Managing chronic widespread pain in primary care : a qualitative study of patient perspectives and implications for treatment delivery

Funding The MUSICIAN trial was supported by an award from Arthritis Research UK, Chesterfield, UK. Grant number: 17292. The funding body approved the design of the study. They played no role in the collection, analysis, and interpretation of data or the writing of the manuscript.

The clinical significance of medicines reconciliation in children admitted to hospital

Aims and Objectives: The NICE/NPSA guidance on Medicines Reconciliation in adults upon hospital admission excludes children under the age of 16.1 Hence the primary aim and objective of this study was to use medicines reconciliation to primarily identify if discrepancies occur upon hospital admission. Secondary objectives were to clinically assess for harm discrepancies that were identified in paediatric patients on long term medications at four hospitals across the UK. Method: Medicines reconciliation is a procedure where the current medication history of a patient prior to hospital admission would be taken and verifying the medication orders made at hospital admission against this history, addressing any discrepancies identified. Medicines reconciliation was carried out prospectively for 244 paediatric patients on chronic medication across four UK hospitals (Birmingham, London, Leeds and North Staffordshire) between January – May 2011. Medicines reconciliation was conducted by a clinical pharmacist using the following sources of information: 1) the patient's Pre-Admission Medication (PAM) from the patient's general practitioner 2) examination of the Patient's Own Medications brought into hospital, 3) a semi-structured interview with the parent-carers and 4) identification of admission medication orders written on the drug chart prior to clinical pharmacy input (Drug Chart). Discrepancies between the PAM and Drug Chart were documented and classified as intentional or unintentional. Intentional discrepancies were defined as changes that were made knowingly by the prescriber and confirmed. Unintentional discrepancies were assessed for clinical significance by an expert panel and assigned a significance score based on the likelihood of causing potential discomfort or clinical deterioration: class 1 unlikely, class 2 moderate and class 3 severe.2 Results: 1004 medication regimens were included from the 244 patients across the four sites. 588 of the 1004 (59%) medicines, had discrepancies between the PAM and Drug Chart; of these 36% (n = 209) were unintentional and included for clinically assessment. 189 drug discrepancies 30% were classified as class 1, 47% were class 2 and 23% were class 3 discrepancies. The remaining 20 discrepancies were cases where deviating from the PAM would have been the right thing to do, which might suggest that an intentional but undocumented discrepancy by the prescriber writing up the admission order may have occurred. Conclusion: The results suggest that medication discrepancies in paediatric patients do occur upon hospital admission, which do have a potential to cause harm and that medicines reconciliation is a potential solution to preventing such discrepancies. References: 1. National Institute for Health and Clinical Excellence. National Patient Safety Agency. PSG001. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: NICE; 2007. 2. Cornish, P. L., Knowles, S. R., Marchesano, et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Archives of Internal Medicine 2005; 165:424–429

Suicide and deliberate self harm in older Irish adults

Background: Hospital-treated deliberate self harm and suicide among older adults have rarely been examined at a national level. Methods: The Irish Central Statistics Office provided suicide and undetermined death data for 1980-2006. The National Registry of Deliberate Self Harm collected data relating to deliberate self harm presentations made in 2006-2008 to all 40 Irish hospital emergency departments. Results: Rates of female suicide among older adults (over 55 years) were relatively stable in Ireland during 1980-2006 whereas male rates increased in the 1980s and decreased in more recent decades. Respectively, the annual male and female suicide and undetermined death rate was 22.1 and 7.6 per 100,000 in 1997-2006. Male and female deliberate self harm was 3.0 and 11.0 times higher at 67.4 and 83.4 per 100,000, respectively. Deliberate self harm and suicide decreased in incidence with increasing age. Deliberate self harm generally involved drug overdose (male: 72%; female 85%) or self-cutting (male: 15%; female 9%). The most common methods of suicide were hanging (41%) and drowning (29%) for men and drowning (39%) and drug overdose (24%) for women. City and urban district populations had the highest rates of hospital-treated self harm. The highest suicide rates were in urban districts. Conclusions: Older Irish adults have high rates of hospital-treated deliberate self harm but below average rates of suicide. Drowning was relatively common as a method of suicide. Restricting availability of specific medications may reduce both forms of suicidal behavior.

Identifying the Structure and Fate of Wastewater Derived Organic Micropollutants by High-resolution Mass Spectrometry

Human activities represent a significant burden on the global water cycle, with large and increasing demands placed on limited water resources by manufacturing, energy production and domestic water use. In addition to changing the quantity of available water resources, human activities lead to changes in water quality by introducing a large and often poorly-characterized array of chemical pollutants, which may negatively impact biodiversity in aquatic ecosystems, leading to impairment of valuable ecosystem functions and services. Domestic and industrial wastewaters represent a significant source of pollution to the aquatic environment due to inadequate or incomplete removal of chemicals introduced into waters by human activities. Currently, incomplete chemical characterization of treated wastewaters limits comprehensive risk assessment of this ubiquitous impact to water. In particular, a significant fraction of the organic chemical composition of treated industrial and domestic wastewaters remains uncharacterized at the molecular level. Efforts aimed at reducing the impacts of water pollution on aquatic ecosystems critically require knowledge of the composition of wastewaters to develop interventions capable of protecting our precious natural water resources.

The goal of this dissertation was to develop a robust, extensible and high-throughput framework for the comprehensive characterization of organic micropollutants in wastewaters by high-resolution accurate-mass mass spectrometry. High-resolution mass spectrometry provides the most powerful analytical technique available for assessing the occurrence and fate of organic pollutants in the water cycle. However, significant limitations in data processing, analysis and interpretation have limited this technique in achieving comprehensive characterization of organic pollutants occurring in natural and built environments. My work aimed to address these challenges by development of automated workflows for the structural characterization of organic pollutants in wastewater and wastewater impacted environments by high-resolution mass spectrometry, and to apply these methods in combination with novel data handling routines to conduct detailed fate studies of wastewater-derived organic micropollutants in the aquatic environment.

In Chapter 2, chemoinformatic tools were implemented along with novel non-targeted mass spectrometric analytical methods to characterize, map, and explore an environmentally-relevant “chemical space” in municipal wastewater. This was accomplished by characterizing the molecular composition of known wastewater-derived organic pollutants and substances that are prioritized as potential wastewater contaminants, using these databases to evaluate the pollutant-likeness of structures postulated for unknown organic compounds that I detected in wastewater extracts using high-resolution mass spectrometry approaches. Results showed that application of multiple computational mass spectrometric tools to structural elucidation of unknown organic pollutants arising in wastewaters improved the efficiency and veracity of screening approaches based on high-resolution mass spectrometry. Furthermore, structural similarity searching was essential for prioritizing substances sharing structural features with known organic pollutants or industrial and consumer chemicals that could enter the environment through use or disposal.

I then applied this comprehensive methodological and computational non-targeted analysis workflow to micropollutant fate analysis in domestic wastewaters (Chapter 3), surface waters impacted by water reuse activities (Chapter 4) and effluents of wastewater treatment facilities receiving wastewater from oil and gas extraction activities (Chapter 5). In Chapter 3, I showed that application of chemometric tools aided in the prioritization of non-targeted compounds arising at various stages of conventional wastewater treatment by partitioning high dimensional data into rational chemical categories based on knowledge of organic chemical fate processes, resulting in the classification of organic micropollutants based on their occurrence and/or removal during treatment. Similarly, in Chapter 4, high-resolution sampling and broad-spectrum targeted and non-targeted chemical analysis were applied to assess the occurrence and fate of organic micropollutants in a water reuse application, wherein reclaimed wastewater was applied for irrigation of turf grass. Results showed that organic micropollutant composition of surface waters receiving runoff from wastewater irrigated areas appeared to be minimally impacted by wastewater-derived organic micropollutants. Finally, Chapter 5 presents results of the comprehensive organic chemical composition of oil and gas wastewaters treated for surface water discharge. Concurrent analysis of effluent samples by complementary, broad-spectrum analytical techniques, revealed that low-levels of hydrophobic organic contaminants, but elevated concentrations of polymeric surfactants, which may effect the fate and analysis of contaminants of concern in oil and gas wastewaters.

Taken together, my work represents significant progress in the characterization of polar organic chemical pollutants associated with wastewater-impacted environments by high-resolution mass spectrometry. Application of these comprehensive methods to examine micropollutant fate processes in wastewater treatment systems, water reuse environments, and water applications in oil/gas exploration yielded new insights into the factors that influence transport, transformation, and persistence of organic micropollutants in these systems across an unprecedented breadth of chemical space.

A THEOLOGICAL NORMATIVE TO THE UNDERSTANDING OF FATHERHOOD IN THE AFRICAN AMERICAN COMMUNITY

ABSTRACT

This thesis examines the theological correlation between the role of the church, the identity and role of the African American male, and the effectiveness of fatherhood. The study begins with an in-depth analysis of how absentee fathers cause a crisis in the family. The absence of fathers from the home causes children to suffer financially, socially and psychologically, and therefore causes a disruption in the community as a whole. Focus on the Family founder and leader, Dr. James Dobson, confirms that “our very survival as a people will depend upon the presence or absence of masculine leadership in millions of homes.” In person interviews of African American Christian males and interpretation of the scriptures are just two of the methods used in this study to explore the theological norm of fatherhood. Collectively, the case studies and statistical data within this study explore attempts to remedy the crisis through governmental policies and networking within the community. The final chapter examines the role of urban churches and clergy in teaching effective fatherhood practices. Within the conclusion, it is made clear that the church is responsible for establishing the theological framework and principles for understanding the intended role of being a father. Another conclusion of this study is the acknowledgement of the African American community’s role in shaping and reforming the identity and role of the African American male as a father in the home. The African American community and the church must continue working in tandem to encourage organic social networks that will promote a model for effective fatherhood practices.

Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.

RATIONALE: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. OBJECTIVES: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. METHODS: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. MEASUREMENTS AND MAIN RESULTS: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. CONCLUSIONS: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.

Modern major element concentrations and ratios measured in Atlantic surface sediments (36°N-49°S)

Numerous studies use major element concentrations measured on continental margin sediments to reconstruct terrestrial climate variations. The choice and interpretation of climate proxies however differ from site to site. Here we map the concentrations of major elements (Ca, Fe, Al, Si, Ti, K) in Atlantic surface sediments (36°N-49°S) to assess the factors influencing the geochemistry of Atlantic hemipelagic sediments and the potential of elemental ratios to reconstruct different terrestrial climate regimes. High concentrations of terrigenous elements and low Ca concentrations along the African and South American margins reflect the dominance of terrigenous input in these regions. Single element concentrations and elemental ratios including Ca (e.g., Fe/Ca) are too sensitive to dilution effects (enhanced biological productivity, carbonate dissolution) to allow reliable reconstructions of terrestrial climate. Other elemental ratios reflect the composition of terrigenous material and mirror the climatic conditions within the continental catchment areas. The Atlantic distribution of Ti/Al supports its use as a proxy for eolian versus fluvial input in regions of dust deposition that are not affected by the input of mafic rock material. The spatial distributions of Al/Si and Fe/K reflect the relative input of intensively weathered material from humid regions versus slightly weathered particles from drier areas. High biogenic opal input however influences the Al/Si ratio. Fe/K is sensitive to the input of mafic material and the topography of Andean river drainage basins. Both ratios are suitable to reconstruct African and South American climatic zones characterized by different intensities of chemical weathering in well-understood environmental settings.

(Table T1) Lithologic and ichnologic description of ODP Hole 174-1073A

When examined in their sedimentologic and stratigraphic context, ichnofabrics and component ichnofossils can help decipher paleoceanography and sea-level histories from marine deposits (Savrda, 1995, http://www.jstor.org/stable/3515095). Thus far, applications of ichnology in paleoceanographic investigations have been restricted to slowly deposited, predominantly biogenic sediments and/or strata deposited in oxygen-deficient, tectonically active basins. Moreover, ichnologic applications in sequence stratigraphic studies largely have been restricted to strata deposited in relatively shallow-water shelf or foreland basin settings. The limits of previous studies provided impetus for detailed postcruise examination of Quaternary deposits recovered at Ocean Drilling Program (ODP) Site 1073 on the New Jersey margin. These deposits provide the opportunity to assess the sedimentary and ichnofabric record of glacio-eustatic cycles in a passive continental slope setting characterized by relatively rapid accumulation of siliciclastic sediments in an area not far removed from the Laurentide ice margin. The primary purpose of this data report is to present basic sedimentologic and ichnologic observations made at the decimeter scale throughout the Quaternary sequence from Site 1073. Data analysis and interpretation in the context of climate and sea-level histories, as inferred from oxygen isotopic, palynologic, and seismic studies, are ongoing and will be presented in subsequent papers prepared for open literature (e.g., Savrda et al., in press).

Organizing and Interpreting Unstructured Qualitative Data

In the last several years there has been an increase in the amount of qualitative research using in-depth interviews and comprehensive content analyses in sport psychology. However, no explicit method has been provided to deal with the large amount of unstructured data. This article provides common guidelines for organizing and interpreting unstructured data. Two main operations are suggested and discussed: first, coding meaningful text segments, or creating tags, and second, regrouping similar text segments,or creating categories. Furthermore, software programs for the microcomputer are presented as away to facilitate the organization and interpretation of qualitative data

Representing the Unrepresentable: The Photographs of Lee Miller at Buchenwald and Dachau

This article proposes a reflection on what the historian Saul Friedlander called “the limits of representation” of the massacres and genocides, in order to provide evidence to help settle the old debate about the Holocaust unrepresentability. To achieve this, we will carry out a textual analysis of five of the most painful images that the American photographer Lee Miller realized in the Nazi concentration camps of Buchenwald and Dachau, in April 1945. The war correspondent, who had been Man Ray’s assistant photographer, muse and lover, witnessed the horror, and if she knew how to represent it, that was, in a great extent, thanks to its surreal look.

