Social connections and social identity as a basis for learning and support: Experiences of medical students with minoritised and non-minoritised ethnic identities

BACKGROUND

Social connections between medical students provide a key basis for learning and support. These connections, and associated social identity, may be patterned by ethnicity, and students often perform similarly academically to those they connect with. The mechanisms that underpin the formation of these connections and the role that they play are not fully understood. This study explored how medical students connect with each other, and the potential impact of this on their academic attainment and well-being, with a focus on students with minoritised ethnic identities.

METHODS

A mixed methods study combining (1) a survey to establish the number and strength of connections formed by Years 1 and 2 medical students with both minoritised and non-minoritised ethnicities and (2) semi-structured interviews to understand how connections were formed, whether this was shaped by ethnicity and the role of connections in supporting students with their learning and well-being.

RESULTS

One hundred fifty-one students (15.5% response rate) completed the survey. Students connected regularly with three to four peers with the goal of supporting learning and 71.9% of students reported a sense of social identification with this group. There was no statistical difference between ethnically minoritised and White students on either of these measures (t = 0.1, p = 0.92, χ2  = 2.9, p = 0.56). Interviews with 19 students found that social connections were shaped by perceptions of their self-identity and the need to find 'equilibrium' by forming relationships with compatible others. The education environment, including its ethnic diversity, impacted on the opportunities to make connections. Students who were ethnically minoritised reported encountering challenges, especially in the clinical environment, and described the burden of these for them.

DISCUSSION

Curriculum designers should consider the time and space that is afforded to student interaction during course development, as finding compatible others with whom students can socially connect is important to balancing well-being with academic performance.

Measurement of Dark Ice-Ablator Mix in Inertial Confinement Fusion

We present measurements of ice-ablator mix at stagnation of inertially confined, cryogenically layered capsule implosions. An ice layer thickness scan with layers significantly thinner than used in ignition experiments enables us to investigate mix near the inner ablator interface. Our experiments reveal for the first time that the majority of atomically mixed ablator material is "dark" mix. It is seeded by the ice-ablator interface instability and located in the relatively cooler, denser region of the fuel assembly surrounding the fusion hot spot. The amount of dark mix is an important quantity as it is thought to affect both fusion fuel compression and burn propagation when it turns into hot mix as the burn wave propagates through the initially colder fuel region surrounding an igniting hot spot. We demonstrate a significant reduction in ice-ablator mix in the hot-spot boundary region when we increase the initial ice layer thickness.

Ottawa 2020 consensus statement for programmatic assessment - 1. Agreement on the principles

INTRODUCTION

In the Ottawa 2018 Consensus framework for good assessment, a set of criteria was presented for systems of assessment. Currently, programmatic assessment is being established in an increasing number of programmes. In this Ottawa 2020 consensus statement for programmatic assessment insights from practice and research are used to define the principles of programmatic assessment.

METHODS

For fifteen programmes in health professions education affiliated with members of an expert group (n = 20), an inventory was completed for the perceived components, rationale, and importance of a programmatic assessment design. Input from attendees of a programmatic assessment workshop and symposium at the 2020 Ottawa conference was included. The outcome is discussed in concurrence with current theory and research.

RESULTS AND DISCUSSION

Twelve principles are presented that are considered as important and recognisable facets of programmatic assessment. Overall these principles were used in the curriculum and assessment design, albeit with a range of approaches and rigor, suggesting that programmatic assessment is an achievable education and assessment model, embedded both in practice and research. Knowledge on and sharing how programmatic assessment is being operationalized may help support educators charting their own implementation journey of programmatic assessment in their respective programmes.

Record Energetics for an Inertial Fusion Implosion at NIF

Inertial confinement fusion seeks to create burning plasma conditions in a spherical capsule implosion, which requires efficiently absorbing the driver energy in the capsule, transferring that energy into kinetic energy of the imploding DT fuel and then into internal energy of the fuel at stagnation. We report new implosions conducted on the National Ignition Facility (NIF) with several improvements on recent work [Phys. Rev. Lett. 120, 245003 (2018)PRLTAO0031-900710.1103/PhysRevLett.120.245003; Phys. Rev. E 102, 023210 (2020)PRESCM2470-004510.1103/PhysRevE.102.023210]: larger capsules, thicker fuel layers to mitigate fuel-ablator mix, and new symmetry control via cross-beam energy transfer; at modest velocities, these experiments achieve record values for the implosion energetics figures of merit as well as fusion yield for a NIF experiment.

Evidence of Three-Dimensional Asymmetries Seeded by High-Density Carbon-Ablator Nonuniformity in Experiments at the National Ignition Facility

Inertial confinement fusion implosions must achieve high in-flight shell velocity, sufficient energy coupling between the hot spot and imploding shell, and high areal density (ρR=∫ρdr) at stagnation. Asymmetries in ρR degrade the coupling of shell kinetic energy to the hot spot and reduce the confinement of that energy. We present the first evidence that nonuniformity in the ablator shell thickness (∼0.5% of the total thickness) in high-density carbon experiments is a significant cause for observed 3D ρR asymmetries at the National Ignition Facility. These shell-thickness nonuniformities have significantly impacted some recent experiments leading to ρR asymmetries on the order of ∼25% of the average ρR and hot spot velocities of ∼100  km/s. This work reveals the origin of a significant implosion performance degradation in ignition experiments and places stringent new requirements on capsule thickness metrology and symmetry.

