-designed preventive programmes will lead to a reduction in  morbidity, and in particular to a reduced incidence and prevalence of chronic diseases. This, in turn, is to lead to a comparative reduction in health care cost. Although the comparative cost in the Kinzigtal region has been reduced from the onset of Gesundes Kinzigtal Integrated Care, only future research will have to demonstrate whether - and to what extent - cost reduction may be attributed to a real population health gain.

  12. Crossing 138: two approaches to churn under the Affordable Care Act.

    Science.gov (United States)

    Ravel, Gabriel; DeSantis, J Angelo

    2014-01-01

    A predicted side effect of the Medicaid expansion and state-based Exchanges under the Affordable Care Act is churn. Churn is the shifting into and out of eligibility for insurance affordability programs due to income changes. Because the line between Medicaid and Exchange eligibility is fine -138% of the federal poverty level -millions of Americans are expected to gain and lose eligibility. Frequently, this churning undermines continuity of care, raises costs, and frustrates those affected. This article explores two proposed programs to mitigate the effects of churn: the Basic Health Program and the Bridge Program. This article evaluates both programs' ability to mitigate the effects of churn, the likely side effects to states' implementing them, and legal and practical obstacles to their implementation. It concludes that the Bridge Program is the better approach.

  13. The significance of Helicobacter pylori in the approach of dyspepsia in primary care

    NARCIS (Netherlands)

    Arents, Nicolaas Lodevikus Augustinus

    2003-01-01

    Summary and conclusions In this thesis the management of dyspepsia in primary care in relation to Helicobacter pylori (H. pylori) infection was studied. In chapter two several important issues considering the approach of dyspepsia are discussed. It is clear that dyspepsia is not a disease but merely

  14. The critical care cascade: a systems approach.

    Science.gov (United States)

    Ghosh, Rishi; Pepe, Paul

    2009-08-01

    To emphasize the evolving body of evidence that supports the need for a more seamless and interconnected continuum of patient care for a growing compendium of critical care conditions, starting in the prehospital and emergency department (ED) phases of management and continuing through ICU and rehabilitation services. The care of critically ill and injured patients has become increasingly complex. It now has been demonstrated that, for a number of such critical care conditions, optimal management not only relies heavily on the talents of highly coordinated, multidisciplinary teams, but it also may require shared responsibilities across a continuum of longitudinal care involving numerous specialties and departments. This continuum usually needs to begin in the prehospital and ED settings with management extending through specialized in-hospital diagnostic and interventional suites to traditional ICU and rehabilitation programs. In recent years, examples of these conditions have included the development of systems of care for trauma, cardiac arrest, myocardial infarction, stroke, sepsis syndromes, toxicology and other critical illnesses. Although the widespread implementation of such multidisciplinary, multispecialty critical care cascades of care has been achieved most commonly in trauma care, current healthcare delivery systems generally tend to employ compartmentalized organization for the majority of other critical care patients. Accordingly, optimal systematic care often breaks down in the management of these complex patients due to barriers such as lack of interoperable communication between teams, disjointed transfers between services, unnecessary time-consuming, re-evaluations and transitional pauses in time-dependent circumstances, deficiencies in cross-disciplinary education and quality assurance loops, and significant variability in patient care practices. Such barriers can lead to adverse outcomes in this fragile patient population. This article discusses

  15. Persistence of the Gender Gap and Low Employment of Female Workers in a Stratified Labor Market: Evidence from South Korea

    Directory of Open Access Journals (Sweden)

    Joonmo Cho

    2015-09-01

    Full Text Available The gender gap in working conditions has barely improved in South Korea where various measures for gender equality have been in place for a relatively long time. Furthermore, the female employment rate is also the lowest in OECD (Organization for Economic Cooperation and Development countries. This study will evaluate the stratified structure of the labor market to identify the causes and will analyze changes in the gender employment distribution and mobility. This study conducted an empirical analysis of gender distribution and labor mobility in the South Korean labor market, utilizing long-term data (2005–2014 from the supplementary survey by employment type on the Economically Active Population of the Korea National Statistical Office. From the analysis, women showed a relatively smaller increase than men in the primary labor market, classified as the large and standard employment market, in 2014 compared with 2005, but showed a relatively greater increase than men in the secondary labor market, comprising the small–medium and non-standard employment market. Thus, gender skewness in employment distribution was greater in the stratified labor market. On the other hand, the non-economically active population more than doubled for women compared to men. From the analysis of labor mobility by gender, a higher proportion of women were employed in the peripheral labor market than in the core labor market and women were also more likely to be employed in the relatively weak peripheral labor market. These results imply that dichotomous gender equality policies for resolving the gender gap have a certain limitation in the stratified labor market. Thus, what is needed is a holistic approach that takes into account the labor market structure.

  16. Construction of an Interface Terminology on SNOMED CT Generic Approach and Its Application in Intensive Care

    NARCIS (Netherlands)

    Bakhshi-Raiez, F.; Ahmadian, L.; Cornet, R.; de Jonge, E.; de Keizer, N. F.

    2010-01-01

    Objective: To provide a generic approach for developing a domain-specific interface terminology on SNOMED CT and to apply this approach to the domain of intensive care. Methods: The process of developing an interface terminology on SNOMED CT can be regarded as six sequential phases: domain analysis,

  17. The effect of sediments on turbulent plume dynamics in a stratified fluid

    Science.gov (United States)

    Stenberg, Erik; Ezhova, Ekaterina; Brandt, Luca

    2017-11-01

    We report large eddy simulation results of sediment-loaded turbulent plumes in a stratified fluid. The configuration, where the plume is discharged from a round source, provides an idealized model of subglacial discharge from a submarine tidewater glacier and is a starting point for understanding the effect of sediments on the dynamics of the rising plume. The transport of sediments is modeled by means of an advection-diffusion equation where sediment settling velocity is taken into account. We initially follow the experimental setup of Sutherland (Phys. Rev. Fluids, 2016), considering uniformly stratified ambients and further extend the work to pycnocline-type stratifications typical of Greenland fjords. Apart from examining the rise height, radial spread and intrusion of the rising plume, we gain further insights of the plume dynamics by extracting turbulent characteristics and the distribution of the sediments inside the plume.

  18. Sutudy on exchange flow under the unstably stratified field

    OpenAIRE

    文沢, 元雄

    2005-01-01

    This paper deals with the exchange flow under the unstably stratified field. The author developed the effective measurement system as well as the numerical analysis program. The system and the program are applied to the helium-air exchange flow in a rectangular channel with inclination. Following main features of the exchange flow were discussed based on the calculated results.(1) Time required for establishing a quasi-steady state exchange flow.(2) The relationship between the inclination an...

  19. Volunteer navigation partnerships: Piloting a compassionate community approach to early palliative care.

    Science.gov (United States)

    Pesut, Barbara; Duggleby, Wendy; Warner, Grace; Fassbender, Konrad; Antifeau, Elisabeth; Hooper, Brenda; Greig, Madeleine; Sullivan, Kelli

    2017-07-03

    A compassionate community approach to palliative care provides important rationale for building community-based hospice volunteer capacity. In this project, we piloted one such capacity-building model in which volunteers and a nurse partnered to provide navigation support beginning in the early palliative phase for adults living in community. The goal was to improve quality of life by developing independence, engagement, and community connections. Volunteers received navigation training through a three-day workshop and then conducted in-home visits with clients living with advanced chronic illness over one year. A nurse navigator provided education and mentorship. Mixed method evaluation data was collected from clients, volunteer navigators, the nurse navigator, and other stakeholders. Seven volunteers were partnered with 18 clients. Over the one-year pilot, the volunteer navigators conducted visits in home or by phone every two to three weeks. Volunteers were skilled and resourceful in building connections and facilitating engagement. Although it took time to learn the navigator role, volunteers felt well-prepared and found the role satisfying and meaningful. Clients and family rated the service as highly important to their care because of how the volunteer helped to make the difficult experiences of aging and advanced chronic illness more livable. Significant benefits cited by clients were making good decisions for both now and in the future; having a surrogate social safety net; supporting engagement with life; and ultimately, transforming the experience of living with illness. Overall the program was perceived to be well-designed by stakeholders and meeting an important need in the community. Sustainability, however, was a concern expressed by both clients and volunteers. Volunteers providing supportive navigation services during the early phase of palliative care is a feasible way to foster a compassionate community approach to care for an aging population

  20. Developing a web-based information resource for palliative care: an action-research inspired approach

    Directory of Open Access Journals (Sweden)

    Gliddon Terry

    2007-09-01

    Full Text Available Abstract Background General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website 1. Method The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197 scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166. Results Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers. Conclusion Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to

  1. Gender Stratified Monopoly: Why Do I Earn Less and Pay More?

    Science.gov (United States)

    Smith, Stacy L.

    2017-01-01

    A modified version of Monopoly has long been used as a simulation exercise to teach inequality. Versions of Modified Monopoly (MM) have touched on minority status relative to inequality but without an exploration of the complex interaction between minority status and class. This article introduces Gender Stratified Monopoly (GSM), an adaptation…

  2. Longevity of Compositionally Stratified Layers in Ice Giants

    Science.gov (United States)

    Friedson, A. J.

    2017-12-01

    In the hydrogen-rich atmospheres of gas giants, a decrease with radius in the mixing ratio of a heavy species (e.g. He, CH4, H2O) has the potential to produce a density stratification that is convectively stable if the heavy species is sufficiently abundant. Formation of stable layers in the interiors of these planets has important implications for their internal structure, chemical mixing, dynamics, and thermal evolution, since vertical transport of heat and constituents in such layers is greatly reduced in comparison to that in convecting layers. Various processes have been suggested for creating compositionally stratified layers. In the interiors of Jupiter and Saturn, these include phase separation of He from metallic hydrogen and dissolution of dense core material into the surrounding metallic-H envelope. Condensation of methane and water has been proposed as a mechanism for producing stable zones in the atmospheres of Saturn and the ice giants. However, if a stably stratified layer is formed adjacent to an active region of convection, it may be susceptible to progressive erosion as the convection intrudes and entrains fluid into the unstable envelope. We discuss the principal factors that control the rate of entrainment and associated erosion and present a specific example concerning the longevity of stable layers formed by condensation of methane and water in Uranus and Neptune. We also consider whether the temporal variability of such layers may engender episodic behavior in the release of the internal heat of these planets. This research is supported by a grant from the NASA Solar System Workings Program.

  3. Gestalt therapy approaches with aggressive children in a day care setting

    OpenAIRE

    Maxey, Win

    1987-01-01

    This research study was designed to evaluate whether or not Gestalt therapy approaches could be used effectively when intervening with aggressive acts in a day care setting. Five focus children were observed at timed intervals as to whether or not they were aggressive, how the caretaker intervened, and how the children responded to the caretaker intervention. After a baseline of aggressive acts was established, caretakers were trained to use Gestalt therapy interventio...

  4. Effect of stratified inequality of blood flow on gas exchange in liquid-filled lungs.

    Science.gov (United States)

    West, J. B.; Maloney, J. E.; Castle, B. L.

    1972-01-01

    This investigation set out to answer two questions: (1) are the distal alveoli in the terminal lung units less well perfused than the proximal alveoli, i.e., is there stratification of blood flow; and (2) if so, does this enhance gas exchange in the presence of stratified inequality of ventilation. Excised dog lungs were ventilated with saline and perfused with blood. Following single inspirations of xenon 133 in saline and various periods of breath holding, the expired xenon concentration against volume was measured and it confirmed marked stratified inequality of ventilation under these conditions. By measuring the rate of depletion of xenon from alveoli during a period of blood flow, we showed that the alveoli which emptied at the end of expiration had 16% less blood flow than those exhaling earlier. However, by measuring the xenon concentration in pulmonary venous blood, we found that about 10% less tracer was transferred from the alveoli into the blood when the inspired xenon was stratified within the respiratory zone. Thus while stratification of blood flow was confirmed, it was shown to impair rather than enhance the efficiency of gas transfer.

  5. NGO management and health care financing approaches in the Eastern Democratic Republic of the Congo.

    Science.gov (United States)

    Dijkzeul, D; Lynch, C A

    2006-01-01

    The role of cost-sharing in health care is a crucial, yet contentious issue. In conflict situations, cost-sharing becomes even more controversial as health and other institutions are failing. In such situations, NGOs manage health programmes which aim to aid populations in crisis and improve or at least sustain a deteriorating health system. This study looks at the issue of cost-sharing in the wider context of utilization rates and management approaches of three NGOs in the chronic, high-mortality crisis of the eastern DRC. Approaches to increase access to health care were found to exist, yet cost-recovery, even on the basis of maximum utilization rates, would only partially sustain the health system in the eastern DRC. Factors external to the direct management of NGO health programs, such as the wider economic and security situation, local management structures, and international donor policies, need to be taken into account for establishing more integrated management and financing approaches.

  6. Characteristics of primary care practices associated with high quality of care.

    Science.gov (United States)

    Beaulieu, Marie-Dominique; Haggerty, Jeannie; Tousignant, Pierre; Barnsley, Janet; Hogg, William; Geneau, Robert; Hudon, Éveline; Duplain, Réjean; Denis, Jean-Louis; Bonin, Lucie; Del Grande, Claudio; Dragieva, Natalyia

    2013-09-03

    No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

  7. STRESS DISTRIBUTION IN THE STRATIFIED MASS CONTAINING VERTICAL ALVEOLE

    Directory of Open Access Journals (Sweden)

    Bobileva Tatiana Nikolaevna

    2017-08-01

    Full Text Available Almost all subsurface rocks used as foundations for various types of structures are stratified. Such heterogeneity may cause specific behaviour of the materials under strain. Differential equations describing the behaviour of such materials contain rapidly fluctuating coefficients, in view of this, solution of such equations is more time-consuming when using today’s computers. The method of asymptotic averaging leads to getting homogeneous medium under study to averaged equations with fixed factors. The present article is concerned with stratified soil mass consisting of pair-wise alternative isotropic elastic layers. In the results of elastic modules averaging, the present soil mass with horizontal rock stratification is simulated by homogeneous transversal-isotropic half-space with isotropy plane perpendicular to the standing axis. Half-space is loosened by a vertical alveole of circular cross-section, and virgin ground is under its own weight. For horizontal parting planes of layers, the following two types of surface conditions are set: ideal contact and backlash without cleavage. For homogeneous transversal-isotropic half-space received with a vertical alveole, the analytical solution of S.G. Lekhnitsky, well known in scientific papers, is used. The author gives expressions for stress components and displacements in soil mass for different marginal conditions on the alveole surface. Such research problems arise when constructing and maintaining buildings and when composite materials are used.

  8. The Growth of a Family: A family-oriented approach to pregnancy care

    OpenAIRE

    Carroll, June C.; Biringer, Anne

    1991-01-01

    Caring for a family during pregnancy and birth is an ideal opportunity for family physicians to assess family functioning and help the family adjust to the birth of a new child. Stress and support systems can influence the course of pregnancy, including obstetric and perinatal outcomes. A family-centered approach can help patients during this critical stage of family development.

  9. The importance of quality, access and price to health care consumers in Bulgaria: A self-explicated approach'

    NARCIS (Netherlands)

    Pavlova, M.; Groot, W.J.N.; van Merode, F.

    2003-01-01

    One approach to the problem of low patient satisfaction in Bulgaria is to identify attributes of health care services that the consumers value most and to focus on their improvement. Based on data from a household survey, this paper examines the importance that health care consumers attach to

  10. E25 stratified torch ignition engine emissions and combustion analysis

    International Nuclear Information System (INIS)

    Rodrigues Filho, Fernando Antonio; Baêta, José Guilherme Coelho; Teixeira, Alysson Fernandes; Valle, Ramón Molina; Fonseca de Souza, José Leôncio

    2016-01-01

    Highlights: • A stratified torch ignition (STI) engine was built and tested. • The STI engines was tested in a wide range of load and speed. • Significant reduction on emissions was achieved by means of the STI system. • Low cyclic variability characterized the lean combustion process of the torch ignition engine. • HC emission is the main drawback of the stratified torch ignition engine. - Abstract: Vehicular emissions significantly increase atmospheric air pollution and greenhouse gases (GHG). This fact associated with fast global vehicle fleet growth calls for prompt scientific community technological solutions in order to promote a significant reduction in vehicle fuel consumption and emissions, especially of fossil fuels to comply with future legislation. To meet this goal, a prototype stratified torch ignition (STI) engine was built from a commercial existing baseline engine. In this system, combustion starts in a pre-combustion chamber, where the pressure increase pushes the combustion jet flames through calibrated nozzles to be precisely targeted into the main chamber. These combustion jet flames are endowed with high thermal and kinetic energy, being able to generate a stable lean combustion process. The high kinetic and thermal energy of the combustion jet flame results from the load stratification. This is carried out through direct fuel injection in the pre-combustion chamber by means of a prototype gasoline direct injector (GDI) developed for a very low fuel flow rate. In this work the engine out-emissions of CO, NOx, HC and CO_2 of the STI engine are presented and a detailed analysis supported by the combustion parameters is conducted. The results obtained in this work show a significant decrease in the specific emissions of CO, NOx and CO_2 of the STI engine in comparison with the baseline engine. On the other hand, HC specific emission increased due to wall wetting from the fuel hitting in the pre-combustion chamber wall.

  11. Application of Smart Infrastructure Systems approach to precision medicine

    Directory of Open Access Journals (Sweden)

    Diddahally R. Govindaraju

    2015-12-01

    Full Text Available All biological variation is hierarchically organized dynamic network system of genomic components, organelles, cells, tissues, organs, individuals, families, populations and metapopulations. Individuals are axial in this hierarchy, as they represent antecedent, attendant and anticipated aspects of health, disease, evolution and medical care. Humans show individual specific genetic and clinical features such as complexity, cooperation, resilience, robustness, vulnerability, self-organization, latent and emergent behavior during their development, growth and senescence. Accurate collection, measurement, organization and analyses of individual specific data, embedded at all stratified levels of biological, demographic and cultural diversity – the big data – is necessary to make informed decisions on health, disease and longevity; which is a central theme of precision medicine initiative (PMI. This initiative also calls for the development of novel analytical approaches to handle complex multidimensional data. Here we suggest the application of Smart Infrastructure Systems (SIS approach to accomplish some of the goals set forth by the PMI on the premise that biological systems and the SIS share many common features. The latter has been successfully employed in managing complex networks of non-linear adaptive controls, commonly encountered in smart engineering systems. We highlight their concordance and discuss the utility of the SIS approach in precision medicine programs.

  12. Examining leadership as a strategy to enhance health care service delivery in regional hospitals in South Africa

    Science.gov (United States)

    Govender, Sagaren; Gerwel Proches, Cecile N; Kader, Abdulla

    2018-01-01

    Background Four public hospitals in South Africa, which render both specialized and nonspecialized services to thousands of patients, were examined to determine the impact of leadership on health care service delivery. These hospitals were inundated by various problems that were impacting negatively on health care service delivery. Purpose This research study aimed to gain a comprehensive understanding of the challenges, complexities and constraints facing public health care in KwaZulu-Natal (KZN) and to examine leadership as a strategy to enhance healthcare service delivery with a particular focus on four regional hospitals in the KZN Province. Methods The mixed-method research approach was utilized. Purposive sampling and stratified random sampling were employed in the research setting, and in-depth, semistructured interviews and questionnaires were used to collect data. Data were analyzed using the Nvivo computer software package for in-depth interviews and the Statistical Package for the Social Sciences (SPSS) software for the quantitative analysis. Results The research findings showed that the current leadership framework adopted by the health care leaders in regional hospitals in KZN is weak and is contributing to poor health care service delivery. Conclusion This study, therefore, aimed to address the current challenges and weaknesses that are impacting negatively on health care service delivery in regional hospitals in the KZN Province and made recommendations for improvement. PMID:29535529

  13. Meanings of Care: A Culture-Centered Approach to Left-Behind Family Members in the Countryside of China.

    Science.gov (United States)

    Sun, Kang; Dutta, Mohan J

    2016-11-01

    Critical studies of health communication foreground the importance of meanings as organizing frameworks for constituting health. The contested and contradictory meanings articulated around health offer insights into the constraining and enabling roles of structures. Through ethnographic fieldwork conducted in a village in China embedded within the activist framework of the culture-centered approach, this project explores understandings of family care amid left-behind families in rural China against the backdrop of the migration of the middle generation of working adults from families located in rural contexts to cities. We work with the culture-centered approach to explore local meanings of care, understanding everyday care as integral to the health of an aging population that has been erased from the discursive space by market reforms and the hegemonic narrative of national development in China.

  14. Rural geriatric glue: a nurse practitioner-led model of care for enhancing primary care for frail older adults within an ecosystem approach.

    Science.gov (United States)

    Prasad, Sadhana; Dunn, Wendy; Hillier, Loretta M; McAiney, Carrie A; Warren, Rex; Rutherford, Paul

    2014-09-01

    This article describes the implementation of the Care for Seniors model of care, an innovative approach to improving care coordination and integration, and provides preliminary evidence of effective use of specialist resources and acute care services. Retrospective. Primary care; cross-sector. Older adults living in a rural area in southwestern Ontario, Canada. Number of new geriatrician referrals and follow-up visits before and after the launch of the Care for Seniors program, number of Nurse Practitioner visits in a primary care setting, in-home, retirement home and hospital, number of discharges home from hospital and length of hospital stay between. In the 2 years before the launch of the program, the total number of visits to the geriatrician for individuals from this FHT was relatively low, 21 and 15, respectively for 2005-06 and 2006-07, increasing to 73 for the 2011-12 year. Although the absolute number of individuals supported by the NP-Geri has remained relatively the same, the numbers seen in the primary care office or in the senior's clinic has declined over time, and the number of home visits has increased, as have visits in the retirement homes. The percentage of individuals discharged home increased from 19% in 2008-09 to 31% in 2009-10 and 26% in 2011-12 and the average length of stay decreased over time. This model of care represents a promising collaboration between primary care and specialist care for improving care to frail older adults living in rural communities, potentially improving timely access to health care and crisis intervention. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

  15. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline.

    Science.gov (United States)

    Jeronimo, Jose; Castle, Philip E; Temin, Sarah; Denny, Lynette; Gupta, Vandana; Kim, Jane J; Luciani, Silvana; Murokora, Daniel; Ngoma, Twalib; Qiao, Youlin; Quinn, Michael; Sankaranarayanan, Rengaswamy; Sasieni, Peter; Schmeler, Kathleen M; Shastri, Surendra S

    2017-10-01

    To provide resource-stratified, evidence-based recommendations on the secondary prevention of cervical cancer globally. ASCO convened a multidisciplinary, multinational panel of oncology, primary care, epidemiology, health economic, cancer control, public health, and patient advocacy experts to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, a formal consensus-based process, and a modified ADAPTE process to adapt existing guidelines were conducted. Other experts participated in formal consensus. Seven existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Four systematic reviews plus cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies by setting are as follows: maximal: ages 25 to 65, every 5 years; enhanced: ages 30 to 65, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: ages 30 to 49, every 10 years; and basic: ages 30 to 49, one to three times per lifetime. For basic settings, visual assessment is recommended as triage; in other settings, genotyping and/or cytology are recommended. For basic settings, treatment is recommended if abnormal triage results are present; in other settings, colposcopy is recommended for abnormal triage results. For basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure (or ablation) is recommended. Twelve-month post-treatment follow-up is recommended in all settings. Women who are HIV positive should be screened with HPV testing after diagnosis and screened twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in

  16. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline

    Directory of Open Access Journals (Sweden)

    Jose Jeronimo

    2017-10-01

    Full Text Available Purpose: To provide resource-stratified, evidence-based recommendations on the secondary prevention of cervical cancer globally. Methods: ASCO convened a multidisciplinary, multinational panel of oncology, primary care, epidemiology, health economic, cancer control, public health, and patient advocacy experts to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, a formal consensus-based process, and a modified ADAPTE process to adapt existing guidelines were conducted. Other experts participated in formal consensus. Results: Seven existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Four systematic reviews plus cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. Recommendations: Human papillomavirus (HPV DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies by setting are as follows: maximal: ages 25 to 65, every 5 years; enhanced: ages 30 to 65, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: ages 30 to 49, every 10 years; and basic: ages 30 to 49, one to three times per lifetime. For basic settings, visual assessment is recommended as triage; in other settings, genotyping and/or cytology are recommended. For basic settings, treatment is recommended if abnormal triage results are present; in other settings, colposcopy is recommended for abnormal triage results. For basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure (or ablation is recommended. Twelve-month post-treatment follow-up is recommended in all settings. Women who are HIV positive should be screened with HPV testing after diagnosis and screened twice as many times per lifetime as the general

  17. [Outsourcing in long-term care: a risk management approach].

    Science.gov (United States)

    Guimarães, Cristina Machado; Carvalho, José Crespo de

    2012-05-01

    This article seeks to investigate outsourcing decisions in supply chain management of healthcare organizations, namely the motives and constraints behind the decision, the selection criteria for activities to be outsourced to third parties, the type of possible agreements, and the impact of this decision on the organization per se. A case study of the start-up phase of a Long-term Care unit with an innovative approach and high levels of customization was conducted to understand the outsourcing process in a start-up context (not in the standard context of organizational change) and a risk evaluation matrix was created for outsourcing activities in order to define and implement a performance monitoring process. This study seeks to understand how to evaluate and assess the risks of an outsourcing strategy and proposes a monitoring model using risk management tools. It was shown that the risk management approach can be a solution for monitoring outsourcing in the organizational start-up phase. Conclusions concerning dissatisfaction with the results of outsourcing strategies adopted are also presented.

  18. A panchayat level primary-care approach for adolescent services.

    Science.gov (United States)

    Nair, M K C; Leena, M L; George, Babu; Sunitha, R M; Prasanna, G L; Russell, P S

    2012-01-01

    To develop a model for providing community adolescent care services in the primary care setting Need assessment was done among adolescents and perceived problems of adolescents were studied using qualitative and quantitative methods. Based on the results of these studies, a Family Life Education (FLE) module was prepared. Awareness programs were organized for all stakeholders in the community on adolescent issues. All anganwadi workers in the panchayat were trained to take interactive sessions for all the adolescents in the panchayat using the FLE module. Ward based Teen Clubs were formed in all the 13 wards of the Panchayat separately for boys and girls and FLE classes were given to them through anganwadi workers. An Adolescent Clinic was set up to provide necessary medical and counseling facilities. Adolescent Health Card was distributed to all Teen Club members and those who attended the adolescent clinics. The present approach stresses the need and feasibility of adolescent-centered, community-based interventions. The authors' experience showed that before starting any adolescent program, community awareness generation about the need and content of the program is very important for its success. The experience of this model has made it possible to up-scale the program to seven districts of southern Kerala as a service model. The experiences of the program gave a realistic picture of the needs and problems of adolescents and a simple feasible model for providing services to adolescents in the primary care setting that can be easily replicated in other parts of India.

  19. Individualising Chronic Care Management by Analysing Patients’ Needs – A Mixed Method Approach

    Directory of Open Access Journals (Sweden)

    P. Timpel

    2017-11-01

    Full Text Available Background: Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. Method: A mixed method study was conducted. A standardised survey (n = 92 of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22 of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650. Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. Results: The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. Conclusion: The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care

  20. Recommendations for palliative and bereavement care in the NICU: a family-centered integrative approach.

    Science.gov (United States)

    Kenner, C; Press, J; Ryan, D

    2015-12-01

    Technological advances have increased our ability to detect a life-threatening, life-limiting or lethal problem early in pregnancy, leaving parents months to anticipate a death or a prematurely born infant. Babies can also be born with unanticipated problems that could lead to death. In either scenario, perinatal palliative care should be offered as a strategy for family support. Since the preponderance of professional training focuses on saving lives, many health professionals are uncomfortable with palliative care. This article's purpose is to define best practices for the provision of family-centered perinatal and neonatal palliative care and provision of support to bereaved families experiencing anticipated and unanticipated life-limiting conditions or death of their infant. An overview of core concepts and values is presented, followed by intervention strategies to promote an integrated family-centered approach to palliative and bereavement care. The concluding section presents evidence-based recommendations.

  1. Community genomics among stratified microbial assemblages in the ocean's interior

    DEFF Research Database (Denmark)

    DeLong, Edward F; Preston, Christina M; Mincer, Tracy

    2006-01-01

    Microbial life predominates in the ocean, yet little is known about its genomic variability, especially along the depth continuum. We report here genomic analyses of planktonic microbial communities in the North Pacific Subtropical Gyre, from the ocean's surface to near-sea floor depths. Sequence......, and host-viral interactions. Comparative genomic analyses of stratified microbial communities have the potential to provide significant insight into higher-order community organization and dynamics....

  2. Mathematical modeling of turbulent stratified flows. Application of liquid metal fast breeders

    Energy Technology Data Exchange (ETDEWEB)

    Villand, M; Grand, D [CEA-Service des Transferts Thermiques, Grenoble (France)

    1983-07-01

    Mathematical model of turbulent stratified flow was proposed under the following assumptions: Newtonian fluid; incompressible fluid; coupling between temperature and momentum fields according to Boussinesq approximation; two-dimensional invariance for translation or rotation; coordinates cartesian or curvilinear. Solutions obtained by the proposed method are presented.

  3. A Critical Interdisciplinary Analysis of Culturally Appropriate Research Approach and Practices in Health Care and Social Work

    Science.gov (United States)

    Shams, Manfusa; Robinson, Lena

    2005-01-01

    This paper presents a critique of research approaches used in health and social care research with vulnerable and socially disadvantaged groups, and children and young people from minority ethnic backgrounds in Britain. The paper aims to critically examine research processes in health and social care from a psychological perspective and a social…

  4. Experimental and numerical investigation of stratified gas-liquid flow in inclined circular pipes

    International Nuclear Information System (INIS)

    Faccini, J.L.H.; Sampaio, P.A.B. de; Botelho, M.H.D.S.; Cunha, M.V.; Cunha Filho, J.S.; Su, J.

    2012-01-01

    In this paper, a stratified gas-liquid flow is experimentally and numerically investigated. Two measurement techniques, namely an ultrasonic technique and a visualization technique, are applied on an inclined circular test section using a fast single transducer pulse-echo technique and a high-speed camera. A numerical model is employed to simulate the stratified gas-liquid flow, formed by a system of non-linear differential equations consisting of the Reynolds averaged Navier-Stokes equations with the κ-ω turbulence model. The test section used in this work is comprised mainly of a transparent circular pipe with inner diameter 1 inch, and inclination angles varying from -2.5 to -10.0 degrees. Numerical solutions are obtained for the liquid height as a function of inclination angles, and compared with our own experimental data. (author)

  5. Resistant hypertension: an approach to management in primary care

    Directory of Open Access Journals (Sweden)

    Julian P Yaxley

    2015-01-01

    Full Text Available Hypertension is widely encountered in family medicine. Despite its prevalence, many patients have uncontrolled or difficult-to-control blood pressure. Resistant hypertension is defined as hypertension that is poorly responsive to treatment and requires the use of multiple medications to achieve acceptable blood pressure ranges. It may be a consequence of secondary hypertension or have no identifiable cause. Resistant hypertension is important to recognise because it places patients at risk of end-organ damage. Primary care physicians should be aware of the therapeutic approach for hypertension when traditional therapy fails. This article aims to familiarise readers with the evaluation and management of resistant hypertension by outlining the most recent evidence-based treatment options.

  6. Oregon's Coordinated Care Organizations and Their Effect on Prenatal Care Utilization Among Medicaid Enrollees.

    Science.gov (United States)

    Oakley, Lisa P; Harvey, S Marie; Yoon, Jangho; Luck, Jeff

    2017-09-01

    Introduction Previous studies indicate that inadequate prenatal care is more common among women covered by Medicaid compared with private insurance. Increasing the proportion of pregnant women who receive early and adequate prenatal care is a Healthy People 2020 goal. We examined the impact of the implementation of Oregon's accountable care organizations, Coordinated Care Organizations (CCOs), for Medicaid enrollees, on prenatal care utilization among Oregon women of reproductive age enrolled in Medicaid. Methods Using Medicaid eligibility data linked to unique birth records for 2011-2013, we used a pre-posttest treatment-control design that compared prenatal care utilization for women on Medicaid before and after CCO implementation to women never enrolled in Medicaid. Additional stratified analyses were conducted to explore differences in the effect of CCO implementation based on rurality, race, and ethnicity. Results After CCO implementation, mothers on Medicaid had a 13% increase in the odds of receiving first trimester care (OR 1.13, CI 1.04, 1.23). Non-Hispanic (OR 1.20, CI 1.09, 1.32), White (OR 1.20, CI 1.08, 1.33) and Asian (OR 2.03, CI 1.26, 3.27) women on Medicaid were more likely to receive initial prenatal care in the first trimester after CCO implementation and only Medicaid women in urban areas were more likely (OR 1.14, CI 1.05, 1.25) to initiate prenatal care in the first trimester. Conclusion Following Oregon's implementation of an innovative Medicaid coordinated care model, we found that women on Medicaid experienced a significant increase in receiving timely prenatal care.

  7. Analysis of flame propagation phenomenon in simplified stratified charge conditions; Tanjunkasareta sojo kyukiba ni okeru kaen denpa gensho no kansatsu

    Energy Technology Data Exchange (ETDEWEB)

    Moriyoshi, Y; Morikawa, H [Chiba University, Chiba (Japan); Kamimoto, T [Tokyo Institute of Technology, Tokyo (Japan)

    1997-10-01

    Since the local inhomogeneity of mixture concentration inside the cylinder affects the combustion characteristics, a basic research on combustion phenomenon in stratified charge conditions is required. The authors have made experiments with a constant-volume chamber, which can simulate an idealized stratified charge field by using a removable partition, to obtain the combustion characteristics. Also, numerical calculations are made using some combustion models. As a result, the important feature that the combustion speed is faster in stratified condition than in homogeneous condition can be predicted by the two-step reaction model. 4 refs., 8 figs.

  8. A region-based palliative care intervention trial using the mixed-method approach: Japan OPTIM study

    Directory of Open Access Journals (Sweden)

    Morita Tatsuya

    2012-01-01

    Full Text Available Abstract Background Disseminating palliative care is a critical task throughout the world. Several outcome studies explored the effects of regional palliative care programs on a variety of end-points, and some qualitative studies investigated the process of developing community palliative care networks. These studies provide important insights into the potential benefits of regional palliative care programs, but the clinical implications are still limited, because: 1 many interventions included fundamental changes in the structure of the health care system, and, thus, the results would not be applicable for many regions where structural changes are difficult or unfeasible; 2 patient-oriented outcomes were not measured or explored only in a small number of populations, and interpretation of the results from a patient's view is difficult; and 3 no studies adopted a mixed-method approach using both quantitative and qualitative methodologies to interpret the complex phenomenon from multidimensional perspectives. Methods/designs This is a mixed-method regional intervention trial, consisting of a pre-post outcome study and qualitative process studies. The primary aim of the pre-post outcome study is to evaluate the change in the number of home deaths, use of specialized palliative care services, patient-reported quality of palliative care, and family-reported quality of palliative care after regional palliative care intervention. The secondary aim is to explore the changes in a variety of outcomes, including patients' quality of life, pain intensity, family care burden, and physicians' and nurses' knowledge, difficulties, and self-perceived practice. Outcome measurements used in this study include the Care Evaluation Scale, Good Death Inventory, Brief pain Inventory, Caregiving Consequence Inventory, Sense of Security Scale, Palliative Care Knowledge test, Palliative Care Difficulties Scale, and Palliative Care Self-reported Practice Scale. Study

  9. Intervention pattern in crisis: mental health as a nursing care approach at a general hospital

    OpenAIRE

    Oliveira, Elias Barbosa; Kestenberg, Célia Caldeira Fonseca; Silva, Alexandre Vicente

    2013-01-01

    Objective: Testing and validating the application of Intervention in Crisis theory as an approach in mental health on HIV/AIDS patients care who are interned at a general hospital. Method: Help Interview has been accomplished as an activity for Mental Health subject according to an applied guide by graduation in nursing students in order to identify this illness psycho-social repercussion and draft therapeutic plan for patients under their care. The outcomes were the reports results presented...

  10. Prospective Health: Duke's Approach to Improving Employee Health and Managing Health Care Costs

    Science.gov (United States)

    Davidson, H. Clint, Jr.

    2004-01-01

    If developing a healthy workforce is critical to reining in the skyrocketing cost of health care, then why have so many attempts at preventive health or disease management fallen short? How can employers connect with employees to engage them in changing unhealthy habits or lifestyles? Duke University has launched an innovative new approach called…

  11. Internal and vorticity waves in decaying stratified flows

    Science.gov (United States)

    Matulka, A.; Cano, D.

    2009-04-01

    Most predictive models fail when forcing at the Rossby deformation Radius is important and a large range of scales have to be taken into account. When mixing of reactants or pollutants has to be accounted, the range of scales spans from hundreds of Kilometers to the Bachelor or Kolmogorov sub milimiter scales. We present some theoretical arguments to describe the flow in terms of the three dimensional vorticity equations, using a lengthscale related to the vorticity (or enstrophy ) transport. Effect of intermittent eddies and non-homogeneity of diffusion are also key issues in the environment because both stratification and rotation body forces are important and cause anisotropy/non-homogeneity. These problems need further theoretical, numerical and observational work and one approach is to try to maximize the relevant geometrical information in order to understand and therefore predict these complex environmental dispersive flows. The importance of the study of turbulence structure and its relevance in diffusion of contaminants in environmental flows is clear when we see the effect of environmental disasters such as the Prestige oil spill or the Chernobil radioactive cloud spread in the atmosphere. A series of Experiments have been performed on a strongly stratified two layer fluid consisting of Brine in the bottom and freshwater above in a 1 square meter tank. The evolution of the vortices after the passage of a grid is video recorded and Particle tracking is applied on small pliolite particles floating at the interface. The combination of internal waves and vertical vorticity produces two separate time scales that may produce resonances. The vorticity is seen to oscilate in a complex way, where the frecuency decreases with time.

  12. The EFQM excellence model: European and Dutch experiences with the EFQM approach in health care. European Foundation for Quality Management.

    Science.gov (United States)

    Nabitz, U; Klazinga, N; Walburg, J

    2000-06-01

    One way to meet the challenges in creating a high performance organization in health care is the approach of the European Foundation for Quality Management (EFQM). The Foundation is in the tradition of the American Malcolm Baldrige Award and was initiated by the European Commission and 14 European multi-national organizations in 1988. The essence of the approach is the EFQM Model, which can be used as a self-assessment instrument on all levels of a health care organization and as an auditing instrument for the Quality Award. In 1999 the EFQM Model was revised but its principles remained the same. In The Netherlands many health care organizations apply the EFQM Model. In addition to improvement projects, peer review of professional practices, accreditation and certification, the EFQM Approach is used mainly as a framework for quality management and as a conceptualization for organizational excellence. The Dutch National Institute for Quality, the Instituut Nederlandse Kwaliteit, delivers training and supports self-assessment and runs the Dutch quality award programme. Two specific guidelines for health care organizations, 'Positioning and Improving' and 'Self-Assessment', have been developed and are used frequently. To illustrate the EFQM approach in The Netherlands, the improvement project of the Jellinek Centre is described. The Jellinek Centre conducted internal and external assessments and received in 1996, as the first health care organization, the Dutch Quality Prize.

  13. Dominance of a clonal green sulfur bacterial population in a stratified lake

    DEFF Research Database (Denmark)

    Gregersen, Lea H; Habicht, Kirsten S; Peduzzi, Sandro

    2009-01-01

    surveys using FISH cell counting and population multilocus sequence typing [clone library sequence analysis of the small subunit (SSU) rRNA locus and two loci involved in photosynthesis in GSB: fmoA and csmCA]. All bacterial populations clearly stratified according to water column chemistry. The GSB...

  14. LES of stratified-wavy flows using novel near-interface treatment

    Science.gov (United States)

    Karnik, Aditya; Kahouadji, Lyes; Chergui, Jalel; Juric, Damir; Shin, Seungwon; Matar, Omar K.

