Understanding access to general practice through the lens of Candidacy: a critical review of the literature.

BACKGROUND: Dominant conceptualisations of access to healthcare are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished. AIM: We aimed to characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy. DESIGN AND SETTING: Qualitative review guided by the principles of critical interpretive synthesis. METHODS: We conducted a literature review using an "author-led" approach, involving iterative analytically-guided searches. Papers were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework. RESULTS: 229 papers were included in the final synthesis. Each of the seven features identified in the original Candidacy Framework is highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent and subject to constant negotiation. These influences are socio-economically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed. CONCLUSION: The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.

Successful Distribution of Tecovirimat During the Peak of the Mpox Outbreak - Los Angeles County, June 2022-January 2023.

Tecovirimat is the first-line antiviral treatment recommended for severe mpox or for persons with mpox who are at risk for severe disease; tecovirimat is available in the United States under an expanded access investigational new drug (IND) protocol. During the 2022-2023 mpox outbreak, local U.S. health jurisdictions facilitated access to tecovirimat. In June 2022, Los Angeles County (LAC) rapidly developed strategies for tecovirimat distribution using existing medical countermeasure distribution networks established by the Public Health Emergency Preparedness Program and the Hospital Preparedness Program, creating a hub and spoke distribution network consisting of 44 hub facilities serving 456 satellite sites across LAC. IND patient intake forms were analyzed to describe mpox patients treated with tecovirimat. Tecovirimat treatment data were matched with case surveillance data to calculate time from specimen collection to patients receiving tecovirimat. Among 2,281 patients with mpox in LAC, 735 (32%) received tecovirimat during June 2022-January 2023. Among treated patients, approximately two thirds (508; 69%) received treatment through community clinics and pharmacies. The median interval from specimen collection to treatment was 2 days (IQR = 0-5 days). Local data collection and analysis helped to minimize gaps in treatment access and facilitated network performance monitoring. During public health emergencies, medical countermeasures can be rapidly deployed across a large jurisdiction using existing distribution networks, including clinics and pharmacies.

The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care.

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

General practice is the foundation of the UK's National Health Service (NHS). But these foundations are creaking. More and more people need care, but there are fewer general practitioners (GPs). Job satisfaction for doctors is falling, and public satisfaction with general practice has plummeted. Politicians are promising major changes to the way general practice is organized, but it's not clear what these changes will be. We wanted to understand whether fundamental changes to the whole model of general practice in England are needed. To do this, we measured the performance of general practice in England against a set of features, widely regarded as defining the characteristics of high-performing primary care systems. We found that, although, in theory, the design of English general practice aligns well with these features, in practice, performance is less good and is getting worse. In particular, people are struggling to access care, and their ability to see the same doctor regularly is declining. There are also unfair differences between population groups. We conclude that the crisis in English general practice has more to do with previous policy decisions and longstanding lack of funding than the fundamental design of NHS general practice. Policymakers should focus on giving the system enough resources and supporting GPs to improve the quality of local services.

Directed conservation of the world's reef sharks and rays.

Many shark populations are in decline around the world, with severe ecological and economic consequences. Fisheries management and marine protected areas (MPAs) have both been heralded as solutions. However, the effectiveness of MPAs alone is questionable, particularly for globally threatened sharks and rays ('elasmobranchs'), with little known about how fisheries management and MPAs interact to conserve these species. Here we use a dedicated global survey of coral reef elasmobranchs to assess 66 fully protected areas embedded within a range of fisheries management regimes across 36 countries. We show that conservation benefits were primarily for reef-associated sharks, which were twice as abundant in fully protected areas compared with areas open to fishing. Conservation benefits were greatest in large protected areas that incorporate distinct reefs. However, the same benefits were not evident for rays or wide-ranging sharks that are both economically and ecologically important while also threatened with extinction. We show that conservation benefits from fully protected areas are close to doubled when embedded within areas of effective fisheries management, highlighting the importance of a mixed management approach of both effective fisheries management and well-designed fully protected areas to conserve tropical elasmobranch assemblages globally.

Effectiveness of JYNNEOS vaccine against symptomatic mpox disease in adult men in Los Angeles County, August 29, 2022 to January 1, 2023.

