Multiple and multi-dimensional transitions from trainee to trained doctor: A qualitative longitudinal study in the UK

Objectives To explore trainee doctors’ experiences of the transition to trained doctor, we answer three questions: (1) What multiple and multidimensional transitions (MMTs) are experienced as participants move from trainee to trained doctor? (2) What facilitates and hinders doctors’ successful transition experiences? (3) What is the impact of MMTs on trained doctors? Design: A qualitative longitudinal study underpinned by MMT theory. Setting: Four training areas (health boards) in the UK. Participants: 20 doctors, 19 higher-stage trainees within 6 months of completing their postgraduate training and 1 staff grade, associate specialist or specialty doctor, were recruited to the 9-month longitudinal audio-diary (LAD) study. All completed an entrance interview, 18 completed LADs and 18 completed exit interviews. Methods: Data were analysed cross-sectionally and longitudinally using thematic Framework Analysis. Results: Participants experienced a multiplicity of expected and unexpected, positive and negative work-related transitions (eg, new roles) and home-related transitions (eg, moving home) during their trainee–trained doctor transition. Factors facilitating or inhibiting successful transitions were identified at various levels: individual (eg, living arrangements), interpersonal (eg, presence of supportive relationships), systemic (eg, mentoring opportunities) and macro (eg, the curriculum provided by Medical Royal Colleges). Various impacts of transitions were also identified at each of these four levels: individual (eg, stress), interpersonal (eg, trainees’ children spending more time in childcare), systemic (eg, spending less time with patients) and macro (eg, delayed start in trainees’ new roles). Conclusions: Priority should be given to developing supportive relationships (both formal and informal) to help trainees transition into their trained doctor roles, as well as providing more opportunities for learning. Further longitudinal qualitative research is now needed with a longer study duration to explore transition journeys for several years into the trained doctor role

Fe K\alpha emission from photoionized slabs: the impact of the iron abundance

Iron K\alpha emission from photoionized and optically thick material is observed in a variety of astrophysical environments including X-ray binaries, active galactic nuclei, and possibly gamma-ray bursts. This paper presents calculations showing how the equivalent width (EW) of the Fe K line depends on the iron abundance of the illuminated gas and its ionization state -- two variables subject to significant cosmic scatter. Reflection spectra from a constant density slab which is illuminated with a power-law spectrum with photon-index \Gamma are computed using the code of Ross & Fabian. When the Fe K EW is measured from the reflection spectra alone, we find that it can reach values greater than 6 keV if the Fe abundance is about 10 times solar and the illuminated gas is neutral. EWs of about 1 keV are obtained when the gas is ionized. In contrast, when the EW is measured from the incident+reflected spectrum, the largest EWs are ~800 keV and are found when the gas is ionized. When \Gamma is increased, the Fe K line generally weakens, but significant emission can persist to larger ionization parameters. The iron abundance has its greatest impact on the EW when it is less than 5 times solar. When the abundance is further increased, the line strengthens only marginally. Therefore, we conclude that Fe K lines with EWs much greater than 800 eV are unlikely to be produced by gas with a supersolar Fe abundance. These results should be useful in interpreting Fe K emission whenever it arises from optically thick fluorescence.Comment: 5 pages, 5 figures, accepted by MNRAS Letter

Health Case Studies

I. PrologueII. Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)III. Case Study #2: PneumoniaIV. Case Study #3: Unstable Angina (UA)V. Case Study #4: Heart Failure (HF)VI. Case Study #5: Motor Vehicle Collision (MVC)VII. Case Study #6: SepsisVIII. Case Study #7: Colon CancerIX. Case Study #8: Deep Vein Thrombosis (DVT)Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation

A past capture event at Sagittarius A* inferred from the fluorescent X-ray emission of Sagittarius B clouds

The fluorescent X-ray emission from neutral iron in the molecular clouds (Sgr B) indicates that the clouds are being irradiated by an external X-ray source. The source is probably associated with the Galactic central black hole (Sgr A*), which triggered a bright outburst one hundred years ago. We suggest that such an outburst could be due to a partial capture of a star by Sgr A*, during which a jet was generated. By constraining the observed flux and the time variability ($\sim$ 10 years) of the Sgr B's fluorescent emission, we find that the shock produced by the interaction of the jet with the dense interstellar medium represents a plausible candidate for the X-ray source emission.Comment: 7 pages, 1 figure, accepted for publication in MNRA

First Constraints on Iron Abundance versus Reflection Fraction from the Seyfert~1 Galaxy MCG--6-30-15

