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This paper considers whether biblical narrative was used as part of a technology of the self in Jewish antiquity. Many have seen the assumption that Israel’s ancestors were perfect and, hence, worthy of imitation as essential to the Bible’s identity as Scripture around the turn of the Common Era. Recently several scholars have detailed the specific dynamics of exemplarity among certain readers of the Bible, such as Philo, particularly in light of Hellenistic and Roman models. Such work draws attention to the relative lack of explicit attestation for such a practice in much of ancient Jewish literature. As a next step, we need to further delineate what constitutes a literary practice of exemplarity and explore alternatives or additions to it, such as memorialization. To do so, this paper examines a range of texts, including the Genesis Apocryphon, the Book of Jubilees, Ben Sira, Philo, Josephus, and the rabbinic collection, Genesis Rabbah.

Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

The CoViD-19 pandemic ceased to be describable by a susceptible-infected-recovered (SIR) model when lockdowns were enforced. We introduce a theoretical framework to explain and predict changes in the reproduction number of SARS-CoV-2 (Sudden Acute Respiratory Syndrome Coronavirus 2) in terms of individual mobility and interpersonal proximity (alongside other epidemiological and environmental variables) during and after the lockdown period. We use an infection-age structured model described by a renewal equation. The model predicts the evolution of the reproduction number up to a week ahead of well-established estimates used in the literature. We show how lockdown policies, via reduction of proximity and mobility, reduce the impact of CoViD-19 and mitigate the risk of disease resurgence. We validate our theoretical framework using data from Google, Voxel51, Unacast, The CoViD-19 Mobility Data Network, and Analisi Distribuzione Aiuti.

To replicate and extend a study by the Agency for Healthcare Research and Quality (AHRQ) and Rutgers on antipsychotic use among youths in Medicaid, the authors analyzed Indiana Medicaid claims from 2004 to 2012, extending the earlier study by focusing on second-generation antipsychotics, including both fee-for-service (FFS) and non-FFS patients, and analyzing cost trends.The authors evaluated the impact of several Indiana Medicaid policy changes on medication utilization and cost among children enrolled for at least one month during 2004-2012 (N=683,716-793,637), using an exhaustive antipsychotic list to search the database.Annual utilization rates for antipsychotics were 2%-3% but were much higher among foster children (10%-15%). Policies implemented in 2007 or later were associated with a significant plateauing of utilization in 2008-2012.Growth of second-generation antipsychotic utilization and costs was similar to trends described in the AHRQ-Rutgers study. Several containment strategies appeared effective in addressing these trends.

Noting that, in the Hebrew Bible, law, but not narrative, is attributed to Moses, this paper argues that the notion of the “Torah of Moses” as revealed literature, word for word dictation to Moses, is to be traced to a late Second Temple construction of the Pentateuch as apocalypse. The move is evident in the Book of Jubilees, who introduces his work with a detailed account of revelation at Sinai that includes his own work, the “Divisions of the Times,” an apocalypse, but not the “Torah of Moses.” However, as Jubilees overlaps with Genesis in great measure and, it is argued, refrains from alluding to the Pentateuch throughout, the claim would seem to be that the “Divisions of the Times” actually preceded the Pentateuch as one of its sources. The implications of this view for understanding Rewritten Bible and interpretation in the late Second Temple period are considered.

Telemental health has been promoted to address long-standing access barriers to rural mental health care, including low supply and long travel distances. Examples of rural telemental health programs are common; there is a less clear picture of how widely implemented these programs are, their organization, staffing, and services. There is also a need to understand the business case for these programs and assess whether and how they might realize their promise. To address these gaps, a national study was conducted of rural telemental health programs including an online survey of 53 programs and follow-up interviews with 23 programs. This article describes the current landscape and characteristics of these programs and then examines their business case. Can rural telemental health programs be sustained within current delivery systems and reimbursement structures? This question is explored in four areas: need and demand, infrastructure and workforce, funding and reimbursement, and organizational fit and alignment.

While the research base on implementation in child welfare has grown, applying implementation science to child welfare system change is still relatively new. There is a gap in knowledge of what factors are most important in different implementation stages and system contexts. This study examines 12 implementation keys that support building infrastructure, developing inter-organizational networks, and addressing contextual issues in child welfare system change initiatives in three states. Research questions address which keys are most important in different implementation stages, the major components and context of these keys during implementation, and the overlap between implementation keys.

