Academic literature on the topic 'Common pill bug'

This paper expounds the model pile of various types and different loading measurement method, and introduces the model test of pile foundation; big full scale model test of pile foundation, pile foundation indoor common model test research and its limitations, this paper expounds the advantages and disadvantages of different test methods.

Settlement reducing pile foundation has recently been proposed as an important progress in the design theory of pile foundation, which is one type of deformation-based foundations. Compared with the common design method, settlement reducing pile foundation can greatly reduce the number of required piles. Aimed to the influence of pile cap, cushion, pile spacing, pile length on bearing behavior of settlement reducing pile foundation, the indoor tests on steel pipe settlement reducing pile foundation for immersed tunnel were carried out in sand. Based on uniform design, the six groups of tests with 3×4 pile groups were conducted, furthermore, earth pressure, axial force of pile shaft, and foundation settlement were measured. When the load applied increased, the plastic failure of the soil occurred under the corner of immersed tunnel. The result shows that the earth pressure distribution against immersed tunnel is similar to the normal base reaction in sand which is big in the center and small in the border. The correlation analysis result indicates that apply pile cap, reduce cushion thickness, increase pile spacing and increase pile length can increase the pile load sharing ratio. Compared with the average value of correlation coefficient of each influencing factor, pile length has the most remarkable effect on the pile load sharing ratio, then cushion and pile cap, and pile spacing has the minimal effect among these influencing factors. The research can provide a reference for design of relevant projects.

based on the finite element method of superstructure-the pile raft foundation-the foundation soil action and interaction are studied. Research shows that the common function is considered, fundamental overall settlement and differential settlement with the increase of floor of a nonlinear trend. The influence of superstructure form is bigger for raft stress, the upper structure existing in secondary stress, and the bending moment and axial force than conventional design method slants big; With the increase of the floors, pile load sharing ratio is reduced gradually,but soil load sharing ratio is increased. Along with the increase of the upper structure stiffness, the load focused on corner and side pile; Increasing thickness of raft, can reduce the certain differential settlement and foundation average settlement, thus reducing the upper structure of secondary stress and improving of foundation soil load sharing ratio, at the same time the distribution of counterforce on the pile head is more uneven under raft, thus requiring more uneven from raft stress, considering the piles under raft and the stress of soils to comprehensive determines a reasonable raft thickness, which makes the design safety economy. As the foundation soil modulus of deformation of foundation soil improvement, sharing the upper loads increases, counterforce on the pile head incline to average, raft maximum bending moment decrease gradually.

Abstract This paper argues that the Wukan Incident reflects the common difficulties faced at the state-society level by contemporary China as the country finds itself experiencing both an important strategic chapter in its development, and a period during which social problems are coming to the fore. As such, the task of developing an understanding of the Wukan Incident offers the chance to draw crucial lessons about China’s future political and economic development. Firstly, the modernization development model, according to which economic growth and development take precedence above all else, has already led to a building up of serious social problems. China’s future development efforts must draw on and put into practice the theories of the Scientific Outlook on Development. Secondly, the demands made by the villagers of Wukan could feasibly become political and economic problems common throughout the whole country. This includes issues such as how state-owned assets and land are dealt with; transparency of public finances; and safeguards for the democratic rights and interests of Chinese citizens. The government must face these difficulties and use reforms to tackle each of them. Should it fail to do so, these issues could spark a serious social crisis or even affect the stability of the political order. Thirdly, the current mechanisms by which the Party and the government respond to the public’s interest-related claims require urgent improvement. Finally, there is no magic pill to solve the political and economic problems faced in China today. Elections are certainly not a magic solution.

Tuberculosis, commonly known as TB, is the second most fatal infectious disease after AIDS, caused by bacterium calledMycobacterium tuberculosis. Prolonged treatment, high pill burden, low compliance, and stiff administration schedules are factors that are responsible for emergence of MDR and XDR cases of tuberculosis. Till date, only BCG vaccine is available which is ineffective against adult pulmonary TB, which is the most common form of disease. Various unique antibodies have been developed to overcome drug resistance, reduce the treatment regimen, and elevate the compliance to treatment. Therefore, we need an effective and robust system to subdue technological drawbacks and improve the effectiveness of therapeutic drugs which still remains a major challenge for pharmaceutical technology. Nanoparticle-based ideology has shown convincing treatment and promising outcomes for chronic infectious diseases. Different types of nanocarriers have been evaluated as promising drug delivery systems for various administration routes. Controlled and sustained release of drugs is one of the advantages of nanoparticle-based antituberculosis drugs over free drug. It also reduces the dosage frequency and resolves the difficulty of low poor compliance. This paper reviews various nanotechnology-based therapies which can be used for the treatment of TB.

Abstract Polypharmacy (typically defined as the concomitant use of 5 or more medications) affects 40-50% of older adults in the U.S., and is associated with geriatric syndromes, a higher risk of medication non-adherence, and adverse drug events. Medication non-adherence is a common frustrating clinical issue for clinicians who provide care for older adult patients. Simultaneously, patients often find medication regimens to be complicated and confusing. This may contribute to medication non-adherence, which may further lead to adverse drug events and/or negative health outcomes. The more medications a patient is taking, the higher the risk for non-adherence. Thirty-eight students enrolled in an adult-gerontology primary care nurse practitioner program were given a bag of five mock medications that are commonly prescribed for older adults. Students were instructed to follow the directions on each of the bottles for approximately one month. A private messaging system was available for students if refills were needed or if they had questions about their medications. A debriefing session for this month-long, ungraded simulation was held, at which time students returned medication bottles. Pill counts were not analyzed, but all returned bottles contained mock medications. Approximately 52.6% of students estimated adhering to the medication regimen 0-24% of the time, whereas 26.3% reported an adherence rate of 25-50%. The most commonly cited barrier to adherence (55.3%) was “forgetfulness”. Nearly all students (89.5%) reported that the exercise “very much” increased their awareness of challenges patients face when managing medications, and 97% cited an increased awareness of ways to improve medication adherence.

