Delivering stepped care: an analysis of implementation in routine practice

addresses: Mood Disorders Centre, University of Exeter, Exeter, EX4 4QG, UK. [email protected]: PMCID: PMC3283464types: Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't© 2012 Richards et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.In the United Kingdom, clinical guidelines recommend that services for depression and anxiety should be structured around a stepped care model, where patients receive treatment at different 'steps,' with the intensity of treatment (i.e., the amount and type) increasing at each step if they fail to benefit at previous steps. There are very limited data available on the implementation of this model, particularly on the intensity of psychological treatment at each step. Our objective was to describe patient pathways through stepped care services and the impact of this on patient flow and management

Depression and anxiety, an Indicated Prevention (DIP) protocol in homes for the elderly: feasibility and (cost) effectiveness of a stepped care programme

BACKGROUND: Depressive and anxiety disorders are a very common, serious and underdetected problem in homes for the elderly. Elderly persons in residential homes are at high risk for developing major depressive and anxiety disorders, and, therefore, deserve attention with regard to prevention. METHODS/DESIGN: This protocol describes a randomised trial on the feasibility and (cost) effectiveness of a stepped-care programme for prevention of depressive and anxiety disorders in homes for the elderly. The main outcome measure is the incidence of depressive and anxiety disorder in one year with a two years follow up. Secondary outcomes are symptoms of depression and anxiety, quality of life, direct health care costs and satisfaction with treatment. DISCUSSION: The number of studies examining the effects of preventive interventions on the incidence of mental disorders in the elderly population is very small. However, indicated prevention by means of a stepped-care programme seems to be an important option for decreasing the burden of illness for residents and their caregivers. This study contributes to the body of knowledge in this field. Positive effects may contribute to further use and development of tailored, (cost-) effective and easy to use interventions in a preventive stepped-care programme. TRIAL REGISTRATION: The Dutch Cochrane Centre, ISRCTN2754073

Methodology of calculation of construction and hydrodynamic parameters of a foam layer apparatus for mass-transfer processes

Промислова реалізація методу стабілізації газорідинного шару дозволяє значно розширити галузь застосування пінних апаратів і відкриває нові можливості інтенсифікації технологічних процесів з одночасним створенням маловідходних технологій. У статті встановлені основні параметри, що впливають на гідродинаміку пінних апаратів, розглянуті основні конструкції та режими роботи пінних апаратів. Виявлено зв'язок гідродинамічних параметрів. Розглянуто гідродинамічні закономірності пінного шару. Вказані фактори, що впливають на процес масообміну, як в газовій, так і в рідкій фазах. Проведений аналіз ряду досліджень показав, що перспективним напрямком інтенсифікації процесу масообміну є розробка апаратів з трифазним псевдозрідженим шаром зрошуваної насадки складних форм із сітчастих матеріалів. Отже, необхідне проведення спеціальних досліджень гідродинамічних режимів роботи апарату з сітчастою насадкою і визначенням параметрів, що впливають на швидкість переходу насадки з одного режиму в інший.Industrial implementation of the stabilization method of the gas-liquid layer can significantly expand the field of use of foaming apparatus and opens up new opportunities for intensifying technological processes with the simultaneous creation of low-waste technologies. The article establishes the basic parameters influencing the hydrodynamics of foam apparatus, considers the basic constructions and operating modes of foam apparatus. The connection of hydrodynamic parameters is revealed. The hydrodynamic laws of the foam layer are considered. The indicated factors affecting the process of mass transfer, both in the gas and in the liquid phases. The conducted analysis of a number of studies showed that the perspective direction of intensification of the mass transfer process is the development of apparatuses with a three-phase fluidized bed of an irrigated nozzle of complex forms with mesh materials

Dislocation Climb in AlN Crystals Grown at Low-Temperature Gradients Revealed by 3D X-ray Diffraction Imaging

