Workforce thresholds and the non-linear association between registered nurse staffing and care quality in long-term residential care: A retrospective longitudinal study of English care homes with nursing.

BACKGROUND: Care needs amongst 425,000 dependent older residents in English care homes are becoming more complex. The quality of care in these homes is influenced by staffing levels, especially the presence of registered nurses (RNs). Existing research on this topic, often US-focused and relying on linear assumptions, has limitations. This study aims to investigate the non-linear relationship between RN staffing and care quality in English care homes using machine learning and administrative data from two major care home providers. METHODS: A retrospective observational study was conducted using data from two English care home providers. Each was analysed separately due to variations in data reporting and care processes. Various care quality indicators and staffing metrics were collected for a 3.5-year period. Regression analysis and machine learning (random forest) were employed to identify non-linear relationships. Ethical approval was obtained for the study. RESULTS: Using linear methods, higher skill mix - more care provided by RNs - was associated with lower incidence of adverse outcomes, such as urinary tract infections and hospitalisations. However, non-linear skill mix-outcome relationship modelling revealed both low and high skill mix levels were linked to higher risks. The effects of agency RN usage varied between providers, increasing risks in one but not the other. DISCUSSION: The study highlights the cost implications of increasing RN staffing establishments to improve care quality, suggesting a non-linear relationship and an optimal staffing threshold of around one-quarter of care provided by nurses. Alternative roles, such as care practitioners, merit exploration for meeting care demands whilst maintaining quality. This research underscores the need for a workforce plan for social care in England. It advocates for the incorporation of machine learning models alongside traditional regression-based methods. Our results may have limited generalisability to smaller providers and experimental research to redesign care processes effectively may be needed. CONCLUSION: RNs are crucial for quality in care homes. Contrary to the assumption that higher nurse staffing necessarily leads to better care quality, this study reveals a nuanced, non-linear relationship between RN staffing and care quality in English care homes. It suggests that identifying an optimal staffing threshold, beyond which increasing nursing inputs may not significantly enhance care quality may necessitate reconsidering care system design and (human) resource allocation. Further experimental research is required to elucidate resource-specific thresholds and further strengthen evidence for care home staffing. TWEETABLE ABSTRACT: How much nursing care is needed to assure quality in care homes? Evidence from 2 English care home providers shows that nurse sensitive outcomes (an indicator of quality) are better when ~25 % of care is provided by nurses. Nurse shortages increase risks for residents.

Electrical behaviour and evolutionary computation in thin films of bovine brain microtubules.

We report on the electrical behaviour of thin films of bovine brain microtubules (MTs). For samples in both their dried and hydrated states, the measured currents reveal a power law dependence on the applied DC voltage. We attribute this to the injection of space-charge from the metallic electrode(s). The MTs are thought to form a complex electrical network, which can be manipulated with an applied voltage. This feature has been exploited to undertake some experiments on the use of the MT mesh as a medium for computation. We show that it is possible to evolve MT films into binary classifiers following an evolution in materio approach. The accuracy of the system is, on average, similar to that of early carbon nanotube classifiers developed using the same methodology.

South Australian Medicines Evaluation Panel in review: providing evidence-based guidance on the use of high-cost medicines in the South Australian public health system.

Objective The South Australian Medicines Evaluation Panel (SAMEP) was established in 2011 to make evidence-based recommendations on the funding of high-cost medicines in South Australian public hospitals via a high-cost medicines formulary. SAMEP represents one component of South Australia's process for state-based health technology assessment (HTA). The aim of this study was to describe the experience of SAMEP in the context of Australia's complex governance model for hospital-based care. Methods A retrospective review was conducted of the SAMEP process and outcomes of medicine evaluations. Decision summaries and meeting minutes were reviewed and reflected upon by the authors to explore the views of the SAMEP membership regarding the function of the committee and state-based HTA more broadly. Results SAMEP has reviewed 29 applications, with 14 (48%) listed on the high-cost medicines formulary. Three applications have been the subject of outcome review and confirm expectations of patient benefit. Conclusion Retrospective review of the committee experience suggests that state-based HTA as operationalised by SAMEP is feasible, provides greater equity of access to high-cost medicines in the South Australian public hospital system and allows for access with evidence development. What is known about the topic? State-based hospital funders often need to make decisions on the provision of high-cost medicines for which there is no national guidance or subsidy. Little published information exists about state-based approaches to medicines evaluation and reimbursement within public hospitals in Australia. What does this paper add? The South Australian experience demonstrates a method for states and territories to tackle the challenges of providing evidence-based access to high-cost medicines in Australian public hospitals. What are the implications for practitioners? This paper provides information for other jurisdictions considering state-based approaches to medicines evaluation and contributes to the broader literature about state-based HTA in Australia.