The article is an attempt to present the fi nal proof of the mythological origin, instead of the historical one, of the image of the Vedic Thunderer Indra as puraṁdará “breaker-down of forts” (Ralph T. H. Griffi th), or “stronghold-splitter” (Stephanie W. Jamison and Joel P. Brereton). The proof can be found in the Baltic (Lithuanian, Latvian and partly Byelorussian) analogues of the image. One Lithuanian example: Pasakojama, kad velnias iš akmenų statęs pilį. Perkūnas pastebėjęs, trenkęs ir sudaužęs pilį “They say that the devil had been bilding a fort (or stronghold, castle) of stones. (The thunder-god) Perkūnas beheld that, smote, and destroyed the fort,” etc. Moreover, Lith. pilis and Lat. pils are exact linguistic equivalents to Vedic pur, pura, puri, etc. It is also probable that there is a connection between the Baltic devil Lith. velnias, Lat. velns and the Vedic stronghold-demon vala. As the Baltic devil is a purely mythological being that usually hides from the Thunderer under big stones, stone piles, and stone constructions, it is unlikely that there is even a slightest hint of any historical event behind the plot. The same applies to his ‘forts' destroyed by the Thunder-god (cf. Lith. griauti “to thunder” and at the same time “to destroy”). Mythology can serve and has often served as an explanation of common life events, hence the quasi-historical legends, as the following Latvian one about the mound near the homestead Sakaiņu: Kādreiz pils īpašnieks apbraukājis savus laгkus. Ceļā uznākusi liela vētra un pērkoņa negaiss. Līdz ar kādu pērkoņa grāvienu pils nogrimusi “Once the landlord of the castle was taking a tour around his fi elds, when a heavy thunderstorm started. One of the thunderbolts made the castle collapse” The origin of the plot (particularly when the owner of the castle or manor is equated to devil) is apparently mythological, not historical. A similar parallel can be drawn with the case of the Vedic “breaker-down of forts” Indra: even if it refl ected a real event of warfare, the image itself sheerly originates in mythology, not in history.

