How should teaching on whole person medicine, including spiritual issues, be delivered in the undergraduate medical curriculum in the United Kingdom?

Background

Although the General Medical Council recommends that United Kingdom medical students are taught ‘whole person medicine’, spiritual care is variably recognised within the curriculum. Data on teaching delivery and attainment of learning outcomes is lacking. This study ascertained views of Faculty and students about spiritual care and how to teach and assess competence in delivering such care.

A questionnaire comprising 28 questions exploring attitudes to whole person medicine, spirituality and illness, and training of healthcare staff in providing spiritual care was designed using a five-point Likert scale. Free text comments were studied by thematic analysis. The questionnaire was distributed to 1300 students and 106 Faculty at Queen’s University Belfast Medical School.

351 responses (54 staff, 287 students; 25 %) were obtained. >90 % agreed that whole person medicine included physical, psychological and social components; 60 % supported inclusion of a spiritual component within the definition. Most supported availability of spiritual interventions for patients, including access to chaplains (71 %), counsellors (62 %), or members of the patient’s faith community (59 %). 90 % felt that personal faith/spirituality was important to some patients and 60 % agreed that this influenced health. However 80 % felt that doctors should never/rarely share their own spiritual beliefs with patients and 67 % felt they should only do so when specifically invited. Most supported including training on provision of spiritual care within the curriculum; 40-50 % felt this should be optional and 40 % mandatory. Small group teaching was the favoured delivery method. 64 % felt that teaching should not be assessed, but among assessment methods, reflective portfolios were most favoured (30 %). Students tended to hold more polarised viewpoints but generally were more favourably disposed towards spiritual care than Faculty. Respecting patients’ values and beliefs and the need for guidance in provision of spiritual care were identified in the free-text comments.

Students and Faculty generally recognise a spiritual dimension to health and support provision of spiritual care to appropriate patients. There is lack of consensus whether this should be delivered by doctors or left to others. Spiritual issues impacting patient management should be included in the curriculum; agreement is lacking about how to deliver and assess.

Social Equality: On what it means to be equals

The first collected volume on social and relational equality.
Addresses a gap in the literature - while many philosophers have pointed to the importance of social equality, it requires much more theoretical development, which this volume aims to provide.
Offers a unique answer to the debate about whether or not equality is valuable.
Features a foreword by eminent political theorist David Miller
Includes new contributions by some of the most well-known contemporary moral and political philosophers, such as Samuel Scheffler and Jonathan Wolff.
Is equality valuable? This question dominates many discussions of social justice, which tend to center on whether certain forms of distributive equality are valuable, such as the equal distribution of primary social goods. But these discussions often neglect what is known as social or relational equality. Social equality suggests that equality is foremost about relationships and interactions between people, rather than being primarily about distribution.

A number of philosophers have written about the significance of social equality, and it has also played an important role in real-life egalitarian movements, such as feminism and civil rights movements. However, as it has been relatively neglected in comparison to the debates about distributive equality, it requires much more theoretical attention. This volume brings together a collection of ten original essays which present new analyses of social and relational equality in philosophy and political theory. The essays analyze the nature of social equality, as well as its relationship to justice and politics.

Readership: The book is primarily aimed at professionals in the field - philosophers (especially in moral, social and political philosophy) and political theorists. It is also aimed at the academic library market. Moreover, the book should be of interest to advanced undergraduate and postgraduate students attending courses on theories of equality and/or social justice.

“How Can a Woman Who Has Been Raped Be Believed?”: Andrea Dworkin, Sexual Violence and the Ethics of Belief

In June 2000, Andrea Dworkin, an American feminist activist and author, published an account of being raped in a Paris hotel room a year earlier. The story was met with widespread disbelief, including from feminist readers. This article explores the reasons for this disbelief, asking how and why narratives of rape are granted – or denied – truth status by their readers. The article argues for understanding the conferral of belief as a narrative transaction involving the actions of both narrator and reader. It posits that Dworkin was widely seen as an unreliable narrator but argues that for ideologically charged narratives such as rape narratives judgements of reliability and belief inevitably draw upon the normative standpoint of the reader. I suggest that there are opposing criteria for establishing the truth of rape narratives; a ‘factual’ or legal model, which sees rape narratives as requiring scrutiny, and an ‘experiential’ model, located within certain strands of feminist politics, which emphasises the ethical importance of believing women’s narratives. The article finishes with a consideration of the place of belief within an ethics of reading and reception of rape narratives.

Ultrasound entropy may be a new non-invasive measure of pre-clinical vascular damage in young hypertensive patients

Background: The identification of pre-clinical microvascular damage in hypertension by non-invasive techniques has proved frustrating for clinicians. This proof of concept study investigated whether entropy, a novel summary measure for characterizing blood velocity waveforms, is altered in participants with hypertension and may therefore be useful in risk stratification.

