Examining the impact of a novel integrated care pathway for faecal incontinence on patients and within a National Health Service organisation

Background: Faecal incontinence (FI) is a common healthcare problem. The management of FI patients is widely reported as being disjointed. In response to this and governmental guidance, an integrated care pathway (ICP) was implemented at a local NHS trust. Aim: To assess how the implementation of a community-based ICP affects the key stakeholders and to observe the process of organisational change within the trust using normalization process theory (NPT). Methods: Mixed methodology combining semi-structured interviews of key stakeholders, narrative interviews with patients, focus group discussion, observational work and clinical quantitative data. Qualitative data was analysed using thematic analysis and the Framework Method, with NPT being used to structure the qualitative findings. Results: Key facilitators to the implementation of the ICP included clinical leadership, staff commitment, teamwork, adequate clinical capacity and good clinical outcomes. There was a delay in the implementation due to lack of organisational management input and key stakeholder time From a patient perspective, benefits were identified such as improved access to the service and symptom improvement. Conclusions: An ICP for FI could provide an answer to the long-standing issues that have blighted continence services. Patients report satisfaction based on improved access to the service alongside good clinical outcomes

Jupiter as a Giant Cosmic Ray Detector

We explore the feasibility of using the atmosphere of Jupiter to detect Ultra-High-Energy Cosmic Rays (UHECR's). The large surface area of Jupiter allows us to probe cosmic rays of higher energies than previously accessible. Cosmic ray extensive air showers in Jupiter's atmosphere could in principle be detected by the Large Area Telescope (LAT) on the Fermi observatory. In order to be observed, these air showers would need to be oriented toward the Earth, and would need to occur sufficiently high in the atmosphere that the gamma rays can penetrate. We demonstrate that, under these assumptions, Jupiter provides an effective cosmic ray "detector" area of $3.3 \times 10^7$ km$^2$. We predict that Fermi-LAT should be able to detect events of energy $>10^{21}$ eV with fluence $10^{-7}$ erg cm$^{-2}$ at a rate of about one per month. The observed number of air showers may provide an indirect measure of the flux of cosmic rays $\gtrsim 10^{20}$ eV. Extensive air showers also produce a synchrotron signature that may be measurable by ALMA. Simultaneous observations of Jupiter with ALMA and Fermi-LAT could be used to provide broad constraints on the energies of the initiating cosmic rays.Comment: 8 pages, 5 figures. Accepted for publication in the Astrophysical Journal Letter

Ionisation and discharge in cloud-forming atmospheres of brown dwarfs and extrasolar planets

Brown dwarfs and giant gas extrasolar planets have cold atmospheres with rich chemical compositions from which mineral cloud particles form. Their properties, like particle sizes and material composition, vary with height, and the mineral cloud particles are charged due to triboelectric processes in such dynamic atmospheres. The dynamics of the atmospheric gas is driven by the irradiating host star and/or by the rotation of the objects that changes during its lifetime. Thermal gas ionisation in these ultra-cool but dense atmospheres allows electrostatic interactions and magnetic coupling of a substantial atmosphere volume. Combined with a strong magnetic field , a chromosphere and aurorae might form as suggested by radio and x-ray observations of brown dwarfs. Non-equilibrium processes like cosmic ray ionisation and discharge processes in clouds will increase the local pool of free electrons in the gas. Cosmic rays and lighting discharges also alter the composition of the local atmospheric gas such that tracer molecules might be identified. Cosmic rays affect the atmosphere through air showers in a certain volume which was modelled with a 3D Monte Carlo radiative transfer code to be able to visualise their spacial extent. Given a certain degree of thermal ionisation of the atmospheric gas, we suggest that electron attachment to charge mineral cloud particles is too inefficient to cause an electrostatic disruption of the cloud particles. Cloud particles will therefore not be destroyed by Coulomb explosion for the local temperature in the collisional dominated brown dwarf and giant gas planet atmospheres. However, the cloud particles are destroyed electrostatically in regions with strong gas ionisation. The potential size of such cloud holes would, however, be too small and might occur too far inside the cloud to mimic the effect of, e.g. magnetic field induced star spots

Plays, Performances and Power Struggles - Examining Copyright's ‘Integrity’ in the Field of Theatre

This article explores the notion of ‘integrity’ under copyright law by analysing examples of 'integrity-based objections' in the field of theatre. These objections typically involve playwrights objecting to changes being made to their copyright works by other parties, such as directors and actors. This analysis is deepened by the use of two concepts from the field of art theory – ‘aura’, as put forward by Walter Benjamin, and ‘trajectory’, as outlined by Bruno Latour and Adam Lowe. Finally, to shed further light on the issues raised, the work of Pierre Bourdieu is used to present new empirical research recently undertaken by the author in the field of UK theatre. This research demonstrates that ‘power struggles’ are a common feature of theatrical collaboration; that copyright is deeply implicated in the way such power struggles are conceived; and moreover, that resolving these power struggles successfully – including taking account of ‘integrity-based objections’ – is crucial to theatrical practice

High Prevalence of Multidrug-Tolerant Bacteria and Associated Antimicrobial Resistance Genes Isolated from Ornamental Fish and Their Carriage Water

