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Tom Dishion, a pioneer in prevention science, was one of the first to recognize the importance of adapting interventions to the needs of individual families. Building towards this goal, we suggest that prevention trials be used to assess baseline target moderated mediation (BTMM), where preventive intervention effects are mediated through change in specific targets, and the resulting effect varies across baseline levels of the target. Four forms of BTMM found in recent trials are discussed including compensatory, rich-get-richer, crossover, and differential iatrogenic effects. A strategy for evaluating meaningful preventive effects is presented based on preventive thresholds for diagnostic conditions, midpoint targets and proximal risk or protective mechanisms. Methods are described for using the results from BTMM analyses of these thresholds to estimate indices of intervention risk reduction or increase as they vary over baseline target levels, and potential cut points are presented for identifying subgroups that would benefit from program adaptation because of weak or potentially iatrogenic program effects. Simulated data are used to illustrate curves for the four forms of BTMM effects and how implications for adaptation change when untreated control group outcomes also vary over baseline target levels.
The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.
We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.
This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.
Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).
Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.
A key task of the team leader in a medical emergency is effective information gathering. Studying information gathering patterns is readily accomplished with the use of gaze-tracking glasses. This technology was used to generate hypotheses about the relationship between performance scores and expert-hypothesized visual areas of interest in residents across scenarios in simulated medical resuscitation examinations.
Emergency medicine residents wore gaze-tracking glasses during two simulation-based examinations (n=29 and 13 respectively). Blinded experts assessed video-recorded performances using a simulation performance assessment tool that has validity evidence in this context. The relationships between gaze patterns and performance scores were analyzed and potential hypotheses generated. Four scenarios were assessed in this study: diabetic ketoacidosis, bradycardia secondary to beta-blocker overdose, ruptured abdominal aortic aneurysm and metabolic acidosis caused by antifreeze ingestion.
Specific gaze patterns were correlated with objective performance. High performers were more likely to fixate on task-relevant stimuli and appropriately ignore task-irrelevant stimuli compared with lower performers. For example, shorter latency to fixation on the vital signs in a case of diabetic ketoacidosis was positively correlated with performance (r=0.70, p<0.05). Conversely, total time spent fixating on lab values in a case of ruptured abdominal aortic aneurysm was negatively correlated with performance (r= −0.50, p<0.05).
There are differences between the visual patterns of high and low-performing residents. These findings may allow for better characterization of expertise development in resuscitation medicine and provide a framework for future study of visual behaviours in resuscitation cases.
As the concept of ecosystem services is applied more widely in conservation, its users will encounter the issue of poverty alleviation. Policy initiatives involving ecosystem services are often marked by their use of win-win narratives that conceal the trade-offs they must entail. Modelling this paper on an earlier essay about conservation and poverty, we explore the different views that underlie apparent agreement. We identify five positions that reflect different mixes of concern for ecosystem condition, poverty and economic growth, and we suggest that acknowledging these helps to uncover the subjacent goals of policy interventions and the trade-offs they involve in practice. Recognizing their existence and foundations can ultimately support the emergence of more legitimate and robust policies.
To collect and synthesize the literature describing the use of real-time video-based technologies to provide support in the care of patients presenting to emergency departments.
Six electronic databases were searched, including Medline, CINAHL, Embase, the Cochrane Database, DARE, and PubMed for all publications since the earliest date available in each database to February 2016.
Selected articles were full text articles addressing the use of telemedicine to support patient care in pre-hospital or emergency department settings. The search yielded 2976 articles for review with 11 studies eligible for inclusion after application of the inclusion and exclusion criteria. A scoping review of the selected articles was performed to better understand the different systems in place around the world and the current state of evidence supporting telemedicine use in the emergency department.
Telemedicine support for emergency department physicians is an application with significant potential but is still lacking evidence supporting improved patient outcomes. Advances in technology, combined with more attractive price-points have resulted in widespread interest and implementation around the world. Applications of this technology that are currently being studied include support for minor treatment centres, patient transfer decision-making, management of acutely ill patients and scheduled teleconsultations.
Simulation-based education (SBE) is an important training strategy in emergency medicine (EM) postgraduate programs. This study sought to characterize the use of simulation in FRCPC-EM residency programs across Canada.
A national survey was administered to residents and knowledgeable program representatives (PRs) at all Canadian FRCPC-EM programs. Survey question themes included simulation program characteristics, the frequency of resident participation, the location and administration of SBE, institutional barriers, interprofessional involvement, content, assessment strategies, and attitudes about SBE.