This chapter introduces the Geo Capabilities project to explore school geography's contribution to citizenship education. The Geo Capabilities project is not explicitly concerned with citizenship education, still less about "spatial citizenship"—a term first coined by Thomas Jekel and colleagues. To organize teaching in a way that brings about powerful school geography requires what the Geo Capabilities project describes as specialist "curriculum leadership," manifest through effective curriculum making. Spatial citizenship captures the importance of using spatial representations to develop competence with Geographical Information technologies, in order to participate effectively in society. A strong sense of the global is derived from powerful geographical knowledge that is available to all—if there are specialist teachers equipped and available to teach it. The prominent geographer Doreen Massey argued that geography is a discipline that helps us "take on the world" by revealing the concept of the planet as a whole and the realization that every locality on Earth is connected to global processes.

We study the connection between multi-fractality and crucial events. Multi-fractality is frequently used as a measure of physiological variability. Crucial events are known to play a fundamental role in the transport of information between complex networks. To establish a connection we focus on the special case of heartbeat time series and on the search for a diagnostic prescription to distinguish healthy from pathologic subjects. Over the last twenty years two apparently different diagnostic techniques have been established: the first is based on the observation that the multi-fractal spectrum of healthy patients is broader than the multi-fractal spectrum of pathologic subjects; the second is based on the observation that heartbeat dynamics are a superposition of crucial and Poisson events, with pathologic patients hosting Poisson events with larger probability than the healthy patients. In this paper, we prove that increasing the percentage of Poisson events hosted by heartbeats has the effect of making their multi-fractal spectrum narrower, thereby establishing that the two different diagnostic techniques are compatible with one another and, at the same time, establishing a dynamic interpretation of multi-fractal processes that has been previously overlooked., Comment: 9 pages and 11 figures. Submitted to PRE

This paper examines the association between sell-side analysts' short and long-term EPS forecasts, growth rates, and forecast errors, and measures of technological conditions in the firm's industry investment environment. Our contention is analysts' industry knowledge includes an understanding of the technological conditions to which the firms' investments are exposed and how these technological conditions within industries map into future earnings. We predict and find as the horizon lengthens that interactions between technological conditions and current EPS are significantly associated with analysts' EPS and growth forecasts. The long horizon EPS growth results align with Jung, Shane and Yang who suggest analysts' growth forecasts reflect efforts to evaluate the firms' long-run prospects. We also present results for analysts' forecast errors that suggest analysts' technological knowledge is associated with optimistically biased long-term forecasts. Our evidence suggests analysts' industry knowledge includes the implications of technological conditions within industries for firms' future earnings.

This volume collects twelve historical papers, some published here for the first time, in which Stephen Lambert explores the implications of the inscribed Athenian laws and decrees for the history of Athens in the age of Demosthenes.

Geography as a school subject is expressed in a wide variety of ways across different national jurisdictions. This article explores some of the issues arising from attempts to represent geography as a subject for study in schools through the organisational structures offered by national standards and/or national curricula. It serves as an introduction to this special issue, which primarily concerns itself with the contemporary analysis of geography education in seven national settings across the globe. We stress the importance of considering political, cultural, social and philosophical traditions when analysing the curriculum choices made for geography education. Although it may be assumed that geography as a disciplinary specialism is concerned with a body of knowledge that is common across the globe, the creative tensions generated between the disciplines, educational trends and matters of social or policy concern play out differently, making comparisons across jurisdictions hazardous. Understanding this, we argue, is of great significance to those who plan and shape the geography curriculum. Despite the difficulties we hope to offer something more useful than a series of descriptions of geography teaching in different national settings. The purpose of this paper is to introduce a set of robust and irresistible arguments for the inclusion of the study of geography in schools. We argue that geographical knowledge is a vital component of the education of young people across the globe, even though it may be expressed in different ways in different national settings

This article describes a new measure designed to examine the process of implementation of child welfare systems change. The measure was developed to document the status of the interventions and strategies that are being implemented and the drivers that are being installed to achieve sustainable changes in systems. The measure was used in a Children's Bureau-supported national effort to assess the ongoing implementation of 24 systems-change projects in child welfare jurisdictions across the country. The article describes the process for measure development, method of administration and data collection, and quantitative and qualitative findings.

