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Despite policy and practice mandates for patient involvement, people with serious mental illness often feel marginalised in decisions about antipsychotic medication.
To examine stakeholder perspectives of barriers and facilitators to involving people with serious mental illness in antipsychotic prescribing decisions.
Systematic thematic synthesis.
Synthesis of 29 studies identified the following key influences on involvement: patient's capability, desire and expectation for involvement, organisational context, and the consultation setting and processes.
Optimal patient involvement in antipsychotic decisions demands that individual and contextual barriers are addressed. There was divergence in perceived barriers to involvement identified by patients and prescribers. For example, patients felt that lack of time in consultations was a barrier to involvement, something seldom raised by prescribers, who identified organisational barriers. Patients must understand their rights to involvement and the value of their expertise. Organisational initiatives should mandate prescriber responsibility to overcome barriers to involvement.
Rearing quality dairy heifers is essential to maintain herds by replacing culled cows. Information on the key factors influencing the cost of rearing under different management systems is, however, limited and many farmers are unaware of their true costs. This study determined the cost of rearing heifers from birth to first calving in Great Britain including the cost of mortality, investigated the main factors influencing these costs across differing farming systems and estimated how long it took heifers to repay the cost of rearing on individual farms. Primary data on heifer management from birth to calving was collected through a survey of 101 dairy farms during 2013. Univariate followed by multivariable linear regression was used to analyse the influence of farm factors and key rearing events on costs. An Excel spreadsheet model was developed to determine the time it took for heifers to repay the rearing cost. The mean±SD ages at weaning, conception and calving were 62±13, 509±60 and 784±60 days. The mean total cost of rearing was £1819±387/heifer with a mean daily cost of £2.31±0.41. This included the opportunity cost of the heifer and the mean cost of mortality, which ranged from £103.49 to £146.19/surviving heifer. The multivariable model predicted an increase in mean cost of rearing of £2.87 for each extra day of age at first calving and a decrease in mean cost of £6.06 for each percentile increase in time spent at grass. The model also predicted a decrease in the mean cost of rearing in autumn and spring calving herds of £273.20 and £288.56, respectively, compared with that in all-year-round calving herds. Farms with herd sizes⩾100 had lower mean costs of between £301.75 and £407.83 compared with farms with <100 milking cows. The mean gross margin per heifer was £441.66±304.56 (range £367.63 to £1120.08), with 11 farms experiencing negative gross margins. Most farms repaid the cost of heifer rearing in the first two lactations (range 1 to 6 lactations) with a mean time from first calving until breaking even of 530±293 days. The results of the economic analysis suggest that management decisions on key reproduction events and grazing policy significantly influence the cost of rearing and the time it takes for heifers to start making a profit for the farm.
Cross-sectorial surveillance and general collaboration between the animal and the public health sectors are increasingly recognized as needed to better manage the impacts of zoonoses. From 2009, the Swiss established a Campylobacter mitigation system that includes human and poultry surveillance data-sharing within a multi-sectorial platform, in a ‘One Health’ approach. The objective of this study was to explore the economics of this cross-sectorial approach, including surveillance and triggered interventions. Costs and benefits of the One Health and of the uni-sectorial approach to Campylobacter surveillance were identified using an economic assessment framework developed earlier. Cost information of surveillance activities and interventions was gathered and disability-adjusted life years (DALYs) associated with the disease estimated for 2008 and 2013. In the first 5 years of this One Health approach to Campylobacter mitigation, surveillance contributed with information mainly used to perform risk assessments, monitor trends and shape research efforts on Campylobacter. There was an increase in costs associated with the mitigation activities following integration, due mainly to the allocation of additional resources to research and implementation of poultry surveillance. The overall burden of campylobacteriosis increased by 3·4–8·8% to 1751–2852 DALYs in 2013. In the timing of the analysis, added value associated with this cross-sectorial approach to surveillance of Campylobacter in the country was likely generated through non-measurable benefits such as intellectual capital and social capital.
Animal health surveillance enables the detection and control of animal diseases including zoonoses. Under the EU-FP7 project RISKSUR, a survey was conducted in 11 EU Member States and Switzerland to describe active surveillance components in 2011 managed by the public or private sector and identify gaps and opportunities. Information was collected about hazard, target population, geographical focus, legal obligation, management, surveillance design, risk-based sampling, and multi-hazard surveillance. Two countries were excluded due to incompleteness of data. Most of the 664 components targeted cattle (26·7%), pigs (17·5%) or poultry (16·0%). The most common surveillance objectives were demonstrating freedom from disease (43·8%) and case detection (26·8%). Over half of components applied risk-based sampling (57·1%), but mainly focused on a single population stratum (targeted risk-based) rather than differentiating between risk levels of different strata (stratified risk-based). About a third of components were multi-hazard (37·3%). Both risk-based sampling and multi-hazard surveillance were used more frequently in privately funded components. The study identified several gaps (e.g. lack of systematic documentation, inconsistent application of terminology) and opportunities (e.g. stratified risk-based sampling). The greater flexibility provided by the new EU Animal Health Law means that systematic evaluation of surveillance alternatives will be required to optimize cost-effectiveness.
