Invest to progress? a survey of the cost of postgraduate training prior to specialty applications in the United Kingdom

Aim: Clinical training is expensive. This survey of foundation doctors across four UK foundation deaneries (Severn, Wales, South Thames and Scotland) identifies that highly variable sums of money were spent by foundation doctors applying for specialty training. Place and Duration of Study: Bristol Royal Infirmary and University Hospital of Wales, between September 2015 and July 2016. Methodology: A total of 1506 foundation year two (FY2) doctors were invited to participate in the online survey. Participants were canvassed via ten questions pertaining to their involvement in four groups of career enhancing activities: training courses; postgraduate examinations; qualifications, and conference attendances. The survey was closed after a ‘live’ period of 5 months. 100 FY2 doctors had completed the survey at the time of its closure. Results: Of the 100 participants, 89 (89.0%) had undertaken at least one career enhancing activity, with a mean expenditure of £1460 per respondent. Surgical and academic programme applicants spent on average over double the amount of those for anaesthetics (p = 0.01) and medicine (p = 0.001) and ten times that of applicants to general practice (p = 0.0001). Conclusions: These results have potential implications for training expectations, allocation of study budgets and specialty application processes as a whole

Identification of the key elements included in a community college women's leadership program

Numerous managerial and organizational theorists have worked to develop a set of concepts and theories that encapsulate the key elements of leadership. Contemporary research links leadership to such matters as gender and organizational mission or focus. The present study was undertaken in response to a new approach to leadership theory which suggests that gender may be a significant determinant of the traits, behaviors, and attitudes of successful leaders. Feminine leadership style, which posits the existence of a specifically female method of leading, was investigated through both a review of relevant literature and an empirical study. Another major focus of the present study was to evaluate the effectiveness of one woman's leadership training program, the Oregon Institute for Leadership Development (OILD). Drawing upon the literature, two survey instruments were developed. The first was addressed to OILD participants. The second was addressed to community college supervisors whose staff members had participated in OILD. The goal of the study was to identify the key elements involved in a community college women's leadership program that enhance the development of women's leadership skills. The study found that while OILD work site supervisors identified the existence and partial nature of a feminine leadership style, male supervisors tended to be less convinced that such a style exists. The study also determined that both OILD participants and their supervisors had a generally high level of regard for OILD and its programs. It was determined that the key element of OILD training was its capacity for enhancing the self-esteem and self-confidence of participants, encouraging them to assume more responsibility on the job and to pursue further educational credentials. While supervisors were less able to identify specific program components leading to this result than participants, both groups of respondents appear to regard the intangible rather than the tangible elements of OILD as most influential in influencing participants' careers and self-image. The study also demonstrated that the subjects believe that the community college is, as the literature suggests, an ideal locus for the development of women's leadership potential and for fostering career aspirations

Listening to Voices: Understanding and Self-Management of Auditory Verbal Hallucinations in Young Adults

Aims Auditory Verbal Hallucinations (AVH) are a hallmark of psychosis, but affect many other clinical populations. Patients’ understanding and self-management of AVH may differ between diagnostic groups, change over time, and influence clinical outcomes. We aimed to explore patients’ understanding and self-management of AVH in a young adult clinical population. Method 35 participants reporting frequent AVH were purposively sampled from a youth mental health service, to capture experiences across psychosis and non-psychosis diagnoses. Diary and photo-elicitation methodologies were used – participants were asked to complete diaries documenting experiences of AVH, and to take photographs representing these experiences. In-depth, unstructured interviews were held, using participant-produced materials as a topic guide. Conventional content analysis was conducted, deriving results from the data in the form of themes. Result Three themes emerged: (1)Searching for answers, forming identities – voice-hearers sought to explain their experiences, resulting in the construction of identities for voices, and descriptions of relationships with them. These identities were drawn from participants’ life-stories (e.g., reflecting trauma), and belief-systems (e.g., reflecting supernatural beliefs, or mental illness). Some described this process as active / volitional. Participants described re-defining their own identities in relation to those constructed for AVH (e.g. as diseased, 'chosen', or persecuted), others considered AVH explicitly as aspects of, or changes in, their personality. (2)Coping strategies and goals – patients’ self-management strategies were diverse, reflecting the diverse negative experiences of AVH. Strategies were related to a smaller number of goals, e.g. distraction, soothing overwhelming emotions, 'reality-checking', and retaining agency. (3)Outlook – participants formed an overall outlook reflecting their self-efficacy in managing AVH. Resignation and hopelessness in connection with disabling AVH are contrasted with outlooks of “acceptance” or integration, which were described as positive, ideal, or mature. Conclusion Trans-diagnostic commonalities in understanding and self-management of AVH are highlighted - answer-seeking and identity-formation processes; a diversity of coping strategies and goals; and striving to accept the symptom. Descriptions of “voices-as-self”, and dysfunctional relationships with AVH, could represent specific features of voice-hearing in personality disorder, whereas certain supernatural/paranormal identities and explanations were clearly delusional. However, no aspect of identity-formation was completely unique to psychosis or non-psychosis diagnostic groups. The identity-formation process, coping strategies, and outlooks can be seen as a framework both for individual therapies and further research

Geological imprint of methane seepage on the seabed and biota of the convergent Hikurangi Margin, New Zealand: box core and grab carbonate results

