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Routine symptom monitoring and feedback improves out-patient outcomes, but the feasibility of its use to inform decisions about discharge from in-patient care has not been explored.
To examine the potential value to clinical decision-making of monitoring symptoms during psychiatric in-patient hospitalisation.
A total of 1102 in-patients in a private psychiatric hospital, primarily with affective and neurotic disorders, rated daily distress levels throughout their hospital stay. The trajectories of patients who had, and had not, met a criterion of clinically significant improvement were examined.
Two-thirds of patients (n=604) met the clinically significant improvement criterion at discharge, and three-quarters (n=867) met the criterion earlier during their hospital stay. After meeting the criterion, the majority (73.2%) showed stable symptoms across the remainder of their hospital stay, and both classes showed substantially lower symptoms than at admission.
Monitoring of progress towards this criterion provides additional information regarding significant treatment response that could inform clinical decisions around discharge readiness.
Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.
This was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.
During the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.
In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.
SchauerSG, CunninghamCW, FisherAD, DeLorenzoRA. A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department. Prehosp Disaster Med. 2017;32(6):679–681.
To aid in preparation of military medic trainers for a possible new curriculum in teaching junctional tourniquet use, the investigators studied the time to control hemorrhage and blood volume lost in order to provide evidence for ease of use.
Models of junctional tourniquet could perform differentially by blood loss, time to hemostasis, and user preference.
In a laboratory experiment, 30 users controlled simulated hemorrhage from a manikin (Combat Ready Clamp [CRoC] Trainer) with three iterations each of three junctional tourniquets. There were 270 tests which included hemorrhage control (yes/no), time to hemostasis, and blood volume lost. Users also subjectively ranked tourniquet performance. Models included CRoC, Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). Time to hemostasis and total blood loss were log-transformed and analyzed using a mixed model analysis of variance (ANOVA) with the users represented as random effects and the tourniquet model used as the treatment effect. Preference scores were analyzed with ANOVA, and Tukey’s honest significant difference test was used for all post-hoc pairwise comparisons.
All tourniquet uses were 100% effective for hemorrhage control. For blood loss, CRoC and SJT performed best with least blood loss and were significantly better than JETT; in pairwise comparison, CRoC-JETT (P < .0001) and SJT-JETT (P = .0085) were statistically significant in their mean difference, while CRoC-SJT (P = .35) was not. For time to hemostasis in pairwise comparison, the CRoC had a significantly shorter time compared to JETT and SJT (P < .0001, both comparisons); SJT-JETT was also significant (P = .0087). In responding to the directive, “Rank the performance of the models from best to worst,” users did not prefer junctional tourniquet models differently (P > .5, all models).
The CRoC and SJT performed best in having least blood loss, CRoC performed best in having least time to hemostasis, and users did not differ in preference of model. Models of junctional tourniquet performed differentially by blood loss and time to hemostasis.
KraghJFJr, LunatiMP, KharodCU, CunninghamCW, BaileyJA, StockingerZT, CapAP, ChenJ, AdenJK3d, CancioLC. Assessment of Groin Application of Junctional Tourniquets in a Manikin Model. Prehosp Disaster Med. 2016;31(4):358–363.
Finch trichomonosis is an emerging infectious disease affecting European passerines caused by a clonal strain of Trichomonas gallinae. Migrating chaffinches (Fringilla coelebs) were proposed as the likely vector of parasite spread from Great Britain to Fennoscandia. To test for such parasite carriage, we screened samples of oesophagus/crop from 275 Apodiform, Passeriform and Piciform birds (40 species) which had no macroscopic evidence of trichomonosis (i.e. necrotic ingluvitis). These birds were found dead following the emergence of trichomonosis in Great Britain, 2009–2012, and were examined post-mortem. Polymerase chain reactions were used to detect (ITS1/5·8S rRNA/ITS2 region and single subunit rRNA gene) and to subtype (Fe-hydrogenase gene) T. gallinae. Trichomonas gallinae was detected in six finches [three chaffinches, two greenfinches (Chloris chloris) and a bullfinch (Pyrrhula pyrrhula)]. Sequence data had 100% identity to the European finch epidemic A1 strain for each species. While these results are consistent with finches being vectors of T. gallinae, alternative explanations include the presence of incubating or resolved T. gallinae infections. The inclusion of histopathological examination would help elucidate the significance of T. gallinae infection in the absence of macroscopic lesions.
