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An increasing body of evidence suggests that transitioning from school to adult life can be challenging for young people with intellectual disability. Transition from secondary school includes preparation of students before leaving the school environment and may continue several years into adult life. Transition challenges may include isolation, mental health problems, and reduced participation in employment and tertiary education. Some literature indicate links between poor post-school outcomes, and ineffective collaboration between school systems, disability services, and employers. Yet, consolidated evidence to understand how young people themselves experience transition from school is needed. The aim of this scoping review is to draw together current literature reporting what young people with intellectual disability say about transitioning to life after school. Methods: Using the Joanna Briggs scoping review methodology and the population, concept, context (PCC) framework, a systematic strategy will identify peer-reviewed qualitative research and grey literature reporting the voices of young people with intellectual disability to better understand personal experiences of transition to life after school. The PCC framework outlined in this section directed the research question and the development of the search strategy for this study. Population The population in this review will be young people with intellectual disability aged 15-30 years to capture a broad transition period. This age range reflects the varied definitions of what constitutes a young person. Increasing evidence also indicates that the transition to adulthood often extends well into the 20s or even later (1, 22), particularly for people with intellectual disability (23). There is no universally accepted definition of intellectual disability, and language use changes over time and in different contexts. Therefore, for the purposes of this scoping review a broad approach to searching will be taken, utilising a range of current and older terms including disability or disabled or handicap; intellectual, learning, and developmental; cognitive impairment; and mental retardation to include US literature prior to 2013. The term ‘mental retardation’ is now considered derogatory in most English speaking countries, and was officially removed from the DSM-5 and ICD-11 in 2007, but was retained in some publications for several years. The use of the term also persisted in US federal policies until 2010, when President Obama signed the legislation required to replace the term with intellectual disability (24). The final rule was adopted in January 2013 (25). Concept The concept or phenomenon of interest to be explored in this scoping review is the experiences of young people with intellectual disability transitioning to life after school. This phenomenon incorporates three key phases for which varying terminology is used within the literature before, during and after transitioning. In the context of this scoping review, the search strategy will include terms that relate to: a) planning for the end of secondary education, which should take place several years in advance, b) the time of leaving high school and moving and settling into what comes next, for example, c) living independently, community participation, education and training, and/or employment. Therefore research and grey literature about any post-school setting will be considered, including on post-secondary education, disability services, and the wider community. However, if used as a main search string, these terms may narrow the results significantly, so it is likely the settings will be considered in the extraction phase to help organise the review and analysis. Context Literature reporting young people’s own experiences and views on the transition to adulthood will be prioritised to better understand what they consider important about their transition from school. Young people have a moral and ethical right to be involved in decisions that impact their lives, in line with the UN Convention of Rights of the Child (UNCRC) (26) and UN Convention of Rights of Persons with Disability (UNCRPD) (27). The searches will be for qualitative research involving young people with intellectual disability as participants, and grey literature that focuses on what is important to young people. Qualitative study designs including, but not limited to, phenomenological, grounded theory, ethnographic, action research and narrative inquiry will be considered. Papers that include a range of perspectives will be included so long as the views or experiences of young people themselves can be clearly distinguished in the findings. Where voices of parents, educators, service providers have been included, the reviewers will prioritise the perspectives of young people. The review will explore scope and foci of topics, identify gaps in current evidence, and highlight approaches and methods used by investigators to include young peoples’ voices. Database searches for relevant qualitative research will include ERIC via Proquest, Ovid MEDLINE, selected EbscoHost databases, and Web of Science. Non-indexed and grey literature such as policies and reports will be searched via TROVE, ProQuest Dissertations & Theses, and Google (with URL control and by crawling key agency websites). Studies will be selected using a three-step process: i) managing search results and removing duplicates, ii) title and abstract screening by two independent reviewers, and iii) full text review of included articles against inclusion criteria by two independent reviewers. Data will be tabulated and presented in a narrative summary, aligning with the objectives and scope of this review. Discussion: Review findings will inform policy makers, educators and disability support organisations of transition challenges experienced by young people with intellectual disability. The findings will enable the design and implementation of more accessible and holistic transition to address barriers in the process, ensuring future guidelines reflect the voices of those they intend to support.

