Complex trauma and intimate relationships: The impact of shame, guilt and dissociation

Background: This study examined dissociation, shame, guilt and intimate relationship difficulties in those with chronic and complex PTSD. Little is known about how these symptom clusters interplay within the complex PTSD constellation. Dissociation was examined as a principle organizing construct
within complex PTSD. In addition, the impact of shame, guilt and dissociation on relationship difficulties was explored.
Methods: Sixty five treatment-receiving adults attending a Northern Irish service for conflict-related trauma were assessed on measures of dissociation, state and trait shame, behavioral responses to shame, state and trait guilt, complex PTSD symptom severity and relationship difficulties.
Results: Ninety five percent (n=62) of participants scored above cut-off for complex PTSD. Those with clinical levels of dissociation (n=27) were significantly higher on complex PTSD symptom severity, state and trait shame, state guilt, withdrawal in response to shame and relationship preoccupation than subclinical dissociators (n=38). Dissociation and state and trait shame predicted complex PTSD. Fear of relationships was predicted by dissociation, complex PTSD and avoidance in response to shame, while complex PTSD predicted relationship anxiety and relationship depression.
Limitations: The study was limited to a relatively homogeneous sample of individuals with chronic and complex PTSD drawn from a single service.
Conclusions: Complex PTSD has significant consequences for intimate relationships, and dissociation makes an independent contribution to these difficulties. Dissociation also has an organizing effect on
complex PTSD symptoms.

Military Service Pensions for Veterans of the Irish Revolution, 1916–1923

In 1924 the Irish Free State government passed legislation to award pensions to veterans of the Irish revolution and Civil War. This article argues that the motivation for the pensions was the need to placate the national army after a failed mutiny in 1924 and that this explains their unusual nature in being based on service alone rather than disability. It will also explore the problems this created for defining service, examine the extension of eligibility to former republican enemies of the state and women revolutionaries in 1934, and describe the application and assessment procedure.

How Much Multiuser Diversity is Required for Energy Limited Multiuser Systems?

Multiuser diversity (MUDiv) is one of the central concepts in multiuser (MU) systems. In particular, MUDiv allows for scheduling among users in order to eliminate the negative effects of unfavorable channel fading conditions of some users on the system performance. Scheduling, however, consumes energy (e.g., for making users' channel state information available to the scheduler). This extra usage of energy, which could potentially be used for data transmission, can be very wasteful, especially if the number of users is large. In this paper, we answer the question of how much MUDiv is required for energy limited MU systems. Focusing on uplink MU wireless systems, we develop MU scheduling algorithms which aim at maximizing the MUDiv gain. Toward this end, we introduce a new realistic energy model which accounts for scheduling energy and describes the distribution of the total energy between scheduling and data transmission stages. Using the fact that such energy distribution can be controlled by varying the number of active users, we optimize this number by either i) minimizing the overall system bit error rate (BER) for a fixed total energy of all users in the system or ii) minimizing the total energy of all users for fixed BER requirements. We find that for a fixed number of available users, the achievable MUDiv gain can be improved by activating only a subset of users. Using asymptotic analysis and numerical simulations, we show that our approach benefits from MUDiv gains higher than that achievable by generic greedy access algorithm, which is the optimal scheduling method for energy unlimited systems. © 2010 IEEE.

Pharmacological treatments in ARDS; a state-of-the-art update

Despite its high incidence and devastating outcomes, acute respiratory distress syndrome (ARDS) has no specific treatment, with effective therapy currently limited to minimizing potentially harmful ventilation and avoiding a positive fluid balance. Many pharmacological therapies have been investigated with limited success to date. In this review article we provide a state-of-the-art update on recent and ongoing trials, as well as reviewing promising future pharmacological therapies in ARDS.