    2017-11-01

    The pressure drop in horizontal stratified wavy flows is influenced by interfacial shear stress. The near-interface behavior of the lighter phase is akin to that near a moving wall. We employ a front-tracking code, Blue, to simulate and capture the near-interface behaviour of both phases. Blue uses a modified Smagorinsky LES model incorporating a novel near-interface treatment for the sub-grid viscosity, which is influenced by damping due to the wall-like interface, and enhancement of the turbulent kinetic energy (TKE) due to the interfacial waves. Simulations are carried out for both air-water and oil-water stratified configurations to demonstrate the applicability of the present method. The mean velocities and tangential Reynolds stresses are compared with experiments for both configurations. At the higher Re, the waves penetrate well into the buffer region of the boundary layer above the interface thus altering its dynamics. Previous attempts to capture the secondary structures associated with such flows using RANS or standard LES methodologies have been unsuccessful. The ability of the present method to reproduce these structures is due to the correct estimation of the near-interface TKE governing energy transfer from the normal to tangential directions. EPSRC, UK, MEMPHIS program Grant (EP/K003976/1), RAEng Research Chair (OKM).

  15. OA38 From service delivery to community enablement: a public health approach to palliative care.

    Science.gov (United States)

    McLoughlin, Kathleen; Rhatigan, Jim; Richardson, Marie; Lloyd, Rebecca

    2015-04-01

    : Milford Care Centre is the only hospice in Ireland to make a strategic decision to embrace a public health approach to palliative care, through the development, implementation and evaluation of the Compassionate Communities Project. This presentation seeks to examine why Milford made the decision to move toward a community enablement model, describes the development and implementation of the Compassionate Communities Project to date, presents key findings from recent evaluations and highlights our plans for the future. The presentation uses a reflective, story telling approach to meet it's aims, coupled with data and statistics gathered from the evaluations, and includes a new short film 'Tell Me' developed by recent Computer Science graduates for the Project to use to engage with communities during Café Conversations. The presentation will highlight the relevance of Health Promoting Palliative Care theory to the development of a three-tier model of programme activity, examine the challenges in implementing such an approach and will discuss the impact of upstream intervention to downstream service provision using case studies. © 2015, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  16. Are Staffing, Work Environment, Work Stressors, and Rationing of Care Related to Care Workers' Perception of Quality of Care? A Cross-Sectional Study.

    Science.gov (United States)

    Zúñiga, Franziska; Ausserhofer, Dietmar; Hamers, Jan P H; Engberg, Sandra; Simon, Michael; Schwendimann, René

    2015-10-01

    To describe care worker-reported quality of care and to examine its relationship with staffing variables, work environment, work stressors, and implicit rationing of nursing care. Cross-sectional study. National, randomly selected sample of Swiss nursing homes, stratified according to language region and size. A total of 4311 care workers of all educational backgrounds (registered nurses, licensed practical nurses, nurse aides) from 402 units in 155 nursing homes completed a survey between May 2012 and April 2013. Care worker-reported quality of care was measured with a single item; predictors were assessed with established instruments (eg, Practice Environment Scale-Nurse Working Index) adapted for nursing home use. A multilevel logistic regression model was applied to assess predictors for quality of care. Overall, 7% of care workers rated the quality of care provided as rather low or very low. Important factors related to better quality of care were higher teamwork and safety climate (odds ratio [OR] 6.19, 95% confidence interval [CI] 4.36-8.79); better staffing and resources adequacy (OR 2.94, 95% CI 2.08-4.15); less stress due to workload (OR 0.71, 95% CI 0.55-0.93); less implicit rationing of caring, rehabilitation, and monitoring (OR 0.34, 95% CI 0.24-0.49); and less rationing of social care (OR 0.80, 95% CI 0.69-0.92). Neither leadership nor staffing levels, staff mix, or turnover was significantly related to quality of care. Work environment factors and organizational processes are vital to provide high quality of care. The improvement of work environment, support in handling work stressors, and reduction of rationing of nursing care might be intervention points to promote high quality of care in nursing homes. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

  17. Optimal approaches to the health economics of palliative care: report of an international think tank.

    Science.gov (United States)

    Gomes, Barbara; Harding, Richard; Foley, Kathleen M; Higginson, Irene J

    2009-07-01

    More people will need palliative care in aging societies with stretched health budgets and less ability to provide informal care. The future will bring new and tougher challenges to sustain, optimize, and expand the 8000 dedicated palliative care services that currently exist in the world. The full breakdown of the costs of palliative care is yet to be unveiled, and this has left huge unresolved questions for funding, costing, evaluating, and modeling palliative care. At an international meeting in London in November 2007, a group of 40 researchers, health economists, policy makers, and advocates exchanged their experiences, concerns, and recommendations in five main areas: shared definitions, strengths and weaknesses of different payment systems, international and country-specific research challenges, appropriate economic evaluation methods, and the varied perspectives to the costs of palliative care. This article reports the discussions that took place and the views of this international group of experts on the best research approaches to capture, analyze, and interpret data on both costs and outcomes for families and patients toward the end of life.

  18. Modification of Measures of Acute Kidney Injury to Risk Stratify Combat Casualties

    Science.gov (United States)

    2017-08-26

    REPORT TYPE 08/26/2017 Poster 4. TJTLE AND SUBTITLE t\\.1odification of l’vfeasures,of Acute Kidney Injury to Risk Stratify Cotnbat Casualties 6...profiles and potential future conflicts , identifying acute kidney injury (AKI) early can help us determine the need for rapidity of evacuation

  19. Consumer Decision-Making Abilities and Long-Term Care Insurance Purchase.

    Science.gov (United States)

    McGarry, Brian E; Tempkin-Greener, Helena; Grabowski, David C; Chapman, Benjamin P; Li, Yue

    2018-04-16

    To determine the impact of consumer decision-making abilities on making a long-term care insurance (LTCi) purchasing decision that is consistent with normative economic predictions regarding policy ownership. Using data from the Health and Retirement Study, multivariate analyses are implemented to estimate the effect of decision-making ability factors on owning LTCi. Stratified multivariate analyses are used to examine the effect of decision-making abilities on the likelihood of adhering to economic predictions of LTCi ownership. In the full sample, better cognitive capacity was found to significantly increase the odds of ownership. When the sample was stratified based on expected LTCi ownership status, cognitive capacity was positively associated with ownership among those predicted to own and negatively associated with ownership among those predicted not to own who could likely afford a policy. Consumer decision-making abilities, specifically cognitive capacity, are an important determinant of LTCi decision outcomes. Deficits in this ability may prevent individuals from successfully preparing for future long-term care expenses. Policy makers should consider changes that reduce the cognitive burden of this choice, including the standardization of the LTCi market, the provision of consumer decision aids, and alternatives to voluntary and private insuring mechanisms.

  20. Rapid shelf-wide cooling response of a stratified coastal ocean to hurricanes.

    Science.gov (United States)

    Seroka, Greg; Miles, Travis; Xu, Yi; Kohut, Josh; Schofield, Oscar; Glenn, Scott

    2017-06-01

    Large uncertainty in the predicted intensity of tropical cyclones (TCs) persists compared to the steadily improving skill in the predicted TC tracks. This intensity uncertainty has its most significant implications in the coastal zone, where TC impacts to populated shorelines are greatest. Recent studies have demonstrated that rapid ahead-of-eye-center cooling of a stratified coastal ocean can have a significant impact on hurricane intensity forecasts. Using observation-validated, high-resolution ocean modeling, the stratified coastal ocean cooling processes observed in two U.S. Mid-Atlantic hurricanes were investigated: Hurricane Irene (2011)-with an inshore Mid-Atlantic Bight (MAB) track during the late summer stratified coastal ocean season-and Tropical Storm Barry (2007)-with an offshore track during early summer. For both storms, the critical ahead-of-eye-center depth-averaged force balance across the entire MAB shelf included an onshore wind stress balanced by an offshore pressure gradient. This resulted in onshore surface currents opposing offshore bottom currents that enhanced surface to bottom current shear and turbulent mixing across the thermocline, resulting in the rapid cooling of the surface layer ahead-of-eye-center. Because the same baroclinic and mixing processes occurred for two storms on opposite ends of the track and seasonal stratification envelope, the response appears robust. It will be critical to forecast these processes and their implications for a wide range of future storms using realistic 3-D coupled atmosphere-ocean models to lower the uncertainty in predictions of TC intensities and impacts and enable coastal populations to better respond to increasing rapid intensification threats in an era of rising sea levels.

  1. Rapid shelf‐wide cooling response of a stratified coastal ocean to hurricanes

    Science.gov (United States)

    Miles, Travis; Xu, Yi; Kohut, Josh; Schofield, Oscar; Glenn, Scott

    2017-01-01

    Abstract Large uncertainty in the predicted intensity of tropical cyclones (TCs) persists compared to the steadily improving skill in the predicted TC tracks. This intensity uncertainty has its most significant implications in the coastal zone, where TC impacts to populated shorelines are greatest. Recent studies have demonstrated that rapid ahead‐of‐eye‐center cooling of a stratified coastal ocean can have a significant impact on hurricane intensity forecasts. Using observation‐validated, high‐resolution ocean modeling, the stratified coastal ocean cooling processes observed in two U.S. Mid‐Atlantic hurricanes were investigated: Hurricane Irene (2011)—with an inshore Mid‐Atlantic Bight (MAB) track during the late summer stratified coastal ocean season—and Tropical Storm Barry (2007)—with an offshore track during early summer. For both storms, the critical ahead‐of‐eye‐center depth‐averaged force balance across the entire MAB shelf included an onshore wind stress balanced by an offshore pressure gradient. This resulted in onshore surface currents opposing offshore bottom currents that enhanced surface to bottom current shear and turbulent mixing across the thermocline, resulting in the rapid cooling of the surface layer ahead‐of‐eye‐center. Because the same baroclinic and mixing processes occurred for two storms on opposite ends of the track and seasonal stratification envelope, the response appears robust. It will be critical to forecast these processes and their implications for a wide range of future storms using realistic 3‐D coupled atmosphere‐ocean models to lower the uncertainty in predictions of TC intensities and impacts and enable coastal populations to better respond to increasing rapid intensification threats in an era of rising sea levels. PMID:28944132

  2. Reducing Bottlenecks to Improve the Efficiency of the Lung Cancer Care Delivery Process: A Process Engineering Modeling Approach to Patient-Centered Care.

    Science.gov (United States)

    Ju, Feng; Lee, Hyo Kyung; Yu, Xinhua; Faris, Nicholas R; Rugless, Fedoria; Jiang, Shan; Li, Jingshan; Osarogiagbon, Raymond U

    2017-12-01

    The process of lung cancer care from initial lesion detection to treatment is complex, involving multiple steps, each introducing the potential for substantial delays. Identifying the steps with the greatest delays enables a focused effort to improve the timeliness of care-delivery, without sacrificing quality. We retrospectively reviewed clinical events from initial detection, through histologic diagnosis, radiologic and invasive staging, and medical clearance, to surgery for all patients who had an attempted resection of a suspected lung cancer in a community healthcare system. We used a computer process modeling approach to evaluate delays in care delivery, in order to identify potential 'bottlenecks' in waiting time, the reduction of which could produce greater care efficiency. We also conducted 'what-if' analyses to predict the relative impact of simulated changes in the care delivery process to determine the most efficient pathways to surgery. The waiting time between radiologic lesion detection and diagnostic biopsy, and the waiting time from radiologic staging to surgery were the two most critical bottlenecks impeding efficient care delivery (more than 3 times larger compared to reducing other waiting times). Additionally, instituting surgical consultation prior to cardiac consultation for medical clearance and decreasing the waiting time between CT scans and diagnostic biopsies, were potentially the most impactful measures to reduce care delays before surgery. Rigorous computer simulation modeling, using clinical data, can provide useful information to identify areas for improving the efficiency of care delivery by process engineering, for patients who receive surgery for lung cancer.

  3. Family Child Care Learning Environments: Caregiver Knowledge and Practices Related to Early Literacy and Mathematics

    Science.gov (United States)

    Phillips, Beth M.; Morse, Erika E.

    2011-01-01

    This paper presents findings from a stratified-random survey of family child care providers' backgrounds, caregiving environments, practices, attitudes, and knowledge related to language, literacy, and mathematics development for preschool children. Descriptive results are consistent with prior studies suggesting that home-based providers are…

  4. Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.

    Science.gov (United States)

    Le-Abuyen, Sheila; Ng, Jessica; Kim, Susie; De La Franier, Anne; Khan, Bibi; Mosley, Jane; Gardam, Michael

    2014-04-01

    A survey pilot asked patients to observe the hand hygiene compliance of their health care providers. Patients returned 75.1% of the survey cards distributed, and the overall hand hygiene compliance was 96.8%. Survey results and patient commentary were used to motivate hand hygiene compliance. The patient-as-observer approach appeared to be a viable alternative for hand hygiene auditing in an ambulatory care setting because it educated, engaged, and empowered patients to play a more active role in their own health care. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

  5. Relational autonomy in informed consent (RAIC) as an ethics of care approach to the concept of informed consent.

    Science.gov (United States)

    Osuji, Peter I

    2018-03-01

    The perspectives of the dominant Western ethical theories, have dominated the concepts of autonomy and informed consent for many years. Recently this dominant understanding has been challenged by ethics of care which, although, also emanates from the West presents a more nuanced concept: relational autonomy, which is more faithful to our human experience. By paying particular attention to relational autonomy, particularity and Process approach to ethical deliberations in ethics of care, this paper seeks to construct a concept of informed consent from the perspective of ethics of care which is here called relational autonomy-in-informed consent (RAIC). Thus, providing a broader theoretical basis for informed consent beyond the usual theoretical perspectives that are particularly Western. Care ethics provides such a broader basis because it appeals to a global perspective that encompasses lessons from other cultures, and this will help to enrich the current ideas of bioethics principles of autonomy and informed consent. This objective will be achieved by exploring the ethics of care emphasis on relationships based on a universal experience of caring; and by contrasting its concept of autonomy as relational with the understanding of autonomy in the approaches of the dominant moral theories that reflect rational, individualistic, and rights-oriented autonomy of the American liberalism.

  6. FAMILY BEHAVIOR IN MAINTENANCE STATUS HB CHRONIC RENAL FAILURE PATIENTS THROUGH FAMILY CENTERED CARE APPROACH OF DIET FE MANAGEMENT

    Directory of Open Access Journals (Sweden)

    Anggia Fajar Hardianti

    2017-04-01

    Full Text Available Introduction: Erythropoietic agent as standard practice for anemia treatment, which has a function to increase the value of hemoglobin (Hb to 12 g/dl in patients with chronic renal failure (CRF, who receiving dialysis treatment. The use of erythropoietin has to keep of the iron/Fe amount in the body. Family who have a duty of care should have knowledge, attitude, and behavior to maintain patient’s Hb by giving support to the patient to obey the Fe diet. The aimed of this study was to investigate the effect of family centered care approach in management Fe diet toward family’s behaviour in maintenance Hb level of CRF patients in hemodialysis ward, Gambiran Hospital, Kediri. Method: This study was used a pre experimental design. Total sample were 10 respondents, who met to inclusion criteria. The independent variables were knowledge, attitude, and psychomotor of family in maintenance of Hb level in CRF’s patients. The dependent variable was Fe diet management with family centered care approach. Data was collected by using a structured questionnaire and home visit observation. Result: Data was analyzed by using Wilcoxon Sign Rank Test with significance level α≤0.05. Results showed that Fe diet management with family centered care approach took effect to family’s knowledge (p=0.011, family’s attitude (p=0.005 and family’s psychomotor (p=0.005 in maintenance Hb level of CRF patients. Discussion: Family’s knowledge, attitude, and psychomotor were effected by experiences during the care of a patient, not affordable to access information and patient’s own decision. The strengths and weaknesses in the family to got a better plan of care can be made by discuss and sharing among researcher, patient and his family. It can be concluded that Fe diet management with family centered care approach took effect to family’s behaviour. Further studies should involve larger respondents and better measurement tools to obtain more accurate results.

  7. An analysis direct-contact condensation in horizontal cocurrent stratified flow of steam and cold water

    International Nuclear Information System (INIS)

    Lee, Suk Ho; Kim, Hho Jung

    1992-01-01

    The physical benchmark problem on the direct-contact condensation under the horizontal cocurrent stratified flow was analyzed using the RELAP5/MOD2 and /MOD3 one-dimensional model. Analysis was performed for the Northwestern experiments, which involved condensing steam/water flow in a rectangular channel. The study showed that the RELAP5 interfacial heat transfer model, under the horizontal stratified flow regime, predicted the condensation rate well though the interfacial heat transfer area was underpredicted. However, some discrepancies in water layer thickness and local heat transfer coefficient with experimental results were found especially when there is a wavy interface, and those were satisfied only within the range. (Author)

  8. Symptomatic pain and fibromyalgia treatment through multidisciplinary approach for primary care.

    Science.gov (United States)

    Gonzalez Gonzalez, Jaime; del Teso Rubio, Maria del Mar; Waliño Paniagua, Carmen Nelida; Criado-Alvarez, Juan Jose; Sanchez Holgado, Javier

    2015-01-01

    Fibromyalgia is a chronic disease of unknown etiology characterized by widespread muscle pain, with occupational, familial, social, physical and psychological performance involvement. The multidisciplinary approach to the disease leads to improvement in quality of life and symptomatology. To evaluate the improvement of activities of daily living (ADL) and quality of life following a multidisciplinary intervention (Health Primary Care and Occupational Therapy). Pretest-posttest study performed with a simple random sample of 21 patients with fibromyalgia (range 16-55 years). The measurement was performed with the Barthel scale (ADL), the scale of Lawton and Brody (IADL), the FIQ questionnaire, and no standardized surveys to assess the pre and post intervention situation. An intervention on motor skills (basic motor skills, pool exercise, outdoor exercise, restructuring, occupational performance and graded activity and intervention in ADL) was performed, combining pharmacological control of their symptoms and treatment. Fibromyalgia patients are not fully satisfied with their treatment; Primary Care receives a score of 6.89, and Hospital Care 5.79, improving the Barthel, Lawton and Brody and FIQ indexes, being statistically significant (p<.05). After the combined procedure the number of independent women in ADL and IADL increases. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

  9. Association of Group Prenatal Care With Gestational Weight Gain.

    Science.gov (United States)

    Kominiarek, Michelle A; Crockett, Amy; Covington-Kolb, Sarah; Simon, Melissa; Grobman, William A

    2017-04-01

    To compare gestational weight gain among women in group prenatal care with that of women in individual prenatal care. In this retrospective cohort study, women who participated in group prenatal care from 2009 to 2015 and whose body mass indexes (BMIs) and gestational weight gain were recorded were matched with the next two women who had the same payer type, were within 2-kg/m prepregnancy BMI and 2-week gestational age at delivery, and had received individual prenatal care. Bivariate comparisons of demographics and antenatal complications were performed for women in group and individual prenatal care, and weight gain was categorized as "below," "met," or "exceeded" goals according to the 2009 Institute of Medicine guidelines. Logistic regression analysis estimated the association between excessive weight gain and model of care, with adjustment for confounders, stratified by BMI. Women in group prenatal care (n=2,117) were younger and more commonly non-Hispanic black, nulliparous, and without gestational diabetes (P≤.005 for all). Women in group prenatal care more commonly exceeded the weight gain goals (55% compared with 48%, Pprenatal care, compared with individual prenatal care, is associated with excessive gestational weight gain.

  10. An interdisciplinary approach to palliative care - context and challenges in basic education programmes

    DEFF Research Database (Denmark)

    Sangild Stølen, Karen Marie; Breum, Wanda Elisabeth; Andersen, Tanja Thinggaard

    Background: In Denmark, persons diagnosed with life-threatening diseases are an essential key task in Danish Health system. Work carried out by health care professionals with these patients and their families requires specific professional expertise. A holistic approach focused on the physical, p...... in the palliative area, the physiotherapy and psychomotor education programmes have made valuable contributions to developing the understanding of palliative care to the benefit of patients with life-threatening illnesses and their families......., psychological, social and existential perspectives is necessary in order to be able to meet the needs of these people. The health education programmes should therefore offer instruction in palliative care. On this background, University College Capital has developed an interdisciplinary elective course....... Results: The three courses that have been carried out with the participation of 60 nursing students, 12 physiotherapy students and two psychomotor- therapist students two students have shown that the students and staff from the three programmes have benefitted greatly from the different professional...

