An obituary to Yukio Yoneda (1950-2023)

Yukio Yoneda died on 31 December 2023, at 73 years old after a long fight against cancer. He was an eminent neurochemist in academia and industry and also had leadership roles within the International Society for Neurochemistry (ISN) and the Asian Pacific Society for Neurochemistry (APSN) and Japanese Society for Neurochemistry (JSN). Photo credit: Yukio Yoneda provided the APSN with the photo during his service to APSN.

Measuring the digital divide among people with severe mental ill health using the essential digital skills framework

AIMS

Amid the vast digitalisation of health and other services during the pandemic, people with no digital skills are at risk of digital exclusion. This risk might not abate by the end of the pandemic. This article seeks to understand whether people with severe mental ill health (SMI) have the necessary digital skills to adapt to these changes and avoid digital exclusion.

METHODS

Two hundred and forty-nine adults with SMI across England completed a survey online or offline. They provided information on their digital skills based on the Essential Digital Skills (EDS) framework, sociodemographic information, and digital access. This is the first time that the EDS is benchmarked in people with SMI.

RESULTS

42.2% had no Foundation Skills, and 46.2% lacked skills for daily life (lacking Foundation or Life Skills). 23.0% of those working lacked skills for professional life (lacking Foundation or Work Skills). The most commonly missing skills were handling passwords and using the device settings (Foundation Skills) and online problem solving (Skills for Life). People were interested in learning more about approximately half of the skills they did not have. People were more likely to lack Foundation Skills if they were older, not in employment, had a psychosis-spectrum disorder, or had no Internet access at home.

CONCLUSION

A significant portion of people with SMI lacked Foundation Skills in this objective and benchmarked survey. This points to a high risk for digital exclusion and the need for focused policy and tailored health sector support to ensure people retain access to key services and develop digital skills and confidence. To our knowledge, this is the first time this has been described using the EDS framework. Services, including the National Health Service (NHS), need to be aware of and mitigate the risks.

Digital health literacy and digital engagement for people with severe mental ill health across the course of the COVID-19 pandemic in England

BACKGROUND

An unprecedented acceleration in digital mental health services happened during the COVID-19 pandemic. However, people with severe mental ill health (SMI) might be at risk of digital exclusion, partly because of a lack of digital skills, such as digital health literacy. The study seeks to examine how the use of the Internet has changed during the pandemic for people with SMI, and explore digital exclusion, symptomatic/health related barriers to internet engagement, and digital health literacy.

METHODS

Over the period from July 2020 to February 2022, n = 177 people with an SMI diagnosis (psychosis-spectrum disorder or bipolar affective disorder) in England completed three surveys providing sociodemographic information and answering questions regarding their health, use of the Internet, and digital health literacy.

RESULTS

42.5% of participants reported experiences of digital exclusion. Cochrane-Q analysis showed that there was significantly more use of the Internet at the last two assessments (80.8%, and 82.2%) compared to that at the beginning of the pandemic (65.8%; ps < 0.001). Although 34.2% of participants reported that their digital skills had improved during the pandemic, 54.4% still rated their Internet knowledge as being fair or worse than fair. Concentration difficulties (62.6%) and depression (56.1%) were among the most frequently reported symptomatic barriers to use the Internet. The sample was found to have generally moderate levels of digital health literacy (M = 26.0, SD = 9.6). Multiple regression analysis showed that higher literacy was associated with having outstanding/good self-reported knowledge of the Internet (ES = 6.00; 95% CI: 3.18-8.82; p < .001), a diagnosis of bipolar disorder (compared to psychosis spectrum disorder - ES = 5.14; 95% CI: 2.47-7.81; p < .001), and being female (ES = 3.18; 95% CI: 0.59-5.76; p = .016).

CONCLUSIONS

These findings underline the need for training and support among people with SMI to increase digital skills, facilitate digital engagement, and reduce digital engagement, as well as offering non-digital engagement options to service users with SMI.

Trends in the Prevalence of Methylchloroisothiazolinone/Methylisothiazolinone Contact Allergy in North America and Europe

Importance

The common use of isothiazolinones as preservatives is a global cause of allergic contact dermatitis. Differences in allowable concentrations of methylisothiazolinone (MI) exist in Europe, Canada, and the US.

