Music in the Park. An integrating metaphor for the emerging primary (health) care system

Background Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns. Reflections Parks, like health services, are embedded in their local landscape, serving their communities, but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there. Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be ‘in the moment’, to take personal risks and to draw energy and inspiration from the participants. Hence ‘audiences’ are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co‐constructed experience. Conclusions Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients ‘co‐producers’ of their own health and ‘co‐shapers’ of their health services.     

The social construction of chronicity – a key to understanding chronic care transformations

Purpose The purpose of this paper is to argue the importance of contemporary analysis of the modern social construction of chronicity – encapsulating the world views of the chronically ill, and the medical and health system constructions of chronic disease, through the nature of care for chronic conditions. It is argued that chronic diseases are themselves, socially constructed, despite widely accepted disease classification systems. Thus, there is a need to examine how different ideas have permeated our clinical and health system developments and their social context and vice versa. Methods We examine historical ideas, theory and evidence about the tensions in social construction of chronic illness by those afflicted and the responses of society, the medical and health professions and increasingly the public and private institutions that shape health care. This is with the background of major differences in the two cultures that create knowledge: those based upon argument and intellectual logic – hermeneutic, and those based upon ‘objectivist’ empirical science, often called heuristic. Evidence‐based medicine (EBM) is the flagship of disease management, increasingly narrative‐based medicine and other similar genres are becoming the pragmatic face of social constructions, yet sit in juxtaposition without synthesis. A third culture has emerged of scientific intellectuals who straddle these cultures and in health care their public face is ‘mixed methods’. Findings Recent cases of modern ideas about improving chronic care were reviewed. We found that despite developments of social theory, the world view of the chronically ill exerts small influence in health system redesign, apparently dominated by chronic disease models. Confusion remains within health system reforms as to the social construction of chronicity – chronic disease, chronic condition or chronic illness and chronic care transformations. The role of Primary Care remains ambiguous straddling disease and illness. Radical redesign of health systems is taking place without an understanding and discourse about the nature of their construction. Ad hoc eclectism with unquestioning adoption of the dominant EBM paradigm is driving a new health culture based on disease‐based performance incentives, which is intrusive beyond the medical model and pays little attention to narratives of illness and even less to the whole social reconstruction of illness and wellness. Conclusions Health care systems cannot afford to avoid, and should actively embrace the critiques of social theory and analyses in the transformations of health systems to improve chronic care. Creative tensions between empirical and intellectual critique, and a synthetic middle ground are likely to lead to more realistic and innovative approaches spanning the nature of chronicity and the transformation of Primary Care.     

Making sense of polarities in health organizations for policy and leadership

Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense‐Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense‐Making schema is proposed.     

Immune Complexes in ovarian carcinoma

Immunodiagnostic screening may improve the survival of ovarian carcinoma by earlier detection and follow-up during treatment. Presently, several ovarian cancer-associated antigens are being utilized to monitor treatment response; a specific and precise test for screening is not currently available. The present study was designed to investigate the presence and clinical significance of circulating immune complexes (IC) in patients with ovarian carcinoma using a polyethylene glycol (PEG) assay. If this assay were to prove clinically useful in patients with ovarian carcinoma, its potential as a screening test would then be evaluated. Serum was obtained from 38 patients with advanced ovarian carcinoma preoperatively, postoperatively, and prior to the administration of a combination chemotherapy regimen containing cisplatin. Five patients had values greater than or equal to 0.10. This test identified only 12.5% of the patients with active disease. Serial sampling failed to reveal any correlation with disease status. Our experience does not support the usefulness of IC levels in studying or treating patients with ovarian carcinoma.     

Congenital pernicious anemia: report of seven patients, with studies of the extended family

Unstimulated whole saliva was collected from 203 uninfected individuals at various ages from birth until adulthood. Levels of specific antibodies against Escherichia coli O antigens of secretory IgA, secretory IgM and IgG, as well as total amounts of SIgA, were determined using ELISA. Levels of SIgA antibodies found in adults were approached by the age of 12 months, but high levels could be attained earlier, presumably in response to antigenic exposure at the mucosal level. During the first few months of life, secretory IgM antibodies appeared in the saliva, possibly compensating for the relative lack of IgA.     