Campylobacter is the leading cause of bacterial diarrhoeal disease worldwide, with raw and undercooked poultry meat and products the primary source of infection. Colonization of broiler chicken flocks with Campylobacter has proved difficult to prevent, even with high levels of biosecurity. Dipteran flies are proven carriers of Campylobacter and their ingress into broiler houses may contribute to its transmission to broiler chickens. However, this has not been investigated in the UK. Campylobacter was cultured from 2195 flies collected from four UK broiler farms. Of flies cultured individually, 0·22% [2/902, 95% confidence interval (CI) 0–0·53] were positive by culture for Campylobacter spp. Additionally, 1293 flies were grouped by family and cultured in 127 batches: 4/127 (3·15%, 95% CI 0·11-6·19) from three broiler farms were positive for Campylobacter. Multilocus sequence typing of isolates demonstrated that the flies were carrying broiler-associated sequence types, responsible for human enteric illness. Malaise traps were used to survey the dipteran species diversity on study farms and also revealed up to 612 flies present around broiler-house ventilation inlets over a 2-h period. Therefore, despite the low prevalence of Campylobacter cultured from flies, the risk of transmission by this route may be high, particularly during summer when fly populations are greatest.
Scholarly assessments of Chaucer's fabliaux seldom acknowledge that these tales are erotic as well as funny; even less frequently do such investigations delve into why fabliaux are a source of pleasure. As Tom Hanks and W. W. Allman note in their article ‘Rough Love: Notes toward an Erotics of The Canterbury Tales’, scholars seem ‘to have averted their gaze when Chaucer's characters leap into bed’. Allman and Hanks, as their title implies, study an erotics of violence, mostly of men doing violence to women, and they focus in particular on the Merchant's Tale and its ‘erotics of stabbing’. A more positive erotic reading of the Merchant's Tale appears in Andrew Taylor's 1996 essay ‘Reading the Dirty Bits’. Taylor notes the lingering gaze of another scholar, E. Talbot Donaldson, upon a description of young May's body:
Hir fresshe beautee and hir age tendre,
Hir myddel smal, hire armes longe and sklendre,
Hir wise governaunce, hir gentilesse,
Hir wommanly berynge, and hire sadnesse.
Donaldson writes, ‘the Spring of pretty young girls is a permanent thing, and that May in their personas will always warm the masculine heart’. Taylor suggests that pleasure taken in this description and in Donaldson's gloss of it is mimetic: ‘For the young college man to share Donaldson's and Chaucer's pleasure in May is to become, like them, a connoisseur of both good writing and pretty girls, a master of ironic detachment and well-modulated heterosexual desire’.
As Roger Ascham famously observed, Malory's Morte Darthur is primarily concerned with ‘open manslaughter, and bold bawdry’. I would not disagree; in fact, I would say that these themes are not only dominant but are inextricably interwoven. Male sexuality, in Malory, is consistently portrayed as potentially violent and disruptive, dangerous not only to individuals but to the whole structure of society, and therefore in need of controlling measures. The medieval world did not, of course, often portray any form of sexuality positively. Sexual desire leads both men and women to sin: both directly in committing fornication, incest and adultery, and indirectly in committing treason or disregarding their duties. It could easily be assumed that this is a divide between the clergy on the one side, themselves compelled to live in celibacy and thus suspicious of sexual desire, and the more relaxed nobility and commons on the other, cheerfully ignoring the rules when it suited them. However, this is too simple a dichotomy. Malory himself, despite the bold bawdry, shares in the suspicion of unregulated desire, in his nostalgia for a chaster time,
nowadayes men can nat love sevennyght but they muste have all their desyres … But the olde love was nat so. for men and women coulde love togydirs seven yerys, and no lycoures lustis was betwyxte them, and than was love trouthe and faythefulnes.
