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In medieval England, a defendant who refused to plead to a criminal indictment was sentenced to pressing with weights as a coercive measure. Using peine forte et dure ('strong and hard punishment') as a lens through which to analyse the law and its relationship with Christianity, Butler asks: where do we draw the line between punishment and penance? And, how can pain function as a vehicle for redemption within the common law? Adopting a multidisciplinary approach, this book embraces both law and literature. When Christ is on trial before Herod, he refused to plead, his silence signalling denial of the court's authority. England's discontented subjects, from hungry peasant to even King Charles I himself, stood mute before the courts in protest. Bringing together penance, pain and protest, Butler breaks down the mythology surrounding peine forte et dure and examines how it functioned within the medieval criminal justice system.
Geography is not only the study of the surface of the planet and the exploration of spatial and human - environment relationships, but also a way of thinking about the world. Guided by the Australian Curriculum and the Professional Standards for Teaching School Geography (GEOGstandards), Teaching Secondary Geography provides a comprehensive introduction to both the theory and practice of teaching Geography. This text covers fundamental geographical knowledge and skills, such as working with data, graphicacy, fieldwork and spatial technology, and provides practical guidance on teaching them in the classroom. Each chapter features short-answer and 'Pause and Think' questions to enhance understanding of key concepts, and 'Bringing It Together' review questions to consolidate learning. Classroom scenarios and a range of information boxes are provided throughout to connect students to additional material. Written by an author team with extensive teaching experience, Teaching Secondary Geography is an exemplary resource for pre-service teachers.
Of all the doctrines of the law of nations that have come down to the present day, few, if any, have been as closely identified with a single individual as the freedom of the seas has with Hugo Grotius. The legal status of the seas and oceans engaged the attention of writers and statesmen long before Grotius appeared on the scene. It is presumed that the limitations of marine technologies required trading, fishing and warships to remain, as a rule, within sight of land in the pre-Roman and Roman eras, with the possible exception of the Mediterranean, Black, Baltic and East Asian regional seas. Fishing was largely a coastal operation, with minor coastal areas making forays into coal, salt, mineral and oyster or related offshore beds. From the standpoint of ocean boundaries and maritime jurisdiction, these eras have been called ‘primitive’.
Following the national lockdown in the UK in March 2020 in response to the COVID-19 pandemic, we instigated regular online tutorials for fourth year medical students undertaking their psychiatry placement.
The aims of these tutorials were threefold: to ensure that students covered a range of key psychiatry topics, to enable them to have the opportunity for interactive tutorials with experienced psychiatrists and, not least, to create a sense of continuity and connection with their tutors and peers across the mental health block.
Each student was allocated to a tutorial group comprising 10 – 15 medical students and a psychiatrist facilitator. These groups met weekly for 7 consecutive weeks at an agreed time for 60 – 90 minutes via an online platform and all covered the same allocated topic each week. We evaluated these groups via an online survey sent to the students following the programme.
The students rated the tutorials on average as 4.5/5 on whether they met the defined learning outcomes. On average the students did not consider that the virtual format made a significant difference to their learning, but this disguised a wide range of views that were expressed via a comment box.
The evaluation of this project supports the use of virtual tutorials as a valuable learning tool but educators need to be aware that student views’ on these can be varied and so, long-term, a blend of virtual and face to face learning is most likely to meet the needs of all students.
The COVID-19 pandemic led to changes in how healthcare was accessed and delivered. It was suggested that COVID-19 will lead to an increased delirium burden in its acute phase, with variable effect on mental health in the longer term. Despite this, there are limited data on the direct effects of the pandemic on psychiatric care.
1) describe the mental health presentations of a diverse acute inpatient population, 2) compare findings with the same period in 2019, 3) characterise the SARS-CoV-2 positive cohort of patients.
