Social network analysis of rural medical school immersion in a rural clinical school

Background: The impact of new medical graduates on the social dimensions of the rural medical workforce is yet to be examined. Social Network Analysis (SNA) is able to visualize and measure these dimensions. We apply this method to examine the workforce characteristics of graduates from a representative Australian Rural Clinical School. Methods: Participants were medical graduates of the Rural Clinical School of Western Australia (RCSWA) from the 2001–2014 cohorts, identified as being in rural work in 2017 by the Australian Health Practitioner Regulation Agency. SNA was used to examine the relationships between site of origin and of work destination. Data were entered into UCInet 6 as tied pairs, and visualized using Netdraw. UCINet statistics relating to node centrality were obtained from the node editor. Results: SNA measures showed that the 124 of 709 graduates in rural practice were distributed around Australia, and that their practice was strongly focused on the North, with a clear centre in the remote Western Australian town of Broome. Women were strongly recruited, and were widely distributed. Conclusions: RCSWA appears to be a “weak tie” according to SNA theory: the School attracts graduates to rural nodes where they had only passing prior contact. The multiple activities that comprise the social capital of the most attractive, remote, node demonstrate the clear workforce effects of being a “bridge, broker and boundary spanner” in SNA terms, and add new understanding about recruiting to the rural workforce

New approaches in detection and treatment of familial hypercholesterolemia

Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder that clinically leads to increased low density lipoprotein-cholesterol (LDL-C) levels. As a consequence, FH patients are at high risk for cardiovascular disease (CVD). Mutations are found in genes coding for the LDLR, apoB, and PCSK9, although FH cannot be ruled out in the absence of a mutation in one of these genes. It is pivotal to diagnose FH at an early age, since lipid lowering results in a decreased risk of cardiovascular complications especially if initiated early, but unfortunately FH is largely underdiagnosed. While a number of clinical criteria are available, identification of a pathogenic mutation in any of the three aforementioned genes is seen by many as a way to establish a definitive diagnosis of FH. It should be remembered that clinical treatment is based on LDL-C levels and not solely on presence or absence of genetic mutations as LDL-C is what drives risk. Traditionally, mutation detection has been done by means of dideoxy sequencing. However, novel molecular testing methods are gradually being introduced. These next generation sequencing-based methods are likely to be applied on broader scale once their efficacy and effect on cost are being established. Statins are the first-line therapy of choice for FH patients as they have been proven to reduce CVD risk across a range of conditions including hypercholesterolemia (though not specifically tested in FH). However, in a significant proportion of FH patients LDL-C goals are not met, despite the use of maximal statin doses and additional lipid-lowering therapies. This underlines the need for additional therapies, and inhibition of PCSK9 and CETP is among the most promising new therapeutic options. In this review, we aim to provide an overview of the latest information about the definition, diagnosis, screening, and current and novel therapies for F

The Property of Rationality: A Guide to What Rationality Requires?

Can we employ the property of rationality in establishing what rationality requires? According to a central and formal thesis of John Broome’s work on rational requirements, the answer is ‘no’ – at least if we expect a precise answer. In particular, Broome argues that (i) the property of full rationality (i.e. whether or not you are fully rational) is independent of whether we formulate conditional requirements of rationality as having a wide or a narrow logical scope. That is, (ii) by replacing a wide-scope requirement with a corresponding narrow-scope requirement (or vice versa), we do not alter the situations in which a person is fully rational. As a consequence, (iii) the property of full rationality is unable to guide us in determining whether a rational requirement has a wide or a narrow logical scope. We cannot resolve the wide/narrow scope debate by appealing to a theory of fully rational attitudes. This paper argues that (i), (ii) and (iii) are incorrect. Replacing a wide- with a corresponding narrow-scope requirement (or vice versa) can alter the set of circumstances in which a person is fully rational. The property of full rationality is therefore not independent of whether we formulate conditional requirements of rationality as having a wide or a narrow logical scope. As a consequence, the property of full rationality can guide us in determining what rationality requires – even in cases where we expect a precise answer

