Creative cross-sectoral collaboration: a conceptual framework of factors influencing partnerships for arts, health and wellbeing.

OBJECTIVES: The objective of this study was to investigate the factors impacting cross-sectoral collaboration in arts, health and wellbeing programme, policy and strategy development in South West England. STUDY DESIGN: The study used a participatory action research approach and qualitative methods in the context of a broader effort to develop a regional arts, health and wellbeing strategy. METHODS: Data collection methods included participant observation, semi-structured interviews, a focus group and feedback collected through collaborative online discussion documents. Data were coded using qualitative data analysis software and analysed using thematic analysis. Data were used inductively to develop the conceptual framework of key factors influencing cross-sectoral collaboration in arts, health and wellbeing. RESULTS: Seven key factors that affect cross-sectoral collaboration for arts, health and wellbeing activities were derived from the data and analysis: value and legitimacy, relationships, policy and system complexity, power, capacity, resources and alignment. A conceptual framework shows how these factors relate to each other in multiple configurations and shape cross-sectoral collaborations. CONCLUSIONS: There are increasing opportunities for organisations to partner on arts, health and wellbeing activities. This study highlights key factors influencing the ability to collaborate across sectors and to align with local and national policy agendas. The proposed conceptual framework offers a way to think holistically about how to design for and manage these collaborations.

Extended Water-Level Drawdowns in Dammed Rivers Enhance Fish Habitat: Environmental Pool Management in the Upper Mississippi River.

Environmental Pool Management (EPM) can improve ecosystem function in rivers by restoring aspects of the natural flow regime lost to dam construction. EPM recreates summer baseflow conditions and promotes the growth of terrestrial vegetation which is inundated in the fall, thereby improving habitat heterogeneity for many aquatic taxa. A three-year experiment was conducted wherein terrestrial floodplain areas were dewatered through EPM water-level reductions and the resulting terrestrial vegetation was (1) allowed to remain or (2) removed in paired plots in Mississippi River pool 25. Fish assemblage and abundance were quantified in paired plots after inundation. Abundances of many fish species were greater in vegetated plots, especially for species that utilize vegetation during portions of their life history. Fish assemblages varied more between plot types when the magnitude of EPM water-level drawdowns was greater, which produced greater vegetation growth. Young-of-year individuals, especially from small, early maturing species and/or species reliant on vegetation for refuge, feeding, or life history, utilized vegetated plots more than devegetated plots. Vegetation growth produced under EPM was heavily used by river fishes, including young-of-year individuals, which may ultimately positively influence recruitment. Increased habitat heterogeneity may mitigate some of the negative impacts of dam construction and water-level regulation on river fishes. Annual variability in vegetation responses that occurs under EPM enhances natural environmental variability which could ultimately contribute to increased fish diversity. Low-cost programs like EPM can be implemented as a part of adaptive management plans to help maintain biodiversity and ecosystem health in anthropogenically altered rivers.

Understanding how transport choices are affected by the environment and health: views expressed in a study on the use of carbon calculators.

OBJECTIVES: To examine the influence that the provision of environmental information might be able to make on personal travel behaviour through analysis of the views of members of the public expressed in a study for the UK Department for Transport on attitudes towards carbon calculator tools. STUDY DESIGN: A three-stage qualitative survey taking an ideographic approach to analysing public attitudes to the use of carbon calculator tools in relation to making transport decisions. METHODS: Interviews and discussion groups with stakeholders, non-users and users providing extensive data that were analysed using the British Market Research Bureau's matrix mapping methodology. RESULTS: Despite considerable awareness of climate change as an issue, personal carbon emissions were not found to have much influence on personal transport choice, which could be seen as being dominated by issues of cost (both in time and money), comfort and convenience. CONCLUSIONS: The spatial and temporal dislocation of the cause and effects of climate change make it difficult to link the impacts of personal travel behaviour with specific activities. If environmental- and health-based information is to be provided as a lever to change travel behaviour, it may be necessary to provide information on issues such as local air pollution and personal health impacts in order to link wider benefits with a travel user's self-interest.

The effect of keto-analogues of essential amino acids in severe chronic uremia.