Point Prevalence of Adult Intestinal Failure in Republic Of Ireland

Parenteral Nutrition (PN) is a life-saving treatment used for patients with Intestinal Failure (IF). PN is complex and demands highly specialised care to avoid serious complications in the home setting. All tertiary centres in the Republic of Ireland (ROI) were contacted to assess the prevalence of IF requiring PN and complications, over a one year period. Sixty-seven patients were treated across 15 centres: a period prevalence of 14.6 and 9.6 patients per million for long-term PN and home PN respectively. Three-quarters of patients experienced at least one major complication with 18% mortality rate over the study period. There were 2.86 admissions per HPN patient, each lasting mean 13.4 days. One-third experienced catheter-related infections. There was a reduced length of stay during emergency re-admissions in high volume centres (mean 31 v 43 days, p=0.17). The establishment of a National Centre for IF/HPN in ROI is integral to reducing PN-associated complications.

Publisher's Note: X-ray shadow imprint of hydrodynamic instabilities on the surface of inertial confinement fusion capsules by the fuel fill tube [Phys. Rev. E 95, 031204(R) (2017)]

This corrects the article DOI: 10.1103/PhysRevE.95.031204.

X-ray shadow imprint of hydrodynamic instabilities on the surface of inertial confinement fusion capsules by the fuel fill tube

Measurements of hydrodynamic instability growth for a high-density carbon ablator for indirectly driven inertial confinement fusion implosions on the National Ignition Facility are reported. We observe significant unexpected features on the capsule surface created by shadows of the capsule fill tube, as illuminated by laser-irradiated x-ray spots on the hohlraum wall. These shadows increase the spatial size and shape of the fill tube perturbation in a way that can significantly degrade performance in layered implosions compared to previous expectations. The measurements were performed at a convergence ratio of ∼2 using in-flight x-ray radiography. The initial seed due to shadow imprint is estimated to be equivalent to ∼50-100 nm of solid ablator material. This discovery has prompted the need for a mitigation strategy for future inertial confinement fusion designs as proposed here.

Potential of Earlier Detection and Treatment of Disease-Related Malnutrition with Oral Nutrition Supplements to Release Acute Care Bed Capacity

A recent systematic review and meta-analysis shows that appropriate use of oral nutrition supplements (ONS) in community patients is associated with a significant reduction in hospitalisations. Given higher use of acute care resource by malnourished versus normally nourished patients, this paper examines the potential to reduce bed utilisation by applying these results to Irish inpatient and malnutrition prevalence data. In 2013, adults admitted to hospital with medium or high malnutrition risk scores used an estimated 36% of adult acute inpatient bed days. Targeted use of ONS in community patients might reduce hospitalisation by 168,438 adult bed days per year, equivalent to 460 beds per day. This is particularly important, given high bed occupancy rates and twelve month daily averages of 254 patients on trolleys. Relevant stakeholders should consider strategies to ensure effective ONS use with a view to improving outcomes and reducing pressure on the acute care system.

Initial experience with a rapid access blackouts triage clinic

Transient loss of consciousness (T-LOC), or blackout, is common in acute medicine. Clinical skills are not done well, with at least 74,000 patients misdiagnosed and mistreated for epilepsy in England alone. The aim of this study was to provide a rapid, structured assessment and an electrocardiogram (ECG) for patients with blackouts, aiming to identify high risk, reduce misdiagnoses, reduce hospital admission rates for low-risk patients, diagnose and treat where appropriate, and also provide onward specialist referral. The majority of patients had syncope, and very few had epilepsy. A high proportion had an abnormal ECG. A specialist-nurse-led rapid access blackouts triage clinic (RABTC) provided rapid effective triage for risk, a comprehensive assessment format, direct treatment for many patients, and otherwise a prompt appropriate onward referral. Rapid assessment through a RABTC reduced re-admissions with blackouts. Widespread use of the web-based blackouts tool could provide the NHS with a performance map. The U.K. has low rates of pacing compared to Western Europe, which RABTCs might help correct. The RABTC sits between first responders and specialist referral, providing clinical assessment and ECG in all cases, and referral where appropriate.

Association between serum perfluorooctanoic acid (PFOA) and thyroid disease in the U.S. National Health and Nutrition Examination Survey

BACKGROUND

Perfluorooctanoic acid (PFOA, also known as C8) and perfluorooctane sulfonate (PFOS) are stable compounds with many industrial and consumer uses. Their persistence in the environment plus toxicity in animal models has raised concern over low-level chronic exposure effects on human health.

OBJECTIVES

We estimated associations between serum PFOA and PFOS concentrations and thyroid disease prevalence in representative samples of the U.S. general population.

