To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.
3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. “+risk” was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.
731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.
Significance of results
We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
The COVID-19 pandemic has placed unprecedented demands on health systems, where hospitals have become overwhelmed with patients amidst limited resources. Disaster response and resource allocation during such crises present multiple challenges. A breakdown in communication and organization can lead to unnecessary disruptions and adverse events. The Federal Emergency Management Agency (FEMA) promotes the use of an incident command system (ICS) model during large-scale disasters, and we hope that an institutional disaster plan and ICS will help to mitigate these lapses. In this article, we describe the alignment of an emergency department (ED) specific Forward Command structure with the hospital ICS and address the challenges specific to the ED. Key components of this ICS include a hospital-wide incident command or Joint Operations Center (JOC) and an ED Forward Command. This type of structure leads to a shared mental model with division of responsibilities that allows institutional adaptations to changing environments and maintenance of specific roles for optimal coordination and communication. We present this as a model that can be applied to other hospital EDs around the country to help structure the response to the COVID-19 pandemic while remaining generalizable to other disaster situations.
OBJECTIVES/GOALS: This study evaluates the utility of self-reported quality of life measure in children with hearing loss. We will compare self-reported HEAR-QL scores with parent-reported HEAR-QL scores. We will then test the relationship between HEAR-QL scores and scores on a standardized assessment of cognition, the NIH Cognition Battery. METHODS/STUDY POPULATION: We will administer the HEAR-QL questionnaire to children with hearing loss and their parents. We will then administer the NIH Cognition Battery to the child. We will include in our population children ages 7 to 14 with hearing loss of any severity or side. We will exclude those with intellectual disability, disorders of speech or language, or those who would be unable to complete the questionnaires for any reason. Children will be recruited from Otolaryngology clinics at St. Louis Children’s Hospital based on ICD diagnosis of sensorineural hearing loss between 01/2015 – 03/2020. RESULTS/ANTICIPATED RESULTS: We will aim to recruit 44 patients in total, which is the sample size needed to detect a moderate correlation (r = 0.4) with a 1-sided α = 0.05 and 1-β = 0.8. HEAR-QL scores and NIH Cognition Battery scores will be reported using descriptive statistics. Linear regression as well as correlation analysis between HEAR-QL scores and cognitive testing scores will be performed using a 1-sided α = 0.05, with 1-β = 0.8. If recruitment is sufficient, we will adjust for demographics that are significantly correlated with the outcome on multivariate analysis. Finally, we will test for agreement between parent report and child report by calculating a Kappa statistic. DISCUSSION/SIGNIFICANCE OF IMPACT: There is little clarity on the necessity of amplification in children with hearing loss, yet the child’s perspective is not routinely assessed in clinical practice. This study employs self-report in a pediatric population with hearing loss to find out if children provide new and reliable information.
To evaluate the relationship between fruits and vegetables (F&V) availability at home and young people’s F&V consumption behaviour, and how the theory of planned behaviour (TPB) constructs could potentially mediate the relationship.
Cross-sectional face-to-face survey questionnaire to assess the TPB constructs and home food availability assessed using open inventories method. F&V availability was categorised into low and high levels based on median split.
Two hundred and ten households (each consisting one parent–child pair) recruited via stratified cluster sampling with child participants ranging from 9 to 16 years of age.
Mediation analyses were conducted using structural equation modelling. The relationship between home F&V availability and F&V consumption behaviour did not have a significant direct association, but there were significant indirect effects through the routes of perceived behavioural control (PBC) and intention as well as attitude and intention. Specifically, higher level of F&V availability at home was related to more positive PBC and attitude towards F&V, and subsequently greater intention to consume F&V and higher consumption of F&V.
Parents should make F&V more readily available at home as increased exposure to F&V could be related to enhanced liking, sense of control and intention to consume F&V and facilitate children’s healthy diet.
Introduction: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) practitioners are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. Our goal is to enhance rural trauma care by identifying obstacles rural EM physicians face in Saskatchewan. Methods: This was a cross sectional survey study, emailed to family physicians practicing rural EM in Saskatchewan identified through the Saskatchewan Medical Association database. Inclusion criteria included physicians who are providing EM care currently or within the past year. Rural was assumed to be communities in Saskatchewan that were outside of Saskatoon and Regina. The survey was an anonymous self-assessment regarding demographics, training, hospital resources and comfort. Results: 113 physicians of the 479 rural physicians agreed to participate, 78 met our inclusion criteria. Most (67%) were from communities with less than 10,000 population, 70% had less than 300 ED visits per month. Most (68%) were less than 45 years of age. In terms of training, 57% had completed undergraduate training out of Canada and 63% had completed residency training in Canada. Most had been practicing for more than 2 years (76%). Most (59%) had current ATLS credentials, however only 37% had ever completed the EDE course. Regarding available resources, most centers had plain radiography (99%), POCUS (68%), PRBC (78%) and TXA (93%). However, fresh frozen plasma (41%) and platelets (26%) were not widely available. Comfort was measured on a Likert scale. The types of trauma that respondents were least comfortable with included pediatric (39%), vascular (46%), spine (56%) and genitourinary (60%). The types skills that participants were least comfortable with included pericardiocentesis (19%), and surgical airway (25%). The majority had not performed Pediatric endotracheal tube insertion (79%), surgical airways (99%), pericardiocentesis (99%), central venous line placement (80%) and needle thoracentesis (71%) within the past 12 months. Conclusion: This self-assessment helped us identify aspects of rural trauma medicine that are the most challenging for rural practitioners. Understanding the most difficult challenges in light of the critical resources available to rural trauma medicine providers will inform future professional development initiatives.