Resident and PR response rates were 63% (203/321) and 100% (16/16), respectively. Residents reported a median of 20 (range 0–150) hours of annual simulation training, with 52% of residents indicating that the time dedicated to simulation training met their needs. PRs reported the frequency of SBE sessions ranging from weekly to every 6 months, with 15 (94%) programs having an established simulation curriculum. Two (13%) of the programs used simulation for resident assessment, although 15 (94%) of PRs indicated that they would be comfortable with simulation-based assessment. The most common PR-identified barriers to administering simulation were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Interprofessional involvement in simulation was strongly valued by both residents and PRs.
SBE is frequently used by Canadian FRCPC-EM residency programs. However, there exists considerable variability in the structure, frequency, and timing of simulation-based activities. As programs transition to competency-based medical education, national organizations and collaborations should consider the variability in how SBE is administered.
Reducing pauses during cardiopulmonary resuscitation (CPR) compressions result in better outcomes in cardiac arrest. Artefact filtering technology (AFT) gives rescuers the opportunity to visualize the underlying electrocardiogram (ECG) rhythm during chest compressions, and reduces the pauses that occur before and after delivering a shock. We conducted a simulation study to measure the reduction of peri-shock pause and impact on chest compression fraction (CCF) through AFT.
In a simulator setting, participants were given a standardized cardiac arrest scenario and were randomly assigned to perform CPR/defibrillation using the protocol from one of three experimental arms: 1) Standard of Care (pauses for rhythm analysis and shock delivery); 2) AFT (no pauses for rhythm analysis, but a pause for defibrillation); or 3) AFT with hands-on defibrillation (no pauses for rhythm analysis or defibrillation). The primary outcomes were CCF and peri-shock pause duration, with secondary outcomes of pre- and post-shock pause duration.
AFT with hands-on defibrillation was found to have the highest CCF (86.4%), as compared to AFT alone (83.8%, p<0.001), and both groups significantly improved CCF in comparison with the Standard of Care (76.7%, p<0.001). AFT with hands-on defibrillation was associated with a reduced peri-shock pause (2.6 seconds) as compared to AFT alone (5.3 seconds, p<0.001), and the Standard of Care (7.4 seconds, p<0.001).
In this cardiac arrest model, AFT results in a greater CCF by reducing peri-shock pause duration. There is also a small but detectable improvement in CCF with the addition of hands-on defibrillation.
Background: Delirium is common in critically ill patients and its presence is associated with increased mortality and increased likelihood of poor cognitive function among survivors. However, the cause of delirium is unknown. The purpose of this study was to demonstrate the feasibility of using near-infrared spectroscopy (NIRS) to assess brain tissue oxygenation in patients with septic shock, who are at high risk of developing delirium. Methods: This prospective observational study was conducted in a 33-bed general medical surgical intensive care unit (ICU). Patients with severe sepsis or septic shock were eligible for recruitment. The FORESIGHT NIRS monitor was used to assess brain tissue oxygenation in the frontal lobes for the first 72 hours of ICU admission. Physiological data was also recorded. We used the Confusion Assessment Method-ICU to screen for delirium.Results: From March 1st 2014-September 30th 2014, 10 patients with septic shock were recruited. The NIRS monitor captured 81% of the available data. No adverse events were recorded. Brain tissue oxygenation demonstrated significant intra- and inter-individual variability in the way it correlated with physiological parameters, such as mean arterial pressure, heart rate, and peripheral oxygen saturation. Mean brain tissue oxygen levels were significantly lower in patients who were delirious for the majority of their ICU stay. Conclusion: It is feasible to record brain tissue oxygenation with NIRS in patients with septic shock. This study provides the infrastructure necessary for a larger prospective observational study to further examine the relationship between brain tissue oxygenation, physiological parameters, and acute neurological dysfunction.
Sarcocystis neurona is an apicomplexan parasite that causes severe neurological disease in horses and marine mammals. The Apicomplexa are all obligate intracellular parasites that lack purine biosynthesis pathways and rely on the host cell for their purine requirements. Hypoxanthine-xanthine-guanine phosphoribosyltransferase (HXGPRT) and adenosine kinase (AK) are key enzymes that function in two complementary purine salvage pathways in apicomplexans. Bioinformatic searches of the S. neurona genome revealed genes encoding HXGPRT, AK and all of the major purine salvage enzymes except purine nucleoside phosphorylase. Wild-type S. neurona were able to grow in the presence of mycophenolic acid (MPA) but were inhibited by 6-thioxanthine (6-TX), suggesting that the pathways involving either HXGPRT or AK are functional in this parasite. Prior work with Toxoplasma gondii demonstrated the utility of HXGPRT as a positive-negative selection marker. To enable the use of HXGPRT in S. neurona, the SnHXGPRT gene sequence was determined and a gene-targeting plasmid was transfected into S. neurona. SnHXGPRT-deficient mutants were selected with 6-TX, and single-cell clones were obtained. These Sn∆HXG parasites were susceptible to MPA and could be complemented using the heterologous T. gondii HXGPRT gene. In summary, S. neurona possesses both purine salvage pathways described in apicomplexans, thus allowing the use of HXGPRT as a positive-negative drug selection marker in this parasite.
