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 firstname.lastname@example.org
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.
Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.
To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.
Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.
Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient’s mental capacity at the time of writing), time constraints and significant legal/ethical complexities.
The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.
Declaration of interest
D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
The mental health of university students, especially medical students, is of growing concern in the UK.
To estimate the prevalence of mental disorder in health sciences students and investigate help-seeking behaviour.
An online survey from one English university (n = 1139; 53% response rate) collected data on depression (using the nine-item Patient Health Questionnaire), anxiety (seven-item Generalised Anxiety Disorder Assessment), alcohol use (Alcohol Use Disorders Identification Test), self-harm and well-being, as well as help seeking.
A quarter of the students reported symptoms of moderate/severe depression and 27% reported symptoms of moderate/severe anxiety. Only 21% of students with symptoms of severe depression had sought professional help; the main reason for not seeking help was fear of documentation on academic records.
The study highlights the extent of mental health problems faced by health science students. Barriers to help seeking due to concerns about fitness-to-practise procedures urgently need to be addressed to ensure that this population of students can access help in a timely fashion.
In mammalian assemblages, size distributions reflect conditions of vegetation and climate as well as biotic interactions among mammals. Paleogene (Wyoming/Montana) and Neogene (Siwalik) mammalian faunas depict strikingly different size distributions in the cenograms below (rank v. size of herbivorous and omnivorous species), because evolutionary increase to substantial size did not become widespread among lineages until the middle Eocene (after our record).
In the Paleocene to early Eocene, substantial faunal turnover with accompanying change in guild structure occurred with little change in size distributions. While maintaining relatively small sizes, lineages of modern mammalian orders replaced species from archaic groups. However, most mammalian lineages experienced size increase, especially through the Wasatchian (early Eocene).
From the middle to late Miocene, significant size increases occurred upsection within several families of Siwalik carnivores, artiodactyls, and rodents. Families of insectivores, primates, proboscideans, and perissodactyls exhibited little change in species sizes despite changes in species composition and number. The trend toward increasing size preceded the widespread development of C4 grasslands in the Siwaliks, suggesting that biotic rather than abiotic factors influenced the size increase.
Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.
To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.
A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.
In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).
Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.
Fieldwork conducted in the Wasatch Formation in and around Fossil Butte has yielded a diverse assemblage of early Eocene vertebrates. Fossil vertebrates are distributed through three discrete stratigraphic intervals within the uppermost 180 m of the main body of the Wasatch Formation underlying the Green River Formation. These assemblages were derived primarily from fluvial overbank mudstone units overprinted with variably well-developed paleosols. The lowest (20 m) and highest (60 m) sections are characterized by less mature and more hydromorphic paleosols, whereas the middle section (100 m) is typified by more mature paleosols and more abundant channel sandstones.
The combined assemblages contain at least 46 species of mammals. Faunal characteristics include high abundances of equid perissodactyls and a relatively high abundance and diversity of notharctines primates, an apparent absence of omomyid primates, relatively high rodent diversity, and relatively diverse and abundant artiodactyls. One new genus (Eoictops new genus) and three new species (Eoictops novaceki new species, Palaeosinopa lacus new species, and ?Notoparamys blochi new species) are included in the Fossil Butte assemblage. Also recorded are late occurrences of two hyopsodontid condylarths and an early occurrence of a rare phenacodontid condylarth. The relatively high abundances of equids and notharctines suggest that vertebrate samples were derived from relatively open paleohabitats that included forested areas along water courses.
All three assemblages contain characteristic Lysitean (Wasatchian biochron Wa-6) elements, but the occurrence of the palaeotheriid perissodactyl Lambdotherium in the uppermost horizon indicates a Lostcabinian (Wa-7) age for at least the top of the Wasatch Formation. The overlying predominantly fish-bearing Fossil Butte Member of the Green River Formation also contains Lambdotherium and is therefore Wa-7 in age as well.
