Associations between corporate ownership of primary care providers and doctor wellbeing, workload, access, organizational efficiency, and service quality.

Traditionally, in many countries general practices have been privately-owned independent small businesses. However, the last three decades has seen the rise of large corporate medical groups defined as private companies which are able to have non-GP shareholders and with branches across many locations. The greater prominence of profit motives may have implications for costs, access to care and quality of care. We estimate that 45% of GPs in Australia worked in a practice that was a private company, and within this group over one third (19.9% of total) worked in a corporate medical group (a private company with 10 or more practice locations). We examine the association between being in a corporate medical group and 19 outcomes classified into five groups: GP wellbeing, workload, patient access, organizational efficiency, and service quality. GPs who worked in such groups were more likely to be older, qualified overseas, and to have a conscientious personality. There was mixed evidence on GPs wellbeing, with GPs in corporate medical groups reporting a higher turnover of GPs but similar levels of job satisfaction. GP workload was similar in terms of hours worked and after hours work but they reported a lower work-life balance. Patient access was better in terms of lower fees charged to patients but there was weak evidence that patients waited longer. GPs in corporate medical groups reported higher organisational efficiency because GPs spent less time spent on administration and management, had more nurses per GP, but despite this GPs were more likely to undertake tasks someone less qualified could do suggesting that nurses were complements not substitutes. There were no differences in service quality (teaching, patient complaints, consultation length, patients seen per hour). Corporate medical groups have become a substantial part of primary care provision in Australia. There is evidence they are more efficient, patient access is better with lower out of pocket costs and there are no differences in our measures service quality, but concerns remain about GP's wellbeing and work-life balance. Further research is needed on continuity of care and patient reported experiences and health outcomes.

A randomised controlled trial of email versus mailed invitation letter in a national longitudinal survey of physicians.

Despite their low cost, the use of email invitations to distribute surveys to medical practitioners have been associated with lower response rates. This research compares the difference in response rates from using email approach plus online completion rather than a mailed invitation letter plus a choice of online or paper completion. A parallel randomised controlled trial was conducted during the 11th annual wave of the nationally representative Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The control group was invited using a mailed paper letter (including a paper survey plus instructions to complete online) and three mailed paper reminders. The intervention group was approached in the same way apart from the second reminder when they were approached by email only. The primary outcome is the response rate and the statistical analysis was blinded. 18,247 doctors were randomly allocated to the control (9,125) or intervention group (9,127), with 9,108 and 9,107 included in the analysis. Using intention to treat analysis, the response rate in the intervention group was 35.92% compared to 37.59% in the control group, a difference of -1.66 percentage points (95% CI: -3.06 to -0.26). The difference was larger for General Practitioners (-2.76 percentage points, 95% CI: -4.65 to -0.87) compared to other specialists (-0.47 percentage points, 95% CI: -2.53 to 1.60). For those who supplied an email address, the average treatment effect on the treated was higher at -2.63 percentage points (95% CI: -4.50 to -0.75) for all physicians, -3.17 percentage points (95% CI: -5.83 to -0.53) for General Practitioners, and -2.1 percentage points (95% CI: -4.75 to 0.56) for other specialists. For qualified physicians, using email to invite participants to complete a survey leads to lower response rates compared to a mailed letter. Lower response rates need to be traded off with the lower costs of using email rather than mailed letters.

Nanopore sequencing of clonal IGH rearrangements in cell-free DNA as a biomarker for acute lymphoblastic leukemia.

