Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study.

INTRODUCTION: People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI? METHODS AND ANALYSIS: We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting. ETHICS AND DISSEMINATION: This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

In a niche of time: do specialty hospitals outperform general services hospitals?

Niche hospitals represent a growing segment in the health care industry. Niche facilities are primarily engaged in the treatment of cardiac or orthopedic conditions. The effectiveness of this strategy is of interest because niche hospitals focus on only the most profitable services. The purpose of this research was to assess the financial effectiveness of the niche strategy. We theorize that firm and market-level factors concomitantly with the strategy of the hospital-niche versus traditional-are associated with financial performance. This research used 2 data sources, the 2003 Medicare Cost Report and the 2003 Area Resource File. The sample was limited to only for-profit, urban, nongovernmental hospitals (n = 995). The data were analyzed using hierarchical least squares regression. Financial performance was operationalized using the hospital's return on assets. The principal finding of this project is that niche hospitals had significantly higher performance than traditional facilities. From the organizational perspective, the niche strategy leads to better financial performance. From a societal perspective, the niche strategy provides increased focus and efficiencies through repetition. Despite the limited focus of this strategy, patients who can access these providers may experience better outcomes than patients in more traditional hospitals.

{2,6-Bis[(2,6-diisopropyl-phosphan-yl)-oxy]-4-fluoro-phenyl-κ(3)P,C(1),P'}(1H-pyrazole-κN(2))nickel(II) hexa-fluoro-phosphate.

The title compound, [Ni(C(18)H(30)FO(2)P(2))(C(3)H(4)N(2))]PF(6), was prepared by halide abstraction with TlPF(6) in the presence of CH(3)CN in CDCl(3) from the respective neutral pincer chlorido analogue followed by addition of pyrazole. The PO-C-OP pincer ligand acts in typical trans-P(2) tridentate fashion to generate a distorted square-planar nickel structure. The Ni-N(pyrazole) distance is 1.925 (2) Šand the plane of the pyrazole ligand is rotated 56.2 (1)° relative to the approximate square plane surrounding the Ni(II) center in which the pyrazole is bound to the Ni(II) atom through its sp(2)-hybridized N atom. This Ni-N distance is similar to bond lengths in the other reported Ni(II) pincer-ligand square-planar pyrazole complex structures; however, its dihedral angle is significantly larger than any of those for the latter set of pyrazole complexes.

{2,6-Bis[(2,6-diphenyl-phosphan-yl)-oxy]-4-fluoro-phenyl-κP,C,P'}(6-methyl-2,2,4-trioxo-3,4-dihydro-1,2,3-oxathia-zin-3-ido-κN)palladium(II).

The title acesulfamate complex, [Pd(C(30)H(22)FO(2)P(2))(C(4)H(4)NO(4)S)], contains a four-coordinate Pd(II) ion with the expected, although relatively distorted, square-planar geometry where the four L-Pd-L angles range from 79.58 (8) to 102.47 (7)°. The acesulfamate ligand is N-bound to Pd [Pd-N = 2.127 (2) Å] with a dihedral angle of 76.35 (6)° relative to the square plane. Relatively long phen-yl-acesulfamate C-H⋯O and phen-yl-fluorine C-H⋯F inter-actions consolidate the crystal packing.

Review: hCG, preeclampsia and regulatory T cells.

Human chorionic gonadotropin (hCG) is crucial for successful pregnancy. Its many functions include angiogenesis and immune regulation. Despite years of research, the etiology of preeclampsia remains unknown. Marked by insufficient trophoblast invasion and poor spiral artery remodeling, preeclampsia has also been linked to immune dysregulation. Here we discuss the roles of hCG in the context of endovascular cross-talk between trophoblasts and endothelial cells and immune tolerance. We propose that functional and glycosylation modifications of hCG may contribute to the pathogenesis of preeclampsia.

Dichlorido(η-p-cymene)(4-fluoro-aniline-κN)ruthenium(II).