We report on a joint ASCA and RXTE observation spanning an $\sim$ 400~ks time interval of the bright Seyfert~1 galaxy MCG--6-30-15. The data clearly confirm the presence of a broad skewed iron line ($W_{K\alpha} \sim$ 266 eV) and Compton reflection continuum at higher energies reported in our previous paper. We also investigate whether the gravitational and Doppler effects that affect the iron line may also be manifest in the reflected continuum. The uniqueness of this data set is underlined by the extremely good statistics that we obtain from the approximately four million photons that make up the 2-20 keV RXTE PCA spectrum alone. This, coupled with the high energy coverage of HEXTE and the spectral resolution of ASCA in the iron line regime has allowed us to constrain the relationship between abundance and reflection fraction for the first time at the 99 per cent confidence level. The reflection fraction is entirely consistent with a flat disk, i.e. the cold material subtends $\rm 2 \pi$ sr at the source, to an accuracy of 20 per cent. Monte Carlo simulations show that the observed strong iron line intensity is explained by an overabundance of iron by a factor of $\sim$ 2 and an underabundance of the lower-Z elements by a similar factor. By considering non-standard abundances, a clear and consistent picture can be made in which both the iron line and reflection continuum come from the same material such as e.g. an accretion disk.Comment: 8 pages, 8 figures, accepted for publication MNRAS 7/9

GRB 070311: a direct link between the prompt emission and the afterglow

We present prompt gamma-ray, early NIR/optical, late optical and X-ray observations of the peculiar GRB 070311 discovered by INTEGRAL, in order to gain clues on the mechanisms responsible for the prompt gamma-ray pulse as well as for the early and late multi-band afterglow of GRB 070311. We fitted with empirical functions the gamma-ray and optical light curves and scaled the result to the late time X-rays. The H-band light curve taken by REM shows two pulses peaking 80 and 140 s after the peak of the gamma-ray burst and possibly accompanied by a faint gamma-ray tail. Remarkably, the late optical and X-ray afterglow underwent a major rebrightening between 3x10^4 and 2x10^5 s after the burst with an X-ray fluence comparable with that of the prompt emission extrapolated in the same band. Notably, the time profile of the late rebrightening can be described as the combination of a time-rescaled version of the prompt gamma-ray pulse and an underlying power law. This result supports a common origin for both prompt and late X-ray/optical afterglow rebrightening of GRB 070311 within the external shock scenario. The main fireball would be responsible for the prompt emission, while a second shell would produce the rebrightening when impacting the leading blastwave in a refreshed shock (abridged).Comment: 14 pages, 11 figures, 4 tables, accepted to A&

Cytoplasmic PML promotes TGF-β-associated epithelial–mesenchymal transition and invasion in prostate cancer

Epithelial–mesenchymal transition (EMT) is a key event that is involved in the invasion and dissemination of cancer cells. Although typically considered as having tumour-suppressive properties, transforming growth factor (TGF)-β signalling is altered during cancer and has been associated with the invasion of cancer cells and metastasis. In this study, we report a previously unknown role for the cytoplasmic promyelocytic leukaemia (cPML) tumour suppressor in TGF-β signalling-induced regulation of prostate cancer-associated EMT and invasion. We demonstrate that cPML promotes a mesenchymal phenotype and increases the invasiveness of prostate cancer cells. This event is associated with activation of TGF-β canonical signalling pathway through the induction of Sma and Mad related family 2 and 3 (SMAD2 and SMAD3) phosphorylation. Furthermore, the cytoplasmic localization of promyelocytic leukaemia (PML) is mediated by its nuclear export in a chromosomal maintenance 1 (CRM1)-dependent manner. This was clinically tested in prostate cancer tissue and shown that cytoplasmic PML and CRM1 co-expression correlates with reduced disease-specific survival. In summary, we provide evidence of dysfunctional TGF-β signalling occurring at an early stage in prostate cancer. We show that this disease pathway is mediated by cPML and CRM1 and results in a more aggressive cancer cell phenotype. We propose that the targeting of this pathway could be therapeutically exploited for clinical benefit

Interstellar gas in the Galaxy and the X-ray luminosity of Sgr A* in the recent past

Information about the X-ray luminosity of the supermassive black hole located at the Galactic center (GC), Sgr A*, and its temporal variations in the past is imprinted in the scattered emission observed today in the direction towards giant molecular clouds (GMCs) located in our Galaxy. Due to light travel time effects these clouds probe the activity of Sgr A* at different times in the past depending on their position relative to the GC and the observer. In this paper we combine results of recent ASCA observations along the Galactic plane, providing upper limits for the scattered flux in the 4-10 keV range produced in a given direction, with data from CO surveys of the same regions. These CO surveys map the position and mass of the molecular gas which the GMCs are made up of. Demanding the scattered flux to be not larger than the observed one, this data enables us to derive upper limits for the 4-10 keV luminosity of Sgr A* at certain times during the last 40.000 years down to about 8*10^40 erg/s. At other times the limits are less tight, of the order of 10^41-10^42 erg/s. The more extended and continuous HI distribution in the Galactic disk, which also scatters the radiation emitted by Sgr A*, allows us to extend the time coverage further into the past, back to about 110.000 years, albeit the limits are becoming less tight. We thereby can rule out a long term X-ray activity phase of Sgr A* at one per cent of its Eddington level ending less than about 80.000 years ago. The limits presented in this paper can be improved by observations of emission in the fluorescent iron K_alpha-line. We study the feasibility of these methods to investigate past nuclear activity in other spiral galaxies observed with the angular resolution of X-ray telescopes like Chandra and XMM-Newton