We present a descriptive summary of the referrals to a UK psychiatric liaison department during the exponential phase of the pandemic, and compare this to the same period in 2019.
show a 40.3% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for delirium and psychosis. One third (28%) of referred patients tested positive for COVID-19 during their admission, with 39.7% of these presenting with delirium as a consequence of their COVID-19 illness. Our data indicate decreased clinical activity for our service during the pandemic’s peak. There was a marked increase in delirium, though in no other psychiatric presentations.
In preparation for further exponential rises in COVID-19 cases, we would expect seamless integration of liaison psychiatry teams in general hospital wards to optimise delirium management in patients with COVID-19. Further consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the potentially increasing number of people reluctant to visit the emergency department.
The delivery of medical education has changed alongside the effects of COVID-19. As a result, the undergraduate psychiatry training for medical students at Guy’s King’s and St Thomas’ School of Medicine had to adapt rapidly. This poster portrays the journey in which the teaching sessions were developed and delivered throughout the first academic term of 2020-2021.
To deliver an interactive online teaching day that can provide students with the knowledge and understanding of common psychiatric disorders in the interface of other medical conditions.
A clinical skills teaching day was developed to deliver the sessions via the online video calling platform Zoom. Published articles regarding online medical education as well as guidelines from the Royal College of Psychiatry were used as a resource to develop the structure. Feedback of the teaching day was collected via an anonymous survey.
78 responses were collected in total from 4 teaching days. Overall satisfaction was high with a score of 86.5/100 in overall satisfaction. Themes for positive feedback included utilising actors in simulation (38% 30/78) and high interactivity within the teaching (31% 24/78). There were a number of students who found the whole day session online tiring (13% 10/78) and others felt the variation of scenarios were too limited (12% 9/78).
As lockdown has forced students to have less patient contact, they have suffered from the lack of learning opportunities. This teaching day showed the importance of organising high fidelity scenarios in order to try and fill the void that has been created due to COVID-19.
The intravenous (IV) is one of the main parenteral routes for drug administration. Rapid onset of action, precise titration, patient-specific dosing and bypass of liver metabolism are a few of its advantages, while hypersensitivity reactions, adverse effects, infection risk and a higher overall cost some of its most debated downsides. Unlike other areas of Medicine, IV has been significantly under-utilized in Psychiatry.
This systematic review analyzed the evidence for effectiveness and safety behind the use of IV medication used for the management of acute disturbance.
APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible studies. Studies were included if they used IV medication to treat acute disturbance, in English language, had participants aged >18. The quality of the included studies was assessed using the National Institutes of Health quality checklist.
17 studies were deemed eligible. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly between each study. Findings showed strong evidence for efficacy and safety of dexmedetomidine, droperidol, midazolam, and olanzapine. These medications displayed a short time to sedation, reduction in agitation levels, or large percentage of patients adequately sedated with a low number of adverse events. Results did not provide enough evidence for the use of IV ketamine, haloperidol, diazepam, lorazepam, and promethazine.
This review supports dexmedetomidine, droperidol, midazolam, and olanzapine as safe and efficacious options for managing acute disturbance via the intravenous route, particularly in special clinical settings where trained staff, optimal monitoring, resuscitation equipment and ventilators are all at hand.
Assessing risk is an important core skill yet there is not a consensus as to how to teach it. Clinically, there has been a move away from using risk prediction tools in favour of clinical judgement.We describe an iterative process to develop high quality, online teaching around risk assessment for medical undergraduates.
To teach the clinical skill of risk assessment to enable medical students to evaluate and manage risk when encountering patients with mental health issues.
A half day tutorial was designed and refined in an iterative process using feedback from participants on this session and other concurrent teaching occurring in the department. Sessions were also reviewed by external medical educators to ensure quality and learning objectives were met.
The average rating from 62 students was 4.4/5. Students commented that the session was well organised and delivered. Following feedback, the use of actors was prioritised to simulate evolving clinical situations. Students placed a high value on this: “simulated patients were amazing! They were really interesting and I was able to practice the skills I learnt over placement”. Logistical changes e.g. more breaks, followed appreciation of the exhausting nature of the session and maintained student engagement. There was increased emphasis on promoting group interaction through functions like a ‘break-out room’.