METHODS

Analyses of PFOA/PFOS versus disease status in the National Health and Nutrition Examination Survey (NHANES) for 1999-2000, 2003-2004, and 2005-2006 included 3,974 adults with measured concentrations for perfluorinated chemicals. Regression models were adjusted for age, sex, race/ethnicity, education, smoking status, body mass index, and alcohol intake.

RESULTS

The NHANES-weighted prevalence of reporting any thyroid disease was 16.18% (n = 292) in women and 3.06% (n = 69) in men; prevalence of current thyroid disease with related medication was 9.89% (n = 163) in women and 1.88% (n = 46) in men. In fully adjusted logistic models, women with PFOA >or= 5.7 ng/mL [fourth (highest) population quartile] were more likely to report current treated thyroid disease [odds ratio (OR) = 2.24; 95% confidence interval (CI), 1.38-3.65; p = 0.002] compared with PFOA <or= 4.0 ng/mL (quartiles 1 and 2); we found a near significant similar trend in men (OR = 2.12; 95% CI, 0.93-4.82; p = 0.073). For PFOS, in men we found a similar association for those with PFOS >or= 36.8 ng/mL (quartile 4) versus <or= 25.5 ng/mL (quartiles 1 and 2: OR for treated disease = 2.68; 95% CI, 1.03-6.98; p = 0.043); in women this association was not significant.

CONCLUSIONS

Higher concentrations of serum PFOA and PFOS are associated with current thyroid disease in the U.S. general adult population. More work is needed to establish the mechanisms involved and to exclude confounding and pharmacokinetic explanations.

Circulating beta-carotene levels and type 2 diabetes-cause or effect?

AIMS/HYPOTHESIS

Circulating beta-carotene levels are inversely associated with risk of type 2 diabetes, but the causal direction of this association is not certain. In this study we used a Mendelian randomisation approach to provide evidence for or against the causal role of the antioxidant vitamin beta-carotene in type 2 diabetes.

METHODS

We used a common polymorphism (rs6564851) near the BCMO1 gene, which is strongly associated with circulating beta-carotene levels (p = 2 x 10(-24)), with each G allele associated with a 0.27 standard deviation increase in levels. We used data from the InCHIANTI and Uppsala Longitudinal Study of Adult Men (ULSAM) studies to estimate the association between beta-carotene levels and type 2 diabetes. We next used a triangulation approach to estimate the expected effect of rs6564851 on type 2 diabetes risk and compared this with the observed effect using data from 4549 type 2 diabetes patients and 5579 controls from the Diabetes Genetics Replication And Meta-analysis (DIAGRAM) Consortium.

RESULTS

A 0.27 standard deviation increase in beta-carotene levels was associated with an OR of 0.90 (95% CI 0.86-0.95) for type 2 diabetes in the InCHIANTI study. This association was similar to that of the ULSAM study (OR 0.90 [0.84-0.97]). In contrast, there was no association between rs6564851 and type 2 diabetes (OR 0.98 [0.93-1.04], p = 0.58); this effect size was also smaller than that expected, given the known associations between rs6564851 and beta-carotene levels, and the associations between beta-carotene levels and type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Our findings in this Mendelian randomisation study are in keeping with randomised controlled trials suggesting that beta-carotene is not causally protective against type 2 diabetes.

The 9p21 myocardial infarction risk allele increases risk of peripheral artery disease in older people

BACKGROUND

A common variant at chromosome 9p21 (tagged by the rs1333049 or rs10757278 single-nucleotide polymorphism) is strongly associated with myocardial infarction and major arterial aneurysms. An association with peripheral arterial disease (PAD) was also reported in a sample younger than 75 years, but this disappeared on removal of respondents with a myocardial infarction history, resulting in an odds ratio of 1.09 for PAD (P=0.075). We aimed at estimating the association of this variant with an Ankle-Brachial Index (ABI) and PAD in 3 older populations.

METHODS AND RESULTS

We used data from the InCHIANTI, Baltimore Longitudinal Study of Aging, and Health, Aging, and Body Composition studies. In 2630 white individuals (mean age, 76.4 years), the C allele at rs1333049 was associated with lower mean ABI measures and with an increased prevalence of PAD. These associations remained after removal of baseline and incident myocardial infarction cases over a 6-year follow-up for both ABI (-0.017 ABI units; 95% CI, -0.03 to -0.01; P = 1.3 x 10(-4)) and PAD (per allele odds ratio, 1.29; 95% CI, 1.06 to 1.56; P = 0.012). These associations also remained after adjustment for known atherosclerosis risk factors, including diabetes mellitus, smoking, hypercholesterolemia, and hypertension.

CONCLUSIONS

The C allele at rs1333049 is associated with an increased prevalence of PAD and lower mean ABI. This association was independent of the presence of diagnosed myocardial infarction and atherosclerotic risk factors in 3 older white populations.

