Whom, Why and How to Refer

When a medical practitioner decides that the time has come to refer his patient to a specialist, certain psychological problems arise which may, at times, interfere with the smooth accomplishment of the referral. These problems can and do occur daily in medical practice, and it often makes little difference whether the specialist is a thoracic surgeon, a neurosurgeon or a psychiatrist. Referrals create certain anxieties and fears in the mind of the patient. Some of these anxieties are common to all referrals. The patient asks himself, What\u27s going on? What does the doctor think I really have? How serious is it? Will I come out of this alive, incapacitated, disfigured? Is this referral necessary? Why can\u27t I go on as I am? Is the specialist he\u27s sending me to really good? When good communications exist between the physician and his patient (and also between the physician and the specialist), the level of anxiety drops, and referral is much more easily accomplished

gp130 cytokines are positive signals triggering changes in gene expression and axon outgrowth in peripheral neurons following injury

Adult peripheral neurons, in contrast to adult central neurons, are capable of regeneration after axonal damage. Much attention has focused on the changes that accompany this regeneration in two places, the distal nerve segment (where phagocytosis of axonal debris, changes in the surface properties of Schwann cells, and induction of growth factors and cytokines occur) and the neuronal cell body (where dramatic changes in cell morphology and gene expression occur). The changes in the axotomized cell body are often referred to as the “cell body response.” The focus of the current review is a family of cytokines, the glycoprotein 130 (gp130) cytokines, which produce their actions through a common gp130 signaling receptor and which function as injury signals for axotomized peripheral neurons, triggering changes in gene expression and in neurite outgrowth. These cytokines play important roles in the responses of sympathetic, sensory, and motor neurons to injury. The best studied of these cytokines in this context are leukemia inhibitory factor (LIF) and interleukin (IL)-6, but experiments with conditional gp130 knockout animals suggest that other members of this family, not yet determined, are also involved. The primary gp130 signaling pathway shown to be involved is the activation of Janus kinase (JAK) and the transcription factors Signal Transducers and Activators of Transcription (STAT), though other downstream pathways such as mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) may also play a role. gp130 signaling may involve paracrine, retrograde, and autocrine actions of these cytokines. Recent studies suggest that manipulation of this cytokine system can also stimulate regeneration by injured central neurons

Triangle configurations, and Beilinson's conjecture for K1(2)K_{1}^{(2)} of the product of a curve with itself

The aim of this thesis is to look into Beilinson's conjecture on the rank of the integral part of certain algebraic $K$-groups of varieties over number fields, as applied to $K_{1}^{(2)}(C\times C)$ where $C$ is a (smooth projective) curve. In particular, it examines whether non-zero integral elements can be obtained from linear combinations of certain special types of elements which I refer to as ``triangle'' configurations. Most of the thesis examines the special case where $C$ is an elliptic curve. The main result is that whenever any rational linear combination of such triangle configurations lies in the integral part of $K_{1}^{(2)}(E\times E)$, then its image under the Beilinson regulator map is the same as that of a ``decomposable'' integral element, which is to say, one consisting only of constant functions along various curves. Hence, if Beilinson's conjecture is correct and the regulator is injective on the integral part, then no previously unknown integral elements can be produced from these triangle constructions. I will also examine the same question for some slighly more general elements of $K_{1}^{(2)}(E\times E)$, and will show that (subject to one conjecture, which seems highly likely to be true, although I have been unable to prove it rigorously) the same result holds, provided that we restrict ourselves to an individual ``triangle'', as opposed to arbitrary linear combinations. This will follow from conditions on such a triangle which are both necessary (always) and sufficient (at least for certain special types of elliptic curve) for integrality

Experimental Analysis of Water Based Drilling Fluid Aging Processes at High Temperature and High Pressure Conditions

In efforts to render the safest, fastest, and most cost efficient drilling program for a high temperature and high pressure (HT/HP) well the maximization of drilling operational efficiencies is key. Designing an adequate, HT/HP well specific, drilling fluid is of most importance and a technological challenge that can greatly affect the outcome of the overall operational efficiency. It is necessary to have a sound fundamental understanding of the behavior that water-based muds (WBM) exhibit when exposed to HT/HP conditions. Therefore, in order to adequately design and treat a WBM for a HT/HP well specific drilling program, it is essential that the mud be evaluated at HT/HP conditions. Currently, industry standard techniques used to evaluate WBM characteristics involve aging the fluid sample to a predetermined temperature, based on the anticipated bottom hole temperature (BHT), either statically or dynamically, for a predetermined length, then cooling and mixing the fluid and measuring its rheological properties at a significantly lower temperature. This, along with the fact that the fluid is not subjected to the anticipated bottom hole pressure (BHP) during or after the aging process, brings to question if the properties recorded are those that are truly experienced down-hole. Furthermore, these testing methods do not allow the user to effectively monitor the changes during the aging process. The research in this thesis is focused on evaluating a high performance WBM and the current test procedures used to evaluate their validity. Experimental static and dynamic aging tests were developed for comparative analysis as well to offer a more accurate and precise method to evaluate the effects experienced by WBM when subjected to HT/HP conditions. The experimental tests developed enable the user to monitor and evaluate, in real-time, the rheological changes that occur during the aging of a WBM while being subjected to true BHT and BHP. Detailed standard and experimental aging tests were conducted and suggest that the standard industry tests offer false rheological results with respect to true BHT and BHP. Furthermore, the experimental aging tests show that high pressure has a significant effect on the rheological properties of the WBM at elevated temperatures