Service user perspectives on palliative care education for health and social care professionals supporting people with learning disabilities

Background and objectives
Evidence from European and American studies indicates limited referrals of people with learning (intellectual) disabilities to palliative care services. Although professionals’ perceptions of their training needs in this area have been studied, the perceptions of people with learning disabilities and family carers are not known. This study aimed to elicit the views of people with learning disabilities, and their family carers concerning palliative care, to inform healthcare professional education and training.

Methods
A qualitative, exploratory design was used. A total of 17 people with learning disabilities were recruited to two focus groups which took place within an advocacy network. Additionally, three family carers of someone with a learning disability, requiring palliative care, and two family carers who had been bereaved recently were also interviewed.

Results
Combined data identified the perceived learning needs for healthcare professionals. Three subthemes emerged: ‘information and preparation’, ‘provision of care’ and ‘family-centred care’.

Conclusions
This study shows that people with learning disabilities can have conversations about death and dying, and their preferred end-of-life care, but require information that they can understand. They also need to have people around familiar to them and with them. Healthcare professionals require skills and knowledge to effectively provide palliative care for people with learning disabilities and should also work in partnership with their family carers who have expertise from their long-term caring role. These findings have implications for educators and clinicians.

Key performance indicators – A new approach for specifying concrete and assessing state of health of concrete structure

The focus of this paper is to outline a method for consolidating and implementing the work on performance-based specification and testing. First part of the paper will review the mathematical significance of the variables used in common service life models. The aim is to identify a set of significant variables that influence the ingress of chloride ions into concrete. These variables are termed as Key Performance Indicators (KPI’s). This will also help to reduce the complexity of some of the service life models and make them more appealing for practicing engineers. The second part of the paper presents a plan for developing a database based on these KPI’s so that relationships can then be drawn between common concrete mix parameters and KPI’s. This will assist designers in specifying a concrete with adequate performance for a particular environment. This, collectively, is referred to as the KPI based approach and the concluding remarks will outline how the authors envisage the KPI theory to relate to performance assessment and monitoring.

Service User Involvement in Assessments:

Increasingly providers of mental health nurse education are required to demonstrate user involvement in all aspects of these programmes including student selection, programme design and student assessment. There has been limited analysis of how nursing students perceive user involvement in nurse education programmes. The aim of this study has been to explore mental health nursing student’s perceptions of involving users in all aspects of pre-registration mental health nursing programme. Researchers completed a number of focus group interviews with 12 ex-mental health nursing students who had been recruited by purposeful sampling. Each focus group interview was recorded and analysed using a series of data reduction, data display and verification
methods. The study confirms many of the findings reported in earlier user participation in education studies. Three main themes related to user involvement have been identified: the protection of users, enhanced student learning and the added value benefits associated with user involvement.

The current state of abortion law and practice in Northern Ireland

This paper reviews current abortion law and practice in Northern Ireland (NI). It explores the origins of NI's abortion law and its complexity in relation to current practice. it reviews issues relating to women seeking terminations in NI and Great Britain and reviews attempts by the Family Planning Association NI to require the Department of Health and Social Services and Public Safety NI to provide guidance for health professionals engaged in this practice. The paper also discusses some of the issues surrounding abortion in NI and seeks to explain why this subject is causing controversy and debate, especially following a judicial review in February and Marie Stopes opening a termination service in Belfast.

Polymorphism in Sulfadimidine/4-Aminosalicylic Acid Cocrystals: Solid-State Characterization and Physicochemical Properties

Polymorphism of crystalline drugs is a common phenomenon. However, the number of reported polymorphic cocrystals is very limited. In this work, the synthesis and solid-state characterization of a polymorphic cocrystal composed of sulfadimidine (SD) and 4-aminosalicylic acid (4-ASA) is reported for the first time. By liquid-assisted milling, the SD:4-ASA 1:1 form I cocrystal, the structure of which has been previously reported, was formed. By spray drying, a new polymorphic form (form II) of the SD:4-ASA 1:1 cocrystal was discovered which could also be obtained by solvent evaporation from ethanol and acetone. Structure determination of the form II cocrystal was calculated using high-resolution X-ray powder diffraction. The solubility of the SD:4-ASA 1:1 cocrystal was dependent on the pH and predicted by a model established for a two amphoteric component cocrystal. The form I cocrystal was found to be thermodynamically more stable in aqueous solution than form II, which showed transformation to form I. Dissolution studies revealed that the dissolution rate of SD from both cocrystals was enhanced when compared with a physical equimolar mixture and pure SD.

