Chronic Pain Management With Opioids: An Assessment of Alaska Nurse Practitioner Practices

Presented to the Faculty of the University of Alaska Anchorage in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCEThe purpose of this project was to determine chronic opioid pain management practices of Alaskan Nurse Practitioners (NPs) in primary care, compare them to best practices, and describe perceived barriers to evidence-based guideline use. Participants included NPs in Alaska who work in primary care and currently have an active Alaska NP license and Alaska mailing address. This project answered the questions of to what extent primary care NP practices are consistent with current Federation of State Medical Boards (2013) guidelines when managing chronic non-cancer pain with opioid therapy as well as identified the perceived barriers to guideline use. A cross sectional, descriptive design was used. The principal investigator mailed a paper survey to a convenience sample of NPs in Alaska. Nurse practitioners in Alaska follow guidelines when initiating opioid therapy most of the time, with all but three guidelines being followed ‘very frequently’ by at least 50% of respondents. Respondents follow guidelines less often when managing opioid therapy with only one guidelines being followed ‘very frequently’ by at least 50% of respondents. Two major barriers to guideline use include resource and knowledge barriers. The findings of this project were used to make clinical recommendations for improved practice.Signature Page / Title Page / Abstract / Table of Contents / List of Figures / List of Tables / List of Appendices / Introduction / Significance to Alaska Advance Nursing Practice / Purpose / Literature Review / Research Question / Methods / Results / Discussion / Implications / Dissemination / References / Appendice

Behavioral Differences Between Two Recently Sympatric Paper Wasps, the Native \u3ci\u3ePolistes Fuscatus\u3c/i\u3e and the Invasive \u3ci\u3ePolistes Dominulus\u3c/i\u3e

Polistes dominulus (Christ), an old world paper wasp, was introduced into the eastern United States in the 1970s and has been rapidly spreading westward. Recently, it has displaced the native Polistes fuscatus (F.) in at least some areas of Michigan. In order to understand why P. dominulus has been so successful, several behavioral attributes were compared between P. dominulus and P. fuscatus at a Michigan field site that contained colonies of both species nest- ing semi-naturally in plywood nestboxes. Preworker colonies of P. dominulus had a significantly greater tendency to store nectar (and had significantly higher proportions of cells with nectar) than preworker colonies of P. fuscatus. This finding may explain the higher survivorship of P. dominulus foundresses reported in a previous study. P. dominulus also had a significantly greater tendency to build vertical nests and had significantly more pedicels per comb and per cell than P. fuscatus. These findings suggest that compared to P. fuscatus, P. dominulus may have more flexibility in the positioning of its combs and, because of a possibly stronger attachment of the comb to a substrate, may be less susceptible to bird predation. The higher winter survivorship reported for P. fuscatus over P. dominulus in a previous study does not appear to be due to differences in the proportions of gynes stranded on their nests late in the fall. Finally, behavioral evidence from videography was consistent with previous reports that P. dominulus is not replacing P. fuscatus through direct agonistic interactions

Sexueller Missbrauch als Ausdruck von Macht und Gewalt

Während die kirchliche Diskussion den sexuellen Missbrauch als ein Sexualdelikt begreift und in Kategorien der Sexualethik behandelt, wird der Kindesmissbrauch in diesem Aufsatz im Zusammenhang von Macht und Gewalt verortet. Auf diese Weise kommen neue strukturelle Dimensionen in den Blick, die im Anschluss an die handlungstheoretische Gewaltforschung analysiert werden. Nach Hinweisen auf die Verbreitung des sexuellen Missbrauchs werden zentrale Merkmale der Erfahrungen der Missbrauchsopfer (die Nivellierung als Subjekt, das Abgeschnitten‐Sein von den sozialen Bezügen und die Traumatisierung) sowie Kennzeichen des Täterverhaltens (langfristiges und planvolles Vorgehen sowie Absicherung in der sozialen Umwelt und in Machtallianzen) benannt. Zu der Frage, wie Missbrauchssysteme so lange unbehelligt bestehen können, verweist die Gewaltforschung auf Machtkartelle und Allianzsysteme, die sich gegenseitig legitimieren. Solche Allianzen konnte man auch bei der Zusammenarbeit von staatlichen Behörden und der Kirche, die Kinder in Heimen erzog, beobachten. Wenn es heute solche Heime auch kaum noch gibt, so ist doch nach Machtkartellen und Allianzen in heutigen Institutionen zu suchen, in denen Gewalt und Missbrauch unentdeckt bleiben. In der Frage, wie solche Machtkartelle, die das Bewusstsein von Mächtigen und Ohnmächtigen bestimmen, aufgebrochen werden können, wird auf Empathie für die Leidenden verwiesen.While the ecclesiastic discussion understands sexual abuse as a sexual offense and treats it in the category of sexual ethics, in this article, child sexual abuse is located in the context of power and violence. In this way, new structural dimensions are coming into view, which are analyzed according to action theoretical research of violence. After indicating the prevalence of sexual abuse, central signs of the experiences of victims of sexual abuse (the leveling as subject, the being disconnected from social relations and traumatization), and the characteristics of the behavior of perpetrators (long term and tactical advancement as well as safeguarding in the social environment and alliances of power) are named. Concerning the question how systems of abuse can persist for so long without being challenged, violence research points to power cartels and alliance systems, which legitimize each other. Such alliances could also be found in the cooperation of public authorities and the church, which educated children in institutions. Although such institutions rarely exist anymore, one still has to search for power cartels and alliances, in which violence and sexual abuse remain undetected today. Concerning the question of how such power cartels, which rule the consciousness of powerful and powerless, can be broken up, the need to listen to the suffering of the subjects and to enable empathy is emphasized