  11. Competition and quality in health care markets: a differential-game approach.

    Science.gov (United States)

    Brekke, Kurt R; Cellini, Roberto; Siciliani, Luigi; Straume, Odd Rune

    2010-07-01

    We investigate the effect of competition on quality in health care markets with regulated prices taking a differential game approach, in which quality is a stock variable. Using a Hotelling framework, we derive the open-loop solution (health care providers set the optimal investment plan at the initial period) and the feedback closed-loop solution (providers move investments in response to the dynamics of the states). Under the closed-loop solution competition is more intense in the sense that providers observe quality in each period and base their investment on this information. If the marginal provision cost is constant, the open-loop and closed-loop solutions coincide, and the results are similar to the ones obtained by static models. If the marginal provision cost is increasing, investment and quality are lower in the closed-loop solution (when competition is more intense). In this case, static models tend to exaggerate the positive effect of competition on quality.

  12. Social network approaches to recruitment, HIV prevention, medical care, and medication adherence

    OpenAIRE

    Latkin, Carl A.; Davey-Rothwell, Melissa A.; Knowlton, Amy R.; Alexander, Kamila A.; Williams, Chyvette T.; Boodram, Basmattee

    2013-01-01

    This article reviews current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates and treatment access and outcomes. Social network analysis is a value tool to link social structural factors to individual behaviors. Social networks provide an avenue for low cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social ne...

  13. Decision tree analysis to stratify risk of de novo non-melanoma skin cancer following liver transplantation.

    Science.gov (United States)

    Tanaka, Tomohiro; Voigt, Michael D

    2018-03-01

    Non-melanoma skin cancer (NMSC) is the most common de novo malignancy in liver transplant (LT) recipients; it behaves more aggressively and it increases mortality. We used decision tree analysis to develop a tool to stratify and quantify risk of NMSC in LT recipients. We performed Cox regression analysis to identify which predictive variables to enter into the decision tree analysis. Data were from the Organ Procurement Transplant Network (OPTN) STAR files of September 2016 (n = 102984). NMSC developed in 4556 of the 105984 recipients, a mean of 5.6 years after transplant. The 5/10/20-year rates of NMSC were 2.9/6.3/13.5%, respectively. Cox regression identified male gender, Caucasian race, age, body mass index (BMI) at LT, and sirolimus use as key predictive or protective factors for NMSC. These factors were entered into a decision tree analysis. The final tree stratified non-Caucasians as low risk (0.8%), and Caucasian males > 47 years, BMI decision tree model accurately stratifies the risk of developing NMSC in the long-term after LT.

  14. What can the treatment of Parkinson's disease learn from dementia care; applying a bio-psycho-social approach to Parkinson's disease.

    Science.gov (United States)

    Gibson, Grant

    2017-12-01

    Within contemporary medical practice, Parkinson's disease (PD) is treated using a biomedical, neurological approach, which although bringing numerous benefits can struggle to engage with how people with PD experience the disease. A bio-psycho-social approach has not yet been established in PD; however, bio-psycho-social approaches adopted within dementia care practice could bring significant benefit to PD care. This paper summarises existing bio-psycho-social models of dementia care and explores how these models could also usefully be applied to care for PD. Specifically, this paper adapts the bio-psycho-social model for dementia developed by Spector and Orrell (), to suggest a bio-psycho-social model, which could be used to inform routine care in PD. Drawing on the biopsychosocial model of Dementia put forward by Spector and Orrell (), this paper explores the application of a bio-psycho-social model of PD. This model conceptualises PD as a trajectory, in which several interrelated fixed and tractable factors influence both PD's symptomology and the various biological and psychosocial challenges individuals will face as their disease progresses. Using an individual case study, this paper then illustrates how such a model can assist clinicians in identifying suitable interventions for people living with PD. This model concludes by discussing how a bio-psycho-social model could be used as a tool in PD's routine care. The model also encourages the development of a theoretical and practical framework for the future development of the role of the PD specialist nurse within routine practice. A biopsychosocial approach to Parkinson's Disease provides an opportunity to move towards a holistic model of care practice which addresses a wider range of factors affecting people living with PD. The paper puts forward a framework through which PD care practice can move towards a biopsychosocial perspective. PD specialist nurses are particularly well placed to adopt such a model

  15. Role of Soft Computing Approaches in HealthCare Domain: A Mini Review.

    Science.gov (United States)

    Gambhir, Shalini; Malik, Sanjay Kumar; Kumar, Yugal

    2016-12-01

    In the present era, soft computing approaches play a vital role in solving the different kinds of problems and provide promising solutions. Due to popularity of soft computing approaches, these approaches have also been applied in healthcare data for effectively diagnosing the diseases and obtaining better results in comparison to traditional approaches. Soft computing approaches have the ability to adapt itself according to problem domain. Another aspect is a good balance between exploration and exploitation processes. These aspects make soft computing approaches more powerful, reliable and efficient. The above mentioned characteristics make the soft computing approaches more suitable and competent for health care data. The first objective of this review paper is to identify the various soft computing approaches which are used for diagnosing and predicting the diseases. Second objective is to identify various diseases for which these approaches are applied. Third objective is to categories the soft computing approaches for clinical support system. In literature, it is found that large number of soft computing approaches have been applied for effectively diagnosing and predicting the diseases from healthcare data. Some of these are particle swarm optimization, genetic algorithm, artificial neural network, support vector machine etc. A detailed discussion on these approaches are presented in literature section. This work summarizes various soft computing approaches used in healthcare domain in last one decade. These approaches are categorized in five different categories based on the methodology, these are classification model based system, expert system, fuzzy and neuro fuzzy system, rule based system and case based system. Lot of techniques are discussed in above mentioned categories and all discussed techniques are summarized in the form of tables also. This work also focuses on accuracy rate of soft computing technique and tabular information is provided for

  16. Direct numerical simulation of homogeneous stratified rotating turbulence

    Energy Technology Data Exchange (ETDEWEB)

    Iida, O.; Tsujimura, S.; Nagano, Y. [Nagoya Institute of Technology, Department of Mech. Eng., Nagoya (Japan)

    2005-12-01

    The effects of the Prandtl number on stratified rotating turbulence have been studied in homogeneous turbulence by using direct numerical simulations and a rapid distortion theory. Fluctuations under strong stable-density stratification can be theoretically divided into the WAVE and the potential vorticity (PV) modes. In low-Prandtl-number fluids, the WAVE mode deteriorates, while the PV mode remains. Imposing rotation on a low-Prandtl-number fluid makes turbulence two-dimensional as well as geostrophic; it is found from the instantaneous turbulent structure that the vortices merge to form a few vertically-elongated vortex columns. During the period toward two-dimensionalization, the vertical vortices become asymmetric in the sense of rotation. (orig.)

  17. Managed Care Approaches to Children's Services within Public Systems of Care.

    Science.gov (United States)

    Pumariega, Andres; Fallon, Theodore, Jr.

    This report presents two discussions of conceptual and infrastructure issues that state mental health systems serving children with emotional disturbances must consider to make an effective transition towards a managed care organization of services under Medicaid. The first discussion, "Clinical Experiences in Managed Care Implementation for…

  18. ProvenCare-Psoriasis: A disease management model to optimize care.

    Science.gov (United States)

    Gionfriddo, Michael R; Pulk, Rebecca A; Sahni, Dev R; Vijayanagar, Sonal G; Chronowski, Joseph J; Jones, Laney K; Evans, Michael A; Feldman, Steven R; Pride, Howard

    2018-03-15

    There are a variety of evidence-based treatments available for psoriasis. The transition of this evidence into practice is challenging. In this article, we describe the design of our disease management approach for Psoriasis (ProvenCare®) and present preliminary evidence of the effect of its implementation. In designing our approach, we identified three barriers to optimal care: 1) lack of a standardized and discrete disease activity measure within the electronic health record, 2) lack of a system-wide, standardized approach to care, and 3) non-uniform financial access to appropriate non-pharmacologic treatments. We implemented several solutions, which collectively form our approach. We standardized the documentation of clinical data such as body surface area (BSA), created a disease management algorithm for psoriasis, and aligned incentives to facilitate the implementation of the algorithm. This approach provides more coordinated, cost effective care for psoriasis, while being acceptable to key stakeholders. Future work will examine the effect of the implementation of our approach on important clinical and patient outcomes.

  19. Management of severe childhood pneumonia by day care approach in developing countries

    Directory of Open Access Journals (Sweden)

    Yasmin Jahan

    2018-01-01

    Full Text Available Background: Background: Pneumonia is a major cause of child mortality among children under 5 years, worldwide. Pneumonia infection may be caused by bacteria, viruses, or fungi in single or in both lungs. According to recent criteria developed by the World Health Organization(WHO in September (2013, pneumonia can be classified into severe pneumonia, pneumonia and no pneumonia. Most of the deaths occur from severe pneumonia.Methods: Disease management of severe childhood pneumonia requires early identification,prompt referral and the availability of intensive quality care. Under 5 years old children with severe pneumonia should receive day care, with antibiotic treatment, feeding, and supportive care with similar 24-hour hospital treatment.Discussion: Considering that difficulties, International Centre for Diarrheal Disease Research,Bangladesh (ICDDR, B initiated Day Care Approach (DCA model, as an innovative, safe,effective and less expensive alternative to hospital management of severe childhood pneumonia.A 24 months old girl came to the health care center with severe breathing difficulty, cough,history of fever and head nodding. The management described below was continued daily until there was clinical improvement; no fever, no fast breathing, no lower chest wall in drawing, no danger signs, no rales on auscultation, and no hypoxemia. Conclusion: Considering the WHO case management protocol for severe pneumonia, DCA recommends that diagnosis of severe pneumonia should be based primarily on visible clinical parameters. On that basis, severe childhood pneumonia can be successfully managed at daycare clinics including for children with hypoxemia who is required prolong (4-6 hours oxygen therapy.

  20. Multimodal Stepped Care Approach Involving Topical Analgesics for Severe Intractable Neuropathic Pain in CRPS Type 1: A Case Report

    Directory of Open Access Journals (Sweden)

    David J. Kopsky

    2011-01-01

    Full Text Available A multimodal stepped care approach has been successfully applied to a patient with complex regional pain syndrome type 1 and severe intractable pain, not responding to regular neuropathic pain medication. The choice to administer drugs in creams was made because of the intolerable adverse effects to oral medication. With this method, peak-dose adverse effects did not occur. The multimodal stepped care approach resulted in considerable and clinically relevant decrease in pain after every step, using topical amitriptyline, ketamine, and dimethylsulphoxide.

  1. Designing Wood Supply Scenarios from Forest Inventories with Stratified Predictions

    Directory of Open Access Journals (Sweden)

    Philipp Kilham

    2018-02-01

    Full Text Available Forest growth and wood supply projections are increasingly used to estimate the future availability of woody biomass and the correlated effects on forests and climate. This research parameterizes an inventory-based business-as-usual wood supply scenario, with a focus on southwest Germany and the period 2002–2012 with a stratified prediction. First, the Classification and Regression Trees algorithm groups the inventory plots into strata with corresponding harvest probabilities. Second, Random Forest algorithms generate individual harvest probabilities for the plots of each stratum. Third, the plots with the highest individual probabilities are selected as harvested until the harvest probability of the stratum is fulfilled. Fourth, the harvested volume of these plots is predicted with a linear regression model trained on harvested plots only. To illustrate the pros and cons of this method, it is compared to a direct harvested volume prediction with linear regression, and a combination of logistic regression and linear regression. Direct harvested volume regression predicts comparable volume figures, but generates these volumes in a way that differs from business-as-usual. The logistic model achieves higher overall classification accuracies, but results in underestimations or overestimations of harvest shares for several subsets of the data. The stratified prediction method balances this shortcoming, and can be of general use for forest growth and timber supply projections from large-scale forest inventories.

  2. Sample size calculations for cluster randomised crossover trials in Australian and New Zealand intensive care research.

    Science.gov (United States)

    Arnup, Sarah J; McKenzie, Joanne E; Pilcher, David; Bellomo, Rinaldo; Forbes, Andrew B

    2018-06-01

    The cluster randomised crossover (CRXO) design provides an opportunity to conduct randomised controlled trials to evaluate low risk interventions in the intensive care setting. Our aim is to provide a tutorial on how to perform a sample size calculation for a CRXO trial, focusing on the meaning of the elements required for the calculations, with application to intensive care trials. We use all-cause in-hospital mortality from the Australian and New Zealand Intensive Care Society Adult Patient Database clinical registry to illustrate the sample size calculations. We show sample size calculations for a two-intervention, two 12-month period, cross-sectional CRXO trial. We provide the formulae, and examples of their use, to determine the number of intensive care units required to detect a risk ratio (RR) with a designated level of power between two interventions for trials in which the elements required for sample size calculations remain constant across all ICUs (unstratified design); and in which there are distinct groups (strata) of ICUs that differ importantly in the elements required for sample size calculations (stratified design). The CRXO design markedly reduces the sample size requirement compared with the parallel-group, cluster randomised design for the example cases. The stratified design further reduces the sample size requirement compared with the unstratified design. The CRXO design enables the evaluation of routinely used interventions that can bring about small, but important, improvements in patient care in the intensive care setting.

  3. Psychiatric Cultures Compared : Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches

    NARCIS (Netherlands)

    Gijswijt-Hofstra, Marijke; Oosterhuis, Harry; Vijselaar, Joost; Freeman, Hugh

    2005-01-01

    The history of mental health care in the twentieth century is a relatively uncharted territory. Exemplifying a new emphasis on the comparative approach, this volume offers overviews of various national psychiatric cultures and explores new research subjects. By confronting Dutch psychiatry with

  4. A Flipped Classroom Approach to Improving the Quality of Delirium Care Using an Interprofessional Train-the-Trainer Program.

    Science.gov (United States)

    Sockalingam, Sanjeev; James, Sandra-Li; Sinyi, Rebecca; Carroll, Aideen; Laidlaw, Jennifer; Yanofsky, Richard; Sheehan, Kathleen

    2016-01-01

    Given the prevalence and morbidity associated with delirium, there is a need for effective and efficient institutional approaches to delirium training in health care settings. Novel education methods, specifically the "flipped classroom" (FC) and "train-the-trainer" (TTT), have the potential to address these delirium training gaps. This study evaluates the effect of a TTT FC interprofessional delirium training program on participants' perceived ability to manage delirium, delirium knowledge, and clinicians' delirium assessment behaviors. FC Delirium TTT sessions were implemented in a large four-hospital network and consisted of presession online work and a 3-hour in-session component. The 156 TTT interprofessional participants who attended the sessions (ie, trainers) were expected to then deliver delirium training to their patient care units. Delirium care self-efficacy and knowledge test scores were measured before, after, and 6 months after the training session. Clinician delirium assessment rates were measured by chart audits before and 3 months after trainer's implementation of delirium training sessions. Delirium knowledge test scores (7.8 ± 1.6 versus 9.7 ± 1.2, P approach can improve participants' perceived delirium care skills and confidence, and delirium knowledge up to 6 months after the session. This approach provides a model for implementing hospitalwide delirium education that can change delirium assessment behavior while minimizing time and personnel requirements.

  5. Experimental observation of the stratified electrothermal instability on aluminum with thickness greater than a skin depth

    Science.gov (United States)

    Hutchinson, T. M.; Awe, T. J.; Bauer, B. S.; Yates, K. C.; Yu, E. P.; Yelton, W. G.; Fuelling, S.

    2018-05-01

    A direct observation of the stratified electrothermal instability on the surface of thick metal is reported. Aluminum rods coated with 70 μ m Parylene-N were driven to 1 MA in 100 ns , with the metal thicker than the skin depth. The dielectric coating suppressed plasma formation, enabling persistent observation of discrete azimuthally correlated stratified thermal perturbations perpendicular to the current whose wave numbers, k , grew exponentially with rate γ (k ) =0.06 n s-1-(0.4 n s-1μ m2ra d-2 ) k2 in ˜1 g /c m3 , ˜7000 K aluminum.

  6. Experimental Observation of the Stratified Electrothermal Instability on Aluminum with Thickness Greater than a Skin Depth

    Energy Technology Data Exchange (ETDEWEB)

    Hutchinson, Trevor M. [Univ. of Nevada, Reno, NV (United States); Hutchinson, Trevor M. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Awe, Thomas James [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Bauer, Bruno S. [Univ. of Nevada, Reno, NV (United States); Yates, Kevin [Univ. of New Mexico, Albuquerque, NM (United States); Yu, Edmund p. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Yelton, William G. [Sandia National Lab. (SNL-NM), Albuquerque, NM (United States); Fuelling, Stephan [Univ. of Nevada, Reno, NV (United States)

    2017-07-01

    The first direct observation of the stratified electrothermal instability on the surface of thick metal is reported. Aluminum rods coated with 70 μm Parylene-N were driven to 1 MA in approximately 100 ns, with the metal thicker than the skin depth. The dielectric coating suppressed plasma formation, enabling persistent observation of discrete azimuthally-correlated stratified structures perpendicular to the current. Strata amplitudes grow rapidly, while their Fourier spectrum shifts toward longer wavelength. Assuming blackbody emission, radiometric calculations indicate strata are temperature perturbations that grow exponentially with rate γ = 0.04 ns -1 in 3000- 10,000 K aluminum.

  7. Thermo-diffusion effect on free convection heat and mass transfer in a thermally linearly stratified non-darcy porous media

    KAUST Repository

    Murthy, P.V.S.N.

    2011-12-26

    Thermo-diffusion effect on free convection heat and mass transfer from a vertical surface embedded in a liquid saturated thermally stratified non - Darcy porous medium has been analyzed using a local non-similar procedure. The wall temperature and concentration are constant and the medium is linearly stratified in the vertical direction with respect to the thermal conditions. The fluid flow, temperature and concentration fields are affected by the complex interactions among the diffusion ratio Le, buoyancy ratio N, thermo-diffusion parameter Sr and stratification parameter ?. Non-linear interactions of all these parameters on the convective transport has been analyzed and variation of heat and mass transfer coefficients with thermo-diffusion parameter in the thermally stratified non-Darcy porous media is presented through computer generated plots.

  8. Thermo-diffusion effect on free convection heat and mass transfer in a thermally linearly stratified non-darcy porous media

    KAUST Repository

    Murthy, P.V.S.N.; El-Amin, Mohamed

    2011-01-01

    Thermo-diffusion effect on free convection heat and mass transfer from a vertical surface embedded in a liquid saturated thermally stratified non - Darcy porous medium has been analyzed using a local non-similar procedure. The wall temperature and concentration are constant and the medium is linearly stratified in the vertical direction with respect to the thermal conditions. The fluid flow, temperature and concentration fields are affected by the complex interactions among the diffusion ratio Le, buoyancy ratio N, thermo-diffusion parameter Sr and stratification parameter ?. Non-linear interactions of all these parameters on the convective transport has been analyzed and variation of heat and mass transfer coefficients with thermo-diffusion parameter in the thermally stratified non-Darcy porous media is presented through computer generated plots.

  9. Developing a medication communication framework across continuums of care using the Circle of Care Modeling approach

    Science.gov (United States)

    2013-01-01

    Background Medication errors are a common type of preventable errors in health care causing unnecessary patient harm, hospitalization, and even fatality. Improving communication between providers and between providers and patients is a key aspect of decreasing medication errors and improving patient safety. Medication management requires extensive collaboration and communication across roles and care settings, which can reduce (or contribute to) medication-related errors. Medication management involves key recurrent activities (determine need, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and between each. Despite its importance, there is a lack of conceptual models that explore medication communication specifically across roles and settings. This research seeks to address that gap. Methods The Circle of Care Modeling (CCM) approach was used to build a model of medication communication activities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system; providers and other roles are then modeled around the patient as a web of relationships. Recurrent medication communication activities were mapped to the medication management framework. The research occurred in three iterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion, Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration 3 consisted of interviews and a discussion group in the larger community. Results Each iteration provided further detail to the Circle of Care medication communication model. Specific medication communication activities were mapped along each communication pathway between roles and to the medication management framework. We could not map all medication communication activities to the medication management framework; we added Coordinate as a separate and distinct recurrent activity

  10. Developing a medication communication framework across continuums of care using the Circle of Care Modeling approach.