The title compound, [RuCl(2)(C(10)H(14))(C(6)H(6)FN)], a pseudo-octa-hedral d(6) complex, has the expected piano-stool geometry around the Ru(II) atom. The fluoro-aniline ring forms a dihedral angle of 19.3 (2)° with the p-cymene ring. In the crystal, two mol-ecules form an inversion dimer via a pair of N-H⋯Cl hydrogen bonds. Weak inter-molecular C-H⋯Cl inter-actions involving the p-cymene ring consolidate the crystal packing.

Chlorido{2-[(dimethyl-amino)-methyl]phenyl-κC,N}(1-methyl-1H-imidazole-κN)palladium(II).

In the title compound, [Pd(C(9)H(12)N)Cl(C(4)H(6)N(2))], which was synthesized from the reaction of 1-methyl-imidazole with dimeric dichloridobis[2-(dimethyl-amino)-benz-yl]palla-dium(II), the ring-deprotonated N,N-dimethyl-benzyl-amine ligand acts in a C,N-bidentate fashion. The dihedral angle between the ring of the 1-methyl-imidazole ligand and the palladacycle plane is 57.88 (16)°. The two N atoms from the N,N-dimethyl-benzyl-amine and 1-methyl-imidazole ligands are trans coordinated to the Pd(II) atom.

Pilot study on light dosimetry variables for photodynamic therapy of Barrett's esophagus with high-grade dysplasia.

PURPOSE: Photodynamic therapy (PDT) is used to treat Barrett's esophagus with high-grade dysplasia and mucosal carcinoma. Outcomes are variable with some patients having persistent disease, whereas others develop strictures. The aims of this study were (a) to compare porfimer sodium tissue uptake, light dose, and esophageal thickness with clinical outcomes and (b) to determine the selectivity of porfimer sodium uptake in diseased and normal epithelium. EXPERIMENTAL DESIGN: Forty-eight hours after porfimer sodium infusion, patients underwent mucosal biopsy for quantification of the porfimer sodium. Laser light was delivered at 48 hours and again 24 or 48 hours later. Porfimer sodium was extracted from the biopsy samples and quantified using fluorescence spectroscopy. The enhanced photodynamic dose was determined as [porfimer sodium content * light dose/esophageal thickness]. PDT efficacy was determined 6 to 8 weeks later based on persistence or complete ablation of dysplasia or carcinoma. RESULTS: Mean porfimer sodium content of 6.2 mg/kg (range, 2.6-11.2 mg/kg) and mean total light dose of 278 J/cm (range, 225-360 J/cm) resulted in a complete treatment. Mean porfimer sodium tissue content of 3.9 mg/kg (range, 2.1-8.1 mg/kg) and mean total light dose of 268 J/cm (range, 250-350 J/cm) resulted in an incomplete treatment. The total esophageal thickness (range, 1.7-6.0 mm) and enhanced photodynamic dose were correlated with treatment outcome. CONCLUSIONS: Esophageal thickness is the strongest predictor of treatment outcome. The porfimer sodium content of Barrett's and normal tissue is not significantly different. "Photodynamic dose" for esophageal PDT should incorporate the esophageal thickness.

Monte carlo model of stricture formation in photodynamic therapy of normal pig esophagus.

Photodynamic therapy (PDT) is FDA-approved for use in patients with Barrett's esophagus using porfimer sodium (2 mg per kg) and a recommended light dose of 130 J cm(-1) for high grade dysplasia. Despite uniform drug and light doses, the clinical outcome of PDT is variable. A significant number of PDT cases result in esophageal strictures, a side effect related to excessive energy absorption. The purpose of this project was to model esophageal stricture formation with a Monte Carlo simulation. An original multilayer Monte Carlo computer simulation was developed for esophageal PDT. Optical absorption and scattering coefficients were derived for mucosal and muscle layers of normal porcine esophagus. Porfimer sodium was added to each layer by increasing the absorption coefficient by the appropriate amount. A threshold-absorbed light dose was assumed to be required for stricture formation and ablation. The simulation predicted irreversible damage to the mucosa with a 160 J cm(-1) light dose and damage to the muscle layer with an additional 160 J cm(-1) light dose for a tissue porfimer sodium content of 3.5 mg kg(-1). The simulation accurately modeled photodynamic stricture formation in normal pig in vivo esophageal tissue. This preliminary work suggests that the absorbed light threshold for stricture formation may be between 2 and 4 J per gram of tissue.