Hagiography is by definition about measuring the distance between the human and the sacred: the saint's own distance, but also the hagiographer's and ours. Reginald of Durham's late-twelfth-century life of Godric of Finchale, begun during the saint's lifetime and finished not long after his death, probes all sorts of distances. It is no accident that many of Godric's feats and miracles involve clairvoyance and its auditory equivalent: feats of overcoming spatial or temporal distances in one's seeing and one's hearing. The Vita has a precise sense of place, centered on Godric's cell in the forest, but within a concentric circle of larger and larger horizons: the region, the territory of Durham, the sea shore, the ocean, Jerusalem; for Godric was a seafaring merchant before he became a hermit, and also a Jerusalem pilgrim who lived in the Holy Land for several years.
There is not very much scholarly literature on Godric, but interest in him has been constant. There is even a modern novel about him. Historians have long recognized the Vita's value as testimony to many aspects of medieval culture that are rarely illuminated by the narrative sources of the period. It is a life of a man of the people. Pirenne drew attention to Godric's early life as a merchant, as an international trader, and as a man of relatively humble origins working his way up by engaging in trade. Tom Licence and Susan Ridyard have studied him as a lay religious figure, integrated – or perhaps coopted or even coerced – by the monks of Durham into their project of possessing, controlling, and shaping their surrounding territory both economically and spiritually. The monks gained in him a hermitage, a cell with adjacent lands – but they also acquired a revered lay saint who could help their outreach to the laity of the region by modeling a spiritual life appropriate to them. Michael Clanchy has discussed Godric as an interesting example of a layman living on the periphery of monastic and literate culture.
Violent disorder broke out in various parts of England during the political turmoil of 1326–7 and included particularly severe rioting in the monastic towns of Abingdon, St Albans, and Bury St Edmunds in Suffolk. In January 1327 agitators from London roused the townspeople at Bury to conspire to attack and destroy the abbey of St Edmund. An armed mob forced entrance through the gates of the abbey on 14 January and seized and imprisoned the officials of the convent and several monks. They carried away all the treasures of the abbey, including the charters, muniments, and papal bulls from the sacristy and the treasury. Accounts of the legal process that followed the riots show the magnitude of the abbey's losses: in one, the monks alleged that the rioters had carried off three copies of a charter of King Cnut in their favour and four copies of a charter in Harthacnut's name. So denuded were the archives that the abbot had to pay the king to stay a suit against him in the royal courts, since he claimed the deeds he would have used for the defence of his case had been stolen by the rioters.
Rebels targeted Bury's archives again during the Peasants' Revolt in 1381. This time, however, they sought not to destroy the deeds but rather to consult them for evidence to substantiate some of their own claims. Like the authors of cahiers de doléance produced by the third estate in France in 1789, the rebels believed that the burdens of taxation and obligation had fallen less heavily on earlier generations, and that the abbey’s earliest charters would confirm their view. They thus demanded that the monks produce, ‘in the sight of the commons’, the charters of liberty for ‘the vill which Cnut, the founder of the monastery had once granted’. The monks duly brought out before the guildhall all the charters they could find and showed them to the mayor, the aldermen, ‘and a whole crowd of villeins’. When the rebels declared themselves unhappy with the documents produced by the abbey, the monks agreed to search their charters again to find the evidence for the liberties which St Edmund’s claimed; further, they promised that if they found none, they would produce new ones to serve the purpose.
Contained in two manuscripts preserved in the Biblioteca Apostolica Vaticana is a little-known chronicle by an anonymous writer of the mid-twelfth century which may shed more light on an epoch-making event on the eve of the Crusades: the Norman conquest of Sicily. This source, collated into a single transcription by Giambattista Caruso in 1723 and reproduced in the Rerum Italicarum Scriptores by Ludovico Muratori in 1726, is called the Historia Sicula a Normannis ad Petrum Aragonensem by Anonymus Vaticanus. Despite the fact that it is one of a very few sources to describe a seminal episode in Mediterranean history, the Historia Sicula has not been discussed in any depth for over a century. This essay seeks to correct that oversight.