The past three years have seen an overwhelming increase in the number of dysphonic patients in our clinics. This phenomenon goes hand in hand with increased opening of call centers nationwide and increased demand for teachers, singers and performers abroad. This article discusses simple steps for the Otolaryngologist interested in evaluating these patients with different voice demands. It is important to recognize these common voice problems and address them promptly, or to refer them accordingly to Voice Centers if necessary. Chief Complaint The most common chief complaint is change in the quality of the voice or hoarseness. Hoarseness means a change in the perception of one’s voice, described as harsh, raspy, “paos” or “malat.” Other complaints include breathiness, throat pain, neck pain, inability and unrealibility to reach high notes. Inability to reach high notes suggests edema of the vocal folds making them more plump, as can be found in reflux laryngitis, allergies, or smoking. Lesions such as nodules, polyps and cysts cannot be discounted because they prevent vocal fold closure especially during high notes1 Throat and neck pain without an accompanying history of infection may suggest muscle tension dysphonia, especially in a voice professional who later develops maladaptive ways of talking that could strain other throat and neck muscles in an effort to speak.2 Frequent throat clearing, a sensation of phlegm in the throat and cough are also important chief complaints that may lead the otolaryngologist to the cause of the voice problem. In the absence of upper respiratory tract infections and post-nasal discharge, these could be suggestive of laryngopharyngeal reflux.3 History Does the hoarseness occur on and off? Was it sudden? After shouting in a basketball event? Is it becoming worse and permanent? What triggers or relieves it? Intermittent hoarseness could be due to voice abuse and misuse especially in a voice professional. Sudden hoarseness especially after watching a basketball event could be suggestive of vocal fold hemorrhage. A voice problem becoming worse and permanent could be a growing polyp or cyst, vocal fold paralysis in laryngeal cancer or thyroid cancer. A long lecture triggering the hoarseness and rest relieving it may suggest soft nodules, or Reinke’s edema due to vocal fold trauma of voice abuse and misuse. To begin with, it is important to know the occupation of our patient. Is our patient a voice professional- someone who uses his or her voice for a living? Voice demands at work contribute to voice change significantly and voice abuse and misuse is one of the most common causes of hoarseness. What are the other associated symptoms? Medical problems like a recent bout of upper respiratory tract infection and allergies are among the most common causes of hoarseness and should not be discounted immediately. Symptoms of hyperacidity are also significant.4 Is there a history of breathiness and difficulty of breathing? Voice fatigue, tremor, hypo or hypernasal voice? Choking, globus, odynophagia or dysphagia? Neck pain or head and neck trauma? These questions can give clues to the clinician regarding the possible cause of the problem. Past Medical History Asthma, COPD, pulmonary malignancy are associated with voice changes due to decreased airflow. Gastric ulcers and GERD can be suggestive of associated laryngopharyngeal reflux disease changing the vocal fold mucosa leading to voice change.3 Parkinsonism, myasthenia, traumatic brain injury and movement disorders can cause tremors, weakness or strained voice quality. Rheumatoid arthritis, SLE, and other autoimmune disorders can cause voice changes such as paralysis in RA. Endocrine problems such as hypothyroidism can cause edema of the vocal folds leading to decrease in pitch. Thyroid cancer can cause vocal fold paralysis. A history of radiation secondary to malignancies in the head and neck can cause vocal fold scarring leading to voice change.1 Personality and psychiatric disorders also lead to diagnosis. The outgoing, type A personality usually has vocal fold nodules; while inhibited and shy persons have functional dysphonias.5 Traumatic life events are also very important to take note of. History of surgery for neck trauma, thyroid nodules or malignancies, spine, cardiac, pulmonary and brain surgeries or previous endotracheal intubation can cause voice changes, usually related to vocal fold mobility problems. 1 Medications such as inhalational steroids for asthma can cause fungal laryngitis. ARB and ACE inhibitors for hypertension can cause non specific vocal fold masses. Antitussives, decongestants, antihistamines and Vitamin C are known to cause dryness of the vocal folds. Pills with sexual hormones can cause either elevations or decreases in pitch.6 Smoking can cause polypoid conditions in the vocal folds, pre-malignant or malignant changes. Intake of alcohol, diet and lifestyle can contribute to reflux problems and dysphonia. Physical Examination Hearing the patient and forming a subjective impression of the patient’s voice should automatically be part of the interview process. Ranking the voice according to a standard scale is subjective but becomes increasingly reproducible and precise with training and experience. Voice can be evaluated according to pitch, loudness, and vocal quality. Pitch is the highness or lowness of the voice. Is the speaking voice too low for the soprano? This could be the problem why a trained singer would have dysphonia. Does the woman sound like a man over the phone? This could be Reinke’s edema, maybe she is a smoker as well. Does the adult male suddenly speak with elevated pitch? This could be vocal fold paralysis. Loudness is the power of the voice. This is due to the source of power, the lungs. Posture, type of breathing, technique or training can affect this. Systemic problems like generalized weakness and cachexia are contributory. Of course pulmonary problems can contribute to decreased power. Voice quality can be evaluated using the GRBAS system.7 Just hearing the voice and using this system is helpful in making an impression. G- grade R- roughness B- breathiness A- asthenia S- strain GRBAS uses a 0 to 3 scale (0= normal or absence of deviance; 1=slight deviance; 2=moderate deviance; 3= severe deviance). Grade relates to the overall voice quality, integrating all deviant components GRBAS Sounds Probable Conditions Roughness Grainy quality; diplophonic Vocal fold masses such as nodules, polyps, cysts, laryngitis Breathiness Airy Unilateral paralysis, bowing, atrophy, abductor spasmodic dysphonia Asthenia No voice Bilateral paralysis in paramedian position, vocal fold atrophy Strain Tight quality Abductor spasmodic dysphonia, muscle tension dysphonia Head and Neck Examination Palpating the neck, especially the base of the tongue, and neck muscles which are tense and tender can be suggestive of an ongoing muscle tension dysphonia as a cause of the voice change.8 Thyroid masses, neck nodes, etc can be helpful in leading the clinician to a diagnosis. Visualizing the larynx has evolved as advances in technology have improved the understanding of vocal fold anatomy, physiology and voice production. At present, there is no single laryngeal examination tool that is superior to the others. What is important is that it gives a thorough visualization of the anatomy and a good functional evaluation of the larynx. Selecting the appropriate instrumentation will be possible if we recognize the advantages and limitations of the diagnostic tool we are using.9 Sometimes, a combination of these tools is important to make an accurate diagnosis. Advantages and Limitations of the Different Instruments to Visualize the Larynx Instrument Advantages Limitations Indirect Mirror Laryngoscopy Readily available; inexpensive Gives a gross idea of the anatomy; mobility; mucus; and mass (if big enough) Limited in patients who are hypergag; patient is not in a normal physiologic position; hard to detect paresis and small lesions Transnasal Flexible laryngoscopy Helpful for hypergag patients; patients physiology involving the tongue, pharynx and palate are well visualized; can assess paresis from paralysis; can be recorded for review Small lesions are hard to differentiate; color might not be reliable depending on the camera; may be expensive Rigid 70 or 90 degrees laryngoscope Extremely clear and magnified view; less expensive; can be recorded for review Limited in patients who are hypergag; patient is not in a normal physiologic position; hard to detect paresis and muscle tension dysphonia Videostroboscopy10 Provides a slow motion evaluation of vocal fold vibratory pattern, closure, mucosal wave; can differentiate benign vocal fold lesions Expensive; requires additional training Some helpful vocal tasks when using a flexible scope: Task Endoscopic Findings /ii/ Adduction Sniff Abduction Hee-hee-hee Either decreased adduction or abduction Sniff then /ii/ Fatigues the vocal folds; detects paresis/ weakness /ii/ glide form low to high pitch ability to lengthen the vocal folds Despite technological advances in laryngology, a good history and physical examination are still crucial in the diagnosis of voice disorders. Certain clues can be provided by a good history that especially point to a hoarse patient. Because no single instrument is superior for visualization of the larynx, it is important to recognize the advantages and limitations of each.