Effects of fiber-optic probe design and probe-to-target distance on diffuse reflectance measurements of turbid media: an experimental and computational study at 337 nm.

Fiber-optic probes are widely used in optical spectroscopy of biological tissues and other turbid media. Only limited information exists, however, on the ways in which the illumination-collection geometry and the overall probe design influence the interrogation of media. We have investigated both experimentally and computationally the effect of probe-to-target distance (PTD) on the diffuse reflectance collected from an isotropically (Lambertian) scattering target and an agar-based tissue phantom. Studies were conducted with three probes characterized by either common (single-fiber) or separate (two bifurcated multifiber probes) illumination and collection channels. This study demonstrates that PTD, probe design, and tissue scattering anisotropy influence the extent of the transport of light into the medium, the light-collection efficiency, and the sampling volume of collected light. The findings can be applied toward optimization of fiber-optic probe designs for quantitative optical spectroscopy of turbid media including biological tissues.

Sweet success: Ionic liquids derived from non-nutritive sweeteners.

The anions of the sweeteners saccharin and acesulfame form ionic liquids when paired with a variety of organic cations.

Vibration as a possible explanation for putative electromagnetic field effects: a case study on marine diatoms.

PURPOSE: We examined the conjecture that mechanical vibration, being an uncontrolled and variable factor from one trial to another, might explain the inconsistency of results from investigations of the influence of extremely low frequency electromagnetic fields on the Ca-dependent motility of marine diatoms (Amphora coffeaeformis, strain #2038). MATERIALS AND METHODS: Owing to slight differences in culture of diatoms in previous studies, culture techniques are described in detail here. Diatoms showed maximal motility in logarithmic growth and motility was dependent on external [Ca], reducing at <.25 mM added Ca. Ninety-six different vertical vibration treatments were applied to the petri dishes containing the agar on which the diatoms were placed. The envelope of amplitudes varied from 50-500 pmicro at 10Hz to 100 nm-l1mmicro at 500 Hz. RESULTS: No significant effect of the mechanical vibrations on the motility response of diatoms was observed. We were unable to impose deliberate vibrations in a horizontal direction though some component of horizontal movement was probably present in our tests. CONCLUSIONS: The results imply that the variability of earlier experiments with extremely low frequency electromagnetic fields is unlikely to be ascribable to mechanical vibration.

A priori assessment of the stereoelectronic profile of phosphines and phosphites.

This research has demonstrated the utility of a rigorously calibrated, molecular mechanics/semiempirical quantum mechanical protocol for developing stereoelectronic (Tolman) maps for phosphine ligands. A computational analysis of alkyl and aryl phosphines in common usage suggests that these ligands are quite similar stereoelectronically. A noticeable gap in the Tolman map for common phosphines is observed for large, electron-poor phosphines. Several candidates meeting these criteria were identified, the most promising of which is P(t-C(4)F(9))(3). Phosphines in which the phosphorus participates in a ring, which comprise a very small subset of reported phosphines, have very interesting stereoelectronic properties, particularly those in which the ligating phosphorus is part of a three-membered ring. In terms of steric properties, the symmetric deformation coordinate proposed by Orpen and co-workers on the basis of crystallographic studies is calculated with sufficient accuracy using PM3(tm) to allow good confidence in predictions of novel phosphines. For quantification of the electronic properties of phosphines, we analyzed changes in the CO stretching frequency upon changing the ancillary phosphine ligands.

Sorption of fluoroacetate (compound 1080) by Colestipol, activated charcoal and anion-exchange in resins in vitro and gastrointestinal decontamination in rats.