Evaluation of a partnership between primary and secondary care providing an accessible Level 1 sexual health service in the community

Comprehensive testing for asymptomatic sexually transmitted infections in Northern Ireland has traditionally been provided by genitourinary medicine clinics. As patient demand for services has increased while budgets have remained limited, there has been increasing difficulty in accommodating this demand. In May 2013, the newly commissioned specialist Sexual Health service in the South Eastern Trust sought to pilot a new model of care working alongside a GP partnership of 12 practices. A training programme to enable GPs and practice nurses to deliver Level 1 sexual health care to heterosexual patients aged >16 years, in accordance with the standards of BASHH, was developed. A comprehensive care pathway and dedicated community health advisor supported this new model with close liaison between primary and secondary care. Testing for Chlamydia, gonorrhoea, HIV and syphilis was offered. The aims of the pilot were achieved, namely to provide accessible, cost-effective sexual health care within a framework of robust clinical governance. Furthermore, it uncovered a high positivity rate for Chlamydia, especially in young men attending their general practice, and demonstrated a high level of patient satisfaction. Moreover the capacity of secondary care to deliver Levels 2 and 3 services was increased.

Establishing a nurse practitioner collaborative: evolution, development, and outcomes

The first Australian palliative care nurse practitioner (NP) was endorsed in 2003. In 2009 the Victoria Department of Health funded the development of the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC). Its aim was to promote the NP role, develop resources, and provide education and mentorship to NPs, nurse practitioner candidates (NPCs), and health service managers. Four key objectives were developed: identify the demographic profile of palliative care NPCs in Victoria; develop an education curriculum and practical resources to support the training and education of palliative care NPCs and NPs; provide mentorship to NPs, NPCs, and service managers; and ensure effective communication with all key stakeholders. An NPC survey was also conducted to explore NPC demographics, models of care, the hours of study required for the role, the mentoring process, and education needs. This paper reports on the establishment of the VPCNPC, the steps taken to achieve its objectives, and the results of the survey. The NP role in palliative care in Australia continues to evolve, and the VPCNPC provides a structure and resources to clearly articulate the benefits of the role to nursing and clinical services. The advanced clinical practice role of the nurse practitioner (NP) has been well established in North America for several decades and across a range of specialties (Ryan-Woolley et al, 2007; Poghosyan et al, 2012). The NP role in Australia and the UK is a relatively new initiative that commenced in the early 2000s (Gardner et al, 2009). There are over 1000 NPs across all states and territories of Australia, of whom approximately 130 work in the state of Victoria (Victorian Government Health Information, 2012). Australian NPs work across a range of specialties, including palliative, emergency, older person, renal, cardiac, respiratory, and mental health care. There has been increasing focus nationally and internationally on developing academic programmes specifically for nurses working toward NP status (Gardner et al, 2006). There has been less emphasis on identifying the comprehensive clinical support requirements for NPs and NP candidates (NPCs) to ensure they meet all registration requirements to achieve and/or maintain endorsement, or on articulating the ongoing requirements for NPs once endorsed. Historically in Australia there has been a lack of clarity and limited published evidence on the benefits of the NP role for patients, carers, and health services (Quaglietti et al, 2004; Gardner and Gardner, 2005; Bookbinder et al, 2011; Dyar et al, 2012). An NP is considered to be at the apex of clinical nursing practice. The NP role typically entails comprehensively assessing and managing patients, prescribing medicines, making direct referrals to other specialists and services, and ordering diagnostic investigations (Australian Nursing and Midwifery Council, 2009). All NPs in Australia are required to meet the following generic criteria: be a registered nurse, have completed a Nursing and Midwifery Board of Australia approved postgraduate university Master's (nurse practitioner) degree