Common variation in the beta-carotene 15,15'-monooxygenase 1 gene affects circulating levels of carotenoids: a genome-wide association study

Low plasma levels of carotenoids and tocopherols are associated with increased risk of chronic disease and disability. Because dietary intake of these lipid-soluble antioxidant vitamins is only poorly correlated with plasma levels, we hypothesized that circulating carotenoids (vitamin A-related compounds) and tocopherols (vitamin E-related compounds) are affected by common genetic variation. By conducting a genome-wide association study in a sample of Italians (n = 1190), we identified novel common variants associated with circulating carotenoid levels and known lipid variants associated with alpha-tocopherol levels. Effects were replicated in the Women's Health and Aging Study (n = 615) and in the alpha-Tocopherol, beta-Carotene Cancer Prevention (ATBC) study (n = 2136). In meta-analyses including all three studies, the G allele at rs6564851, near the beta-carotene 15,15'-monooxygenase 1 (BCMO1) gene, was associated with higher beta-carotene (p = 1.6 x 10(-24)) and alpha-carotene (p = 0.0001) levels and lower lycopene (0.003), zeaxanthin (p = 1.3 x 10(-5)), and lutein (p = 7.3 x 10(-15)) levels, with effect sizes ranging from 0.10-0.28 SDs per allele. Interestingly, this genetic variant had no significant effect on plasma retinol (p > 0.05). The SNP rs12272004, in linkage disequilibrium with the S19W variant in the APOA5 gene, was associated with alpha-tocopherol (meta-analysis p = 7.8 x 10(-10)) levels, and this association was substantially weaker when we adjusted for triglyceride levels (p = 0.002). Our findings might shed light on the controversial relationship between lipid-soluble anti-oxidant nutrients and human health.

A genome-wide association study identifies protein quantitative trait loci (pQTLs)

There is considerable evidence that human genetic variation influences gene expression. Genome-wide studies have revealed that mRNA levels are associated with genetic variation in or close to the gene coding for those mRNA transcripts – cis effects, and elsewhere in the genome – trans effects. The role of genetic variation in determining protein levels has not been systematically assessed. Using a genome-wide association approach we show that common genetic variation influences levels of clinically relevant proteins in human serum and plasma. We evaluated the role of 496,032 polymorphisms on levels of 42 proteins measured in 1200 fasting individuals from the population based InCHIANTI study. Proteins included insulin, several interleukins, adipokines, chemokines, and liver function markers that are implicated in many common diseases including metabolic, inflammatory, and infectious conditions. We identified eight Cis effects, including variants in or near the IL6R (p = 1.8×10⁻⁵⁷), CCL4L1 (p = 3.9×10⁻²¹), IL18 (p = 6.8×10⁻¹³), LPA (p = 4.4×10⁻¹⁰), GGT1 (p = 1.5×10⁻⁷), SHBG (p = 3.1×10⁻⁷), CRP (p = 6.4×10⁻⁶) and IL1RN (p = 7.3×10⁻⁶) genes, all associated with their respective protein products with effect sizes ranging from 0.19 to 0.69 standard deviations per allele. Mechanisms implicated include altered rates of cleavage of bound to unbound soluble receptor (IL6R), altered secretion rates of different sized proteins (LPA), variation in gene copy number (CCL4L1) and altered transcription (GGT1). We identified one novel trans effect that was an association between ABO blood group and tumour necrosis factor alpha (TNF-alpha) levels (p = 6.8×10⁻⁴⁰), but this finding was not present when TNF-alpha was measured using a different assay , or in a second study, suggesting an assay-specific association. Our results show that protein levels share some of the features of the genetics of gene expression. These include the presence of strong genetic effects in cis locations. The identification of protein quantitative trait loci (pQTLs) may be a powerful complementary method of improving our understanding of disease pathways.

One of the central dogmas of molecular genetics is that DNA is transcribed to RNA which is translated to protein and alterations to proteins can influence human diseases. Genome-wide association studies have recently revealed many new DNA variants that influence human diseases. To complement these efforts, several genome-wide studies have established that DNA variation influences mRNA expression levels. Loci influencing mRNA levels have been termed “eQTLs”. In this study we have performed the first genome-wide association study of the third piece in this jigsaw – the role of DNA variation in relation to protein levels, or “pQTLs”. We analysed 42 proteins measured in blood fractions from the InCHIANTI study. We identified eight cis effects including common variants in or near the IL6R, CCL4, IL18, LPA, GGT1, SHBG, CRP and IL1RN genes, all associated with blood levels of their respective protein products. Mechanisms implicated included altered transcription (GGT1) but also rates of cleavage of bound to unbound soluble receptor (IL6R), altered secretion rates of different sized proteins (LPA) and variation in gene copy number (CCL4). Blood levels of many of these proteins are correlated with human diseases and the identification of “pQTLs” may in turn help our understanding of disease.

Enhancing cell survival of atrazine degrading Rhodococcus erythropolis NI86/21 cells encapsulated in alginate beads

AIMS

To develop a method to produce beads with encapsulated Rhodococcus erythropolis NI86/21 with high cell density, extended shelf life, ease of handling and good atrazine degradation capabilities in both liquid and in agricultural soil.

