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Cloud computing is a new paradigm that is transforming the information technology (IT) industry and reshaping the way enterprise services are developed, deployed, sold, delivered, and consumed. Instead of managing complex IT systems, customers can focus on the core competence of their enterprise while obtaining all required IT functions as a service. From the perspective of a cloud provider, remaining competitive and realizing full potential of economies of scale that the cloud paradigm promises require extreme levels of standardization, automation, and optimization. This paper describes the evolution of the Common Cloud Management Platform (CCMP), a management system providing business and operations support for cloud services. We cover its initial implementation and applications, discuss the latest challenges faced when adapting enterprise solutions to the cloud, and introduce the exploratory research topics to which this work led. We address the business services aspects, including framework-based integration of the catalog, and customer and revenue management, as well as the operational aspects, including novel approaches for scalable virtual machine provisioning and adaptive workload placement optimization. We discuss architecture, design, and implementation details of key CCMP components and highlight the challenging aspects of providing such architecture while promoting scalability, modularity, and reuse. [ABSTRACT FROM AUTHOR]

Objectives: Community pharmacists play an important role in primary care access and delivery for all patients, including patients with a family physician or nurse practitioner ("attached") and patients without a family physician or nurse practitioner ("unattached"). During the COVID-19 pandemic, community pharmacists were accessible care providers for unattached patients and patients who had difficulty accessing their usual primary care providers ("semi-attached"). Before and during the pandemic, pharmacist services expanded in several Canadian provinces. The aim of this qualitative study was to explore patient experiences receiving care from community pharmacists, and their perspectives on the scope of practice of community pharmacists., Methods: Fifteen patients in Nova Scotia, Canada, were interviewed. Participant narratives pertaining to pharmacist care were analyzed thematically., Key Findings: Attached, "semi-attached," and unattached patients valued community pharmacists as a cornerstone of care and sought pharmacists for a variety of health services, including triaging and system navigation. Patients spoke positively about expanding the scope of practice for community pharmacists, and better optimization of pharmacists in primary care., Conclusions: System decision-makers should consider the positive role community pharmacists can play in achieving primary care across the Quintuple Aim (population health, patient and provider experiences, reducing costs, and supporting equity in health)., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.)

Purpose: Preoperative breast MRI has been recommended at our center since 2016 for invasive lobular carcinoma and cancers in dense breasts. This study examined how preoperative breast MRI impacted surgical timing and outcomes for patients with newly diagnosed breast cancer. Methods: Retrospective single-center study of consecutive women diagnosed with new breast cancer between June 1, 2019, and March 1, 2021, in whom preoperative breast MRI was recommended. MRI, tumour histology, breast density, post-MRI biopsy, positive predictive value of biopsy (PPV3), surgery, and margin status were recorded. Time from diagnosis to surgery was compared using t -tests. Results: There were 1054 patients reviewed, and 356 were included (mean age 60.9). Of these, 44.4% (158/356) underwent preoperative breast MRI, and 55.6% (198/356) did not. MRI referral was more likely for invasive lobular carcinoma, multifocal disease, and younger patients. Following preoperative MRI, 29.1% (46/158) patients required additional breast biopsies before surgery, for a PPV3 of 37% (17/46). The time between biopsy and surgery was 55.8 ± 21.4 days for patients with the MRI, compared to 42.8 ± 20.3 days for those without ( P  < .00001). MRI was not associated with the type of surgery (mastectomy vs breastconserving surgery) ( P  = .44) or rate of positive surgical margins ( P  = .52). Conclusion: Among patients who underwent preoperative breast MRI, we observed significant delays to surgery by almost 2 weeks. When preoperative MRI is requested, efforts should be made to mitigate associated delays., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There are few contemporary studies on the time taken to complete dental procedures, those most heavily relied on in the United Kingdom date back to 1999., Objectives: This work aimed to establish how long members of the dental team took to complete specific dental procedures, relevant to their scope of practice., Methods: Data were collected via a purposive sample of 96 dentists, dental hygienists/therapists and dental nurses. Via an online survey, participants were asked to state the mean, minimum and maximum time they estimated that they took to complete individual dental procedures., Results: The mean time taken to complete procedures common to both dentists and dental hygienists/therapists ranged from 3.7 to 4 min respectively for clinical note reading prior to seeing patients to 30.1 and 28 min to undertake root surface debridement. There were no significant differences between the time taken by dentists and dental hygienists/therapists to treat adult patients. However, in all but one procedure, dental hygienists/therapists reported taking longer (p = 0.04) to treat child patients., Conclusions: The data provided here represent an up to date assessment of the time taken to complete specific tasks by different members of the dental team. These data will be of value to service planners and commissioners interested in evolving a dental care system that employs a greater degree of skill-mix and preventively oriented care., (© 2023. The Author(s).)

