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Opioids are more commonly prescribed for chronic pain in rural settings in the USA, yet little is known about how the rural context influences efforts to improve opioid medication management.
The Six Building Blocks is an evidence-based program that guides primary care practices in making system-based improvements in managing patients using long-term opioid therapy. It was implemented at 6 rural and rural-serving organizations with 20 clinic locations over a 15-month period. To gain further insight about their experience with implementing the program, interviews and focus groups were conducted with staff and clinicians at the six organizations at the end of the 15 months and transcribed. Team members used a template analysis approach, a form of qualitative thematic analysis, to code these data for barriers, facilitators, and corresponding subcodes.
Facilitators to making systems-based changes in opioid management within a rural practice context included a desire to help patients and their community, external pressures to make changes in opioid management, a desire to reduce workplace stress, external support for the clinic, supportive clinic leadership, and receptivity of patients. Barriers to making changes included competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources in rural areas.
The barriers and facilitators identified here point to potentially unique determinants of practice that should be considered when addressing opioid prescribing for chronic pain in the rural setting.
A geological disposal facility (GDF) will include fissile materials that could, under certain conditions, lead to criticality. Demonstration of criticality safety therefore forms an important part of a GDF's safety case.
Containment provided by the waste package will contribute to criticality safety during package transport and the GDF operational phase. The GDF multiple-barrier system will ensure that criticality is prevented for some time after facility closure. However, on longer post-closure timescales, conditions in the GDF will evolve and it is necessary to demonstrate: an understanding of the conditions under which criticality could occur; the likelihood of such conditions occurring; and the consequences of criticality should it occur.
Work has addressed disposal of all of the UK's higher-activity wastes in three illustrative geologies. This paper, however, focuses on presenting results to support safe disposal of spent fuel, plutonium and highlyenriched uranium in higher-strength rock.
The results support a safety case assertion that post-closure criticality is of low likelihood and, if it was to occur, the consequences would be tolerable.
The boundaries of psychotic illness and the extent to which operational diagnostic categories are distinct in the long term remain poorly understood. Clarification of these issues requires prospective evaluation of diagnostic trajectory, interplay and convergence/divergence across psychotic illness, without a priori diagnostic or other restrictions.
The Cavan-Monaghan First Episode Psychosis Study (CAMFEPS), conducted using methods to attain the closest approximation to epidemiological completeness, incepts all 12 DSM-IV psychotic diagnoses. In this study we applied methodologies to achieve diagnostic reassessments on follow-up, at a mean of 6.4 years after first presentation, for 196 (97%) of the first 202 cases, with quantification of prospective and retrospective consistency.
Over 6 years, the 12 initial psychotic diagnoses were characterized by numerous transitions but only limited convergence towards a smaller number of more stable diagnostic nodes. In particular, for initial brief psychotic disorder (BrP), in 85% of cases this was the harbinger of long-term evolution to serious psychotic illness of diagnostic diversity; for initial major depressive disorder with psychotic features (MDDP), in 18% of cases this was associated with mortality of diverse causality; and for initial psychotic disorder not otherwise specified (PNOS), 31% of cases continued to defy DSM-IV criteria.
CAMFEPS methodology revealed, on an individual case basis, a diversity of stabilities in, and transitions between, all 12 DSM-IV psychotic diagnoses over 6 years; thus, psychotic illness showed longitudinal disrespect to current nosology and may be better accommodated by a dimensional model. In particular, a first episode of BrP or MDDP may benefit from more vigorous, sustained interventions.
Intermediate-level wastes (ILW) include substantial quantities of fissile material and controls are required to ensure that its storage, transport and disposal does not present a nuclear criticality hazard. This paper describes the Radioactive Waste Management Directorate's research to develop package fissile material limits (in the form of screening levels) for four different categories of ILW, defined according to uranium or plutonium composition: (1) irradiated natural and slightly enriched uranium (uranium containing up to 1.9 wt.% 235U); (2) low-enriched uranium (uranium containing up to 4 wt.% 235U); (3) high-enriched uranium (uranium containing up to 100 wt.% 235U); and (4) separated plutonium (plutonium containing up to 100 wt.% 239Pu).
The derivation of package screening levels was supported by neutron transport calculations that addressed conditions during waste package transport to a geological disposal facility (GDF), during the GDF operational phase and after GDF closure. The analysis included consideration of combinations of events and processes that could result in fissile material accumulation and concentration after GDF closure, when waste packages have deteriorated sufficiently for fissile material to be mobilized. The results of the calculations have provided input to Radioactive Waste Management Directorate's decision making on setting waste package screening levels.
