Shared decision-making in ongoing outpatient psychiatric treatment

Objective: Research on patient involvement in decision-making in psychiatry has focused on first encounters. This study investigated what decisions are made, level of patient involvement and factors influencing patient involvement in ongoing outpatient visits. Methods:72 visits conducted by 20 psychiatrists were video recorded. Patients had a diagnosis of depression or schizophrenia. Results: On average, there was one medication related and one other decision per visit. Some psychiatrists involved patients more in decisions, as did female psychiatrists. Involvement was lower when patients had more negative symptoms. Conclusion: Involvement in decision-making appears to be influenced by the individual psychiatrist and specific symptoms but not visit length. Practice implications:It is noteworthy that patient involvement is not influenced by length of the visit given that this would be a barrier in busy clinical practice. The next step would be to identify the communication patterns of psychiatrists who involve patients more in decision-making

Effect of NOx level on secondary organic aerosol (SOA) formation from the photooxidation of terpenes

Secondary organic aerosol (SOA) formation from the photooxidation of one monoterpene (α-pinene) and two sesquiterpenes (longifolene and aromadendrene) is investigated in the Caltech environmental chambers. The effect of NOx on SOA formation for these biogenic hydrocarbons is evaluated by performing photooxidation experiments under varying NOx conditions. The NOx dependence of α-pinene SOA formation follows the same trend as that observed previously for a number of SOA precursors, including isoprene, in which SOA yield (defined as the ratio of the mass of organic aerosol formed to the mass of parent hydrocarbon reacted) decreases as NOx level increases. The NOx dependence of SOA yield for the sesquiterpenes, longifolene and aromadendrene, however, differs from that determined for isoprene and α-pinene; the aerosol yield under high-NOx conditions substantially exceeds that under low-NOx conditions. The reversal of the NOx dependence of SOA formation for the sesquiterpenes is consistent with formation of relatively low-volatility organic nitrates, and/or the isomerization of large alkoxy radicals leading to less volatile products. Analysis of the aerosol chemical composition for longifolene confirms the presence of organic nitrates under high-NOx conditions. Consequently the formation of SOA from certain biogenic hydrocarbons such as sesquiterpenes (and possibly large anthropogenic hydrocarbons as well) may be more efficient in polluted air

Partial encapsulation of Pd particles by reduced ceria-zirconia

Direct observation of metal-oxide interfaces with atomic resolution can be achieved by cross-sectional high-resolution transmission electron microscopy (HRTEM). Using this approach to study the response of a model, single-crystal thin film automotive exhaust-gas catalyst, Pd particles supported on the (111) ceria-zirconia (CZO) surface, to a redox cycle, we have found two distinct processes for the partial encapsulation of the Pd particles by the reduced CZO surface that depend on their relative crystallographic orientations. In the case of the preferred orientation found for Pd particles on CZO, Pd(111)[110]//CZO(111)[110]Pd(111)[110]∕∕CZO(111)[110], a flat and sharp metal/oxide interface was maintained upon reduction, while ceria-zirconia from the adjacent surface tended to accumulate on and around the Pd particle. In rare cases, Pd particles with other orientations tended to sink into the oxide support upon reduction. Possible mechanisms for these encapsulation processes are proposed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87836/2/201915_1.pd

Determination of 3D Trajectories of Knots in Solar Prominences Using MSDP Data

In this paper we present a new method of restoration of the true thee-dimensional trajectories of the prominence knots based on ground-based observations taken with a single telescope, which is equipped with a Multi-Channel Subtractive Double Pass imaging spectrograph. Our method allows to evaluate true three-dimensional trajectories of the prominence knots without any assumptions concerning the shape of the trajectories or dynamics of the motion. The reconstructed trajectories of several knots observed in three prominences are presented.Comment: 14 pages, 9 figures, accepted for publication in Solar Physic