Background Medical student mental health and wellbeing is highly topical and the subject of much research. While theoretically informed definitions of wellbeing abound, how do medical students themselves understand and perceive wellbeing? What aspects of the curriculum do they regard as affecting their wellbeing and mental health? This study explored these questions, and aimed to identify factors associated with student acceptability of wellbeing programs and interventions. Methods All students at an Australian undergraduate medical school (n = 619) were invited to complete a qualitative online questionnaire between 2017 and 2018 following the introduction of several wellbeing initiatives, including “Wellbeing Days” (WBD). WBD allow students to take single absence days for self-care. Open-ended questions were asked about perceptions and experience of mental health and wellbeing, and views on interventions to improve wellbeing such as WBD. Thematic analysis was conducted across all responses. Three authors developed preliminary themes, which were then refined and confirmed by all researchers. Thematic saturation was achieved within data from the 68 respondents, which included participants from all cohorts. Results Participants described wellbeing as positively experienced work/life balance, impacted by four factors; contact hours, peer relationships, staff relationships, and trust in how wellbeing initiatives were used. Long contact hours were deemed incompatible with self-care activities, maintaining employment, and seeking professional medical/psychological help. Peers could promote wellbeing by offering social and academic support, but also undermine wellbeing by being competitors. Degree of trust, engagement and communication with staff influenced acceptability of interventions. Participants viewed initiatives such as WBD favourably, but distrust of peers, and of staff, led to perceptions that WBD could be prone to misuse, or used for surveillance rather than support. Conclusion Our findings suggest that wellbeing days which allow self-care, reduction in contact hours, and peer support may promote student wellbeing, but the acceptability of any interventions is influenced by relationships between staff and students, and in particular, trust in these relationships. We suggest strategies to strengthen trust and further research to investigate the relationship between trust and perceptions of wellbeing in self and peers.

I argue that many of the priority rankings that have been proposed by effective altruists seem to be in tension with apparently reasonable assumptions about the rational pursuit of our aims in the face of uncertainty. The particular issue on which I focus arises from recognition of the overwhelming importance and inscrutability of the indirect effects of our actions (so-called cluelessness), conjoined with the plausibility of a permissive decision principle governing cases of deep uncertainty, known as the maximality rule. I conclude that we lack a compelling decision theory that is consistent with a longtermist perspective and does not downplay the depth of our uncertainty, while also supporting orthodox effective altruist conclusions about cause prioritization.

According to large number scepticism, intuitions about the Repugnant Conclusion and related problems in normative ethics shouldn’t be trusted because we can’t adequately grasp the very large numbers involved. This chapter argues that the case for large number scepticism is unconvincing. I respond to arguments for large number scepticism offered by John Broome and Michael Huemer, as well as more empirically grounded arguments due to Joshua Greene and Adam Cureton. I consider what we can learn from evidence of scope insensitivity in contingent valuation, people’s diminishing sensitivity to increasing numbers of lives lost or saved, well-established limitations of the mind/brain’s core number systems, and evidence that people are more moved by single victims than by groups. In each case, I argue that the case for large number scepticism should not convince us.

Systematic separation of cow and calf early after calving is common practice in both organic and conventional dairy farming. The main objective of this paper was to develop different scenarios for dam-calf contact and quantify their effects on milk uptake by the calf and environmental sustainability of the produced milk and meat from these systems. Scenarios were set up of organic dairy systems to analyse the effect of different dam-calf systems with either half-time or full-time contact between cow and calf for 28, 51 or 91 days. Based on experience from practice and literature, we assumed a total milk uptake of 1,110 kg ECM milk with part-time contact and 1,207 kg ECM milk with full-time contact over 91 days. These scenarios were compared to traditional calf rearing systems with direct separation after birth and milk feeding from a bucket with low or high milk feeding levels of 460 and 630 kg ECM, respectively, in the first 91 days. The scenarios were analysed at a milk production level of 9,000 kg ECM per cow per year and with a sensitivity analysis covering yield levels of 7,000, 11,000 and 13,000 kg ECM per cow per year. At a production level of 9,000 kg ECM per year and full-time dam-calf contact throughout the milk period, only 85% of the milk produced could be delivered to the dairy company, compared to 93% when a low-level of milk is fed from a bucket. This means that there were fewer kg products to bear the environmental impacts, and hence the carbon footprint and land use from production per kg of ECM milk and meat sold was increased by between 5 and 9%, while the corresponding increase in impact at the highest yield level of 13,000 kg ECM was only between 4 and 6%. Besides environmental sustainability of cow-calf contact systems, the broader context of such systems need to be analysed including animal welfare and the economic effect for the farmer.