BACKGROUND Painful vaso-occlusive crises (VOC) are the most common reason for acute care utilization in patients with sickle cell disease (SCD), and the emergency department (ED) is often the site of initial management and treatment. Treatment guidelines recommend initiation of analgesia with parenteral opioids within 30 minutes of presentation, timely reassessment of pain, and additional opioids as needed every 15-30 minutes. These targets are infrequently met, resulting in uncontrolled pain, increased likelihood of hospital admission, and deterioration of physician-patient relationships. METHODS We undertook a multidisciplinary effort to improve the management of VOC in the ED, by development and implementation of an evidence-based clinical care pathway. The clinical pathway was implemented at the Hospital of the University of Pennsylvania in December 2018, with direct education of hematology and ED providers around the content of the clinical pathway, and availability of the pathway on the institutional intranet. Specific areas of focus in the pathway included appropriate triaging of patients as emergency severity index 2, timely administration of initial opioid dose, rapid reassessment and administration of additional opioid doses as needed, as well as appropriate laboratory evaluation and evaluation for other common and/or serious complications of SCD. Outcome measures included time from ED registration to administration of first opioid dose, time between administration of first opioid dose and second opioid dose, and proportion of patients discharged from the ED. Balance measures included rate of ED readmission and length of stay. RESULTS There were 602 ED visits from 103 unique patients in the study period, with 256 visits in the six-month period prior to pathway implementation and 346 visits in the six-month period after implementation. Following pathway implementation, time from registration to first opioid dose fell from 114 minutes to 93 minutes (p = 0.003). The proportion of patients receiving their first opioid dose within 60 minutes of registration increased from 19% to 33%. Time from administration of the first opioid dose to the second opioid dose improved from 117 minutes to 94 minutes (p = 0.002). The proportion of patients receiving their second opioid dose within 60 minutes of the first opioid dose increased from 27% to 37%. There was no change in the rate of hospital admission from the ED, or in the proportion of patients who left without being seen (p = 0.710). There was also no change in rate of ED readmissions (p = 0.138) or length of stay (p = 0.483). CONCLUSION Implementation of an evidence-based clinical care pathway in the ED for SCD patients presenting with VOC led to significant improvement in outcomes, with decreased time to first opioid dose and decreased time from first to second opioid dose. Nevertheless, very few patients received guideline-based care, particularly with the goal of time to first opioid dose of less than 30 minutes. While our data demonstrate that provider education and clinical pathways clearly improve the management of VOC in the ED, additional interventions will be required to target other barriers to optimal management, including implicit biases, negative provider attitudes, and social stigma surrounding SCD. Disclosures No relevant conflicts of interest to declare.

Anatomic testing with coronary computed tomography angiography (CCTA) and functional stress testing are both appropriate first-line testing for evaluation of low to intermediate risk chest discomfort in the emergency department (ED). Real world data on rates of revascularization, time to discharge

The SCOT-HEART trial recently showed that the use of coronary computed tomography angiography (CCTA) in stable coronary artery disease (CAD) was associated with lower rates of cardiovascular death or nonfatal myocardial infarction compared to standard care. This was attributed to increased use of

Context. Perinatal palliative care is an area of increasing focus among clinicians supporting newborns and their families. Although not every newborn will survive the neonatal period, assuring their comfort and quality of life remains an imperative for their care providers. It can be challenging to administer medications such as opioids in a minimally invasive yet effective manner. Objectives. To describe the experience using intranasal (IN) fentanyl in the management of distress in a case series of 11 dying neonates. Methods. A retrospective chart review was undertaken of 58 consecutive referrals of newborns and infants aged six months or younger between November 2006 and July 2010 to the Winnipeg Regional Health Authority Pediatric Palliative Care Service to determine how often IN fentanyl was used and review documented responses after the medication. Results. Of 58 referrals, IN fentanyl was used in 11 patients, in all cases for concerns regarding respiratory distress. Chart documentation indicated that fentanyl was tolerated well, with no circumstances of drug-related apnea and no occurrences of chest wall rigidity. In most cases, labored breathing and restlessness settled after medication administration. The average time from administration of the last dose of fentanyl until death was 61 minutes. Conclusion. We found IN fentanyl, which can be administered in a variety of care settings, to be a minimally invasive means of palliating distress in dying newborns and infants. No adverse events related to its use were noted. J Pain Symptom Manage 2012;-:-e-. 2012 U.S. Cancer Pain Relief Committee. Published

The economic and environmental crises that face humanity today require an educational response. This article accepts the proposition that education may play a part in preparing human beings to survive impacts of human-induced climate change for example. However, education, according to some conceptualizations, is also in crisis. It therefore appears far from clear what a ‘curriculum of survival’ consists of. This article adopts a sceptical viewpoint on education for sustainability. Rather than be concerned with ever tighter definitions of what this may mean, or prescriptions of more effective practices, it turns its gaze towards what is there already – the imperfect but long-standing idea and disciplinary enquiry called geography. Geography as the ‘world subject’ is of great salience. It is about human occupation of the planet and has always ultimately been concerned with survival. This article explores the two ideas of geography and education, and appeals for a re-assessment of the role of the ‘traditional’ disciplines, especially geography, in a curriculum of survival.

This paper examines the pattern and extent of energy development in steppe landscapes of northeast Colorado, United States. We compare the landscape disturbance created by oil and gas production to that of wind energy inside the Pawnee National Grasslands eastern side. This high-steppe landscape consists of a mosaic of federal, state, and private lands where dominant economic activities include ranching, agriculture, tourism, oil and gas extraction, and wind energy generation. Utilizing field surveys, remote sensing data and geographic information systems techniques, we quantify and map the footprint of energy development at the landscape level. Findings suggest that while oil and gas and wind energy development have resulted in a relatively small amount of habitat loss within the study area, the footprint stretches across the entire zone, fragmenting this mostly grassland habitat. Futhermore, a third feature of this landscape, the non-energy transportation network, was also found to have a significant impact. Combined, these three features fragment the entire Pawnee National Grasslands eastern side, leaving very few large intact core, or roadless areas. The primary objective of this ongoing work is to create a series of quantifiable and replicable surface disturbance indicators linked to energy production in semi-arid grassland environments. Based on these, and future results, we aim to work with industry and regulators to shape energy policy as it relates to environmental performance, with the aim of reducing the footprint and thus increasing the sustainability of these extractive activities.

Objectives: This study investigated inpatient psychiatric units in small rural hospitals to determine their characteristics, the availability of community-based services after discharge, and the impact of the new Medicare payment system on these units. Methods: Unit managers in all rural hospitals with fewer than 50 beds that had a psychiatric unit in 2006 (N=74) were surveyed on the telephone. Results: On average these units had ten beds and 230 admissions per year. Medicare was the major payer (median of 84%). Typical staffing includes no more than one staff member from each category: psychiatrist, psychologist, social worker, counselor or therapist, and nurse practitioner. Common diagnoses reported were depression (74% of units), schizophrenia or other psychoses (42% of units), and dementia or Alzheimer’s disease (57% of units). Conclusions: Hospital staff reported little difficulty obtaining postdischarge care, and most staff clinicians provided outpatient services locally. Thus mental health services infrastructure appears better in these communities than in most rural communities, but it may be weakened by recent closures reported by some units, caused, in part, by changes in Medicare reimbursement. (Psychiatric Services 61: 620–623, 2010)

Survey researchers commonly use RDD (random digit dialing) samples that are purged of listed business telephone numbers to increase interviewer productivity by removing numbers that are assumed to be ineligible for household surveys. This study investigates this practice and finds an unintended consequence: an increase in household noncoverage. The data come from national RDD surveys using samples that were not purged of listed business numbers. Phone numbers were flagged as listed businesses or not and respondents were asked about how their phone lines are used. Five percent of respondents were interviewed on lines classified as business numbers that normally would have been purged from the sample. But were these valid household interviews or should they have been excluded? The data show that these are, in fact, primarily households. Ninety-four percent of these numbers rang at residences. Moreover, these phone numbers are used as household rather than business-only lines. Ninety-three percent said any adult in the household can answer the phone line in question. A more important finding is that business-line purging increases noncoverage. Sixty-five percent of those contacted on numbers that normally would have been purged from the sample said they had no other phone lines in the household―a noncoverage rate of 3.6 percentage points had these numbers been excluded from the sample. The study concludes with an examination of the characteristics of those interviewed on presumed business numbers, and considers the cost/benefit implications of including these numbers in the sample.

Bid prices were elicited for standard-label cookies, muffins, and potato chips and those guaranteed to be free of genetically modified (GM) ingredients using an nth price Vickery experimental auction. A non-GM guarantee increased bids over those offered for standard-label products using paired-samples t-tests. However, product labeling did not significantly effect bid price estimated using standard ordinary least squares. Overall, providing information about the positive or negative impact of biotechnology on the environment did not affect the bid for the standard—labeled (presumed GM) product. An exception was among students with an agriculture major for whom positive (negative) information decreased (increased) bids for GM products.

The cell phone, now the most widely used medium in Asia, has major educational implications. Most users, however, do not realize the cell phone's potential for education, nor even for the communication functions for which it was originally designed. Most educators still see the computer and the cell phone as unrelated devices, and the tiny cell phone more as a personal accessory, especially for young people. With falling prices and increasing functionality, however, it is virtually certain that not too far in the future all of the world's students will have a cell phone. This is sufficient reason and motivation for educators to explore the possibility of making the cell phone an important tool in the educational systems of developed and developing countries. This article describes the experience of two major projects that are studying the potential of cell phone and short message service (SMS) techniques for formal and nonformal education in the Philippines and Mongolia. The studies have yielded positive ...

Context:National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue. Purpose: This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face. Methods: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded. Key Findings: About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment. Conclusions: The lack of community resources may impact CAHs’ ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

The controversies over the Atlantic slave-trade and slavery itself can be usefully understood as what Catherine Hall has termed a 'war of representation'. At stake was 'the question as to the truth about the system of slavery' and, from 1823, in particular, both supporters and opponents of slavery were 'interested in mobilising public opinion, that increasingly powerful phenomenon'.1 This 'war' took place over a variegated terrain: the 'truth' about the nature of the enslaved African and Afro-Caribbean subject was clearly of great importance, but so was that of the enslaving white Creole subject.2 In this paper, however, the focus is not on the subjects of the slavery controversy, but its sites and spaces. Hall notes that the war of representation 'took place on many sites: in the press, in pamphlets, in fiction, in poetry, in paintings and engravings, in public meetings'.3 Yet beyond these textual, visual and performative sites were a series of worldly spaces over which the truth about slavery was fought. As Hall has demonstrated, the main worldly focus was the Caribbean itself, but other spaces the East Indies, Sierra Leone, the Gold Coast and West Africa more broadly featured too, and hence the war of representation over slavery was fought across multiple theatres, some lying far beyond the Caribbean. Politically and ideologically motivated comparisons between different worldly sites were common currency in the war of representation. For instance, abolitionists sought to establish and emphasize the cultural and moral difference of Caribbean slavedom from metropolitan British society, whilst their opponents asserted the essential unity of the British Atlantic world, the loyalty of the West Indies, and the duty of care that Britain owed to its colonies. This differentiation between a ' "slave-world" aberration' and a metropolitan '"free-world" norm' asserted by humanitarians, contested by defenders of slavery was one of the key spatial features in the war of representation.4 More fine-grained distinctions were also made. For example, supporters of slavery contrasted supposedly ordered and productive West Indian colonies with Haiti, which was made to serve as a portent for what might happen after emancipation. On the other side of the Atlantic, the West African colony of Sierra Leone was represented by humanitarians as a kind of anti-Caribbean space a free African labour

The recent article \cite{hebbian} discusses the emergence of intelligence via criticality as a consequence of locality breakdown. Herein, we use criticality for the foundation of a novel generation of game theory making the local interaction between players yield long-range effects. We first establish that criticality is not confined to the Ising-like structure of the sociological model of \cite{hebbian}, called the decision making model (DMM), through the study of the emergence of altruism using the altruism-selfishness model (ASM). Both models generate criticality, one by imitation of opinion (DMM) the other by imitation of behavior (ASM). The dynamics of a sociological network $\mathcal{S}$ influences the behavioral network $\mathcal{F}$ through two game theoretic paradigms: (i) \emph{the value of altruism} ; (ii) \emph{the benefit of rapid consensus}. In (i) the network $\mathcal{S}$ debates the moral issue of altruism by means of the DMM, while at the level $\mathcal{F}$ the individuals operate according to the ASM. The individuals of the level $\mathcal{S}$, through a weak influence on the individuals of the level $\mathcal{F}$, exert a societal control on $\mathcal{F}$, fitting the principle of complexity management and complexity matching. In (ii) the benefit to society is the rapid attainment of consensus in the $\mathcal{S}$ level. The agents of the level $\mathcal{F}$ operate according to the prisoner's dilemma prescription, with the defectors acting as DMM contrarians at the level $\mathcal{S}$. The contrarians, acting as the inhibitory links of neural networks, exert on society the same beneficial effect of maintaining the criticality-induced resilience that they generate in neural networks. The conflict between personal and social benefit makes the networks evolve toward criticality. Finally, we show that the theory of this article is compatible with recent discoveries in the burgeoning field of social neuroscience.

he provision of mental healthcare in rural communities has been a vexing challenge for clinicians and patients for many years. There is a chronic shortage of specialty mental health providers, particularly psychiatrists and psychologists, which has shifted much of the burden of care to primary care. Primary care clinicians have historically lacked the training and time within their busy practices to feel comfortable providing mental healthcare, particularly since the shortage of specialty mental health clinicians deprives them of consultation and referral sources. People who live in rural areas must often overcome significant travel distances, stigma, and lack of insurance and other resources to access the scarce mental health services that do exist. 1 Despite this difficult picture, rural primary care and specialty mental health clinicians have persevered to provide some level of mental healthcare to people in rural areas. Over the last decade, improvements in clinical screening tools, treatment protocols and guidelines, and information technology have significantly enhanced the potential to increase access to and improve the quality of mental health services in rural communities, particularly to underserved populations. Recent policy initiatives hold much promise to provide the structural and financial support necessary to help rural communities realize these improvements. In this commentary, we first present a general discussion of the issues related to the delivery of mental health services in the United States with particular attention to how these issues complicate the delivery of services in rural areas. Next we describe the renewed call for integrating primary care and mental health in rural areas (hence “the once and future role of primary care” in our title) and related clinical and policy support to do so. We close by briefly describing the policy interventions and resources needed to further these integration efforts and to improve access to services for rural underserved populations. Our Fragmented Mental Health Delivery System The mental health delivery system in the United States is characterized by a fragmentation of services, separation of funding streams and delivery systems, poor reimbursement, inadequate access to specialty mental health providers, and the mal-distribution of existing resources. These issues greatly complicate the delivery of services in rural areas. The United States mental health system is not a coordinated system of specialty mental health services but, rather, a fragmented collection of services and providers that has come to be known as

In many ways, historic parks and gardens have thrived in the last 20 years, following a dawning of recognition heralded by the impact of the 1987 hurricanes. The English Heritage Register is now a material consideration in planning decisions, local authorities have included it in the development planning and control processes; the voluntary sector is thriving as county gardens trusts blossom, while the Garden History Society is now a statutory consultee on planning applications and a well-established part of the national amenity societies scene. High-profile restoration projects and the generosity of the Heritage Lottery Fund (HLF) towards urban parks have raised public awareness to a welcome degree.But that is not the whole story. English Heritage is cutting resources, the HLF is tightening its belt, the National Trust is struggling to maintain standards—and in all these cases, parks and gardens tend to bear the brunt. At a local level, planning authorities, still hamstrung by the dearth of conse...

An association has been reported between Wiskott-Aldrich syndrome and necrotizing vasculitis and aneurysmal arterial dilatation. We present here the first endovascular repair of descending thoracic aortic aneurysm in a 35-year-old male patient with the classical Wiskott-Aldrich syndrome phenotype. He had a successful endovascular repair with early discharge from hospital with no postoperative complications. His 1-year follow-up computed tomography scan confirmed appropriate stent position, aneurysm sac resolution with no evidence of endoleak, and no further aneurysm formation.

Despite a wide-spread interest in the "testament" genre,1 relatively little attention has been paid to the many last testaments in the Book of Jubilees.2 What treatment does exist tends to emphasize the theological at the expense of the exegetical, assuming that the particular content of the testaments is determined solely by concerns essential to the author of Jubilees rather than by interpretation of Scripture.3 The following is a representative view: "The author places in the mouth of the patriarchs the commands and admonitions that he himself wishes to make to his readers. The most striking example of this occurs in Abraham's three testaments... ."4 Scholars have thus conceived of the last testament in Jubilees as "summation speeches"5 that the author "freely

In this paper we outline how the Institute of Education's new Master of Teaching degree for teachers in their early professional development applies the concept of scholarship of teaching, developed originally in the context of higher education teaching, to the education and development of teachers at primary, secondary and post‐compulsory level in order to foster intellectual dimensions of teaching. We delineate how we are working towards new approaches to pedagogy around computer‐mediated communication drawing on social interactionist perspectives on learning and the notion of knowledge construction. We argue that unless such novel ways to teacher development are conceived and unless higher education teacher education is prepared to re‐conceptualize its role, purpose and nature, lifelong teacher learning is in danger of remaining mere rhetoric.

As of 2000, 21 states had implemented Medicaid managed behavioral health (MMBH) programs for a significant portion of their rural population. It is not clear how MMBH programs may work in rural areas since they are primarily designed to control mental health utilization. In rural areas the challenge is often to enhance service delivery, not to reduce it. MMBH programs may also affect important features of rural delivery systems, including access to care and coordination of primary care and specialty mental health providers. This article describes the implementation of MMBH programs in rural areas based on an inventory of states implementing MMBH programs in rural counties conducted between June 1999 and June 2000. The experience of MMBH programs in rural areas is also described based on case studies conducted in six states. All 21 states included the general Medicaid population (Temporary Assistance for Needy Families); 17 states included special Medicaid populations (adults with serious and persistent mental illness and children with serious emotional disturbances). Slightly less than half the states integrated (carved-in) behavioral health with physical health services in serving the general Medicaid population; only one state integrated these services for the special Medicaid population. Access to mental health care in rural areas had generally not been restricted. MMBH had little impact on the linkage between primary care and mental health. Local Managed Behavioral Health Organizations, formed by public sector entities and providers, played an increasingly important role in the evolution of MMBH.

This paper presents the innovative plans and novel erection sequences developed to build an economical and durable replacement bridge for the 75 year old Ocean City-Longport steel bridge. The proposed designs that met the owners' need for minimal maintenance was a 26-span precast/prestressed concrete bridge that used continuous spliced girders, cylinder piles, pile caps, and half-deck panels.

