Joining the dots: Day to day challenges for practitioners in delivering integrated dementia care.

Despite the increasing policy focus on integrated dementia care in the UK, little is known about the opportunities and challenges encountered by practitioners charged with implementing these policies on the ground. We undertook an extensive, mixed-methods analysis of how a contemporary multidisciplinary dementia pathway in the UK was experienced and negotiated by service providers. Our pragmatic mixed methods design incorporated three types of research interaction with practitioners: (a) Semi-structured interviews (n = 31) and focus group discussions (n = 4), (b) Practitioner 'shadowing' observations (n = 19), and (c) Service attendance and performance metrics reviews (n = 8). Through an abductive analysis of practitioner narratives and practice observations, we evidenced how inter-practitioner prejudices, restrictive and competitive commissioning frameworks, barriers to effective data sharing and other resource constraints, all challenged integrative dementia care and led to unintended consequences such as practice overlap and failure to identify and respond to people's needs. In order to more successfully realise integrated dementia pathways, we propose innovative commissioning frameworks which purposefully seek to diffuse power imbalances, encourage inter-provider respect and understanding, and determine clear lines of responsibility.

'In sight, out of mind': the experiences of the compliantly engaged community psychiatric out-patient.

Research on engagement within community-based psychiatric services in the UK has mainly focussed on factors related to those 'at risk' of non-attendance or non-compliance, with the tacit assumption that those in regular attendance are largely content and hence not a priority. The present study systematically explored the experiences and views of 25 people with severe and enduring mental illness who had regularly attended out-patient settings for more than 5 years. Regular attendance at consultations was not synonymous with satisfaction-in fact it masked varying levels of unmet needs and 'de-humanisation'. In order to establish and maintain non-coercive community services that prioritise 'recovery' above illness and 'risk' containment, it is essential that the experiences of people in established and apparently 'less troublesome' therapeutic relationships are also taken into account and integrated into policy and practice.

Phylogeography of a pan-Atlantic abyssal protobranch bivalve: implications for evolution in the Deep Atlantic.

The deep sea is a vast and essentially continuous environment with few obvious barriers to gene flow. How populations diverge and new species form in this remote ecosystem is poorly understood. Phylogeographical analyses have begun to provide some insight into evolutionary processes at bathyal depths (<3000 m), but much less is known about evolution in the more extensive abyssal regions (>3000 m). Here, we quantify geographical and bathymetric patterns of genetic variation (16S rRNA mitochondrial gene) in the protobranch bivalve Ledella ultima, which is one of the most abundant abyssal protobranchs in the Atlantic with a broad bathymetric and geographical distribution. We found virtually no genetic divergence within basins and only modest divergence among eight Atlantic basins. Levels of population divergence among basins were related to geographical distance and were greater in the South Atlantic than in the North Atlantic. Ocean-wide patterns of genetic variation indicate basin-wide divergence that exceeds what others have found for abyssal organisms, but considerably less than bathyal protobranchs across similar geographical scales. Populations on either side of the Mid-Atlantic Ridge in the North Atlantic differed, suggesting the Ridge might impede gene flow at abyssal depths. Our results indicate that abyssal populations might be quite large (cosmopolitan), exhibit only modest genetic structure and probably provide little potential for the formation of new species.

'These psychiatrists rate themselves as gods': disengagement and engagement discourses of people living with severe mental illness.

Positioning analysis, a variant of discourse analysis, was used to explore the narratives of 40 psychiatric patients (11 females and 29 males; mean age = 40 years) who had manifest difficulties with engagement with statutory mental health services. Positioning analysis is a qualitative method that captures how people linguistically position the roles and identities of themselves and others in their day-to-day lives and narratives. The language of disengagement incorporated the passive positioning of self in relation to their lives and treatment through the use of metaphor, the passive voice and them and us attribution, while the discourse of engagement incorporated more active positioning of self achieved through the use of the personal pronoun we and metaphoric references to balanced relationships. The findings corroborate previous thematic analysis that highlighted the importance of identity and agency in the 'making or breaking' of therapeutic relationships (Priebe et al. 2005). Implications are discussed in relation to how positioning analysis may help signal and emphasize important life and therapeutic experiences in spoken narratives as well as clinical consultations.

Analyses of synteny between Arabidopsis thaliana and species in the Asteraceae reveal a complex network of small syntenic segments and major chromosomal rearrangements.

Comparative genomic studies among highly divergent species have been problematic because reduced gene similarities make orthologous gene pairs difficult to identify and because colinearity is expected to be low with greater time since divergence from the last common ancestor. Nevertheless, synteny between divergent taxa in several lineages has been detected over short chromosomal segments. We have examined the level of synteny between the model species Arabidopsis thaliana and species in the Compositae, one of the largest and most diverse plant families. While macrosyntenic patterns covering large segments of the chromosomes are not evident, significant levels of local synteny are detected at a fine scale covering segments of 1-Mb regions of A. thaliana and regions of <5 cM in lettuce and sunflower. These syntenic patches are often not colinear, however, and form a network of regions that have likely evolved by duplications followed by differential gene loss.

Processes of disengagement and engagement in assertive outreach patients: qualitative study.

BACKGROUND: Assertive outreach has been established to care for'difficult to engage' patients, yet little is known about how patients experience their disengagement with mainstream services and later engagement with outreach teams. AIMS: To explore the views of disengagement and engagement held by patients of assertive outreach teams. METHOD: In-depth interviews were conducted with 40 purposefully selected patients and analysed using components of both thematic analysis and grounded theory. RESULTS: Patients reported a desire to be independent, a poor therapeutic relationship and a loss of control due to medication effects as most important for disengagement. Time and commitment of staff, social support and engagement without a focus on medication, and a partnership model of the therapeutic relationship were most relevant for engagement. CONCLUSIONS: The findings underline the importance of a comprehensive care model, committed staff with sufficient time, and a focus on relationship issues in dealing with 'difficult to engage' patients.