Studying clinical reasoning, part 2: Applying social judgement theory

Part 1 of this paper (Harries and Harries 2001) examined the reasoning studies of the 1980s and 1990s and critiqued the ethnographic and informationprocessing approaches, based on stated information use. The need for an approach that acknowledged the intuitive nature of experienced thinkers’ reasoning was identified. Part 2 describes such an approach ± social judgement theory ± and presents a pilot application in occupational therapy research. The method used is judgement analysis. The issue under study is that of prioritisation policies in community mental health work. The results present the prioritisation policies of four occupational therapists in relation to managing community mental health referrals

The use of ultrasound for detecting particles suspended in lubricant and hydraulic fluids

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Line and continuum radiative transfer modelling of AA Tau

We present photometric and spectroscopic models of the Classical T Tauri star AA Tau. Photometric and spectroscopic variability present in observations of AA Tau is attributed to a magnetically induced warp in the accretion disc, periodically occulting the photosphere on an 8.2--day timescale. Emission line profiles show signatures of both infall, attributed to magnetospherically accreting material, and outflow. Using the radiative transfer code TORUS, we have investigated the geometry and kinematics of AA Tau's circumstellar disc and outflow, which is modelled here as a disc wind. Photometric models have been used to constrain the aspect ratio of the disc, the offset angle of the magnetosphere dipole with respect to the stellar rotation axis, and the inner radius of the circumstellar disc. Spectroscopic models have been used to constrain the wind and magnetosphere temperatures, wind acceleration parameter, and mass loss rate. We find observations are best fitted by models with a mass accretion rate of $5\times10^{-9}$ M$_\odot$ yr$^{-1}$, a dipole offset of between $10^\circ$ and $20^\circ$, a magnetosphere that truncates the disc from 5.2 to 8.8 R$_\star$, a mass-loss-rate to accretion-rate ratio of ~ 0.1, a magnetosphere temperature of 8500 -- 9000 K, and a disc wind temperature of 8000 K.Comment: 22 pages, 32 figures, 4 tables. Accepted by MNRAS. V3: Corrected typ

To adopt is to adapt: The process of implementing the ICF with an acute stroke multidisciplinary team in England

Copyright @ 2012 Informa Plc. The article can be accessed from the link below.This article has been made available through the Brunel Open Access Publishing Fund.Purpose: The success of the International Classification of Functioning, Disability and Health (ICF) depends on its uptake in clinical practice. This project aimed to explore ways the ICF could be used with an acute stroke multidisciplinary team and identify key learning from the implementation process. Method: Using an action research approach, iterative cycles of observe, plan, act and evaluate were used within three phases: exploratory; innovatory and reflective. Thematic analysis was undertaken, using a model of immersion and crystallisation, on data collected via interview and focus groups, e-mail communications, minutes from relevant meetings, field notes and a reflective diary. Results: Two overall themes were determined from the data analysis which enabled implementation. There is a need to: (1) adopt the ICF in ways that meet local service needs; and (2) adapt the ICF language and format. Conclusions: The empirical findings demonstrate how to make the ICF classification a clinical reality. First, we need to adopt the ICF as a vehicle to implement local service priorities e.g. to structure a multidisciplinary team report, thus enabling ownership of the implementation process. Second, we need to adapt the ICF terminology and format to make it acceptable for use by clinicians.This study is funded by The Elizabeth Casson Trust. This article is made available through the Brunel Open Access Publishing Fund

The trajectory to diagnosis with pulmonary arterial hypertension: a qualitative study

Objectives To investigate the patient's experience of the trajectory to receiving a diagnosis of pulmonary arterial hypertension (PAH) and inform the provision of care for this patient group. Design Qualitative study using in-depth one-to-one interviews and pictorial representations. Data were analysed using thematic analysis. Setting Participants were interviewed in their own homes across England. Participants 30 patients with a diagnosis of pulmonary hypertension (18 participants were women, mean age 56 and range 26-80 02years and time since diagnosis ranged from a few months to more than 12 02years) participated. Results All participants, regardless of the time since diagnosis, vividly described the process from manifestation of symptoms to receiving a confirmed diagnosis. The authors present data using three major themes: (i) making sense of symptoms, (ii) process of elimination and (iii) being diagnosed with PAH. Making sense of symptoms represented an early period of perseverance 14people tried to carry-on as usual despite 18unexplained breathlessness 19. As time progressed, this period was punctuated by critical events that triggered seeking medical advice. Once medical contact had been made, patients described a period of 18elimination 19 and convoluted contact with the medical profession. Dyspnoea misdiagnosis was a key factor that delayed the PAH diagnosis. Diagnosis disclosure by some medical professionals was also viewed as lacking empathy. More positive experiences were relayed when the medical team disclosing the diagnosis acknowledged previous limitations. Conclusions A lack of awareness of this illness from both the sufferer themselves and the medical profession emerged as a central theme and led to prolonged periods of being misdiagnosed. The application of a diagnostic pathway for unexplained dyspnoea that alerts practitioners to rare conditions could expedite the process of correct diagnosis

The timing of death in patients with tuberculosis who die during anti-tuberculosis treatment in Andhra Pradesh, South India

