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    ABSTRACT: The language used by National Health Service (NHS) "commissioning" managers when discussing their roles and responsibilities can be seen as a manifestation of "identity work", defined as a process of identifying. This paper aims to offer a novel approach to analysing "identity work" by triangulation of multiple analytical methods, combining analysis of the content of text with analysis of its form. Fairclough's discourse analytic methodology is used as a framework. Following Fairclough, the authors use analytical methods associated with Halliday's systemic functional linguistics. While analysis of the content of interviews provides some information about NHS Commissioners' perceptions of their roles and responsibilities, analysis of the form of discourse that they use provides a more detailed and nuanced view. Overall, the authors found that commissioning managers have a higher level of certainty about what commissioning is not rather than what commissioning is; GP managers have a high level of certainty of their identity as a GP rather than as a manager; and both GP managers and non-GP managers oscillate between multiple identities depending on the different situations they are in. This paper offers a novel approach to triangulation, based not on the usual comparison of multiple data sources, but rather based on the application of multiple analytical methods to a single source of data. This paper also shows the latent uncertainty about the nature of commissioning enterprise in the English NHS.
    Journal of Health Organisation and Management 03/2013; 27(1):4-23. DOI:10.1108/14777261311311771
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    ABSTRACT: General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful 'gatekeepers'. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience. To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work. Ethnographic observation in seven urban general practices in the north-west of England. Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters. Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to 'play' the system. Framing the receptionist-patient encounter as one between the 'powerful' and the 'vulnerable' gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings.
    British Journal of General Practice 03/2013; 63(608):177-84. DOI:10.3399/bjgp13X664225
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    ABSTRACT: Context:There is little information on the potential impact of serum 1,25-dihydroxyvitamin D [1,25(OH)(2)D] on bone health including turnover.Objective:The objective of the study was to determine the influence of 1,25(OH)(2)D and 25-hydroxyvitamin D [25(OH)D] on bone health in middle-aged and older European men.Design, Setting, and Participants:Men aged 40-79 years were recruited from population registers in 8 European centers. Subjects completed questionnaires that included questions concerning lifestyle and were invited to attend for quantitative ultrasound (QUS) of the heel, assessment of height and weight, and a fasting blood sample from which 1,25(OH)(2)D, 25(OH)D, and PTH were measured. 1,25(OH)(2)D was measured using liquid chromatography tandem mass spectrometry. Bone markers serum N-terminal propeptide of type 1 procollagen (P1NP) and crosslinks (β-cTX) were also measured. Dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine was performed in 2 centers.Main Outcome Measure(s):QUS of the heel, bone markers P1NP and β-cTX, and DXA of the hip and lumbar spine were measured.Results:A total of 2783 men, mean age 60.0 years (SD 11.0) were included in the analysis. After adjustment for age and center, 1,25(OH)(2)D was positively associated with 25(OH)D but not with PTH. 25(OH)D was negatively associated with PTH. After adjustment for age, center, height, weight, lifestyle factors, and season, 1,25(OH)(2)D was associated negatively with QUS and DXA parameters and associated positively with β-cTX. 1,25(OH)(2)D was not correlated with P1NP. 25(OH)D was positively associated with the QUS and DXA parameters but not related to either bone turnover marker. Subjects with both high 1,25(OH)(2)D (upper tertile) and low 25(OH)D (lower tertile) had the lowest QUS and DXA parameters and the highest β-cTX levels.Conclusions:Serum 1,25(OH)(2)D is associated with higher bone turnover and poorer bone health despite being positively related to 25(OH)D. A combination of high 1,25(OH)(2)D and low 25(OH)D is associated with the poorest bone health.