This paper aims to open a dialogue between philosophers working in decision theory and operations researchers and engineers working on decision-making under deep uncertainty. Specifically, we assess the recommendation to follow a norm of robust satisficing when making decisions under deep uncertainty in the context of decision analyses that rely on the tools of Robust Decision-Making developed by Robert Lempert and colleagues at RAND. We discuss two challenges for robust satisficing: whether the norm might derive its plausibility from an implicit appeal to probabilistic representations of uncertainty of the kind that deep uncertainty is supposed to preclude; and whether there is adequate justification for adopting a satisficing norm, as opposed to an optimizing norm that is sensitive to considerations of robustness. We discuss decision-theoretic and voting-theoretic motivations for robust satisficing, and use these motivations to select among candidate formulations of the robust satisficing norm.

IntroductionThe assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021.Methods and analysisThe intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might ‘work’ to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders.Ethics and disseminationEthics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

Schools, as diverse communities where children live much of their daily lives, are significant for their impact on children’s well-being. The chapter is a nuanced exploration of how the children we talked with in our research project, respond to the potentially contradictory expectations school poses for experiences of well-being in the present and well-becoming in the future. We move beyond describing the tensions between well-being and well-becoming by framing our discussion around what children told us about their experiences of well-being at school, in terms of opportunities to pursue agency and competency, defined in our discussion as self-determination, and the requirements to prepare for a future, what we refer to as adult-imposed aspirations. We argue, from our findings that, while the opportunities school provides children for self-determination promote their sense of well-being, the pressures from adult-imposed aspirations, particularly for secondary school children, can undermine well-being in the present.

According to the Psychological Account of personal identity, personal identity across time is maintained by some form of psychological overlap or continuance. I show that the Psychological Account has trouble accommodating cases of transient retrograde amnesia. In such cases, the transitivity of psychological continuity may break down. I consider various means of responding to this problem, arguing that the best available response will undercut our ability to rely on intuitions about brain transplantation to support the Psychological Account. When the Psychological Account is re-interpreted in such a way as to overcome the problems posed by cases of transient retrograde amnesia, it turns out that standard brain transplantation cases involve details which are strictly irrelevant according to the theory. On the other hand, these features seem to drive our intuitions about survival in these cases. In this way, my argument undermines one of the key motivations for adopting the Psychological Account.

Peter Singer argues that middle-class members of affluent countries have an obligation to give away almost all their income to fight poverty in the developing world. Others, however, argue that this view is too demanding: it is asking more of us than morality truly requires. This chapter proposes a weaker principle, the very weak principle of sacrifice: Most middle-class members of affluent countries ought, morally, to use at least 10 percent of their income to effectively improve the lives of others. This principle is not very demanding at all, and therefore the “demandingness” objection has not even pro tanto force against it.

Given the inevitability of scarcity, should public institutions ration healthcare resources so as to prioritize those who contribute more to society? Intuitively, we may feel that this would be somehow inegalitarian. I argue that the egalitarian objection to prioritizing treatment on the basis of patients’ usefulness to others is best thought of as semiotic: i.e. as having to do with what this practice would mean, convey, or express about a person's standing. I explore the implications of this conclusion when taken in conjunction with the observation that semiotic objections are generally flimsy, failing to identify anything wrong with a practice as such and having limited capacity to generalize beyond particular contexts.

