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.
Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types.
Observational, retrospective study.
Tertiary-care, academic medical center in Madison, Wisconsin.
We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD.
Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident–led services used more antibiotics than senior resident–led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident–led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts.
Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.
ll antipsychotics act via dopaminergic receptor antagonism. This pharmacology is shared by all first (FGA) & second (SGA) generation antipsychotics. We reviewed the efficacy & safety of all antipsychotics in clinical use for BMJ Clinical Evidence (Barry et al 2012).
Methods & questions
Our paper summarises key results from this systematic review based on comprehensive literature search of the Medline, Embase, Cochrane Library, and other databases including safety information from the FDA and MHRA in UK. The main clinical questions of interest were: What is the efficacy of drug treatments for positive, negative, or cognitive symptoms of schizophrenia? How effective are treatments for people with schizophrenia resistant to standard antipsychotic drugs?
We found 51 systematic reviews, RCTs, or observational studies that met our inclusion/quality criteria and performed GRADE analysis to assess quality of evidence. Key results are presented for efficacy & safety for: amisulpiride, chlorpromazine, clozapine, depot haloperidol, haloperidol, olanzapine, pimozide, quetiapine, risperidone, sulpiride, ziprasidone, zotepine, aripiprazole, sertindole, paliperidone, flupentixol, depot flupentixol, zuclopenthixol, depot zuclopenthixol, and clozapine.
The evidence for some ‘standard’ treatments is surprisingly weak. Up to 1/3 -1/2 of patients fail to respond to currently available antipsychotics, and all antipsychotics cause side effects in most people. This downbeat conclusion is not surprising, given clinical experience and the common mechanism of action of all antipsychotics. More efficacious antipsychotic medication will only be developed from understanding the biological pathogenesis of schizophrenia.Barry S, Gaughin T, and Hunter R. Schizophrenia. BMJ Clinical Evidence 13 July 2012.
Empathy is critical to the development of professionalism in medical students, but evidence suggests that empathy actually declines over the course of undergraduate medical education.
Improving medical student empathy by encouraging students to think about the person behind the illness.
Two interventions were studied. From December 2015 until November 2016, a fourth year psychiatry medical student book club was conducted. Students were asked to read an autobiography of a lived experience of psychosis. The old age simulation suit aims to simulate the sensory and physical impairments faced by older adults with age related illnesses. A training session provided a transient experience of old age for the students.
Forty-four students completed the feedback on the book club. Twenty-eight (64%) stated that they strongly agreed with the statement ‘the book club encouraged me to consider the person behind the illness’. Thirty-nine (89%) stated that after attending the book club their empathy towards people with mental health problems had increased. Eleven students completed full feedback following the old age simulation session. Empathy statements relating to living in an ageing body improved from the pre-test median score of 4 (range 1–7) to a median score of 6 (range 2–8) post-teaching session. Empathy statements focusing on sensory and physical impairments had pre-test score median of 3 (range 1–7) and post-test median 8 (range 3–9).
Feedback from these sessions has demonstrated that with a little creativity, empathy training can be delivered to medical students with a positive impact.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
North East London NHS Foundation Trust (NELFT) provides an extensive range of integrated community and mental health services for people living in London serving a population of 1.5 million people. With an annual budget of £325 million NELFT is one of the largest community service providers in the United Kingdom (UK). NELFT is responsible for the education and training of the entire workforce and in August 2016, it employed a nurse fellow to work with the medical education fellows so it could focus on multidisciplinary team (MDT) teaching.
(1) Providing MDT teaching by delivered by a MDT medical education team.
(2) Improving the training experience of all trainees, nurses and allied health professionals in NELFT.
(3) Improving physical health knowledge for mental health staff.
(4) Improving mental health knowledge of physical health staff.
Two psychiatrists and one nurse manager worked together on joint projects to deliver the MDT teaching. Teaching sessions where at least one psychiatrist and nurse manager delivered teaching on serious incidents affecting patient care, identification and management of sepsis in community settings and empathy training using an old age simulation suit.