Background: Antimicrobials are used to directly control bacterial infections in pet (ornamental) fish and are routinely added to the water these fish are shipped in to suppress the growth of potential pathogens during transport. Methodology/Principal Findings: To assess the potential effects of this sustained selection pressure, 127 Aeromonas spp. isolated from warm and cold water ornamental fish species were screened for tolerance to 34 antimicrobials. Representative isolates were also examined for the presence of 54 resistance genes by a combination of miniaturized microarray and conventional PCR. Forty-seven of 94 Aeromonas spp. isolates recovered from tropical ornamental fish and their carriage water were tolerant to >= 15 antibiotics, representing seven or more different classes of antimicrobial. The quinolone and fluoroquinolone resistance gene, qnrS2, was detected at high frequency (37% tested recent isolates were positive by PCR). Class 1 integrons, IncA/C broad host range plasmids and a range of other antibiotic resistance genes, including floR, blaTEM21, tet(A), tet(D), tet(E), qacE2, sul1, and a number of different dihydrofolate reductase and aminoglycoside transferase coding genes were also detected in carriage water samples and bacterial isolates. Conclusions: These data suggest that ornamental fish and their carriage water act as a reservoir for both multi-resistant bacteria and resistance genes

Towards Better Sharing of Cultural Heritage -- An Agenda for Copyright Reform

This paper is intended to act as a pillar and reference point for CC's advocacy work in copyright reform in the cultural heritage context, with a focus on issues arising in the digital environment. It may serve to support members of the CC community in their own advocacy efforts, guide policymakers in their legislative processes, and inform anyone interested in the policy issues gravitating around access and reuse of culture and cultural heritage. It will likely be adapted into a GLAM Guide for Policymakers and will be augmented with real-life examples, case studies and practical advice.It starts with an overview of copyright challenges to the legitimate activities of GLAMs, notably preservation (largely through digitization) and sharing of digital and digitized content images and data for access, use and reuse. It also notes copyright's chilling effects in the face of the GLAM sector's general risk aversion. The paper then offers insights towards effective copyright reform addressing those challenges, with a focus on the opportunities related to the digital environment. The proposals for reform aim to create legal certainty and international harmonization as well as to facilitate cross-border transactions.The paper encourages policymakers to recognize and support the pivotal roles of GLAMs in preserving and providing access to knowledge and culture to all members of society. It urges policymakers to engage with stakeholders to ensure there are clear, simple, and effective policies in place to support better sharing of cultural heritage in the public interest.The paper provides a high-level overview of the policy issues and, as a whole, it does not necessarily reflect the current situation in any specific jurisdiction.

An integrative Review of multicomponent weight management interventions for adults with intellectual difficulties

Background: Obesity is more prevalent in people with intellectual disabilities and increases the risk of developing serious medical conditions. UK guidance recommends multicomponent weight management interventions (MCIs), tailored for different population groups. Methods: An integrative review utilizing systematic review methodology was conducted to identify the types of MCIs delivered to adults with intellectual disabilities. Findings: Five studies were identified. All of the studies’ MCIs were tailored for adults with intellectual disabilities. Tailoring included measures such as simplified communication tools, individualized sessions, and the presence of carers where appropriate. Conclusions: Emerging evidence suggests ways in which MCIs can be tailored for adults with intellectual disabilities but, given the few studies identified, it is not possible to recommend how they can be routinely tailored. Further studies are justified for adults with intellectual disabilities at risk of obesity-related conditions

Weight management interventions in adults with intellectual disabilities and obesity: a systematic review of the evidence

o evaluate the clinical effectiveness of weight management interventions in adults with intellectual disabilities (ID) and obesity using recommendations from current clinical guidelines for the first line management of obesity in adults. Full papers on lifestyle modification interventions published between 1982 to 2011 were sought by searching the Medline, Embase, PsycINFO and CINAHL databases. Studies were evaluated based on 1) intervention components, 2) methodology, 3) attrition rate 4) reported weight loss and 5) duration of follow up. Twenty two studies met the inclusion criteria. The interventions were classified according to inclusion of the following components: behaviour change alone, behaviour change plus physical activity, dietary advice or physical activity alone, dietary plus physical activity advice and multi-component (all three components). The majority of the studies had the same methodological limitations: no sample size justification, small heterogeneous samples, no information on randomisation methodologies. Eight studies were classified as multi-component interventions, of which one study used a 600 kilocalorie (2510 kilojoule) daily energy deficit diet. Study durations were mostly below the duration recommended in clinical guidelines and varied widely. No study included an exercise program promoting 225–300 minutes or more of moderate intensity physical activity per week but the majority of the studies used the same behaviour change techniques. Three studies reported clinically significant weight loss (≥ 5%) at six months post intervention. Current data indicate weight management interventions in those with ID differ from recommended practice and further studies to examine the effectiveness of multi-component weight management interventions for adults with ID and obesity are justified

The state of the Martian climate

60°N was +2.0°C, relative to the 1981–2010 average value (Fig. 5.1). This marks a new high for the record. The average annual surface air temperature (SAT) anomaly for 2016 for land stations north of starting in 1900, and is a significant increase over the previous highest value of +1.2°C, which was observed in 2007, 2011, and 2015. Average global annual temperatures also showed record values in 2015 and 2016. Currently, the Arctic is warming at more than twice the rate of lower latitudes