Background: India has 2.0 million estimated tuberculosis (TB) cases per annum with an estimated 280,000 TBrelated deaths per year. Understanding when in the course of TB treatment patients die is important for determining the type of intervention to be offered and crucially when this intervention should be given. The objectives of the current study were to determine in a large cohort of TB patients in India:- i) treatment outcomes including the number who died while on treatment, ii) the month of death and iii) characteristics associated with “early” death, occurring in the initial 8 weeks of treatment. Methods: This was a retrospective study in 16 selected Designated Microscopy Centres (DMCs) in Hyderabad, Krishna and Adilabad districts of Andhra Pradesh, South India. A review was performed of treatment cards and medical records of all TB patients (adults and children) registered and placed on standardized anti-tuberculosis treatment from January 2005 to September 2009. Results: There were 8,240 TB patients (5183 males) of whom 492 (6%) were known to have died during treatment. Case-fatality was higher in those previously treated (12%) and lower in those with extra-pulmonary TB (2%). There was an even distribution of deaths during anti-tuberculosis treatment, with 28% of all patients dying in the first 8 weeks of treatment. Increasing age and new as compared to recurrent TB disease were significantly associated with “early death”. Conclusion: In this large cohort of TB patients, deaths occurred with an even frequency throughout anti-TB treatment. Reasons may relate to i) the treatment of the disease itself, raising concerns about drug adherence, quality of anti-tuberculosis drugs or the presence of undetected drug resistance and ii) co-morbidities, such as HIV/ AIDS and diabetes mellitus, which are known to influence mortality. More research in this area from prospective and retrospective studies is needed

Role of microRNAs in the age-associated decline of pancreatic beta cell function in rat islets

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.AIMS/HYPOTHESIS: Ageing can lead to reduced insulin sensitivity and loss of pancreatic beta cell function, predisposing individuals to the development of diabetes. The aim of this study was to assess the contribution of microRNAs (miRNAs) to age-associated beta cell dysfunction. METHODS: The global mRNA and miRNA profiles of 3- and 12-month-old rat islets were collected by microarray. The functional impact of age-associated differences in miRNA expression was investigated by mimicking the observed changes in primary beta cells from young animals. RESULTS: Beta cells from 12-month-old rats retained normal insulin content and secretion, but failed to proliferate in response to mitotic stimuli. The islets of these animals displayed modifications at the level of several miRNAs, including upregulation of miR-34a, miR-124a and miR-383, and downregulation of miR-130b and miR-181a. Computational analysis of the transcriptomic modifications observed in the islets of 12-month-old rats revealed that the differentially expressed genes were enriched for miR-34a and miR-181a targets. Indeed, the induction of miR-34a and reduction of miR-181a in the islets of young animals mimicked the impaired beta cell proliferation observed in old animals. mRNA coding for alpha-type platelet-derived growth factor receptor, which is critical for compensatory beta cell mass expansion, is directly inhibited by miR34a and is likely to be at least partly responsible for the effects of this miRNA. CONCLUSIONS/INTERPRETATION: Changes in the level of specific miRNAs that occur during ageing affect the proliferative capacity of beta cells. This might reduce their ability to expand under conditions of increased insulin demand, favouring the development of type 2 diabetes.Swiss National Science FoundationFondation Francophone pour la Recherche sur le DiabèteWellcome Trust Senior Investigator AwardMRC Programme GrantRoyal Society Wolfson Research Merit AwardWellcome Trust project gran

Benchmark problems for continuum radiative transfer. High optical depths, anisotropic scattering, and polarisation

Solving the continuum radiative transfer equation in high opacity media requires sophisticated numerical tools. In order to test the reliability of such tools, we present a benchmark of radiative transfer codes in a 2D disc configuration. We test the accuracy of seven independently developed radiative transfer codes by comparing the temperature structures, spectral energy distributions, scattered light images, and linear polarisation maps that each model predicts for a variety of disc opacities and viewing angles. The test cases have been chosen to be numerically challenging, with midplane optical depths up 10^6, a sharp density transition at the inner edge and complex scattering matrices. We also review recent progress in the implementation of the Monte Carlo method that allow an efficient solution to these kinds of problems and discuss the advantages and limitations of Monte Carlo codes compared to those of discrete ordinate codes. For each of the test cases, the predicted results from the radiative transfer codes are within good agreement. The results indicate that these codes can be confidently used to interpret present and future observations of protoplanetary discs.Comment: 15 pages, 10 figures, accepted for publication in A&

Radiative Transfer in Star Formation: Testing FLD and Hybrid Methods

We perform a comparison between two radiative transfer algorithms commonly employed in hydrodynamical calculations of star formation: grey flux limited diffusion and the hybrid scheme, in addition we compare these algorithms to results from the Monte-Carlo radiative transfer code MOCASSIN. In disc like density structures the hybrid scheme performs significantly better than the FLD method in the optically thin regions, with comparable results in optically thick regions. In the case of a forming high mass star we find the FLD method significantly underestimates the radiation pressure by a factor of ~100.Comment: 4 Pages; to appear in the proceedings of 'The Labyrinth of Star Formation', Crete, 18-22 June 201