Background: Acute Lymphoblastic Leukemia (ALL) is the most common pediatric cancer, and patients with relapsed ALL have a poor prognosis. Detection of ALL blasts remaining at the end of treatment, or minimal residual disease (MRD), and spread of ALL into the central nervous system (CNS) have prognostic importance in ALL. Current methods to detect MRD and CNS disease in ALL rely on the presence of ALL blasts in patient samples. Cell-free DNA, or small fragments of DNA released by cancer cells into patient biofluids, has emerged as a robust and sensitive biomarker to assess cancer burden, although cfDNA analysis has not previously been applied to ALL. Methods: We present a simple and rapid workflow based on NanoporeMinION sequencing of PCR amplified B cell-specific rearrangement of the (IGH) locus in cfDNA from B-ALL patient samples. A cohort of 5 pediatric B-ALL patient samples was chosen for the study based on the MRD and CNS disease status. Results: Quantitation of IGH-variable sequences in cfDNA allowed us to detect clonal heterogeneity and track the response of individual B-ALL clones throughout treatment. cfDNA was detected in patient biofluids with clinical diagnoses of MRD and CNS disease, and leukemic clones could be detected even when diagnostic cell-count thresholds for MRD were not met. These data suggest that cfDNA assays may be useful in detecting the presence of ALL in the patient, even when blasts are not physically present in the biofluid sample. Conclusions: The Nanopore IGH detection workflow to monitor cell-free DNA is a simple, rapid, and inexpensive assay that may ultimately serve as a valuable complement to traditional clinical diagnostic approaches for ALL.

Do Physicians Prefer to Complete Online or Mail Surveys? Findings From a National Longitudinal Survey.

Survey response rates for physicians are falling generally, and surveys of physicians tend to have lower response rates than those of the general population. To maximize response, respondents are often given a choice of modes in which to respond. The aim of this article is to describe mode response patterns and identify factors related to physicians' decisions to complete surveys online rather than by mail. The data are from the fifth annual wave of the Medicine in Australia: Balancing Employment and Life longitudinal survey of physicians, in which there was a 43.5% response rate (10,746/24,711) and 33.7% of respondents completed the survey online. Online completion was more likely when the physician had completed the survey online in the previous wave, was a general practitioner rather than other medical specialist or doctor-in-training, worked in a remote location, and was young and male. Free-text spontaneous comments from respondents indicated that mode choice was based on a combination of preference, previous experience, and feasibility. These results provide support for the use of mixed mode survey designs, which can accommodate doctors with different mode preferences and cast doubt over the possibility of tailoring mode based on respondent characteristics.

Impact of Austropuccinia psidii (myrtle rust) on Myrtaceae-rich wet sclerophyll forests in south east Queensland.

In April 2010, Austropuccinia psidii (formerly Puccinia psidii) was detected for the first time in Australia on the central coast of New South Wales. The fungus spread rapidly along the east coast and can now be found infecting vegetation in a range of native forest ecosystems with disease impacts ranging from minor leaf spots to severe shoot and stem blight and tree dieback. Localised extinction of some plant species has been recorded. In 2014, the impact of A. psidii was observed for the first time in a wet sclerophyll site with a rainforest understory, dominated by species of Myrtaceae, in Tallebudgera Valley, south east Queensland, Australia. This study aimed to determine the impact of A. psidii on individual species and species composition. Here we provide quantitative and qualitative evidence on the significant impact A. psidii has in native ecosystems, on a broader range of species than previously reported. Archirhodomyrtus beckleri, Decaspermum humile, Gossia hillii and Rhodamnia maideniana are in serious decline, with significant increases in tree mortality over the period of our study. This research further highlights the potential of this invasive pathogen to negatively impact native ecosystems and biodiversity.

Me and my 400 friends: the anatomy of college students' Facebook networks, their communication patterns, and well-being.

Is there a trade-off between having large networks of social connections on social networking sites such as Facebook and the development of intimacy and social support among today's generation of emerging adults? To understand the socialization context of Facebook during the transition to adulthood, an online survey was distributed to college students at a large urban university; participants answered questions about their relationships by systematically sampling their Facebook contacts while viewing their Facebook profiles online. Results confirmed that Facebook facilitates expansive social networks that grow disproportionately through distant kinds of relationship (acquaintances and activity connections), while also expanding the number of close relationships and stranger relationships, albeit at slower rates. Those with larger networks estimated that larger numbers of contacts in their networks were observing their status updates, a form of public communication to one's entire contact list. The major function of status updates was emotional disclosure, the key feature of intimacy. This finding indicates the transformation of the nature of intimacy in the environment of a social network site. In addition, larger networks and larger estimated audiences predicted higher levels of life satisfaction and perceived social support on Facebook. These findings emphasize the psychological importance of audience in the Facebook environment. Findings also suggest that social networking sites help youth to satisfy enduring human psychosocial needs for permanent relations in a geographically mobile world--college students with higher proportions of maintained contacts from the past (primarily high school friends) perceived Facebook as a more useful tool for procuring social support.