Dear Editor, Thyroidectomy is a common surgical procedure performed by us otolaryngologists on our patients. Quite often, we make our post-operative rounds on them, not knowing that the patient may have a lot of concerns regarding his or her operation that we somehow take lightly or worse, do not take seriously. I would like to share with other Ear Nose Throat (ENT) surgeons how it was to be a patient who underwent total thyroidectomy. My journey began in the mid- 1990s with an incidental finding of thyroid nodules when I underwent a Magnetic Resonance Imaging (MRI) of the cervical spine. It was then when I started medical suppression and yearly thyroid ultrasound examinations. However as the years passed, the nodules became more numerous involving both lobes and enlarging. It was last July when ultrasonography revealed that 2 of the nodules were solid and large. I then underwent ultrasound guided Fine Needle Aspiration Biopsy of the thyroid nodules for which the result was Bethesda 1 (the biopsy was non-conclusive). It was unanimously decided by the endocrinologist and my ENT surgeons, Dr. Alfredo Pontejos Jr. and Dr. Arsensio Cabungcal, that I would undergo total thyroidectomy. I had myself admitted at the Manila Doctors Hospital (MDH) on September 18, 2017 and underwent the surgical procedure on September 19, 2017. Pre-operatively, I told the ENT chief resident, Dr. Catherine Oseña my special “bilins”: 1) that I had a cervical spine problem so I could not hyperextend the neck; 2) that I was allergic to Penicillin; 3) that I had ceased antiplatelets (Clopidogrel, Aspirin) and fish oil omega for one week; 4) I had allergies to some non-steroidal anti-inflammatory drugs (NSAIDs); 5) if possible the suturing be subcuticular so that there wouldn’t be any need to remove any stitches post-op; and 6) the superior thyroid artery be ligated 2 times and the end of the stump sealed by harmonic scalpel. I had some anxieties regarding the surgery: losing my voice, undergoing tracheostomy for bilateral abductor paralysis since both thyroid lobes would be removed, having a malignant histopathologic result and hypocalcemia. DAY 0: “This is it”, I said to myself, when the nurse fetched me from my room at 6:00 AM to be brought to the operating room (O.R.) for my 7:00 AM schedule. At the O.R., everybody who saw me greeted me with phrases such as “Ikaw pala ang pasyente, kaya mo yan,” “Good luck” and “God bless.” Here I saw one of my surgeons, Dr. Cabungcal enter the OR suite. It was then when I saw my anesthesiologists, Dr. Ariel La Rosa and Dr. Greg Macasaet. The last memory I had pre-op was that of Dr. La Rosa inserting an intravenous (I.V.) line in my right wrist and that was the last thing I remembered. I woke up, already in the Post-Anesthesia Care Unit (PACU) or Recovery Room (RR) when I felt severe pain in my neck (surgical area). I also wanted to fix the pillow at the back of my head, but I did not want to cause any strain on my anterior neck. It was also here when I was very happy to hear my own voice. It was then I said that the surgeons preserved my voice. “Whataguys!” I said to my self, “Thank God.” It was very painful then, I remember the PACU nurse injecting something thru my I.V. line. I felt the medication run thru the I.V. line towards my arm and throughout my body and this made me sleep again (later I found out that it was nalbuphine). I recognize seeing my wife Lil, my son Vinci and the ENT resident, Dr. Dindo Retreta at the PACU. The medication I was given made me sleep again. I woke up again and heard that I was being wheeled out of the PACU to be brought to my room. I only learned later that I slept about an hour after the nalbuphine was given. In my hospital room, the pain in the neck was really painful (9/10) and I had difficulty expelling the phlegm from my trachea. Each time I swallowed my saliva, I could feel my trachea move up with accompanying pain. When the resident-on-duty (ROD) visited, I was given N-acetylcysteine effervescent tablet BID (Ed: bis in die; twice a day) that was very helpful as it made my expectoration easier. I could feel the pressure dressing over my neck, which was now stiff due to dried blood. I had my first meal at around 4:00 PM. I remember it was a tuna sandwich and cold water which I drank using a straw from the hospital plastic cup. Every bite and swallow was painful in the neck and throat. I could not detect whether the pain was coming from the throat or from the surgical site. My antibiotic was given I.V. and so was the pain reliever parecoxib, paracetamol and tranexamic acid. I still did not resume the blood thinners to prevent any post-op bleeding. I tried to get up after dinner to walk around but warm serosnguinous fluid came out of the drain soaking my hospital gown. I then had the nurse call the ENT ROD to change my thyroid dressing. In a few minutes, a new fluffy gauze pressure dressing was applied by the ROD and my hospital gown was replaced. I had a good sleep with some pain still at the surgical site and throat. DAY 1: The day started with Holy Communion in my room, a good breakfast and my usual morning breakfast pills (thyroxine, nevibolol and folic acid). The residents came and changed the dressing. The resident “milked” the neck trying to see if there was any accumulated blood or serum at the surgical site. This was the most painful of the whole surgical experience (10/10), and it was good news that there was no hematoma in the operative site. They then mobilized the drain by a few centimeters. The dressing was still replaced with less fluffy dressing. I have allergic rhinitis, and the act of sneezing caused recurrent pain in the surgical site, so I asked for an antihistamine tablet. My neck and throat were still painful on Day 1 (8/10) but relieved every time the I.V. analgesic was given. In the afternoon, I had a sponge bath given by the nurse on duty with me lying in bed. I still had throat phlegm but thanks to the acetylcysteine effervescent tablet it was easier to expectorate. Every time the ROD made rounds, he checked for hypocalcemia-- fortunately I did not have it. DAY 2: The day again started with Holy Communion and breakfast in my hospital room. My main attending surgeon, Dr. Pontejos made his rounds late morning and he changed the dressing and removed the drain. I was here that I realized that the superior and inferior flaps including the incision were all numb. There was no pain on drain removal as well as on tying of the standby suture to close the drain site. They were all numb. At this point, I realized that in all our patients, this removal of the drain and the tying the standby suture were painless. After a bath in the mid-afternoon before discharge, I was then feeling better but the pain was still there (7/10). On the way home, I bought some sterile gauze, plaster, mupirocin ointment and hydrogen peroxide (H2O2) for my neck wound dressing at home. DAY 3. The pain was less (5/10), and I did not have to take any analgesic from hereon. Bathing became a problem, but I devised a way to bathe that I adopted for the following days. In the shower, I first shampooed by hair with my head and face facing down with my wife holding the telephone shower and focusing it where it was needed. After this I dried my head and hair with a clean towel then bathed the rest of the body in standing position with the telephone shower targeting the area needing to be rinsed. I did this method of bathing for a week until I decided that I could now bathe without my head looking down. I was at rest at home for 2 weeks. DAY 6: It was one of the best days of my life when the chief resident told me that the histopathologic result was multinodular goiter and no malignancy. Yehey! Thanks to God! God is really good! To summarize some of the things I want to share with other thyroid surgeons: I didn’t realize that the post-op pain was really painful, so I can now understand my patients if they experience pain post-operatively. It was difficult to expel throat phlegm and the N-acetylcysteine effervescent tablet was a big help in liquefying the phlegm. The whole area is numb (superior and inferior flaps), thus the removal of the drain and sutures would not cause any pain on the patient. The “milking” of the site was painful and this procedure should be gently done. If the patient has nasal allergy, cover the patient with an antihistamine to prevent sneezing and unnecessary pain. Teach your patient the way I bathed and order a sponge bath on Day 1 and 2. I hope this sharing of experience will benefit all your patients who will undergo the same procedure- thyroidectomy. I would like to thank my surgeons (Dr. Alfredo Pontejos Jr. and Dr. Arsenio Cabungcal), the anesthesiologists (Dr. Ariel La Rosa and Dr. Greg Macasaet), the surgical assistants (MDH ORL residents – Drs. Catehrine Elise Oseña and Dindo Retreta), my endocrinologist Dr. Robert Mirasol and my Cardiologist Dr. Rogelio Tangco, for the excellent job, well done. I would like to thank my family-- Lil my wife, Vinci, Ericka, Raymond for their love and support and for taking care of me. I would like to thank the MDH ORL Residents for taking care of me and for a job well done as well. I would also like to thank all the nursing staff at the MDH tower 1 and the OR, PACU nurses for taking care of me as well. Sincerely yours, Cesar V. Villafuerte Jr. MD, MHA