Die vielschichtige Rede von den Zeichen der Zeit. Anmerkungen zu einem Ortswechsel theologischer Erkenntnis und diakonisch-pastoraler Praxis

Die Rede von den Zeichen der Zeit und ihrer Deutung ist so faszinierend wie rätselhaft zugleich.Der Artikel erschließt drei unterschiedliche Zugangsweisen. Ein narrativ-existenziellerZugang vermittelt, dass gerade die Exkludierten der Gesellschaft die „Zeichen der Zeit“ zuverstehen vermögen, weil sie nach Gott fragen. Ein biblischer Zugang zeigt auf, dass Jesusdie Forderung von Zeichen ablehnte und stattdessen auf die innere Umkehr verwies. Im Kontextdes Konzils schließlich wird die Rede im Blick auf die Spuren Gottes und die Hoffnungszeichenin einer krisenhaften Welt verwendet. Abschließend wird der Versuch unternommen,die drei Zugänge miteinander zu vermitteln. Durch die Umkehr und einen Standortwechsel andie Seite der Bedrängten lassen sich die Zeichen der Zeit aus deren Frage nach Gott als GottesHeilszeichen für ihr Leben wahrnehmen und deuten.The expression „signs of the time“ and its interpretation is fascinating and enigmatic at thesame time. This article discusses three different approaches. A narrative-existential approachindicates that especially the outsiders of society are able to understand the „signs of the time“because they ask about God. A biblical approach shows that Jesus rejected the claim for„signs“, and asked for an inner change instead. In the context of Vatican II, finally, the expressionis used to talk about the signs of God and the message of hope in a world characterizedby crises. Finally, the attempt is made to reconcile the three approaches with each other.Through repentance and a change of one’s point of view towards the side of the beleaguered,the „signs of the time“ can be perceived and interpreted as their question about and for Godand as God’s signs of salvation for their lives

Relapse prevention strategies for recurrent depression

Depression is a recurrent disorder with a substantial disease burden for individuals and society. Given the high relapse/recurrence rates, especially for individuals with previous depressive episodes, relapse prevention is of paramount importance. This dissertation focused on current gaps in the knowledge of relapse prevention. We developed and validated a tool to predict relapse/recurrence risk for an individual and concluded that more studies are needed to enhance the performance before implementing it into clinical practice. We also explored beliefs about the causes of depression and recovery (i.e., causal beliefs) and whether they predicted antidepressant use in terms of adherence, dosage, and successful tapering antidepressants, which was not the case. In addition, we examined several relapse prevention strategies for individuals remitted from at least two depressive episodes. We found that adding Preventive Cognitive Therapy (PCT) to long-term antidepressants had positive effects on depressive relapse/recurrence over 24 months and was cost-effective compared to continuing antidepressants. Continuing antidepressants was not superior compared to PCT while tapering antidepressants but was cost-effective. Adding an internet-based version of PCT with minimal therapist support to Treatment As Usual (TAU) was neither effective nor cost-effective over 24 months compared to TAU alone. The most important clinical implications of the studies are that face-to-face PCT as started after recovery on antidepressants is recommended and that PCT might form an alternative for individuals with a wish to taper antidepressants, but that extra costs might be involved when tapering antidepressants