Alpha keto-analogues of valine, leucine, isoleucine, methionine, phenylalanine, and (in one instance) tryptophan and histidine, along with the remaining essential amino acids, were administered orally to 10 patients with severe chronic uremia fed a diet low in protein but adequate in calories. Ketoacid dosage varied from 6 to 14 g daily, as sodium or calcium salts. Net nitrogen intake, calculated as intake minus urinary protein nitrogen, averaged 1.8 g/day. The urea space was either estimated or measured with [(14)C]urea and daily changes in the body urea pool were calculated. Urea appearance was measured as the sum of urea excretion and the change in urea pool. If these ketoacids were converted to amino acids and utilized for protein synthesis, a fall in urea nitrogen appearance should occur. In five subjects, ketoacids were given for 15-18 days and then withdrawn. Urea nitrogen appearance increased 1.55 g/day on withdrawing ketoacids, and corrected nitrogen balance decreased by 1.73 g/day. In two other subjects ketoacid administration was followed, on two occasions each, by a period of administration of nine essential amino acids. In three of these four instances, urea appearance rose significantly with amino acids. In four patients studied at high blood urea levels, ketoacid treatment was relatively ineffective; two of these patients responded more favorably when studied again after peritoneal dialysis. One of these improved enough clinically to be managed as an out-patient for short intervals, despite virtual anuria. No accumulation of ketoacids in plasma or urine could be detected, and no toxicity was identified.

Synthesis of essential amino acids from their alpha-keto analogues by perfused rat liver and muscle.

Most essential amino acids can be replaced by their alpha-keto-analogues in the diet. These ketoacids have therefore been proposed as substitutes for dietary protein. In order to determine their fate in tissues of normal animals, isolated rat liver and hindquarter (muscle) preparations were perfused with keto-analogues of valine, leucine, isoleucine, methionine, or phenylalanine. When perfused at 1.5-2.0 mM, all five compounds were utilized rapidly by the liver of 48-h starved rats, at rates varying from 49 to 155 mumol/h per 200g rat. The corresponding amino acids appeared in the medium in significantly increased concentrations. Perfusion with phenylpyruvate also led to the appearance of tyrosine. Urea release was unaltered. Measurement of metabolite concentrations in freeze-clamped liver revealed two abnormalities, particularly at ketoacid concentrations of 5 mM or above: a large increase in alpha-ketoglutarate, and a moderate to marked decrease in tissue glutamine. This decrease was quantitatively sufficient to account for nitrogen appearing in newly synthesized amino acids. Isolated hindquarters of fed rats were perfused with the same ketoacids at concentrations of 1.3-8.0 mM. All were utilized at rates varying from 1.4 to 7.0 mumol/h per g muscle perfused. The corresponding amino acids were released at greatly increased rates. Alanine and glutamate levels fell in some perfusions, but the principal nitrogen donor in muscle was not identified; the content of glutamine in tissue, and its rate of release into the perfusate remained constant.

Simplified preparation of rabbit Fab fragments.

Papain attached to solid-phase CH-Sepharose 4B was used to digest rabbit IgG. Protein A-Sepharose CL-4B was used to remove undigested IgG and Fc fragments. Pure Fab fragments free of IgG, Fc fragments and papain were readily obtained by this procedure with a yield of about 75%. Polyacrylamide gel electrophoresis of the Fab in the presence of sodium dodecyl sulphate gave a single band under both reducing and non-reducing conditions. The molecular weight of the Fab determined by sedimentation equilibrium was 49,200. Unlike the IgG, the Fab obtained did not form precipitin lines when used in immunoelectrophoresis.

Differences in antischistosomal and mutagenic properties between an isothiocyano- and an isocyanonitrodiphenylamine.

While 4-isothiocyano-4'-nitrodiphenylamine has high schistosomicidal activity in vivo and is devoid of mutagenic properties in vitro, the reverse is true for the isocyano analogue of this compound; i.e., replacement of the sulfur by oxygen results in a compound that has no demonstrable antischistosomal effects and exhibits significant mutagenic activity.

Early management of bites by the eastern diamondback rattlesnake (Crotalus adamanteus): studies in monkeys (Macaca fascicularis).

Monkeys were injected subcutaneously with 6 mg of Crotalus adamanteus venom and a solid phase radioimmunoassay was used to measure levels of venom in plasma and urine. When no attempt was made to retard venom movement from the site of injection, plasma levels as high as 1,300 ng/ml occurred within 15 min of injection and progressive swelling developed in the injected limb. When first aid was employed (firm pressure to the injection site and immobilization of limb with a splint), plasma levels remained very low until cessation of first aid. No swelling of the injected limb occurred while the first aid measures were in position, and animals which received first aid an antivenom fared much better than did those which received antivenom alone. The best result was obtained when antivenom was infused prior to removal of the pressure bandages and splint. This first aid procedure is effective in delaying venom movement, and its simplicity and safety suggest it should be considered for use in cases of human envenoming by C. adamanteus.