Populations of blue-footed boobies in the Galápagos Islands have declined by at least 50% compared with numbers recorded during the 1960s. Recently, concern has been expressed about potential adverse effects of introduced blood parasites; in particular, malarial parasites (i.e. Plasmodium sp.), which are frequently pathogenic and can cause mortality and morbidity in birds, and blood parasites of the genus Haemoproteus, which can reduce fitness. We screened blue-footed boobies at six breeding colonies within Galápagos for both genera of parasite. At two sites, we also investigated whether there was any relationship between infection status and physiological condition or breeding success. We found a high prevalence of Haemoproteus spp. in adults and chicks using PCR, although none was found on blood smears. We found no evidence of Plasmodium. Effects of parasitism on the condition of birds were limited. Also, there was no evidence that infection with Haemoproteus adversely affected breeding success or chick growth. Our results suggest that poor success of breeding birds was not strongly associated with Haemoproteus infection. However, regular colony monitoring and examination of dead birds are necessary to assess whether acute Haemoproteus infection might be responsible for some mortality, particularly of chicks.
Massive stars are some of the most important objects in the Universe, shaping the evolution of galaxies, creating chemical elements, and hence shaping the evolution of the Universe. However, the processes by which they form, and how they shape their environment during their birth processes, are not well understood. We are using NH3 data from the “The H2O Southern Galactic Plane Survey” (HOPS) to define the positions of dense cores/clumps of gas in the southern Galactic plane that are likely to form stars. We did a comparative study with different methods for finding clumps and found Fellwalker to be the best for this dataset. We detected ~ 500 clumps with mean kinetic temperature ~ 20 K and virial mass ~ 680 solar masses.
The Chinese giant salamander Andrias davidianus is endemic to China and is Critically Endangered, largely because of overexploitation for food. This species is an expensive delicacy in China, and a rapidly growing industry to farm the species has developed throughout much of the country, centred on the Qinling Mountain region of Shaanxi Province. During a 2010 workshop on Chinese giant salamander conservation, which involved a range of stakeholders from across China, it became clear that the conservation community knew little about the salamander farming industry and whether it posed actual or potential threats or opportunities for conservation of the Chinese giant salamander. We therefore conducted a series of investigations to understand the industry better. Our results indicate that although farming of Chinese giant salamanders has the potential to be a positive development for conservation by supplying market demand with farmed animals, it is currently more likely to threaten than support conservation of the species, with continued overexploitation and the potential added impacts of infectious disease and genetic pollution arising from farming practices such as movement of animals across the country and the release of untreated farm wastewater and farmed salamanders to the wild.
The Critically Endangered Chinese giant salamander Andrias davidianus, the world's largest amphibian, is severely threatened by unsustainable exploitation of wild individuals. However, field data with which to assess the salamander's status, population trends, or exploitation across its geographical range are limited, and recent field surveys using standard ecological field techniques have typically failed to detect wild individuals. We conducted community-based fieldwork in three national nature reserves (Fanjingshan, Leigongshan and Mayanghe) in Guizhou Province, China, to assess whether local ecological knowledge constitutes a useful tool for salamander conservation. We collected a sample of dated salamander sighting records and associated data from these reserves for comparative assessment of the relative status of salamander populations across the region. Although Fanjingshan and Leigongshan are still priority sites for salamander conservation, few recent sightings were recorded in either reserve, and respondents considered that salamanders had declined locally at both reserves. The species may already be functionally extinct at Mayanghe. Although respondent data on threats to salamanders in Guizhou are more difficult to interpret, overharvesting was the most commonly suggested explanation for salamander declines, and it is likely that the growing salamander farming industry is the primary driver of salamander extraction from Guizhou's reserves. Questionnaire-based surveys can collect novel quantitative data that provide unique insights into the local status of salamander populations, and we advocate wide-scale incorporation of this research approach into future salamander field programmes.
To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection.
Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network.
Setting and Participants.
Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities.
The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan.
Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet.
A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.
When a Master doth a thing a second time, lightly it is for the better.