Multiple teaching sessions were delivered to MDTs within the Trust. Staffs were receptive to learning in MDTs rather than traditional splits according to professions. Due to the success of this teaching and the reputation of the medical education team, neighboring Trusts have expressed an interest in working in partnership with the team to further enhance teaching and learning in acute and community settings.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Role-playing scenarios are widely used in psychiatry education, both as a means of assessment and for teaching various clinical skills. But can you get as much from them by learning vicariously as an observer? Fourth-year medical students from Queen Mary University of London were invited to a psychiatry practice OSCE (objective structured clinical examination), shortly before end of year exams. We created 96 places, approximately 40% of the year, but to maximize numbers students also rotated through the six-station OSCE circuit in pairs. For each scenario students alternated either undertaking the OSCE task or observing.
Objectives and methods
We sought to identify if there was a significant difference in student experience depending on whether they were the ‘candidate’ or ‘observer’. Students were asked to rate their learning experience in each station on a five-point Likert scale and this was analyzed using an ordinal logistic regression model.
While students rated their experiences as ‘observers’ marginally lower than that of ‘candidates’, we found no statistically significant difference (OR = 0.629, P = 0.093). Practice OSCEs took place over six half-days with different facilitators and role-players, but we identified no interaction from these factors. For one station on depression, we found a statistically significant interaction in which ‘candidates’ rather than ‘observers’ rated better experiences (P = 0.032).
Observation by learners is frequently used within simulated clinical scenarios and may have a number of potential advantages. However, while unable to examine the direct impact on knowledge or skills, we found no significant difference in student-reported experiences between ‘candidate’ and ‘observer’ positions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Clinic referrals for attention-deficit/hyperactivity disorder (ADHD) and conduct problems are relatively common. Thus, utilizing evidence-based assessment approaches is particularly paramount for proper recognition of these difficulties and treatment planning. This chapter presents an overview of important considerations in clinical assessments of child behavioral difficulties, including the selection of assessment methods and informants. Importantly, research demonstrates that developmental factors (e.g., age of onset, differences in the manifestation of ADHD symptoms, and conduct problems) must be considered in the assessment process, and these issues as they relate to assessment procedures are noted. Additional areas of emphasis include the heterogeneous behaviors that fall under the umbrella of conduct problems and the need to assess for limited prosocial emotions in conjunction with evaluations for conduct disorder. A brief review of commonly used parent- and teacher-rating scales, technological advances, and cultural considerations is also provided.
Al-doped ZnO (AZO) is a promising earth-abundant alternative to Sn-doped In2O3 (ITO) as an n-type transparent conductor for electronic and photovoltaic devices. We have deposited AZO films with resistivities as low as 1.1 × 10−3 Ω·cm by atomic layer deposition (ALD) using trimethylaluminum (TMA), diethylzinc (DEZ), and water at 200 °C. The work functions of the films were measured using a scanning Kelvin probe (sKP) to investigate the role of aluminum concentration. The work function of AZO films prepared by two different ALD recipes were compared: a “Al-terminated” recipe and a “ZnO-terminated” recipe. As aluminum doping increases, the Al-terminated recipe produces films with a consistently higher work function than the ZnO-terminated recipe. The resistivity of the Al-terminated recipe films shows a minimum at a 1:16 Al:Zn atomic ratio and using a ZnO-terminated recipe, minimum resistivity was seen at 1:19. The film thicknesses were characterized by ellipsometry, chemical composition by EDX, and resistivity by a four-point probe.