Breast tissue density (BTD) is known to increase the risk of breast cancer but is not routinely used in the risk assessment of the population-based High-Risk Ontario Breast Screening Program (HROBSP). This prospective, IRB-approved study assessed the feasibility and impact of incorporating breast tissue density (BTD) into the risk assessment of women referred to HROBSP who were not genetic mutation carriers. All consecutive women aged 40-69 years who met criteria for HROBSP assessment and referred to Genetics from 1 December 2020 to 31 July 2021 had their lifetime risk calculated with and without BTD using Tyrer-Cuzick model version 8 (IBISv8) to gauge overall impact. McNemar's test was performed to compare eligibility with and without density. 140 women were referred, and 1 was excluded ( BRCA gene mutation carrier and automatically eligible). Eight of 139 (5.8%) never had a mammogram, while 17/131 (13%) did not have BTD reported on their mammogram and required radiologist review. Of 131 patients, 22 (16.8%) were clinically impacted by incorporation of BTD: 9/131 (6.9%) became eligible for HROBSP, while 13/131 (9.9%) became ineligible ( p = 0.394). It was feasible for the Genetics clinic to incorporate BTD for better risk stratification of eligible women. This did not significantly impact the number of eligible women while optimizing the use of high-risk supplemental MRI screening.

Plastics are a ubiquitous pollutant in the marine environment. Despite growing concerns, quantitative and qualitative data on microplastics in aquatic and marine environments of Atlantic Canada is just emerging. Surface water plastics were measured and categorized by morphology (thread, microfibre, fragment, foam, film, pellet, and microbead) in two locations in Nova Scotia and one in Newfoundland and Labrador, Canada. All sites within the three locations contained plastic with an average abundance of 9669 items/km 2 . Most plastics (68 %) were sized as microplastics (0.425-5 mm), and plastic fragments were the most common morphological type. Polyethylene accounted for a third (30 %) of all particles found across all three locations, followed by polypropylene (23 %). Results can inform future research for community-based environmental groups, government, and academia., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To describe the development and application of the Assessment of Clinical Oral Risks and Needs (ACORN) stratification tool based on a traffic light system in National Health Service (NHS) general dental services (GDS) Wales, UK., Materials and Methods: This was a secondary analysis of routinely-collected dental care data. All courses of treatment provided in dental practices participating in NHS GDS Reform Programme between July 2018 and September 2019, in which an ACORN assessment and age were recorded were included in the analysis., Results: A total of 236,490 subjects contributed 339,933 courses of treatment during the study period. 'Amber' and 'red' ACORN outcomes were associated with more courses of treatment per annum than 'green' outcomes. Outcomes indicating an increased risk of decay or other dental problems were associated with a greater likelihood of several operative treatment items. Patients at greater risk of poor periodontal health were more likely to receive extractions and dentures than low-risk patients. Patients were most likely to either remain in the same ACORN outcome categories or move to a healthier state between assessments., Conclusion: More research is required to understand the utility of the ACORN tool in risk communication and behaviour change., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to date., Methods: A realist-informed qualitative study was conducted with unattached patients in Nova Scotia, Canada. Semi-structured interviews with nine participants were conducted and transcribed for analysis. The framework method was used to carry out analysis, which was guided by Donabedian's model of assessing healthcare access and quality., Results: Five key findings were noted in this study: 1) Participants experienced a range of consequences from not having a regular PHC provider. Participants used creative strategies to 2) attempt to gain attachment to a regular PHC provider, and, to 3) address their health needs in the absence of a regular PHC provider. 4) Participants experienced negative feelings about themselves and the healthcare system, and 5) stress related to the consequences and added work of being unattached and lost care., Conclusions: Unattached patients experienced a burden of care related to lost care and managing their own health and related information, due to the download of medical record management and system navigation to them. These findings may underestimate the consequences for further at-risk populations who would not have been included in our recruitment. This may result in poorer health outcomes, which could be mitigated by interventions at the structural level, such as enhanced centralized waitlists to promote attachment. Such waitlists may benefit from a triage approach to appropriately attach patients based on need., (© 2022. The Author(s).)

