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Correspondence to Prof Sanjay Agrawal, Department of Respiratory Medicine, Glenfield Hospital, Institute for Lung Health, Leicester, UK; sanjay.agrawal@uhl-tr.nhs.uk Summary of key clinical practice points Building block 1: screen for tobacco dependence Ask every patient if they smoke Record ‘tobacco dependency’ as an active disease in the medical history Ensure any electronic systems for recording smoking status and supporting referral to the specialist tobacco dependency team are completed Building block 2: advise on the role of nicotine Nicotine drives the dependency to tobacco but is NOT the cause of the harms of smoking The harms of smoking come from thousands of toxic chemicals produced when tobacco is burnt to create smoke Keeping these toxic chemicals out of the body during the hospital admission will help acutely unwell patients recover more quickly Nicotine withdrawal can be very unpleasant, and it is important to provide nicotine in safe, alternative ways to help alleviate this Being smoke-free does not have to mean being nicotine-free during a hospital admission or after discharge from hospital Building block 3: initiate combination nicotine replacement therapy (NRT) as soon as possible Use a Rapid Inpatient NRT Prescribing Protocol and prescribe a 25 mg/16hour nicotine patch plus a fast-acting nicotine product (inhalator, lozenge, mouth spray) The most serious risk of relapsing back to smoking is prescribing an insufficient dose of NRT and not adequately addressing the patient’s withdrawal symptoms and urges to smoke Building block 4: complete a referral to an on-site tobacco dependency advisor (TDA) Refer all patients with tobacco dependence to the TDA team unless they opt-out or ensure automated referral processes to the TDA team when the patient is recorded as tobacco dependent, allowing them to opt-out at first approach by the TDA Advise on the benefits of working with specialist tobacco dependency advisors If no on-site team is available, complete an automated onward referral to local community services to provide ongoing treatment & support after discharge Building block 5: provide accurate and consistent information on Vaping Nicotine vapes deliver high dose fast-acting nicotine which can help to alleviate withdrawal and urges to smoke Vaping is an effective tool in the treatment for tobacco dependency and can be used to support patients during a hospital admission and to help achieve long term abstinence When using nicotine vapes as part of their tobacco dependency treatment plan, inpatients should be advised to switch entirely from smoking to vaping (and NRT) to maximise the harm reduction, both during the admission and after discharge If provided in the inpatient setting, nicotine vapes should be used alongside combination NRT as patients may not be able to use the vape at certain times or in certain environments (eg, the internal hospital building) Vaping is more likely to be effective when provided alongside behaviour change support from a TDA during the hospital admission and after discharge Vaping is not risk free. Additional information on reputable sources can be sought from local government stop smoking services From an environmental perspective, avoid single-use products Vapes should not be used when using home oxygen therapy Building block 6: discuss, offer and prescribe nicotine analogue medications Nicotine analogue medications (varenicline, cytisine) are effective treatments for tobacco dependency and can be discussed and commenced at the point of admission or during the admission Combination therapies (eg, NRT and nicotine analogues) are as effective if not more effective than single therapies and support abstinence in the unique environment of the inpatient setting (NRT provides additional nicotine needed during the escalation phase of varenicline during a smoke-free admission) Scope This Clinical Statement provides evidenced-based, practical advice for hospital clinicians to identify, initiate treatment and ensure specialist care for adult inpatients with a dependency to tobacco. By following the framework set out below, hospital clinicians can ensure optimal patient outcomes by: helping to alleviate withdrawal and urges to smoke for inpatients facilitating smoke-free hospital admissions referring for specialist support to help change deeply engrained smoking behaviours and start many patients on the journey to achieving long term abstinence from tobacco While the interventions and pharmacotherapy used in hospital are similar to those in community settings or other outpatient settings, the focus of this clinical statement is inpatients in the hospital setting. Building Blocks Framework – quick reference version Specialist behaviour change training and motivational interviewing for tobacco dependency advisors was considered outside the scope of this document and outside that of most hospital clinicians’ day to day work.

Purpose - To deliver an \"introduction to life coaching\" workshop to local government lawyers and the benefits they could get from life coaching.Design methodology approach - The nature of the interactive workshop is outlined and the responses of the delegates examined.Findings - The findings of the paper focus on the benefits to the delegates at both personal and professional levels. The holistic approach of life coaching impacting on how difficulties are viewed and the consequent reduction in stress.Originality value - A case study on the experiences of delegates exposed to life coaching. This paper will be of value to HR in local government and high stress business environments.

