Blending Behavioural Theory and Narrative Analysis to Explore the Lived Experience of Obesity and Assess Potential Engagement in a UK Weight Management Service: Theory and Narrative Approaches in Weight Management

Background: Current treatments for people with obesity emphasise the need for person-centred approaches that consider complex biopsychosocial factors and value the lived experience of people when attempting to lose weight. Methods: Narrative interviews (n = 20) were conducted with people living with obesity to explore the causes of their weight gain and their expectations and engagement with treatment at a Weight Management Clinic. A mixed inductive and deductive qualitative analysis identified utterances that represented psychological constructs used to understand self-appraisal and health behaviour. A narrative analysis was used to situate these findings in the context of a participant’s life story. Results: Locus of control was a dominant construct evidenced through a person’s attributional style and self-efficacy. Transcripts represented a heightened sense of self-understanding and shifts in control, and styles of attribution and efficacy resulted in either stasis or self-actualisation. The Stages of Change model could be applied to narratives to ascertain a patient’s motivation to access treatment. Importantly, narrative interviews also allowed for the consideration of how a person’s systemic context influenced their weight. Conclusion: Narrative interaction supports both self- and shared understandings of the causes and consequences of obesity for individuals, in a non-blaming or shaming manner. It provides an opportunity to enhance engagement through tailored, person-centred treatments.</jats:p

Admission Decision-Making in Hospital Emergency Departments: the Role of the Accompanying Person

In resource-stretched emergency departments, people accompanying patients play key roles in patients' care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 healthcare professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient-carer relationship contrasted with accompanying persons' varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relations with patients. Taking a relationship-centered approach could improve attention to accompanying persons as co-producers of healthcare and participants in decision-making

South African Hypertension Guideline 2006

Outcomes. Extensive data from many randomised controlled trials have shown the benefit of treating hypertension. The target blood pressure (BP) for antihypertensive management should be systolic BP < 140 mmHg, diastolic BP < 90 mmHg, with minimal or no drug side-effects. However, a lesser reduction will elicit benefit although this is not optimal. The reduction of BP in the elderly should generally be achieved gradually over 6 months. Stricter BP control is required for patients with end-organ damage, co-existing risk factors and co-morbidity, e.g. diabetes mellitus. Co-existent risk factors should also be controlled. Benefits. Reduction in risk of stroke, cardiac failure, renal insufficiency and coronary artery disease. The major precautions and contraindications to each antihypertensive drug recommended are listed. Recommendations. Correct BP measurement procedure is described. Evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. The total cardiovascular disease risk profile should be determined for all patients and this should inform management strategies. Lifestyle modification and patient education are cornerstones in the management of every patient. Drug therapy for the patient with uncomplicated hypertension should be as follows: first line – low-dose thiazide or thiazide-like diuretics; second line – add either an angiotensin-converting enzyme inhibitor (ACE-I) or a calcium channel blocker (CCB); third line – add another second-line drug not already used. In resistant hypertension where a fourth drug is needed, use either a centrally acting drug, vasodilator, alpha-blocker, or beta-blocker. The order of drug choice may change in those with compelling indications for a particular drug class. The guideline includes management of specific situations including hypertensive emergency and urgency, severe hypertension with target-organ damage and hypertension in diabetes mellitus, etc. Validity. The guideline was developed by a joint Southern African Hypertension Society and National Department of Health Directorate: Chronic Diseases, Disabilities and Geriatrics working group. Input was also obtained from representatives of the various related professional societies

Ultraviolet Imaging Observations of the cD Galaxy in Abell 1795: Further Evidence for Massive Star Formation in a Cooling Flow