This session may give educators confidence that they can take risks when teaching the skill of risk assessment. Students were receptive and meaningfully engaged with concepts such as clinical judgement and bio-psycho-social formulations as opposed to ‘tick box’ assessments.
Effective stewardship strategies such as an “antibiotic timeout” to encourage prescriber reflection on the use of broad-spectrum antibiotics are critical to reduce the threat of multidrug-resistant organisms. We sought to understand the facilitators and barriers of the implementation of the Antibiotic Self-Stewardship Timeout Program (SSTOP), which used a template note integrated into the electronic health record system to guide decision making regarding anti- methicillin-resistant S. aureus (MRSA) therapy after 3 days of hospitalization. We conducted interviews at 10 Veterans’ Affairs medical centers (VAMCs) during the preimplementation period (N = 16 antibiotic stewards) and postimplementation (N = 13 antibiotic stewards) ~12 months after program initiation. Preimplementation interviews focused on current stewardship programs, whereas postimplementation interviews addressed the implementation process and corresponding challenges. We also directly asked about the impact of COVID-19 on stewardship activities at each facility. Interviews were transcribed and analyzed using consensus-based inductive and deductive coding. Codes were iteratively combined into barrier and facilitator groupings. Barriers identified in the preimplementation interviews included challenges with staffing, the difficulties of changing prescribing culture, and academic affiliates (eg, rotating physician trainees). Facilitators included intellectual support (eg, providers who understand the concept of stewardship), facility support, individual strengths of antibiotic stewards (eg, diplomacy, strong relationships with surgeons), and resources such as VA policies mandating stewardship. By the postimplementation phase, all sites reported a high volume of COVID-19 cases. Additional demands were placed on infectious disease providers who comprise the antibiotic stewardship teams, which complicated the implementation of SSTOP. Many barriers and facilitators mentioned were similar to those identified during preimplementation interviews. Staffing problems and specific providers not “getting it [stewardship activities]” continued, whereas facilitators centered around strong institutional support. Specific pandemic-related barriers included slow down or stoppage of stewardship activities including curbing of regular MRSA screening practices, halting weekly stewardship rounds, and delaying stewardship committee planning. Pandemic-specific staffing problems occurred due to the need for “all hands on deck” and challenges with staff working from home, as well as being pulled in multiple directions, (eg, writing COVID-19 policies). Furthermore, an increase in antibiotic use was also reported at sites during COVID-19 surges. Our findings indicate that SSTOP implementation met with barriers at most times; however, pandemic-specific barriers were particularly powerful. Sites with strong staffing resources were better equipped to deal with these challenges. Understanding how the program evolves with subsequent COVID-19 surges will be important to support the broad implementation of SSTOP.
This chapter reviews five decades of research on reactions to mirrors and self-recognition in nonhuman primates, starting with Gallup’s (1970) pioneering experimental demonstration of self-recognition in chimpanzees and its apparent absence in monkeys. Taking a decade-by-decade approach, developments in the field are presented separately for great apes on the one hand, and all other primates on the other (prosimians, monkeys, and so-called lesser apes), considering both empirical studies and theoretical issues. The literature clearly shows that among nonhuman primates the most compelling evidence for something approaching human-like visual self-recognition is seen only in great apes, despite an impressive range of sometimes highly original procedures employed to study many monkey species. In the past decade, research has been shifting from simple questions about whether great apes can self-recognize (now considered beyond doubt), to addressing possible biological bases for individual and species differences in the strength of self-recognition, analysis of possible adaptive functions of the capacity for self-visualization, and searching for evidence of self-recognition in a range of nonprimate species.