Objective

To compare the prevalence of positive patch test reactions to the methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) combination and MI alone in North America and Europe from 2009 to 2018.

Design, Setting, and Participants

This retrospective analysis of North American Contact Dermatitis Group, European Surveillance System on Contact Allergies (ESSCA), and the Information Network of Departments of Dermatology (IVDK) databases included data from patients presenting for patch testing at referral patch test clinics in North America and Europe.

Exposures

Patch tests to MCI/MI and MI.

Main Outcomes and Measures

Prevalence of allergic contact dermatitis to MCI/MI and MI.

Results

From 2009 to 2018, participating sites in North America and Europe patch tested a total of 226 161 individuals to MCI/MI and 118 779 to MI. In Europe, positivity to MCI/MI peaked during 2013 and 2014 at 7.6% (ESSCA) and 5.4% (IVDK) before decreasing to 4.4% (ESSCA) and 3.2% (IVDK) during 2017 and 2018. Positive reactions to MI were 5.5% (ESSCA) and 3.4% (IVDK) during 2017 and 2018. In North America, the frequency of positivity to MCI/MI increased steadily through the study period, reaching 10.8% for MCI/MI during 2017 and 2018. Positive reactions to MI were 15.0% during 2017 and 2018.

Conclusions and Relevance

The study results suggest that in contrast to the continued increase in North America, isothiazolinone allergy is decreasing in Europe. This trend may coincide with earlier and more stringent government regulation of MI in Europe.

Trophic interactions of fish communities at midwater depths enhance long-term carbon storage and benthic production on continental slopes

Biological transfer of nutrients and materials between linked ecosystems influences global carbon budgets and ecosystem structure and function. Identifying the organisms or functional groups that are responsible for nutrient transfer, and quantifying their influence on ecosystem structure and carbon capture is an essential step for informed management of ecosystems in physically distant, but ecologically linked areas. Here, we combine natural abundance stable isotope tracers and survey data to show that mid-water and bentho-pelagic-feeding demersal fishes play an important role in the ocean carbon cycle, bypassing the detrital particle flux and transferring carbon to deep long-term storage. Global peaks in biomass and diversity of fishes at mid-slope depths are explained by competitive release of the demersal fish predators of mid-water organisms, which in turn support benthic fish production. Over 50% of the biomass of the demersal fish community at depths between 500 and 1800 m is supported by biological rather than detrital nutrient flux processes, and we estimate that bentho-pelagic fishes from the UK-Irish continental slope capture and store a volume of carbon equivalent to over 1 million tonnes of CO2 every year.

Unilateral pupillary dilatation following septoplasty: cause for concern?

We report and explain unilateral pupillary dilatation following routine septoplasty and trimming of inferior turbinates. The unilateral pupillary dilatation was caused by inadvertent instillation of sympathomimetic, (xylometazoline hydrochloride) in the eye during preparation for nasal surgery. The effect was short-lived and the patient made a full recovery. Unilateral pupillary dilatation after sinonasal surgery can be alarming due to the possibility of injury to the globe and intracranial haemorrhage but can also be explained by the mydriatic effect of the sympathomimetic nasal drops and sprays used to decongest the nose. Such possibility should be borne in mind and would help to explain and reduce the anxiety and avoid unnecessary investigations.

Infectious disease. The stability of malaria elimination

Eradication may not be necessary before countries can eliminate, scale back control, and rely on health systems.

Sol-Gel Deposition of Electronic Ceramic Films

We describe a dip-coating method of depositing thin electronic ceramic coatings on various substrates from sol-gel solutions. The solutions we use are alkoxide-based, although the specific formulations depend on the system being deposited. We are working with two electronic ceramic systems: barium titanate on glass, and alumina, and yttrium barium copper oxide on alumina. We discuss methods used to reduce and remove processing defects such as crazing, cracking and pin-holing. We are also studying the effects of varying the processing conditions (dipping, hydrolysis and firing) on the electronic properties of the films. Initial results on BaTiO3 indicate that it is better to deposit thin films (∼0.1 – 0.2μm) and build up the coating thickness by repeated dipping.

The Shikani Optical Stylet: a useful adjunct to airway management in a neonate with popliteal pterygium syndrome

The craniofacial abnormalities of popliteal pterygium syndrome present unique challenges to the pediatric anesthetist. Congenital fibrous bands between the maxilla and mandible limit mouth opening and the tongue may be fused to the palate. We describe the use of the Shikani Optical Stylet, a novel fiberoptic endoscope, in the airway management of a neonate with popliteal pterygium syndrome and syngnathia.