In his formative work, Mohammed and Charlemagne, the great Belgian historian Henri Pirenne contended that ‘the rapid and unexpected advance of Islam’ had precipitated ‘the end of Mediterranean unity’ by vanquishing the mare nostrum of ancient Rome. The resultant loss of Sicily to the Aghlabids of North Africa in the ninth century established what maritime historian A.R. Lewis termed ‘the Islamic Imperium’ and inspired the fourteenth-century Arab scholar Ibn Khaldūn to claim that ‘the Muslims had gained control over the whole of the Mediterranean’. At the beginning of the eleventh century, the Mediterranean was, in effect, a Muslim lake with most of its major islands, including Sicily, firmly ensconced in Dar al-Islam (the ‘House of Islam’).
A string of recent publications has sought to emphasize the relationship between the memorial and the material in the medieval period. Drawing on this body of work, this essay explores the dynamic relationship between physical objects and the memories associated with them in the Historia ecclesiastica of Orderic Vitalis. Written between c. 1114 and 1141 at the abbey of St Evroul, located in the pays d'Ouche on the southern frontier of Normandy, the massive thirteen-book Historia is widely recognized by scholars as being one of the most important sources for the history of the Anglo-Norman world and beyond, and it has been the subject of much study since the 1950s. Whilst it is a well known fact that Orderic drew on a large number of written and oral sources in the writing of the Historia, the exact role played by the material and the visual in this process has remained largely unexplored. The focus of this article is thus on the way in which these objects are described in Orderic's narrative and the implications of this for our understanding of the Historia as a whole.
Leonie Hicks has recently highlighted ‘the visibility of the past’ as an important theme in historical writing, observing that for the Anglo-Norman chroniclers, ‘monuments and places … were much more than just illustrations to or diversions from the main narrative: they were in fact integral to the message they were trying to convey'. Thus, while such descriptive passages are interesting in and of themselves, the purpose of examining this largely unexplored aspect of Orderic’s magnum opus here is to highlight the textual richness of the Historia and to demonstrate what these passages reveal about the purpose of its narrative. For the more one studies Orderic, the more one notices passages concerning objects that he claimed were still in existence at the time of his writing, such as a memorial roll, a Psalter, and a stone arch.
The study of crusading religious practices has often focused on practices undertaken at home or at the beginning of a crusade, such as liturgy or the practice of taking the cross. In contrast, the religious practices performed routinely during the crusade itself have been relatively less explored. Yet, analyzing the devotional activities of crusaders while they were actually on crusade has the potential to illuminate not only the crusading movement but also points of intersection and divergence between that movement and larger cultural trends. Furthermore, although some crusading accounts admittedly provide little information on the religious practices of crusaders, others are more forthcoming. Among these, the Anglo-Norman account of the 1147 conquest of Lisbon during the Second Crusade, the De expugnatione Lyxbonensi, is a particularly rich source of information on the daily religious lives of men and women on crusade.
As I will demonstrate, religious practices in the De expugnatione Lyxbonensi resonate with ideals and themes active in both contemporary monastic reform and the development of lay piety. Furthermore, they are articulated via the social customs associated with coniuratio, a sworn, oath-bound society. A connection between crusading and monastic ideals is hardly surprising, ever since Jonathan Riley-Smith noted that the First Crusaders were in effect ‘a military monastery on the move’. For the most part, however, historians' development of this idea has understandably focused on the ways in which crusaders were like monks and/or inhabited a similar ideological universe to that of advocates of reform monasticism.
Self-flagellation in the twenty-first century seems more masochistic than religious, and spirituality today has little place for the ascetical use of a whip or other instruments of torture. Yet the practice will not quite disappear. We see it in film, and not just in medieval contexts such as Ingmar Bergman's The Seventh Seal (1957) or Monty Python and the Holy Grail (1975), but also in contemporary manifestations such as Silas, the renegade Opus Dei member in Dan Brown's novel The Da Vinci Code (2003), or the video images of Shi'ite pilgrims flagellating themselves with chains and slashing their foreheads with swords while they commemorate 'Ashura.
Such forms of ascetic practice have long been studied in their Latin Christian context. According to the traditional narrative, which this study attempts to destabilize, self-flagellation was an ancient monastic expression of penance. How ancient has been debated, but certainly by the eleventh century it is well documented among Italian hermits. In the thirteenth century it would have entered lay society as part of the ‘monasticization of the laity’, the top-down process by which religious elites impose their values on the masses. In the words of André Vauchez, the preeminent authority on lay spirituality, ‘The confraternities of penitents and flagellants were clearly animated by the desire to appropriate the spiritual resources of monasticism…. The most telling example of this was flagellation — a monastic practice which some lay people in the thirteenth century appropriated in order to win the rewards associated with it.