Unethical Mental Health Law; History Repeats Itself

The powers enshrined in mental health legislation go directly to fundamental principles central to any caring and democratic society. The tension and dilemma that exists is, on the one hand, the importance of respect for an individual’s right to make decision’s affecting his/her own life to, on the other, the recognition that there are people with mental disabilities that may be vulnerable to abuse and/or neglect and who throughout their lives or at particular times need care and/or treatment, which they may not seek or be able to consent to themselves. In any society it is through case law and statute that an attempt is made to resolve this tension and to ensure that individual rights are not infringed and that those who need care and treatment receive what is in their best interest. Thus a change in such legislation requires the most rigorous of examination and must be judged on the grounds that it a) does not infringe accepted principles such as those of the United Nations Declaration of Human Rights and the European Convention, b) is based on sound ethical principles and does not conflict with the established law of the country, and c) it is practicable and achieves the right balance with respect to the potential tension described above. As practising clinicians (one working in an acute psychiatric service the other in a district learning disability service) we are not in a position expertly to judge the first of these but we believe we can contribute to the second and the third. In this paper we consider specifically the reasons for, and the consequences that follow, the failure on the Government’s part to accept the central importance of decision-making capacity assessment in any new mental health legislation.The Green Paper proposals for a new Mental Health Act for England and Wales have now been published. A broad definition of ‘mental disorder’ has been retained, a new system of tribunals is to be established and compulsory treatment in the community would become lawful. However, it rejects the recommendation of the expert committee chaired by Professor Richardson that the assessment of an individual’s decision-making capacity should be a determining factor in the use of compulsory detention. Given this, it does not address the relationship between this legislation and the proposed Mental Incapacity Act. The failure to recognise the central place of decision-making capacity in a modern Mental Health Act is, we believe, a serious omission as it is a reflection of a failure to acknowledge that the basic principle of autonomy is central to such legislation

Teaching responsible conduct responsibly.

The advancement of science requires trust – trust in the literature, in our collaborators, in the data we are handed, and most of all in ourselves. Policies issued by U.S. federal funding agencies (e.g., the National Institutes of Health and National Science Foundation) have been valuable in prompting institutions to initiate formal mechanisms for providing instruction in the responsible conduct of research (RCR). However, the guidelines vary greatly in scope, detail, and the types of individuals to which they apply. Unfortunately, at many institutions, the provision of RCR instruction has become a bureaucratic exercise aimed at fulfilling a regulatory requirement, instead of an activity optimized for promoting a climate of integrity. We argue that for RCR instruction to be effective it should (1) be provided to everyone involved in the research enterprise, be they students, trainees, faculty, or staff, (2) be infused throughout one’s time at an institution. For graduate students, that would include from orientation to thesis completion, including integration into all “core classes” within their discipline, as well as into discussions at research group meetings. (3) We also advocate that the bulk of the instruction should be provided primarily by active researchers who know the issues and have relevance to, and credibly with, those being taught, and (4) that the instruction actively engages the learners. Not only will we be providing RCR instruction in a much more optimized manner, such an approach also emphasizes through our actions, not just in words, that behaving responsibly is an essential skill for researchers

Toward a Climate of Scientific Integrity

A review of the new edition of Macrina's "Scientific integrity: Text and cases in responsible conduct of research" highlights the continuing need for teaching ethical guidelines to young researchers

Depression and anxiety in adolescents and adults with cystic fibrosis in the UK: A cross-sectional study

Background The International Depression/anxiety Epidemiological Study (TIDES) in the UK aimed: (i) to establish the prevalence of anxiety and depression amongst people with CF compared to a normative sample; (ii) to establish the association between mood, demographic and clinical variables; and (iii) to provide guidance for specialist-referral decision-making. Methods Patients (≥ 12 years) completed the Hospital Anxiety and Depression Scale (HADS). CF-HADS scores, expressed as percentiles, were compared with a normative sample. Multiple-regression analysis explored associations between demographic, clinical and mood variables. Results Thirty-nine CF centres recruited 2065 patients. Adults with CF were similar in terms of anxiety and depression to the general population. Adolescents with CF were less anxious and depressed. For adult patients, older age, unemployment for health reasons and poor lung function were associated with disordered mood. Gender-specific CF-percentile scores were calculated. Conclusion Surveillance, with attention to gender and risk factors is advocated. This work provides unique benchmark scores to aid referral decision-making