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Religious believers are often commanded to love like God. On classical accounts, God seems a poor model for human beings: an immutable and impassable being seems incapable of the kind of episodic emotion (sympathy, empathy) that seems required for the best sorts of human love. Models more conducive to human love, on the other hand, are often rejected because they seem to limit God's power and glory. This Element looks first at God and then divine love within the Abrahamic traditions—Islam, Christianity and Judaism. It will then turn to love and the problem of hell, which is argued as primarily a problem for Christians. The author discusses the kind of love each tradition asks of humans and wonders, given recent work in the relevant cognitive and social sciences, if such love is even humanly possible. This title is also available as Open Access on Cambridge Core.
This national pre-pandemic survey compared demand and capacity of adult community eating disorder services (ACEDS) with NHS England (NHSE) commissioning guidance.
Thirteen services in England and Scotland responded (covering 10.7 million population). Between 2016–2017 and 2019–2020 mean referral rates increased by 18.8%, from 378 to 449/million population. Only 3.7% of referrals were from child and adolescent eating disorder services (CEDS-CYP), but 46% of patients were aged 18–25 and 54% were aged >25. Most ACEDS had waiting lists and rationed access. Many could not provide full medical monitoring, adapt treatment for comorbidities, offer assertive outreach or provide seamless transitions. For patient volume, the ACEDS workforce budget was 15%, compared with the NHSE workforce calculator recommendations for CEDS-CYP. Parity required £7 million investment/million population for the ACEDS.
This study highlights the severe pressure in ACEDS, which has increased since the COVID-19 pandemic. Substantial investment is required to ensure NHS ACEDS meet national guidance, offer evidence-based treatment, reduce risk and preventable deaths, and achieve parity with CEDS-CYP.
Handaxes have a uniquely prominent role in the history of Palaeolithic archaeology, and their early study provides crucial information concerning the epistemology of the field. We have little conclusive evidence, however, of their investigation or societal value prior to the mid seventeenth century. Here we investigate the shape, colour and potential flake scarring on a handaxe-like stone object seen in the Melun Diptych, painted by the French fifteenth-century artist Jean Fouquet, and compare its features with artefacts from diverse (including French) Acheulean handaxe assemblages. Commissioned by a high-status individual, Étienne Chevalier, Fouquet's work (Étienne Chevalier with Saint Stephen) depicts an important religious context, while the handaxe-like object points to the stoning to death of an important Christian saint. Our results strongly support the interpretation that the painted stone object represents a flint Acheulean handaxe, likely sourced from northern France, where Fouquet lived. Identifying a fifteenth-century painting of a handaxe does not change what we know about Acheulean individuals, but it does push back the evidence for when handaxes became a prominent part of the ‘modern’ social and cultural world.
1. To evaluate demand, capacity and flow of an integrated community learning disability service in a peri- and post-COVID-19 pandemic setting. 2. To improve flow of a community learning disability service. 3. To improve staff and service user satisfaction by engaging them and identifying common priorities.
We collected demand and capacity data of all disciplines in a community learning disability service for 2021–2022.
We carried out focus groups with service users and their carers (N = 5) and surveyed them with a questionnaire consisting of 6 quantitative and 2 qualitative questions (N = 63), investigating the impact of waiting times on service user experience.
We surveyed staff from all disciplines (N = 20) with a questionnaire consisting of 3 qualitative questions, to identify their views on waiting times and areas to optimise.
We performed thematic analysis on all qualitative responses. We analysed quantitative data with descriptive statistics.
From 2021–22, the number of accepted referrals to individual disciplines increased: for example referrals to psychiatry increased by 51.6% and referrals to OT increased by 32%.
With regard to flow, the ratio of discharges to accepted referrals in the psychiatry discipline decreased from 1.5:1 to 0.6:1.
A significant proportion of service users reported waiting months (31%) or years (16%) to be seen by the learning disability team. 28% of service users reported additional problems while waiting to be seen. 31% were unaware whether they were on a waiting list or not. Quantitative data showed average waiting times for psychiatry services did not change from 2021–2022 (23.1 and 23.3 days respectively).
Thematic analysis from service users’ responses revealed an anxiety about needs not being met; a feeling of problems deteriorating while waiting; and communication issues.
Staff responses revealed desires to intervene sooner to prevent unnecessary deteriorations; and to increase team working between disciplines.
Quantitative data analysis suggests a greatly increased demand for our service following the COVID-19 pandemic.
Our thematic analysis identifies concern of deterioration secondary to prolonged waiting times. It also highlights that communication could be improved.
As a result of this mixed-methods approach, the following change ideas were generated and are now being tested:
1. Improve communication with patients on waiting lists by testing an accessible customisable letter.
2. Organise more joint assessments and reviews of service users with multiple disciplines.
3. Short-term allocation of more urgent casework via a new integrated health and social care duty system.
Recent developments in computational psychiatry have led to the hypothesis that mood represents an expectation (prior belief) on the likely interoceptive consequences of action (i.e. emotion). This stems from ideas about how the brain navigates its external world by minimising an upper bound on surprisal (free energy) of sensory information and echoes developments in other perceptual domains.
In this paper we aim to present a simple partial observable Markov decision process that models mood updating in response to stressful or non-stressful environmental fluctuations while seeking to minimise surprisal in relation to prior beliefs about the likely interoceptive signals experienced with specific actions (attenuating or amplifying stress and pleasure signals).
