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Assessing risk is an important core skill yet there is not a consensus as to how to teach it. Clinically, there has been a move away from using risk prediction tools in favour of clinical judgement.We describe an iterative process to develop high quality, online teaching around risk assessment for medical undergraduates.
To teach the clinical skill of risk assessment to enable medical students to evaluate and manage risk when encountering patients with mental health issues.
A half day tutorial was designed and refined in an iterative process using feedback from participants on this session and other concurrent teaching occurring in the department. Sessions were also reviewed by external medical educators to ensure quality and learning objectives were met.
The average rating from 62 students was 4.4/5. Students commented that the session was well organised and delivered. Following feedback, the use of actors was prioritised to simulate evolving clinical situations. Students placed a high value on this: “simulated patients were amazing! They were really interesting and I was able to practice the skills I learnt over placement”. Logistical changes e.g. more breaks, followed appreciation of the exhausting nature of the session and maintained student engagement. There was increased emphasis on promoting group interaction through functions like a ‘break-out room’.
This session may give educators confidence that they can take risks when teaching the skill of risk assessment. Students were receptive and meaningfully engaged with concepts such as clinical judgement and bio-psycho-social formulations as opposed to ‘tick box’ assessments.
Immediate facial nerve reconstruction is the standard of care following radical parotidectomy; however, quality of life comparisons with those undergoing limited superficial parotidectomy without facial nerve sacrifice is lacking.
Patients who underwent parotidectomy were contacted to determine quality of life using the University of Washington Quality of Life and Parotidectomy Specific Quality of Life questionnaires. A total of 29 patients (15 in the radical parotidectomy and 14 in the limited superficial parotidectomy groups) completed and returned questionnaires.
Using the University of Washington Quality of Life Questionnaire, similar quality of life was noted in both groups, with the radical parotidectomy group having significantly worse speech and taste scores. Using the Parotidectomy Specific Quality of Life Questionnaire, the radical parotidectomy group reported significantly worse speech, eye symptoms and eating issues.
Those undergoing radical parotidectomy with reconstruction had comparable overall quality of life with the limited superficial parotidectomy group. The Parotidectomy Specific Quality of Life Questionnaire better identified subtle quality of life complaints. Eye and oral symptoms remain problematic, necessitating better rehabilitation and more focused reconstructive efforts.
Identifying predictors of patient outcomes evaluated over time may require modeling interactions among variables while addressing within-subject correlation. Generalized linear mixed models (GLMMs) and generalized estimating equations (GEEs) address within-subject correlation, but identifying interactions can be difficult if not hypothesized a priori. We evaluate the performance of several variable selection approaches for clustered binary outcomes to provide guidance for choosing between the methods.
We conducted simulations comparing stepwise selection, penalized GLMM, boosted GLMM, and boosted GEE for variable selection considering main effects and two-way interactions in data with repeatedly measured binary outcomes and evaluate a two-stage approach to reduce bias and error in parameter estimates. We compared these approaches in real data applications: hypothermia during surgery and treatment response in lupus nephritis.
Penalized and boosted approaches recovered correct predictors and interactions more frequently than stepwise selection. Penalized GLMM recovered correct predictors more often than boosting, but included many spurious predictors. Boosted GLMM yielded parsimonious models and identified correct predictors well at large sample and effect sizes, but required excessive computation time. Boosted GEE was computationally efficient and selected relatively parsimonious models, offering a compromise between computation and parsimony. The two-stage approach reduced the bias and error in regression parameters in all approaches.
Penalized and boosted approaches are effective for variable selection in data with clustered binary outcomes. The two-stage approach reduces bias and error and should be applied regardless of method. We provide guidance for choosing the most appropriate method in real applications.
Child protection work is one of the most difficult and complex areas of human services practice. Working within a trauma-laden environment often means that practitioner susceptibility to trauma-related mental health issues is an occupational hazard. However, many practitioners are reluctant to seek support when they start to experience symptoms of traumatic stress. This paper considers current literature relating to child protection workers’ exposure to work-related traumatic material, resulting traumatic stress symptomology and organisational responses to practitioner distress. Results from a recent doctoral study that explores the experiences of child protection practitioners based in Queensland will be presented. Findings from the study were derived from qualitative in-depth, semi-structured interviews. The study findings indicate that the organisational culture within statutory child protection agencies creates an environment where practitioners are labelled as incompetent or not suitable for child protection work when they disclose experiencing symptoms of traumatic stress. The experience of bullying and retribution by supervisors and colleagues and the fear of rejection by the workgroup were also found to be significant barriers for workers seeking support.