The sorption of sodium fluoroacetate (FA) by activated charcoal (AC) and 5 anion exchange resins (AERs) was tested in 2 simulated gastrointestinal (GI) fluids. Each sorbent was incubated with FA in a shaker-water-bath at 37 C for 24 h. Supernatant was removed and filtered, and the concentration of FA was determined by gas chromatographic detection of the dichloroaniline derivative. Under simulated gastric conditions (0.1 M HCl at approximately pH 1.5), the sorbents removed the following proportions of FA from solution: Carbosorb AC, 87 +/- 2%; cholestyramine, 28 +/- 7%; colestipol, 96 +/- 0%; Amberlite IRA-96, 70 +/- 2%; DEAE-Sephadex, 7 +/- 4%; Chitosan, 66 +/- 2%. Under simulated intestinal conditions (0.05 M sodium phosphate at approximately pH 7.4), binding was as follows: Carbosorb AC, 68 +/- 4%; cholestyramine, 53 +/- 5%; colestipol, 46 +/- 2%; AmberliteIRA-96, 10 +/- 20%; DEAE-Sephadex, 64 +/- 7%; Chitosan, 5 +/- 2%. All findings differed significantly from control, with the exception of Amberlite IRA-96 and Chitosan in phosphate buffer, and DEAE-Sephadex in HCI. In a second study, rats were given 5 mg FA/kg, and then gavaged with 2 g/kg Carbosorb AC, colestipol or bentonite. Over 4 h, the area under the curve of serum FA versus time (AUC) decreased by 39% in the rats treated with colestipol and 42% in those treated with bentonite. In contrast, Carbosorb AC did not affect the AUC,yet increased Tmax In another study, mortality was assessed 96 h after rats were orally dosed with 5 mg FA/kg followed by gavage with 2 g/kg Carbosorb AC, colestipol or water immediatey or 30 min after dosing. When the sorbents were given immediately, mortality was the same as control (75%). Surprisingiy, the 30-min delay resulted in lower mortality in colestipol-treated rats, (approximately 38%) compared to 100% in the group treated with Carbosorb AC. Before any recommendation can be made regarding the use of colestipol as a GI decontaminant, the latter findings require confirmation in an intensive care setting. The potential for synergistic effects with 2 or more sorbents also warrant investigating.

Slow muscle induction by Hedgehog signalling in vitro.

Muscles are composed of several fibre types, the precise combination of which determines muscle function. Whereas neonatal and adult fibre type is influenced by a number of extrinsic factors, such as neural input and muscle load, there is little knowledge of how muscle cells are initially determined in the early embryo. In the zebrafish, fibres of the slow twitch class arise from precociously specified myoblasts that lie close to the midline whereas the remainder of the myotome differentiates as fast myosin expressing muscle. In vivo evidence has suggested the Sonic Hedgehog glycoprotein, secreted from the notochord, controls the formation of slow twitch and fast twitch muscle fates. Here we describe an in vitro culture system that we have developed to test directly the ability of zebrafish myoblasts to respond to exogenous Sonic Hedgehog peptide. We find that Sonic Hedgehog peptide can control the binary cell fate choice of embryonic zebrafish myoblasts in vitro. We have also used this culture system to assay the relative activities of different Hedgehog-family proteins and to investigate the possible involvement of heterotrimeric G-proteins in Hedgehog signal transduction.

Drawing specimens for coagulation testing: is a second tube necessary?