2-Mercaptoethane sulfonate prevents doxorubicin-induced plasma protein oxidation and TNF-α release: implications for the reactive oxygen species-mediated mechanisms of chemobrain.

Doxorubicin (DOX), an anthracycline used to treat a variety of cancers, is known to generate intracellular reactive oxygen species. Moreover, many patients who have undergone chemotherapy complain of cognitive dysfunction often lasting years after cessation of the chemotherapy. Previously, we reported that intraperitoneal administration of DOX led to elevated TNF-α and oxidative stress in the plasma and brain of mice. However, the mechanisms involved in nontargeted tissue damage remain unknown. In this study, we measured plasma oxidative stress and cytokine levels in patients treated with DOX. We observed increased plasma protein carbonylation and elevation of TNF-α 6 h after DOX administration in the context of multiagent chemotherapy regimens. Importantly, patients not treated coincidentally with 2-mercaptoethane sulfonate (MESNA) showed statistically significantly increased plasma protein-bound 4-hydroxynonenal, whereas those who had been coincidentally treated with MESNA as part of their multiagent chemotherapy regimen did not, suggesting that concomitant administration of the antioxidant MESNA with DOX prevents intravascular oxidative stress. We demonstrate in a murine model that MESNA suppressed DOX-induced increased plasma oxidative stress indexed by protein carbonyls and protein-bound HNE, and also suppressed DOX-induced increased peripheral TNF-α levels. A direct interaction between DOX and MESNA was demonstrated by MESNA suppression of DOX-induced DCF fluorescence. Using redox proteomics, we identified apolipoprotein A1 (APOA1) in both patients and mice after DOX administration as having increased specific carbonyl levels. Macrophage stimulation studies showed that oxidized APOA1 increased TNF-α levels and augmented TNF-α release by lipopolysaccharide, effects that were prevented by MESNA. This study is the first to demonstrate that DOX oxidizes plasma APOA1, that oxidized APOA1 enhances macrophage TNF-α release and thus could contribute to potential subsequent TNF-α-mediated toxicity, and that MESNA interacts with DOX to block this mechanism and suggests that MESNA could reduce systemic side effects of DOX.

The effect of stopping smoking on perceived stress levels.

AIMS: Many smokers believe that smoking helps them to cope with stress, and that stopping smoking would deprive them of an effective stress management tool. Changes in stress levels following long-term smoking cessation are not well mapped. This longitudinal project was designed to provide more robust data on post-cessation changes in perceived stress levels by following a cohort of smokers admitted to hospital after myocardial infarction (MI) or for coronary artery bypass (CAB) surgery, as such patients typically achieve higher continuous abstinence rates than other comparable samples. DESIGN: A total of 469 smokers hospitalized after MI or CAB surgery and wanting to stop smoking were seen in the hospital and completed 1-year follow-ups. Ratings of helpfulness of smoking in managing stress at baseline, smoking status (validated by salivary cotinine concentration) and ratings of perceived stress at baseline and at 1-year follow-up were collected. FINDINGS: Of the patients, 41% (n = 194) maintained abstinence for 1 year. Future abstainers and future smokers did not differ in baseline stress levels or in their perception of coping properties of smoking. However, abstainers recorded a significantly larger decrease in perceived stress than continuing smokers, and the result held when possible confounding factors were controlled for (P < 0.001). CONCLUSIONS: In highly dependent smokers who report that smoking helps them cope with stress, smoking cessation is associated with lowering of stress. Whatever immediate effects smoking may have on perceived stress, overall it may generate or aggravate negative emotional states. The results provide reassurance to smokers worried that stopping smoking may deprive them of a valuable coping resource.