Depression in older people is likely to become a growing global health problem with aging populations. Significant cultural variation exists in beliefs about depression (terminology, symptomatology, and treatments) but data from sub-Saharan Africa are minimal. Low-resource interventions for depression have been effective in low-income settings but cannot be utilized without accurate diagnosis. This study aimed to achieve a shared understanding of depression in Tanzania in older people.
Using a qualitative design, focus groups were conducted with participants aged 60 and over. Participants from rural villages of Kilimanjaro, Tanzania, were selected via randomized sampling using census data. Topic guides were developed including locally developed case vignettes. Transcripts were translated into English from Swahili and thematic analysis conducted.
Ten focus groups were held with 81 participants. Three main themes were developed: a) conceptualization of depression by older people and differentiation from other related conditions (“too many thoughts,” cognitive symptoms, affective and biological symptoms, wish to die, somatic symptoms, and its difference to other concepts); b) the causes of depression (inability to work, loss of physical strength and independence, lack of resources, family difficulties, chronic disease); c) management of depression (love and comfort, advice, spiritual support, providing help, medical help).
This research expands our understanding of how depression presents in older Tanzanians and provides information about lay beliefs regarding causes and management options. This may allow development of culturally specific screening tools for depression that, in turn, increase diagnosis rates, support accurate diagnosis, improve service use, and reduce stigma.
Joyce Carol Oates (1938– ) is an American author, National Book Award winner, and professor at Princeton University. Her entry here, “Secret Observations on the Goat-Girl” (1988) is a delightful twist on the monster. The goat-girl, which the narrator names Astrid, physically resembles a faun from Greco-Roman mythology, though there are few—if any— other similarities.
Astrid seems to be connected with the narrator's family in some important but unspoken way. This familial connection is what sets Oates's entry apart from the others, for the monster is as much an avenue for thinking about the dynamics of a particular family as it is thinking about the monster itself. The “observations” lead the reader to no better understanding of Astrid, but they do lead to a better understanding of the narrator's family. Oates uses the way the narrator, her brother, her father, and her mother think about and respond to the goat-girl to tell us so much about these characters and their relationships to each other. There is the typically stoic refusal to acknowledge or discuss the abnormal, the desire to kill the thing that disrupts or causes discomfort, and empathy for the outcast and those less fortunate. The goat-like physical form and the possible blindness, just like the goat-girl herself, is not at the centre of the story; instead, the story is about how a family and individuals adapt (or fail to adapt) to something unexpected and outside the pale. Oates's short tale illustrates the ability of the monster to reinforce or challenge norms and reveals the social manner in which we define our individual identities.
Are you able to create a mental picture of Astrid? If not, think about what Oates has withheld that you might need to create one. If so, go back through the story to see if your mental picture matches with the details given or if you’ve filled in the blanks spots with your own imagination.
Astrid is greatly disturbing to everyone except the narrator, and Oates leaves something unspoken about this family dynamic that seems to revolve around Astrid. Speculate about why these characters allow something disturbing to remain so close to them for years.
Earthquakes associated with gas production have been recorded in the northern part of the Netherlands since 1986. The Huizinge earthquake of 16 August 2012, the strongest so far with a magnitude of ML = 3.6, prompted reassessment of the seismicity induced by production from the Groningen gas field. An international research programme was initiated, with the participation of many Dutch and international universities, knowledge institutes and recognised experts.
The prime aim of the programme was to assess the hazard and risk resulting from the induced seismicity. Classic probabilistic seismic hazard and risk assessment (PSHA) was implemented using a Monte Carlo method. The scope of the research programme extended from the cause (production of gas from the underground reservoir) to the effects (risk to people and damage to buildings). Data acquisition through field measurements and laboratory experiments was a substantial element of the research programme. The existing geophone and accelerometer monitoring network was extended, a new network of accelerometers in building foundations was installed, geophones were placed at reservoir level in deep wells, GPS stations were installed and a gravity survey was conducted.
Results of the probabilistic seismic hazard and risk assessment have been published in production plans submitted to the Minister of Economic Affairs, Winningsplan Groningen 2013 and 2016 and several intermediate updates. The studies and data acquisition further constrained the uncertainties and resulted in a reduction of the initially assessed hazard and risk.