Borings in fossil turtle shells collected from the lowermost beds of the early Eocene Cathedral Bluffs Tongue of the Wasatch Formation in the northwestern part of the Green River Basin near South Pass, Wyoming, are herein described. Individual turtle shells in the study area are characterized by as few as one or two and as many as >100 borings. The borings include both non-penetrative forms (those which do not pass fully though the shell) as well as penetrative forms (those which pass fully from the exterior to the interior surface of the shell). All non-penetrative forms occur on external surfaces of the carapace and plastron (i.e. those that would have been accessible while the host taxon was alive). Two new ichnogenera and four new ichnospecies are established to describe these borings. Karethraichnus (new ichnogenus) includes three ichnospecies: K. lakkos (new ichnospecies), K. kulindros (new ichnospecies), and K. fiale (new ichnospecies). Karethraichnus lakkos are shallow (non-penetrating), hemispherical pits with rounded, to flattened bases. Karethraichnus kulindros are deep, non-penetrative traces with a cylindrical profile, an axis approximately perpendicular to the substrate surface and with rounded to flattened, hemispherical termini. Karethraichnus fiale are penetrative traces with a cylindrical to bi-convex or flask-shaped profile, and an axis approximately perpendicular to the substrate surface. Thatchtelithichnus (new ichnogenus) Thatchtelithichnus holmani (new ichnospecies) consist of non-penetrative borings into a bone substrate. They consist of a ring-shaped trace, with a central pedestal or platform. The position of the borings on the shells, and evidence of syn-emplacement healing of the borings in several of the turtles, indicates that these borings were emplacement by ectoparasites/mesoparasites while the animals were living. Similar traces in modern emydid turtles are attributed to ticks, leeches, or spirorchid liver flukes.
Although a great deal has been written about the perestroika movement in turn-of-the century political science its actual place in the history of the discipline has been poorly understood by its founders, defenders, and critics. Perestroika can be best understood as a manifestation of the persistent crises of identity that have characterized the discipline of political science, and it cannot be explained apart from the manner in which it was reflection of issues that attended both the origins of the field and periods such as the 1920s and aftermath of the behavioral era. What has been particularly important in each case has been the impact on both American politics and political science of the ethic of pluralism, which has created significant difficulties for both the practical and epistemic relationship between the discipline and its subject matter. — John Gunnell.
This essay is followed by responses from James Farr, Robert O. Keohane, David D. Laitin, Kristen Renwick Monroe, Anne Norton, and Sanford F. Schram. John Gunnell then offers a response to commentators.
Man Is by Nature a Political Animal: Evolution, Biology, and Politics. Edited by Peter K. Hatemi and Rose McDermott. Chicago: The University of Chicago Press, 2011. 352p. $80.00 cloth, $27.50 paper.
Peter K. Hatemi and Rose McDermott's Man Is by Nature a Political Animal brings together some of the most important social scientists working at the intersection of political science, psychology, biology, and cognitive neuroscience. Given recent advances in cognitive neuroscience and given the proliferation of work in political science that draws on these advances, we have decided to invite a range of political scientists to comment on the promise and the limits of this line of inquiry. What can scientific developments in psychology, biology, and neuroscience tell us about “human nature”? Can these discourses reckon with the variation in time and space that has traditionally been at the heart of political science, perhaps even going back to the classic text from which Hatemi and McDermott derive their title, Aristotle's Politics?—Jeffrey C. Isaac, Editor
The turn to the philosophy of scientific realism as a meta-theory for the study of International Relations manifests a reluctance to confront the basic problem of the relationship between philosophy and social scientific inquiry. Despite the realists' rejection of traditional empiricism, and particularly the instrumentalist account of scientific theory, the enthusiasm for realism neglects many of the same problems that, more than a generation earlier, were involved in the social scientific embrace of positivism. One of these problems was a lack of understanding regarding the character and history of the philosophy of natural science and its relationship and applicability to the study of social phenomena. Proponents of realism have also neither adequately articulated and defended realism as a philosophical position, and distinguished it from other perspectives, nor confronted the fundamental challenge to realism and other foundationalist philosophies which has been mounted by the contemporary critique of traditional representational philosophy.
Hanging is the most frequently used method of suicide in the UK and has high case fatality (>70%).
To explore factors influencing the decision to use hanging.
Semi-structured qualitative interviews with 12 men and 10 women who had survived a near-fatal suicide attempt. Eight respondents had attempted hanging. Data were analysed thematically and with constant comparison.