We describe real-world estimates of JYNNEOS vaccine effectiveness (VE) against symptomatic mpox in Los Angeles County (LAC). We conducted a retrospective cohort study of men aged ≥18 years residing in LAC who were at risk for mpox and eligible for the JYNNEOS vaccine from 5/19/2022 to 1/1/2023. Case demographics and route of JYNNEOS administration were obtained through vaccine administration data systems. HIV and sexually transmitted infection (STI) status was obtained through disease reporting systems for HIV and STI diagnoses in LAC. To estimate VE, we calculated weekly incidence of confirmed mpox for unvaccinated, partially vaccinated (episode date ≥14 days after first dose), and fully vaccinated (episode date ≥14 days after second dose) cohorts starting on 8/29/2022, when fully vaccinated coverage exceeded 3 %, and ending on 1/1/2023. Overall, 2,171 men had confirmed mpox, and 1,002 (46 %) of those were persons living with diagnosed HIV (PLWDH). 2,019 (93 %) mpox cases were unvaccinated, 114 (5 %) were partially vaccinated and 38 (2 %) were fully vaccinated. VE was 69 % (95 % CI 59-77) for partially vaccinated and 84 % (95 % CI 80-87) for fully vaccinated individuals. Among PLWDH, VE was 72 % (95 % CI 57-82) for fully vaccinated and 28 % (95 % CI -96 to 73) VE for partially vaccinated individuals. Among persons not living with diagnosed HIV, VE was 88 % (95 % CI 86-90) for fully vaccinated and 80 % (95 % CI 76-83) for partially vaccinated individuals. Of 111 individuals hospitalized with mpox, one was partially vaccinated, and the remaining were unvaccinated. Our results align with other published studies that reported that two doses of the JYNNEOS vaccine provided significant protection against symptomatic mpox.

Investigating the Implementation of Community-Based Stroke Telerehabilitation in England; A Realist Synthesis Study Protocol.

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England.

BACKGROUND: Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives. METHODS: Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners. RESULTS: Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward. CONCLUSIONS: Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Circulating and Imaging Biomarkers of Radium-223 Response in Metastatic Castration-Resistant Prostate Cancer.

PURPOSE: Radium-223 improves overall survival (OS) and reduces skeletal events in patients with bone metastatic castration-resistant prostate cancer (CRPC), but relevant biomarkers are lacking. We evaluated automated bone scan index (aBSI) and circulating tumor cell (CTC) analyses as potential biomarkers of prognosis and activity. PATIENTS AND METHODS: Patients with bone metastatic CRPC were enrolled on a prospective single-arm study of standard radium-223. 99mTc-MDP bone scan images at baseline, 2 months, and 6 months were quantitated using aBSI. CTCs at baseline, 1 month, and 2 months were enumerated and assessed for RNA expression of prostate cancer-specific genes using microfluidic enrichment followed by droplet digital polymerase chain reaction. RESULTS: The median OS was 21.3 months in 22 patients. Lower baseline aBSI and minimal change in aBSI (<+0.7) from baseline to 2 months were each associated with better OS (P = .00341 and P = .0139, respectively). The higher baseline CTC count of ≥5 CTC/7.5 mL was associated with worse OS (median, 10.1 v 32.9 months; P = .00568). CTCs declined at 2 months in four of 15 patients with detectable baseline CTCs. Among individual genes in CTCs, baseline expression of the splice variant AR-V7 was significantly associated with worse OS (hazard ratio, 5.20 [95% CI, 1.657 to 16.31]; P = .00195). Baseline detectable AR-V7, higher aBSI, and CTC count ≥5 CTC/7.5 mL continued to have a significant independent negative impact on OS after controlling for prostate-specific antigen or alkaline phosphatase. CONCLUSION: Quantitative bone scan assessment with aBSI and CTC analyses are prognostic markers in patients treated with radium-223. AR-V7 expression in CTCs is a particularly promising prognostic biomarker and warrants validation in larger cohorts.

Incorporating uncertainty in Indigenous sea Country monitoring with Bayesian statistics: Towards more informed decision-making.

Partnerships in marine monitoring combining Traditional Ecological Knowledge and western science are developing globally to improve our understanding of temporal changes in ecological communities that better inform coastal management practices. A fuller communication between scientists and Indigenous partners about the limitations of monitoring results to identify change is essential to the impact of monitoring datasets on decision-making. Here we present a 5-year co-developed case study from a fish monitoring partnership in northwest Australia showing how uncertainty estimated by Bayesian models can be incorporated into monitoring management indicators. Our simulation approach revealed there was high uncertainty in detecting immediate change over the following monitoring year when translated to health performance indicators. Incorporating credibility estimates into health assessments added substantial information to monitoring trends, provided a deeper understanding of monitoring limitations and highlighted the importance of carefully selecting the way we evaluate management performance indicators.

Toxicity of herbicides to the marine microalgae Tisochrysis lutea and Tetraselmis sp.