In her seminal 1980 essay Pouvoirs de l'horreur, Julia Kristeva identifies ‘the abject’ as the human reaction to a breakdown in meaning caused by the loss of distinction between the subject and the object, the interior and the exterior, or the self and the Other. Her classic example of a site of abjection is that of the human corpse, which although a continuation of the dead person's corporeal presence also becomes simultaneously a marker of his or her spiritual absence, and thus must be rejected or repressed, causing the subjective experience of ‘horror’. Kristeva argues that human rationality necessarily involves a series of such repressions, and that the association of the human with the unrepressed thus becomes a site of potential tension. ‘The abject confronts us’, she suggests, ‘with those fragile states where man strays on the territories of animal’. This borderland between the acceptable and the unacceptable thus becomes the site of the carnivalesque, the comedic and the socially transgressive, as attested by post-medieval writers from Rabelais to Bakhtin and beyond.
In the first decade of the sixteenth century, the abject was also a major concern for the poet William Dunbar, writing at the court of King James IV. Dunbar's poems are critically regarded as some of the most brilliant – and, frequently, the most offensive – writings produced in late medieval/ early modern Scotland. Many of his satirical pieces depict the court of James (who would later go on to lose his life at the disastrous Battle of Flodden) at play, simultaneously parodying and affirming the excesses of late medieval/Renaissance aristocratic culture.
George Ripley, in his apostrophic preface to God in the Compound of Alchemy, claims to have ‘renounced … fleshly lust’ and asks God to provide him (and, presumably, other worthy alchemists) with His ‘secret treasure’: ‘Shew us thy secrets and to us be bounteous’ (21.4). Throughout the Compound, Ripley guides readers away from worldly pleasures, urging them instead to focus their desires on God-granted alchemical secrets and ‘our stone of great delight’ (37.2). Likewise, Thomas Norton, in his prologue to the Ordinal of Alchemy, warns of avaricious would-be alchemists who ‘in fyre / Of brennyng couetise haue therto desire’ (27–8). Norton emphatically shuns ‘wordly werkis’ in favour of alchemical ‘connyng’, advising his reader to ‘sett fully his trust’ in God and ‘in connyng be fixid al his lust’ (509, 517, 535–6): ‘For above all erthlye thynge / I mooste desire & love connynge’ (2595–6). Desire or lust, in both the Compound and the Ordinal, is thus redirected from the physical body and material world toward the divinely inspired knowledge of the alchemical corpus. Moreover, as I will illustrate, Norton and Ripley both direct their reader to focus on the text's rhetorical structures in order to achieve desired alchemical objectives.
In her 2007 essay ‘“Wordy vnthur wede”: Clothing, Nakedness and the Erotic in some Romances of Medieval Britain’, Amanda Hopkins examines the interplay of clothing and nudity in creating erotic moments, noting the connection of eroticism with female aggression on the one hand, and the erotic link between female nudity and passivity on the other. Lancelot's encounter with Elaine at Corbyn in Malory's Morte Darthur is marked by erotic moments featuring female nudity that appear emblematic of the latter. The eroticism of the moment when Lancelot rescues the ‘dolerous lady’ (2.791) from the boiling water by taking her by the hand, ‘naked as a nedyll’ (2.792), depends both on her total nudity and her status as victim – that is to say that the moment is erotic not just because she is naked, but because that nudity is not of her own making. Later, when Elaine ‘skypped oute of her bedde all naked’ (2.795) and kneels at Lancelot's feet to beg for her life, both her nudity and her vulnerability work to produce an erotic effect. Certainly Lancelot quickly changes his mind and turns from threatening her to embracing her. Yet to view Elaine as completely passive is a mistake – at the least her passivity is manipulated and Lancelot's presence in her bed is the result of machinations in which Elaine plays a willing part.
Sir Thopas's resolution to forsake human women in order to seek out an elf-queen as his lover satirizes one of the most well-known romance motifs: the fairy mistress who offers herself to the human protagonist of the narrative. It is characteristic of this motif that, with relatively few exceptions, the fairy offers sexual intercourse to the hero without any demand for the commitment of marriage and without stipulating any directly connected negative consequences. The motif's origins are a good deal earlier than those of romance – it features in several early medieval Irish narratives – but it is with romance that the motif is most particularly associated. It is noticeable that this extramarital sex is generally not explicitly condemned in the romances. Of course, romance authors are not prone to sermonizing digressions, so this might be passed over as merely a reflex of the genre; however, condemnation need not be overtly stated to still be clear and, in this respect, romance differs markedly from fabliaux, the other genre which frequently portrays extra-marital sex.