A broad survey and analysis of Wright's critical reputation from its low point at the time of his death to the great revival of interest in his work from the mid-1960s to the present day. Wright is seen not only as a major American writer but also as a transnational figure of global importance. Wright scholarship is discussed in terms of a rich historical and cultural context rooted in a number of American social and political forces as well as significant worldwide freedom movements. Careful attention is paid to major biographical studies, feminist responses to Wright's work, and new directions in Wright scholarship.
The aim of this project is to improve the training experience of Psychiatry trainees across CNWL. In QI terms, we want to achieve a satisfaction rating of above 7/10 for all themes identified by August 2021.
Collected baseline data on satisfaction and priority ratings on 7 training themes Held discussion groups with trainees for specific themes to generate issues and solutions Developed and provided Quality Improvement training for trainees and trainers, 1:1 support and QI clinics – empowering trainees to develop their own local project and to make changes to issues on the ground Enacted central changes in communication, responsiveness, recognising success.
Reassessed and fedback to the trainees throughout.
Our baseline satisfaction survey was completed in June 2020. Trainees their satisfaction for each theme out of 10 and to rank their priorities for change. Results showed satisfaction was lowest in morale and in safety and highest in education and supervision. Their highest priorities for change were safety, then morale, with induction as the lowest priority.
We repeated the survey in October 2020. This showed improvements in most themes (apart from induction, perhaps due to induction having to be delivered virtually). Satisfaction in key priority areas of morale and safety increased from 4.53 to 6.37, and 5.12 to 6.70 respectively. We also asked what ‘one thing’ would they improve about their training. Key phrases included teaching, on-call, communication and induction.
From this data, and softer feedback from trainees, it is encouraging that we are moving in a positive direction, but we are continuing to make changes.
• Trainees must be central to the work in improving their training
• Using QI methodology helps – developing a structure and breaking down a bigger task helps make a plan
• Feedback is key – but people are busy and receive a lot of emails and requests to fill surveys – catching people ‘in person’ (virtually) was the best way to ensure a lot of responses
• Trainees have loads of great ideas, but they need support, time and resources to be able to develop their projects and changes
• Flexibility is crucial: some topics work better locally, driven by trainees and some require a more coordinated, central role
We hope that developing a structured approach to a large task like improving training will help make changes sustainable, and enables us to share our learning with others.
Delirium is a common medical problem with a prevalence of over 50% in over 65s admitted to general hospitals (1,2) . Delirium is linked with poor clinical outcome, including increased risk of falls, prolonged admissions and an overall increased risk of morbidity and mortality (2,3,4). Delirium in older adults is also associated with an increased rate of cognitive decline, future risk of cognitive decline and a risk of depression (5,6,7). There is potential to improve clinical practice by improving assessment and management of delirium. It is imperative that where delirium is detected, it should be clearly documented to aid handover to primary care providers and medical teams (8,9).
The standard for this audit was set according to SIGN 157 (9). Data were collected retrospectively from consults sent to a liaison psychiatry of old age service within an acute hospital setting. The medical discharge summaries from July to December 2019 were reviewed. Two key data points were collated, the diagnoses of delirium by either medical or liaison psychiatry team and the inclusion of this diagnosis in the patient discharge summaries. An updated delirium protocol was devised and introduced in the hospital setting in January 2020 to include tools for effective diagnosis of delirium and instruction to include this diagnosis if made in patient's discharge summaries. Re-audit was initiated following the introduction of the updated delirium protocol for the period of January to March 2020.
A total of 116 patients were assessed from July to December 2019. 102 discharge summaries were available for review for the purpose of this audit. Prior to the introduction of the updated delirium protocol, delirium was diagnosed by the liaison team in 57% of all referrals. Delirium was underdiagnosed by medical teams in 73% of those subsequently diagnosed. The diagnosis of delirium was present in 42% of all discharge summaries to primary care providers. Subsequent to the introduction of the updated protocol, delirium was diagnosed in 48% of all liaison referrals during the time period specified. The proportion of under-diagnosis of delirium by medical teams stayed at 73%, the diagnosis of delirium was present in 53% of discharge summaries.