Hanging was adopted or contemplated for two main reasons: the anticipated nature of a death from hanging; and accessibility. Those favouring hanging anticipated a certain, rapid and painless death with little awareness of dying and believed it was a ‘clean’ method that would not damage the body or leave harrowing images for others. Materials for hanging were easily accessed and respondents considered it ‘simple’ to perform without the need for planning or technical knowledge. Hanging was thus seen as the ‘quickest’ and ‘easiest’ method with few barriers to completion and sometimes adopted despite not being a first choice. Respondents who rejected hanging recognised it could be slow, painful and ‘messy’, and thought technical knowledge was needed for implementation.
Prevention strategies should focus on countering perceptions of hanging as a clean, painless and rapid method that is easily implemented. However, care is needed in the delivery of such messages as some individuals could gain information that might facilitate fatal implementation. Detailed research needs to focus on developing and evaluating interventions that can manage this tension.
Despite the impact of Leo Strauss on American political science and political theory, where, exactly, Strauss was “coming from,” in both senses of that phrase, has been far from clear. Carl Friedrich, reviewing the, at that point, unknown author's book on Hobbes, noted that Strauss might have been more forthcoming about his own position, but he believed that it was safe to conclude that he was a “historical relativist.” Friedrich may have been closer to the mark than many subsequent commentators realized, but in order to understand Strauss's work, it is necessary to return to the universe he inhabited before “coming to America.” Since Strauss's death, his enterprise has been subject to careful scrutiny, but his early life and work have remained opaque.
The implementation of a revised government strategy for UK health research led to a reorientation of primary care research, largely focused on recruitment to, and involvement in, clinical trials. This reorientation prompted consideration of new approaches to developing clinical research facilities able to deliver this agenda. The provision of local enhanced services (LES) allow primary care organizations to provide additional services and thereby offer potential for involving primary care staff in clinical research. This paper describes the development and evaluation of one such LES scheme in the East of England, and highlights potential barriers and facilitators to progress.
In the evolution of the social sciences, disciplines (forms of research, training, and instruction) preceded professions (distinct occupational identities). Although professionalism has often been viewed as a conservative force, what was arguably the most prominent transformation in the history of political science was the result of a professional challenge to the discipline. The founding of the American Political Science Association represented not only an ideological break with some of the principal voices in the discipline but a reformulation of the reigning vision of the relationship between political science and politics. Despite the markedly different circumstances, the dissenting claims emanating from the subfield of political theory during the behavioral era reflected, in many respects, a similar form of confrontation.
As Thomas Kuhn noted, it is almost inevitable that scientific practitioners read the history of their field backward and perceive earlier stages as, at best, prototypical of the present. This is the manner in which political scientists, and even historians, have imaged the relationship between the debates about science and democracy that took place during the 1920s and 1950s. Despite the importance of Charles Merriam's role in the history of American political science, his work was not the discursive axis of the paradigmatic disciplinary shift that took place in the first quarter of the 20th century. It was the arguments of G. E. G. Catlin and W. Y. Elliott that most distinctly represented the transformation in both the theory of democracy and the image of science, and that, for the next two generations, set the terms of the debate about these issues as well as about the relationship between the mainstream discipline and the subfield of political theory. And, despite the theoretical and ideological differences between Catlin and Elliott, their exchange points to the intensely practical concerns that originally informed the controversy about the scientific study of politics.
In his introduction to the 1991 edition of Louis Hartz's The Liberal Tradition in America, journalist Tom Wicker noted its relevance for understanding the ambivalent appeal of values that had led both to the downfall of communism and to the “demonization” of Saddam Hussein. Wicker also noted that Hartz's synoptic use of “liberal” as encompassing what is commonly referred to in American political discourse as “liberal” and “conservative” ideologies might “add to some Americans' confusion” about the already “confused and abused” use of the term. As we reach the fiftieth anniversary of the publication of Hartz's book, it is important to reassess the work, especially in light of what might seem an obvious parallel between his concerns in the context of the Cold War and contemporary worries about the relationship between American foreign policy and domestic politics that has evolved since 2001. Whether the valence has been negative or positive, Hartz's image of a liberal consensus in the United States has created a picture that has held the academic mind captive and shaped its approach to both scholarship and political analysis.