Public perceptions of pandemic viral threats and government policies can influence adherence to containment, delay, and mitigation policies such as physical distancing, hygienic practices, use of physical barriers, uptake of testing, contact tracing, and vaccination programs. The UK COVID-19 Public Experiences (COPE) study aims to identify determinants of health behaviour using the Capability, Opportunity, Motivation (COM-B) model using a longitudinal mixed-methods approach. Here, we provide a detailed description of the demographic and self-reported health characteristics of the COPE cohort at baseline assessment, an overview of data collected, and plans for follow-up of the cohort. The COPE baseline survey was completed by 11,113 UK adult residents (18+ years of age). Baseline data collection started on the 13th of March 2020 (10-days before the introduction of the first national COVID-19 lockdown in the UK) and finished on the 13th of April 2020. Participants were recruited via the HealthWise Wales (HWW) research registry and through social media snowballing and advertising (Facebook®, Twitter®, Instagram®). Participants were predominantly female (69%), over 50 years of age (68%), identified as white (98%), and were living with their partner (68%). A large proportion (67%) had a college/university level education, and half reported a pre-existing health condition (50%). Initial follow-up plans for the cohort included in-depth surveys at 3-months and 12-months after the first UK national lockdown to assess short and medium-term effects of the pandemic on health behaviour and subjective health and well-being. Additional consent will be sought from participants at follow-up for data linkage and surveys at 18 and 24-months after the initial UK national lockdown. A large non-random sample was recruited to the COPE cohort during the early stages of the COVID-19 pandemic, which will enable longitudinal analysis of the determinants of health behaviour and changes in subjective health and well-being over the course of the pandemic., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To determine surgical outcomes and breast cancer disease-free survival outcomes of women with early stage breast cancer with and without use of preoperative breast MRI according to breast tissue density., Methods: Women with early stage breast cancer diagnosed from 2004 to 2009 were classified into 2 groups: 1) those with dense and heterogeneously dense breasts (DB); 2) those with nondense breasts (NDB) (scattered fibroglandular and fatty replaced tissue). The 2 groups were reviewed to determine who underwent preoperative MRI. Breast tissue density was determined with mammography according to ACR BI-RADS. Patients were compared according to tumor size, grade, stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates., Results: In total, 261 patients with mean follow-up of 85 months (25-133) were included: 156 DB and 105 NDB. Disease-free survival outcomes were better in the DB group in patients with MRI than in those without MRI: patients with MRI had significantly fewer local recurrences (P < 0.016) and metachronous contralateral breast cancers (P < 0.001), but this was not the case in the NDB group. Mastectomies were higher in the DB group with preoperative MRI than in those without MRI (P < 0.01), as it was in the NDB group (P > 0.05)., Conclusions: Preoperative breast MRI was associated with reduced local recurrence and metachronous contralateral cancers in the DB group, but not in the NDB group; however, the DB patients with MRI had higher mastectomy rates., (© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Percutaneous breast biopsy in a tertiary referral high volume breast centre: can we improve the patient experience?, Purpose: The study was performed to evaluate patient experience during ultrasound-guided (UGB) and vacuum-assisted stereotactic breast biopsy (SBB) and determine what factors could improve the patient experience., Methods: Consecutive patients who underwent image guided breast biopsy from 01- 05/30, 2015 were approached in a structured telephone interview to evaluate pain and bruising from the procedure. Three hundred and fifty-one patients were interviewed (116 SBB and 235 UGB). Information about the radiologist performing the biopsy, biopsy type, needle gauge, and number of cores was collected from the biopsy reports. Correlation was done using Spearman rank test., Results: Average patient scores of pain with UGB and SBB were 2.3 and 3.1 (out of 10). There was a significant correlation between pain during SBB and physician experience (p = 0.013), and no correlation with pain during UGB (p > 0.05). No correlation was found between needle gauge and pain experienced during breast biopsy or between numbers of cores and pain (p > 0.05). Body position during SBB was mentioned to cause discomfort and pain in 28% of patients while during UGB was mentioned by 0.4% of patients., Conclusion: SBB was inferior to UGB for patient experience, but years of radiologists' experience correlated with improved patient scores of pain for SBB., Key Points: • To achieve high quality, an institution must emphasise patient-centred care. • Increased radiologist training with stereotactic biopsy may contribute to improved patient experience. • Stereotactic breast biopsy was inferior to ultrasound biopsy for patient experience. • Radiologists' experience correlated with improved patient scores of pain for stereotactic biopsy.