Across eight experiments (N = 2,310), we studied whether people would prioritize rescuing individuals who may be thought to contribute more to society. We found that participants were generally dismissive of general rules that prioritize more socially beneficial individuals, such as doctors instead of unemployed people. By contrast, participants were more supportive of one-off decisions to save the life of a more socially beneficial individual, even when such cases were the same as those covered by the rule. This generality effect occurred robustly even when controlling for various factors. It occurred when the decision-maker was the same in both cases, when the pairs of people differing in the extent of their indirect social utility was varied, when the scenarios were varied, when the participant samples came from different countries, and when the general rule only covered cases that are exactly the same as the situation described in the one-off condition. The effect occurred even when the general rule was introduced via a concrete precedent case. Participants’ tendency to be more supportive of the one-off proposal than the general rule was significantly reduced when they evaluated the two proposals jointly as opposed to separately. Finally, the effect also occurred in sacrificial moral dilemmas, suggesting it is a more general phenomenon in certain moral contexts. We discuss possible explanations of the effect, including concerns about negative consequences of the rule and a deontological aversion against making difficult trade-off decisions unless they are absolutelynecessary.

Background In Australia, the proportion of medical students with disability remains low compared to students with disability in other university courses and to the prevalence of disability in society. Arguments for inclusion include medical school obligations to respond to community values in their programs, and that doctors with disabilities can offer valuable insights for patient care from their experiences. This study aimed to inform inclusive and socially accountable medical programs by investigating community views on doctors and medical students with disability. Methods A concurrent mixed methods study was conducted, simultaneously collecting quantitative fixed responses, and qualitative free text responses to provide in-depth and triangulated data on community views. Frequency and thematic analysis within and across response categories was used to identify patterns and relationships, providing context and meaning to the quantitative data for the integrated findings. Results Of 207 respondents aged 17 to 71 years, 71% were female, and 60.2% had university level education. Most (92.3%) knew someone with a long standing disability, illness, mental health condition or learning difficulty, 74.7% agreed that a person with a disability should be encouraged to study medicine, 79.7% agreed that a person with a disability should be accepted into medical school, and 81.4% that including people with disability would be an advantage in the medical profession. Five integrated themes explained these views: 1) Fair selection, support and monitoring is expected of medical schools, 2) Life experiences of disability promotes real empathy in doctors, 3) Career considerations for those with disability, 4) Medical role models to address disabling social barriers, and 5) Responsibility to monitor own health and ability to perform. Conclusions This study indicates Australian community support for inclusion of people with disability as medical students and practitioners. Findings also suggest community expectations and trust in medical schools to effectively select and graduate only those who will be capable doctors, and to support health and development of all students towards being competent graduates. These findings provide support for medical schools to develop inclusive practices in medical education and training relevant to the health services and communities they serve. Electronic supplementary material The online version of this article (10.1186/s12909-019-1715-7) contains supplementary material, which is available to authorized users.

BACKGROUND Uterus transplantation is an emerging surgical innovation offering the option of genetic and gestational motherhood to women with absolute uterine factor infertility. More than 15 centres worldwide have now commenced clinical trials, but the procedure has not been performed in Australia. AIM To explore the awareness, attitudes and perceptions regarding uterus transplantation among Australian women with absolute uterine infertility. MATERIALS AND METHODS An online survey targeting Australian women with absolute uterine factor infertility was performed. Data collected included demographic data, infertility circumstances, considered motherhood options and wellbeing, followed by specific questions regarding uterus transplantation. In total, the participants completed 50 items. RESULTS All 57 respondents (90% response rate) indicated awareness of uterus transplantation. Of the women who desired parenthood, more than two-thirds indicated a strong desire to carry their own child, with an even higher number (80%) endorsing the need for the procedure to be an option in Australia. Which donor model is preferred (deceased or live), requires further exploration. CONCLUSION This study indicates that uterus transplantation is desired by the majority of Australian women with absolute uterine factor infertility. Clinical introduction of uterus transplantation in Australia has strong support from the women who would benefit from the procedure.

I argue that there are cases in which ecumenical expressivism cannot distinguish between endorsement of certain trivial and substantive normative judgments. I consider the extent to which this problem generalizes across different formulations of the ecumenical view. I suggest that we may not be able to escape the problem if we hope to retain the ability to solve the Frege-Geach problem in the way promised by ecumenical expressivism.