    Science.gov (United States)

    Kitson, Nicole A; Price, Morgan; Lau, Francis Y; Showler, Grey

    2013-10-17

    Medication errors are a common type of preventable errors in health care causing unnecessary patient harm, hospitalization, and even fatality. Improving communication between providers and between providers and patients is a key aspect of decreasing medication errors and improving patient safety. Medication management requires extensive collaboration and communication across roles and care settings, which can reduce (or contribute to) medication-related errors. Medication management involves key recurrent activities (determine need, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and between each. Despite its importance, there is a lack of conceptual models that explore medication communication specifically across roles and settings. This research seeks to address that gap. The Circle of Care Modeling (CCM) approach was used to build a model of medication communication activities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system; providers and other roles are then modeled around the patient as a web of relationships. Recurrent medication communication activities were mapped to the medication management framework. The research occurred in three iterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion, Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration 3 consisted of interviews and a discussion group in the larger community. Each iteration provided further detail to the Circle of Care medication communication model. Specific medication communication activities were mapped along each communication pathway between roles and to the medication management framework. We could not map all medication communication activities to the medication management framework; we added Coordinate as a separate and distinct recurrent activity. We saw many examples of

  11. Direct numerical simulation of thermally-stratified turbulent boundary layer subjected to adverse pressure gradient

    International Nuclear Information System (INIS)

    Hattori, Hirofumi; Kono, Amane; Houra, Tomoya

    2016-01-01

    Highlights: • We study various thermally-stratified turbulent boundary layers having adverse pressure gradient (APG) by means of DNS. • The detailed turbulent statistics and structures in various thermally-stratified turbulent boundary layers having APG are discussed. • It is found that the friction coefficient and Stanton number decrease along the streamwise direction due to the effects of stable thermal stratification and APG, but those again increase due to the APG effect in the case of weak stable thermal stratification. • In the case of strong stable stratification with or without APG, the flow separation is observed in the downstream region. - Abstract: The objective of this study is to investigate and observe turbulent heat transfer structures and statistics in thermally-stratified turbulent boundary layers subjected to a non-equilibrium adverse pressure gradient (APG) by means of direct numerical simulation (DNS). DNSs are carried out under conditions of neutral, stable and unstable thermal stratifications with a non-equilibrium APG, in which DNS results reveal heat transfer characteristics of thermally-stratified non-equilibrium APG turbulent boundary layers. In cases of thermally-stratified turbulent boundary layers affected by APG, heat transfer performances increase in comparison with a turbulent boundary layer with neutral thermal stratification and zero pressure gradient (ZPG). Especially, it is found that the friction coefficient and Stanton number decrease along the streamwise direction due to the effects of stable thermal stratification and APG, but those again increase due to the APG effect in the case of weak stable thermal stratification (WSBL). Thus, the analysis for both the friction coefficient and Stanton number in the case of WSBL with/without APG is conducted using the FIK identity in order to investigate contributions from the transport equations, in which it is found that both Reynolds-shear-stress and the mean convection terms

  12. Experimental investigation on isothermal stratified flow mixing in a horizontal T-junction

    Energy Technology Data Exchange (ETDEWEB)

    Isaev, Alexander; Kulenovic, Rudi; Laurien, Eckart [Stuttgart Univ. (Germany). Inst. fuer Kernenergetik und Energiesysteme (IKE)

    2016-10-15

    Turbulent and stratified flows can lead to thermal fatigue in piping systems of nuclear power plants (NPP). Such flows can be investigated in the University of Stuttgart Fluid-Structure-Interaction (FSI) facility with a T-Junction at thermal conditions with temperature differences of up to 255 K and at pressures of maximum 75 bars.

  13. Numerical simulation of stratified shear flow using a higher order Taylor series expansion method

    Energy Technology Data Exchange (ETDEWEB)

    Iwashige, Kengo; Ikeda, Takashi [Hitachi, Ltd. (Japan)

    1995-09-01

    A higher order Taylor series expansion method is applied to two-dimensional numerical simulation of stratified shear flow. In the present study, central difference scheme-like method is adopted for an even expansion order, and upwind difference scheme-like method is adopted for an odd order, and the expansion order is variable. To evaluate the effects of expansion order upon the numerical results, a stratified shear flow test in a rectangular channel (Reynolds number = 1.7x10{sup 4}) is carried out, and the numerical velocity and temperature fields are compared with experimental results measured by laser Doppler velocimetry thermocouples. The results confirm that the higher and odd order methods can simulate mean velocity distributions, root-mean-square velocity fluctuations, Reynolds stress, temperature distributions, and root-mean-square temperature fluctuations.

  14. Scattering by multiple parallel radially stratified infinite cylinders buried in a lossy half space.

    Science.gov (United States)

    Lee, Siu-Chun

    2013-07-01

    The theoretical solution for scattering by an arbitrary configuration of closely spaced parallel infinite cylinders buried in a lossy half space is presented in this paper. The refractive index and permeability of the half space and cylinders are complex in general. Each cylinder is radially stratified with a distinct complex refractive index and permeability. The incident radiation is an arbitrarily polarized plane wave propagating in the plane normal to the axes of the cylinders. Analytic solutions are derived for the electric and magnetic fields and the Poynting vector of backscattered radiation emerging from the half space. Numerical examples are presented to illustrate the application of the scattering solution to calculate backscattering from a lossy half space containing multiple homogeneous and radially stratified cylinders at various depths and different angles of incidence.

  15. Stability of unstably stratified shear flow between parallel plates

    Energy Technology Data Exchange (ETDEWEB)

    Fujimura, Kaoru; Kelly, R E

    1987-09-01

    The linear stability of unstably stratified shear flows between two horizontal parallel plates was investigated. Eigenvalue problems were solved numerically by making use of the expansion method in Chebyshev polynomials, and the critical Rayleigh numbers were obtained accurately in the Reynolds number range of (0.01, 100). It was found that the critical Rayleigh number increases with an increase of the Reynolds number. The result strongly supports previous stability analyses except for the analysis by Makino and Ishikawa (J. Jpn. Soc. Fluid Mech. 4 (1985) 148 - 158) in which a decrease of the critical Rayleigh number was obtained.

  16. Stability of unstably stratified shear flow between parallel plates

    International Nuclear Information System (INIS)

    Fujimura, Kaoru; Kelly, R.E.

    1987-01-01

    The linear stability of unstably stratified shear flows between two horizontal parallel plates was investigated. Eigenvalue problems were solved numerically by making use of the expansion method in Chebyshev polynomials, and the critical Rayleigh numbers were obtained accurately in the Reynolds number range of [0.01, 100]. It was found that the critical Rayleigh number increases with an increase of the Reynolds number. The result strongly supports previous stability analyses except for the analysis by Makino and Ishikawa [J. Jpn. Soc. Fluid Mech. 4 (1985) 148 - 158] in which a decrease of the critical Rayleigh number was obtained. (author)

  17. Attitudes towards care robots among Finnish home care personnel : a comparison of two approaches

    OpenAIRE

    Rantanen, Teemu; Lehto, Paula; Vuorinen, Pertti; Coco, Kirsi

    2017-01-01

    Study's rationale The significance of care robotics has been highlighted in recent years. Aims and objective The article examines the adoption of care robots in home care settings, and in particular Finnish home care personnel's attitudes towards robots. The study compares the importance of the Negative Attitudes towards Robots Scale advanced by Nomura and specific positive attitudes related to the usefulness of care robots for different tasks in the home care. Methodological ...

  18. A purposeful Yet Nonimposing Approach: How Japanese Home Care Nurses Establish Relationships With Older Clients and Their Families.

    Science.gov (United States)

    Iwasaki, Takako; Yamamoto-Mitani, Noriko; Sato, Kana; Yumoto, Yoshie; Noguchi-Watanabe, Maiko; Ogata, Yasuko

    2017-11-01

    Relationship development is crucial to nursing practice with families. However, little is known about the process of building relationships with multiple family members in home care settings and in various cultures. The objective of this study was to explore the experiences of home care nurses about how they established relationships with older clients and their families in Japan. Grounded theory was used to guide the research. Twenty-three expert home care nurses participated in semistructured interviews concerning their family nursing practice. The establishment of relationships with clients/family members was based on a purposeful yet nonimposing approach composed of four aspects: keeping a mindful distance from the family, not being a threat to family life, being a comfortable neighbor, and gaining trust as a competent nurse. Through a purposeful nonimposing approach, Japanese home care nurses promoted and nurtured nurse-family relationships and became involved in the life of the family. These findings provide a useful foundation to guide practice with families and grow knowledge about the process of establishing relationships with multiple family members in home settings.

  19. Measures to assess the prognostic ability of the stratified Cox proportional hazards model

    DEFF Research Database (Denmark)

    (Tybjaerg-Hansen, A.) The Fibrinogen Studies Collaboration.The Copenhagen City Heart Study; Tybjærg-Hansen, Anne

    2009-01-01

    Many measures have been proposed to summarize the prognostic ability of the Cox proportional hazards (CPH) survival model, although none is universally accepted for general use. By contrast, little work has been done to summarize the prognostic ability of the stratified CPH model; such measures...

  20. Attitudes towards care robots among Finnish home care personnel - a comparison of two approaches.

    Science.gov (United States)

    Rantanen, Teemu; Lehto, Paula; Vuorinen, Pertti; Coco, Kirsi

    2017-08-22

    The significance of care robotics has been highlighted in recent years. The article examines the adoption of care robots in home care settings, and in particular Finnish home care personnel's attitudes towards robots. The study compares the importance of the Negative Attitudes towards Robots Scale advanced by Nomura and specific positive attitudes related to the usefulness of care robots for different tasks in the home care. A cross-sectional study conducted by questionnaire. The research data were gathered from a survey of Finnish home care personnel (n = 200). Exploratory factor analysis, Pearson's correlation coefficient and linear regression analysis. The Negative Attitudes towards Robots Scale (NARS), by Nomura, with a specific behavioural intention scale based on Ajzen's theory of planned behaviour, and a measure of positive attitudes towards the usefulness of care robots for different tasks in home care and the promotion of independent living of older persons. The study shows that NARS helps to explain psychological resistance related to the introduction of care robots, although the scale is susceptible to cultural differences. Care personnel's behavioural intentions related to the introduction of robot applications are influenced also by the perception of the usefulness of care robots. The study is based only on a Finnish sample, and the response rate of the study was relatively small (18.2%), which limits the generalisability of the results. The study shows that the examination of home care personnel's attitudes towards robots is not justified to focus only on one aspect, but a better explanation is achieved by combining the perspectives of societal attitudes, attitudes related to psychological reactions and the practical care and promotion of the independent living of older people. © 2017 Nordic College of Caring Science.

  1. Stratified flows and internal waves in the Vema Fracture Zone of the Mid Atlantic Ridge

    Science.gov (United States)

    Makarenko, Nikolay; Morozov, Eugene; Tarakanov, Roman; Demidova, Tatiana; Frey, Dmitri; Grigorenko, Klim

    2017-04-01

    In this paper, we study stratified flows and internal waves in the Vema fracture zone of the Mid Atlantic Ridge. This fracture provides intense transportation of cold abyssal waters from the West Atlantic to the equatorial region of the East Atlantic [1]. The results of measurements [2,3] carried out in the cruises of RV Akademik Sergey Vavilov in 2014-2016 are presented. The structure of the near-bottom flow is studied experimentally on the basis of CTD- and LADCP profiling. Theoretical analysis involves mathematical formulation of stratified fluid flow which uses CTD-data obtained from field observation. Spectral properties and kinematic characteristics of internal waves are calculated and discussed. This work was supported by RFBR (grants No 15-01-03942, 16-35-50158). References [1] Morozov E., Demidov A., Tarakanov R. and Zenk W. Abyssal Channels in the Atlantic Ocean: Water Structure and Flows, Springer, Dordrecht, 2010. [2] Morozov E.G., Tarakanov R.Yu., and Makarenko N.I. Flows of Antarctic Bottom Water through fractures in the southern part of the North Mid Atlantic Ridge, Oceanology, 2015, 55, 796-800. [3] Grigorenko K.S., Makarenko N.I., Morozov E.G., Tarakanov R.Yu., and Frey D.I. Stratified flows and internal waves in the Central West Atlantic, J. Physics: Conf. Series, 2016, 722, 012011.

  2. Critical care physicians’ approaches to negotiating with surrogate decision makers: a qualitative study

    Science.gov (United States)

    Brush, David R.; Brown, Crystal E.; Alexander, G. Caleb

    2013-01-01

    Objective To describe how critical care physicians manage conflicts with surrogates about withdrawing or withholding patients’ life support. Design Qualitative analysis of key informant interviews with critical care physicians during 2010. We transcribed interviews verbatim and used grounded theory to code and revise a taxonomy of themes and to identify illustrative quotes. Setting 3 academic medical centers, 1 academic-affiliated medical center and 4 private practice groups or private hospitals in a large Midwestern city Subjects 14 critical care physicians Measurements and main results Physicians reported tailoring their approach to address specific reasons for disagreement with surrogates. Five common approaches were identified: (1) building trust, (2) educating and informing, (3) providing surrogates more time, (4) adjusting surrogate and physician roles, and (5) highlighting specific values. When mistrust was an issue, physicians endeavored to build a more trusting relationship with the surrogate before re-addressing decision making. Physicians also reported correcting misunderstandings by providing targeted education, and some reported highlighting specific patient, surrogate, or physician values that they hoped would guide surrogates to agree with them. When surrogates struggled with decision making roles, physicians attempted to reinforce the concept of substituted judgment. Physicians noted that some surrogates needed time to “come to terms” with the patent’s illness before agreeing with physicians. Many physicians had witnessed colleagues negotiate in ways they found objectionable, such as providing misleading information, injecting their own values into the negotiation, or behaving unprofessionally towards surrogates. While some physicians viewed their efforts to encourage surrogates’ agreement as persuasive, others strongly denied persuading surrogates and described their actions as “guiding” or “negotiating.” Conclusions Physicians

  3. Attributes associated with eye care use in the United States: a meta-analysis.

    Science.gov (United States)

    Wagner, Laura Danielle; Rein, David B

    2013-07-01

    To model the factors that are associated with the use of eye care services among the US population with and without diabetes, stratifying by age group. Meta-analysis. We analyzed data from 3 datasets: the Behavioral Risk Factors Surveillance System combined years 2006-2009, the National Health and Nutrition Examination Survey combined years 2005-2008, and the National Health Interview Survey year 2008. For all 3 datasets, we analyzed data from all survey participants aged 40 years or older who participated in vision-related survey modules. We performed multivariate logistic regression analyses to assess associations between any eye care use within the previous year and 14 indicators of patient demographics and health. We estimated separate regressions for persons with and without diabetes stratified by age group. We combined estimates across datasets using a random effects model estimated using Markov Chain Monte Carlo algorithms. Use of eye care in the previous year and personal factors associated with eye care use. Annual eye care use rates ranged from 46% to 51% in participants without diabetes and 64% to 72% in participants with diabetes. For people with and without diabetes, health insurance, an eye disease diagnosis, and higher income were associated with higher odds of eye care use. Being male was associated with lower odds of eye care use in some diabetes status and age group categories. Other variables, such as more education, being married, black race, Hispanic/Latino ethnicity, health status, heavy drinking, and limited ability to read small print, were associated with eye care use in only some diabetes status and age group categories. Our findings indicate that economic and ocular health factors are associated with the greatest odds of annual eye care use. Access to health insurance and income levels greater than $35 000 US dollars (value at the time of interview) are associated with eye care use independently of other demographic factors. Copyright

  4. How oncology fellows discuss transitions in goals of care: a snapshot of approaches used prior to training.

    Science.gov (United States)

    Back, Anthony L; Michaelsen, Kate; Alexander, Stewart; Hopley, Elizabeth; Edwards, Kelly; Arnold, Robert M

    2010-04-01

    The moment when a physician raises the possibility of discontinuing palliative chemotherapy at the end of life is a critical moment in the illness, and a difficult conversation. Expert recommendations cite the importance of giving bad news in these situations but there is limited research addressing how physicians should discuss transitions in goals of care from disease-modifying therapy to end-of-life care. While existing research includes survey data and observational studies of oncologist outpatient visits with patient who have advanced cancer, there are no studies that characterize actual physician communication behaviors when the physician tried to initiate a transitions conversation with a patient who has advanced cancer. In this study, we examined the communication approaches used by oncology fellows discussing transitions with a standardized patient using audiorecordings collected prior to an intensive communication skills workshop. In this preworkshop encounter, each oncology fellow had the task of discussing a transition in goals of care with a patient who was experiencing cancer progression despite treatment with existing evidence-based therapies. We used qualitative methodology to characterize the approaches used by oncology fellows in 20 of these pre-workshop conversations. We identified two themes in the approaches that fellows used: (1) the limitations of biomedical disease-modifying treatments and (2) the possibility of a new direction for medical care when disease-modifying treatments have been exhausted. We found that for each theme, fellows tended to emphasize a logical frame or an experiential frame. Understanding these frames could be useful in designing future communication skills training interventions.

  5. Ethical theory, ethnography, and differences between doctors and nurses in approaches to patient care.

    Science.gov (United States)

    Robertson, D W

    1996-01-01

    OBJECTIVES: To study empirically whether ethical theory (from the mainstream principles-based, virtue-based, and feminist schools) usefully describes the approaches doctors and nurses take in everyday patient care. DESIGN: Ethnographic methods: participant observation and interviews, the transcripts of which were analysed to identify themes in ethical approaches. SETTING: A British old-age psychiatry ward. PARTICIPANTS: The more than 20 doctors and nurses on the ward. RESULTS: Doctors and nurses on the ward differed in their conceptions of the principles of beneficence and respect for patient autonomy. Nurses shared with doctors a commitment to liberal and utilitarian conceptions of these principles, but also placed much greater weight on relationships and character virtues when expressing the same principles. Nurses also emphasised patient autonomy, while doctors were more likely to advocate beneficence, when the two principles conflicted. CONCLUSION: The study indicates that ethical theory can, contrary to the charges of certain critics, be relevant to everyday health care-if it (a) attends to social context and (b) is flexible enough to draw on various schools of theory. PMID:8910782

  6. Altruism and mature care: some rival moral considerations in care ethics.

    Science.gov (United States)

    Hem, Marit Helene; Halvorsen, Kristin; Nortvedt, Per

    2014-11-01

    We discuss Carol Gilligan's original concept of mature care in the light of the altruistic approach to caring and good clinical judgment. In particular, we highlight how the concept of mature care can capture important challenges in today's nursing. Further, we illuminate how mature care might differ normatively from an altruistic approach to caring and the traditional prudential virtues in nursing. We also discuss similarities between mature care and virtue ethics. For nursing and nurses' identity, in today's health care system that is increasingly pressured to 'produce' health, we believe it is important to both developing further theories on mature care and having normative discussions about care. © The Author(s) 2014.

  7. Transport of particles, drops, and small organisms in density stratified fluids

    Science.gov (United States)

    Ardekani, Arezoo M.; Doostmohammadi, Amin; Desai, Nikhil

    2017-10-01

    Sedimenting particles and motile organisms are ubiquitously found in oceans and lakes, where density stratification naturally occurs due to temperature or salinity gradients. We explore the effects of stratification on the fundamental hydrodynamics of settling particles, rising drops, and small organisms. The results of our direct numerical simulations of the sedimentation of particles show that the presence of vertical density gradients in the water column can substantially affect the settling dynamics of a particle, interaction between a pair of particles, and settling rates and microstructure of suspension of particles. We show that elongation of particles affects both the settling orientation and the settling rate of particles in stratified fluids, which will have direct consequences on the vertical flux of particulate matter and carbon flux in the ocean. We further demonstrate an unexpected effect of buoyancy, potentially affecting a broad range of processes at pycnoclines in oceans and lakes. In particular, stratification has a major effect on the flow field, energy expenditure, and nutrient uptake of small organisms. In addition, the role of stratification in pattern formation of bioconvection plumes of algal cells and in biogenic mixing is investigated. In particular, the numerical approach allows for considering the effects of background turbulence and hydrodynamic perturbations produced by swimming organisms, shedding light on the contribution of organisms in the mixing process in aqueous environments.

  8. Enhancing Care of Aged and Dying Prisoners: Is e-Learning a Feasible Approach?

    Science.gov (United States)

    Loeb, Susan J; Penrod, Janice; Myers, Valerie H; Baney, Brenda L; Strickfaden, Sophia M; Kitt-Lewis, Erin; Wion, Rachel K

    Prisons and jails are facing sharply increased demands in caring for aged and dying inmates. Our Toolkit for Enhancing End-of-life Care in Prisons effectively addressed end-of-life (EOL) care; however, geriatric content was limited, and the product was not formatted for broad dissemination. Prior research adapted best practices in EOL care and aging; but, delivery methods lacked emerging technology-focused learning and interactivity. Our purposes were to uncover current training approaches and preferences and to ascertain the technological capacity of correctional settings to deliver computer-based and other e-learning training. An environmental scan was conducted with 11 participants from U.S. prisons and jails to ensure proper fit, in terms of content and technology capacity, between an envisioned computer-based training product and correctional settings. Environmental scan findings focused on content of training, desirable qualities of training, prominence of "homegrown" products, and feasibility of commercial e-learning. This study identified qualities of training programs to adopt and pitfalls to avoid and revealed technology-related issues to be mindful of when designing computer-based training for correctional settings, and participants spontaneously expressed an interest in geriatrics and EOL training using this learning modality as long as training allowed for tailoring of materials.