We apply two methods to estimate the 21-cm bispectrum from data taken within the Epoch of Reionisation (EoR) project of the Murchison Widefield Array (MWA). Using data acquired with the Phase II compact array allows a direct bispectrum estimate to be undertaken on the multiple redundantly spaced triangles of antenna tiles, as well as an estimate based on data gridded to the uv-plane. The direct and gridded bispectrum estimators are applied to 21 h of high-band (167–197 MHz; z = 6.2–7.5) data from the 2016 and 2017 observing seasons. Analytic predictions for the bispectrum bias and variance for point-source foregrounds are derived. We compare the output of these approaches, the foreground contribution to the signal, and future prospects for measuring the bispectra with redundant and non-redundant arrays. We find that some triangle configurations yield bispectrum estimates that are consistent with the expected noise level after 10 h, while equilateral configurations are strongly foreground-dominated. Careful choice of triangle configurations may be made to reduce foreground bias that hinders power spectrum estimators, and the 21-cm bispectrum may be accessible in less time than the 21-cm power spectrum for some wave modes, with detections in hundreds of hours.
The objective was to determine the longitudinal associations between callous-unemotional (CU) and oppositional defiant (OD) behaviors from the first to fourth grades for Spanish children. Four possible outcomes were evaluated: (a) CU behaviors in the first grade predict increases in OD behaviors in the fourth grade, controlling for OD behaviors in the first grade; (b) OD behaviors in the first grade predict increases in CU behaviors in the fourth grade, controlling for CU behaviors in the first grade; (c) both unique effects are significant; and (d) neither unique effect is significant. A longitudinal panel model with two latent variables (CU and OD behaviors), three sources (mothers, fathers, teachers), and two occasions (spring of the first and fourth grades) was used to evaluate the four possibilities among 758 (54% boys) first grade and 469 (53% boys) fourth grade Spanish children. For mother-, father-, and teacher-reports, OD behaviors in the first grade predicted increases in CU behaviors in the fourth grade, after controlling for CU behaviors in the first grade, whereas CU behaviors in the first grade did not predict increases in OD behaviors in the fourth grade, after controlling for OD behaviors in the first grade. OD behaviors thus conferred independent vulnerability to increases in CU behaviors 3 years later among young children.
This study investigated the characteristics of subjective memory complaints (SMCs) and their association with current and future cognitive functions.
A cohort of 209 community-dwelling individuals without dementia aged 47–90 years old was recruited for this 3-year study. Participants underwent neuropsychological and clinical assessments annually. Participants were divided into SMCs and non-memory complainers (NMCs) using a single question at baseline and a memory complaints questionnaire following baseline, to evaluate differential patterns of complaints. In addition, comprehensive assessment of memory complaints was undertaken to evaluate whether severity and consistency of complaints differentially predicted cognitive function.
SMC and NMC individuals were significantly different on various features of SMCs. Greater overall severity (but not consistency) of complaints was significantly associated with current and future cognitive functioning.
SMC individuals present distinctive features of memory complaints as compared to NMCs. Further, the severity of complaints was a significant predictor of future cognition. However, SMC did not significantly predict change over time in this sample. These findings warrant further research into the specific features of SMCs that may portend subsequent neuropathological and cognitive changes when screening individuals at increased future risk of dementia.
The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT (i.e. methadone, buprenorphine) is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration.
This article argues that correctional institutions violate the Eighth Amendment when they refuse to establish MAT programs and prevent doctors from exercising medical judgment to properly treat incarcerated people with OUD.
Nurses are critical to the research enterprise. However all nurses are not prepared to participate as members of the research team since education and training in clinical research nursing and nurse-specific Good Clinical Practice are not consistently included in nursing curricula. The lack of nurse education and training in clinical research and Good Clinical Practice leaves research participants vulnerable with a nursing workforce that is not prepared to balance fidelity to protocol and patient quality care and safety.
A collaborative network of nurses within Clinical and Translational Science Awards and beyond was established to address this education and training need. Over a 2-year period, using expert opinion, Delphi methods, and measures of validity and reliability the team constructed curriculum and knowledge test items.
A pilot modular electronic curriculum, including knowledge pretest and post-tests, in clinical research nursing and nurse-specific Good Clinical Practice competencies was developed.