This thesis seeks to examine how adult family members from the Traveller Communities think and talk about attachment processes to people and place in their childhoods. The research described in this thesis consists of the use of adapted Adult Attachment Interview questions during guided conversation interviews. The transcripts were analysed using interpretative phenomenological analysis (IPA) methodology. The findings indicate that for the participants of this study, interesting variations on the meaning of attachment emerged. It was noticeable, for example, that for most of them, 'movement' created some of the conditions for their stability and 'felt security'. The addition of the word 'felt' is pivotal here: it is their nuanced memories of connection to 'people and place' that forms their lived experience of attachment. As with many Travellers, this is an unconventional, untypical and, from the house-dweller's perspective at any rate, 'unexpected' way of experiencing security, but for many Gypsies and Travellers, 'constant planned movement' was how they were able to feel safe as a child. Therefore, for many other Gypsies and Travellers, 'being settled' is in effect, unsettling, resulting in increased feelings of emotional insecurity and loss of their secure base. The findings also highlighted that the Gypsies' and Travellers' cultures within this study seem to enjoy a shared approach to caring for the children within their family group. This appears to have provided the children and the group with the best chance of survival. Most of the participants reported that they had multiple care providers during childhood, enabling them to develop attachment relationships with their older siblings, grandmothers and aunts. The lack of secure sites, together with constant forced evictions, have fragmented the children's attachment relationships to both people and place and have had a negative effect on the children's feelings of safety and security.

Introduction: The concepts of standardizing work processes and continuous process improvement (CPI) have spread from manufacturing into other disciplines, including healthcare. CPI focuses on analyzing processes, identifying problems, standardizing repeatable elements, and testing results. The Department of Dentistry at Seattle Children’s Hospital (SCH) identified dental inpatient consultations as an area to implement standardization to achieve improvements and introduced a standard dental consultation tool, the DCT, in 2009. An important part of CPI is reanalyzing workflow after change such as the DCT, are introduced. Objectives: This study was designed to assess the use of the DCT at SCH. The primary objectives were: 1) to describe inpatient dental consultations at SCH, 2) to determine the frequency of use of the DCT at SCH, 3) to examine associations between DCT use and types of information documented in the consultation note, and 4) to evaluate the effectiveness of the DCT by comparing dental outcomes in consultations that utilized the DCT to consultations that did not utilize the DCT. Methods: This study is a retrospective chart review of all inpatient dental consultations at SCH between May 1, 2009 and May 31, 2013. Descriptive statistics were calculated for all variables. Associations with types of data documented in the consultation and whether the DCT was utilized was tested using a Chi-square Test or a Fisher’s Exact Test. Results: A total of 632 consultations were included in the study, with 354 using the DCT (61.2%). The most frequent requesting service for the consultations was Hematology-Oncology (50.6%) and the most frequent reason for a dental consultation request was baseline consultation (47.3%). Caries (23.6%) was the most frequent dental pathology identified. Data related to caries risk assessment were frequently omitted from consultation notes when the DCT was not used. It was not possible to analyze patient outcomes following dental consultation due to data limitations. Conclusion: The DCT was used during 61.2% of all consultations and for 69.8% of baseline consultations. Use of the DCT most improved documentation of factors key to caries risk assessment. As a result of this study, the SCH Department of Dentistry is modifying the DCT to improve ease of use, creating a second DCT specific to problem-focused dental consultations, and exploring methods to improve tracking of patients with dental needs identified during the consultation. The evolution of the DCT at SCH is an example of using CPI principles to improve patient care.

Presenting an evidence-based model for assessing children with disorganized attachment and their adult carers, this book outlines key indicators of child maltreatment and effective interventions for child protection workers.

The term tablet PC been around for a decade now, but it seems that the launch of Apple's iPad has brought these devices into mainstream awareness. One company that has embraced the iPad for daily use is Clayco, a design -- build and real estate development firm headquartered in St Louis, MO. is known for its sleek product designs and attractive user interfaces, and its iOS devices are recognized for their convenient access to media. For Clayco, these features make the iPad a great marketing tool. Tomislav Zigo, director of virtual design and construction, said the firm has created videos that show off its building information modeling work and formatted them for display on the iPad. In its forward-thinking fashion, Clayco is looking ahead to expanded use of mobile applications -- for example, Autodesk Inventor Publisher Mobile Viewer, which allows users to interactively view animated 3D assembly instructions created with Autodesk Inventor Publisher desktop software.