Medical student confidence to care for a dying patient and their family: a systematic review

Background: The General Medical Council expects medical graduates to care for dying patients with skill, clinical judgement and compassion. UK surveys continually demonstrate low confidence and increasing distress amongst junior doctors when providing care to the dying. Aim: This systematic review aims to determine what has been evidenced within worldwide literature regarding medical undergraduate confidence to care for dying patients. Design: A systematic electronic search was undertaken. Data extraction included measurements of baseline confidence, associated assessment tools, and details of applied educational interventions. Pre/post-intervention confidence comparisons were made. Factors influencing confidence levels were explored. The review was prospectively registered via PROSPERO (CRD42019119057). Data sources: MEDLINE, CINAHL, EMBASE, ISI Web of Science, ERIC, PsychINFO, British Education Index and Cochrane Review databases were accessed, with no restrictions on publication year. Eligible studies included the terms ‘medical student’, ‘confidence’, and ‘dying’, alongside appropriate MeSH headings. Study quality was assessed using the Mixed Methods Appraisal Tool. Results: Fifteen eligible studies were included, demonstrating a diversity of assessment tools. Student confidence was low in provision of symptom management, family support, and psycho-spiritual support to dying patients. Eight interventional studies demonstrated increased post-interventional confidence. Lack of undergraduate exposure to dying patients and lack of structure within undergraduate palliative care curricula were cited as factors responsible for low confidence. Conclusion: This review clarifies the objective documentation of medical undergraduate confidence to care for the dying. Identifying where teaching fails to prepare graduates for realities in clinical practice will help inform future undergraduate palliative care curriculum planning

Age and sex influence expression of plasmid DNA directly injected into mouse skeletal muscle

AbstractDirect injection of plasmid DNA into the skeletal muscle has been proposed as a means of effecting somatic gene therapy. We examined the influence of age and sex on the level of expression of an SV40-CAT construct injected into mouse muscle. Age markedly affected expression, with peak values in the 4–6 week age class which were significantly higher than in animals older than 10 weeks. Sex also altered expression, with higher levels of CAT activity seen in males compared to females. We conclude that the rate of growth is important in determining leves of expression of directly injected DNA

Implementing Compositional Analysis Using Intersection Types With Expansion Variables

AbstractA program analysis is compositional when the analysis result for a particular program fragment is obtained solely from the results for its immediate subfragments via some composition operator. This means the subfragments can be analyzed independently in any order. Many commonly used program analysis techniques (in particular, most abstract interpretations and most uses of the Hindley/Milner type system) are not compositional and require the entire text of a program for sound and complete analysis.System I is a recent type system for the pure λ-calculus with intersection types and the new technology of expansion variables. System I supports compositional analysis because it has the principal typings property and an algorithm based on the new technology of β-unification has been developed that finds these principal typings. In addition, for each natural number k, typability in the rank-k restriction of System I is decidable, so a complete and terminating analysis algorithm exists for the rank-k restriction.This paper presents new understanding that has been gained from working with multiple implementations of System I and β-unification-based analysis algorithms. The previous literature on System I presented the type system in a way that helped in proving its more important theoretical properties, but was not as easy to follow as it could be. This paper provides a presentation of many aspects of System I that should be clearer as well as a discussion of important implementation issues

Indigenous accounts of environmental stewardship in light of the theory and language of Maharishi Vedic Science

The principles and practice of sustainability have gained momentum in the last 15 years and now form a central part of conversations around social praxis and the future. It has been proposed that the theories driving sustainability science are embedded in Indigenous history, and it has been shown that many ancient traditions always concerned themselves with sustainable and ethical living. Among the traditions identified with environmental stewardship are Aboriginal and Torres Strait Islanders of Australia and Māori of New Zealand. Of interest in this context is the Vedic tradition, a tradition of sustainability and ecological awareness which identifies the source of sustainability in Natural Law, the universal source of tradition, language, and knowledge. In this paper we survey two Indigenous traditions as they relate to environmental stewardship, and explore their relation to the Vedic tradition

Industrial sustainability and the circular economy as counterparts to the self-referral mechanics of Natural Law: part I—A theoretical foundation

In Maharishi Vedic Science, the self-referral mechanics of Natural Law are considered fundamental to any complete understanding of nature’s functioning, since Natural Law is understood to be the unmanifest (i.e., non-physical) home of all the laws of nature and the unbounded source of order and intelligence responsible for creating and guiding the physical universe. This proposition is recognizable in modern scientific theories of the ‘unified field’. Moreover, the circular structure and self-referral loops of Natural Law are said to underlie and guide every level of a manifest hierarchy. Among the hallmarks of industrial sustainability are its emphasis on harnessing renewable energy and recycling principles, both designed to limit the impact of polluting activities on the environment and to improve commercial performance. To circumvent the so-called ‘take, make, dispose’ linear economic mentality of the past, contemporary industry has also begun embracing models of circular economy, in which materials and energy are circulated and cascaded through the economic system, with waste either minimized, reused or eliminated altogether. The self-referential nature of recycling and the cascading circularity of circular economies thus bear a prima facie similarity to how Natural Law is structured and functions in continuous self-referral loops. For that reason, in this Part I of a two-part series of research papers, we explore the fundamental nature of industrial sustainability and circular economy, showing them to be counterparts to the self-referral feedback mechanism of Natural Law as described in Maharishi Vedic Science

Convection in a mushy-layer along a heated wall

Motivated by the mushy zones of sea ice, volcanoes, and icy moons of the outer solar system, we perform a theoretical and numerical study of boundary-layer convection along a vertical heated wall in a bounded ideal mushy region. The mush is comprised of a porous and reactive binary alloy with a mixture of saline liquid in a solid matrix, and is studied in the near-eutectic approximation. Here we demonstrate the existence of four regions and study their behavior asymptotically. Starting from the bottom of the wall, the four regions are (i) an isotropic corner region; (ii) a buoyancy dominated vertical boundary layer; (iii) an isotropic connection region; and (iv) a horizontal boundary layer at the top boundary with strong gradients of pressure and buoyancy. Scalings from numerical simulations are consistent with the theoretical predictions. Close to the heated wall, the convection in the mushy layer is similar to a rising buoyant plume abruptly stopped at the top, leading to increased pressure and temperature in the upper region, whose impact is discussed as an efficient melting mechanism

The C-terminal head domain of Burkholderia pseudomallei BpaC has a striking hydrophilic core with an extensive solvent network

Gram-negative pathogens like Burkholderia pseudomallei use trimeric autotransporter adhesins such as BpaC as key molecules in their pathogenicity. Our 1.4 angstrom crystal structure of the membrane-proximal part of the BpaC head domain shows that the domain is exclusively made of left-handed parallel beta-roll repeats. This, the largest such structure solved, has two unique features. First, the core, rather than being composed of the canonical hydrophobic Ile and Val, is made up primarily of the hydrophilic Thr and Asn, with two different solvent channels. Second, comparing BpaC to all other left-handed parallel beta-roll structures showed that the position of the head domain in the protein correlates with the number and type of charged residues. In BpaC, only negatively charged residues face the solvent-in stark contrast to the primarily positive surface charge of the left-handed parallel beta-roll "type" protein, YadA. We propose extending the definitions of these head domains to include the BpaC-like head domain as a separate subtype, based on its unusual sequence, position, and charge. We speculate that the function of left-handed parallel beta-roll structures may differ depending on their position in the structure.Peer reviewe