Disclosure of Depression in Primary Care: A Qualitative Study of Women’s Perceptions

Background Health care providers are better able to diagnose depression and initiate treatment when patients disclose symptoms. However, many women are reluctant to disclose depressive symptoms. Little is known about the experience of disclosing depression symptoms in primary care among racially and ethnically diverse women across the life course. We qualitatively explore experiences of disclosure of depressive symptoms to primary care providers among self-identified African American, Hispanic and non-Hispanic White women. Methods Twenty-four women with depression were recruited for open-ended interviews. We recorded, transcribed, and coded interviews using inductive content analysis. Findings Two distinct domains emerged: participant factors that hinder and facilitate disclosure and provider cues that encourage and dissuade discussing depression. Participants described perceptions about primary care not being the appropriate place, fear of not having a choice in treatment decisions, and the emotional cost of retelling as impediments to disclosure; perceiving an increased likelihood of getting help was described as a facilitator. Women identified provider behaviors of asking about depression and showing concern as facilitators, and provider time constraints as a barrier to disclosure. Conclusions Women perceive that primary care is not the appropriate place to disclose depression symptoms. Increased public education about behavioral health management in primary care, as well as more robust integration of the two, is needed. Efforts to improve depression disclosure in primary care must also encompass systematic use of depression screening tools and implementation of targeted interventions to cultivate provider empathy

Water Quality Trading and Offset Initiatives in the U.S.: A Comprehensive Survey

This document summarizes water quality trading and offset initiatives in the United States, including state-wide policies and recent proposals. The following format was used to present information on each program. We attempted to have each program summary reviewed by at least one contact person for program accuracy. In the cases where this review occurred, we added the statement "Reviewed by.." at the end of the case summary

Fathers Know Best? Christian Families in the Age of Asceticism

Fathers Know Best? Christian Families in the Age of Asceticis

Space Shuttle Orbiter Atlantis Liquid Oxygen Prevalve Detent Roller Cracking Investigation

During routine inspections of the Space Shuttle's Main Propulsion System (MPS) Liquid Oxygen (LO2) pre-valve, the mechanism provided to maintain the valve in the open position was found cracked. The mechanism is a Vespel roller held against the valve visor by a stack of Belleville springs. The roller has been found cracked 3 times. All three instances were in the same valve in the same location. There are 6 pre-valves on each orbiter, and only one has exhibited this problem. Every-flight inspections were instituted and the rollers were found to be cracked after only one flight. Engineers at Marshall Space Flight Center, Johnson Space Center and Kennedy Space Center worked together to determine a solution. There were several possible contributors to the failure: a mis-aligned visor, an out of specification edge with a sharp radius, an out of specification tolerance stack up of a Belleville spring stack that caused un-predicted loads on the Vespel SP-21 roller, and a dimple machined into the side of the roller to indicate LO2 compatibility that created a stress riser. The detent assembly was removed and replaced with parts that were on the low-side of the tolerance stack up to eliminate the potential for high loads on the detent roller. After one flight, the roller was inspected and showed fewer signs of wear and no cracks

Gesundheitsfonds: Effizientere Steuerung des Gesundheitssystems?

Vor mehr als fünf Jahren wurde der Gesundheitsfonds eingeführt, verbunden mit der Erwartung, dass mehr Gerechtigkeit und Wettbewerb in das Krankenversicherungssystem Einzug hielte. Vor allem der erhoffte Übergang vom Preis- zum Qualitätswettbewerb ist aber offenbar nicht gelungen. Der Gesundheitsfonds hat nach der Auffassung einiger Autoren auch die Nachhaltigkeit der Finanzierung nicht verbessert, die vorhandene strukturelle Einnahmenschwäche wurde vielmehr durch die gute Konjunktur und die hohen Beitragssätze überdeckt. Wie sich die neuerliche Umstellung von pauschalen Zusatzbeiträgen, die in den letzten Jahren von keiner Kasse erhoben wurden, auf einkommensabhängige Beiträge auswirkt, wird unterschiedlich beurteilt.In 2009 the German central health fund was implemented. It was the result of a political compromise. One political party intended to equalise the risk structure among 130 different health care funds, and the other wanted to intensify competition and to improve efficiency among the different health insurances. The fund is fl anked by a health-based risk adjustment and is aimed at sustainably ensuring the funding of the statutory health insurance system. It also constitutes the basis for competition among statutory health care funds, securing quality and efficiency in health care provision. To cover additional expenditures, health insurers had to charge flatrate premiums. A new law, which will come into effect in January 2015, will oblige health insurers to charge income related contributions. It is not clear how this will change competition among insurers. The federal government will not need to finance subsidies to low income individuals anymore. Income redistribution will only take place within the public health insurance system, exempting the privately insured and public servants from supporting low income individuals. The authors claim that the health care fund will not succeed in its aim of securing a sustainable financial basis for the statutory health insurance system. Most of the authors argue that there is no evidence of greater efficiency thus far, and they offer proposals on how to achieve improved performance

Effect of fixed-dose subcutaneous reslizumab on asthma exacerbations in patients with severe uncontrolled asthma and corticosteroid sparing in patients with oral corticosteroid-dependent asthma : results from two phase 3, randomised, double-blind, placebo-controlled trials

