Patients' unvoiced agendas in general practice consultations.

Objective: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. Design: Qualitative study. Setting: 20 general practices in south east England and the West Midlands. Participants: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. Results: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. Conclusion: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agenda

Preliminary testing of a prototype portable X-ray fluorescence spectrometer

A portable X-ray fluorescence spectrometer for use as an analyzer in mineral resource investigative work was built and tested. The prototype battery powered spectrometer, measuring 11 by 12 by 5 inches and weighing only about 15 pounds, was designed specifically for field use. The spectrometer has two gas proportional counters and two radioactive sources, Cd (10a) and Fe (55). Preliminary field and laboratory tests on rock specimens and rock pulps have demonstrated the capability of the spectrometer to detect 33 elements to date. Characteristics of the system present some limitations, however, and further improvements are recommended

Complexity theory and tourism policy research

This paper investigates applications of complexity theory in the social sphere and considers its potential contribution to enhance understanding of tourism policy making. Five concepts are identified to explore complex social circumstances and human interactions that influence policy. Social applications of complexity suggest a move towards localised and deeper studies to explore the dynamics of policy enactment in context. It suggests complexity theory might be used as a thinking tool to enable a more holistic approach to policy analysis and investigate policy in its context, considering interactions between different policies/programmes, and the implications of human agency

Active Carbon and Oxygen Shell Burning Hydrodynamics

We have simulated 2.5$\times10^3$ s of the late evolution of a $23 \rm M_\odot$ star with full hydrodynamic behavior. We present the first simulations of a multiple-shell burning epoch, including the concurrent evolution and interaction of an oxygen and carbon burning shell. In addition, we have evolved a 3D model of the oxygen burning shell to sufficiently long times (300 s) to begin to assess the adequacy of the 2D approximation. We summarize striking new results: (1) strong interactions occur between active carbon and oxygen burning shells, (2) hydrodynamic wave motions in nonconvective regions, generated at the convective-radiative boundaries, are energetically important in both 2D and 3D with important consequences for compositional mixing, and (3) a spectrum of mixed p- and g-modes are unambiguously identified with corresponding adiabatic waves in these computational domains. We find that 2D convective motions are exaggerated relative to 3D because of vortex instability in 3D. We discuss the implications for supernova progenitor evolution and symmetry breaking in core collapse.Comment: 5 pages, 4 figures in emulateapj format. Accepted for publication in ApJ Letters. High resolution figure version available at http://spinach.as.arizona.ed

Misunderstandings in general practice prescribing decisions: a qualitative study

Objectives: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. Design: Qualitative study. Setting: 20 general practices in the West Midlands and south east England. Participants: 20 general practitioners and 35 consulting patients. Main outcome measures: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. Results: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. Conclusions: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings