How is the future of automobility envisioned in US policy discourse? This paper examines the policy documents of the US Energy Department, Transportation Department, and Environmental Protection ...Agency, as well as the writings of the post-carbon movement. Using discourse analysis, the paper investigates how, in narrating the future of the automobile in the US, these texts perform political work: producing forms of subjecthood and legitimating action. It concludes that the dominance of automobility in the American imagination is being unsettled as discourse about the future of the automobile fragments into three distinct narratives of progress, return, and radical change.
Opioid tapering has been identified as an effective strategy to prevent the dangers associated with long-term opioid therapy for patients with chronic pain. However, many patients are resistant to ...tapering, and conversations about tapering can be challenging for health care providers. Pharmacists can play a role in supporting both providers and patients with the process of opioid tapering.
Qualitatively describe patient experiences with a unique phone-based and pharmacy-led opioid tapering program implemented within an integrated health care system.
In-depth telephone interviews with patients who completed the program were recorded, transcribed, and analyzed. Themes were identified through a constant comparative approach.
We completed 25 interviews; 80% of patients were women (20), with a mean age of 58 years, and 72% (18) had been using opioids for pain management for 10 or more years. Most (60%) described a positive and satisfying experience with the tapering program. Strengths of the program reported by patients included a patient-centered and compassionate taper approach, flexible taper pace, easy access to knowledgeable pharmacist advocates, and resultant improvements in quality of life (e.g., increased energy). Challenges reported included: unhelpful or difficult-to-access nonpharmacological pain management options, negative quality of life impacts (e.g., inability to exercise), and lack of choice in the taper process. At the end of tapering, most patients (72%) described their pain as reduced or manageable rather than worse and expressed willingness to use the program in the future if a need should arise.
Patients in a pharmacist-led opioid tapering program appreciated the program's individualized approach to care and access to pharmacist' expertise. Most interviewed patients successfully reduced their opioid use and recommended that the program should continue as an offered service. To improve the program, patients suggested increased personalization of the taper process and additional support for withdrawal symptoms and nonpharmacological pain management.
Opioid tapering is recommended when risks of chronic opioid use outweigh benefits. Little is known about patient characteristics or factors related to tapering success. We sought to identify ...characteristics that predict a 50% reduction in opioid use and qualitatively characterize factors that impact tapering success.
We used multilevel hierarchical modeling to identify predictors of a 50% reduction in opioid use among Kaiser Permanente Northwest patients who underwent pharmacist-led tapering between 2012 and 2017. We conducted qualitative interviews among patients and pharmacists to identify factors influencing tapering success.
We identified 1384 patients who, on average, were dispensed 207 milligram morphine equivalents per day at baseline. After 12 months, 56% of patients reduced their opioid use by 50%. Increased odds of 50% reduction were associated with younger age 21-49 years (Odds ratio OR 1.32, P = 0.004); previous surgery (OR 2.24, P < 0.001); increased number of Addiction Medicine encounters (OR 1.25, P = 0.011); substance use disorder (OR 1.62, P = 0.001); anxiety (OR 1.32, P = 0.003); non-narcotic analgesic (OR 1.22, P = 0.025) or antipsychotic medication use (OR 1.53, P = 0.006); and opioid days supplied in the previous year (OR 1.08, P < 0.001). Patients and pharmacists noted that success was influenced by patients' willingness or resistance to change opioid use, the level of patient engagement achieved through communication with their provider, aspects of the tapering process such as pace, and external factors including health issues or caregiving responsibilities.
Over one-half of patients who underwent tapering reduced their opioid use by 50%. Patient demographic and clinical characteristics were predictive of tapering success; however, patients and pharmacists noted that patient willingness, motivation, and personal circumstances also influence tapering outcome. Opioid tapering requires an individualized approach. Both clinical factors and personal circumstances should be considered when opioid tapering is being discussed as a possible solution for a patient.
Abstract
Objective
To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid ...tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers.
Design
Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program.
Setting
An integrated healthcare system (HCS) in the Northwest United States.
Subjects
Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff.
Methods
Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes.
Results
Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals.
Conclusions
PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.
Primary care practitioners (PCPs) are concerned about adverse effects and poor outcomes of opioid use but may find opioid tapering difficult because of a lack of pain management training or time ...constraints limiting patient counseling. In 2010, Kaiser Permanente Northwest implemented a pharmacist-led opioid tapering program-Support Team Onsite Resource for Management of Pain (STORM)-to address high rates of opioid use, alleviate PCPs' workload demands, and improve patient outcomes.
To describe the rationale, structure, and delivery of this unique pharmacist-led program, which partners with PCPs and provides individualized care to help patients reduce opioid use, and the Facilitating Lower Opioid Amounts through Tapering study, which examines the program's effectiveness, cost-effectiveness, and implementation.
The STORM program includes a pain medicine physician, a social worker or nurse, and pharmacists who have received specialized clinical and communications training. The program has a 2-fold role: 1) to provide PCP education about pain management and opioid use and 2) to offer clinician and patient support with opioid tapering and pain management. After program training, PCPs are equipped to discuss the need for tapering with a patient and to refer to the program. Program pharmacists provide a range of services, including opioid taper plans, nonopioid pain management recommendations, and taper-support outreach to patients.
The STORM program provides individualized care to assist patients with opioid tapering while reducing the burden on PCPs.
The STORM program may be a valuable addition to health care systems and settings seeking options to address their patients' opioid tapering needs.