Anorgasmia in women

This article reports on the etiology and treatment of anorgasmia. Etiological factors include childhood and adolescent experiences, current individual attitudes, and lifestyle factors, as well as the quality and dynamics of past and present committed relationships. It is important to assess the nature of each of the previously mentioned factors in determining the nature of the orgasmic dysfunction as well as assisting in the development of a treatment plan. Treatment approaches for anorgasmia need to address individual factors (e.g., performance anxiety, poor body image) as well as interpersonal problems. A systemic treatment framework would appear to be the most useful approach to treat this sexual dysfunction, as this type of strategy identifies and treats the difficulties experienced by the anorgasmic woman within the total context of her life. Of course, this approach necessitates the involvement of the partner in therapy, and treatment is unlikely to be effective unless the problems experienced by both the woman and her partner are addressed. Limitations of past research in terms of inadequate evaluation of treatment, low sample sizes, and poorly defined interventions are discussed. Finally, directions for future research to advance our understanding of the most effective treatments for anorgasmia are considered. <br /

Practical long-distance quantum key distribution system using decoy levels

Quantum key distribution (QKD) has the potential for widespread real-world applications. To date no secure long-distance experiment has demonstrated the truly practical operation needed to move QKD from the laboratory to the real world due largely to limitations in synchronization and poor detector performance. Here we report results obtained using a fully automated, robust QKD system based on the Bennett Brassard 1984 protocol (BB84) with low-noise superconducting nanowire single-photon detectors (SNSPDs) and decoy levels. Secret key is produced with unconditional security over a record 144.3 km of optical fibre, an increase of more than a factor of five compared to the previous record for unconditionally secure key generation in a practical QKD system.Comment: 9 page

The staircase method: integrals for periodic reductions of integrable lattice equations

We show, in full generality, that the staircase method provides integrals for mappings, and correspondences, obtained as traveling wave reductions of (systems of) integrable partial difference equations. We apply the staircase method to a variety of equations, including the Korteweg-De Vries equation, the five-point Bruschi-Calogero-Droghei equation, the QD-algorithm, and the Boussinesq system. We show that, in all these cases, if the staircase method provides r integrals for an n-dimensional mapping, with 2r<n, then one can introduce q<= 2r variables, which reduce the dimension of the mapping from n to q. These dimension-reducing variables are obtained as joint invariants of k-symmetries of the mappings. Our results support the idea that often the staircase method provides sufficiently many integrals for the periodic reductions of integrable lattice equations to be completely integrable. We also study reductions on other quad-graphs than the regular 2D lattice, and we prove linear growth of the multi-valuedness of iterates of high-dimensional correspondences obtained as reductions of the QD-algorithm.Comment: 40 pages, 23 Figure

Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery

Aim/ Principal Research Question:1) To determine whether pre-operative assessment carried out by an appropriately trained nurse (ATN) is equivalent in quality to that carried out by a pre-registration house officer (PRHO).2) To assess whether pre-assessments carried out by ATNs and PRHOs are equivalent in terms of cost.3) To determine whether assessments carried out by ATNs are acceptable to patients.4) To investigate the quality of communication between senior medical staff and ATNs.Factors of Interest:The extended role of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery.Methods:The study design was principally a prospective randomised equivalence trial but was accompanied by additional qualitative assessment of patient and staff perceptions, and an economic evaluation.The intervention consisted of a pre-operative assessment carried out by either an ATN or a PRHO. Of the patients who completed the study with a full evaluation, 926 patients were randomised to the PRHO arm of the trial and 948 to the ATN arm. Three ATNs took part in the study, one from each centre, together with a total of 87 PRHOs.Immediately following the initial assessment of a patient by a PRHO or an ATN, one of a number of clinical research fellows, all specialist registrars in anaesthetics, repeated the assessment and recorded it on a study form, together with a list of investigations required. The clinical research fellow then evaluated the competency of the initial assessor by comparing the quality of their assessment with their own. Any deficiencies in ordering of investigations and referral to other specialities were met in order to maximise patient care.Sample groups:All patients attending at one site for assessment prior to general anaesthetic for elective general, vascular, urological or breast surgery were potentially included in the study. Of 1907 patients who were randomised, 1874 completed the study with a full evaluation.The study was carried out at four NHS hospitals, three of which were teaching hospitals, in three NHS Trusts in Southampton, Sheffield and Doncaster.Outcome measures:Three areas of ATN and PRHO performance were judged separately, history taking, examination and ordering of tests, and each was graded into one of four categories, the most important of which was under-assessment, which would possibly have affected peri-operative management. In the case of ordering of tests, it was possible to have both over- and under-assessed a patient on different tests.Findings:The pre-operative assessments carried out by the ATNs were essentially equivalent to those performed by the PRHOs in terms of under-assessment that might possibly have affected peri-operative management, although there was variation between the ATNs in terms of the quality of history taking. This may be related to the low number of patients seen at one study site.PRHOs ordered significantly more unnecessary tests than the ATNs. The substitution of ATNs for PRHOs was calculated to be cost neutral.The results of the qualitative assessment showed that the use of ATNs for pre-operative assessment was acceptable to patients; however, there was no evidence that communication between senior medical staff and those carrying out pre-operative assessments was improved by their introduction.Conclusions:This study demonstrated no reason to inhibit the development of fully nurse-led pre-operative assessment, provided that the nurses are appropriately trained and maintain sufficient workload to retain skills.Implications for Further Research:Further research is needed in the following areas:1) the extent and type of training needed for nurses undertaking the pre-operative assessment role2) the use, costs and benefits of routine pre-operative testing.<br/