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. Cutcliffe JR, Stevenson C, Jackson S, et al. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Studies 2006:43(7):791–802.16. Lakeman, R. What can qualitative research tell us about helping a person who is suicidal? Nurs Times 2010:106(33):23–26.17. Karman P, Kool N, Poslawsky I, et al. Nurses’ attitudes toward self-harm: a literature review. J Psychiatr Ment Health Nurs 2015:22:65–75.18. Carter B. ‘One expertise among many’ – working appreciatively to make miracles instead of finding problems: Using appreciative inquiry as a way of reframing research. J Res Nurs 2006:11(1): 48–63.19. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative research: Reading, analysis, and interpretation. Sage Publications; 1998.20. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006:3(2):77–101.21. Kishi Y, Otsuka K, Akiyama K, et al. Effects of a training workshop on suicide prevention among emergency room nurses. Crisis 2014:35(5):357–61.

Although women have many contraceptive options—gels, foams, pills, patches, rings, injections, subdermal implants, intrauterine devices, most with low failure rates and good reversibility—men have only the condom, withdrawal, and vasectomy, all with high failure rates or no guarantee of reversibility. This leaves men with unequal options for reproductive control, yet they may be held responsible for support of a child whether they wanted to reproduce or not. Five types of modern male contraception are now under development: they all raise issues of effectiveness, acceptability, and risk, but would give males far greater reproductive control. However, the common “one’s enough” assumption—that it is sufficient if either the male or the female contracepts—means that reproductive control could shift from females to males. “One’s enough” must be challenged in favor of “double coverage,” highly effective long-acting reversible contraception as routine for both parties, the nearest guarantee of female–male equality in reproductive control.

Construction of foundations on soft/loose soil deposits causes some big problems in geotechnical engineering. The vertical loads can cause failure and/or extreme settlement in soft/loose soil deposit. Constructing piles under foundations to transfer the loads to stiff soil layer is one of the widely used solutions to prevent these problems. The interaction between the piles in a group of piles is described as “group efficiency” and this interaction causes the reduction in the load-bearing capacity of the piles. For a safe and economical design, optimization must be done to estimate the optimum number of piles in the group. This chapter aims to investigate the robustness of commonly used optimization algorithms and determine the most efficient algorithms for pile group optimization problems. Consequently, the proposed methods are going to help engineers to make fast, safe, and economical designs for pile groups under vertical foundation loads. In this chapter, bearing capacities and optimization of bored pile groups constructed in soft soils are discussed.

This chapter discusses using skis as a brake. For a skier-sportsman, braking with skis is a more suitable solution, but it requires better command over one's equipment than braking with poles. A skier can brake with both skis, or just one (in two distinct styles). When braking with two skis, the tips draw together while the tails tend to split apart. This method works well on hard snow; in soft snow, one must employ it gradually, otherwise a large pile of snow accumulates in front of the skis, movement stops abruptly, and a skier tumbles forward from their momentum. A variation of this is braking with one ski, which offers two possibilities: both of them are twisting motions.

This chapter discusses the principle of party autonomy. The term ‘party autonomy’ as used in this book is a shorthand expression for the notion that parties to a multistate contract should be allowed, within certain parameters and limitations, to agree in advance on which law will govern the contract. This notion is now considered a universal principle of private international law (PIL) or conflicts law. In 2015, the year in which the Hague Conference on Private International Law adopted the Principles on Choice of Law in International Commercial Contracts, only eleven of the 161 countries surveyed did not adhere to this principle. It has been characterized as ‘perhaps the most widely accepted private international rule of our time’, a ‘fundamental right’, and an ‘irresistible’ principle that belongs to ‘the common core’ of nearly all legal systems. Naturally, there are significant variations from one legal system to the next about not only the exact scope, modalities, parameters, and limitations of this principle, but also about its theoretical source and justification. The chapter then traces the historical origins and subsequent evolution of the basic principle.