As the scope and setting of clinical research changes, it is likely that all practicing nurses, regardless of their practice setting or specialty, will care for patients on research protocol, making all nurses, in essence, clinical research nurses. The curriculum developed by this protocol will address that workforce education and training need.
We begin the discussions of finite nuclei with some general remarks on the systematics of the nuclear ground state. For even-even nuclei (nuclei with an even number of both protons and neutrons) the nucleons making up the nucleus form pairs containing one spin-up and one spin-down nucleon to yield a net spin of zero and even parity. In Chapter 15 we consider elastic electron scattering from such nuclei as the paradigm for what follows. Odd-even and even-odd nuclei often, but not always, have the same spin as the last unpaired valence nucleon; we shall see examples when discussing elastic magnetic electron scattering and magnetic moments also in Chapter 15. Finally, odd-odd nuclei are somewhat unusual. There exist only four stable nuclei having unpaired protons and neutrons, namely, 2H, 6Li, and 14N with spin-parity 1+, and 10B having 3+. The basic characteristics of the known nuclei are the following: they occupy a region in the NZplane whose central valley runs roughly along the N = Z line at values of A below 40 and then bends towards the region having higher values of N than of Z, as shown in Fig. 13.1. Taking cuts across the valley at either constant Z or at constant N, one climbs out of the valley, on the average moving to less bound nuclei until reaching the so-called drip-lines where nuclei are no longer stable to proton or neutron emission. At the bottom of the valley, where the most stable nuclei reside, one finds the binding energy per nucleon to be relatively constant for nuclei beyond A = 40 at a value ̴ 8.5 MeV per nucleon, as shown in Fig. 13.2 and, as the values of N and Z where stable nuclei exist become very large, this valley of stability narrows and then disappears.
One of the key questions in studies of nuclear systematics is: Do “islands of stability” exist at even higher N, Z-values, the so-called superheavy nuclei? An island of stability, first conjectured by Seaborg in the 1960s, is a collection of heavier isotopes of transuranic elements, expected to be more stable than those closer in atomic number to uranium with radioactive decay half-lives of minutes to days.
The past one hundred years has witnessed enormous advances in human understanding of the physical universe in which we have evolved. For the past fifty years or so, the Standard Model of the subatomic world has been systematically developed to provide the quantum mechanical description of electricity and magnetism, the weak interaction, and the strong force. Symmetry principles, expressed mathematically via group theory, serve as the backbone of the Standard Model. At this time, the Standard Model has passed all tests in the laboratory. Notwithstanding this success, most of the matter available to experimental physicists is in the form of atomic nuclei. The most successful description of nuclei is in terms of the observable protons, neutrons, and other hadronic constituents, and not the fundamental quarks and gluons of the Standard Model. Thus, the professional particle or nuclear physicist should be comfortable in applying the hadronic description of nuclei to understanding the structure and properties of nuclei. Experimentally, lepton scattering has proved to be the cleanest and most effective tool for unraveling the complicated structure of hadrons. Its application over different energies and kinematics to the nucleon, fewbody nuclei, and medium- and heavy-mass nuclei has provided the solid body of precise experimental data on which the Standard Model is built.
In addition, the current understanding of the microcosm described in this book provides answers to many basic questions: How does the Sun shine? What is the origin of the elements? How old is the Earth? Further, it underscores many aspects of modern human civilization, e.g., MRI imaging uses the spin of the proton, nuclear isotopes are essential medical tools, nuclear reactions have powered the Voyager spacecraft since 1977 into interstellar space.
The purpose of the book is to allow the graduate student to understand the foundations and structure of the Standard Model, to apply the Standard Model to understanding the physical world with particular emphasis on nuclei, and to establish the frontiers of current research. There are many outstanding questions that the Standard Model cannot answer. In particular, astrophysical observation strongly supports the existence of dark matter, whose direct detection has thus far remained elusive.