Common rashes in children: 2

This second article covering rashes commonly seen in children looks at three further conditions with very distinctive clinical presentations that are none the less commonly misdiagnosed.

Common rashes in children: 1

While one of the great attractions of dermatology is the wide variety of clinical cases seen, a relatively small number of conditions make up the majority of dermatological cases seen in paediatric clinics. A simple lack of both education and clinical exposure mean that these cases often cause a disproportionate amount of anxiety for the doctor asked to diagnose and treat a child with a rash. Most present with a clear history and distinctive examination findings and respond well to appropriate treatment. This is the first of two articles which will help the physician approach a child with a rash with greater confidence.

Quality indicators for end-of-life breast cancer care: Testing the use of administrative databases

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Background: Defining, measuring and monitoring quality of care is a facet of health services research that is growing in importance. Breast cancer offers a disease model to examine quality end-of-life (EOL) care provided to women. Administrative data have the unique potential to provide population-based measures of quality of care. The objective of this study was to assess the feasibility of using routinely-collected administrative data to measure quality EOL care for breast cancer patients. Methods: A cohort of all women in Nova Scotia who died of breast cancer between 01/01/1998 and 31/12/2002 was assembled from the Cancer Registry and Vital Statistics data. The EOL study period was defined as the last 6 months of life. A total of 864 women met the eligibility criteria. After a literature review, an expert panel identified 19 indicators that were potentially measurable through administrative data. Physician billings, hospital discharge abstracts and seniors pharmacare data, supplemented by clinical datasets, were utilized to calculate the statistics with which to represent the indicators. Results: Benchmark measures of care across the cohort show 63.4% died in a hospital, a mean continuity of care index of 0.786, and the mean number of inpatient days in the last 30 was 9.9. Indicators of aggressive care include 9.3% had chemotherapy in the last 14 days, 5.6% had more than 1 emergency room visit in the last 30 days, and 29.1% had more than 14 inpatient days in the last 30 days. Conclusions: Weaknesses of using these data include: 1) fixed variables with an administrative rather than a clinical objective; 2) lack of comprehensiveness of various datasets; and 3) the use of billings data where increasingly physicians are paid through methods other than fee-for-service. Strengths of this approach are: 1) population-based cohort; 2) comprehensiveness of cohort selection through the provincial Vital Statistics file; and 3) accessibility of data.

No significant financial relationships to disclose.

Comparison of cuffed, uncuffed tracheal tubes and laryngeal mask airways in low flow pressure controlled ventilation in children

BACKGROUND

The use of low flow circle systems necessitates a 'leak free' breathing system which is commonly achieved by using a cuffed tracheal tube (TT). We hypothesized that low flow circle system anesthesia can equally effectively be achieved by using the LMA in pediatric anesthesia.

METHODS

Following local ethics committee approval we randomly recruited 45 patients scheduled for elective surgery and requiring mechanical ventilation into three groups (cuffed TT, uncuffed TT and LMA group, n = 15). The size of the TT was determined by means of the formula (age/4) + 4.5 for uncuffed and (age/4) + 4 for cuffed TT whereas the size of the LMA size was dependent on weight. Following induction of anesthesia and muscle paralysis patients were ventilated with pressure controlled ventilation through a pediatric circle system and the lowest fresh gas flow (FGF) determined.

RESULTS

The FGF achieved were (median and range) 0.20 (0.2-0.25) l.min(-1) for the LMA group, 0.20 (0.2-0.4) l.min(-1) for the cuffed TT group and 1.15 (0.2-4.75) l.min(-1) for the uncuffed group. The differences between the LMA and cuffed TT compared with the uncuffed TT were significant (P < 0.0001 and P = 0.0002, respectively). The difference in FGF between LMA and cuffed TT was not significant.

CONCLUSION

We conclude that pressure controlled ventilation using an LMA is an alternative to a cuffed TT during low flow circle system anesthesia in children. Low FGF is unlikely to be achieved consistently using an uncuffed TT because of a substantial leak.