METHODS AND RESULTS

Our findings show that the supplementary recovery step in nutrient broth media shortly after cell encapsulation facilitates cell survival in both wet and dry beads upon extended storage at 4 degrees C. Air drying has little or no impact on encapsulated R. erythropolis cell's ability to degrade atrazine in liquid or soil. Bead storage for periods extending up to 12 months at 4 degrees C did not affect the capacity of R. erythropolis encapsulated cells to degrade atrazine in either BMN or nonsterile soil extracts. Bentonite-amended beads formulated with 1% skim milk and exposed to the supplementary growth step, outperformed all other bead formats. These beads provided adequate numbers of vigorous R. erythropolis cells in either liquid or soil media to degrade atrazine.

CONCLUSIONS

Supplementary growth in nutrient broth media immediately following cell encapsulation greatly enhances R. erythropolis cells survival in both wet and dry beads upon extended storage at 4 degrees C. Wet and dried beads have similar capacity for atrazine degradation, and their usefulness and appeal in agronomic practise will only be known after bioassay evaluation and successful demonstration at field scale using incurred residues.

SIGNIFICANCE AND IMPACT OF THE STUDY

R. erythropolis NI86/21 encapsulated cells have the potential to reduce residual atrazine in soil, thereby minimizing the likelihood of off-site transport to ground or river water and reduce the loss of crops because of phytotoxicity of residual herbicide. Owing to their ease of handling, storage and possible compatibilities with pre-existing mechanical equipment, dried bead formats are ideally suited for agricultural and remediational applications.

Ethics and geographical equity in health care

Important variations in access to health care and health outcomes are associated with geography, giving rise to profound ethical concerns. This paper discusses the consequences of such concerns for the allocation of health care finance to geographical regions. Specifically, it examines the ethical drivers underlying capitation systems, which have become the principal method of allocating health care finance to regions in most countries. Although most capitation systems are based on empirical models of health care expenditure, there is much debate about which needs factors to include in (or exclude from) such models. This concern with legitimate and illegitimate drivers of health care expenditure reflects the ethical concerns underlying the geographical distribution of health care finance.

Capitation and risk adjustment in health care financing: an international progress report

In every system of health care, capitation payments have become the accepted tool used by health care purchasers in much of the developed world to determine prospective budgets. The policy prescription of capitation is perceived to address both equity objectives (of great importance in publicly funded systems of health care) and efficiency objectives (the dominant concern in competitive insurance markets). An examination of the current state of the art in 20 countries outside the United States in which health care capitation has been implemented confirms that capitation has assumed central importance within diverse systems of health care. In practice, however, the setting of capitation payments has been heavily constrained to date by poor data availability and unsatisfactory analytic methodology.

An evaluation of hospital special-ventilation-room pressures

OBJECTIVE

To quantitate the magnitude and consistency of positive (airflow out) and negative (airflow in) hospital special-ventilation-room (SVR) airflow.

DESIGN

A room-pressure evaluation was conducted during two seasons on a total of 18 rooms: standard rooms, airborne infection isolation rooms, and protective environment rooms. The pressures were measured using a digital pressure gauge-piezoresistive pressure sensor that measured pressure differentials. With doors closed, the rooms were measured a minimum of 30 times each for a cooling season and a heating season.

RESULTS

The standard rooms showed the least amount of variability in pressure differential, with an average of -0.2 Pa (median, -0.2 Pa), and an interquartile range (IQR) of 0.4 Pa. Airborne infection isolation rooms showed more variability in pressure, with an average of -0.3 Pa (median, -0.2 Pa) and an IQR of 0.5 Pa. Protective environment rooms had the greatest fluctuation in pressure, with an average of 8.3 Pa (median, 7.7 Pa) and an IQR of 8.8 Pa. Dramatic pressure changes were observed during this evaluation, which may have been influenced by room architectural differences (sealed vs unsealed); heating, ventilation, and air-conditioning zone interactions; and stack effect.

CONCLUSION

The pressure variations noted in this study, which potentially affect containment or exclusion of contaminants, support the need for standardization of pressure requirements for SVRs. To maintain consistent pressure levels, creating an airtight seal and continuous pressure monitoring may be necessary.

Capitation and risk adjustment in health care

Capitation and risk adjustment have become the chosen policy instruments to seek cost containment and equity of access for many developed health care systems. Increasingly, this entails the prospective setting of global budgets for the health care expenditures incurred by health care plans on behalf of their members. Methods of deriving such budgets are diverse and tailored to the specific circumstances of the health care system they seek to serve. This special issue presents a collection of papers devoted to issues surrounding the rationale, derivation, and implementation of capitation and risk adjustment methods of financing health care. These are discussed within the context of health care systems in eight countries, illustrating the range of interest in the topic. Undoubtedly, capitation and risk adjustment will become increasingly significant elements of virtually all systems of health care and we hope the collection of papers will help to stimulate further debate and research in this important and interesting area of health care financing.