CD4+ T Cells Reactive to Enteric Bacterial Antigens in Spontaneously Colitic C3H/HeJBir Mice: Increased T Helper Cell Type 1 Response and Ability to Transfer Disease

C3H/HeJBir mice are a new substrain that spontaneously develop colitis early in life. This study was done to determine the T cell reactivity of C3H/HeJBir mice to candidate antigens that might be involved in their disease. C3H/HeJBir CD4+ T cells were strongly reactive to antigens of the enteric bacterial flora, but not to epithelial or food antigens. The stimulatory material in the enteric bacteria was trypsin sensitive and restricted by class II major histocompatibility complex molecules, but did not have the properties of a superantigen. The precursor frequency of interleuken (IL)-2–producing, bacterial-reactive CD4+ T cells in colitic mice was 1 out of 2,000 compared to 1 out of 20,000–25,000 in noncolitic control mice. These T cells produced predominately IL-2 and interferon γ, consistent with a T helper type 1 cell response and were present at 3–4 wk, the age of onset of the colitis. Adoptive transfer of bacterial-antigen–activated CD4+ T cells from colitic C3H/HeJBir but not from control C3H/HeJ mice into C3H/HeSnJ scid/scid recipients induced colitis. These data represent a direct demonstration that T cells reactive with conventional antigens of the enteric bacterial flora can mediate chronic inflammatory bowel disease

Primary keratinocyte cell culture on EpiGen membranes for autologous skin grafts in paediatric burn patients

Cultured epithelial autografts have been shown to be an effective permanent skin replacement for major burn injuries and have proved life-saving when insufficient donor skin has been available. Several membrane systems have been developed that facilitate the transfer of cultured cells on to the recipient. The aim of the study reported here was to test the effectiveness of EpiGen, a synthetic polymer membrane, as a cell culture support matrix for the transplantation of cultured autografts. Skin biopsies were obtained from 22 paediatric burn patients with an affected total body surface area of between 7% and 80%. Basal keratinocytes were harvested from the dermal/epidermal junction and cultured in a collagen 1-coated flask in modified Green’s medium. After two passages, isolated keratinocytes were grown on EpiGen membranes until semiconfluent. Wound beds were excised and covered with widely (1:3) meshed split skin grafts. Membranes were grafted with the basal cell layer directed against the wound bed. Unseeded membranes were applied and served as controls. Wounds were dressed and closed appropriately. Grafts were regularly inspected for ‘take’ and the membranes were removed 10 days after application. Seven patients had to be excluded from the study. Cell culture results of the remaining 15 patients showed excellent cell growth and expansion on EpiGen membranes within a mean culture time of 2.6 days post membrane seeding. The membranes facilitated easy transfer of cultures onto the recipient. A mean keratinocyte graft ‘take’ of 95% and a mean control graft ‘take’ of 90% were recorded at the time of membrane removal. The mean level of clinically evident re-epithelialization on keratinocyte grafted areas in recipients was 87% as opposed to 60% in the unseeded control areas