Identity loss and maintenance: commonality of experience in cancer and dementia

This paper examines parallel thematic findings from two qualitative studies exploring the experience of disease as it relates to cancer and dementia. The original studies examined the experiences of 16 individuals with cancer and 20 with dementia, and the impact of these first hand experiences and those of their principal family carers. The paper presents findings linked to the common or shared concepts of identity loss and maintenance as expressed by both the affected individual and the family carer.

Tramadol for pain relief in children undergoing tonsillectomy: a comparison with morphine

BACKGROUND

Pain control for paediatric patients undergoing tonsillectomy remains problematic. Tramadol is reported to be an effective analgesic and to have a side-effect profile similar to morphine, but is currently not licensed for paediatric use in the UK.

METHODS

We conducted a prospective, double-blind, randomized controlled trial in children who were scheduled for elective tonsillectomy or adenotonsillectomy at the Royal Aberdeen Children Hospital. Following local ethics committee approval and after obtaining a drug exemption certificate from the Medicines Licensing Agency for an unlicensed drug, we recruited 20 patients each into morphine (0.1 mg.kg(-1)), tramadol (1 mg.kg(-1)) and tramadol (2 mg.kg(-1)) groups. These drugs were given as a single injection following induction of anaesthesia. In addition, all patients received diclofenac (1 mg.kg(-1)) rectally. The postoperative pain scores, analgesic requirements, sedation scores, signs of respiratory depression and nausea and vomiting, as well as antiemetic requirements, were noted at 4-h intervals until discharge.

RESULTS

There were no statistically significant differences in age, weight, type of operation or induction of anaesthesia, 4-h sedation and pain scores and further analgesic requirements. There were no episodes of respiratory depression. Morphine was associated with a significantly higher incidence of vomiting following discharge to the wards (75% versus 40%, P=0.03) compared with both tramadol groups.

CONCLUSIONS

Tramadol has similar analgesic properties, when compared with morphine. The various pharmaceutical presentations and the availability as a noncontrolled substance may make it a useful addition to paediatric anaesthesia if it becomes licensed for paediatric anaesthesia in the UK.

Atopic dermatitis management: comparing the treatment patterns of dermatologists in Japan, U.S.A. and U.K

BACKGROUND

The incidence of atopic dermatitis (AD) is increasing worldwide. No large-scale study has previously compared the therapeutic management of this condition in different countries.

OBJECTIVES

The purpose of this study was to determine the treatment preferences of dermatologists in Japan, the U.S.A. and the U.K., and investigate their relationship with certain factors pertaining to the physician and his practice.

METHODS

A questionnaire was sent to all registered members of dermatological societies in Japan, the U.S.A. and the U.K. Responses were collated and statistical analysis performed using chi2, Mantel-Haenszel and Breslow heterogeneity tests.

RESULTS

Three thousand six hundred and eighty-eight completed surveys were returned. U.S.A. and U.K. physicians were significantly more aggressive in prescribing systemic medications, such as steroids, antibiotics and immunosuppressants, compared with those in Japan. Japanese dermatologists also utilized topical steroids significantly less. The use of alternative remedies was highest in Japan. All three countries had a relatively high degree of optimism for topical immunosuppressants, but less so for other emerging therapies.

CONCLUSIONS

Both similarities and differences in the therapy of AD exist in the three countries studied. Factors related to the physician, patient population and culture may influence these observations.

Hospital reconfiguration. Going places

Two major hospital moves in Lanarkshire were completed smoothly by predicting the number of emergency admissions likely over the crucial periods and involving GPs and all the hospitals concerned. An analysis of emergency admissions was one factor in deciding which days the moves should take place on. A workshop after the first move was finished proved important.

Hydrogen peroxide activates NFkappaB and the interleukin-6 promoter through NFkappaB-inducing kinase

Aging is associated not only with oxidant stress, but also with increased interleukin-6 (IL-6) levels. To determine if oxidative stress could contribute to the age-associated increase IL-6 expression, we exposed LNCaP prostate carcinoma cells and HeLa cervical carcinoma cells to H2O2 as an oxidant challenge. We found that H2O2 induced IL-6 expression through activation of the IL-6 promoter. Furthermore, H2O2-induced activation of the promoter was mediated through nuclear factor-kappaB (NFkappaB) secondary to H2O2-induced phosphorylation and degradation of IkappaBalpha. NFkappaB-inducing kinase (NIK) is upstream of the IkappaB kinase complex that induces IkappaBalpha degradation. Accordingly, we explored if H2O2 induces IL-6 expression through NIK. In addition to H2O2 inducing NIK autophosphorylation, transfection of LNCaP cells with a dominant negative NIK diminished H2O2-mediated NFkappaB and IL-6 promoter activity. Taken together, these results demonstrate that H2O2 induces the IL-6 promoter by activating NFkappaB through NIK. These data provide a candidate mechanism through which oxidant challenge induces IL-6 gene expression with age.