Three recent studies discussed the possibility that the National Committee for Clinical Laboratory Standards (NCCLS) recommendations that the coagulation specimen should be the second or third tube collected are unnecessary. However, only one reagent/instrument was used in each study. Our protocol differed from the previous studies because we performed the assays on three different reagent/instrument systems on the same samples. Our study used photo-optic, mechanical, and nephelometric systems of clot detection. After obtaining informed consent, we obtained two blue-stoppered tubes of blood from 95 subjects: 15 normal patients and 80 patients currently on coumadin therapy. No discard tube was drawn for coagulation testing. A prothrombin time with an international normalized ratio and an activated partial thromboplastin time, were performed on each tube. Laboratory One used a MLA 1600C (Hemoliance) with Thromboplastin DS (Pacific-Hemostasis, ISI of 1.11) and APTT-LS (Pacific-Hemostasis). Laboratory Two used an STA (Diagnostica-Stago) with Neoplastine CI+ (Diagnostica-Stago, ISI of 1.14) and PTT-LT (Diagnostica-Stago). Laboratory Three used an ACL 300 with Plastinex (Biodata, ISI of 1.67) and Actin FSL (Dade Behring). No clinical or statistically significant differences were seen between the first or second tubes on any of the three reagent/instrument combinations in the PT in seconds, international normalized ratio reporting, or APTT results. Our results indicate that the NCCLS guidelines for obtaining a second tube when performing coagulation testing should be considered for elimination when new revisions are published.

Estimates of Sulfate Deposition in the Middle Eastern United States: 1975, 1990, and 2010.

Deposition of airborne sulfates and nitrates is considered to be an important factor in the decline of certain fish populations and of forest health in the eastern United States. A solution has been sought through legislation that mandates significant reductions in anthropogenic emissions of oxides of sulfur and nitrogen, precursors of sulfates and nitrates. This paper looks at the changes in sulfate deposition in the middle eastern United States from 1975 to 1990 and 2010 due to SO2 emission reductions brought about by 1970, 1977, and 1990 clean-air legislation. Recently developed emission inventories, together with a statistical, long-range transport model, were used to construct the estimates. The results show that sulfate deposition decreased over the middle eastern United States by about 25% between 1975 and 1990 and will decrease another 45% between 1990 and 2010-reductions commensurate with the overall decreases in SO2 emissions. The results further indicate that about half of the sulfur deposited in the environmentally sensitive southern Appalachian Mountains comes from states not a part of the southern Appalachian region. These estimates contain a measure of uncertainty due to uncertainty in emission estimates, the interannual variability of meteorology, and uncertainty arising from model assumptions and choices of oxidation and deposition rates. The model was able to reproduce about 10% of the variability in observations of wet sulfate deposition at over 100 sites over a 12-year period.

What is a HISS? Hospital Information Support System.

A HISS is a Hospital Information Support System and the idea is that it is primarily there to support clinical activity not to provide management information. When the concept of a HISS first emerged it was seen as a very large system where all hospital departments shared one computer system and that is the model used by the first few HISS sites. As the Health Service has changed and the difficulties of replacing all the computer systems in a hospital with one large system have been appreciated, so the concept of HISS has developed. We now talk about an incremental approach to HISS. This means looking at the present systems and deciding which ones should be retained and 'interfaced' with the new system. No system is the best for every department and this approach allowing 'foreign' systems to be attached to the main system (usually centred on the Patient Administrative System) does provide a good fit with the needs of the department. This does not need to be implemented immediately but can be introduced at the end of the life of an existing system, thus protecting the past investment in systems.

Neural induction and regionalisation in the chick embryo.

Induction and regionalisation of the chick nervous system were investigated by transplanting Hensen's node into the extra-embryonic region (area opaca margin) of a host embryo. Chick/quail chimaeras were used to determine the contributions of host and donor tissue to the supernumerary axis, and three molecular markers, Engrailed, neurofilaments (antibody 3A10) and XlHbox1/Hox3.3 were used to aid the identification of particular regions of the ectopic axis. We find that the age of the node determines the regions of the nervous system that form: young nodes (stages 2-4) induced both anterior and posterior nervous system, while older nodes (stages 5-6) have reduced inducing ability and generate only posterior nervous system. By varying the age of the host embryo, we show that the competence of the epiblast to respond to neural induction declines after stage 4. We conclude that during normal development, the initial steps of neural induction take place before stage 4 and that anteroposterior regionalisation of the nervous system may be a later process, perhaps associated with the differentiating notochord. We also speculate that the mechanisms responsible for induction of head CNS differ from those that generate the spinal cord: the trunk CNS could arise by homeogenetic induction by anterior CNS or by elongation of neural primordia that are induced very early.