Pesticides are ubiquitous in the catchments of the Great Barrier Reef (GBR) and regularly discharge into the nearshore waters. Effective management of pesticides requires suitable water quality guideline values (WQGVs), and further ecotoxicological data for many pesticides are needed to improve the reliability of environmental risk assessments. To help address this issue, toxicity thresholds were determined to two species of tropical marine microalgae Tisochrysis lutea and Tetraselmis sp. for a suite of herbicides detected in the GBR. Photosystem II (PSII) herbicides significantly reduced growth with no effect concentration (NEC) and 10% effect concentration (EC10) values spanning two orders of magnitude from 0.60 µg L-1 for diuron to 60 µg L-1 for simazine across both species. However, growth was insensitive to the non-PSII herbicides. The NEC/EC10 thresholds for most herbicide-microalgae combinations were greater than recent WQGVs intended to protect 99% of species (PC99); however, metribuzin was toxic to T. lutea at concentrations lower than the current PC99 value, which may have to be revisited. The toxicity thresholds for alternative herbicides derived here further inform the development of national and GBR-specific WQGVs, but more toxicity data is needed to develop WQGVs for the > 50 additional pesticides detected in catchments of the GBR.

Factors influencing employers' support for employees with acquired brain injuries or mental illness to return to- and stay in work: A qualitative systematic review.

BACKGROUND: People with acquired brain injuries (ABIs) often experience residual limitations and co-morbid mental illnesses that restrict work participation. Employers are key in enabling successful return-to-work and job retention. OBJECTIVE: This review aimed to explore employers' perspectives of factors influencing their support for people with ABIs and/or mental illness to return to- and stay in work. Review questions focused on barriers and facilitators to their support, and contextual characteristics present at the time. METHODS: Five databases were searched from October 2010 until November 2023 for relevant qualitative studies published in English. Findings from included studies (N = 25) were synthesised using thematic synthesis. RESULTS: Included studies focused on employees with ABI or mental illness, rather than dually diagnosed ABI and mental illness. Employers' support was influenced by their awareness/knowledge of- and attitudes towards the employee's condition/illness; their skills and experience in supportive strategies; factors related to provision of work accommodations; and stakeholder influence. Similarities and differences in influential factors were observed across the ABI and mental illness literature. Contextual characteristics related to organisational characteristics, cultural taboo, and involvement of certain stakeholders. CONCLUSIONS: ABI survivors (with and without co-morbid mental illness) and their employers may benefit from specialist support and resources to guide them through the return-to-work process. Further research is needed to investigate employers' knowledge of ABI and mental illness and supportive strategies. Exploration of the influence of other stakeholders, socio-demographic characteristics, and contextual factors on employers' return-to-work and retention support for ABI survivors with co-morbid mental illness is warranted.

Methods for estimating no-effect toxicity concentrations in ecotoxicology.

A range of new statistical approaches is being developed and/or adopted in ecotoxicology that, when combined, can greatly improve the estimation of no-effect toxicity values from concentration-response (CR) experimental data. In particular, we compare the existing no-effect-concentration (NEC) threshold-based toxicity metric with an alternative no-significant-effect-concentration (NSEC) metric suitable for when CR data do not show evidence of a threshold effect. Using a model-averaging approach, these metrics can be combined to yield estimates of N(S)EC and of their uncertainty within a single analysis framework. The outcome is a framework for CR analysis that is robust to uncertainty in the model formulation, and for which resulting estimates can be confidently integrated into risk assessment frameworks, such as the species sensitivity distribution (SSD). Integr Environ Assess Manag 2024;20:279-293. © 2023 Commonwealth of Australia and The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

A large-scale experiment finds no consistent evidence of change in mortality or commercial productivity in silverlip pearl oysters (Pinctada maxima) exposed to a seismic source survey.

High-intensity, impulsive sounds are used to locate oil and gas reserves during seismic exploration of the seafloor. The impacts of this noise pollution on the health and mortality of marine invertebrates are not well known, including the silverlip pearl oyster (Pinctada maxima), which comprises one of the world's last remaining significant wildstock pearl oyster fisheries, in northwestern Australia. We exposed ≈11,000 P. maxima to a four-day experimental seismic survey, plus one vessel-control day. After exposure, survival rates were monitored throughout a full two-year production cycle, and the number and quality of pearls produced at harvest were assessed. Oysters from two groups, on one sampling day, exhibited reduced survival and pearl productivity compared to controls, but 14 other groups receiving similar or higher exposure levels did not. We therefore found no conclusive evidence of an impact of the seismic source survey on oyster mortality or pearl production.

Molecular responses of sponge larvae exposed to partially weathered condensate oil.

Anthropogenic inputs of petroleum hydrocarbons into the marine environment can have long lasting impacts on benthic communities. Sponges form an abundant and diverse component of benthic habitats, contributing a variety of important functional roles; however, their responses to petroleum hydrocarbons are largely unknown. This study combined a traditional ecotoxicological experimental design and endpoint with global gene expression profiling and microbial indicator species analysis to examine the effects of a water accommodated fraction (WAF) of condensate oil on a common Indo-Pacific sponge, Phyllospongia foliascens. A no significant effect concentration (N(S)EC) of 2.1 % WAF was obtained for larval settlement, while gene-specific (N(S)EC) thresholds ranged from 3.4 % to 8.8 % WAF. Significant shifts in global gene expression were identified at WAF treatments ≥20 %, with larvae exposed to 100 % WAF most responsive. Results from this study provide an example on the incorporation of non-conventional molecular and microbiological responses into ecotoxicological studies on petroleum hydrocarbons.