"Sub Tiberio quies"? Judaea’s Political Situation under the Prefects (6-41 c.e.), between Reality and Ideology

Deeply conflicting views on the political situation of Judaea under the Roman prefects (6-41 c.e.) have been offered. According to some scholars, this was a period of persistent political unrest and agitation, whilst according to a widespread view it was a quiescent period of political calm (reflected in Tacitus’ phrase sub Tiberio quies). The present article critically examines again the main available sources –particularly Josephus, the canonical Gospels and Tacitus– in order to offer a more reliable historical reconstruction. The conclusions drawn by this survey calls into question some widespread and insufficiently nuanced views on the period. This, in turn, allows a reflection on the non-epistemic factors which might contribute to explain the origin of such views.

„Welch werthvolle und kunstreich geschmiedete kleine Sache.“

Richard Schaukal (1874-1942) wurde als Dichter ignoriert, als Übersetzer geschätzt und als Literaturkritiker geachtet. Es ist erstaunlich, dass dieses Tätigkeitsfeld unvollständig aufgearbeitet ist, zumal bedeutende Exponenten der Zeit wie Thomas Mann, Hermann Hesse oder Rainer Maria Rilke Schaukal um Besprechungen ihrer Werke baten. Er verfasste für zahlreiche Publikationsorgane meist unbequeme Essays, die sich − mehr noch als seine dichterischen Arbeiten − in den Diskurs der kulturkonservativen kritischen Moderne einschrieben. Mit Blick auf seine frühe Phase als Literaturkritiker werden Richard Schaukals ästhetische Positionen, Einflüsse und Funktionen untersucht. Abschließend wird sein Aufsatz über Ferdinand von Saar (1899) einer exemplarischen Analyse unterzogen.

Sherman Alexie’s "The Toughest Indian in the World": Amalgamating the Oral and the Written Traditions

This article argues that The Toughest Indian in the World (2000) by Native-American author Sherman Alexie combines elements of his tribal (oral) tradition with others coming from the Western (literary) short-story form. Like other Native writers — such as Momaday, Silko or Vizenor — , Alexie is seen to bring into his short fiction characteristics of his people’s oral storytelling that make it much more dialogical and participatory. Among the author’s narrative techniques reminiscent of the oral tradition, aggregative repetitions of patterned thoughts and strategically-placed indeterminacies play a major role in encouraging his readers to engage in intellectual and emotional exchanges with the stories. Assisted by the ideas of theorists such as Ong (1988), Evers and Toelken (2001), and Teuton (2008), this article shows how Alexie’s short fiction is enriched and revitalized by the incorporation of oral elements. The essay also claims that new methods of analysis and assessment may be needed for this type of bicultural artistic forms. Despite the differences between the two modes of communication, Alexie succeeds in blending features and techniques from both traditions, thus creating a new hybrid short-story form that suitably conveys the trying experiences faced by his characters.

Digital collaborations and entrepreneurship – the role of shareconomy and crowdsourcing in the era of smart city

The thesis begins with the classical cooperation and transfers it to the digital world. This work gives a detailed overview of the young fields of research smart city, shareconomy and crowdsourcing and links these fields with entrepreneurship. The core research aim is the finding of connections between the research fields smart city, shareconomy and crowdsourcing and entrepreneurial activities and the specific fields of application, success factors and conditions for entrepreneurs. The thesis consists of seven peer-reviewed publications. Based on primary and secondary data, the existence of entrepreneurial opportunities in the fields of smart city, shareconomy and crowdsourcing could be confirmed. The first part (publications 1-3) of the thesis are literature reviews to secure the fundamental base for further research. This part consists of newly created definitions and an extreme sharpening of the research fields for the near future. In the second part of the thesis (publications 4-7), empirical field work (in-depth interviews with entrepreneurs) and quantitative analyses (fuzzy set/qualitative comparative analysis and binary logistic regression analysis) contribute to the field of research with additional new insights. Summarizing, the insights are multi-layered: theoretical (e.g. new definitions, sharpening of the research field), methodical (e.g. first time application of the fuzzy set/qualitative comparative analysis in the field of crowdfunding) and qualitative (first time application of in-depth interviews with entrepreneurs in the fields of smart city and shareconomy). The global research question could be answered: the link between entrepreneurship and smart city, shareconomy and crowdfunding could be confirmed, concrete fields of application could be identified and further developments could be touched upon. This work strongly contributes to the young fields of research through much-needed basic work, new qualitative approaches, innovative methods and new insights and offers opportunities for discussion, criticism and support for further research.

Learning from Text: Examining Teacher Thinking and Practice in AP Environmental Science

Thesis (Ph.D.)--University of Washington, 2016-08