The term “plant-animal interactions” includes a diverse array of biologically important relationships. Plant-herbivore relationships (in which an animal feeds on whole plants or parts of them) are examples of exploitation, because one species benefits from the interaction while the other suffers. Plant-pollinator and plant-seed disperser relationships (in which animals disperse pollen or seeds, usually in return for a food reward) are examples of mutualisms because they are beneficial to both parties. Another class of plant-animal mutualisms involves plants that provide nesting sites and/or food rewards to ants, which often protect the plant from herbivores or competing plants. Plantpollinator and plant-seed disperser mutualisms probably originated as cases of exploitation of plants by animals (Thompson 1982, Crepet 1983, Tiffney 1986). Many of the distinctive plant structures associated with animal-mediated pollen and seed dispersal (e.g., flowers, nectaries, attractive odors, fleshy fruit pulp, and thickened seed coats) presumably evolved to attract consumers of floral or seed resources while preventing them from digesting the pollen or seeds. mutualisms in structuring ecological communities. Competition and predator-prey interactions were more common subjects. Botanists had described the characteristics of the plant and animal players in pollination and seed dispersal mutualisms (Knuth 1906, 1908, 1909, Ridley 1930, van der Pijl 1969, Faegri and van der Pijl 1979), but these descriptive works did not fully examine plant-animal mutualisms in the context of communities. The opportunity to work in the neotropics, facilitated by the Organization for Tropical Studies (OTS), the Smithsonian Tropical Research Institute (STRI), and other institutions, attracted the attention of temperate-zone ecologists to the mutualisms that are much more conspicuous components of tropical systems than of temperate ones (Wheelwright 1988b). Plant-pollinator interactions have attracted more attention in Monteverde than plant-frugivore interactions, and plant-herbivore interactions remain conspicuously understudied. This imbalance probably reflects the interests of those who first worked at Monteverde and later returned with their own students, rather than differences in the significance of the interactions at Monteverde or elsewhere. Aside from a few studies of herbivory in particular species (e.g., Peck, “Agroecology of Prosapia,”), even basic surveys remain to be done.

Just as a house consists of a harmonious arrangement of some common elements (door, hall, kitchen, lounge, bedroom, bathroom, garage), so a presentation consists of a set of standard components (title, outline, introduction, message, conclusion) arranged in such a way that the audience can be informed, educated and entertained. The structure of the talk is important in keeping the audience engaged—a poorly structured talk leaves the audience confused and disorientated. And just as with architecture, there are some conventions. In a house, the main door is usually near the front of the house, the bathrooms tucked away at the side, the kitchen somewhere near the dining room, the lounge leading to a pleasant garden, the bedrooms upstairs and so on. Similarly, a talk usually starts with a title slide, follows with an outline, continues with the introduction, delivers the main message and reaches some conclusions. But sometimes, as with architecture, you may wish to depart, perhaps radically, from this conventional structure—for example, starting with the conclusions because you want the audience to know where you are taking them. However, as with architecture, you need to be sure that this departure from convention serves a purpose—to help the audience understand your message. Failure to structure the talk properly risks reducing your message to a pile of rubble—unattractive, unappreciated and soon forgotten. If the structure of the talk as a whole is like the architecture of a building, the structure of the slides is like the interior decoration of the rooms. Each room, and each slide, is different, but all usually share some common features. In general, slides should have a title which tells the audience what the slide is about, just as, for example, it is often useful to label the bathroom as the bathroom—obvious but, if you are new to it, helpful. The body of the slide contains your message; a figure or figures, lists, tables, pictures, etc. We will discuss the design of the slides in Chapter 5. We note here that the structure of the slides and the structure of the talk must be harmonious.

As with all neurological patients, you will be more likely to pick up the diagnosis if you take a step back and look at the whole patient. Take some time to assess their facial expressions, speech, tremor, and posture. A common instruction at this station, with the patient seated on a chair is ‘Look at this patient, and examine as appropriate’. Candidates are often baffled, when given this instruction. Often the patients with Parkinson’s disease are given specific instructions to interlock the fingers of both hands, or place hands flat on their lap to mask the tremor. Picking up an expressionless face and low volume monotonous speech from the outset will provide useful clues to the diagnosis. If you are not sure at this stage, proceed to examining the gait. Once you are certain, that this is Parkinson’s disease, you may proceed to demonstrate the other features. 1. Patients with Parkinson’s disease have characteristic expressionless facies (hypomimia), often described as ‘mask-like’. This is a manifestation of bradykinesia. There is a reduced blink rate. The glabellar tap (Myerson’s sign) is an unreliable sign and is not recommended in the examination. This involves tapping the patient’s forehead repeatedly. Normal subjects will stop blinking, but in Parkinson’s disease, the patient will continue to blink. The patient may be drooling saliva (resulting from dysphagia and sialorrhoea-due to autonomic dysfunction) 2. Patients may have soft speech (hypophonia). This is also a manifestation of bradykinesia, and characteristically, the speech is low-volume, monotonous and tremulous (appears slurred). 3. Blepharoclonus is tremor of the eyelids. This will only be demonstrated if the eyes are gently closed, as opposed to tightly closing the eyes. 4. The classic tremor is present at rest and asymmetrical (more marked on one side). It is classically described as being 4–6Hz and is the initial symptom in 60% of cases, although 20% of patients never have a tremor. The tremor may appear as a ‘pill-rolling’ motion of the hand or a simple oscillation of the hand or arm. It is easier to spot a tremor if you ask the patient to rest their arms in their lap in the semi-prone position.