The recognition and diagnosis of delirium in the general medical setting continues to be a key issue in the management of older adults. The importance of this diagnosis and it's associated after effects needs to be disseminated amongst all care providers. Greater efforts to enhance these aspects of delirium management in the acute hospital setting are required.
The COVID pandemic has had both a massive impact on clinical service delivery and the way that training and education is provided. CNWL is a large NHS provider and has approximately 7000 staff working across 150 locations, providing mental health and community health services. In response to the need to share learning across the organisation, a trustwide “Safety Conversation Day” took place to spotlight the work being done to promote safety and to act as a platform to share ideas and learning across the trust. This was the first ever virtual conference organised by the trust.
The one-day conference included virtual posters and an all-day open access virtual conversation delivered via zoom. The day was divided into 6 safety themes: Safety tools; Safer Environments; Supporting and Involving Staff; Safer use of Medicines; See Think Act and Relational Security; and Prevention is Better than Cure. Frontline staff delivered 5-6 short presentations each hour highlighting new ways of working, quality improvement, local research etc.
Staff were also encouraged to submit posters for the event, with webinars held on how to write a poster held prior to the safety conversation to promote engagement. Prizes were awarded for best posters in the different categories.
A mentimeter survey was running throughout the day to get feedback from participants.
This was the largest event of this kind held by the trust. 430 unique viewers logged in during the day to watch the presentations.
Feedback was very positive on the mentimeter survey. 3 questions were asked on a likert scale of: Strongly Disagree – Strongly Agree (rated out of 5):
– ‘I found the posters really useful': 4.5/5
– ‘I found the presentations very useful': 4.6/5
– ‘I will share what I've learnt about safety': 4.6/5
Open space questions and word cloud responses also highlighted qualitative feedback with most frequent responses including ‘inspiring', ‘interesting and ‘stimulating’.
174 posters were presented with good representation from all services and staff groups across the trust (18 on safer use of medicines, 15 on co-production, 52 on quality improvement, 50 on COVID and non-COVID safety, 16 on use of technology, 23 on supporting and involving staff). These posters have since been downloaded 4062 times.
The first CNWL safety conference proved an excellent opportunity to celebrate achievements in patient safety in a very difficult year. It was very well-received and well-attended by staff, promoting maximal learning across the organisation.
Globally, increasing life expectancy has escalated demands on psychiatric services caring for a later life population. It is recognised that those with enduring mental illness may have specific needs with advancing age. In this study, we describe the characteristics of a population aged over 60 years attending a general adult community psychiatric service and compare demographic and clinical features across age and diagnostic categories. The study aims to gather preliminary information which may guide future local mental health service planning.
We conducted a cross-sectional observational study using retrospective chart review of all patients aged over 60 years attending four community mental health teams in North Dublin. Cohorts of attenders were stratified by age comparing 60–64 year age group with the population aged 65 years and over. Attenders were also stratified by diagnosis and regression analysis was used to determine predictors of psychotic disorder diagnosis.
The study included 127 patients. There was a higher prevalence of psychotic disorders among those aged 65 years and over (n = 73), while those aged 60–64 years (n = 54) were more likely to have depression and non-affective, non-psychotic disorders. Among the population aged 65 years and over 78% (n = 57) were long-term psychiatric service attenders.
The majority of the sample aged 65 years and over were long-term service attenders with a diagnosis of severe mental illness. Further research is warranted to determine optimal service delivery for later life psychiatric service attenders.