The use of psychotropic medication is an important part of most psychiatrists' clinical practice. We propose here that psychiatry needs to give more prominence to psychopharmacology in order to ensure that psychiatric drugs are used effectively and safely. The issue has several ramifications, including the future of psychiatry as a medical discipline.
There is now widespread concern about the inadequate care and support provided to people with dementia from diagnosis to death. It is acknowledged that while there is a range of effective ways to care for and support people with dementia and their families from diagnosis to death, these have yet to become integral to practice. In England, for example, the National Dementia Strategy seeks to transform the quality of dementia care. One of the key components to transforming the quality of care is to ensure we have an informed and effective workforce. We argue here that in order to transform the quality of care we need to distinguish between the aims of training and education. Whilst there is a place for skills-based workplace training, Higher Education in dementia studies has a key role to play in the provision of specialist knowledge and skills in dementia care emphasizing as it does the development of critical thinking, reflection and action. In this paper we describe dementia studies at Bradford University available at both undergraduate and postgraduate levels. We outline their aims and learning outcomes, curricula, approach to teaching, learning and assessment. We describe the nature of students who study with us, noting their fit with the Higher Education Funding Council in England's agenda for widening participation in higher education. Higher Education in dementia studies has a unique role to play in equipping practitioners and professionals with the information, skills and attitudes to realize the potential for quality of life for people with dementia and their families.
The huge range of political ideas that circulated in early modern Europe can often seem bewildering, and bringing order and unity to this picture of diversity can be difficult. There were ideologies of monarchy, coming from both a Christian tradition and a Roman imperial one; theories of resistance against tyranny; republican political ideas from the Italian city states and the Netherlands; constitutional theories; approaches to politics stemming from epistemological or moral scepticism; political ideas based around the idea of the state; theories of natural law; and scientific approaches to political organization and moral truth. It is extremely difficult to say something intelligible about such a complex array of political ideas, despite their importance for understanding the early modern political world.
Methodologically, the study of such a range of political ideas presents a number of challenges. One recent approach has been to look at the texts concerned not just in terms of their contents and their logic, but also in terms of the context of their creation. This can be thought of either in terms of a particular political situation, or an intellectual tradition or, more fruitfully, as a combination of both. Such an approach would give us a deeper understanding of the nature and the life of these political ideas.
In so doing, it is possible to come to a closer understanding of what a particular text is designed to do, and how it relates to the political culture in question.
The importance of an adequate meatoplasty is often emphasised in mastoid surgery. However, bigger is not always better, as an excessively widened external meatus can be cosmetically unacceptable, provide little extra benefit for cleaning, be an obstacle to the good fitting of hearing aids and expose the mastoid cavity to exaggerated caloric effect.
The problems created by an overly large meatus can occasionally be difficult to manage, prompting consideration of reduction of the meatus. We describe the use of a pedicled, post-auricular skin flap to achieve reduction of an excessively large meatus.
We have analysed a rare occurrence of orange-brown manganotantalite lamellae (visible in hand specimen), intergrown with microlite [(Ca,Na)2(Ta,Nb)2(O,OH,F)7], aggregates of ferrotapiolite, bismuth minerals and apatite to understand more about the mechanisms of crystal growth and secondary modification in Ta-rich minerals. The intergrowth occurs within amblygonite/montebrasite nodules near the quartz core of the highly fractionated rare-metal Li/Be/Ta pegmatite at Rubicon, Karibib, Namibia. Electron microprobe analyses show that manganotantalite lamellae are variable in composition. Primary microlite (Ta2O5 82%, 1.97 Ta a.p.f.u.) forms the matrix mineral between the lamellae. Textural relations suggest an exsolution origin for the lamellae. Manganotantalite is represented by three generations: (1) primary late magmatic; (2) disequilibrium exsolution lamellae; and (3) subsolidus replacement. Crystallization commenced with primary microlite and likely simultaneous intergrowth between ferrotapiolite and a first generation of late-magmatic primary manganotantalite with low Ta (1.1—1.5 a.p.f.u.). On cooling this was followed by exsolution of manganotantalite lamellae, generation (2) with low—medium Ta (1.27—1.7 a.p.f.u.). The replacement of microlite by a highly fractionated late-stage melt rich in Mn2+, Ca2+ with low Na+ finally produces a third generation (3) of manganotantalite with high Ta (1.72—1.99 a.p.f.u.) at the contact with microlite. Native bismuth and bismutite cut across microlite and pseudomorph lamellae as a final hydrothermal replacement. Apatite is ubiquitous at the contact with amblygonite. The stability field of microlite may be extended by incorporation of CaTa2O6-rynersonite and Ca2Ta2O7 — idealized, components in solid solution. However, rynersonite-CaTa2O6 with distorted octahedra has some structural templates which are similar to the structure of pyrochlore (microlite). Hence, via the perovskite/pyrochlore analogy, hypothetical exsolution of manganotantalite-type structures may occur from a microlite (pyrochlore) host by solid-state diffusion via metastable rynersonite-type intermediates. Such a mechanism has the potential to explain the crystallographically controlled intergrowth textures and the compositional heterogeneity.