  9. Stratifying patients with peripheral neuropathic pain based on sensory profiles

    DEFF Research Database (Denmark)

    Vollert, Jan; Maier, Christoph; Attal, Nadine

    2017-01-01

    In a recent cluster analysis, it has been shown that patients with peripheral neuropathic pain can be grouped into 3 sensory phenotypes based on quantitative sensory testing profiles, which are mainly characterized by either sensory loss, intact sensory function and mild thermal hyperalgesia and...... populations that need to be screened to reach a subpopulation large enough to conduct a phenotype-stratified study. The most common phenotype in diabetic polyneuropathy was sensory loss (83%), followed by mechanical hyperalgesia (75%) and thermal hyperalgesia (34%, note that percentages are overlapping...

  10. Exploring the Potential of Predictive Analytics and Big Data in Emergency Care.

    Science.gov (United States)

    Janke, Alexander T; Overbeek, Daniel L; Kocher, Keith E; Levy, Phillip D

    2016-02-01

    Clinical research often focuses on resource-intensive causal inference, whereas the potential of predictive analytics with constantly increasing big data sources remains largely unexplored. Basic prediction, divorced from causal inference, is much easier with big data. Emergency care may benefit from this simpler application of big data. Historically, predictive analytics have played an important role in emergency care as simple heuristics for risk stratification. These tools generally follow a standard approach: parsimonious criteria, easy computability, and independent validation with distinct populations. Simplicity in a prediction tool is valuable, but technological advances make it no longer a necessity. Emergency care could benefit from clinical predictions built using data science tools with abundant potential input variables available in electronic medical records. Patients' risks could be stratified more precisely with large pools of data and lower resource requirements for comparing each clinical encounter to those that came before it, benefiting clinical decisionmaking and health systems operations. The largest value of predictive analytics comes early in the clinical encounter, in which diagnostic and prognostic uncertainty are high and resource-committing decisions need to be made. We propose an agenda for widening the application of predictive analytics in emergency care. Throughout, we express cautious optimism because there are myriad challenges related to database infrastructure, practitioner uptake, and patient acceptance. The quality of routinely compiled clinical data will remain an important limitation. Complementing big data sources with prospective data may be necessary if predictive analytics are to achieve their full potential to improve care quality in the emergency department. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

  11. A new approach to the tradeoff between quality and accessibility of health care.

    Science.gov (United States)

    Tanke, Marit A C; Ikkersheim, David E

    2012-05-01

    Quality of care is associated with patient volume. Regionalization of care is therefore one of the approaches that is suited to improve quality of care. A disadvantage of regionalization is that the accessibility of the facilities can decrease. By investigating the tradeoff between quality and accessibility it is possible to determine the optimal amount of treatment locations in a health care system. In this article we present a new model to quantitatively 'solve' this tradeoff. We use the condition breast cancer in the Netherlands as an example. We calculated the expected quality gains in Quality Adjusted Lifetime Years (QALY's) due to stepwise regionalization using 'volume-outcome' literature for breast cancer. Decreased accessibility was operationalized as increased (travel) costs due to regionalization by using demographic data, drive-time information, and the national median income. The total sum of the quality and accessibility function determines the optimum range of treatment locations for this particular condition, given the 'volume-quality' relationship and Dutch demographics and geography. Currently, 94 locations offer breast cancer treatment in the Netherlands. Our model estimates that the optimum range of treatment locations for this particular condition in the Netherlands varies from 15 locations to 44 locations. Our study shows that the Dutch society would benefit from regionalization of breast cancer care as possible quality gains outweigh heightened travel costs. In addition, this model can be used for other medical conditions and in other countries. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  12. A Cyclical Approach to Continuum Modeling: A Conceptual Model of Diabetic Foot Care

    Directory of Open Access Journals (Sweden)

    Martha L. Carvour

    2017-12-01

    Full Text Available “Cascade” or “continuum” models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. These models may be used to compare care across subgroups or populations and to identify and evaluate interventions intended to improve outcomes on the population level. Previous cascade or continuum models have been limited by several factors. These models are best suited to processes with stepwise outcomes—such as screening, diagnosis, and treatment—with a single defined outcome (e.g., treatment or cure for each member of the population. However, continuum modeling is not well developed for complex processes with non-sequential or recurring steps or those without singular outcomes. As shown here using the example of diabetic foot care, the concept of continuum modeling may be re-envisioned with a cyclical approach. Cyclical continuum modeling may permit incorporation of non-sequential and recurring steps into a single continuum, while recognizing the presence of multiple desirable outcomes within the population. Cyclical models may simultaneously represent the distribution of clinical severity and clinical resource use across a population, thereby extending the benefits of traditional continuum models to complex processes for which population-based monitoring is desired. The models may also support communication with other stakeholders in the process of care, including health care providers and patients.

  13. The ecology of medical care in Beijing.

    Directory of Open Access Journals (Sweden)

    Shuang Shao

    Full Text Available BACKGROUND: We presented the pattern of health care consumption, and the utilization of available resources by describing the ecology of medical care in Beijing on a monthly basis and by describing the socio-demographic characteristics associated with receipt care in different settings. METHODS: A cohort of 6,592 adults, 15 years of age and older were sampled to estimate the number of urban-resident adults per 1,000 who visited a medical facility at least once in a month, by the method of three-stage stratified and cluster random sampling. Separate logistic regression analyses assessed the association between those receiving care in different types of setting and their socio-demographic characteristics. RESULTS: On average per 1,000 adults, 295 had at least one symptom, 217 considered seeking medical care, 173 consulted a physician, 129 visited western medical practitioners, 127 visited a hospital-based outpatient clinic, 78 visited traditional Chinese medical practitioners, 43 visited a primary care physician, 35 received care in an emergency department, 15 were hospitalized. Health care seeking behaviors varied with socio-demographic characteristics, such as gender, age, ethnicity, resident census register, marital status, education, income, and health insurance status. In term of primary care, the gate-keeping and referral roles of Community Health Centers have not yet been fully established in Beijing. CONCLUSIONS: This study represents a first attempt to map the medical care ecology of Beijing urban population and provides timely baseline information for health care reform in China.

  14. Impact of a decision aid about stratified ovarian cancer risk-management on women's knowledge and intentions: a randomised online experimental survey study.

    Science.gov (United States)

    Meisel, Susanne F; Freeman, Maddie; Waller, Jo; Fraser, Lindsay; Gessler, Sue; Jacobs, Ian; Kalsi, Jatinderpal; Manchanda, Ranjit; Rahman, Belinda; Side, Lucy; Wardle, Jane; Lanceley, Anne; Sanderson, Saskia C

    2017-11-16

    Risk stratification using genetic and other types of personal information could improve current best available approaches to ovarian cancer risk reduction, improving identification of women at increased risk of ovarian cancer and reducing unnecessary interventions for women at lower risk. Amounts of information given to women may influence key informed decision-related outcomes, e.g. knowledge. The primary aim of this study was to compare informed decision-related outcomes between women given one of two versions (gist vs. extended) of a decision aid about stratified ovarian cancer risk-management. This was an experimental survey study comparing the effects of brief (gist) information with lengthier, more detailed (extended) information on cognitions relevant to informed decision-making about participating in risk-stratified ovarian cancer screening. Women with no personal history of ovarian cancer were recruited through an online survey company and randomised to view the gist (n = 512) or extended (n = 519) version of a website-based decision aid and completed an online survey. Primary outcomes were knowledge and intentions. Secondary outcomes included attitudes (values) and decisional conflict. There were no significant differences between the gist and extended conditions in knowledge about ovarian cancer (time*group interaction: F = 0.20, p = 0.66) or intention to participate in ovarian cancer screening based on genetic risk assessment (t(1029) = 0.43, p = 0.67). There were also no between-groups differences in secondary outcomes. In the sample overall (n = 1031), knowledge about ovarian cancer increased from before to after exposure to the decision aid (from 5.71 to 6.77 out of a possible 10: t = 19.04, p type of content for decision aids about stratified ovarian cancer risk-management. This study was registered with the ISRCTN registry; registration number: ISRCTN48627877 .

  15. Approaches to health-care provider education and professional development in perinatal depression: a systematic review.

    Science.gov (United States)

    Legere, Laura E; Wallace, Katherine; Bowen, Angela; McQueen, Karen; Montgomery, Phyllis; Evans, Marilyn

    2017-07-24

    lack of strong research in multi-disciplinary, sector, site, and modal approaches to education and professional development for providers to identify and care for women at risk for, or experiencing, depression. To ensure optimal health outcomes, further research comparing diverse educational and professional development approaches is needed to identify the most effective strategies and consistently meet the needs of health-care providers. A protocol for this systematic review was registered on PROSPERO (Protocol number: CRD42015023701 ), June 21, 2015.

  16. Two-phase pressurized thermal shock investigations using a 3D two-fluid modeling of stratified flow with condensation

    International Nuclear Information System (INIS)

    Yao, W.; Coste, P.; Bestion, D.; Boucker, M.

    2003-01-01

    In this paper, a local 3D two-fluid model for a turbulent stratified flow with/without condensation, which can be used to predict two-phase pressurized thermal shock, is presented. A modified turbulent K- model is proposed with turbulence production induced by interfacial friction. A model of interfacial friction based on a interfacial sublayer concept and three interfacial heat transfer models, namely, a model based on the small eddies controlled surface renewal concept (HDM, Hughes and Duffey, 1991), a model based on the asymptotic behavior of the Eddy Viscosity (EVM), and a model based on the Interfacial Sublayer concept (ISM) are implemented into a preliminary version of the NEPTUNE code based on the 3D module of the CATHARE code. As a first step to apply the above models to predict the two-phase thermal shock, the models are evaluated by comparison of calculated profiles with several experiments: a turbulent air-water stratified flow without interfacial heat transfer; a turbulent steam-water stratified flow with condensation; turbulence induced by the impact of a water jet in a water pool. The prediction results agree well with the experimental data. In addition, the comparison of three interfacial heat transfer models shows that EVM and ISM gave better prediction results while HDM highly overestimated the interfacial heat transfers compared to the experimental data of a steam water stratified flow

  17. Minimum intervention dentistry approach to managing early childhood caries: a randomized control trial.

    Science.gov (United States)

    Arrow, Peter; Klobas, Elizabeth

    2015-12-01

    A pragmatic randomized control trial was undertaken to compare the minimum intervention dentistry (MID) approach, based on the atraumatic restorative treatment procedures (MID-ART: Test), against the standard care approach (Control) to treat early childhood caries in a primary care setting. Consenting parent/child dyads were allocated to the Test or Control group using stratified block randomization. Inclusion and exclusion criteria were applied. Participants were examined at baseline and at follow-up by two calibrated examiners blind to group allocation status (κ = 0.77), and parents completed a questionnaire at baseline and follow-up. Dental therapists trained in MID-ART provided treatment to the Test group and dentists treated the Control group using standard approaches. The primary outcome of interest was the number of children who were referred for specialist pediatric care. Secondary outcomes were the number of teeth treated, changes in child oral health-related quality of life and dental anxiety and parental perceptions of care received. Data were analyzed on an intention to treat basis; risk ratio for referral for specialist care, test of proportions, Wilcoxon rank test and logistic regression were used. Three hundred and seventy parents/carers were initially screened; 273 children were examined at baseline and 254 were randomized (Test = 127; Control = 127): mean age = 3.8 years, SD 0.90; 59% male, mean dmft = 4.9, SD 4.0. There was no statistically significant difference in age, sex, baseline caries experience or child oral health-related quality of life between the Test and Control group. At follow-up (mean interval 11.4 months, SD 3.1 months), 220 children were examined: Test = 115, Control = 105. Case-notes review of 231 children showed Test = 6 (5%) and Control = 53 (49%) were referred for specialist care, P < 0.0001. More teeth were filled in the Test group (mean = 2.93, SD 2.48) than in the Control group (mean = 1.54, SD

  18. A modified stratified model for the 3C 273 jet

    International Nuclear Information System (INIS)

    Liu Wenpo; Shen Zhiqiang

    2009-01-01

    We present a modified stratified jet model to interpret the observed spectral energy distributions of knots in the 3C 273 jet. Based on the hypothesis of the single index of the particle energy spectrum at injection and identical emission processes among all the knots, the observed difference of spectral shape among different 3C 273 knots can be understood as a manifestation of the deviation of the equivalent Doppler factor of stratified emission regions in an individual knot from a characteristic one. The summed spectral energy distributions of all ten knots in the 3C 273 jet can be well fitted by two components: a low-energy component (radio to optical) dominated by synchrotron radiation and a high-energy component (UV, X-ray and γ-ray) dominated by inverse Compton scattering of the cosmic microwave background. This gives a consistent spectral index of α = 0.88 (S v ∝ v -α ) and a characteristic Doppler factor of 7.4. Assuming the average of the summed spectrum as the characteristic spectrum of each knot in the 3C 273 jet, we further get a distribution of Doppler factors. We discuss the possible implications of these results for the physical properties in the 3C 273 jet. Future GeV observations with GLAST could separate the γ-ray emission of 3C 273 from the large scale jet and the small scale jet (i.e. the core) through measuring the GeV spectrum.

  19. Respiratory care manpower issues.

    Science.gov (United States)

    Mathews, Paul; Drumheller, Lois; Carlow, John J

    2006-03-01

    Although respiratory care is a relatively new profession, its practitioners are deeply involved in providing patient care in the critical care. In preparation for writing this article, we sought to explore the respiratory therapy manpower needs and activities designed to fulfill those needs in critical care practice. We began by delineating the historical development of respiratory care as a profession, the development of its education, and the professional credentialing system. We then conducted several literature reviews with few articles generated. We requested and received data from the American Association for Respiratory Care (AARC), The National Board for Respiratory Care (NBRC), and the Committee on Accreditation of Respiratory Care education (CoARC) relative to their membership, number of credentialed individuals, and educational program student and graduate data for 2000 through 2004. We then conducted two electronic surveys. Survey 1 was a six-item survey that examined the use of mandatory overtime in respiratory care departments. We used a convenience sample of 30 hospitals stratified by size (or=500 beds). Survey 2 was a five-item instrument distributed by blast E-mail to the Society of Critical Care Medicine's Respiratory Care Section members and members of the RC_World list serve. This survey elicited 51 usable and non-duplicative responses from geographically and size-varied institutions. We analyzed these data in several ways from distribution analysis to one-way analysis of variance procedure and appropriate post hoc analysis techniques. Where appropriate, a matched-pairs analysis was performed and these were compared across the variables intensive care unit (ICU) beds per actual number of respiratory care practitioners (RCPs) and ICU beds per preferred number of RCPs. The data gathered from the professional organizations indicated a relatively stable attrition rate (35.2%+/-1.7-3.1%), even in the face of varying enrollments (6,231 in 2004 vs. 4

  20. Development of a natural gas stratified charge rotary engine

    Energy Technology Data Exchange (ETDEWEB)

    Sierens, R.; Verdonck, W.

    1985-01-01

    A water model has been used to determine the positions of separate inlet ports for a natural gas, stratified charge rotary engine. The flow inside the combustion chamber (mainly during the induction period) has been registered by a film camera. From these tests the best locations of the inlet ports have been obtained, a prototype of this engine has been built by Audi NSU and tested in the laboratories of the university of Gent. The results of these tests, for different stratification configurations, are given. These results are comparable with the best results obtained by Audi NSU for a homogeneous natural gas rotary engine.

  1. Predictors of dental care utilization among working poor Canadians.

    Science.gov (United States)

    Muirhead, V E; Quiñonez, C; Figueiredo, R; Locker, D

    2009-06-01

    This study used the Gelberg-Andersen Behavioral Model for Vulnerable Populations to identify predictors of dental care utilization by working poor Canadians. A cross-sectional stratified sampling study design and telephone survey methodology was used to collect data from a nationally representative sample of 1049 working poor individuals aged 18 to 64 years. Working poor persons worked > or = 20 h a week, were not full-time students and had annual family incomes 1 year ago: male gender (OR = 1.63; P = 0.005), aged 25-34 years (OR = 2.05; P = 0.02), paying for dental care with cash or credit (OR = 2.31; P credit (OR = 2.71; P demand for economically constrained adults.

  2. PHOTOSPHERIC EMISSION FROM STRATIFIED JETS

    International Nuclear Information System (INIS)

    Ito, Hirotaka; Nagataki, Shigehiro; Ono, Masaomi; Lee, Shiu-Hang; Mao, Jirong; Yamada, Shoichi; Pe'er, Asaf; Mizuta, Akira; Harikae, Seiji

    2013-01-01

    We explore photospheric emissions from stratified two-component jets, wherein a highly relativistic spine outflow is surrounded by a wider and less relativistic sheath outflow. Thermal photons are injected in regions of high optical depth and propagated until the photons escape at the photosphere. Because of the presence of shear in velocity (Lorentz factor) at the boundary of the spine and sheath region, a fraction of the injected photons are accelerated using a Fermi-like acceleration mechanism such that a high-energy power-law tail is formed in the resultant spectrum. We show, in particular, that if a velocity shear with a considerable variance in the bulk Lorentz factor is present, the high-energy part of observed gamma-ray bursts (GRBs) photon spectrum can be explained by this photon acceleration mechanism. We also show that the accelerated photons might also account for the origin of the extra-hard power-law component above the bump of the thermal-like peak seen in some peculiar bursts (e.g., GRB 090510, 090902B, 090926A). We demonstrate that time-integrated spectra can also reproduce the low-energy spectrum of GRBs consistently using a multi-temperature effect when time evolution of the outflow is considered. Last, we show that the empirical E p -L p relation can be explained by differences in the outflow properties of individual sources

  3. Comprehensive Care

    Science.gov (United States)

    ... Comprehensive Care Share this page Facebook Twitter Email Comprehensive Care Understand the importance of comprehensive MS care ... In this article A complex disease requires a comprehensive approach Today multiple sclerosis (MS) is not a ...

  4. Homogeneous and Stratified Liquid-Liquid Flow Effect of a Viscosity Reducer: I. Comparison in parallel plates for heavy crude

    Directory of Open Access Journals (Sweden)

    E. J. Suarez-Dominguez

    2016-12-01

    Full Text Available Production of heavy crude oil in Mexico, and worldwide, is increasing which has led to the application of different methods to reduce viscosity or to enhance transport through stratified flow to continue using the existing infrastructures. In this context, injecting a viscosity improver that does not mix completely with the crude, establishes a liquid-liquid stratified flow. On the basis of a parallel plates model, comparing the increase of flow that occurs in the one-phase case which assumes a complete mixture between the crude and the viscosity improver against another stratified liquid-liquid (no mixing between the oil and compared improver; it was found that in both cases there is a flow increase for the same pressure drop with a maximum for the case in which the flow improver is between the plates and the crude.

  5. Parental Reflective Functioning: An Approach to Enhancing Parent-Child Relationships in Pediatric Primary Care.

    Science.gov (United States)

    Ordway, Monica Roosa; Webb, Denise; Sadler, Lois S; Slade, Arietta

    2015-01-01

    The current state of science suggests that safe, responsive, and nurturing parent-child relationships early in children's lives promotes healthy brain and child development and protection against lifelong disease by reducing toxic stress and promoting foundational social-emotional health. Pediatric health care providers (HCPs) have a unique opportunity to foster these relationships. However, such a role requires a shift in pediatric health care from a focus only on children to one that includes families and communities, as well as the inclusion of children's social and emotional health with their physical health. To foster healthy parent-child relationships, HCPs must develop the expertise to integrate approaches that support the family's socioemotional health into pediatric primary care. This article suggests ways in which pediatric HCPs can integrate a focus on parental reflective functioning into their clinical work, helping parents to understand some of the thoughts and feelings that underlie their children's behavior. Copyright © 2015 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

  6. Energy Cascade from Internal Modes in Non-uniformly Stratified Fluid through Excitation of Superharmonic Disturbances

    Science.gov (United States)

    Sutherland, B. R.