Methods: Doppler ultrasound waveforms were obtained from the carotid and retrobulbar circulation in 42 participants with uncomplicated grade 1 hypertension (mean systolic/diastolic blood pressure (BP) 142/92 mmHg), and 26 healthy controls (mean systolic/diastolic BP 116/69 mmHg). Mean wavelet entropy was derived from flow-velocity data and compared with traditional haemodynamic measures of microvascular function, namely the resistive and pulsatility indices.

Results: Entropy, was significantly higher in control participants in the central retinal artery (CRA) (differential mean 0.11 (standard error 0.05 cms(-1)), CI 0.009 to 0.219, p 0.017) and ophthalmic artery (0.12 (0.05), CI 0.004 to 0.215, p 0.04). In comparison, the resistive index (0.12 (0.05), CI 0.005 to 0.226, p 0.029) and pulsatility index (0.96 (0.38), CI 0.19 to 1.72, p 0.015) showed significant differences between groups in the CRA alone. Regression analysis indicated that entropy was significantly influenced by age and systolic blood pressure (r values 0.4-0.6). None of the measures were significantly altered in the larger conduit vessel.

Conclusion: This is the first application of entropy to human blood velocity waveform analysis and shows that this new technique has the ability to discriminate health from early hypertensive disease, thereby promoting the early identification of cardiovascular disease in a young hypertensive population.

Energy levels, radiative rates and electron impact excitation rates for transitions in Be-like Cl XIV, K XVI and Ge XXIX

Results for energy levels, radiative rates and electron impact excitation (effective) collision strengths for transitions in Be-like Cl XIV, K XVI and Ge XXIX are reported. For the calculations of energy levels and radiative rates the general-purpose relativistic atomic structure package is adopted, while for determining the collision strengths and subsequently the excitation rates, the Dirac atomic R-matrix code is used. Oscillator strengths, radiative rates and line strengths are listed for all E1, E2, M1 and M2 transitions among the lowest 98 levels of the n ≤ 4 configurations. Furthermore, lifetimes are provided for all levels and comparisons made with available theoretical and experimental results. Resonances in the collision strengths are resolved in a fine energy mesh and averaged over a Maxwellian velocity distribution to obtain the effective collision strengths. Results obtained are listed over a wide temperature range up to 10^7.8 K, depending on the ion.

Energy levels, radiative rates and electron impact excitation rates for transitions in Be-like Ti XIX

We report calculations of energy levels, radiative rates and electron impact excitation cross sections and rates for transitions in Be-like Ti XIX. The general-purpose relativistic atomic structure package is adopted for calculating energy levels and radiative rates. For determining the collision strengths and subsequently the excitation rates, the Dirac atomic R-matrix code (darc) is used. Oscillator strengths, radiative rates and line strengths are reported for all E1, E2, M1 and M2 transitions among the lowest 98 levels of the n≤ 4 configurations. Additionally, theoretical lifetimes are listed for all 98 levels. Collision strengths are averaged over a Maxwellian velocity distribution and the effective collision strengths obtained listed over a wide temperature range up to 10 ^7.7K. Comparisons are made with similar data obtained from the flexible atomic code (fac) to highlight the importance of resonances, included in calculations with darc, in the determination of effective collision strengths. Discrepancies between the collision strengths from darc and fac, particularly for forbidden transitions, are also discussed. 

Electron impact excitation of Be-like ions: a comparison of DARC and ICFT results

Emission lines of Be-like ions are frequently observed in astrophysical plasmas, and many are useful for density and temperature diagnostics. However, accurate atomic data for energy levels, radiative rates (A-values) and effective electron excitation collision strengths ($\Upsilon$) are required for reliable plasma modelling. In general it is reasonably straightforward to calculate energy levels and A- values to a high level of accuracy. By contrast, considerable effort is required to calculate $\Upsilon$, and hence it is not always possible to assess the accuracy of available data. Recently, two independent calculations (adopting the $R$-matrix method) but with different approaches (DARC and ICFT) have appeared for a range of Be-like ions. Therefore, in this work we compare the two sets of $\Upsilon$, highlight the large discrepancies for a significant number of transitions and suggest possible reasons for these.