Prospects for the development of new vaccine adjuvants.

This review focuses on the impact of various new adjuvant formulations on the efficacy of existing and new human vaccines. Despite major advances in our understanding of immunology and vaccine adjuvants, existing and even new prophylactic vaccines seem likely to maintain their dependence upon aluminium salts for the foreseeable future. Additional immunomodulators may be included in these formulations to improve efficacy. A number of immunotherapeutic cancer vaccines appear likely to be registered soon and these will be dependent for efficacy upon new adjuvant formulations. The most useful to date have been the saponins e.g. QS-21, detox-B and Mycobacterial cells (either live as BCG, or killed). Vaccines to treat chronic infections will doubtless benefit from these developments. Adjuvant formulations and technologies exist to permit development of mucosal delivery, needle-free parenteral delivery and single dose vaccines. However, each of these will require intensive development, which will doubtless arrive when demanded by a specific application. Possibilities exist to improve responses in the elderly and to overcome the inhibitory effects of maternal antibodies in neonates. However, considerable work is required to establish the practicality and general utility of new approaches.

Patients' experiences with hospital care in five countries.

Analysis of patient surveys carried out in Germany, Sweden, Switzerland, the United Kingdom, and the United States in 1998-2000 revealed high rates of problems during inpatient hospital stays. Problems with information and education, coordination of care, respect for patients' preferences, emotional support, physical comfort, involvement of family and friends, and continuity and transition were prevalent in all five countries. These dimensions of patients' experience appear to be salient and relevant in each of the five countries, but attempts to develop international rankings based on this type of evidence will have to overcome a number of methodological problems.

Patient safety: what about the patient?

Plans for improving safety in medical care often ignore the patient's perspective. The active role of patients in their care should be recognised and encouraged. Patients have a key role to play in helping to reach an accurate diagnosis, in deciding about appropriate treatment, in choosing an experienced and safe provider, in ensuring that treatment is appropriately administered, monitored and adhered to, and in identifying adverse events and taking appropriate action. They may experience considerable psychological trauma both as a result of an adverse outcome and through the way the incident is managed. If a medical injury occurs it is important to listen to the patient and/or the family, acknowledge the damage, give an honest and open explanation and an apology, ask about emotional trauma and anxieties about future treatment, and provide practical and financial help quickly.

Computer held chronic disease registers in general practice: a validation study.

Lists of patients receiving repeat prescriptions for epilepsy, diabetes, thyroid disease and asthma were compared with chronic disease registers stored on seven practice computers. Diabetes was the most accurately recorded disease: the names of 72% of patients receiving medication for this condition appeared on the relevant disease registers. Agreement between the two data sources was 68% for thyroid disease, 58% for asthma and 49% for epilepsy. The levels of accuracy are not yet high enough for the computerised chronic disease registers to provide an accurate estimate of the prevalence of these conditions, but new system developments suggest a more optimistic outlook for the future.

Evidence for the sensitivity of the SF-36 health status measure to inequalities in health: results from the Oxford healthy lifestyles survey.

OBJECTIVES: The short form 36 (SF-36) health questionnaire may not be appropriate for population surveys assessing health gain because of the low responsiveness (sensitivity to change) of domains on the measure. An hypothesised health gain of respondents in social class V to that of those in social class I indicated only marginal improvement in self reported health. Subgroup analysis, however, showed that the SF-36 would indicate dramatic changes if the health of social class V could be improved to that of social class I. DESIGN: Postal survey using a questionnaire booklet containing the SF-36 and a number of other items concerned with lifestyles and illness. A letter outlining the purpose of the study was included. SETTING: The sample was drawn from family health services authority (FHSA) computerised registers for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire. SAMPLE: The questionnaire was sent to 13,042 randomly selected subjects between the ages of 17-65. Altogether 9332 (72%) responded. OUTCOME MEASURES: Scores for the eight dimensions of the SF-36. STATISTICS: The sensitivity of the SF-36 was tested by hypothesising that the scores of those in the bottom quartile of the SF-36 scores in class V could be improved to the level of the scores from the bottom quartile of SF-36 scores in class I using the effect size statistic. RESULTS: SF-36 scores for the population at the 25th, 50th, and 75th centiles were provided. Those who reported worse health on each dimension of the SF-36 (ie in the lowest 25% of scores) differ dramatically between social class I and V. Large effect sizes were gained on all but one dimension of the SF-36 when the health of those in the bottom quartile of the SF-36 scores in class V were hypothesised to have improved to the level of the scores from the bottom quartile of SF-36 scores in class I. CONCLUSIONS: Analysis of SF-36 data at a population level is inappropriate; subgroup analysis is more appropriate. The data suggest that if it were possible to improve the functioning and wellbeing of those in worst health in class V to those reporting the worst health in class I the improvement would be dramatic. Furthermore, differences between the classes detected by the SF-36 are substantial and more dramatic than might previously have been imagined.

Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care.

OBJECTIVE: To determine what aspects of healthcare provision are most likely to influence satisfaction with care and willingness to recommend hospital services to others and, secondly, to explore the extent to which satisfaction is a meaningful indicator of patient experience of healthcare services. DESIGN: Postal survey of a sample of patients who underwent a period of inpatient care. Patients were asked to evaluate their overall experience of this episode of care and to complete the Picker Inpatient Survey questionnaire on specific aspects of their care. SAMPLE: Patients aged 18 and over presenting at five hospitals within one NHS trust in Scotland. METHOD: 3592 questionnaires were mailed to patients' homes within 1 month of discharge from hospital during a 12 month period. Two reminders were sent to non-responders; 2249 (65%) questionnaires were returned. RESULTS: Almost 90% of respondents indicated that they were satisfied with their period of inpatient care. Age and overall self-assessed health were only weakly associated with satisfaction. A multiple linear regression indicated that the major determinants of patient satisfaction were physical comfort, emotional support, and respect for patient preferences. However, many patients who reported their satisfaction with the care they received also indicated problems with their inpatient care as measured on the Picker Inpatient Survey; 55% of respondents who rated their inpatient episode as "excellent" indicated problems on 10% of the issues measured on the Picker questionnaire. DISCUSSION: The evidence suggests that patient satisfaction scores present a limited and optimistic picture. Detailed questions about specific aspects of patients' experiences are likely to be more useful for monitoring the performance of various hospital departments and wards and could point to ways in which delivery of health care could be improved.

Factors affecting response to an invitation to attend for a health check.

OBJECTIVE: To describe the characteristics of general practice patients who fail to respond to an invitation to attend for a health check, in relation to demographic variables, risk factor status, health status, and attitudes to behaviour modification. DESIGN: Postal questionnaire before invitation to attend a health check and subsequent record of attendance. SETTING: Five urban general practices in Bedfordshire, UK. SUBJECTS: A total of 2678 patients aged 35-64 years were invited for a health check in 1989-90. RESULTS: The number of patients who did not attend was low overall but was higher among men than women (21 v 15%, p < 0.001), and in unmarried than married patients (24 v 16%, p < 0.001). Failure to attend was also higher among people in manual than in non-manual occupations (21 v 15%, p < 0.001), in people living in rented accommodation than in homeowners (29 v 16%, p < 0.001), and in those without access to a car than in car users (27 v 16%, p < 0.001). There was no difference in non-attendance rate according to age at completion of full time education. After adjustment for age, sex, marital state, and social class, the odds ratio for non-attendance was 1.74 (95% confidence interval (CI) 1.41, 2.14) for smokers; 1.07 (95% CI 0.76, 1.51) for heavy drinkers; 1.91 (95% CI 1.41, 2.58) for those with a less healthy diet; and 1.50 (95% CI 1.09, 2.07) for those who were obese. Patients who had visited their general practice more frequently and those who indicated a willingness to change their behaviour were significantly more likely to attend the health check. CONCLUSIONS: Health check attendance was lowest among patients who rarely attended the surgery and those who reported higher risk behaviour. Attendance was not, however, confined to the 'worried well'. Equal numbers of those with and without chest pain attended, as did at least three quarters of those in each risk group. This high rate of attendance reflects the time and effort invested in systematic recruitment. The development of a robust recruiting strategy is essential if substantial numbers, and particularly those at highest risk, are to be reached.

The mass of venom injected by two elapidae: the taipan (Oxyuranus scutellatus) and the Australian tiger snake (Notechis scutatus).