    The Journal of Clinical Endocrinology and Metabolism 02/2013; 98(3). DOI:10.1210/jc.2012-2772
  • BMJ (online) 12/2012; 345:e8508. DOI:10.1136/bmj.e8508
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    ABSTRACT: Background:  Recent models of the early emergence of autism spectrum disorder (ASD) propose that infant intrinsic risk susceptibilities in behaviour may be amplified by interaction within the early social environment into an increasingly atypical developmental trajectory. This study examines whether 6- and 12-month parent-infant interactions in at-risk siblings differ from those with low-risk and whether - in at-risk siblings - such interactions predict later 3-year classification of ASD or no ASD. Method:  Within the British Autism Study of Infant Siblings (BASIS), 6-min videotaped episodes of parent-infant free play in infants at 6-10 months (45 at-risk siblings and 47 low-risk siblings) and 12-15 months (43 at-risk siblings and 48 low-risk siblings) in a laboratory setting were rated on the Manchester Assessment of Caregiver-Infant Interaction (MACI), blind to participant information. Standard tests were administered for concurrent behavioural signs of ASD features and developmental level. Systematic consensus diagnostic classification of ASD was made at 3 years for the at-risk siblings. Results:  Parent nondirectiveness and sensitive responsiveness differed in relation to ASD/risk status (at-risk ASD, at-risk no-ASD and low-risk) at both 6 and 12 months. At 6 months, infant liveliness was lower in the at-risk groups; at 12 months, infant attentiveness to parent and positive affect were lower in the at-risk group later diagnosed with ASD. Dyadic mutuality and intensity of engagement showed a group effect at 12 months. Dyadic mutuality, infant positive affect and infant attentiveness to parent at 12 months (but not 6 months) predicted 3-year ASD outcome, whereas infant ASD-related behavioural atypicality did not. Conclusions:  This is the first prospective evidence that early dyadic interaction between at-risk infants and their parents is associated with later diagnostic outcome in ASD. Possible explanations for these findings and their theoretical implications are considered.
    Journal of Child Psychology and Psychiatry 12/2012; 54(7). DOI:10.1111/jcpp.12032
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    ABSTRACT: It is known that measurement error leads to bias in assessing exposure effects, which can however, be corrected if independent replicates are available. For expensive replicates, two-stage (2S) studies that produce data 'missing by design', may be preferred over a single-stage (1S) study, because in the second stage, measurement of replicates is restricted to a sample of first-stage subjects. Motivated by an occupational study on the acute effect of carbon black exposure on respiratory morbidity, we compare the performance of several bias-correction methods for both designs in a simulation study: an instrumental variable method (EVROS IV) based on grouping strategies, which had been recommended especially when measurement error is large, the regression calibration and the simulation extrapolation methods. For the 2S design, either the problem of 'missing' data was ignored or the 'missing' data were imputed using multiple imputations. Both in 1S and 2S designs, in the case of small or moderate measurement error, regression calibration was shown to be the preferred approach in terms of root mean square error. For 2S designs, regression calibration as implemented by Stata software is not recommended in contrast to our implementation of this method; the 'problematic' implementation of regression calibration although substantially improved with use of multiple imputations. The EVROS IV method, under a good/fairly good grouping, outperforms the regression calibration approach in both design scenarios when exposure mismeasurement is severe. Both in 1S and 2S designs with moderate or large measurement error, simulation extrapolation severely failed to correct for bias. Copyright © 2012 John Wiley & Sons, Ltd.
    Statistics in Medicine 12/2012; 31(28). DOI:10.1002/sim.5422
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    ABSTRACT: Abstract The somatoform disorders, as currently defined in DSM-IV and ICD-10, have been criticized for their complexity and poor clinical utility. In this paper we consider these criticisms as well as the conceptual question of whether there is sufficient evidence for classifying them as mental and behavioural disorders. The review suggests that, as currently defined, somatoform disorders do not fulfil a recently articulated set of criteria for mental and behavioural disorders. In particular, the disorders are not defined according to positive psychological and behavioural disorders and evidence is sparse to support their classification as different and distinct diagnoses. Any revision of the disorders should not be based on 'medically unexplained' symptoms. Rather, the relevant diagnoses should include a combination of bothersome somatic symptoms with several other psychological features including beliefs about somatic symptoms and evidence of marked concerns about health and illness. Finally, the review presents a set of proposals for the revision of these disorders, by the Somatic Disorders and Dissociative Disorders Working Group of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, which attempt to take account of the criticisms and current understanding of somatic experiences.