Increasingly inequitable distribution of general practitioners in Australia, 1986-96

OBJECTIVE

To document trends in the distribution of general practitioners (GPs) in Australia between 1986 and 1996, adjusted for community need.

METHODS

Data on the location of GPs, population size and crude mortality in statistical divisions (SD) were obtained from the Australian Bureau of Statistics Census of Population and Housing in 1986 and 1996. From these data, we calculated measures of distribution equality (number of people sharing each GP in each SD) and distribution equity (number of people sharing each GP divided by the crude mortality rate; the Robin Hood Index), and analysed temporal changes in the distribution of GPs.

RESULTS

Nationally, the number of people sharing each GP fell 11% from 1,038 in 1986 to 921 in 1996. However, in 41 of 57 SDs (72%, p=0.01) the number of people sharing a GP actually increased over this time, and the average Robin Hood Index across SDs fell from 0.943 to 0.783 (p=0.004), indicating increasingly inequitable distribution. Comparing the Robin Hood Index values of all SDs ranked in pairs, the value fell in 53 of 57 (93%, p<0.001) paired SDs over the decade. These patterns demonstrate increasing inequity over the decade. The number of people sharing each GP was consistently and substantially lower in the capital city SDs and the Robin Hood Index values were consistently and substantially higher (overserved) compared with country SDs.

CONCLUSIONS

Despite there being more GPs per capita in Australia, their distribution became increasingly unequal and inequitable between 1986 and 1996, such that rural and remote areas became increasingly poorly served.

Interprofessional learning modules at Dalhousie University

Interprofessional education has been advocated to improve teamwork in the health sector. This paper reports on the first two years of operational experience by a School of Health Services Administration (SHSA) with three-hour interprofessional learning modules (IPLMs). SHSA students participated along with students from nursing, medicine, social work, physiotherapy, occupational therapy, pharmacy, speech language pathology, audiology, dental hygiene, dentistry, leisure studies, health education and kinesiology. The five IPLMs required for SHSA students were: professional roles and values, integrity in scholarly activity, disability, interpersonal violence and HIV/AIDS. This article describes the development, delivery and evaluation of these modules from an SHSA perspective. The IPLMs' evaluation findings indicated that IPLMs are worthwhile, but have taken years and ongoing senior management support to operationalize; inclusion of health services administration is worthwhile but challenging; vigilance is needed to retain an IP rather than module content focus; and faculty and facilitator development, along with student preparation and debriefing, is required. Student feedback was favourable; faculty members have gained by their involvement; and field practitioner support has been sustained. Evaluation and reflection are critical to IPLM evolution. The norms, strengths and constraints of the university must be taken into account, and thus IPLMs must be adapted for each educational setting. Schools of health services administration must decide whether they wish to be involved in interprofessional learning.

Aspiration and regurgitation prophylaxis in paediatric anaesthesia

BACKGROUND

Surveys of aspiration prophylaxis in paediatric anaesthesia do not exist.

METHODS

A postal survey was sent out to all UK members of the Association of Paediatric Anaesthetists (APA) to assess current practice. We asked about minimum fasting times for liquids and solids/milk, their routine acid aspiration prophylaxis and perceived risk factors for emergency and elective surgery in children those less than 1 year old and those aged 1-14 years. We also asked if the APA member had more than 10 years experience in paediatric anaesthesia.

RESULTS

One hundred and two (55.1%) APA members replied out of a total of 185 questionnaires sent. Eighty-eight (88/102) were considered valid. Fasting in emergencies is approximately 4 h for solids/milk and 2 h for clear liquids. Fasting for elective surgery is between 5 and 6 h for solids/milk and 2 h for clear liquids. Pharmacological methods to reduce the risk of aspiration are not used. Mechanical methods vary from 40-50% for cricoid pressure and 20-30% for nasogastric aspiration if a tube is present. The presence of a hiatus hernia is perceived by over 80% as a risk factor, previous aspiration by over 60%, difficult intubation, cerebral palsy and sepsis by 20-30%.