Many moral philosophers accept the Debunking Thesis, according to which facts about natural selection provide debunking explanations for certain of our moral beliefs. I argue that philosophers who accept the Debunking Thesis beg important questions in the philosophy of biology. They assume that past selection can explain why you or I hold certain of the moral beliefs we do. A position advanced by many prominent philosophers of biology implies that this assumption is false. According to the Negative View, natural selection cannot explain the traits of individuals. Hence, facts about past selection cannot provide debunking explanations for any of our moral beliefs. The aim of this paper is to explore the conflict between the Debunking Thesis and the Negative View.

Upon discovering that certain beliefs we hold are contingent on arbitrary features of our background, we often feel uneasy. I defend the proposal that if such cases of contingency anxiety involve defeaters, this is because of the epistemic significance of disagreement. I note two hurdles to our accepting this Disagreement Hypothesis. Firstly, some cases of contingency anxiety apparently involve no disagreement. Secondly, the proposal may seem to make our awareness of the influence of arbitrary background factors irrelevant in determining whether to revise our beliefs. I show that each of these problems can be successfully accommodated by the Disagreement Hypothesis.

Most people believe that some optimific acts are wrong. Since we are not permitted to perform wrong acts, we are not permitted to carry out optimific wrongs. Does the moral relevance of the distinction between action and omission nonetheless permit us to allow others to carry them out? I show that there exists a plausible argument supporting the conclusion that it does. To resist my argument, we would have to endorse a principle according to which, for any wrong action, there is some reason to prevent that action over and above those reasons associated with preventing harm to its victim(s). I argue that it would be a mistake to value the prevention of wrong acts in the way required to resist my argument.

Many philosophers believe that natural selection explanations debunk our moral beliefs or would do so if moral realism were true, relying on the assumption that explanations of this kind show that moral facts play no role in explaining human moral beliefs. Here I argue that this assumption rests on a confusion of proximate and ultimate explanatory factors. Insofar as evolutionary debunking arguments hinge on the assumption that moral facts play no role in explaining human moral beliefs, these arguments fall short.

This article was migrated. The article was marked as recommended. Background: Ensuring diversity, and that the medical profession is representative of the varied communities it serves is a worldwide equity concern. The widening participation movement in higher education aims to attract more students from non-traditional backgrounds into university. Yet, there is persistent under-representation of students with disabilities in medical education, and subsequently, the profession. The inclusion of these students is greatly influenced by the policies which regulate and accredit medical schools, which demand that educators consider students with disabilities as future doctors. While these policies may aim to promote inclusion, they may also have unintended consequences. In this paper we critically analyse key policies in undergraduate medical education to examine how disability in medical students is represented and problematized, and the educational implications of such representations. Method: Key policies concerning medical school accreditation and educational standards from the General Medical Council (UK), Australian Medical Council (Australia) were selected for analysis. Carol Bacchi's 'What's the Problem Represented to Be?' six critical questions approach was applied to conduct a critical interpretive analysis of how disability is problematized in these policies. Findings: Our analysis revealed a distinctive construction of disability in medicine, supported by themes of containment of disability, disability and competence, and disability and risk. Disability is framed as risk and potential educational burden for schools which must adapt practices to meet legal requirements. Risk is conceptualised as a quality of individuals, rather than being constructed through interactions between persons and environments. The ways in which disability is problematized relates to presuppositions which have the effect of restricting access for learners with disabilities. Conclusions: The policies which regulate medical education can inadvertently limit inclusion of students with disabilities by being silent on the value of a diverse medical workforce. Bacchi's six critical questions are an accessible and practical method for identifying the norms and assumptions which may impede change in educational policy and practice. By making visible these hidden suppositions and their consequences for learners, their impact may be ameliorated, and progress made.

There is a lack of consideration for the effects that labels such as autism, and the associated diagnostic processes, have on the children to whom they are applied. In this article we present research conducted with five teenagers diagnosed with autism. Through a collaborative, participatory research approach, these teenagers shared their experiences of their diagnosis using communication methods of their choice. The young people's accounts illustrate the understandings they had of autism. Important findings from the research illustrate how the participants integrated this knowledge with their sense of self, how they negotiated issues of identity and the meanings that feeling 'different' had for them. Whether the diagnosis was experienced as advantage or disadvantage by the young people depended on the extent to which it facilitated knowledge and control. The article concludes with a discussion of the significance a diagnosis may have for the ways in which children and young people construct their personal identity and their social relations, and in terms of negotiating control in their lives. We suggest that ways of minimising stigma and marginalisation associated with a diagnosis of autism need to be considered at a policy level.