This paper reviews the evolution of a sequence of seismological models developed and implemented as part of a workflow for Probabilistic Seismic Hazard and Risk Assessment of the seismicity induced by gas production from the Groningen gas field. These are semi-empirical statistical geomechanical models derived from observations of production-induced seismicity, reservoir compaction and structure of the field itself. Initial versions of the seismological model were based on a characterisation of the seismicity in terms of its moment budget. Subsequent versions of the model were formulated in terms of seismic event rates, this change being driven in part by the reduction in variability of the model forecasts in this domain. Our approach makes use of the Epidemic Type After Shock model (ETAS) to characterise spatial and temporal clustering of earthquakes and has been extended to also incorporate the concentration of moment release on pre-existing faults and other reservoir topographic structures.
Little is known about the current views and practices of healthcare professionals (HCPs) in Sub-Saharan Africa (SSA) regarding delivery of hospital palliative care. The present qualitative study explored the views of nursing staff and medical professionals on providing palliative and end-of-life care (EoLC) to hospital inpatients in Tanzania.
Focus group discussions were conducted with a purposive sample of HCPs working on the medical and pediatric wards of the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania. Transcriptions were coded using a thematic approach.
In total, 32 healthcare workers were interviewed via 7 focus group discussions and 1 semistructured interview. Four major themes were identified. First, HCPs held strong views on what factors were important to enable individuals with a life-limiting diagnosis to live and die well. Arriving at a state of “acceptance” was the ultimate goal; however, they acknowledged that they often fell short of achieving this for inpatients. Thus, the second theme involved identifying the “barriers” to delivering palliative care in hospital. Another important factor identified was difficulty with complex communications, particularly “breaking bad news,” the third theme. Fourth, participants were divided about their personal preferences for “place of EoLC,” but all emphasized the benefits of the hospital setting so as to enable better symptom control.
Significance of results:
Despite the fact that all the HCPs interviewed were regularly involved in providing palliative and EoLC, they had received limited formal training in its provision, although they identified such training as a universal requirement. This training gap is likely to be present across much of SSA. Palliative care training, particularly in terms of communication skills, should be comprehensively integrated within undergraduate and postgraduate education. Research is needed to develop culturally appropriate curricula to equip HCPs to manage the complex communication challenges that occur in caring for a diverse inpatient group with palliative care needs.
The Russian and American media spheres converged to an unprecedented degree during the 2016 US presidential elections when reports of a possible dossier on Donald Trump emerged. This article considers the degree to which the media tactic of kompromat, which is the Russian abbreviation for “compromising material,” can infiltrate the US media ecology.
This study examined the response of forage crops to composted dairy waste (compost) applied at low rates and investigated effects on soil health. The evenness of spreading compost by commercial machinery was also assessed. An experiment was established on a commercial dairy farm with target rates of compost up to 5 t ha−1 applied to a field containing millet [Echinochloa esculenta (A. Braun) H. Scholz] and Pasja leafy turnip (Brassica hybrid). A pot experiment was also conducted to monitor the response of a legume forage crop (vetch; Vicia sativa L.) on three soils with equivalent rates of compost up to 20 t ha−1 with and without ‘additive blends’ comprising gypsum, lime or other soil treatments. Few significant increases in forage biomass were observed with the application of low rates of compost in either the field or pot experiment. In the field experiment, compost had little impact on crop herbage mineral composition, soil chemical attributes or soil fungal and bacterial biomass. However, small but significant increases were observed in gravimetric water content resulting in up to 22.4 mm of additional plant available water calculated in the surface 0.45 m of soil, 2 years after compost was applied in the field at 6 t ha−1 dried (7.2 t ha−1 undried), compared with the nil control. In the pot experiment, where the soil was homogenized and compost incorporated into the soil prior to sowing, there were significant differences in mineral composition in herbage and in soil. A response in biomass yield to compost was only observed on the sandier and lower fertility soil type, and yields only exceeded that of the conventional fertilizer treatment where rates equivalent to 20 t ha−1 were applied. With few yield responses observed, the justification for applying low rates of compost to forage crops and pastures seems uncertain. Our collective experience from the field and the glasshouse suggests that farmers might increase the response to compost by: (i) increasing compost application rates; (ii) applying it prior to sowing a crop; (iii) incorporating the compost into the soil; (iv) applying only to responsive soil types; (v) growing only responsive crops; and (vi) reducing weed burdens in crops following application. Commercial machinery incorporating a centrifugal twin disc mechanism was shown to deliver double the quantity of compost in the area immediately behind the spreader compared with the edges of the spreading swathe. Spatial variability in the delivery of compost could be reduced but not eliminated by increased overlapping, but this might represent a potential 20% increase in spreading costs.