Combating Canine 'Visiting Cards': Public Hygiene and the Management of Dog Mess in Paris since the 1920s.

This article examines the history of dog mess in Paris, from its 'discovery' in the late 1920s to the management regime of the early twenty-first century. Mayor Jacques Chirac's anti-excrement campaigns in the 1980s are a particular focus. Situating the meaning and management of dog mess within histories of public hygiene and disgust, and mobilising insights from work on public hygiene, biopolitics and governmentality, this article shows how Chirac's attempt to produce self-regulating and responsible dog owners through education failed to persuade them to overcome their disgust at their pets' excrement. Fining alongside education proved a more effective management strategy. The history of dog mess in Paris highlights the biopolitical problems raised by animal excrement decades after the apogee of the public hygiene movement, and shows how human-animal partnerships expose the limits of governmentality approaches to public hygiene and neo-liberal urban governance.

Reorienting rabies research and practice: Lessons from India.

In this article, we reflect on the institutional and everyday realities of people-street dog relations in India to develop a case for decolonised approaches to rabies and other zoonoses. Dog-mediated rabies in Asia and Africa continues be a major concern in transnational public health agendas despite extensive research and knowledge on its prevention. In India, which carries 35% of the global rabies burden and has large street dog populations, One Health-oriented dog population management programmes have been central to the control of this zoonotic disease. Yet, rabies continues to be a significant problem in the country. In this article, we address this impasse in rabies research and practice through investigations of interactions between people, policy, and street dogs. Drawing primarily on field and archival research in Chennai city, we track how street dogs are perceived by people, explore how these animals have come into interface with (public) health concerns over time, and examine the biosocial conditions that frame people-dog conflict (and thereby rabies). These analyses create a picture of the multidimensional character of people-dog relations to offer new insights on why One Health-oriented rabies initiatives have not borne out their full promise. In effect, the article makes a case for a shift in public health orientations-away from intervening on these animals as vectors to be managed, and towards enabling multispecies habitats. This, we argue, requires the decolonisation of approaches to dog-mediated rabies, and expanded conceptions of 'healthy more-than-human publics'. In conclusion, the article chalks out broader implications for public health approaches to zoonoses in a world marked by mutual risk and vulnerability that cuts across human and nonhuman animals.

Current use of chromosomal microarray by Australian paediatricians and implications for the implementation of next generation sequencing.

AIM: Chromosomal microarray (CMA) is an important diagnostic test for children with multiple congenital anomalies or certain developmental behavioural problems suggestive of an underlying genetic diagnosis. However, there are medical and ethical complexities to its use and few Australian policies to guide practice. We aimed to describe the current practice of Australian paediatricians in relation to CMA testing. We hypothesised that there are knowledge gaps in their use of CMA. METHODS: Online survey completed between September 2015 and January 2016 by paediatricians in secondary care settings. Participants were members of the Australian Paediatric Research Network. One hundred and sixty five (43%) of 383 active members responded. Our main outcome measures comprised: (i) the indications for which paediatricians request CMA; (ii) their approach to consent; (iii) their interpretation of results; and (iv) their understanding of the impact on patient management. RESULTS: A significant proportion of paediatricians (21-52%) did not regularly use CMA for conditions with established evidence of diagnostic yield. Paediatricians under-estimated the potential for CMA findings to alter patient management. There was wide variability in paediatricians' approach to consent, and low use of consent forms and fact sheets. Paediatricians reported difficulties interpreting CMA results, with high rates of referral to clinical genetics services. CONCLUSIONS: The reported practice of Australian paediatricians is not consistent with international standards on CMA. Australian practice could be improved by a standardised approach to ordering CMA, consenting patients and interpreting results. We provide resources for CMA ordering and make recommendations about preparation for next generation sequencing.