George Gage to Sir Dudley Carleton, 1 November 1617
This chapter will probe early modern notions of creativity by considering the artistic activities, in and for England, of the most sought-after painter in seventeenth-century Europe – Peter Paul Rubens. The artist's busy workshop helped to satisfy the demand for his works, and as a result Rubens's English patrons, ranging from various dignitaries to Charles I himself, were the recipients of paintings with varying degrees of the master's own participation. An inquiry into Rubens's practice of delegating to studio assistants, and into the value placed by him and his British viewers on autography, will elucidate attitudes towards the manual aspects of creation. A related area of investigation will focus on the phenomenon of self-repetition in the artist's works for his English clients, some of which works were replicas of earlier compositions or reused motifs from previous inventions. Finally, a broader exploration of responses to self-replication, extending at times beyond the shores of England or the confines of painting, will bring to the fore the tensions inherent in early modern attitudes to art.
Replicas and Studio Hands
Although Rubens's stay in England as a diplomatic envoy dates to 1629–30, his relationship with English patrons had begun some thirteen years earlier when Sir Dudley Carleton, the English Ambassador to The Hague, had sought to trade a diamond chain for a hunt scene by the artist.
This book has its origins in an interdisciplinary conference of the same name, held at the University of Manchester in September 2008 as part of a four-year research project entitled ‘Musical Creativity in Restoration England’, which was funded by the Arts and Humanities Research Council in the UK. The conference brought together a group of seventeenth-century specialists including those working in cultural studies, print culture, the history of ideas, and of course historians of art, architecture, theatre, literature and music, to explore how we can seek to understand what it meant to be creative in the early modern period in England. Te symposium revealed the wide variety of approaches to studying creativity being taken by scholars and research students across the humanities, and led to exciting and fruitful cross-fertilization of ideas between its participants, resulting in discussions that in some cases have led to long-lasting research collaborations.
Tis book presents a selection of twelve essays that were developed from the twenty papers given at the conference. In selecting this group, the editors have sought to include a representative sample of the research that was presented, while also aiming to ensure that the collection is accessible to a genuinely interdisciplinary readership. While music examples are used in some of the chapters, these are kept to a minimum, and are supported by audio samples available at www.alc.manchester. ac.uk/subjects/music/research/projects/musicalcreativity.
This essay grows from a concern with the old art-historical problem of how the perception of art, or in this case more specifically architecture, changes over time. It sets out to explore how verbal representations preserve clues about such changes in the way we see the world, while proposing that the dialogue between subject and object is perhaps more palpable in texts than it is in pictures. The protagonist is seventeenth-century diarist John Evelyn, who travelled in Italy between 1644 and 1646. The account of this journey forms part of his seminal Diary, which he compiled mainly retrospectively from the 1660s onwards. One of the main seventeenth-century English sources for historians of all fields and by some even regarded as having changed travel writing, Evelyn is nevertheless well known for having copied generous parts of his text from earlier guidebooks.2 In the following I will try to dismantle sentence by sentence one short passage in which he describes the city of Genoa. Comparing his text to other seventeenth-century guidebooks allows us to see not only what Evelyn copied, but also what he altered, what he added, and, more importantly, what these alterations and additions tell us about contemporary modes of perception and representation. The ensuing analysis raises questions about concepts of creativity and originality in the period while probing the ordering of vision and knowledge in the seventeenth century.
Creation: a making or forming of something, as it were, out of nothing Edward Phillips, The New World of Words
Edward Phillips's attempt to define creation in 1671 highlights a number of issues that are central to developments in thinking about creativity, knowledge and artistic innovation during the seventeenth century. His idea of creating ‘something’ from ‘nothing’ implies, at one level, absolute novelty: a lack of precedence, a complete rupture with and effacement of a past state or experience; something appears where once there was emptiness or blankness. Simultaneously, however, the emphasis on ‘making’ and especially ‘forming’ suggests that there are materials to be moulded: existing matter to be reshaped into something new; Phillips suggests that creation has to be made from something, even as this ‘some-thing’ is described as ‘no-thing’. This ambivalence – the ‘as it were’ in the definition – hints at the multiple concepts and interpretations of creativity that existed in the seventeenth century.
In the early modern period – particularly in the realm of epistemology – creation was understood both in terms of reshaping, translating and reconfiguring that which exists and as the production of fresh entities ‘out of nothing’. Seventeenth-century theories of creativity seem to emanate from precisely this tension between novelty and precedent, between the purity of the new and the foundation of the old.