Short box cores (to 30 cm bsf) and seafloor carbonate grab samples were acquired at mapped hydrocarbon seep sites (600–1200 m water depths) during the 2007 RV SONNE SO191 cruise on the Hikurangi Margin offshore eastern North Island, New Zealand, to evaluate the influence of methane seepage on sedimentologic, biotic, mineralogic and stable isotopic attributes of seabed sediments. Sedimentary horizons in the box cores consist of siliciclastic silts and sands, shell beds and nodular, microcrystalline aragonite bands up to 15 cm thick. The megafauna is dominated by infaunal to semi-infaunal chemosymbiotic bivalves (Calyptogena, Lucinoma, and Acharax), as well as associated worms and carnivorous and grazing gastropods. Burrows in silts, some occupied by worms or juvenile Acharax, mainly have simple morphologies more typical of high-energy, nearshore settings than deep-sea environments, while a few are large and sparsely branched with wall scratch marks inferred to be of decapod crustacean origin. The box core silts and nodular carbonate samples vary in TOC content from 0.2 to 0.9 wt.%, carbonate content from 4 to 78%, and δ13C and δ18O values from − 50.3 to − 0.6‰ PDB and + 0.77 to + 3.2‰ PDB, respectively. Low carbonate content silt samples have the most enriched δ13C values, implying a seawater source for their pore water bicarbonate. Negative δ13C and positive δ18O values typify the nodular, microcrystalline aragonite bands, indicating formation during microbially mediated, sulphate-dependent anaerobic oxidation of methane (AOM) in a cold, near-seafloor environment, as is also supported by lipid biomarker data. A clear isotopic mixing trend of decreasing δ13C and increasing δ18O and carbonate content in the fine (< 100 µm) carbonate fraction of the host silts also has been reported from other methane seep provinces, and suggests a heterogeneous influx of methane-rich see

Tackling dementia together via the Australian dementia network (ADNeT): A summary of initiatives, progress and plans

In 2018, the Australian Dementia Network (ADNeT) was established to bring together Australia\u27s leading dementia researchers, people with living experience and clinicians to transform research and clinical care in the field. To address dementia diagnosis, treatment, and care, ADNeT has established three core initiatives: the Clinical Quality Registry (CQR), Memory Clinics, and Screening for Trials. Collectively, the initiatives have developed an integrated clinical and research community, driving practice excellence in this field, leading to novel innovations in diagnostics, clinical care, professional development, quality and harmonization of healthcare, clinical trials, and translation of research into practice. Australia now has a national Registry for Mild Cognitive Impairment and dementia with 55 participating clinical sites, an extensive map of memory clinic services, national Memory and Cognition Clinic Guidelines and specialized screening for trials sites in five states. This paper provides an overview of ADNeT\u27s achievements to date and future directions. With the increase in dementia cases expected over coming decades, and with recent advances in plasma biomarkers and amyloid lowering therapies, the nationally coordinated initiatives and partnerships ADNeT has established are critical for increased national prevention efforts, co-ordinated implementation of emerging treatments for Alzheimer\u27s disease, innovation of early and accurate diagnosis, driving continuous improvements in clinical care and patient outcome and access to post-diagnostic support and clinical trials. For a heterogenous disorder such as dementia, which is now the second leading cause of death in Australia following cardiovascular disease, the case for adequate investment into research and development has grown even more compelling

Emergency care in 59 low- and middle-income countries: a systematic review

Abstract Objective: To conduct a systematic review of emergency care in low- and middle-income countries (LMICs). Methods: We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards. Findings: We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. Conclusion: Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings

Predicting resistance as indicator for need to switch from first-line antiretroviral therapy among patients with elevated viral loads: development of a risk score algorithm

Abstract Background In resource-limited settings, where resistance testing is unavailable, confirmatory testing for patients with high viral loads (VL) delays antiretroviral therapy (ART) switches for persons with resistance. We developed a risk score algorithm to predict need for ART change by identifying resistance among persons with persistently elevated VL. Methods We analyzed data from a Phase IV open-label trial. Using logistic regression, we identified demographic and clinical characteristics predictive of need for ART change among participants with VLs ≥1000 copies/ml, and assigned model-derived scores to predictors. We designed three models, including only variables accessible in resource-limited settings. Results Among 290 participants with at least one VL ≥1000 copies/ml, 51 % (148/290) resuppressed and did not have resistance testing; among those who did not resuppress and had resistance testing, 47 % (67/142) did not have resistance and 53 % (75/142) had resistance (ART change needed for 25.9 % (75/290)). Need for ART change was directly associated with higher baseline VL and higher VL at time of elevated measure, and inversely associated with treatment duration. Other predictors included body mass index and adherence. Area under receiver operating characteristic curves ranged from 0.794 to 0.817. At a risk score ≥9, sensitivity was 14.7–28.0 % and specificity was 96.7–98.6 %. Conclusions Our model performed reasonably well and may be a tool to quickly transition persons in need of ART change to more effective regimens when resistance testing is unavailable. Use of this algorithm may result in public health benefits and health system savings through reduced transmissions of resistant virus and costs on laboratory investigations

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial

Background: Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care. Methods: In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P. Discussion: We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care. Trial registration: Dutch Trial Registry, identifier: NTR4686, Registered on 14 July 2014. © 2017 The Author(s)