We examine how, by altering these prior beliefs we can model mood updating in depression, mania and anxiety.
We discuss how these models provide a computational account of mood and its related psychopathology and relate it to previous research in reward processing.
Models such as this can provide hypotheses for experimental work and also open up the potential modelling of predicted disease trajectories in individual patients.
Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.
Pleistocene periglacial activity in eastern Australia was widespread and has been predicted to have extended along much of the east coast. This paper describes block deposits in the New England Tablelands, Australia, as far north as 30°S. These deposits are characterized by openwork blocks on slopes below the angle of repose. The deposits are positioned where frost cracking was significant and range in area up to 8 ha. Surface exposure dating using the cosmogenic nuclide 36Cl from four block deposits indicate all sites were active late during the last glacial cycle, with a concentration of activity between 15–30 ka. Modern temperature measurements from block deposits highlight the importance of local topography for promoting freezing. Periglacial deposits are likely to have been more extensive than previously recognized at these northern limits, and mean annual temperature more than 8°C colder than today.
To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.
The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.
HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.
Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).
AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.
This chapter presents different spinal pathologies and explains how to examine each case. The specific clinical tests and clinical signs are pointed out for each case. Cases covered include kyphosis, ankylosing spondylosis, cervical myelopathy, rheumatoid spine and spondylolisthesis, amongst others.
Existing mass vaccination clinic guidance calls for staffing and resource requirements that may not be achievable in smaller settings. Practical and scalable solutions to these problems were developed by a volunteer group of continuous improvement professionals, working to assist 2 non-governmental organizations engaged in coordinating refugee health services: the Somali Health Board of Seattle, WA and Community Health Services Inc. of Rochester, MN. Our shared goal was to get more shots in arms by bringing vaccines to small communities through pop-up clinics that are quick to set-up and require minimal resources. The clinics were developed using continuous improvement methods, thereby yielding a 2-minute vaccine administration time and an 8-fold improvement in productivity as a result of Federal Emergency Management Agency (FEMA) guidance. This report details our field-tested methods and achieved results. The relevance and benefits of this approach deserve attention as pandemic response needs continue to evolve and vaccines become more globally available.
Response to lithium in patients with bipolar disorder is associated with clinical and transdiagnostic genetic factors. The predictive combination of these variables might help clinicians better predict which patients will respond to lithium treatment.
To use a combination of transdiagnostic genetic and clinical factors to predict lithium response in patients with bipolar disorder.
This study utilised genetic and clinical data (n = 1034) collected as part of the International Consortium on Lithium Genetics (ConLi+Gen) project. Polygenic risk scores (PRS) were computed for schizophrenia and major depressive disorder, and then combined with clinical variables using a cross-validated machine-learning regression approach. Unimodal, multimodal and genetically stratified models were trained and validated using ridge, elastic net and random forest regression on 692 patients with bipolar disorder from ten study sites using leave-site-out cross-validation. All models were then tested on an independent test set of 342 patients. The best performing models were then tested in a classification framework.
The best performing linear model explained 5.1% (P = 0.0001) of variance in lithium response and was composed of clinical variables, PRS variables and interaction terms between them. The best performing non-linear model used only clinical variables and explained 8.1% (P = 0.0001) of variance in lithium response. A priori genomic stratification improved non-linear model performance to 13.7% (P = 0.0001) and improved the binary classification of lithium response. This model stratified patients based on their meta-polygenic loadings for major depressive disorder and schizophrenia and was then trained using clinical data.
Using PRS to first stratify patients genetically and then train machine-learning models with clinical predictors led to large improvements in lithium response prediction. When used with other PRS and biological markers in the future this approach may help inform which patients are most likely to respond to lithium treatment.
Application of a self-practice self-reflection (SP/SR) framework to clinical training programmes for those learning cognitive behavioural therapy (CBT) have demonstrated positive outcomes. These programmes have typically resulted in reports of enhanced learning, improved clinical skills, heightened empathy, improved interpersonal skills, increased self-awareness, and self-development for those undertaking such training. However, the utility of specific activities within this framework for enhancing trainees’ learning still requires exploration. This study sought to explore the use of a low frustration tolerance (LFT) exercise to enhance trainee’s learning around issues relating to frustration and discomfort tolerance. It also further explored the possible application of SP/SR as a form of competency-based assessment. The study was based on 41 student trainees that engaged in a self-directed LFT exercise. Written reflections on these exercises were then thematically analysed. From a competency basis, the exercise provided an approach for observing the trainee’s competency with formulation skills, intervention planning, and self-reflective capacity. Participants reported both personal and professional development outcomes from the exercise. These included a ‘deepened’ understanding of cognitive behavioural principles related to their experiences, both in terms of principles relating to maintenance of dysfunction and to creating change. Increased self-awareness and learning outcomes relating to the development of interpersonal skills were also commonly reported by trainees.
Key learning aims
(1) To understand the usefulness of a behavioural experiment [a low frustration tolerance (LFT) exercise] for training within a SP/SR framework.
(2) To examine the potential for using SP/SR as a form of competency-based training.
(3) To demonstrate the benefits of experiential learning through SP/SR in training CBT.