While Ca2+ influx is essential for activation of the cell cycle machinery, the processes that regulate Ca2+ influx in this context have not been fully elucidated. Electrophysiological and molecular ...studies have identified multiple Ca2+ channel genes expressed in mammalian cells. Ca(v)3.x gene family members, encoding low voltage-activated (LVA) or T-type channels, were first identified in the central nervous system and subsequently in non-neuronal tissue. Reports of a potential role for T-type Ca2+ channels in controlling cell proliferation conflict. The present study tested the hypothesis that T-type Ca2+ channels, encoded by Ca(v)3.x genes, control pulmonary artery smooth muscle cell proliferation and cell cycle progression. Using quantitative RT/PCR, immunocytochemistry, and immunohistochemistry we found that Ca(v)3.1 was the predominant Ca(v)3.x channel expressed in early passage human pulmonary artery smooth muscle cells in vitro and in the media of human pulmonary arteries, in vivo. Selective blockade of Ca(v)3.1 expression with small interfering RNA (siRNA) and pharmacological blockade of T-type channels completely inhibited proliferation in response to 5% serum and prevented cell cycle entry. These studies establish that T-type voltage-operated Ca2+ channels are required for cell cycle progression and proliferation of human PA SMC.
Widespread use of fuel oxygenates, coupled with their high water solubility and slow degradation rate, have led to an increase in the potential for human exposure. We developed an accurate, precise, ...sensitive, and high-throughput analytical method to simultaneously quantify trace levels (low parts-per-trillion) of four fuel oxygenates in human blood: methyl tert-butyl ether (MTBE), ethyl tert-butyl ether (ETBE), di-isopropyl ether (DIPE), and tert-amyl methyl ether (TAME). The analytes were extracted from the head space above human blood samples, using solid-phase microextraction, desorbed into the heated injector, and chromatographically resolved by capillary gas chromatography. Analytes were detected by high-resolution mass spectrometry with multiple ion monitoring, and quantified against known standard levels by use of stable isotope-labeled internal standards for recovery correction. The low limits of detection (0.6 ng/L) allowed for measurement of MTBE, ETBE, DIPE, and TAME in parts-per-trillion levels with excellent precision (coefficient of variation ranging from 1.7 to 5.4%) and accuracy (96–100%). This method provides a means to assess fuel oxygenate exposure and study the potential relationship between exposure and adverse health outcomes.
The Traffic Light Katherine Reese
Making Things International 1,
05/2015
Book Chapter
From the first highways, which extended the reach of emperors and kings to the hinterlands, to contemporary national motorway systems, the road has long acted to order space into particular ...frameworks of authority. However, the twentieth century saw the traffic light subtly help to transform the road into a well-ordered and internationally legible space. In the everyday lives of the world’s city dwellers, the traffic light has come to act as a powerful but sometimes unnoticed technology of control. It regulates automobility—both in the narrow sense of the word, as movement in automobiles, as well as more broadly, in
How does the United States envision the future of automobility – the autonomous mobility made possible by motor vehicles – in the context of global climate change and resource depletion? This ...dissertation examines official representations of America's mobility future as articulated in texts produced by the advanced vehicle research programs of the US Department of Energy (DOE); the smart growth initiatives of the Department of Transportation (DOT) and Environmental Protection Agency (EPA); and the writings of Transition US, a part of the broader transnational grassroots Transition Movement. Using discourse analysis, the dissertation investigates how, in narrating the future of the automobile in America, these texts perform political work: producing distinct forms of subjecthood and legitimating a range of actions in the present. The findings indicate that automobility's dominance of the American imagination is being unsettled as discourse about the future of the automobile fragments into three narratives. One narrative envisions technological acceleration into a future where climate change is manageable and where Americans remain highly mobile, autonomous, driver-consumers. One sees the future as an opportunity to repair the social and environmental damage wrought by 20th-century automobility by transforming the built environment to resemble the pre-automobile landscape, thereby recovering Americans' latent social nature and affinity for neighborhood. The third expects the inevitable end of the automobile age in the face of runaway climate change and peak oil; it sees this radical discontinuity as an opportunity for human adaptability and community resilience. In each narrative, expectations about what can and should happen derive from irreconcilable core assumptions about human nature and how much of the world is in human hands. As long as these core assumptions remain contested, we can expect to see the American imagination remain unsettled.
The goal of this dissertation is to provide evidence suggesting that many of the distinctive features found in certain dialects of non-standard Dominican Spanish (henceforth NSDS) are remnants of an ...earlier possible semi-creole with an African substrate. It is suggested that these creole-like characteristics entered the language via a process of language contact and shift which triggered substratal transfer and universal adult second-language acquisition strategies. The data used to support my argument are all taken from interviews I conducted while I was in the Dominican Republic. Both the morpho-syntactic and phonological features of NSDS will be examined and compared to those of Spanish-based creoles, Atlantic creoles and Caribbean varieties of Spanish. One of the most intriguing features is a previously unrecorded creole-like past tense construction. Two brothers I interviewed used a as a past tense marker before a reduced infinitive (without-r), e.g. "Si a pende un foforo" 'Yes, I took a match.' While this is quite unlike the standard Spanish past ("Si, prendi un fosforo"), it is very similar to constructions in Palenquero Creole Spanish ("Yo a desi-le$\...$ 'I told him$\...$') and Papiamentu Creole Spanish ("Mi a kumpra un kas" 'I bought a house'). To account for these constructions, I suggest that partial restructuring, or what Holm (1988) calls semi-creolization, is largely responsible. Under this model, the learners (Africans) had no one language in common except what they could learn of the superstrate language. In learning Spanish, they initiated a process of partial restructuring which resulted in a variety of Spanish that shows substantial simplification and clear substratal influence. The data are evaluated in light of what is known about the origins of Caribbean vernacular Spanish, with particular reference to the monogenesis theory.
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