We present images from the Ultraviolet Imaging Telescope of the Abell 1795 cluster of galaxies. We compare the cD galaxy morphology and photometry of these data with those from existing archival and published data. The addition of a far--UV color helps us to construct and test star formation model scenarios for the sources of UV emission. Models of star formation with rates in the range \sim5-20M_{\sun}yr$^{-1}$ indicate that the best fitting models are those with continuous star formation or a recent ($\sim4$ Myr old) burst superimposed on an old population. The presence of dust in the galaxy, dramatically revealed by HST images complicates the interpretation of UV data. However, we find that the broad--band UV/optical colors of this cD galaxy can be reasonably matched by models using a Galactic form for the extinction law with $E_{B-V}=0.14$. We also briefly discuss other objects in the large UIT field of view.Comment: To appear in the Astrophysical Journal. 14 AAS preprint style pages plus 7 figure

Cosmological Simulations with Scale-Free Initial Conditions I: Adiabatic Hydrodynamics

We analyze hierarchical structure formation based on scale-free initial conditions in an Einstein-de Sitter universe, including a baryonic component. We present three independent, smoothed particle hydrodynamics (SPH) simulations, performed with two different SPH codes (TreeSPH and P3MSPH) at two resolutions. Each simulation is based upon identical initial conditions, which consist of Gaussian distributed initial density fluctuations that have an n=-1 power spectrum. The baryonic material is modeled as an ideal gas subject only to shock heating and adiabatic heating and cooling. The evolution is expected to be self-similar in time, and under certain restrictions we identify the expected scalings for many properties of the distribution of collapsed objects in all three realizations. The distributions of dark matter masses, baryon masses, and mass and emission weighted temperatures scale quite reliably. However, the density estimates in the central regions of these structures are determined by the degree of numerical resolution. As a result, mean gas densities and luminosities obey the expected scalings only when calculated within a limited dynamic range in density contrast. The temperatures and luminosities of the groups show tight correlations with the baryon masses, which can be well-represented by power-laws. The Press-Schechter (PS) approximation predicts the distribution of group dark matter and baryon masses fairly well, though it tends to overestimate the baryon masses. Combining the PS mass distribution with the measured relations for T(M) and L(M) predicts the temperature and luminosity distributions reasonably, though there are some discrepancies at high temperatures/luminosities. The three simulations agree well for the properties of groups that are resolved by 32 or more particles.Comment: 40 pages, 16 embedded postscript figures, uses AASTEX 4.0 style. Minor wording changes, to appear in ApJ. Abridged abstrac

M33: A Galaxy with No Supermassive Black Hole

Galaxies that contain bulges appear to contain central black holes whose masses correlate with the velocity dispersion of the bulge. We show that no corresponding relationship applies in the pure disk galaxy M33. Three-integral dynamical models fit Hubble Space Telescope WFPC2 photometry and STIS spectroscopy best if the central black hole mass is zero. The upper limit is 1500 M_sun. This is significantly below the mass expected from the velocity dispersion of the nucleus and far below any mass predicted from the disk kinematics. Our results suggest that supermassive black holes are associated only with galaxy bulges and not with their disks.Comment: 8 pages, AJ accepted, November issu

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background: Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown. Aims: To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners. Methods: The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Findings: Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity. Conclusions: This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

WFPC2 Observations of the Cooling Flow Elliptical in Abell 1795

We present WFPC2 images of the core of the cooling flow cD galaxy in Abell 1795. An irregular, asymmetric dust lane extends 7 \h75 kpc in projection to the north-northwest. The dust shares the morphology observed in the H$\alpha$ and excess UV emission. We see both diffuse and knotty blue emission around the dust lane, especially at the ends. The dust and emission features lie on the edge of the radio lobes, suggesting star formation induced by the radio source or the deflection of the radio jets off of pre-existing dust and gas. We measure an apparent R$_V$ significantly less than 3.1, implying that the extinction law is not Galactic in the dust lane, or the presence of line emission which is proportional to the extinction. The dust mass is at least 2$\times10^{5} h_{75}^{-2}$ M\solar\ and is more likely to be 6.5$\times10^{5} h_{75}^{-2}$ M\solar.Comment: 14 pages, LaTeX, Figure 4 included, Postscript Figs. 1-3 available at ftp://astro.nmsu.edu/pub/JASON/A1795/, accepted for publication in ApJ Letter