Pathological dissociation as measured by the child dissociative checklist.

The component structure of the Child Dissociative Checklist was examined among abused children. A factor described as pathological dissociation emerged that was predicted by participants being male. There also were differences in pathological dissociation between groups of sexually abused and physically abused children. Replication of this factor and the establishment of base rates for various groups of children are recommended so that the Child Dissociative Checklist might be used to more effectively eliminate false positives and increase true positives in the screening and ultimate treatment of dissociative children.

Sun-protective behaviors in families at increased risk of melanoma.

The aim of this study was to compare reported behavior in the sun in melanoma families with that of geographical healthy controls and to determine the predictors of that behavior to inform the process of counseling melanoma families. One hundred and seventy individuals with a family history of melanoma and 140 controls completed a postal questionnaire. Thirty-one percent of relatives reported sunburn in the previous summer, compared with 41% of controls. Fifty-five percent of relatives had acquired a suntan so that adherence to health education advice was disappointing. Male relatives were particularly likely to report sunburn. Higher knowledge scores correlated well with greater belief in ability to prevent melanoma, less desire for a tan, and more protective behaviors in relatives only (not in controls). We have shown that some psychological characteristics, sex, and age have an effect on behavior, so that the educational approaches needed will vary. "Better" behaviors were reported by melanoma cases than other relatives and by members of families with larger numbers of cases, which suggests that a belief that an individual is at particular risk of melanoma is important for compliance with preventive behaviors.

Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults.

This article describes a trial of a psychoeducational intervention designed to modify negative attitudes toward flexible sigmoidoscopy screening and thereby increase screening attendance. The intervention materials addressed the multiple barriers shown to be associated with participation in earlier studies. Adults ages 55-64 (N = 2,966), in a "harder-to-reach" group were randomized either to receive an intervention brochure or to a standard invitation group. Attitudes and expectations were assessed by questionnaire, and attendance at the clinic was recorded. Compared with controls, the intervention group had less negative attitudes, anticipated a more positive experience, and had a 3.6% higher level of attendance. These results indicate that psychoeducational interventions can provide an effective means of modifying attitudes and increasing rates of screening attendance.

Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial.

OBJECTIVE: To evaluate a smoking cessation intervention that can be routinely delivered to smokers admitted with cardiac problems. DESIGN: Randomised controlled trial of usual care compared with intervention delivered on hospital wards by cardiac rehabilitation nurses. SETTING: Inpatient wards in 17 hospitals in England. PARTICIPANTS: 540 smokers admitted to hospital after myocardial infarction or for cardiac bypass surgery who expressed interest in stopping smoking. INTERVENTION: Brief verbal advice and standard booklet (usual care). Intervention lasting 20-30 minutes including carbon monoxide reading, special booklet, quiz, contact with other people giving up, declaration of commitment to give up, sticker in patient's notes (intervention group). MAIN OUTCOME MEASURES: Continuous abstinence at six weeks and 12 months determined by self report and by biochemical validation at these end points. Feasibility of the intervention and delivery of its components. RESULTS: After six weeks 151 (59%) and 159 (60%) patients remained abstinent in the control and intervention group, respectively (P=0.84). After 12 months the figures were 102 (41%) and 94 (37%) (P=0.40). Recruitment was slow, and delivery of the intervention was inconsistent, raising concerns about the feasibility of the intervention within routine care. Patients who received the declaration of commitment component were almost twice as likely to remain abstinent than those who did not receive it (P<0.01). Low dependence on tobacco and high motivation to give up were the main independent predictors of positive outcome. Patients who had had bypass surgery were over twice as likely to return to smoking as patients who had had a myocardial infarction. CONCLUSIONS: Single session interventions delivered within routine care may have insufficient power to influence highly dependent smokers.