Derivation of a needs based capitation formula for allocating prescribing budgets to health authorities and primary care groups in England: regression analysis

OBJECTIVE

To develop a weighted capitation formula for setting target allocations for prescribing expenditures for health authorities and primary care groups in England.

DESIGN

Regression analysis relating prescribing costs to the demographic, morbidity, and mortality composition of practice lists.

SETTING

8500 general practices in England.

SUBJECTS

Data from the 1991 census were attributed to practice lists on the basis of the place of residence of the practice population.

MAIN OUTCOME MEASURES

Variation in age, sex, and temporary resident originated prescribing units (ASTRO(97)-PUs) adjusted net ingredient cost of general practices in England for 1997-8 modelled for the impact of health and social needs after controlling for differences in supply.

RESULTS

A needs gradient based on the four variables: permanent sickness, percentage of dependants in no carer households, percentage of students, and percentage of births on practice lists. These, together with supply characteristics, explained 41% of variation in prescribing costs per ASTRO(97)-PU adjusted capita across practices. The latter alone explained about 35% of variation in total costs per head across practices.

CONCLUSIONS

The model has good statistical specification and contains intuitively plausible needs drivers of prescribing expenditure. Together with adjustments made for differences in ASTRO(97)-PUs the model is capable of explaining 62% (35%+0.65% (41%)) of variation in prescribing expenditure at practice level. The results of the study have formed the basis for setting target budgets for 1999-2000 allocations for prescribing expenditure for health authorities and primary care groups.

Do measures of self-reported morbidity bias the estimation of the determinants of health care utilisation?

Most national surveys of health care utilisation capture only self-reported measures of morbidity. If self-reported morbidity is measured with error, then the results of applied work may be misleading. In this paper we propose a model of the relationship between morbidity and health service utilisation which allows for reporting errors and simultaneity. Errors in self-reported morbidity are expressed as a function of person-specific reporting thresholds and recent contact with health services, arising because of better self-evaluation of current health status or a desire to justify consumption of a publicly-provided good. We demonstrate the bias in ignoring the potential problems of reporting errors and simultaneity for a variety of special cases, but in the general case the biases are of ambiguous sign. The empirical nature of these biases is investigated using limiting long-standing illness (LLI) and recent contact with a General Practitioner (GP) in two waves of The UK Health and Lifestyle Survey. Biomedical measures of functioning are used as objective indicators of health status. We find evidence of substantial and significant differences between individuals in reporting thresholds and some evidence that the reporting of LLI may depend on recent visits to a GP. Adjustments for these biases significantly increase the estimated effect of morbidity on utilisation.

Non- and semi-parametric estimation of age and time heterogeneity in repeated cross-sections: an application to self-reported morbidity and general practitioner utilization

Patterns of self-reported morbidity and general practitioner (GP) utilization exhibit complex age, sex and time heterogeneity. Underlying patterns are often obscured by data which are overly 'rough' because of noise associated with adjacent year fluctuations. In this paper we describe methods to obtain smoothed estimates of age, time and birth-cohort effects using data from the General Household Survey (GHS), covering the period 1984-1995/6 inclusive. The methods outlined offer powerful analytic tools to research complex profiles or trends, particularly over age or time. The relationships of the morbidity and GP utilization measures with age, sex and survey year characteristics are estimated non-parametrically using roughness penalized least squares (RPLS). A semi-parametric extension of this model is used to estimate the effect of the morbidity variables on GP utilization. Tests are employed for various forms of age and time heterogeneity including birth-cohort effects. Linear age specifications are rejected for all variables and evidence is found of time heterogeneity in one of the morbidity measures--limiting long-standing illness (LS)--and GP utilization. The advantages of employing non- and semi-parametric estimations in the presence of complex relationships such as those observed for age and time profiles are discussed. Adoption of these techniques by applied econometricians working in health economics is encouraged.

Drinking patterns within households: the estimation and interpretation of individual and group variables

Levels of alcohol consumption tend to be similar for individuals living in the same household. This may be because: (a) individuals with similar characteristics collect in households (correlated effects); (b) individuals in the same household are influenced by common factors (exogenous effects); and/or (c) the consumption levels of an individual directly influences the consumption levels of other individuals in the same household (endogenous effects). Whichever of these three possibilities is the principal reason underlying household clustering of consumption levels has important policy implications. In this paper we propose a testing strategy to distinguish between the three types of effect in a cross-sectional data-set. Allowing for exogenous or endogenous effects shows that the significant socio-economic gradient in a model containing only individual variables arises because of misspecification. However, because we find significant evidence of correlated effects, we cannot identify whether it is endogenous or exogenous effects which give rise to statistically significant group level variables. The results indicate the possible pitfalls of omitting group level influences.

Risk and the general practitioner budget holder

For most individuals, the use made of health care in a given year is determined principally by unpredictable random incidents. Of course, some individuals have a predictably higher predisposition to illness than others. However, the general consensus is that only a fraction of individual variability in health care costs can be predicted. The purpose of this paper is to explore the implications of this inherent randomness for setting health care budgets for general practitioner purchasers of health care. The paper argues that variability in utilization in health care is very high: that no capitation formula can ever completely capture that variability, even for large populations: that the variability may give rise to certain dysfunctional consequences if not managed carefully; and that therefore careful attention should be given to the managerial arrangements associated with any devolution of health care budgets.