    2016-02-01

    It is well established that two-dimensional internal plane waves and modes in uniformly stratified fluid efficiently transfer energy to smaller scale waves and ultimately turbulent mixing through parametric subharmonic instability (PSI). The numerical simulations of MacKinnon & Winters (GRL 2005) predicted PSI should act efficiently to disrupt the internal tide. However, while in situ observations showed the presence of PSI, it was not found to be appreciable. One reason for the discrepancy between simulations and observations is that the former examined an internal mode in uniformly stratified fluid whereas, in reality, the internal tide exists in non-uniform stratification and is manifest as sinusoidal oscillations of the thermocline. Through theory supported by numerical simulations, it is shown that internal modes in non-uniform stratification immediately excite superharmonics, not subharmonic disturbances. These have double the horizontal wavenumber and double the frequency of the parent mode and hence move with the same horizontal phase speed of the parent mode. As the disturbances grow in amplitude, however, they interact with the parent mode generating small-scale vertically propagating internal waves within the strongly stratified layer. The occurrence of PSI over very long times can occur, as in the simulations of Hazewinkel and Winters (JPO 2011). However, a comprehensive understanding of the energy cascade from the internal tide to small scales must consider the evolution of excited superharmonic disturbances.

  7. Investigations of contaminated fluvial sediment deposits: merging of statistical and geomorphic approaches.

    Science.gov (United States)

    Ryti, Randall T; Reneau, Steven L; Katzman, Danny

    2005-05-01

    Concentrations of contaminants in sediment deposits can have large spatial variability resulting from geomorphic processes acting over long time periods. Thus, systematic (e.g., regularly spaced sample locations) or random sampling approaches might be inefficient and/or lead to highly biased results. We demonstrate the bias associated with systematic sampling and compare these results to those achieved by methods that merge a geomorphic approach to evaluating the physical system and stratified random sampling concepts. By combining these approaches, we achieve a more efficient and less biased characterization of sediment contamination in fluvial systems. These methods are applied using a phased sampling approach to characterize radiological contamination in sediment deposits in two semiarid canyons that have received historical releases from the Los Alamos National Laboratory. Uncertainty in contaminant inventory was used as a metric to evaluate the adequacy of sampling during these phased investigations. Simple, one-dimensional Monte Carlo simulations were used to estimate uncertainty in contaminant inventory. We also show how one can use stratified random sampling theory to help estimate uncertainty in mean contaminant concentrations.

  8. Traditional, complementary, and alternative medicine approaches to mental health care and psychological wellbeing in India and China.

    Science.gov (United States)

    Thirthalli, Jagadisha; Zhou, Liang; Kumar, Kishore; Gao, Jie; Vaid, Henna; Liu, Huiming; Hankey, Alex; Wang, Guojun; Gangadhar, Bangalore N; Nie, Jing-Bao; Nichter, Mark

    2016-07-01

    India and China face the same challenge of having too few trained psychiatric personnel to manage effectively the substantial burden of mental illness within their population. At the same time, both countries have many practitioners of traditional, complementary, and alternative medicine who are a potential resource for delivery of mental health care. In our paper, part of The Lancet and Lancet Psychiatry's Series about the China-India Mental Health Alliance, we describe and compare types of traditional, complementary, and alternative medicine in India and China. Further, we provide a systematic overview of evidence assessing the effectiveness of these alternative approaches for mental illness and discuss challenges in research. We suggest how practitioners of traditional, complementary, and alternative medicine and mental health professionals might forge collaborative relationships to provide more accessible, affordable, and acceptable mental health care in India and China. A substantial proportion of individuals with mental illness use traditional, complementary, and alternative medicine, either exclusively or with biomedicine, for reasons ranging from faith and cultural congruence to accessibility, cost, and belief that these approaches are safe. Systematic reviews of the effectiveness of traditional, complementary, and alternative medicine find several approaches to be promising for treatment of mental illness, but most clinical trials included in these systematic reviews have methodological limitations. Contemporary methods to establish efficacy and safety-typically through randomised controlled trials-need to be complemented by other means. The community of practice built on collaborative relationships between practitioners of traditional, complementary, and alternative medicine and providers of mental health care holds promise in bridging the treatment gap in mental health care in India and China. Copyright © 2016 Elsevier Ltd. All rights reserved.

  9. Visualization periodic flows in a continuously stratified fluid.

    Science.gov (United States)

    Bardakov, R.; Vasiliev, A.

    2012-04-01

    To visualize the flow pattern of viscous continuously stratified fluid both experimental and computational methods were developed. Computational procedures were based on exact solutions of set of the fundamental equations. Solutions of the problems of flows producing by periodically oscillating disk (linear and torsion oscillations) were visualized with a high resolutions to distinguish small-scale the singular components on the background of strong internal waves. Numerical algorithm of visualization allows to represent both the scalar and vector fields, such as velocity, density, pressure, vorticity, stream function. The size of the source, buoyancy and oscillation frequency, kinematic viscosity of the medium effects were traced in 2D an 3D posing problems. Precision schlieren instrument was used to visualize the flow pattern produced by linear and torsion oscillations of strip and disk in a continuously stratified fluid. Uniform stratification was created by the continuous displacement method. The buoyancy period ranged from 7.5 to 14 s. In the experiments disks with diameters from 9 to 30 cm and a thickness of 1 mm to 10 mm were used. Different schlieren methods that are conventional vertical slit - Foucault knife, vertical slit - filament (Maksoutov's method) and horizontal slit - horizontal grating (natural "rainbow" schlieren method) help to produce supplementing flow patterns. Both internal wave beams and fine flow components were visualized in vicinity and far from the source. Intensity of high gradient envelopes increased proportionally the amplitude of the source. In domains of envelopes convergence isolated small scale vortices and extended mushroom like jets were formed. Experiments have shown that in the case of torsion oscillations pattern of currents is more complicated than in case of forced linear oscillations. Comparison with known theoretical model shows that nonlinear interactions between the regular and singular flow components must be taken

  10. Investigations on flow reversal in stratified horizontal flow

    International Nuclear Information System (INIS)

    Staebler, T.; Meyer, L.; Schulenberg, T.; Laurien, E.

    2005-01-01

    The phenomena of flow reversal in stratified flows are investigated in a horizontal channel with application to the Emergency Core Cooling System (ECCS) in Pressurized Water Reactors (PWR). In case of a Loss-of-Coolant-Accident (LOCA), coolant can be injected through a secondary pipe within the feeding line of the primary circuit, the so called hot leg, counter-currently to the steam flow. It is essential that the coolant reaches the reactor core to prevent overheating. Due to high temperatures in such accident scenarios, steam is generated in the core, which escapes from the reactor vessel through the hot leg. In case of sufficiently high steam flow rates, only a reduced amount of coolant or even no coolant will be delivered to the reactor core. The WENKA test facility at the Institute for Nuclear and Energy Technologies (IKET) at Forschungszentrum Karlsruhe is capable to investigate the fluid dynamics of two-phase flows in such scenarios. Water and air flow counter-currently in a horizontal channel made of clear acrylic glass to allow full optical access. Flow rates of water and air can be varied independently within a wide range. Once flow reversal sets in, a strong hysteresis effect must be taken into account. This was quantified during the present investigations. Local experimental data are needed to expand appropriate models on flow reversal in horizontal two-phase flow and to include them into numerical codes. Investigations are carried out by means of Particle Image Velocimetry (PIV) to obtain local flow velocities without disturbing the flow. Due to the wavy character of the flow, strong reflections at the interfacial area must be taken into account. Using fluorescent particles and an optical filter allows eliminating the reflections and recording only the signals of the particles. The challenges in conducting local investigations in stratified wavy flows by applying optical measurement techniques are discussed. Results are presented and discussed allowing

  11. Experimental investigation and CFD simulation of horizontal stratified two-phase flow phenomena

    International Nuclear Information System (INIS)

    Vallee, Christophe; Hoehne, Thomas; Prasser, Horst-Michael; Suehnel, Tobias

    2008-01-01

    For the investigation of stratified two-phase flow, two horizontal channels with rectangular cross-section were built at Forschungszentrum Dresden-Rossendorf (FZD). The channels allow the investigation of air/water co-current flows, especially the slug behaviour, at atmospheric pressure and room temperature. The test-sections are made of acrylic glass, so that optical techniques, like high-speed video observation or particle image velocimetry (PIV), can be applied for measurements. The rectangular cross-section was chosen to provide better observation possibilities. Moreover, dynamic pressure measurements were performed and synchronised with the high-speed camera system. CFD post-test simulations of stratified flows were performed using the code ANSYS CFX. The Euler-Euler two fluid model with the free surface option was applied on grids of minimum 4 x 10 5 control volumes. The turbulence was modelled separately for each phase using the k-ω-based shear stress transport (SST) turbulence model. The results compare very well in terms of slug formation, velocity, and breaking. The qualitative agreement between calculation and experiment is encouraging and shows that CFD can be a useful tool in studying horizontal two-phase flow

  12. Experimental investigation and CFD simulation of horizontal stratified two-phase flow phenomena

    International Nuclear Information System (INIS)

    Vallee, Christophe; Hohne, Thomas; Prasser, Horst-Michael; Suhnel, Tobias

    2007-01-01

    For the investigation of stratified two-phase flow, two horizontal channels with rectangular cross-section were built at Forschungszentrum Rossendorf. The channels allow the investigation of air/water co-current flows, especially the slug behaviour, at atmospheric pressure and room temperature. The test-sections are made of acrylic glass, so that optical techniques, like high-speed video observation or particle image velocimetry (PIV), can be applied for measurements. The rectangular cross-section was chosen to provide better observation possibilities. Moreover, dynamic pressure measurements were performed and synchronized with the high-speed camera system. CFD post test simulations of stratified flows were performed using the code ANSYS CFX. The Euler- Euler two fluid model with the free surface option was applied on grids of minimum 4.10 5 control volumes. The turbulence was modelled separately for each phase using the k-ω based shear stress transport (SST) turbulence model. The results compare very well in terms of slug formation, velocity, and breaking. The qualitative agreement between calculation and experiment is encouraging and shows that CFD can be a useful tool in studying horizontal two-phase flow. (authors)

  13. Experimental investigation and CFD simulation of horizontal stratified two-phase flow phenomena

    Energy Technology Data Exchange (ETDEWEB)

    Vallee, Christophe [Forschungszentrum Dresden-Rossendorf e.V., Dresden (Germany)], E-mail: c.vallee@fzd.de; Hoehne, Thomas; Prasser, Horst-Michael; Suehnel, Tobias [Forschungszentrum Dresden-Rossendorf e.V., Dresden (Germany)

    2008-03-15

    For the investigation of stratified two-phase flow, two horizontal channels with rectangular cross-section were built at Forschungszentrum Dresden-Rossendorf (FZD). The channels allow the investigation of air/water co-current flows, especially the slug behaviour, at atmospheric pressure and room temperature. The test-sections are made of acrylic glass, so that optical techniques, like high-speed video observation or particle image velocimetry (PIV), can be applied for measurements. The rectangular cross-section was chosen to provide better observation possibilities. Moreover, dynamic pressure measurements were performed and synchronised with the high-speed camera system. CFD post-test simulations of stratified flows were performed using the code ANSYS CFX. The Euler-Euler two fluid model with the free surface option was applied on grids of minimum 4 x 10{sup 5} control volumes. The turbulence was modelled separately for each phase using the k-{omega}-based shear stress transport (SST) turbulence model. The results compare very well in terms of slug formation, velocity, and breaking. The qualitative agreement between calculation and experiment is encouraging and shows that CFD can be a useful tool in studying horizontal two-phase flow.

  14. Improving coverage of postnatal care in rural Ethiopia using a community-based, collaborative quality improvement approach.

    Science.gov (United States)

    Tesfaye, Solomon; Barry, Danika; Gobezayehu, Abebe Gebremariam; Frew, Aynalem Hailemichael; Stover, Kim Ethier; Tessema, Hana; Alamineh, Lamesgin; Sibley, Lynn M

    2014-01-01

    Ethiopia has high maternal and neonatal mortality and low use of skilled maternity care. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP), a 3.5-year learning project, used a community collaborative quality improvement approach to improve maternal and newborn health care during the birth-to-48-hour period. This study examines how the promotion of community maternal and newborn health (CMNH) family meetings and labor and birth notification contributed to increased postnatal care within 48 hours by skilled providers or health extension workers. Baseline and endline surveys, monthly quality improvement data, and MaNHEP's CMNH change package, a compendium of the most effective changes developed and tested by communities, were reviewed. Logistic regression assessed factors associated with postnatal care receipt. Monthly postnatal care receipt was plotted with control charts. The baseline (n = 1027) and endline (n = 1019) surveys showed significant increases in postnatal care, from 5% to 51% and from 15% to 47% in the Amhara and Oromiya regions, respectively (both P care. Women with any antenatal care were 1.7 times more likely to have had a postnatal care visit (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.10-2.54; P care (OR, 4.86; 95% CI, 2.67-8.86; P care far exceeds the 7% postnatal care coverage rate reported in the 2011 Ethiopian Demographic and Health Survey (EDHS). This result was linked to ideas generated by community quality improvement teams for labor and birth notification and cooperation with community-level health workers to promote antenatal care and CMNH family meetings. © 2014 by the American College of Nurse-Midwives.

  15. Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

    OpenAIRE

    Vos, J.B.M.; Cramm, Jane; Wijngaarden, Jeroen; Bakker, Ton; Mackenbach, Johan; Nieboer, Anna

    2017-01-01

    Summary Background The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital‐related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depressio...

  16. Improved patient selection by stratified surgical intervention

    DEFF Research Database (Denmark)

    Wang, Miao; Bünger, Cody E; Li, Haisheng

    2015-01-01

    BACKGROUND CONTEXT: Choosing the best surgical treatment for patients with spinal metastases remains a significant challenge for spine surgeons. There is currently no gold standard for surgical treatments. The Aarhus Spinal Metastases Algorithm (ASMA) was established to help surgeons choose...... the most appropriate surgical intervention for patients with spinal metastases. PURPOSE: The purpose of this study was to evaluate the clinical outcome of stratified surgical interventions based on the ASMA, which combines life expectancy and the anatomical classification of patients with spinal metastases...... survival times in the five surgical groups determined by the ASMA were 2.1 (TS 0-4, TC 1-7), 5.1 (TS 5-8, TC 1-7), 12.1 (TS 9-11, TC 1-7 or TS 12-15, TC 7), 26.0 (TS 12-15, TC 4-6), and 36.0 (TS 12-15, TC 1-3) months. The 30-day mortality rate was 7.5%. Postoperative neurological function was maintained...

  17. Experimental study of unsteady thermally stratified flow

    International Nuclear Information System (INIS)

    Lee, Sang Jun; Chung, Myung Kyoon

    1985-01-01

    Unsteady thermally stratified flow caused by two-dimensional surface discharge of warm water into a oblong channel was investigated. Experimental study was focused on the rapidly developing thermal diffusion at small Richardson number. The basic objectives were to study the interfacial mixing between a flowing layer of warm water and an underlying body of cold water and to accumulate experimental data to test computational turbulence models. Mean velocity field measurements were carried out by using NMR-CT(Nuclear Magnetic Resonance-Computerized Tomography). It detects quantitative flow image of any desired section in any direction of flow in short time. Results show that at small Richardson number warm layer rapidly penetrates into the cold layer because of strong turbulent mixing and instability between the two layers. It is found that the transfer of heat across the interface is more vigorous than that of momentum. It is also proved that the NMR-CT technique is a very valuable tool to measure unsteady three dimensional flow field. (Author)

  18. Education and patient preferences for treating type 2 diabetes: a stratified discrete-choice experiment

    Directory of Open Access Journals (Sweden)

    Janssen EM

    2017-10-01

    of preference heterogeneity for use in patient-centered benefit–risk assessments and personalized care approaches. Keywords: preference heterogeneity, stated-preference methods, preference heterogeneity, willingness-to-pay, choice experiment, educational attainment

  19. Hydromagnetic stability of rotating stratified compressible fluid flows

    Energy Technology Data Exchange (ETDEWEB)

    Srinivasan, V; Kandaswamy, P [Dept. of Mathematics, Bharathiar University, Coimbatore, Tamil Nadu, India; Debnath, L [Dept. of Mathematics, University of Central Florida, Orlando, USA

    1984-09-01

    The hydromagnetic stability of a radially stratified compressible fluid rotating between two coaxial cylinders is investigated. The stability with respect to axisymmetric disturbances is examined. The fluid system is found to be thoroughly stable to axisymmetric disturbances provided the fluid rotates very rapidly. The system is shown to be unstable to non-axisymmetric disturbances, and the slow amplifying hydromagnetic wave modes propagate against the basic rotation. The lower and upper bounds of the azimuthal phase speeds of the amplifying waves are determined. A quadrant theorem on the slow waves characteristic of a rapidly rotating fluid is derived. Special attention is given to the effects of compressibility of the fluid. Some results concerning the stability of an incompressible fluid system are obtained as special cases of the present analysis.

  20. Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial.

    Science.gov (United States)

    Rowley, M J; Hensley, M J; Brinsmead, M W; Wlodarczyk, J H

    1995-09-18

    To compare continuity of care from a midwife team with routine care from a variety of doctors and midwives. A stratified, randomised controlled trial. 814 women attending the antenatal clinic of a tertiary referral, university hospital. Women were randomly allocated to team care from a team of six midwives, or routine care from a variety of doctors and midwives. Antenatal, intrapartum and neonatal events; maternal satisfaction; and cost of treatment. 405 women were randomly allocated to team care and 409 to routine care; they delivered 385 and 386 babies, respectively. Team care women were more likely to attend antenatal classes (OR, 1.73; 95% CI, 1.23-2.42); less likely to use pethidine during labour (OR, 0.32; 95% CI, 0.22-0.46); and more likely to labour and deliver without intervention (OR, 1.73; 95% CI, 1.28-2.34). Babies of team care mothers received less neonatal resuscitation (OR, 0.59; 95% CI, 0.41-0.86), although there was no difference in Apgar scores at five minutes (OR, 0.86; 95% CI, 0.29-2.57). The stillbirth and neonatal death rate was the same for both groups of mothers with a singleton pregnancy (three deaths), but there were three deaths (birthweights of 600 g, 660 g, 1340 g) in twin pregnancies in the group receiving team care. Team care was rated better than routine care for all measures of maternal satisfaction. Team care meant a cost reduction of 4.5%. Continuity of care provided by a small team of midwives resulted in a more satisfying birth experience at less cost than routine care and fewer adverse maternal and neonatal outcomes. Although a much larger study would be required to provide adequate power to detect rare outcomes, our study found that continuity of care by a midwife team was as safe as routine care.

  1. [Ineffective sexuality pattern in an adolescent: nursing approach in primary health care].

    Science.gov (United States)

    Martín-García, Angel; Oter-Quintana, Cristina; Brito-Brito, Pedro Ruymán; Martín-Iglesias, Susana; Alcolea-Cosín, M Teresa

    2013-01-01

    Adolescent is a phase of continual physiological, psychological and social adaptation. It is during this time that young people tend to have their first sexual experiences. Sexual dysfunctions are characterized by important clinical changes in sexual desire and/or by psycho-physiological changes in the sexual response cycle. Premature ejaculation is one of the most frequent sexual dysfunction amongst men, with a higher prevalence in the younger population compared to other populations. The clinical case is presented of a 17 year-old male who experienced difficulties during his sexual relations. It is discussed whether his condition was a sexual dysfunction or ineffective sexual pattern. The care plan which was developed in nursing consultation was described for ineffective sexual pattern; the pending nursing treatment incorporated activities recommended by scientific evidence. Finally, the role of primary health care nursing professionals is pointed out in the detection and approach of sexual problems in adolescents. Copyright © 2013 Elsevier España, S.L. All rights reserved.

  2. Analysis of natural convection heat transfer and flows in internally heated stratified liquid pools

    International Nuclear Information System (INIS)

    Gubaidullin, A.A. Jr.; Dinh, T.N.; Sehgal, B.R.

