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Training plays a central role in the pursuit of conservation goals, and it is vital to know if it is having the desired effect. However, evaluating the difference it makes is notoriously challenging. Here, we present a practitioner's perspective on overcoming these challenges and developing a framework for ongoing evaluation of a conservation training programme. To do this, we first created a theory of change, describing the pathway of change we expect from training delivery to conservation impact. This provided the clarity and structure needed to identify indicators of change in the short, medium and long term. For data collection, we utilized both quantitative and qualitative methods to provide a more complete understanding of the change expected and capture any that might be unexpected. However, the more time that passes since a training event, the more difficult it becomes to attribute results; in response, we shifted predominantly to the use of qualitative methods to understand the long-term results achieved. After 3 years of implementation, this framework has enabled us to measure the difference our training makes to individuals and their work, and to provide evidence for the contribution it makes to achieving conservation impact. We believe that the lessons learnt can be used to improve the evaluation of training activities across the conservation sector and maximize the impact they achieve.
A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.
In-patients on mental health wards are commonly prescribed hypnotics for the long-term management of disturbed sleep. Specific sleep disorders remain underdiagnosed and effective behavioural interventions are underused. We developed a suite of three educational interventions (a video, poster and handbook) about sleep, sleep disorders, the safe prescribing of hypnotics and use of psychological strategies (sleep hygiene and cognitive–behavioural therapy for insomnia, CBTi) using co-design and multiprofessional stakeholder involvement. This controlled before-and-after study evaluated the effectiveness of these interventions across seven in-patient psychiatric wards, examining their impact on hypnotic prescribing rates and staff confidence scores (data collected by retrospective drug chart analysis and survey respectively).
Results
A marked reduction was seen in the percentage of patients prescribed hypnotics on in-patient prescription charts (−24%), with a 41% reduction in the number of hypnotics administered per patient (mean reduction −1.142 administrations/patient).
Clinical implications
These simple educational strategies about the causes and treatment of insomnia can reduce hypnotic prescribing rates and increase staff confidence in both the medical and psychological management of insomnia.
People with bipolar disorder have moderate cognitive difficulties that tend to be more pronounced during mood episodes but persist after clinical remission and affect recovery. Recent evidence suggests heterogeneity in these difficulties, but the factors underlying cognitive heterogeneity are unclear.
Aims
To examine whether distinct cognitive profiles can be identified in a sample of euthymic individuals with bipolar disorder and examine potential differences between subgroups.
Method
Cognitive performance was assessed across four domains (i.e. processing speed, verbal learning/memory, working memory, executive functioning) in 80 participants. We conducted a hierarchical cluster analysis and a discriminant function analysis to identify cognitive profiles and considered differences in cognitive reserve, estimated cognitive decline from premorbid cognitive functioning, and clinical characteristics among subgroups.
Results
Four discrete cognitive profiles were identified: cognitively intact (n = 25; 31.3%); selective deficits in verbal learning and memory (n = 15; 18.8%); intermediate deficits across all cognitive domains (n = 30; 37.5%); and severe deficits across all domains (n = 10; 12.5%). Cognitive decline after illness onset was greater for the intermediate and severe subgroups. Cognitive reserve scores were increasingly lower for subgroups with greater impairments. A smaller proportion of cognitively intact participants were using antipsychotic medications compared with all other subgroups.
Conclusions
Our findings suggest that individuals with cognitively impaired profiles demonstrate more cognitive decline after illness onset. Cognitive reserve may be one of the factors underlying cognitive variability across people with bipolar disorder. Patients in the intermediate and severe subgroups may be in greater need of interventions targeting cognitive difficulties.
To develop a regional antibiogram within the Chicagoland metropolitan area and to compare regional susceptibilities against individual hospitals within the area and national surveillance data.
Design:
Multicenter retrospective analysis of antimicrobial susceptibility data from 2017 and comparison to local institutions and national surveillance data.