The influence of households on drinking behaviour: a multilevel analysis

This paper examines the influence of household membership and area of residence on individual drinking behaviour using a multilevel modelling approach. The effects are investigated using data from the Health Survey for England (HSE) in which multiple interviews were conducted in the same household. With the use of postal address, the data were organised into a hierarchical structure of individuals within households within enumeration districts. After controlling for characteristics of individuals thought to influence or correlate with drinking behaviour, unexplained variation in alcohol consumption was attributed to individual, household and area effects. Household influences on drinking behaviour far outweigh the influences of place of residence. Policies aimed at reducing alcohol consumption, particularly by heavy drinkers, may be best targeted at the household level.

Receptor-specific induction of NF-kappaB components in primary B cells

The NF-kappaB transcription factor complex plays a key role in the expression of genes involved in immune responses. Nuclear NF-kappaB is induced in B lymphocytes by engagement of either the antigen receptor (sIg) or the CD40 receptor for a T cell activation antigen, although different intracellular pathways appear to be involved. In the present study the protein composition of NF-kappaB complexes triggered by sIg and CD40 was probed by electrophoretic mobility shift, supershift, shift-Western, and Western blot analyses. At the time of peak NF-kappaB induction (2 h), the NF-kappaB components detected in the complexes induced through sIg and through CD40 were the same. However, with continued stimulation RelB completely disappeared from anti-Ig-stimulated kappaB binding material, but remained a component of CD40L-induced NF-kappaB. The loss of DNA-binding RelB from anti-Ig-induced NF-kappaB did not result from depletion of RelB from B cell nuclei, suggesting specific regulation of RelB function which is not directly attributed to IkappaB function. These results indicate that NF-kappaB complexes may undergo protein-specific alterations in a time- and receptor-dependent fashion that may be associated with differences in the outcomes of B cell stimulation through sIg and CD40.

Interaction of NF-kappaB and NFAT with the interferon-gamma promoter

Interferon-gamma (IFN-gamma) is a pleiotropic lymphokine whose production is restricted to activated T cells and NK cells. Along with other cytokines, IFN-gamma gene expression is inhibited by the immunosuppressant cyclosporin A. We have previously identified an intronic enhancer region (C3) of the IFN-gamma gene that binds the NF-kappaB protein c-Rel and that shows partial DNA sequence homology with the cyclosporin A-sensitive NFAT binding site and the 3'-half of the NF-kappaB consensus site. Sequence analysis of the IFN-gamma promoter revealed the presence of two additional C3-related elements (C3-1P and C3-3P). In addition, an NF-kappaB site (IFN-gamma kappaB) was identified within the promoter region. Based on this observation, we have analyzed the potential role of NF-kappaB and NFAT family members in regulating IFN-gamma transcription. Electrophoretic mobility shift assay analysis demonstrated that after T cell activation, the p50 and p65 NF-kappaB subunits bind specifically to the newly identified IFN-gamma kappaB and C3-related sites. In addition, we identified the NFAT proteins as a component of the inducible complexes that bind to the C3-3P site. Site-directed mutagenesis and transfection studies demonstrate that calcineurin-inducible transcriptional factors enhance the transcriptional activity of the IFN-gamma promoter through the cyclosporin-sensitive C3-3P site, whereas NF-kappaB proteins functionally interact with the C3-related sites. In addition, when located downstream to the beta-galactosidase gene driven by the IFN-gamma promoter, the intronic C3 site worked in concert with both the IFN-gamma kappaB and the C3-3P site to enhance gene transcription. These results demonstrate that the coordinate activities of NFAT and NF-kappaB proteins are involved in the molecular mechanisms controlling IFN-gamma gene transcription.

Multilevel models and health economics

Multilevel analyses have become an accepted statistical technique in the field of education where over the past decade or so the methods have been developed to explore the relationships between pupil characteristics and the characteristics of the schools they attend. More recently, widespread use has extended to other social sciences and health research. However, to date, little use has been made of these techniques within the health economics literature. This paper presents an introductory account of multilevel models and describes some of the areas of health economics research that may benefit from their use.

Informing prescribing allocations at district level in England

OBJECTIVES

To derive a predictive model based on the morbidity, demographic and socio-economic characteristics of district populations to explain variations in prescribing costs in England.

METHOD

Inter-relations between morbidity, demographic, socio-economic, general practice supply characteristics and net ingredient cost per age, sex and temporary resident originated prescribing unit (ASTRO-PU) were explored statistically for 90 districts in England using 1994 cost data. The possibility of mutual inter-relationship between 'supply' and 'demand' was examined; then the associations between a range of factors and prescribing costs were estimated using ordinary least squares regression and the predictive power of the possible models was systematically examined.

RESULTS

Whilst there was a relatively weak relationship between the supply factors that were measured, there did not appear to be any reciprocal relationship. Three parsimonious models estimated using ordinary least squares multiple regression techniques based on combinations of permanent sickness, low birth weight and the proportion of general practitioners registered for postgraduate certificate of education were identified. The models explained up to 61% of variation between districts in prescribing costs.

CONCLUSIONS

'Need' and 'supply' characteristics are independently associated with variations in prescribing costs at district level. The negative association between the proportion of general practitioners eligible for postgraduate education allowance and prescribing costs may reflect 'better' prescribing but could not be introduced into a resource allocation formula without introducing perverse incentives. The combination of permanent sickness and low birth weight complement each other by providing a proxy measure of morbidity mostly applicable to adult males (permanent sickness) and mothers (low birth weight being a measure of maternal health). These variables should be considered further for use in the process of allocating resources for prescribing to districts.

Multilevel models: applications to health data

This paper presents an introductory account of multilevel models, highlighting the potential benefits that may be gained by the use of these methods. It draws on recent applications in health services research that have appeared in the literature. Methodological advances in these statistical techniques have taken place in the field of education, where empirical studies have mainly been concerned with comparing pupil achievement across different schools by exploring the relationship between individual and institutional factors. Although recent widespread availability of suitable software packages has enabled other disciplines to adopt these methods, to date they have received little attention in the health services research literature (the investigation of effects of geographical areas on health being a possible exception) despite their obvious application in many areas of current interest. Key areas that could benefit greatly from these techniques include the exploration of variations in clinical practice, comparisons of institutional performance and resource allocation.

Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices

OBJECTIVE

To identify the socioeconomic determinants of consultation rates in general practice.

DESIGN

Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload.

RESULTS

Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of "indices of deprivation" is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas.

CONCLUSIONS

Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice.

Regulation of NF-kappa B activation in T helper 1 and T helper 2 cells

In most cell types, NF-kappa B is activated by release from a cytoplasmic inhibitor protein, I kappa B, followed by its translocation to the nucleus where it binds to the regulatory regions of many genes, including the IL-2 gene in T lymphocytes. We have previously shown by electrophoretic mobility shift assays that nuclear extracts prepared from activated, non-IL-2-producing Th2 cell clones. We show here that Th-1 and Th2 cells have similar levels of cytoplasmic p65(RelA) and p50, but TCR stimulation fails to induce the nuclear translocation of p65(RelA) in Th2 cells. Nuclear translocation of p65(RelA) can be induced by IL-1 stimulation of Th2 cells, indicating that a basic mechanism of NF-Kappa B activation common to many cells is intact in Th2 cells. We demonstrate that IL-1 and TNF induce rapid nuclear translocation of p65(RelA) in T cell clones, whereas TCR-induced NF-Kappa B activation in Th1 cells is delayed and may be longer in duration. This suggests that the TCR pathway of NF-Kappa B activation is different from the cytokine pathway. Furthermore, we show that Th1 and Th2 cells express different levels and/or different forms of I kappa B alpha, and that cytokines, but not TCR stimuli, significantly modulate detectable levels of cytoplasmic I kappa B alpha.

Regulation of NF-kappa B activation in T helper 1 and T helper 2 cells

In most cell types, NF-kappa B is activated by release from a cytoplasmic inhibitor protein, I kappa B, followed by its translocation to the nucleus where it binds to the regulatory regions of many genes, including the IL-2 gene in T lymphocytes. We have previously shown by electrophoretic mobility shift assays that nuclear extracts prepared from activated, non-IL-2-producing Th2 cell clones. We show here that Th-1 and Th2 cells have similar levels of cytoplasmic p65(RelA) and p50, but TCR stimulation fails to induce the nuclear translocation of p65(RelA) in Th2 cells. Nuclear translocation of p65(RelA) can be induced by IL-1 stimulation of Th2 cells, indicating that a basic mechanism of NF-Kappa B activation common to many cells is intact in Th2 cells. We demonstrate that IL-1 and TNF induce rapid nuclear translocation of p65(RelA) in T cell clones, whereas TCR-induced NF-Kappa B activation in Th1 cells is delayed and may be longer in duration. This suggests that the TCR pathway of NF-Kappa B activation is different from the cytokine pathway. Furthermore, we show that Th1 and Th2 cells express different levels and/or different forms of I kappa B alpha, and that cytokines, but not TCR stimuli, significantly modulate detectable levels of cytoplasmic I kappa B alpha.

Is enumeration district level an improvement on ward level analysis in studies of deprivation and health?

AIM

To investigate whether enumeration district (ED) level data reflect the aggregate characteristics of people living in that district better than ward level analysis.

DESIGN AND SETTING

Reanalysis of the fourth national morbidity survey in general practice (MSGP4). Socioeconomic data on patients who had consulted 60 practices over one year were linked via postcode to ED and thence to small area statistics data for that ED and to the corresponding electoral ward.

RESULTS AND CONCLUSIONS

There was no evidence that patients were likely to be more representative samples of the population of an ED than of a ward.