Interventions Targeting Child Undernutrition in Developing Countries May Be Undermined by Dietary Exposure to Aflatoxin

Child undernutrition, a form of malnutrition, is a major public health burden in developing countries. Supplementation interventions targeting the major micronutrient deficiencies have only reduced the burden of child undernutrition to a certain extent, indicating that there are other underlying determinants that need addressed. Aflatoxin exposure, which is also highly prevalent in developing countries, may be considered to be an aggravating factor for child undernutrition. Increasing evidence suggests that aflatoxin exposure can occur in any stage of life including in utero through a trans-placental pathway and in early childhood (through contaminated weaning food and family food). Early life exposure to aflatoxin is associated with adverse effects on low birth weight, stunting, immune suppression and liver function damage. The mechanisms underlying impaired growth and aflatoxin exposure are still unclear but intestinal function damage, reduced immune function and alteration in the insulin-like growth factor axis caused by liver damage, are suggested hypotheses. Given the fact that both aflatoxin and child undernutrition are common in sub-Saharan Africa, effective interventions aimed at reducing undernutrition cannot be satisfactorily achieved until the interactive relationship between aflatoxin and child undernutrition is clearly understood, and an aflatoxin mitigation strategy has taken effect in those vulnerable mothers and children.

Can the scaling behavior of electric conductivity be used to probe the self-organizational changes in solution with respect to the ionic liquid structure? The case of [C8MIM][NTf2]

Electrical conductivity of the supercooled ionic liquid [C8MIM][NTf2], determined as a function of temperature and pressure, highlights strong differences in its ionic transport behavior between low and high temperature regions. To date, the crossover effect which is very well known for low molecular van der Waals liquids has been rarely described for classical ionic liquids. This finding highlights that the thermal fluctuations could be dominant mechanisms driving the dramatic slowing down of ion motions near Tg. An alternative way to analyze separately low and high temperature dc-conductivity data using a density scaling approach was then proposed. Based on which a common value of the scaling exponent [gamma] = 2.4 was obtained, indicating that the applied density scaling is insensitive to the crossover effect. By comparing the scaling exponent [gamma] reported herein along with literature data for other ionic liquids, it appears that [gamma] decreases by increasing the alkyl chain length on the 1-alkyl-3-methylimidazolium-based ionic liquids. This observation may be related to changes in the interaction between ions in solution driven by an increase in the van der Waals type interaction by increasing the alkyl chain length on the cation. This effect may be related to changes in the ionic liquid nanostructural organization with the alkyl chain length on the cation as previously reported in the literature based on molecular dynamic simulations. In other words, the calculated scaling exponent [gamma] may be then used as a key parameter to probe the interaction and/or self-organizational changes in solution with respect to the ionic liquid structure.

Defining the content and delivery of an intervention to Change AdhereNce to treatment in BonchiEctasis (CAN-BE): a qualitative approach incorporating the Theoretical Domains Framework, behavioural change techniques and stakeholder expert panels

Background
Low patient adherence to treatment is associated with poorer health outcomes in bronchiectasis. We sought to use the Theoretical Domains Framework (TDF) (a framework derived from 33 psychological theories) and behavioural change techniques (BCTs) to define the content of an intervention to change patients’ adherence in bronchiectasis (Stage 1 and 2) and stakeholder expert panels to define its delivery (Stage 3).

Methods
We conducted semi-structured interviews with patients with bronchiectasis about barriers and motivators to adherence to treatment and focus groups or interviews with bronchiectasis healthcare professionals (HCPs) about their ability to change patients’ adherence to treatment. We coded these data to the 12 domain TDF to identify relevant domains for patients and HCPs (Stage 1). Three researchers independently mapped relevant domains for patients and HCPs to a list of 35 BCTs to identify two lists (patient and HCP) of potential BCTs for inclusion (Stage 2). We presented these lists to three expert panels (two with patients and one with HCPs/academics from across the UK). We asked panels who the intervention should target, who should deliver it, at what intensity, in what format and setting, and using which outcome measures (Stage 3).

Results
Eight TDF domains were perceived to influence patients’ and HCPs’ behaviours: Knowledge, Skills, Beliefs about capability, Beliefs about consequences, Motivation, Social influences, Behavioural regulation and Nature of behaviours (Stage 1). Twelve BCTs common to patients and HCPs were included in the intervention: Monitoring, Self-monitoring, Feedback, Action planning, Problem solving, Persuasive communication, Goal/target specified:behaviour/outcome, Information regarding behaviour/outcome, Role play, Social support and Cognitive restructuring (Stage 2). Participants thought that an individualised combination of these BCTs should be delivered to all patients, by a member of staff, over several one-to-one and/or group visits in secondary care. Efficacy should be measured using pulmonary exacerbations, hospital admissions and quality of life (Stage 3).

Conclusions
Twelve BCTs form the intervention content. An individualised selection from these 12 BCTs will be delivered to all patients over several face-to-face visits in secondary care. Future research should focus on developing physical materials to aid delivery of the intervention prior to feasibility and pilot testing. If effective, this intervention may improve adherence and health outcomes for those with bronchiectasis in the future.