    International Review of Psychiatry 12/2012; 24(6):556-67. DOI:10.3109/09540261.2012.741063
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    ABSTRACT: BACKGROUND: Shared decision making (SDM) and patient self-management support are key components of US and UK policy for chronic disease management, whereby SDM is seen as enhancing physician-patient negotiation around self-management. The WISE trial is implementing training in self-management support for primary care physicians in one UK region. This article describes preintervention levels of patient-reported SDM and explores how this varies with patient and practice characteristics. METHODS: . We analyzed baseline data from a cluster randomized controlled trial for 2965 patients with diabetes, chronic obstructive pulmonary disease, and irritable bowel syndrome (IBS) from 29 family practices. Patient-level measures included self-report of chronic conditions, SDM (Health Care Climate Questionnaire [HCCQ]), health status, and demographic characteristics. Area and practice characteristics included chronic disease workload and socioeconomic deprivation. RESULTS: . The mean SDM score was 75 (out of 100), but the range was wide. The mean score was lower for IBS patients but did not vary with other disease conditions. Younger patients and those with poorer health status reported lower degrees of SDM. No associations were found with practice characteristics. Limitations. The study was restricted to one socioeconomically deprived region, and hence results may not be nationally representative of the United Kingdom. Ceiling effects on SDM scores may limit the utility of the HCCQ. CONCLUSIONS: . Lower ratings from some patient groups may reflect differences in expectations rather than differences in physician behavior. Overall levels of SDM were high, and no patient or practice characteristic represented a serious barrier to SDM. However, we cannot say to what extent SDM in this chronic population addressed self-management issues rather than clinical care. More nuanced measures of SDM are required that distinguish between different forms of care.
    Medical Decision Making 11/2012; 33(1). DOI:10.1177/0272989X12464825
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    ABSTRACT: OBJECTIVE:: To investigate relationship of mental ill health to absence from work in different occupational classifications. METHOD:: Examined sickness absence, mental health (GHQ-12), physical health, job characteristics, and personal characteristics in 18 waves of the British Household Panel Survey. RESULTS:: Overall sickness absence rate was 1.68%. Increased absence was associated with age greater than 45 years, female gender, lower occupational classification, and public-sector employers. Decreased absence was associated with part-time working. Scoring 4 or more on the General Health Questionnaire 12-item version (GHQ-12 caseness) was strongly associated with sickness absence. Public-sector employers had highest rates of sickness absence. GHQ-12 caseness had largest impact on absence in the public and nonprofit sectors, whereas physical health problems impacted more in the private sector. CONCLUSIONS:: GHQ-12 caseness is strongly associated with increased absence in all classifications of occupations. Differences between sectors require further investigation.
    Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 11/2012; DOI:10.1097/JOM.0b013e3182677d12
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    ABSTRACT: BRCA1 and BRCA2 are major breast cancer susceptibility genes. Nineteen single nucleotide polymorphisms (SNPs) at 18 loci have been associated with breast cancer. We aimed to determine whether these predict breast cancer incidence in women with BRCA1/BRCA2 mutations. BRCA1/2 mutation carriers identified through the Manchester genetics centre between 1996-2011 were included. Using published odds ratios (OR) and risk allele frequencies, we calculated an overall breast cancer risk SNP score (OBRS) for each woman. The relationship between OBRS and age at breast cancer onset was investigated using the Cox proportional hazards model, and predictive ability assessed using Harrell's C concordance statistic. In BRCA1 mutation carriers we found no association between OBRS and age at breast cancer onset (OR for the lowest risk quintile compared to the highest was 1.20 (95% CI 0.82-1.75, Harrell's C=0.54), but in BRCA2 mutation carriers the association was significant (OR for the lowest risk quintile relative to the highest was 0.47 (95% CI 0.33-0.69, Harrell's C =0.59). The 18 validated breast cancer SNPs differentiate breast cancer risks between women with BRCA2 mutations, but not BRCA1. It may now be appropriate to use these SNPs to help women with BRCA2 mutations make maximally informed decisions about management options.
    Clinical Genetics 10/2012; 84(1). DOI:10.1111/cge.12035
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