BACKGROUND: Reslizumab 3 mg/kg administered intravenously is approved for the treatment of severe eosinophilic asthma. We assessed the safety and efficacy of subcutaneous reslizumab 110 mg in two trials in patients with uncontrolled severe asthma and increased blood eosinophils. The aim was to establish whether subcutaneous reslizumab 110 mg can reduce exacerbation rates in these patients (study 1) or reduce maintenance oral corticosteroid dose in patients with corticosteroid-dependent asthma (study 2). METHODS: Both studies were randomised, double-blind, placebo-controlled, phase 3 studies. Entry criteria for study 1 were uncontrolled severe asthma, two or more asthma exacerbations in the previous year, a blood eosinophil count of 300 cells per μL or more (including no more than 30% patients with an eosinophil count <400 cells/μL), and at least a medium dose of inhaled corticosteroids with one or more additional asthma controllers. Patients in study 2 had severe asthma, a blood eosinophil count of 300 cells per μL or more, daily maintenance oral corticosteroid (prednisone 5-40 mg, or equivalent), and high-dose inhaled corticosteroids plus another controller. Patients were randomly assigned (1:1) to subcutaneous reslizumab (110 mg) or placebo once every 4 weeks for 52 weeks in study 1 and 24 weeks in study 2. Patients and investigators were masked to treatment assignment. Primary efficacy outcomes were frequency of exacerbations during 52 weeks in study 1 and categorised percentage reduction in daily oral corticosteroid dose from baseline to weeks 20-24 in study 2. Primary efficacy analyses were by intention to treat, and safety analyses included all patients who received at least one dose of study treatment. These studies are registered with ClinicalTrials.gov, NCT02452190 (study 1) and NCT02501629 (study 2). FINDINGS: Between Aug 12, 2015, and Jan 31, 2018, 468 patients in study 1 were randomly assigned to placebo (n=232) or subcutaneous reslizumab (n=236), and 177 in study 2 to placebo (n=89) or subcutaneous reslizumab (n=88). In study 1, we found no significant difference in the exacerbation rate between reslizumab and placebo in the intention-to-treat population (rate ratio 0·79, 95% CI 0·56-1·12; p=0·19). Subcutaneous reslizumab reduced exacerbation frequency compared with placebo in the subgroup of patients with blood eosinophil counts of 400 cells per μL or more (0·64, 95% CI 0·43-0·95). Greater reductions in annual exacerbation risk (p=0·0035) and longer time to first exacerbation were observed for patients with higher trough serum reslizumab concentrations. In study 2, we found no difference between placebo and fixed-dose subcutaneous reslizumab in categorised percentage reduction in daily oral corticosteroid dose (odds ratio for a lower category of oral corticosteroid use in the reslizumab group vs the placebo group, 1·23, 95% CI 0·70-2·16; p=0·47). The frequency of adverse events and serious adverse events with reslizumab were similar to those with placebo in both studies. INTERPRETATION: Fixed-dose (110 mg) subcutaneous reslizumab was not effective in reducing exacerbation frequency in patients with uncontrolled asthma and increased blood eosinophils (≥300 cells/μL), or in reducing the daily maintenance oral corticosteroid dose in patients with oral corticosteroid-dependent severe eosinophilic asthma. Higher exposures than those observed with 110 mg subcutaneous reslizumab are required to achieve maximal efficacy. FUNDING: Teva Branded Pharmaceutical Products R&D

The Variable Vector Countermeasure Suit (V2Suit) for space habitation and exploration

The “Variable Vector Countermeasure Suit (V2Suit) for Space Habitation and Exploration” is a novel system concept that provides a platform for integrating sensors and actuators with daily astronaut intravehicular activities to improve health and performance, while reducing the mass and volume of the physiologic adaptation countermeasure systems, as well as the required exercise time during long-duration space exploration missions. The V2Suit system leverages wearable kinematic monitoring technology and uses inertial measurement units (IMUs) and control moment gyroscopes (CMGs) within miniaturized modules placed on body segments to provide a “viscous resistance” during movements against a specified direction of “down”—initially as a countermeasure to the sensorimotor adaptation performance decrements that manifest themselves while living and working in microgravity and during gravitational transitions during long-duration spaceflight, including post-flight recovery and rehabilitation. Several aspects of the V2Suit system concept were explored and simulated prior to developing a brassboard prototype for technology demonstration. This included a system architecture for identifying the key components and their interconnects, initial identification of key human-system integration challenges, development of a simulation architecture for CMG selection and parameter sizing, and the detailed mechanical design and fabrication of a module. The brassboard prototype demonstrates closed-loop control from “down” initialization through CMG actuation, and provides a research platform for human performance evaluations to mitigate sensorimotor adaptation, as well as a tool for determining the performance requirements when used as a musculoskeletal deconditioning countermeasure. This type of countermeasure system also has Earth benefits, particularly in gait or movement stabilization and rehabilitation.United States. National Aeronautics and Space Administration (Innovative Advanced Concepts Grant NNX11AR25G)United States. National Aeronautics and Space Administration (Innovative Advanced Concepts Grant NNX12AQ58G

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