Introduction: the diagnosis of thoracic outlet syndrome (TOS) relies heavily on subjective rather than objective assessment criteria. Subsequently, published results after surgical decompression vary considerably. This study aimed to use a symptom-based patient-directed questionnaire to assess the outcome after decompression for TOS. Methods: sixty patients who underwent decompression procedures were identified from a prospectively maintained vascular database. Patient records were analysed for details regarding initial presentation, investigation, type of procedure used for decompression and management. Outcome questionnaires were sent to all identified patients to give a patient-based outcome measure. Results: eighty-four per cent of patients responded. In 90% of these patients there was an improvement in symptoms post-surgery with a median follow up of 43 months. The results were not influenced by the procedure or approach used. Conclusion: surgery remains an effective tool in the management of TOS. A simple patient-directed questionnaire as used in this study could assist in the standardisation of outcome assessment. Eur J Vasc Endovasc Surg 26 , 170-175 (2003)

A naturalistic, prospective study of the influence of genetic variation on dose prescribed, clinical response, and side effects related to stimulant medication in 77 children with attention-deficit/hyperactivity disorder (ADHD) was undertaken. The influence of genetic variation of the CES1 gene coding for carboxylesterase 1A1 (CES1A1), the major enzyme responsible for the first-pass, stereoselective metabolism of methylphenidate, was investigated.Parent- and teacher-rated behavioral questionnaires were collected at baseline when the children were medication naïve, and again at 6 weeks while they were on medication. Medication dose, prescribed at the discretion of the treating clinician, and side effects, were recorded at week 6. Blood and saliva samples were collected for genotyping. Single nucleotide polymorphisms (SNPs) were selected in the coding, non-coding and the 3' flanking region of the CES1 gene. Genetic association between CES1 variants and ADHD was investigated in an expanded sample of 265 Irish ADHD families. Analyses were conducted using analysis of covariance (ANCOVA) and logistic regression models.None of the CES1 gene variants were associated with the dose of methylphenidate provided or the clinical response recorded at the 6 week time point. An association between two CES1 SNP markers and the occurrence of sadness as a side effect of short-acting methylphenidate was found. The two associated CES1 markers were in linkage disequilibrium and were significantly associated with ADHD in a larger sample of ADHD trios. The associated CES1 markers were also in linkage disequilibrium with two SNP markers of the noradrenaline transporter gene (SLC6A2).This study found an association between two CES1 SNP markers and the occurrence of sadness as a side effect of short-acting methylphenidate. These markers were in linkage disequilibrium together and with two SNP markers of the noradrenaline transporter gene.

This program was successful in producing a state-of-the art capability, resulting in the development and implementation of the following: A unique horizontal/vertical precision-ballistics gun system, multiple wave mechanics diagnostics, and two experimental configurations were developed and employed in this research. The diagnostics developed and implemented include a redundant induction-coil system, B-dot (rate change of magnetic field) sensor coils and analysis system for dynamic 5DOF state measurement, a network of flush-mounted surface pressure gages (initial size of phi 6.35 mm, final size phi 1.26 mm), fiber optic break wires, colored particulate mechanics layering method, chemical fixing/sectioning of target, and Scanning Electron Microscope (SEM) particle analysis techniques. This document captures details of the last year (of a three year effort) with an Executive Summary covering the early years and tying the efforts together.

Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed care for physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)- and Supplemental Security Income (SSU-beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states.

This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Purpose: An automated TLD facility has been commissioned and calibrated, and techniques have been developed for the measurement of exit doses in external beam radiotherapy, to enable the routine estimation of delivered tumor doses. Methods and Materials: An automated TLD system, originally intended for use in diagnostic radiology and radiation protection, has been evaluated and configured for the measurement of exit doses in radiotherapy. Linearity, optimum heating cycles and calibration procedures have been determined. At the photon energies used, encapsulated lithium fluoride chips provide insufficient buildup to ensure electronic equilibrium, necessitating calibration to allow for oblique exit surfaces. Expressions are derived to allow the calculation of delivered tumor doses. Results: Under the calibration conditions described, the uncertainty in a single TLD measurement is approximately ±2% (±1 standard deviation ). Over the dose range 0.4-1.5 Gy, TL response is linear. The total heating cycle time, including annealing, is 75 s. Measurements of R exit (the ratio of exit dose with and without full backscatter), used in the estimation of tumor doses, decreases with field size for small fields and varies only slightly for field sizes greater than 7 × 7 cm. Lack of electronic equilibrium leads to a decrease in R exit with increasing exit surface obliquity for all energies considered. Application of the technique to a simulated treatment showed good agreement between estimated and applied tumor doses, when surface obliquity was taken into account. Conclusion: This work describes the commissioning and calibration of an automated TLD facility and demonstrates that exit surface measurements using TLD chips used under conditions where electronic equilibrium was not established, have the potential for identifying discrepancies in delivered tumor doses.

