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Adherence to practice guidelines for diagnosing and treating attention-deficit/hyperactivity disorder (ADHD) by primary care providers (PCPs) is important for optimizing care for many children and youth. However, adherence is often low. To address this problem, we implemented an intensive intervention in 2009 aimed at improving diagnosis and management of ADHD among PCPs.
The study objective is to assess the sustainability of intervention-attributable outcomes.
The study aims are to assess the sustained effect of the intervention on PCP intentions to implement, attitudes toward, and obstacles to implement ADHD practice guidelines.
During November 2009, 48 PCPs from 31 clinical practices completed a 3-day training, 6 months of biweekly telephone peer group reinforcement, and baseline questionnaires; follow-up questionnaires were completed at 12 months. To assess sustainability, we tracked PCPs and administered the questionnaire in 2016.
Intentions to implement ADHD guidelines remained stable over seven years, with all mean values ranging from “probably will” to “definitely will” implement guidelines.
Generally, favorable self-reported intentions (see Exhibits 1 & 2), attitudes and obstacles to implementing ADHD guidelines were sustained seven years after the intensive training and follow-up intervention.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A principal mode of corrosion in combustion or fuel cell environments is the formation of volatile hydroxides and oxyhydroxides from metal or oxide surfaces at high temperatures. It is important to determine the degree of volatility and accurate thermodynamic properties for these hydroxides. Significant gaseous metal hydroxides/oxyhydroxides are discussed, along with available experimental and theoretical methods of characterizing species and determining their thermodynamic properties.
Virtual Engineering (VE), also known as Model-Based Systems Engineering (MBSE), is necessary in both current operational engineering qualifications and to help reduce the costs of future vertical lift design and analysis. As computational power continues to provide increasing capability to the rotorcraft engineering community to perform simulations in both real time and off line, it is imperative that the community develop verification and validation protocols and processes to certify these methods so that they can be reliably used to help reduce engineering cost and schedule. Computational Fluid Dynamics (CFD) has become a major Computational Science and Engineering (CSE) tool in the fixed wing and vertical lift communities, but it has not been developed to the point where it is accepted as a replacement for testing in certification of new or existing systems or vehicles. Since the rise of modern CFD in the 1980s, the promise of CFD’s capabilities has been met or exceeded, but its role in certification arguably remains less prominent than projected. The ability to implement transformative technologies further drives the need for CFD in design. To meet CFD’s role in certification, several goals must be met to provide a true “numerical experiment” from which accuracies (error estimates), sensitivities, and consistent application results can be extracted. This paper discusses the progress and direction towards developing CFD strategies for certification.
An adverse early life environment can increase the risk of metabolic and other disorders later in life. Genetic variation can modify an individual’s susceptibility to these environmental challenges. These gene by environment interactions are important, but difficult, to dissect. The nucleus is the primary organelle where environmental responses impact directly on the genetic variants within the genome, resulting in changes to the biology of the genome and ultimately the phenotype. Understanding genome biology requires the integration of the linear DNA sequence, epigenetic modifications and nuclear proteins that are present within the nucleus. The interactions between these layers of information may be captured in the emergent spatial genome organization. As such genome organization represents a key research area for decoding the role of genetic variation in the Developmental Origins of Health and Disease.
Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred >72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p<0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.
In a recent article, I discussed vocative uses of οὗτος in the works of Aeschylus, Sophocles, Euripides and Aristophanes, showing that there are two types of vocatives: ‘calls’, which are utterance-initial and directed at one whose attention is turned elsewhere, and ‘addresses’, which are non-initial, employed by a speaker who is already conversing with a hearer, and typically indicate a speaker's annoyance at the hearer. Menander uses οὗτος as a vocative in the same ways as the other dramatic poets, but there is one instance in Dyscolus that has been routinely misconstrued and merits clarification.
In this paper, we present novel algorithms for finding small relations and ideal factorizations in the ideal class group of an order in an imaginary quadratic field, where both the norms of the prime ideals and the size of the coefficients involved are bounded. We show how our methods can be used to improve the computation of large-degree isogenies and endomorphism rings of elliptic curves defined over finite fields. For these problems, we obtain improved heuristic complexity results in almost all cases and significantly improved performance in practice. The speed-up is especially high in situations where the ideal class group can be computed in advance.
Trypanosomes and Leishmania are vector-borne parasites associated with high morbidity and mortality. Trypanosoma lewisi, putatively introduced with black rats and fleas, has been implicated in the extinction of two native rodents on Christmas Island (CI) and native trypanosomes are hypothesized to have caused decline in Australian marsupial populations on the mainland. This study investigated the distribution and prevalence of Trypanosoma spp. and Leishmania spp. in two introduced pests (cats and black rats) for three Australian locations. Molecular screening (PCR) on spleen tissue was performed on cats from CI (n = 35), Dirk Hartog Island (DHI; n = 23) and southwest Western Australia (swWA) (n = 58), and black rats from CI only (n = 46). Despite the continued presence of the intermediate and mechanical hosts of T. lewisi, there was no evidence of trypanosome or Leishmania infection in cats or rats from CI. Trypanosomes were not identified in cats from DHI or swWA. These findings suggest T. lewisi is no longer present on CI and endemic Trypanosoma spp. do not infect cats or rats in these locations.
Organized as a series of authoritative discussions, this book presents the application of Jewish law - or Halakhah - to contemporary social and political issues. Beginning with the principle of divine revelation, it describes the contents and canons of interpretation of Jewish law. Though divinely received, the law must still be interpreted and 'completed' by human minds, often leading to the conundrum of divergent but equally authentic interpretations. Examining topics from divorce to war and from rabbinic confidentiality to cloning, this book carefully delineates the issues presented in each case, showing the various positions taken by rabbinic scholars, clarifying areas of divergence, and analyzing reasons for disagreement. Written by widely recognized scholars of both Jewish and secular law, this book will be an invaluable source for all who seek authoritative guidance in understanding traditional Jewish law and practice.