In the late fifteenth-century Squire of Low Degree, the incompetent protagonist woos a Hungarian princess in a way that seems to subject the romance genre to derivative, almost parodic, excess. This excess, however, offers particular insight into the representation of wooing in Middle English romance more broadly. While many romance heroines assume their suitors will display knightly prowess to win their love, this princess seems so aware of the Squire's shortcomings that she explains to him precisely what he must do, focusing on the rather boy-scout-like logistics of riding ‘Over hylles and dales, and hye mountaines, / In wethers wete, both hayle and raynes’, and lodging ‘under a tre, / Among the beastes wyld and tame’. Reminiscent here of how a Sir Thopas might understand chivalry, the text continues its overzealous attempt to ape romance when the princess exhaustively details the accoutrements that she expects from a suitor (203–30), and it is equally unable to find the right register when she offers to bankroll his required adventures (251–5). The envious steward's attempts to ruin the Squire by exposing his amorous inclinations are predictable enough; the results, however, have been seen as uncharacteristic of romance, since the king does not object to the Squire courting his daughter, but rather instructs the steward:
It is often said that the past is a foreign country where they do things differently, and perhaps no type of "doing" is more fascinating than sexual desires and behaviours. Our modern view of medieval sexuality is characterised bya polarising dichotomy between the swooning love-struck knights and ladies of romance on one hand, and the darkly imagined and misogyny of an unenlightened "medieval" sexuality on the other. British medieval sexual culture also exhibits such dualities through the influential paradigms of sinner or saint, virgin or whore, and protector or defiler of women. However, such sexual identities are rarely coherent or stable, and it is in the grey areas, the interstices between normative modes of sexuality, that we find the most compelling instances of erotic frisson and sexual expression. This collection of essays brings together a wide-ranging discussion of the sexual possibilitiesand fantasies of medieval Britain as they manifest themselves in the literature of the period. Taking as their matter texts and authors as diverse as Chaucer, Gower, Dunbar, Malory, alchemical treatises, and romances, the contributions reveal a surprising variety of attitudes, strategies and sexual subject positions. Contributors: Aisling Byrne, Anna Caughey, Kristina Hildebrand, Amy S. Kaufman, Yvette Kisor, Megan G. Leitch, Cynthea Masson, Hannah Priest, Samantha J. Rayner, Robert Allen Rouse, Cory James Rushton, Amy N. Vines.
Poaching with snares has been identified as the main cause of decline of the endemic roan antelope Hippotragus equinuslangheldi in Ruma National Park, Kenya, from > 200 in 1979 to 37 in 2009. However, the spatial snaring patterns in the Park are not clearly understood. The focus of our study was to map the spatial distribution of snares in the Park and to identify the factors influencing this distribution, to develop effective methods of wildlife protection. Using data collected from 56 sample plots during 2006–2008, coupled with geographical information system techniques, we investigated the association between the occurrence of snares and the distribution of geographical features (slope, elevation), infrastructure (roads, fences), essential resources for wildlife (water, salt licks, forage), roan locations and wildlife density. Ripley's L function for assessing complete spatial randomness indicated that snares occurred in clumps (hotspots) up to 4 km apart. Negative binomial regression indicated that these hotspots occurred (1) near water resources, salt licks and the Park boundary, (2) far from roan locations and Park roads, (3) in areas with low gradients and low wildlife density, and (4) in areas with burned vegetation. We recommend concentrating routine security patrol efforts and resources on snare hotspots to reduce snaring and to protect the roan antelope and other threatened wildlife.
The aim of this study was to investigate spatial variation in risk of hospitalization in childhood pneumonia and empyema in the North of England and associated risk factors. Data on childhood (0–14 years) hospital admissions with a diagnosis pneumonia or empyema were linked to postcode districts. Bayesian conditional autoregressive models were used to evaluate spatial variation and the relevance of specific spatial covariates in an area-based study using postcode as the areal unit. There was a sixfold variation in the risk of hospitalization due to pneumonia across the study region. Variation in risk was associated with material deprivation, Child Well-being Index (CWI) health domain score, number of children requiring local authority support, and distance to hospital. No significant spatial variation in risk for empyema was found.
Zircons from a bentonite near the base of the Purley Shale Formation in the Nuneaton area, Warwickshire, yield a 206Pb/238U age of 517.22 ± 0.31 Ma. Based on the fauna of small shelly fossils and the brachiopod Micromitra phillipsii in the underlying Home Farm Member of the Hartshill Sandstone Formation, trilobite fragments that are questionably referred to Callavia from the basal Purley Shale Formation, and the presence of trilobites diagnostic of the sabulosa Biozone 66 m above the base of the Purley Shale Formation, the bentonite likely dates an horizon within Cambrian Stage 3, at about the level of the Fallotaspis or basal Callavia Biozone. This is consistent with bentonite ages from other localities in southern Britain, which constrain the age of the lower and uppermost parts of Cambrian Stage 3. The new date provides additional chronological control on the earliest occurrence of trilobites in the Midland Microcraton, a date for the marine transgression at the base of the Purley Shale Formation, and is the first radiometric age from the Cambrian succession of Warwickshire.