Setting and participants:
The analysis included 51 hospitals from the Chicago–Naperville–Elgin Metropolitan Statistical Area within the state of Illinois. Overall, 18 individual collaborator hospitals provided antibiograms for analysis, and data from 33 hospitals were provided in aggregate by the Becton Dickinson Insights Research Database.
Methods:
All available antibiogram data from calendar year 2017 were combined to generate the regional antibiogram. The final Chicagoland antibiogram was then compared internally to collaborators and externally to national surveillance data to assess its applicability and utility.
Results:
In total, 167,394 gram-positive, gram-negative, fungal, and mycobacterial isolates were collated to create a composite regional antibiogram. The regional data represented the local institutions well, with 96% of the collaborating institutions falling within ±2 standard deviations of the regional mean. The regional antibiogram was able to include 4–5-fold more gram-positive and -negative species with ≥30 isolates than the median reported by local institutions. Against national surveillance data, 18.6% of assessed pathogen–antibiotic combinations crossed prespecified clinical thresholds for disparity in susceptibility rates, with notable trends for resistant gram-positive and gram-negative bacteria.
Conclusions:
Developing an accurate, reliable regional antibiogram is feasible, even in one of the largest metropolitan areas in the United States. The biogram is useful in assessing susceptibilities to less commonly encountered organisms and providing clinicians a more accurate representation of local antimicrobial resistance rates compared to national surveillance databases.
The end of the First World War and the relaxation of restrictions on travel that were in place during it produced a sense of release, among other emotions. Paul Fussell employs an aptly exuberant simile when he refers to the many writers who were ‘propelled on their post-war travels as if by a wartime spring tightly compressed’. Besides those that will be discussed in this chapter, Fussell’s list of several members of the ‘British Literary Diaspora’ who travelled or went to live in exile around the globe includes Norman Douglas, Lawrence Durrell, V. S. Pritchett, and Robert Graves. The propulsion that Fussell describes is evident in D. H. Lawrence’s statement in his Sea and Sardinia (1921): ‘Comes over one an absolute necessity to move.’ This urge to mobility is often accompanied by an energetic sense of inquiry.
‘Border’ has two principal meanings. The first denotes an edge, margin, limit or boundary; the second a frontier between two states. These two senses create an ambiguity, for the first definition suggests the outer reaches and the second a way across to another place. On the one hand, then, there is the implication of getting as far as one can go; on the other, of coming to a line that separates and joins, thus offering the opportunity for further travel in a different region. The concept of the border thereby introduces to travel writing a tension as it points to both the circumscription and the possibilities of travel. The idea of crossing also implies transformation, another important feature of many travel narratives. As Bill Aitken (2002 [1999], 4) puts it: ‘To the traveller borderlands always intrigue with their potential for cultural initiation quite apart from the magic of being on the threshold of the new that all frontier situations involve.’
The Oxford English Dictionary (OED) traces ‘border’ to the late fourteenth century, to the Middle English and Old French bordure and earlier Old French bordeüre, thence back to the late Latin bordatura, meaning ‘edging’. The medieval usage recorded by the OED does not relate specifically to a line between countries. The earliest quotation showing that sense is from the late sixteenth century. Between these two dates the first usage of borders to signify territories is from around 1425. In both their literal and symbolic senses, borders are central to journey accounts. Most obviously, borders refer to the limits around nations. They both define territories and place them in relation to one another, but the physical movement of travellers from one site to another is often metaphoric, also. Travel literature is frequently populated with the representation of borders between the known and the unknown, the civilized and the savage, the domestic and the wild, the land and the sea, the cultivated and the desert. In addition, there are borders between the past and the present which give travel texts their (often problematic) temporal texture. For example, Peter Matthiessen exclaims of the journey recounted in The Snow Leopard that ‘[w] e walked 250 miles over the Himalaya up to the Tibetan plateau. It was like walking into the Middle Ages – just amazing’ (Shapiro 2004, 356).