The Unmet Needs of Caregiving Skills, Support, Emotions, and Finances of Stroke Caregivers: A Multicenter Study.

​​​​​​Background Informal stroke caregivers in Malaysia play an important role in supporting stroke survivors following acute care. Nevertheless, there is a lack of available data to inform the sufficiency of help and resources available to address the needs of local stroke caregivers. This study aimed to determine the unmet needs in caregiving skills, support, emotions, and finances as well as the associated factors of stroke caregivers in Malaysia. Methodology This multicenter, cross-sectional study used a self-administered survey developed and validated for the Malaysian population. It was prepared in paper-based and web-based formats, and it was distributed via direct contact with the respondents, post, and email. Respondents were recruited from different sites in Malaysia. In this study, unmet needs were defined as "help that was needed more or was not provided to assist caregivers and address their specific needs." This article only presents the quantitative data of this study. Data were analyzed using descriptive analysis and logistic regression to determine factors associated with unmet needs. Results Almost all study respondents (91%) reported having unmet needs. Unmet needs ranged from 1 to 10, while the mean unmet needs was 5. The highest unmet need was related to financial support (72.5%), followed by support from professionals to address their own needs (59.2%), skills to care for stroke survivors, i.e., skills in caring for stroke survivors with their daily activities (57.9%), and skills in supporting stroke survivors to perform rehabilitation at home (53.1%). The lowest unmet need was related to support in transporting stroke survivors from place to place (45.3%). Additionally, this study did not identify an association between the reported unmet needs and gender, age, ethnicity, duration of caregiving, and site of participation. Conclusions This study reported a range of unmet needs perceived by stroke caregivers in Malaysia. Further research is warranted to understand the gaps in supporting local stroke caregivers to inform future post-stroke support and services in the country.

Effects of aromatic hydrocarbons and evaluation of oil toxicity modelling for larvae of a tropical coral.

Application of oil toxicity modelling for assessing the risk of spills to coral reefs remains uncertain due to a lack of data for key tropical species and environmental conditions. In this study, larvae of the coral Acropora millepora were exposed to six aromatic hydrocarbons individually to generate critical target lipid body burdens (CTLBBs). Larval metamorphosis was inhibited by all six aromatic hydrocarbons, while larval survival was only affected at concentrations >2000 µg L-1. The derived metamorphosis CTLBB of 9.7 µmol g-1 octanol indicates larvae are more sensitive than adult corals, and places A. millepora larvae among the most sensitive organisms in the target lipid model (TLM) databases. Larvae were also more sensitive to anthracene and pyrene when co-exposed to ecologically relevant levels of ultraviolet radiation. The results suggest that the application of the phototoxic TLM would be protective of A. millepora larvae, provided adequate chemical and light data are available.

Protecting the invisible: Establishing guideline values for copper toxicity to marine microbiomes.

Understanding the rapid responses of marine microbiomes to environmental disturbances is paramount for supporting early assessments of harm to high-value ecosystems, such as coral reefs. Yet, management guidelines aimed at protecting aquatic life from environmental pollution remain exclusively defined for organisms at higher trophic levels. In this study, 16S rRNA gene amplicon sequencing was applied in conjunction with propidium monoazide for cell-viability assessment as a sensitive tool to determine taxon- and community-level changes in a seawater microbial community under copper (Cu) exposure. Bayesian model averaging was used to establish concentration-response relationships to evaluate the effects of copper on microbial composition, diversity, and richness for the purpose of estimating microbiome Hazard Concentration (mHCx) values. Predicted mHC5 values at which a 5 % change in microbial composition, diversity, and richness occurred were 1.05, 0.72, and 0.38 µg Cu L-1, respectively. Threshold indicator taxa analysis was applied across the copper concentrations to identify taxon-specific change points for decreasing taxa. These change points were then used to generate a Prokaryotic Sensitivity Distribution (PSD), from which mHCxdec values were derived for copper, suitable for the protection of 99, 95, 90, and 80 % of the marine microbiome. The mHC5dec guideline value of 0.61 µg Cu L-1, protective of 95 % of the marine microbial community, was lower than the equivalent Australian water quality guideline value based on eukaryotic organisms at higher trophic levels. This suggests that marine microbial communities might be more vulnerable, highlighting potential insufficiencies in their protection against copper pollution. The mHCx values proposed here provide approaches to quantitatively assess the effects of contaminants on microbial communities towards the inclusion of prokaryotes in future water quality guidelines.