Complex multifault rupture during the 2016 Mw 7.8 Kaikoura earthquake, New Zealand.

On 14 November 2016, northeastern South Island of New Zealand was struck by a major moment magnitude (Mw) 7.8 earthquake. Field observations, in conjunction with interferometric synthetic aperture radar, Global Positioning System, and seismology data, reveal this to be one of the most complex earthquakes ever recorded. The rupture propagated northward for more than 170 kilometers along both mapped and unmapped faults before continuing offshore at the island's northeastern extent. Geodetic and field observations reveal surface ruptures along at least 12 major faults, including possible slip along the southern Hikurangi subduction interface; extensive uplift along much of the coastline; and widespread anelastic deformation, including the ~8-meter uplift of a fault-bounded block. This complex earthquake defies many conventional assumptions about the degree to which earthquake ruptures are controlled by fault segmentation and should motivate reevaluation of these issues in seismic hazard models.

The effects of an ActRIIb receptor Fc fusion protein ligand trap in juvenile simian immunodeficiency virus-infected rhesus macaques.

There are no approved therapies for muscle wasting in children infected with human immunodeficiency virus (HIV), which portends poor disease outcomes. To determine whether a soluble ActRIIb receptor Fc fusion protein (ActRIIB.Fc), a ligand trap for TGF-ß/activin family members including myostatin, can prevent or restore loss of lean body mass and body weight in simian immunodeficiency virus (SIV)-infected juvenile rhesus macaques (Macaca mulatta). Fourteen pair-housed, juvenile male rhesus macaques were inoculated with SIVmac239 and, 4 wk postinoculation (WPI) treated with intramuscular injections of 10 mg ⋅ kg(-1) ⋅ wk(-1) ActRIIB.Fc or saline placebo. Body weight, lean body mass, SIV titers, and somatometric measurements were assessed monthly for 16 wk. Age-matched SIV-infected rhesus macaques were injected with saline. Intervention groups did not differ at baseline. Gains in lean mass were significantly greater in the ActRIIB.Fc group than in the placebo group (P < 0.001). Administration of ActRIIB.Fc was associated with greater gains in body weight (P = 0.01) and upper arm circumference than placebo. Serum CD4(+) T-lymphocyte counts and SIV copy numbers did not differ between groups. Administration of ActRIIB.Fc was associated with higher muscle expression of myostatin than placebo. ActRIIB.Fc effectively blocked and reversed loss of body weight, lean mass, and fat mass in juvenile SIV-infected rhesus macaques.

Imaging the evolution of lateral composition modulation in strained alloy superlattices.

Scanning tunneling microscopy is used to investigate the morphological evolution of GaAs/InAs short period superlattice structures. The layers of the superlattice, either grown in compression or tension, exhibit an island or trench morphology. With increasing film thickness, the islands or trenches grow in size and develop a characteristic spacing along [110] of approximately 150 A. This is the first experimental evidence to suggest that lateral composition modulation arises from both thickness variations of the layers and compositional nonuniformities within the atomic plane.

Cerebral arteriosclerosis in an aged captive polar bear (Ursus maritimus).

Cerebral arteriosclerosis was observed upon necropsy of a 36-yr-old female captive polar bear (Ursus maritimus) that developed a sudden onset of seizure-like activity and died. The medium and large cerebral arteries of the meninges had moderate to severe diffuse discoloration and mineralization of the matrix of the tunica media, with little or no associated cellular reaction. Scanning electron microscopy of the affected arteries showed discrete crystalline calcified deposits in the media and sclerosis of the arterial wall. There were no lesions in the brainstem. The findings suggested a sudden and rapidly fatal loss of blood flow to the brain caused by long-standing arterial lesions. Incidental findings included numerous 0.1- to 10-cm-diameter, hepatic cysts lined with hyperplastic biliary epithelium, a unilateral, unipolar, 3-cm-diameter renal tubular adenoma, and approximately 250 active Baylisascaris sp. nematodes in the intestines.