Objective: The purpose of this study is to develop a tool to assess the procedural competence of radiology trainees, with sources of evidence gathered from five categories to support the construct validity of tool: content, response process, internal structure, relations to other variables, and consequences., Subjects and Methods: A pilot form for assessing procedural competence among radiology residents, known as the RAD-Score tool, was developed by evaluating published literature and using a modified Delphi procedure involving a group of local content experts. The pilot version of the tool was tested by seven radiology department faculty members who evaluated procedures performed by 25 residents at one institution between October 2014 and June 2015. Residents were evaluated while performing multiple procedures in both clinical and simulation settings. The main outcome measure was the percentage of residents who were considered ready to perform procedures independently, with testing conducted to determine differences between levels of training., Results: A total of 105 forms (for 52 procedures performed in a clinical setting and 53 procedures performed in a simulation setting) were collected for a variety of procedures (eight vascular or interventional, 42 body, 12 musculoskeletal, 23 chest, and 20 breast procedures). A statistically significant difference was noted in the percentage of trainees who were rated as being ready to perform a procedure independently (in postgraduate year [PGY] 2, 12% of residents; in PGY3, 61%; in PGY4, 85%; and in PGY5, 88%; p < 0.05); this difference persisted in the clinical and simulation settings. User feedback and psychometric analysis were used to create a final version of the form., Conclusion: This prospective study describes the successful development of a tool for assessing the procedural competence of radiology trainees with high levels of construct validity in multiple domains. Implementation of the tool in the radiology residency curriculum is planned and can play an instrumental role in the transition to competency-based radiology training.

Problem Addressed: A recently implemented model of care in long-term care facilities (LTCFs) called Care by Design addresses concerns about a previously uncoordinated care system, a reduction in family physician services, and high rates of ambulance transports to emergency departments., Objective of Program: Care by Design is designed to increase access to care and continuity and quality of care by family physicians, reduce unwanted and unnecessary transfers to the emergency department, and lessen the burden on care teams including physicians and nurses in LTCFs., Program Description: The core of Care by Design is a dedicated family physician for each LTCF floor, with regular on-site visits; physician on-call coverage, 24 hours a day, 7 days a week; and standing orders and protocols. Care by Design also includes a comprehensive geriatric assessment tool, an interdisciplinary team approach, access to a dedicated extended care paramedic program to respond to urgent care needs, and ongoing performance measurement., Conclusion: Care by Design aims to improve on-site care for LTCF residents and family physicians' experiences with providing care in several ways, including increased clinical efficiency, communication, and continuity, and appropriate support within the interdisciplinary team model.

Objectives: Police are often the front-line response to people experiencing mental health crises. This study examined the impact of an integrated mobile crisis team formed in partnership between mental health services, municipal police, and emergency health services. The service offered short-term crisis management, with mobile interventions being attended by a plainclothes police officer and a mental health professional., Methods: We used a mixed-methods design encompassing: a controlled before-and-after quantitative comparison of the intervention area with a control area without access to such a service, for 1 year before and 2 years after program implementation; and qualitative assessments of the views of service recipients, families, police officers, and health staff at baseline and 2 years afterward., Results: The integrated service resulted in increased use by people in crisis, families, and service partners (for example, from 464 to 1666 service recipients per year). Despite increased service use, time spent on-scene and call-to-door time were reduced. At year 2, the time spent on-scene by police (136 minutes) was significantly lower than in the control area (165 minutes) (Student t test = 3.4, df = 1649, P < 0.001). After adjusting for confounders, people seen by the integrated team (n = 295) showed greater engagement than control subjects as measured by outpatient contacts (b = 1.3, chi square = 92.7, df = 1, P < 0.001). The service data findings were supported by the qualitative results of focus groups and interviews., Conclusions: Partnerships between the police department and mental health system can improve collaboration, efficiency, and the treatment of people with mental illness.

This article contrasts values associated with the delivery of housing programs for people with serious mental illness with the typical topics pertaining to housing that are studied by researchers. Six values were identified through a search and content analysis of the literature on housing for people with serious mental illness. A second review of the literature was conducted to identify research on housing for this population. A comparison of findings from the two reviews suggested that whereas values concerned with the therapeutic benefits of housing had received considerable research attention, those concerned with a citizenship dimension had received relatively little. The findings are discussed in terms of their implications for the delivery of housing services and for housing research.