    1999-01-01

    In this paper, natural convection flows and heat transfer in a liquid pool, with two superposed immiscible fluid layers, are analyzed. The objective of the study is to examine the effect of interfacial hydrodynamics and to develop a method which enables energy splitting to be evaluated in a stratified liquid pool. The thermal convection, with and without an internal heat source, in a rectangular cavity with different pairs of fluids was numerically simulated by a CFD code FLOW-3D. It was found that the code performs very well for prediction of heat transfer coefficients for different conditions. The hydrodynamic coupling between immiscible layers was found to have minor, if any, impact on the natural convection heat transfer for the conditions examined. Calculated results were used to develop, and validate, a new correlation for energy splitting and for heat transfer in stratified liquid pools

  3. Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management.

    Science.gov (United States)

    Jump, Robin L P; Crnich, Christopher J; Mody, Lona; Bradley, Suzanne F; Nicolle, Lindsay E; Yoshikawa, Thomas T

    2018-04-01

    The diagnosis, treatment, and prevention of infectious diseases in older adults in long-term care facilities (LTCFs), particularly nursing facilities, remains a challenge for all health providers who care for this population. This review provides updated information on the currently most important challenges of infectious diseases in LTCFs. With the increasing prescribing of antibiotics in older adults, particularly in LTCFs, the topic of antibiotic stewardship is presented in this review. Following this discussion, salient points on clinical relevance, clinical presentation, diagnostic approach, therapy, and prevention are discussed for skin and soft tissue infections, infectious diarrhea (Clostridium difficile and norovirus infections), bacterial pneumonia, and urinary tract infection, as well as some of the newer approaches to preventive interventions in the LTCF setting. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

  4. Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care.

    Science.gov (United States)

    Lloyd, Helen M; Pearson, Mark; Sheaff, Rod; Asthana, Sheena; Wheat, Hannah; Sugavanam, Thava Priya; Britten, Nicky; Valderas, Jose; Bainbridge, Michael; Witts, Louise; Westlake, Debra; Horrell, Jane; Byng, Richard

    2017-11-22

    Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable 'blue print' mean that services are 'experimenting' with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings. Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations. Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the

  5. Anybody Hear Us? Attempting to Meet the Psychological Care Needs of Older People: an Ethnographic Approach

    Directory of Open Access Journals (Sweden)

    Seyed Zia Tabatabaei

    2016-07-01

    Full Text Available Older people who live in residential settings need some psychological support because of vicissitudes of life they faced with. The aim of this study is to explore psychological care needs of older people in a residential home. We used an ethnographic approach from May 2011 till January 2012. Through purposeful sampling, 14 knowledgeable participants were selected. Data were gathered from participant observations, in-depth interviews, review of related documents and field notes. Thematic analysis revealed three key themes including: (a Feelings of sadness (b Emotional desires and (c Choice and control. Findings of current study provided rich and useful information that is useful in charting new guideline for policy makers and care providers in order to support elderly residents' psychological care needs.

  6. Advanced liquid-cooled, turbocharged and intercooled stratified charge rotary engines for aircraft

    Science.gov (United States)

    Mount, Robert E.; Bartel, John; Hady, William F.

    1987-01-01

    Developments concerning stratified-charge rotary (SCR) engines over the past 10 years are reviewed. Aircraft engines being developed using SCR technology are shown and described, and the ability of such technology to meet general aviation engine needs is considered. Production timing and availability of SCR technology for the development of aviation rotary engines are discussed, and continuing efforts toward improving this technology, including NASA efforts, are described.

  7. Integration of naturopathic medicine into acute inpatient care: An approach for patient-centred medicine under diagnosis-related groups.

    Science.gov (United States)

    Romeyke, Tobias; Nöhammer, Elisabeth; Scheuer, Hans Christoph; Stummer, Harald

    2017-08-01

    The integration of naturopathic methods into acute inpatient care has been the subject of very few scientific studies. Patient expectations of the service received in hospital are increasing, and the integration of naturopathy into clinical practice can serve as Unique Selling Proposition. The present study was conducted over a period of two years. In total, over 1700 patients were included in the study. The setting is an acute hospital specialising in a multimodal, patient-centred approach to treatment. Patient satisfaction with the use of holistic care, patient perception of adherence to treatment and the amount of time care staff spend with patients were all investigated. The patients' principal diagnoses were also recorded using the DRG classification system, as were the number of concomitant diseases and the length of their stay in hospital. The majority of patients rate the integration of complementary care in the acute hospital very positively. The effects on patient perception of adherence to treatment and the amount of time care staff spend with patients are also assessed positively. At the same time, we can see that patients who receive patient-centred care in this study predominantly suffer from diseases and disorders of the musculoskeletal system and connective tissue, diseases of the nervous system and mental diseases and disorders. They also have numerous concomitant diseases. It could be shown that patients are very satisfied with the combination of naturopathy and academic medicine and with approaches that take patient preferences into account. Integrating naturopathy can be considered for multimorbid patients, in particular. Moreover, patient-centred care can improve staff satisfaction levels. Copyright © 2017 Elsevier Ltd. All rights reserved.

  8. Association Between Number of Preventive Care Guidelines and Preventive Care Utilization by Patients.

    Science.gov (United States)

    Taksler, Glen B; Pfoh, Elizabeth R; Stange, Kurt C; Rothberg, Michael B

    2018-05-08

    The number of preventive care guidelines is rapidly increasing. It is unknown whether the number of guideline-recommended preventive services is associated with utilization. The authors used Poisson regression of 390,778 person-years of electronic medical records data from 2008 to 2015, in 80,773 individuals aged 50-75 years. Analyses considered eligibility for 11 preventive services most closely associated with guidelines: tobacco cessation; control of obesity, hypertension, lipids, or blood glucose; influenza vaccination; and screening for breast, cervical, or colorectal cancers, abdominal aortic aneurysm, or osteoporosis. The outcome was the rate of preventive care utilization over the following year. Results were adjusted for demographics and stratified by the number of disease risk factors (smoking, obesity, hypertension, hyperlipidemia, diabetes). Data were collected in 2016 and analyzed in 2017. Preventive care utilization was lower when the number of guideline-recommended preventive services was higher. The adjusted rate of preventive care utilization decreased from 38.67 per 100 (95% CI=38.16, 39.18) in patients eligible for one guideline-recommended service to 31.59 per 100 (95% CI=31.29, 31.89) in patients eligible for two services and 25.43 per 100 (95% CI=24.68, 26.18) in patients eligible for six or more services (p-trendvalue services. Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

  9. Know Your Client and Know Your Team: A Complexity Inspired Approach to Understanding Safe Transitions in Care

    Directory of Open Access Journals (Sweden)

    Deborah Tregunno

    2013-01-01

    Full Text Available Background. Transitions in care are one of the most important and challenging client safety issues in healthcare. This project was undertaken to gain insight into the practice setting realities for nurses and other health care providers as they manage increasingly complex care transitions across multiple settings. Methods. The Appreciative Inquiry approach was used to guide interviews with sixty-six healthcare providers from a variety of practice settings. Data was collected on participants’ experience of exceptional care transitions and opportunities for improving care transitions. Results. Nurses and other healthcare providers need to know three things to ensure safe care transitions: (1 know your client; (2 know your team on both sides of the transfer; and (3 know the resources your client needs and how to get them. Three themes describe successful care transitions, including flexible structures; independence and teamwork; and client and provider focus. Conclusion. Nurses often operate at the margins of acceptable performance, and flexibility with regulation and standards is often required in complex sociotechnical work like care transitions. Priority needs to be given to creating conditions where nurses and other healthcare providers are free to creatively engage and respond in ways that will optimize safe care transitions.

  10. Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline

    Directory of Open Access Journals (Sweden)

    Silvina Arrossi

    2017-10-01

    Full Text Available Purpose: To provide resource-stratified (four tiers, evidence-based recommendations on the primary prevention of cervical cancer globally. Methods: The American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group for one round of formal ratings. Results: Existing sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%. Recommendations: In all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus–related cancers and diseases. Basic settings: vaccinating boys is not recommended

  11. Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline.

    Science.gov (United States)

    Arrossi, Silvina; Temin, Sarah; Garland, Suzanne; Eckert, Linda O'Neal; Bhatla, Neerja; Castellsagué, Xavier; Alkaff, Sharifa Ezat; Felder, Tamika; Hammouda, Doudja; Konno, Ryo; Lopes, Gilberto; Mugisha, Emmanuel; Murillo, Rául; Scarinci, Isabel C; Stanley, Margaret; Tsu, Vivien; Wheeler, Cosette M; Adewole, Isaac Folorunso; de Sanjosé, Silvia

    2017-10-01

    To provide resource-stratified (four tiers), evidence-based recommendations on the primary prevention of cervical cancer globally. The American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group) for one round of formal ratings. Existing sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%. In all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus-related cancers and diseases. Basic settings: vaccinating boys is not recommended. It is the view of the American Society of Clinical Oncology that

  12. An extension of theoretical analysis for the onset of slugging criterion in horizontal stratified air-water countercurrent flow

    International Nuclear Information System (INIS)

    Lee, Byung Ryung

    1997-02-01

    This paper presents an experimental and theoretical investigation of interfacial friction factor, wave height and transition criterion from wavy to slug flow in a long horizontal air-water countercurrent stratified flow condition. A series of experiments have been conducted in adiabatic countercurrent stratified flow with the round pipe and rectangular duct test section to develop the interfacial friction factor and the criterion of onset of slugging in horizontal air-water countercurrent stratified flow. An adiabatic semi-empirical correlation for interfacial friction factor has been developed based on the surface roughness concept. A comparison of the measured data in this study and of other investigators with the predictions of the present correlation shows that the agreement is within ±30% error, and that the present correlation is applicable to a broader range of water flow rate than the correlations of previous investigators. The theories which can calculate the wave height and criteria of onset of slug flow in a stratified wavy flow regime have been developed based on the concept of total energy conservation and also wave theory. This theoretical criteria agree better with the measured data than the other criteria available in the literature, but the criteria range about 92∼107% of the measured data. An empirical formula for the criterion has been also developed and compared with the formula in the literatures. Comparison between the measured data and the predictions of the present theory shows that the agreement is within ±8%

  13. Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

    Science.gov (United States)

    Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A

    2016-03-22

    Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of

  14. A chemically defined culture medium containing Rho kinase inhibitor Y-27632 for the fabrication of stratified squamous epithelial cell grafts

    International Nuclear Information System (INIS)

    Aslanova, Afag; Takagi, Ryo; Yamato, Masayuki; Okano, Teruo; Yamamoto, Masakazu

    2015-01-01

    With the development of a culture method for stratified squamous epithelial cells, tissue-engineered epithelial cell sheets have been successfully applied as clinical cell grafts. However, the implementation of these cell sheets without the use of any animal-derived materials is highly desirable. In this study, Rho-associated protein kinase inhibitor Y-27632 was used to develop a chemically defined culture medium for the fabrication of stratified epithelial cell grafts consisting of human epidermal and oral keratinocytes, and the proliferation activity, cell morphology, and gene expressions of the keratinocytes were analyzed. The results of a colorimetric assay indicated that Y-27632 significantly promoted the proliferation of the keratinocytes in culture media both with and without fetal bovine serum (FBS), although there were no indications of Y-27632 efficacy on cell morphology and stratification of the keratinocytes in culture medium without any animal-derived materials. The results of quantitative RT-PCR revealed that gene expressions correlated with cell adhesion, cell–cell junction, proliferation markers, and stem/progenitor markers in cultured keratinocytes were not strongly affected by the addition of Y-27632 to the culture medium. Moreover, gene expressions of differentiation markers in stratified keratinocytes cultured in medium without FBS were nearly identical to those of keratinocytes co-cultured with 3T3 feeder cells. Interestingly, the expressions of differentiation markers in cultured stratified keratinocytes were suppressed by FBS, whereas they were reconstructed by either co-culture of a 3T3 feeder layer or addition of Y-27632 into the culture medium containing FBS. These findings indicate that Y-27632 is a useful supplement for the development of a chemically defined culture medium for fabrication of stratified epithelial cell grafts for clinical applications for the purpose of developing the culture medium with a lower risk of pathogen

  15. A chemically defined culture medium containing Rho kinase inhibitor Y-27632 for the fabrication of stratified squamous epithelial cell grafts

    Energy Technology Data Exchange (ETDEWEB)

    Aslanova, Afag [Department of Surgery, Institute of Gastroenterology, Tokyo Women' s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 (Japan); Institute of Advanced Biomedical Engineering and Science, Tokyo Women' s Medical University, TWIns, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 (Japan); Takagi, Ryo; Yamato, Masayuki; Okano, Teruo [Institute of Advanced Biomedical Engineering and Science, Tokyo Women' s Medical University, TWIns, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 (Japan); Yamamoto, Masakazu, E-mail: yamamoto.ige@twmu.ac.jp [Department of Surgery, Institute of Gastroenterology, Tokyo Women' s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 (Japan)

    2015-05-01

    With the development of a culture method for stratified squamous epithelial cells, tissue-engineered epithelial cell sheets have been successfully applied as clinical cell grafts. However, the implementation of these cell sheets without the use of any animal-derived materials is highly desirable. In this study, Rho-associated protein kinase inhibitor Y-27632 was used to develop a chemically defined culture medium for the fabrication of stratified epithelial cell grafts consisting of human epidermal and oral keratinocytes, and the proliferation activity, cell morphology, and gene expressions of the keratinocytes were analyzed. The results of a colorimetric assay indicated that Y-27632 significantly promoted the proliferation of the keratinocytes in culture media both with and without fetal bovine serum (FBS), although there were no indications of Y-27632 efficacy on cell morphology and stratification of the keratinocytes in culture medium without any animal-derived materials. The results of quantitative RT-PCR revealed that gene expressions correlated with cell adhesion, cell–cell junction, proliferation markers, and stem/progenitor markers in cultured keratinocytes were not strongly affected by the addition of Y-27632 to the culture medium. Moreover, gene expressions of differentiation markers in stratified keratinocytes cultured in medium without FBS were nearly identical to those of keratinocytes co-cultured with 3T3 feeder cells. Interestingly, the expressions of differentiation markers in cultured stratified keratinocytes were suppressed by FBS, whereas they were reconstructed by either co-culture of a 3T3 feeder layer or addition of Y-27632 into the culture medium containing FBS. These findings indicate that Y-27632 is a useful supplement for the development of a chemically defined culture medium for fabrication of stratified epithelial cell grafts for clinical applications for the purpose of developing the culture medium with a lower risk of pathogen

  16. A Participatory Design Approach to Develop a Web-Based Self-Care Program Supporting Early Rehabilitation among Patients after Total Laryngectomy.

    Science.gov (United States)

    Cnossen, Ingrid C; van Uden-Kraan, Cornelia F; Eerenstein, Simone E J; Rinkel, Rico N P M; Aalders, Ijke J; van den Berg, Klaske; de Goede, Cees J T; van Stijgeren, Ans J; Cruijff-Bijl, Yvonne; de Bree, Remco; Leemans, C René; Verdonck-de Leeuw, Irma M

    2015-01-01

    To develop a Web-based self-care program for patients after total laryngectomy according to a participatory design approach. We conducted a needs assessment with laryngectomees (n = 9) and their partners (n = 3) by means of a focus group interview. In 4 focus group sessions, a requirement plan was formulated by a team of health care professionals (n = 10) and translated into a prototype. An e-health application was built including illustrated information on functional changes after total laryngectomy as well as video demonstrations of skills and exercises. Usability of the prototype was tested by end users (n = 4) and expert users (n = 10). Interviews were held to elicit the intention to use and the desired implementation strategy. Six main self-care topics were identified: (1) nutrition, (2) tracheostomy care, (3) voice prosthesis care, (4) speech rehabilitation, (5) smell rehabilitation, and (6) mobility of head, neck, and shoulder muscles. Expert users expressed concerns regarding tailored exercises, indicated a positive intent to implement the intervention in routine care, and expressed a need for guidance when implementing the intervention. End users and expert users appreciated the content completeness and multimedia-based information built into the application. The participatory design is a valuable approach to develop a self-care program to help meet users' needs. © 2016 S. Karger AG, Basel.

  17. Physician Approaches to Conflict with Families Surrounding End-of-Life Decision-making in the Intensive Care Unit. A Qualitative Study.

    Science.gov (United States)

    Mehter, Hashim M; McCannon, Jessica B; Clark, Jack A; Wiener, Renda Soylemez

    2018-02-01

    Families of critically ill patients are often asked to make difficult decisions to pursue, withhold, or withdraw aggressive care or resuscitative measures, exercising "substituted judgment" from the imagined standpoint of the patient. Conflict may arise between intensive care unit (ICU) physicians and family members regarding the optimal course of care. To characterize how ICU physicians approach and manage conflict with surrogates regarding end-of-life decision-making. Semistructured interviews were conducted with 18 critical care physicians from four academically affiliated hospitals. Interview transcripts were analyzed using methods of grounded theory. Physicians described strategies for engaging families to resolve conflict about end-of-life decision-making and tending to families' emotional health. Physicians commonly began by gauging family receptiveness to recommendations from the healthcare team. When faced with resistance to recommendations for less aggressive care, approaches ranged from deference to family wishes to various persuasive strategies designed to change families' minds, and some of those strategies may be counterproductive or harmful. The likelihood of deferring to family in the event of conflict was associated with the perceived sincerity of the family's "substituted judgment" and the ability to control patient pain and suffering. Physicians reported concern for the family's emotional needs and made efforts to alleviate the burden on families by assuming decision-making responsibility and expressing nonabandonment and commitment to the patient. Physicians were attentive to repairing damage to their relationship with the family in the aftermath of conflict. Finally, physicians described their own emotional responses to conflict, ranging from frustration and anxiety to satisfaction with successful resolution of conflict. Critical care physicians described a complex and multilayered approach to physician-family conflict. The reported strategies

  18. Teaching differential diagnosis in primary care using an inverted classroom approach: student satisfaction and gain in skills and knowledge.

    Science.gov (United States)

    Bösner, Stefan; Pickert, Julia; Stibane, Tina

    2015-04-01

    Differential diagnosis is a crucial skill for primary care physicians. General practice plays an increasing important role in undergraduate medical education. Via general practice, students may be presented with an overview of the whole spectrum of differential diagnosis in regard to common symptoms encountered in primary care. This project evaluated the impact of a blended learning program (using the inverted classroom approach) on student satisfaction and development of skills and knowledge. An elective seminar in differential diagnosis in primary care, which utilized an inverted classroom design, was offered to students. Evaluation followed a mixed methods design: participants completed a pre- and post-test, a questionnaire, and a focus group discussion. Interviews were transcribed verbatim and answers were grouped according to different themes. Test results were analysed using the Wilcoxon matched-pairs signed-ranks test. Participants (n = 17) rated the course concept very positively. Especially the inverted classroom approach was appreciated by all students, as it allowed for more time during the seminar to concentrate on interactive and practice based learning. Students (n = 16) showed a post-test significant overall gain in skills and knowledge of 33%. This study showed a positive effect of the inverted classroom approach on students' satisfaction and skills and knowledge. Further research is necessary in order to explore the potentials of this approach, especially the impact on development of clinical skills.

  19. A positive deviance approach to understanding key features to improving diabetes care in the medical home

    NARCIS (Netherlands)

    Gabbay, R.A.; Friedberg, M.W.; Miller-Day, M.; Cronholm, P.F.; Adelman, A.; Schneider, E.C.

    2013-01-01

    PURPOSE The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving

  20. Mixing process of a binary gas in a density stratified layer

    Energy Technology Data Exchange (ETDEWEB)

    Takeda, Tetsuaki [Japan Atomic Energy Research Inst., Oarai, Ibaraki (Japan). Oarai Research Establishment

    1997-09-01

    This study is to investigate the effect of natural convection on the mixing process by molecular diffusion in a vertical stratified layer of a binary fluid. There are many experimental and analytical studies on natural convection in the vertical fluid layer. However, there are few studies on natural convection with molecular diffusion in the vertical stratified layer of a binary gas. Experimental study has been performed on the combined phenomena of molecular diffusion and natural convection in a binary gas system to investigate the mixing process of the binary gas in a vertical slot consisting of one side heated and the other side cooled. The range of Rayleigh number based on the slot width was about 0 < Ra{sub d} < 7.5 x 10{sup 4}. The density change of the gas mixture and the temperature distribution in the slot was obtained and the mixing process when the heavier gas ingress into the vertical slot filled with the lighter gas from the bottom side of the slot was discussed. The experimental results showed that the mixing process due to molecular diffusion was affected significantly by the natural convection induced by the slightly temperature difference between both vertical walls even if a density difference by the binary gas is larger than that by the temperature difference. (author). 81 refs.