Although this book focuses on societal response to earthquake disasters, many common threads can be found in societal response to other types of disasters. Some regions seem especially prone to disasters of all shapes and sizes, perhaps none more so than southern California, which can be star-studded and star-crossed in equal measure. This chapter steps away from the specific responses of societies to one type of disaster to instead consider the response of one society to myriad disasters. In southern California, disasters sometimes seem to pile up like, well, cars on a southern California freeway. During one memorably miserable week in October 2003, for example, firestorms laid waste to almost 700,000 acres in the region—2,000 homes, 24 lives, and a staggering $2 billion in property damage. It was a little like an earthquake in slow motion. The 1989 Loma Prieta earthquake had claimed about three times more lives (63) and total property damage ($6 billion), but the number of homes rendered uninhabitable by that powerful temblor was lower (1,450) than the number destroyed by the firestorms of 2003. That the disaster played out slowly, over the span of several days rather than several tens of seconds, was a curse as well as a blessing. Advance warning kept the death toll from climbing higher; it also generated high anxiety among tens of thousands who would not lose their homes as well as the few thousand who would. Fires are less kind than earthquakes in another critical respect as well: they can reduce an entire house and its contents to ash, whereas much can often be salvaged from even a severely earthquake-ravaged home. Fires can even have their own aftershocks, after a fashion: heavy Christmas Day rains turned parts of two burn areas into torrents of fast-moving debris that swept through two campgrounds and claimed 16 lives, most of them children. Even heavier rains in early 2005 caused a more massive landslide in the coastal community of La Conchita.

Recently, large scale tidal devices have been deployed with a maximum rotor diameter of 20m. These devices impose significant loading on supporting structures. The supporting structure for tidal current power device is under dynamic loadings caused by environmental loadings. Not only the environmental loadings but also the rotating turbine creates dynamic loading as well. The rotating turbine is obviously and continuously deformed for various incoming flow velocities. In many cases, a pile fixed foundation is used to secure the structure. In this study, the commonly used pile fixed type is applied with three blade turbine. A numerical analysis of the hydro-forces from a rotating tidal current turbine to a tower was conducted to determine the deformation distribution along the pile tower. The FSI analysis technique is used in the study.

Gravel, salt, sand, cobbles, and scrap metal – dry bulk materials fundamental to making and maintaining the built environment – are piled in or around coastal cities. The pile is the architecture of the holding stage between a material’s arrival and accumulation from one mode (such as ship or rail) and its distribution into the city through another (most commonly, the truck). Although these piles often approach the scale of large buildings and natural landforms, and their presence is a fixture in the built environment, they are overlooked as a matter of design. In recent decades, some artists and architects have explored piles and pile-making as an abstract formal condition or alternative to conventional modes of formal organization, but engaging the pile as an active form-making structure in the city has been confined to designating territories for piles through use based zoning protocols (“industrial”), or through the construction of containers to enclose them (sheds). Both of these standard practices fail to negotiate the distinctive qualities of piles as a temporary, kinetic, and authentic architecture in the city, and inhibit the collective engagement between the city and an expression of its global material footprint. This paper will explore the morphology of piles and present tactics for engaging them in pursuit of new notions of authenticity, monumentality, and temporality as a byproduct of global flow through three realized projects by our firm, Landing Studio, that choreograph the architecture of industrial road-salt piles in Boston and New York City.

In order to improve the performance of compact heat exchangers engineers and researchers explore different passive techniques of flow manipulation. Among them one can find the delta wing shaped longitudinal vortex generator. In order to assess the optimal shape of finned tube heat exchangers, the engineer has at disposal many coefficients, such as the Colburn factor j and friction factor f. In the present paper the second law of thermodynamics is introduced to explore the flow and thermal field generated by punched longitudinal vortex generators shaped as winglets around an oval tube. The winglets are in common flow up configuration near the leading edge of the fin. Not only the heat transfer and fluid flow characteristics are studied, but also the local irreversibility methodology is applied to predict the two components of entropy generation rate: the one caused by direct dissipation and the other due to heat transfer. The flow velocity and temperature are numerically determined by solving the Navier-Stokes and energy equations with a finite volume method. The local entropy production is then calculated with the use of available information from the solved flow and thermal fields. This paper is based on Chen works. He has studied the flow characteristics for such a geometrical configuration. But here the fin efficiency is supposed to be equal to the unity. The influence of the angle of attack of winglets on the entropy production is studied. Three elemental configurations are displayed. Each one corresponds respectively to an angle of attack β equal to 20°, 30° and 45°. The minimal entropy principle is adopted to evaluate a global heat exchanger build up as a pile up of elemental component.