Using an enzyme immunoassay technique, a new method for measuring, in vivo, the mass of venom injected during snake bite, is presented. The venom injected into mice (as prey) and the venom left on the skin surface during bites by the two Australian Elapidae, the Taipan (Oxyuranus scutellatus) and the Tiger Snake (Notechus scutatus) has been measured. Venom delivery patterns vary significantly between these two species. In the case of the Tiger Snake (a total of 45 bites studied) the mean mass of venom injected in a first bite was 12.7 mg (S.E. 3.4 mg, median 8.1 mg); an average mass of 0.8 mg (S.E. 0.4 mg, median 0.17 mg) was left on the skin surface. A second bite delivered by the same snake yielded a mean venom mass only 27% of the first. In the case of the Taipan (a total of 24 bites) the mean venom mass injected in the first bite was 20.8 mg (S.E. 6.4 mg); with an average of 0.9 mg (S.E. 0.5 mg) left on the skin surface. In contrast to the situation observed with Tiger Snakes, second and third bites delivered in a rapid sequence yielded increasing masses of venom. The mean delivered in the third of a sequence of three bites was 48.8 mg (S.E. 23.8 mg). The ranges of venom mass, by species and by the sequence number of the bite, are also presented. In 66 of the 69 experimental bites studied in this report, venom could be easily detected, the species identified, and the absolute mass of venom measured.

Further studies on the mass of venom injected by Elapid snakes.

Further experimental studies to determine the mass of venom injected by medically-significant Australian elapids are reported. The use of a modified enzyme immunoassay technique to measure venom injected during snake bite is presented. The feeding biting pattern of the Australian eastern brown snake (Pseudonaja textilis) is described. Using data from ten different snakes of this species, it is established that the mass of venom delivered in a first-bite is 4.69 +/- 0.85 mg (mean +/- S.E.) and a mean of 91% of the delivered venom is injected s.c. or into deeper tissues in a first-bite. For this species, the mass of venom delivered sequentially in a bite sequence falls to 1.32 +/- 0.94 mg in the third bite in such a sequence. For the Australian rough-scaled snake (Tropidechis carinatus), the mass of venom delivered in a first feeding bite is 6.15 +/- 2.23 mg, falling to a minimum of 1.92 +/- 0.61 mg in the third bite of a sequence. for the Australian death adder (Acanthophis antarcticus) the mass of venom delivered in a feeding bite is 41.95 +/- 16.13 mg for a first bite. Biting data is also presented for three species of the genus Pseudechis (the Australian mulga (king brown) and black snakes.

Do British women undergo too many or too few hysterectomies?

Hysterectomy is performed much less frequently in Britain than in North America, Australia and some European countries. Various theories have been advanced to explain this lower rate of surgery. These include: fewer health care resources (hospital beds, surgeons); much less fee-for-service medicine; differences in the attitudes of surgeons; differences in health care organisation, in particular the gatekeeping role of general practitioners; and differences in patients' expectations. This paper reviews the evidence on sources of variation and examines the extent to which hysterectomy rates vary between countries, and between small areas and social groups within Britain. Following an examination of national trends, evidence is presented from studies carried out in the Oxford region to illustrate the extent of variation in the rate at which hysterectomy is carried out and to explore the possible reasons for the differences. The article considers the health policy implications of an apparent increase in demand for hysterectomy and argues the case for a thorough evaluation of the impact of this operation on quality of life.

Lack of willpower or lack of wherewithal? "Internal" and "external" barriers to changing diet and exercise in a three year follow-up of participants in a health check.

The aims of this paper were to assess whether anticipated barriers to change in diet and exercise which were cited before a health check intervention were related to subsequent behaviour changes. In 1989 a health and lifestyle questionnaire was posted to 17,965 people aged 35-64 who were registered with five general practices in Bedfordshire. Taking account of non-contacts, a response rate of 80.3% was achieved and 11,090 people described their exercise and dietary habits. Those expressing an interest in changing each behaviour were asked to identify reasons why change might be difficult. Two types of barriers--"internal" and "external"--were identified. A total of 2205 respondents were invited to attend a health check in Year One and a recheck three years later and 1660 attended. In this subgroup improvement in exercise and diet was examined in relation to the participants' baseline characteristics, including the type of barriers selected. Internal barriers to change (e.g. lack of willpower, too lazy, too busy) were chosen most frequently. In a logistic regression including a range of baseline variables those who selected only internal barriers were less likely to take more exercise (OR 0.59, 95% CI 0.41, 0.86) than those who cited only external (e.g. no transport, can't afford sports facilities) or mixed barriers to changing. There was a similar but not statistically significant trend for changing diet (OR 0.78, 95% CI 0.48, 1.28). Those who are aware of external limitations may be better placed to circumvent them. Further research is needed to explore this relationship between type of barrier and behaviour change.