programme, and be able to demonstrate a minimum of 3 years' experience in an advanced practice role (Nursing and Midwifery Board of Australia, 2011). An NPC in Victoria is a registered nurse employed by a service or organisation to work toward meeting the academic and clinical requirements for national endorsement as an NP. During the period of candidacy, which is of variable duration, NPCs consolidate their competence to work at the advanced practice level of an NP. The candidacy period is a process of learning the new role while engaging with mentors (medical and nursing) and accessing other learning opportunities both within and outside one's organisation to meet the educational requirements. Integral to the NP role is the development of a model of care that is responsive to identified service delivery gaps that can be addressed by the skills, knowledge, and expertise of an NP. These are unique to each individual service. The practice of an Australian NP is guided by national standards (Nursing and Midwifery Board of Australia 2014). It is defined by four overarching standards: clinical, education, research, and leadership. Following the initial endorsement of four Victorian palliative care NPs in 2005, there was a lull in recruitment. The Victoria Department of Health (DH) recognised the potential benefits of NPs for health services, and in 2008 it provided funding for Victorian public health services to scope palliative care NP models of care that could enhance service delivery and patient outcomes. The scoping strategy was effective and led to the appointment of 16 palliative care nurses to NPC positions over the ensuing 3 years. The NPCs work across a broad range of care settings, including inpatient, community, and outpatient in metropolitan, regional, and rural areas of Victoria. At the same time, the DH also funded the Centre for Palliative Care to establish the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC) to support the NPs and NPCs. The Centre is a state-wide service that is part of St Vincent's Hospital Melbourne and a collaborative Centre of the University of Melbourne. Its primary function is to provide training and conduct research in palliative care. The purpose of the VPCNPC was to provide support and mentorship and develop resources targeted at palliative care NPs, NPCs, and health service managers. Membership of the VPCNPC is open to all NPs, NPCs, health service managers, and nurses interested in the NP role. The aim of this paper is to describe the development of the VPCNPC, its actions, and the outcomes of these actions.

Solving Decision Problems with Limited Information

We present a new algorithm for exactly solving decision-making problems represented as an influence diagram. We do not require the usual assumptions of no forgetting and regularity, which allows us to solve problems with limited information. The algorithm, which implements a sophisticated variable elimination procedure, is empirically shown to outperform a state-of-the-art algorithm in randomly generated problems of up to 150 variables and 10^64 strategies.

Solving Limited Memory Influence Diagrams

We present a new algorithm for exactly solving decision making problems represented as influence diagrams. We do not require the usual assumptions of no forgetting and regularity; this allows us to solve problems with simultaneous decisions and limited information. The algorithm is empirically shown to outperform a state-of-the-art algorithm on randomly generated problems of up to 150 variables and 10^64 solutions. We show that these problems are NP-hard even if the underlying graph structure of the problem has low treewidth and the variables take on a bounded number of states, and that they admit no provably good approximation if variables can take on an arbitrary number of states.

Solving Limited Memory Influence Diagrams

We present a new algorithm for exactly solving decision making problems represented as influence diagrams. We do not require the usual assumptions of no forgetting and regularity; this allows us to solve problems with simultaneous decisions and limited information. The algorithm is empirically shown to outperform a state-of-the-art algorithm on randomly generated problems of up to 150 variables and 10^64 solutions. We show that the problem is NP-hard even if the underlying graph structure of the problem has small treewidth and the variables take on a bounded number of states, but that a fully polynomial time approximation scheme exists for these cases. Moreover, we show that the bound on the number of states is a necessary condition for any efficient approximation scheme.