The chronic worldwide shortage of psychiatrists has impaired the delivery of first class mental health care (WHO 2008). This international project funded by a World Psychiatric Association grant proposes to examine and compare the effects of country-specific undergraduate and postgraduate factors involved in medical student choice of a psychiatric career. Phase 1 focussed on identifying published proven and novel modifiable factors to improve psychiatric recruitment.
We searched EMBASE, PsychInfo and Medline using the keywords ‘career psychiatry’, ‘medical education’, and ‘career choice’. All 206 papers retrieved using the combined search were reviewed and categorized thematically.
Findings are summarised under three themes:
· Pre-medical school factors: arts & social sciences qualifications, attitudes towards mental illness, high uncertainty tolerance, liberal political views, gender and life goals.
· Medical school factors: availability of psychology/sociology/special-studies modules, electives; length of clinical placement; exposure to motivated patients and effective treatment; quality of teaching and good role models; and conversely negative attitudes from other specialities.
· Post-graduate factors: availability of early clinical posts in psychiatry, work-life balance, remuneration.
· Studies have been limited by small sample sizes, unicentricity, and datedness, given the major reorganisations of mental health services and postgraduate training in many countries.
· During the next stage we will generate the first multicountry comparison, with sufficient power to detect differences in factors influencing a psychiatric career choice at personal, institutional and national level. We will focus on factors that may be modifiable by policy to positively influence career choice towards psychiatry.
Vascular Dementia (VD) patients have increased co-morbidity and higher mortality in comparison to other patients. Neuro-degeneration, cognitive deficits and underlying medical conditions may influence the pattern of co-morbid disorders and their possible effects on mortality in VD.
To investigate whether the pattern of co-morbidity and its relevance for later death differed between hospitalised VD and elderly controls.
Diseases with a prevalence of more than 1% at hospital admission were compared between 341 hospitalised VD and 72244 control subjects aged above 70 years referred to the University of Birmingham Hospital, UK. Risk factors i.e. co-morbidities that were predictors of mortality within the seven year follow-up were identified using logistic regression and cox regression analyses. Confidence intervals of relative risks were used to compare the relevance of risk factors for later mortality between groups.
Subjects with VD suffer more with peripheral vascular disease, atrial fibrillation, type 2 diabetes mellitus, pneumonia, ischemic stroke and urinary tract infections than other hospitalised elderly patients. In contrast, myocardial infarction was less prevalent in VD subjects in comparison with hospitalised controls. The prevalence of hypertension, ischemic heart disease, angina and heart failure was not statistically different in the two groups.
Patients with Vascular Dementia have a different pattern of co-morbidity, but die from the same diseases as other hospitalised patients. Infections including pneumonia may need special attention in patients with vascular dementia who might not be able to identify or report the early symptoms.
Neurodegeneration and cognitive deficits may influence the pattern of co-morbid disorders and their possible effects on mortality in late-onset Alzheimer's disease (AD). However, subjects with AD have to live long enough to experience and be diagnosed with dementia. We investigated whether the pattern of co-morbidity and its relevance for later death differed between hospitalised AD and elderly controls subjects.
Diseases with a prevalence of more than 1% were compared between 634 hospitalised AD and 72244 control subjects aged above 70 years referred to the University of Birmimgham NHS Trust. Predictors of mortality within the seven year follow-up were identified using regression regression analyses. Confidence intervals of relative risks were used to compare the relevance of risk factors for later mortality between groups.
Subjects with AD suffer more infections, brain diseases and neck of femur fractures than other hospitalised elderly patients. In contrast, cardiovascular diseases and diabetes mellitus were less prevalent in AD subjects in comparison with hospitalised controls. Diseases that might contribute to later mortality in AD were pneumonia, ischemic heart disease and gastroenteritis, but there were no significant differences in their impact on mortality compared to other hospitalised elderly control subjects.
Patients with Alzheimer's disease have a different pattern of co-morbidity, but die from the same diseases as other hospitalised patients. Infections including pneumonia, and diseases that may occur secondary to neurodegeneration and confusion may need special attention in patients with Alzheimer disease who might not be able to identify or report the early symptoms.
No figures exist for the prevalence of personality disorder in ethnic minorities, compared to the general UK population, where prevalence figures range between 13% for general practitioner patients to 40-50% of psychiatric in-patients. Differences in diagnosis indicate that Black patients more likely to be diagnosed with Schizophrenia and less likely to be diagnosed with personality disorder. There is underuse of psychotherapy services by ethnic groups and less likelihood of receiving psychological therapies.