Reforms to the structure of the education system of England and Wales in recent years, notably the introduction of a National Curriculum following the Education Reform Act of 1988, have tended to reinforce the subject‐based arrangements of the school curriculum. Moves to establish initial teacher training in a competence‐based model have also emphasised the importance of good ‘subject knowledge’ as a requirement of effective teachers. Increasingly influential research in school improvement and effectiveness has also pointed to the significance of sound academic knowledge and goals as a condition for school, and departmental, effectiveness and improvement. It follows, therefore, that the subject knowledge of beginning teachers is of special interest to those involved in the initial training of teachers. This is particularly the case in a system such as exists in the UK where the current mode of training of secondary teachers is via the Post Graduate Certificate in Education (PGCE), a system which ...

Over a 5-year period a prospective audit was carried out on 1131 patients undergoing surgery for abdominal aortic aneurysm (AAA) in the northern region. A total of 470 operations was performed in teaching hospitals and 661 in district hospitals; emergency operations accounted for 41-5 per cent. The overall mortality rate was 25.8 per cent; for emergency cases this value was 50.0 per cent. Mortality rates for elective surgery were 3.9 per cent in teaching and 12.0 per cent in district hospitals. Patients with ruptured AAA admitted via the accident and emergency department had a higher mortality rate (64.3 per cent) than those admitted by their general practitioner (49.5 per cent) or those referred from the urology department (18.8 per cent). In all, 73 (6.5 per cent) patients were admitted with an alternative diagnosis, ranging from collapse of unknown cause (25) to torsion of the testes (one) and colonic obstruction (one). Age had a profound effect on mortality rates. For emergency cases the mortality rate varied from 47.0 per cent (in teaching plus district hospitals) in those aged less than 80 years to 70.1 per cent in those 80 years or over (χ2 = 7.22; P = 0.007). For elective surgery the mortality rate varied from 7.6 per cent (in teaching plus district hospitals) in those under 80 years to 23.8 per cent in those 80 years or over (P = 0.0006). The overall mortality rate of 25.8 per cent is significantly less than that quoted in the Confidential Enquiry into Perioperative Deaths report of 1987. Furthermore, elective patients over 80 years of age may expect a survival rate of 76 per cent and, in the absence of major medical contraindications, should not automatically be denied surgery. Importantly, it is of note that this prospective audit identified 31 per cent more cases than recognized by regional audit data.

PDV and VISAR have been employed to characterize the detonation products of a high-purity CL-20 based explosive. The explosive was part of an exploding foil initiator (EFI) detonator assembly in which the explosive was contained within a Kovar (Fe-Ni-Co alloy) cup. The back surface of the Kovar serves as the witness plate for interferometry measurements. Detailed reverberations corresponding to shock arrival and release are recorded on the witness plate and the isentropic release path of the explosive is inferred though the velocity history. Two separate window materials are bonded to the Kovar cup in subsequent experiments and are used to further refine the release states.

This paper explores the social construction, or image, of priests and priestesses presented in inscribed decrees of the city of Athens honouring them from the fourth century BC to the Augustan period. Based on an analysis of the 28 surviving decrees of this type, texts and translations of which are presented in an Appendix, the paper seeks to address three questions: (a) What is the image of a good priest or priestess presented in these decrees and what similarities and differences are there as compared with other types of official? (b) To what extent and in what ways is a priestess constructed differently from a priest? (c) What changes are there over time in the way priests and priestesses, their qualities and services, are described, and how should we explain those changes?

Adaptive service selection is acknowledged to provide a certain number of advantages to optimise the service provisioning process or to cater for advanced service brokering. Semantic Web Services, that is services that have been enriched with semantic annotations have often been used for providing adaptive service selection by deferring the binding of services until runtime. Thus far, however, research on Semantic Web Services has mainly been dominated by rich conceptual frameworks such as WSMO and OWL-S which require a significant effort towards the annotation of services and rely on complex reasoning for which there are no efficient solutions that can scale to the Web yet. In this chapter, inline with current trends on the Semantic Web that sacrifice expressivity in favour of performance, we present a novel approach to providing adaptive service selection that relies on simple conceptual models for services and less expressive formalisms for which there currently exist mature and performant implementations. In particular, we present a set of conceptual models defined in RDF(S) that support both Web services and Web APIs and we show how simple templates abstracting user requirements can be automatically transformed into SPARQL to enable service selection in a scalable manner.