CONCLUSION

Perceived risk factors vary with "experience": hiatus hernia, difficult intubation and cerebral palsy are less important whereas previous aspiration and renal failure appear to be more important for paediatric anaesthetists with less than 10 years in paediatric anaesthetic practice.

Where do patients with cancer die in Belfast?

BACKGROUND

Most patients with cancer prefer to die at home but the majority die in institutions.

AIM

To determine place of death for patients with cancer in Belfast, to examine changes over time and identify factors associated with place of death.

METHODS

A survey of deaths registered in Belfast over a six-month period for 1977, 1987 and 1997 identified patients dying from cancer. Epidemiological data included age, gender, malignancy, social class, marital status, area of residence and place of death.

RESULTS

Home deaths fell from 35% in 1977 to 28% in 1997. Hospital deaths fell from 50% in 1977 to 40% in 1987 rising to 42% in 1997. Hospice deaths rose from 13% in 1977 to 25% in 1987 falling to 23% in 1997. There was an association between place of death and age, marital status, type of cancer and area of residence, but not with social class or gender.

CONCLUSION

The majority of people fail to achieve a home death. Resources need to be targeted to those most at risk of an institutional death; females, the elderly, the unmarried, those with haematological malignancies and residents of South Belfast.

Managing awareness: negotiating and coping with a terminal prognosis

This study examined the way in which a terminal cancer prognosis was negotiated by patients and their lay carers, and the complexities involved in managing a context of awareness. Individual semi-structured interviews were undertaken with 16 patients and 14 lay carers. These were transcribed verbatim and analysed using a grounded theory approach. The process started with being given bad news, when the concept of life was no longer open-ended. The need to maintain hope influenced the amount of information sought by patients and their families and was an important strategy in helping patients cope with the knowledge of their disease. Levels of awareness appeared to be influenced less by setting, than by the way the prognosis was managed within individual families. Difficulties facing patients and carers in knowing how to communicate with each other within a context of open awareness suggest that they need help in learning how to do this. Achieving an environment to enable this requires private space and staff skilled in enabling and facilitating the complexities of communication between patients and their carers.

Anaesthetic management of a 6-week-old child with unilateral pulmonary interstitial emphysema

We report the case of a 6-week-old female infant suffering from respiratory distress related to cystic changes affecting the entire left lung. Anaesthesia was induced with sevoflurane in oxygen and spontaneous ventilation was maintained until intubation of the right main bronchus was secured. A left pneumonectomy was performed and the postoperative course was uneventful. The pathological diagnosis was pulmonary interstitial emphysema. This has not been previously reported in an otherwise normal child delivered uneventfully at term. The anaesthetic management of a child with a cystic lung lesion is discussed.

Improving care or professional advantage? What makes clinicians do audit and how well do they fare?

OBJECTIVE

To find out why clinicians undertake audit, the extent to which they complete the process of audit and their perception of the benefits of taking part.

DESIGN

Semi-structured interviews.

SETTING

Twelve trusts in three Scottish Health Boards.

SUBJECTS

One hundred and forty five respondents of different status from a wide range of clinical specialities.

RESULTS

Sixty six per cent of respondents defined clinical audit as a means of making changes with a view to improving care, but 62% reported the purpose of audit as the examination of the usefulness of treatment or the observation of practice. Personal reasons for taking part included justifying practice (32%) and as a means of professional development (15%). Twenty one percent held formal minuted meetings, the majority were informal. Sixty six percent of clinicians completed a project plan but pilot studies (49%) and re-audits (26%) were less common. Twenty four percent changed practice as a result of the audit. The extent to which the audit process had been completed predicted clinicians' ability to make changes.

CONCLUSION

Clinicians' understanding of the concept of audit was not translated into practical projects. The main reasons for this are the organisational difficulties clinicians are faced with when carrying out audit and a lack of attention to all parts of the audit process. Despite this failure to achieve change, many clinicians felt they had benefited from their experience of audit. Management should appeal to these motivations of employees and provide a culture which enforces their importance over and above changing practice.