In 2018, the Neurodevelopmental and Psychosocial Interventions Working Group of the Cardiac Neurodevelopmental Outcome Collaborative convened through support from an R13 grant from the National Heart, Lung, and Blood Institute to survey the state of neurodevelopmental and psychosocial intervention research in CHD and to propose a slate of critical questions and investigations required to improve outcomes for this growing population of survivors and their families. Prior research, although limited, suggests that individualised developmental care interventions delivered early in life are beneficial for improving a range of outcomes including feeding, motor and cognitive development, and physiological regulation. Interventions to address self-regulatory, cognitive, and social-emotional challenges have shown promise in other medical populations, yet their applicability and effectiveness for use in individuals with CHD have not been examined. To move this field of research forward, we must strive to better understand the impact of neurodevelopmental and psychosocial intervention within the CHD population including adapting existing interventions for individuals with CHD. We must examine the ways in which dedicated cardiac neurodevelopmental follow-up programmes bolster resilience and support children and families through the myriad transitions inherent to the experience of living with CHD. And, we must ensure that interventions are person-/family-centred, inclusive of individuals from diverse cultural backgrounds as well as those with genetic/medical comorbidities, and proactive in their efforts to include individuals who are at highest risk but who may be traditionally less likely to participate in intervention trials.
The question of how best to name those who are most vulnerable to precarity and exploitation is both a conceptual and political one. It has been tempting in recent years to consider vulnerability as the foundation for a new politics, but that is an error. Vulnerability cannot be isolated as a new ground for politics. It is always contextual since it belongs to the organization of embodied and social relations. Vulnerability can neither be isolated from the constellation of rage, persistence, and resistance that emerges under specific historical conditions, nor can it be the basis for a new humanism. Rather, the differential exposure of bodies to abandonment, illness, and death, belong to a sphere of power that regulates the grievability of human lives, linked to the climate crisis and the demand for a new political vocabulary that moves beyond anthropocentrism. The differential scheme that governs the grievability of lives is a central component of social inequality at the same time that it belongs to forms of institutional violence that target communities and establish their precarity, if not their dispensability. If and when a population is (or is treated as) grievable, they can be acknowledged as a living population whose deaths would be grieved if their lives were lost. To assert the grievability of human life under conditions in which those lives have already been abandoned is to make a political claim against abandonment, for sustainable infrastructure, and for both the grievability and value of those lives. Mourning is thus linked with public protest, Vulnerability is the possibility of injury, but also of responsive and radical politics, one that asserts continued bodily existence as a form of persistence.
We are living in a time of numerous atrocities and senseless death, and so the enormous ethical and political question becomes: what are the modes of political representation available to us? I want to caution against too quickly developing a politics of vulnerability or a politics of care as an immediate pathway for feminism or for the Left, although I am quite clear that we need to reconsider both notions, and that many people do suffer from disproportionate forms of vulnerability.
This paper explores the interaction of informal constraints on human behaviour by examining the evolution of English football jerseys. The jersey provides an excellent setting to demonstrate how informal constraints emerge from formal rules and shape human behaviour. Customs, approved norms and habits are all observed in this setting. The commercialisation of football in recent decades has resulted in these informal constraints, in many cases dating back over a century, co-existing with branding, goodwill and identity effects. Combined, these motivate clubs to maintain the status quo. As a result, club colours have remained remarkably resilient within a frequently changing landscape.
Isaac Hayes provides a vital public figure through which scholars can analyze, evaluate, and more fully understand the comprehensive nature of the black freedom struggle as it progressed into the 1970s. Hayes merged the integrationist political objectives of mainstream civil rights organizations and leaders with the notions of racial pride, assertiveness, and autonomy that characterized the popular appeal of the black power movement. Hayes, through his “Black Moses” persona and LP of the same name, moved those freedom struggle promises and opportunities into the cultural realm, where he personified African American artistic self-determination. In doing so, he demonstrated that the contemporary conceptualization of black masculinity was not monolithic, as Hayes introduced and embodied an ideal that countered the prevailing notion of black manhood which pervaded popular culture and remains a central component of popular memory concerning black power. Most importantly, Isaac Hayes embodied a model of black masculinity that contradicted the prevailing “black macho” ideal. “Black Moses,” therefore, embodied the freedom of African Americans to move beyond contemporary racial classifications in a cultural capacity and presents scholars with an intriguing model through which to examine the evolution, possibilities, and accomplishments of the post-1960s American black freedom struggle.