A cross-sectional survey of inpatient data collected over 2 years(2007-2009), examined the prevalence of personality disorder, with regards to ethnic distribution, among 6531 psychiatric inpatients. The survey was conducted in Mersey Care NHS Trust, a mental health care provider in the North West of England. Ethnicity was divided into 2 broad categories, White British and Black and Minority Ethnic group (BME).
273(4.2%) patients were diagnosed with personality disorder. 91(33.3%) males and 177(64.8%) females had personality disorder diagnosis. 23(8.4%) BME patients compared to 250(91.6%) White British patients were diagnosed with personality disorder. The most common diagnosis was Emotionally Unstable personality disorder (184 cases). Personality disorder is under-diagnosed in this inpatient population compared to the evidence base. Results support the research evidence base, that personality disorder in BME is under-diagnosed.
Personality disorder is a stigmatizing label and is fraught with diagnostic uncertainty. Pre-existing attitudes in these communities regard mental illness as a non-entity, a stigma or taboo. It is not only the patient population that needs educating but also the professionals responsible for detection and management of personality disorder.
This chapter examines the notable revival of the Nero-Antichrist in the nineteenth century and tracks the resurgence and dissemination of the paradigm beyond late antiquity. Why the idea of the Nero-Antichrist regained its potency in this period has to do with the wider context of a nineteenth-century fascination with antiquity, with religious upheaval, with the fin de siècle anxieties about the end times, and with fin de siècle notions of decadence and decline. As case studies, the authors Ernest Renan, F. W. Farrar, and Oscar Wilde allow us to explore how late nineteenth-century thinkers in England and France worked with and reacted to prevailing conceptions of Nero, and negotiated his identification as the Antichrist. All three were finding a place for Christianity in an era intent upon positivist historiography; Wilde in particular shows that the scientific method was not the only option for interpreting the emperor’s role in Christian history.
The chronic worldwide shortage of psychiatrists has impaired the delivery of first class mental health care. The WHO produced a report on the Mental Health Gap, showing the high burden of mental health, neurological and substance misuse disorders worldwide, estimating a treatment gap of 75% between need and resources.
Aims and objectives
Research to date has highlighted key areas that influence students' choice of a career in psychiatry. There have been several key literature reviews summarising work in the area since the 1950s. The current study updates literature with a systematic review of the past 10 years.
A five level search strategy was used.
A standard Critical Appraisal tool was developed based on the one used by the Best Evidence in Medical Education Group in Dundee. Papers were coded and graded using hierarchies of evidence - Sackett Hierarchy of Evidence and Kirkpatrick Hierarchy.
Results & conclusions
The quality of published studies has risen over the past 30 years, with the past decade producing the most robust evidence. However, it is a complex area to research with many potential confounders, and large gaps in knowledge remain.
This chapter introduces the ‘myths’ about Nero that have circulated since his death in AD 68. One of the most potent of these in the Nero-Antichrist. While the study of the association between Nero and the Antichrist has mainly been confined to New Testament scholarship, this introduction demonstrates why it is so important, following the linguistic turn, to conduct an investigation underpinned by theories of historiography and reception studies.
Christian writers, keen to interpret the apocalyptic scripture that had since become canonical, recognised the intrinsic importance of Nero’s role as first persecutor to the history of Christianity. According to tradition, Nero created the first martyrs, including the apostles Peter and Paul. Millennialists from the third century established the importance of a relationship between the first and last persecutors, affording Nero an apocalyptic role. To add detail to the paradigm, late-antique writers turned ted to non-biblical traditions – mostly classical historiography, but also the apocryphal Sibylline Oracles and Ascension of Isaiah. Here, they could find characteristics to populate their paradigm, be those the traits of the arch-destroyers of apocrypha, or those of the tyrannical Nero of classical texts.
To investigate cultural differences on types of coping strategies employed by male and female patients.
72 Chronic pain patients were selected over 18 months. Patients were screened out if they had any physical disability or were getting psychiatric treatment. Besides demographic data, McGill Pain Questionnaire, Coping Strategies Questionnaire and Berlin Social-Support Scales were employed to record the study variables. Age range of patients varied from 25- 58 years. All the patients were educated, working and belonged to middle class.
Out of 72 patients (40 females: 32 males) 78% patients had impaired physical functioning. Perception of pain depended upon the age, sex, amount of perceived social support and contact with the treating doctor. Females frequently employed “religious coping” (95%) and used “self statements” (80%); as opposed to males who relied on “ignoring the sensations” (88%) and “increasing behavioral activities” (65%). None “diverted attention” through the ways they thought were not religious or culture appropriate.
The study reflected the cultural differences in type of coping strategy employed by a given patient. Female patients were somatically- focused but only 35% met the criteria for Somatization Disorder. Male patients employed techniques that allowed their control on the environment and illness whereas females patients relied on techniques that were passive in nature. Learning to live with a chronic pain is quite challenging for women who are feeling-oriented and look up to men not only to fulfill their needs but to get social approval in the context of Pakistani society.