Experimental demonstration of a directionally-unbiased linear-optical multiport

All existing optical quantum walk approaches are based on the use of beamsplitters and multiple paths to explore the multitude of unitary transformations of quantum amplitudes in a Hilbert space. The beamsplitter is naturally a directionally biased device: the photon cannot travel in reverse direction. This causes rapid increases in optical hardware resources required for complex quantum walk applications, since the number of options for the walking particle grows with each step. Here we present the experimental demonstration of a directionally-unbiased linear-optical multiport, which allows reversibility of photon direction. An amplitude-controllable probability distribution matrix for a unitary three-edge vertex is reconstructed with only linear-optical devices. Such directionally-unbiased multiports allow direct execution of quantum walks over a multitude of complex graphs and in tensor networks. This approach would enable simulation of complex Hamiltonians of physical systems and quantum walk applications in a more efficient and compact setup, substantially reducing the required hardware resources

Pragmatist Ethics and Climate Change [preprint]

This chapter explores some features of pragmatic pluralism as an ethical perspective on climate change. It is inspired in part by Andrew Light’s work on climate diplomacy as U.S. Assistant Secretary of Energy for International Affairs, and by Bryan Norton’s environmental pragmatism, while drawing more explicitly than Light or Norton from classical pragmatist sources such as John Dewey. The primary aim of the chapter is to characterize, differentiate, and advance a general pragmatist approach to climate ethics. The main line of argument is that we are suffering culturally from a sort of “moral jetlag” due in part to “moral fundamentalist” habits, and that a critical focus on pragmatic pluralism—in moral theory generally and climate ethics particularly—would be salutary for our recovery if philosophers are to speak more effectively to “wicked problems” in a way that aids public deliberation and social learning. Moral fundamentalist habits, and the monistic one-way assumption that unintentionally—but not blamelessly—exercises and unduly reinforces them, are obstacles to fostering habits of moral and political inquiry better suited to dealing with predicaments rapidly transforming our warming planet

Improving detection of familial hypercholesterolaemia in primary care using electronic audit and nurse-led clinics

RATIONALE, AIMS AND OBJECTIVES: In the UK fewer than 15% of familial hypercholesterolemia (FH) cases are diagnosed, representing a major gap in coronary heart disease prevention. We wished to support primary care doctors within the Medway Clinical Commissioning Group (CCG) to implement NICE guidance (CG71) and consider the possibility of FH in adults who have raised total cholesterol concentrations, thereby improving the detection of people with FH. METHODS: Utilizing clinical decision support software (Audit+) we developed an FH Audit Tool and implemented a systematic audit of electronic medical records within GP practices, first identifying all patients diagnosed with FH or possible FH and next electronically flagging patients with a recorded total cholesterol of >7.5 mmol L(-1) or LDL-C > 4.9 mmol L(-1) (in adults), for further assessment. After a 2-year period, a nurse-led clinic was introduced to screen more intensely for new FH index cases. We evaluated if these interventions increased the prevalence of FH closer to the expected prevalence from epidemiological studies. RESULTS: The baseline prevalence of FH within Medway CCG was 0.13% (1 in 750 persons). After 2 years, the recorded prevalence of diagnosed FH increased by 0.09% to 0.22% (1 in 450 persons). The nurse advisor programme ran for 9 months (October 2013-July 2014) and during this time, the recorded prevalence of patients diagnosed with FH increased to 0.28% (1 in 357 persons) and the prevalence of patients 'at risk and unscreened' reduced from 0.58% to 0.14%. CONCLUSIONS: Our study shows that two simple interventions increased the detection of FH. This systematic yet simple electronic case-finding programme with nurse-led review allowed the identification of new index cases, more than doubling the recorded prevalence of detected disease to 1 in 357 (0.28%). This study shows that primary care has an important role in identifying patients with this condition