Rainbow trout primary epidermal cell proliferation as an indicator of aquatic toxicity: an in vitro/in vivo exposure comparison

Little or no work has been carried out on primary cell cultures in terms of cellular proliferation and toxicity studies. Cell proliferation represents one of the most relevant cellular functions. Anti-PCNA antibodies have aroused considerable interest recently as potential immunocytochemical markers of proliferation for use in toxicity studies. In this study, PCNA methodology, which was developed primarily for mammalian tissues, was adapted to rainbow trout (Oncorhynchus mykiss (R.)) primary cultured epidermal cells exposed in vivo i.e. whole animal exposures and in vitro for the study of the ecotoxicological potential of the aromatic amine, 2,4-dichloroaniline (2,4-DCA), a member of a little studied and widespread class of aquatic pollutants. There are many approaches to assess the proliferative activity of cells. Immunocytochemical methods offer a high sensitivity and specificity. The immunohistochemical avidin-biotin complex (ABC) method was used for the detection and quantification of PCNA, one of the best-known endogenous proliferation markers, applying the mammalian monoclonal antibody PC-10 to formalin-fixed primary cultures of rainbow trout skin. Here we describe our experience with the immunocytochemical detection and quantification of this proliferation marker. Results indicate that the antibody cross reacts with the corresponding rainbow trout epitope and that the alterations in PCNA labelling in the in vivo and in vitro exposed cultures followed similar patterns. This paper presents data on the validation of rainbow trout primary epidermal culture as an in vitro ecotoxicity model with epidermal proliferation as an endpoint. It can be concluded that cellular proliferation could be used as an indicator of the aquatic toxicity potential of xenobiotics. Correlations between cellular proliferation responses in primary cultures derived from in vivo exposed rainbow trout and primary cultures exposed in vitro were assessed. A dose-response was evidenced in both approaches, however the in vivo exposures appeared to be approximately two orders of magnitude more sensitive than the in vitro exposures. Responses in vitro occurred between 200 and 1000 micro M while in vivo responses were between 2 and 10 micro M. The good qualitative correspondence between the in vitro and in vivo results indicates that studies using trout epidermal cells allow the identification of xenobiotic effects in fish skin. However, further work is required before quantitative predictions i.e. effective concentrations in vivo, can be made from in vitro studies. This study suggests that the in vitro exposed rainbow trout primary cultured cell model with proliferation as an endpoint can be used as an alternative testing procedure to the whole animal assay.     

The drive for quality care in US nursing homes in the era of the prospective payment system

The quality of nursing home care has often given rise to concern from many interested stakeholders. In the US, this has led to the implementation of a major legislative framework in the form of the Nursing Home Reform Act, which sought to improve the quality of care through regulation and inspections. Research has shown that certain elements of care have improved but much remains to be done. Additional pressure is now being placed on the nursing home sector through the introduction of a prospective payment system (PPS), which sets limits on reimbursement for services for Medicare-covered stays. It has been proposed that this new system of payment may lead to difficulties in accessing nursing home care for patients who are deemed to be costly, and initial assessments suggest that patients are now carefully screened before being admitted to nursing homes. This may have major implications for patients who require multiple and expensive drug therapy and other interventions. Although the Nursing Home Reform Act seeks to drive forward the quality agenda in nursing home care, research is urgently required to evaluate the impact of the PPS which may force this healthcare sector to emphasise reducing costs at the expense of residents' needs.     

Reproductive potential of crimson-spotted rainbowfish (Melanotaenia fluviatilis) following short-term exposure to bass strait crude oil and dispersed crude oil

An examination of the potential of crude oil and mixtures of dispersants and crude oil to act as reproductive toxicants is reported in this article. The short-term effects of a water-accommodated fraction of crude oil (WAF) and a dispersed crude oil water-accommodated fraction (DCWAF) on selected reproductive end points were measured by conducting 3-day exposures to the crimson-spotted rainbowfish (Melanotaenia fluviatilis). Exposures were followed by 14-day depuration periods to determine the ability of fish to recover from the exposure. There were no changes to egg production, hatchability, or larval lengths for the WAF and DCWAF test periods. There were no changes to plasma estradiol or testosterone concentrations, gonadosomatic indices, or histopathological organization of gonad tissues after the exposure and depuration periods for both WAF and DCWAF. As reproductive parameters were not altered after 3 days of exposure and 14 days of depuration, crimson-spotted rainbowfish were able to endure short-term exposures to crude oil and dispersed crude oil.