This paper tries to explain why racial profiling involves a serious injustice and to do so in a way that avoids the problems of existing philosophical accounts. An initially plausible view maintains that racial profiling is pro tanto wrong in and of itself by violating a constraint on fair treatment that is generally violated by acts of statistical discrimination based on ascribed characteristics. However, consideration of other cases involving statistical discrimination suggests that violating a constraint of this kind may not be an especially serious wrong in and of itself. To fully capture the significant wrong that occurs when racial profiling is targeted at black Americans or other similarly situated groups, it is argued that we should appeal to the idea that this basic injustice is exacerbated when it forms part of a larger pattern of similar actions that collectively realize a state of cumulative injustice.

People may disagree about moral issues because they have fundamentally different intuitions. I argue that we ought to suspend judgement in such cases. Since we trust our own moral intuitions without positive evidence of their reliability, we must necessarily extend this trust to the moral intuitions of others: a fundamental self-other asymmetry in moral epistemology is untenable. This ensures that disagreements in moral intuition are defeating. In addition, I argue that brute conflicts in moral intuition require suspension of judgement only if we are required to exhibit this kind of default trust with respect to the moral intuitions of others.

Many philosophers believe that there exist distinctive obstacles to relying on moral testimony. In this paper, I criticize previous attempts to identify these obstacles and offer a new theory. I argue that the problems associated with moral deference can't be explained in terms of the value of moral understanding, nor in terms of aretaic considerations related to subjective integration. Instead, our uneasiness with moral testimony is best explained by our attachment to an ideal of authenticity that places special demands on our moral beliefs.

Thirty-one (7%) of 404 patients with acute myocardial infarction (450 consecutive admissions) had a temporary transvenous pacemaker electrode inserted and were artificially paced. The indications for electrical stimulation of the heart were complete heart block in 28 patients, AV block II in two, and extreme sinus bradycardia and nodal bradycardia in one patient. The 31 paced patients were followed up for 2 years or more (mean follow-up time 33 months). Twelve (39%) died during their stay in hospital and another 10 (32%) during the follow-up period. In 21 of these 22 patients the cause of death could be determined; 12 died suddenly. The cumulative survival rate after 25–36 months for the non-paced patients was 53% and for the paced patients 25%; a statistically significant difference (p < 0.01). Age differences between the paced and the non-paced patients were small and could not explain the differences. The prognosis for the temporarily paced patients in this report was poor. Even if most of them died suddenly, it is doubtful whether the prognosis could be significantly improved by long-term cardiac pacing, as the myocardial damage was found to be extensive in the autopsied cases.

A-V nodal rhythm (NR) has been observed on monitoring during the first 24 hours in 79 (18%) of a consecutive series of 450 admissions to a coronary care unit (CCU) subsequently diagnosed as having an acute myocardial infarction. The concomitant CCU mortality was 23% as compared to 8% of the remainder. Similarly the hospital mortality of 33% significantly differs from 19% in the remainder. The survivors were younger, more rarely showed signs of power failure, and a history of previous myocardial infarction was less common. In 7 of the 26 patients who died, NR appeared for the first and only time immediately prior to death. Survival of a period of NR by more than one hour was not associated with a raised mortality. Distinguishing features for patients with NR were a lower rate of previous myocardial infarction, a higher incidence of larger infarctions as judged by SGOT maximum levels and also of inferior infarcts. The validity of the finding of NR in routine monitoring has been assessed by comparing with continuous ECG recording in 95 consecutive patients. Of the 23 (24%) patients with NR on the ECG recording, the arrhythmia was observed in 14, and in a further 4 cases where NR was claimed it could not be verified.

