British pain clinic practitioners' recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate : results of a qualitative study

Background To explore how chronic musculoskeletal pain is managed in multidisciplinary pain clinics for patients for whom physical interventions are inappropriate or ineffective. Methods A qualitative study was undertaken using semi-structured interviews with twenty five members of the pain management team drawn from seven pain clinics and one pain management unit located across the UK. Results All clinics reported using a multidisciplinary bio-psychosocial model. However the chronic pain management strategy actually focussed on psychological approaches in preference to physical approaches. These approaches were utilised by all practitioners irrespective of their discipline. Consideration of social elements such as access to social support networks to support patients in managing their chronic pain was conspicuously absent from the approaches used. Conclusion Pain clinic practitioners readily embraced cognitive/behavioural based management strategies but relatively little consideration to the impact social factors played in managing chronic pain was reported. Consequently multidisciplinary pain clinics espousing a bio-psychosocial model of pain management may not be achieving their maximum potential

Activity and Regulation of Farm Labor Contractors

Labor and Human Capital,

Leaf Anatomy and CO2 Recycling During Crassulacean Acid Metabolism in Twelve Epiphytic Species of Tillandsia (Bromeliaceae)

This is the publisher's official version. It is also available electronically from: http://www.jstor.org/stable/2995609.The relationship between leaf anatomy, specifically the percent of leaf volume occupied by waterstorage parenchyma (hydrenchyma), and the contribution of respiratory C02 during Crassulacean acid metabolism (CAM) was investigated in 12 epiphytic species of Tillandsia. It has been postulated that the hydrenchyma, which contributes to C 0 2 exchange through respiration only, may be causally related to the recently observed phenomenon of C 0 2 recycling during CAM. Among the 12 species of Tillandsia, leaves of T. usneoides and T. bergeri exhibited 0% hydrenchyma, while the hydrenchyma in the other species ranged from 2.9% to 53% of leaf cross-sectional area. Diurnal malate fluctuation and nighttime atmospheric C 0 2 uptake were measured in at least four individuals of each species. A significant excess of diurnal malate fluctuation as compared with atmospheric C 0 2 absorbed overnight was observed only in T. schiedeana. This species had an intermediate proportion (30%) of hydrenchyma in its leaves. Results of this study do not support the hypothesis that C02 recycling during CAM may reflect respiratory contributions of C 0 2 from the tissue hydrenchyma

RECOMMENDATIONS FOR IMPROVING SOFTWARE COST ESTIMATION IN DOD ACQUISITION

Acquisition initiatives within the Department of Defense (DOD) are becoming increasingly reliant on software. While the DOD has ample experience in estimating costs of hardware acquisition, expertise in estimating software acquisition costs is lacking. The objective of this capstone project is to summarize the current software cost estimating methods, analyze existing software cost estimating models, and suggest areas and methods for improvement. To accomplish this, surveys were conducted to gather program cost data, which was run through existing cost estimating models. From here, the outputs were compared to actual program costs. This established a baseline for the effectiveness of existing methods and guided suggestions for areas of improvement. The Software Resource Data Reports (SRDR) data used seemed to have spurious data reporting from at least one source, and the base cost estimation models were not found to be sufficiently accurate in our study. The capstone finds that calibrating the cost models to the data available improved those models dramatically. In all, the capstone recommends performing data realism checks upon SRDR submissions to ensure data accuracy and calibrating cost models for each contractor with the available data before using them to estimate DOD Acquisition costs.Civilian, Department of the ArmyCivilian, Department of the ArmyCivilian, Department of the ArmyCivilian, Department of the ArmyApproved for public release. Distribution is unlimited

Nutritional Quality of Leaves and Unripe Fruit Consumed as Famine Foods by the Flying Foxes of Samoa

Many tropical herbivores alter their diets throughout the year in response to different levels of food availability. Fruit bats, including Pteropus samoensis Peale and Pteropus tonganus Quoy & Gaimard, are phytophagous species that may increase their consumption of foods such as unripe fruit and leaves in periods of low fruit diversity and volume. These periods include the tropical dry season or following the frequent hurricanes that batter the Samoan Archipelago. We examined the nutritional composition of leaves and immature fruits and compared the levels of organic and mineral nutrients with those of ripe fruit. We used principal components analysis (PCA) to examine patterns of variation in nutrient components of leaves, unripe fruit, and ripe fruit, as well as to compare the mean levels of nutrients. Overall, unripe fruit provided levels of nutrients comparable with those of ripe fruit of the same species for many organic and mineral components. Unripe fruit were only half as rich in iron as ripe fruit, but unripe fruit had high levels of calcium compared with ripe fruit of the same species. Leaves are often cited as a rich source of protein for fruit bats, and our results were consistent with this suggestion. Leaves were also found to be rich in zinc, manganese, and calcium. Therefore, flying foxes and other herbivores probably do not avoid unripe fruits and leaves because of their low nutrient levels. It may be that these famine foods are not normally consumed because of the presence of secondary compounds, low concentrations of palatable sugars, or a distasteful and hard pericarp on unripe fruits

How to develop, externally validate, and update multinomial prediction models

Multinomial prediction models (MPMs) have a range of potential applications across healthcare where the primary outcome of interest has multiple nominal or ordinal categories. However, the application of MPMs is scarce, which may be due to the added methodological complexities that they bring. This article provides a guide of how to develop, externally validate, and update MPMs. Using a previously developed and validated MPM for treatment outcomes in rheumatoid arthritis as an example, we outline guidance and recommendations for producing a clinical prediction model using multinomial logistic regression. This article is intended to supplement existing general guidance on prediction model research. This guide is split into three parts: 1) Outcome definition and variable selection, 2) Model development, and 3) Model evaluation (including performance assessment, internal and external validation, and model recalibration). We outline how to evaluate and interpret the predictive performance of MPMs. R code is provided. We recommend the application of MPMs in clinical settings where the prediction of a nominal polytomous outcome is of interest. Future methodological research could focus on MPM-specific considerations for variable selection and sample size criteria for external validation

Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey.