The dislocation evolution in a cross-section a-plane cut through a sublimation-grown aluminum nitride (AlN) crystal grown with low-temperature gradients and subsequent low thermal stress is investigated with different X-ray diffraction imaging methods. Exploiting the so-called weak-beam contrast using monochromatic X-rays in combination with suitable three-dimensional (3D) interpretation and reconstruction allows the identification of individual dislocations as well as tracing their progression in the crystal volume, even in the considerably strained interface region. It is particularly striking that the laterally grown crystal volume is dislocation-free. The dislocation densities in the seed and the bulk volume are similar (1 × 10$^3$ cm$^{–2}$), but while the dislocations in the seed are randomly arranged, the dislocations in the bulk volume show a uniform line shape, indicating a common mechanism of dislocation movement. Since the dislocation slings in the bulk do not lie in slip planes, it can be concluded that the lateral movement does not result from dislocation glide, but from impurity-driven climb of dislocations during growth. The absence of slip can be explained by the low-temperature gradients and the subsequent low thermal stress below the critical resolved shear stress (CRSS)

X-ray characterization of self-standing bent Si crystal plates for Large Hadron Collider beam extraction

Bent crystals can be used to deflect high-energy charged particles for beam extraction and/or beam collimation at accelerator facilities, thanks to the channelling phenomenon. In the present paper, two perfect silicon mono-crystals were bent using two different methods: sandblasting and the application of a carbon fibre composite. In particular, these samples were obtained for the realization of bent crystal prototypes to be used to steer the 7 TeV proton beam of the Large Hadron Collider in the context of the CRYSBEAM project. The two bending methods were selected since they allow a very homogeneous curvature of the crystals to be obtained, which is essential for high channelling efficiency. Moreover, the deformation obtained is self-standing, i.e. there is no need for any external device to keep the samples bent. Self-standing curvature can be useful because the presence of an external bender could be a severe limitation in the collider beam-pipe. The curvature of the samples was measured through high-energy X-ray diffraction at the ID11 beamline of the European Synchrotron Radiation Facility in Grenoble, France. Since the diffraction efficiencies obtained were in good agreement with theoretical expectations, it follows that the manufacturing techniques did not damage the samples, i.e. the crystallographic quality was preserved. Finally, the crystal quality of the sandblasted sample was investigated in detail at the synchrotron source at Karlsruhe Institute of Technology by X-ray white-beam topography. The measurements showed no diffusion of defects from the machined surfaces to the crystal bulk

Phase I dose-escalation study of stereotactic body radiotherapy (SBRT) for poor surgical candidates with localized renal cell carcinoma

To evaluate the tolerability of escalating doses of stereotactic body radiotherapy (SBRT) for primary treatment of localized renal cell carcinoma (RCC) in poor surgical candidates. Eligible patients included those with clinically staged radiographic and or pathologically confirmed RCC who had not undergone previous abdominal or pelvic radiotherapy. All patients had comorbid medical conditions which precluded surgery. Median (range) patient age was 77.6years (range 59–89) years and all patients had Karnofsky Performance Status of ⩾60. Median tumor volume was 57.9cm3 (range 13.8–174.7cm3). Dose-limiting toxicity (DLT) was defined as grade 3 or worse gastrointestinal/genitourinary toxicity by Common Terminology Criteria of Adverse Events (version 4). Tumor response was assessed by imaging results using Response Evaluation Criteria In Solid Tumors (RECIST) measurement and percutaneous biopsy. A total of 19 patients (13 men and 6 women) were treated on protocol from June 2006 through August 2011. Groups of 3–6 patients received 24, 32, 40, and 48Gy in 4 fractions. Median (range) follow-up was 13. 7months (5.9–34.7months). For possibly treatment-related acute toxicities, one patient developed grade 2 fatigue and one developed grade 4 duodenal ulcer. For possibly treatment-related late toxicities, 2 patients experienced grade 3 renal toxicity (worsening chronic kidney disease), one reported grade 2 urinary incontinence and one developed grade 4 duodenal ulcer. Among the 15 patients with evaluable response, 3 and 12 had partial response and stable disease, respectively, utilizing RECIST criteria. Among the 11 patients who had post-SBRT biopsy, only one (9%) was negative on first biopsy and an additional one (9%) turned negative without further therapy on second biopsy. Dose escalation to 48Gy in 4 fractions has been achieved successfully without dose-limiting toxicities. A planned extension of this phase I trial is currently underway treating patients to 60Gy in 3 fractions to further evaluate this experimental therapy