Populations of hosts vary extensively in the types and numbers of parasites that the average individual contains. Understanding the factors that lead to this variation is an important goal for parasite ecologists. We characterized patterns of helminth component community structure in whitefish collected from a cluster of 7 lakes located on an isolated plateau in northern Alberta, Canada. Component communities were species rich (5–6 species per lake), high in mean helminth intensity (approximately 80–500 individuals/host), and high in between-lake similarity (50–100%), a pattern consistent with results from studies on whitefish sampled from other localities in Northern Canada and Europe. Multivariate analyses indicated that the structure of the component communities was associated with 2 opposing environmental gradients. One was defined primarily by water colour, the second by phosphorous concentration. Thus, 4 lakes were characterized by a combination of high colour, low productivity, low parasite intensities, and the absence of larval acanthocephalans. Habitat/species associations were less clear as intensities increased, but the 3 remaining lakes tended to have the opposite characteristics. These results provide evidence that variation in helminth component community structure in fish is associated with variation in physicochemical characteristics that are linked to aquatic productivity.
Low pressure chemical vapor deposition (LPCVD) and plasma enhanced chemical vapor deposition (PECVD) silicon oxide and silicon nitride films were implanted subcutaneously in a rat model to study in vivo behavior of the films. Silicon chips coated with the films of interest were implanted for up to one year, and film thickness was evaluated by spectrophotometry and sectioning. Dissolution rates were estimated to be 0.33 nm/day for LPCVD silicon nitride, 2.0 nm/day for PECVD silicon nitride, and 3.5 nm/day for PECVD silicon oxide. A similar PECVD silicon oxide dissolution rate was observed on a silicon oxide / silicon nitride / silicon oxide stack that was sectioned by focused ion beam etching. These results provide a biostability reference for designing implantable microfabricated devices that feature exposed ceramic films.
Escherichia coli O157 infections cause an estimated 60 deaths and 73000 illnesses annually in the United States. A marked summer peak in incidence is largely unexplained. We investigated an outbreak of E. coli O157 infections at an agricultural fair in Ohio and implicated consumption of beverages made with fairground water and sold by a geographically localized group of vendors who were all on the same branch of the fairground water distribution system. To examine county fair attendance as a risk factor for infection, we conducted two further epidemiological studies. In the first, we enhanced surveillance for E. coli O157 infections in 15 Northeast Ohio counties during the 2000 agricultural fair season and showed increased risk of E. coli O157 infection among fair attendees. In the second study, we examined Ohio Public Health Laboratory Information Service (PHLIS) data for 1999 using a time-varying covariate proportional hazards model and demonstrated an association between agricultural fairs and E. coli O157 infections, by county. Agricultural fair attendance is a risk factor for E. coli O157 infection in the United States and may contribute to the summer peak in incidence. Measures are needed to reduce transmission of enteric pathogens at agricultural fairs.
NGC 7027 is justifiably THE template spectrum for PNe. Its vast range of emission species – from molecular and neutral to ions with ionization potential > 120eV – its high surface brightness and accessibiliy for northern observatories make it the PN laboratory of choice. However the quality of the spectra from the UV to the IR is mixed, many line fluxes and identifications still remaining unchecked from photographic or image tube spectra. Very deep spectra of NGC 7027 (emission line strengths <10-4 of Hβ) in the 0.65 to 1.05μm region (Baluteau et al. 1995) showed the presence of many faint emission lines. Pequignot & Baluteau (1994) showed that heavy elements from the 4th, 5th and 6th rows of the Periodic Table have much higher abundances than Solar, confirming the synthesis of neutron capture elements in low mass stars and providing new constraints on stellar evolution theory.