OBJECTIVE: To investigate the experience of users of out of hours general practitioner services in England, UK. DESIGN: Population based cross sectional postal questionnaire survey. SETTING: General Practice Patient Survey 2012-13. MAIN OUTCOME MEASURES: Potential associations between sociodemographic factors (including ethnicity and ability to take time away from work during working hours to attend a healthcare consultation) and provider organisation type (not for profit, NHS, or commercial) and service users' experience of out of hours care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service), rated on a scale of 0-100. Which sociodemographic/provider characteristics were associated with service users' experience, the extent to which any observed differences could be because of clustering of service users of a particular sociodemographic group within poorer scoring providers, and the extent to which observed differences in experience varied across types of provider. RESULTS: The overall response rate was 35%; 971,232/2,750,000 patients returned surveys. Data from 902,170 individual service users were mapped through their registered practice to one of 86 providers of out of hours GP care with known organisation type. Commercial providers of out of hours GP care were associated with poorer reports of overall experience of care, with a mean difference of -3.13 (95% confidence interval -4.96 to -1.30) compared with not for profit providers. Asian service users reported lower scores for all three experience outcomes than white service users (mean difference for overall experience of care -3.62, -4.36 to -2.89), as did service users who were unable to take time away from work compared with service users who did not work (mean difference for overall experience of care -4.73, -5.29 to -4.17). CONCLUSIONS: Commercial providers of out of hours GP care were associated with poorer experience of care. Targeted interventions aimed at improving experience for patients from ethnic minorities and patients who are unable to take time away from work might be warranted

Use of NHS Digital datasets as trial data in the UK: a position paper

Background: Clinical trial teams increasingly want to make use of data from healthcare systems (“healthcare data”), particularly to enhance recruitment and follow-up of participants, to reduce time and cost, and to stop the duplication of effort. However, there is continued uncertainty of how regulators regard healthcare data used for trial purposes, in terms of provenance, quality and reliability. Objectives: There were two key objectives: First, to demonstrate the data integrity of two datasets held by NHS Digital (NHSD) that are most requested by trial teams; and second, to set out an approach by which any other healthcare systems datasets can be similarly evaluated. Method: The data lifecycles of the datasets were carefully documented, mapping the flow of data from the originating healthcare provider’s databases to NHSD warehouses and onwards to clinical trials teams. These were assessed for evidence of whether the datasets are accurate, reliable, complete, contemporaneous, and well-governed. Result: The assessment method was applied to (a) the Hospital Episode Statistics Admitted Patient Care (HES APC) dataset and (b) the Civil Registration of Deaths (CRD) dataset. This paper clearly demonstrates that their collection and management through NHSD systems ensure their integrity and reliability. The datasets are accurate representations of the data held by the originating providers (acute NHS trusts and local registrars). Conclusion: Based on these findings, the HES APC and CRD datasets satisfy the assessment criteria that demonstrate they are reliable transcribed copies of the original source data. Implications: First, these datasets can be used directly for clinical trial data, with trial teams focusing on the accuracy of algorithms and processes to identify particular outcomes rather than on the integrity of the data flow. Second, this assessment approach should be used to assess whether other healthcare systems datasets are ready to be used as transcribed copies of source data, and for data providers to take appropriate steps to redress this matter if they are not

Overground gait adaptability in older adults with type 2 diabetes in response to virtual targets and physical obstacles

To step over an unexpected obstacle, individuals adapt gait; they adjust step length in the anterior-posterior direction prior to the obstacle and minimum toe clearance height in the vertical direction during obstacle avoidance. Inability to adapt gait may lead to falls in older adults with diabetes as the results of the effects of diabetes on the sensory-motor control system. Therefore, this study aimed to investigate gait adaptability in older adults with diabetes. Would diabetes impair gait adaptability and increase sagittal foot adjustment errors? Three cohorts of 16 people were recruited: young adults (Group I), healthy older adults (Group II), and older adults with diabetes (Group III). Participants walked in baseline at their comfortable speeds. They then walked and responded to what was presented in gait adaptability tests, which included 40 trials with four random conditions: step shortening, step lengthening, obstacle avoiding, and walking through. Virtual step length targets were 40% of the baseline step length longer or shorter than the mean baseline step length; the actual obstacle was a 5-cm height across the walkway. A Vicon three-dimensional motion capture system and four A.M.T.I force plates were used to quantify spatiotemporal parameters of a gait cycle and sagittal foot adjustment errors (differences between desired and actual responses). Analyses of variance (ANOVA) repeated measured tests were used to investigate group and condition effects on dependent gait parameters at a significance level of 0.05. Statistical analyses of Group I (n = 16), Group II (n = 14) and Group III (n = 13) revealed that gait parameters did not differ between groups in baseline. However, they were significantly different in adaptability tests. Group III significantly increased their stance and double support times in adaptability tests, but these adaptations did not reduce their sagittal foot adjustment errors. They had the greatest step length errors and lowest toe-obstacle clearance, which could cause them to touch the obstacle more. The presented gait adaptability tests may serve as entry tests for falls prevention programs