When in shallow waters, not only the risers, but also the structures and equipment are submitted to different conditions from the ones related to deepwater applications. OGX has developed offshore applications in shallow waters in Campos Basin, Brazil, using a FPSO with Lazy S riser configuration, based on the Midwater Arch systems (MWA). MWA systems are feasible due to OGX application scenario, but they present some disadvantages, such as: high compliance of the buoyant section to the FPSO, large static offset (common issue in shallow waters applications), which makes the MWA carry the risers that are clamped at the top; high manufacturing and installation costs, associated to the high weight of the structure, which includes large and heavy buoys; limitation regarding transportation, sometimes requiring heavy duty trucks, and consequently, more expensive ones. These disadvantages could be avoided by using another type of support structure, but it depends on the application conditions. Aiming to optimize the Lazy S configuration for new applications in shallow waters, a viability study of a most simplified concept of support, fixed and less compliant, was carried out considering as a standard scenario the Waimea field (under development), located in Campos Basin, Brazil. As a result of this study, OGX and Wood Group Kenny developed the conceptual project of an innovative design of Riser Support Structure (RSS). Therefore, this paper addresses the technical challenges that were faced during the design of this new concept of Riser Support Structure for shallow waters in offshore applications, including issues regarding the required structural safe response and aspects comprising installation and some decommissioning considerations. Regarding the design, this paper discusses the structural analyses performed to validate the RSS, which include VIV and Finite Element Analyses, presenting its main results, and the critical issues encountered during these analyses. They include issues such as: Overstress due to combined loads; stress concentration in important structural components; and stress concentration due to impact load (issue recognized during dynamic analysis to simulate the pile driving operation).

Resumen: La construcción del espacio mediante la superposición de planos verticales paralelos y franjas espaciales fue empleada por Le Corbusier tanto en sus obras pictóricas como arquitectónicas, tal y como manifestaron Colin Rowe y Robert Slutzky, en 1955-1956, al descomponer y analizar la “transparencia fenoménica” de la Villa Stein en Garches, 1926, y del cuadro Nature morte à la pile d’assiettes, 1920, de Le Corbusier. Un sistema de estratificación espacial vertical mediante superficies opacas, derivado del cubismo, que genera una profundidad bidimensional donde la plástica expresa la plenitud de un volumen sin recurrir a la perspectiva. Una investigación sobre como Le Corbusier emplea la superposición de estratos verticales o de elementos autónomos y espaciados, es decir, de fragmentos de experiencias discontinuas en posiciones relativas, pero fuertemente vinculados entre sí para asegurar la coherencia estable de los resultados prefigurados, pre-determinados, pre-estabilizados. Un recurso donde el uso de relaciones formales directas, y el posicionamiento del objeto, es más importante que la representación del propio objeto. En base a lo cual, la presente comunicación pretende indagar sobre como ocasionar múltiples lecturas de esa nueva espacialidad plana –ampliando los puntos de vista multifocales y las partes independientes, pero manteniendo la unidad compositiva–; y sobre el paso de procesos de transmisión directa de relaciones formales a transformaciones ilegibles que provoquen nuevas emociones. Abstract: The construction of space by overlapping parallel vertical planes and space bands was used by Le Corbusier both in his paintings and architectural projects, just as stated Colin Rowe and Robert Slutzky, in 1955-1956, to break down and analyze the “transparency phenomenal” to the Villa Stein in Garches, 1926, and the painting Nature morte à la pile d'assiettes, 1920, by Le Corbusier. A vertical spatial layering system by opaque surfaces, derivative of cubism, which generates a two-dimensional depth, where the composition expresses the fullness of a volume without resorting to perspective. An investigation about how Le Corbusier employs overlapping vertical layers or autonomous and spaced elements, that is to say, fragments of discontinuous experiences in relative positions, but strongly linked together to ensure stable consistency of the results pre-figured, pre-certain, pre-stabilized. A resource where the use of direct formal relations, and the positioning of the object, is more important than the representation of the object itself. Based on which, the present communication aims to investigate about how to cause multiple readings from this new flat spatiality –increasing multifocal viewpoints and independent parts, while maintaining the compositional unit–; and about the passage from direct transmission processes of formal relations to illegible transformations that cause new emotions. Palabras clave: Espacio; Estratificación; Transparencia fenoménica; Profundidad bidimensional; Le Corbusier. Keywords: Space; Stratification; Transparency phenomenal; Two-dimensional depth; Le Corbusier. DOI: http://dx.doi.org/10.4995/LC2015.2015.690

Many pile mounted jacket type fixed platforms in shallow water have been installed during the last fifty years for producing oil. However, a production platform in 165 feet of water that produces 414,000 barrels of oil and 436 million standard cubit foot of gas per day (mmscfd) is not so common. In November 2003, such a platform has been installed by PEMEX (Petroleos Mexicanos) in the AKAL-L complex of Cantarell field located in the bay of Campeche. The Cantarell field development is a very high-profile development undertaken by PEMEX at a cost of more than US $10 billion. Although it is a shallow water platform, many design considerations are quite challenging because of the methods of construction, loadout, transportation, installation, etc. For example, the production deck of this installation weighs approximately 11,500 tonnes, including rigging. In the early stage of design, it required consideration of one-piece construction vs. multi-piece construction for cost effectiveness. The decision process included considerations of not only the capabilities of fabrication facilities, but also the availability and capacity of an installation/crane barge, such as the Saipem S-7000. The deck was finally constructed in five modules, one large 7000 tonnes module, and four smaller modules for generator and compressors each weighing approximately 900 tonnes. Proper planning of loadout, lifting operations and related engineering issues proved crucial to the successful installation of the platform. The deck of the platform was built in Dragados Offshore yard in Ca´diz, Spain, and was then dry towed on a large deck cargo barge, S-44, owned by Saipem. The water level at the loadout dock site and range of tides in the area made it necessary to ground the S-44 during deck loadout. Grounding of the barge raised several engineering issues, such as, the adequacy of the barge structure during the loadout operation, preparation of the mudline at the dock, developing of a detailed ballasting sequence, inspection of barge structure before sail-away, etc. The transportation of the deck not only required proper design of seafastening structures, but also required verifying the structural integrity of the deck and other structures of the module. This paper presents an overview of the design features of the platform as well as the methods of loadout, transportation and installation.