Introduction Goal setting is a complex skill. The use of formal goal writing procedures (including the use of the SMART goal model) has been advocated. However, a standardised method of writing and evaluating SMART goals is currently lacking. This study comprised of two phases. The aims of phase one was to (i) develop the SMART Goal Evaluation Method (SMART-GEM) based on a SMART goal model; and (ii) investigate the content validity of the SMART-GEM. The aim of phase two of the study was to test the inter-rater reliability of the SMART-GEM. Methods Development of the SMART- GEM involved defining and constructing evaluation criteria suitable for auditing goal statements. A content validity assessment was conducted using an expert panel of Occupational Therapists (n = 10). Inter-rater reliability of the SMART-GEM was examined using a purposive sample of multiple raters (n = 24). Results The SMART- GEM was rated as having good content validity (individual items CVI ranged from 0.90 to 1.00; total SMART- GEM CVI = 0.99, ρ = 0.05). Agreement between raters on individual items ranged from poor (κ = 0.254) to excellent (κ = 0.965) and agreement of overall grades was fair to good (κ = 0.582). Inter-rater agreement on total scores was found to be very good (ICC = 0.895, 95% CI = 0.743 to 0.986, ρ = 0.001) with excellent internal consistency (α = 0.995). Conclusion The SMART-GEM demonstrated good construct validity and very good inter-rater reliability on total score and shows promise as a standardised method to writing and evaluating clinical goals.

8 páginas, 5 figuras -- PAGS nros. 342-349, A multidisciplinary study was carried out to analyse the chromosome doubling process during the early stages of in vitro maize microspore embryogenesis. The main stages (microspore derivatives) that were formed in the course of the culture were analysed. Chromosome number was determined from squashed cells, and DNA content was measured by cytometry. In parallel, an ultrastructural analysis of the microspore derivatives demonstrated the occurrence of a nuclear fusion process. It seems likely that nuclear fusion ensures chromosome doubling at early stages of induced microspore embryogenesis. It occurs precisely at the 5/7 day stage in the embryonic domain and probably leads to polyploidy in the endosperm domain of the microspore derivatives. As a conclusion a scheme summarises the results and proposes an interpretation of the sequence of chromosome doubling events during early maize microspore embryogenesis. Understanding of this process will be important for future efforts to increase the percentage of homozygous plants for crop improvement, This work was partly supported by PAI-Picasso contract (Nr04262VK) in the frame of France/Spain European exchanges

We used fluorescence in situ hybridization to identify and map the position of B chromosomes (supernumerary chromosomes) within maize sperm cells. Observations on over 1,000 sperm cells from several genotypes show that, on average, the B chromosomes are positioned in the tip one-fourth of the sperm nucleus two-thirds of the time. In contrast, the centromeres and knobs of the A chromosomes (the normal set) are not restricted to the tip portion of the nucleus. To our knowledge, this is the first example of specific chromosome positioning within a plant gamete. Studies on nuclear architecture of somatic cells in both plants and animals suggest that chromosome behavior and gene expression may correlate with chromosome position within the nucleus. The functional significance of nonrandom positioning of the B chromosomes within maize sperm is as yet unclear.

Fifty-five patients with acute myocardial infarction were examined with thallium-201 scintigraphy before discharge from hospital. Fifty-one showed significant scintigraphic defects. The number of abnormal Q waves in a 12-lead ECG but not the maximal ASAT value for each patient were correlated to the total estimated image defect. Mortality during the follow-up period of 14–28 months was not related to the estimated total image defect, but the two early deaths occurred among patients with the most dilated left ventricles.

A high incidence of thrombophlebitis has been noted in a Coronary Care Unit, where 2% lignocaine was given prophylactically to every second patient. The incidence of thrombophlebitis after 16–24 hours was about 50% when giving glucose as a drip in association with lignocaine from a pump. When only a glucose drip was given, or when lignocaine was replaced by glucose in the pump, the incidence was 4–10%. Therefore, lignocaine solution seems to promote the development of thrombophlebitis in i.v. infusions.

Quantities of DNA were estimated in the nuclei of mechanically isolated egg and zygote protoplasts in two cultivars of barley using 4[prime],6-diamidino-2-phenylindole staining and microfluorometry. Unlike many previous studies on DNA amounts within the sex cells of flowering plants, we obtained consistent and unambiguous results indicating that the egg and sperm nuclei are at the 1C DNA level (basic haploid amount) at the time of karyogamy. Karyogamy was initiated within 60 min postpollination, and the male chromatin became completely integrated into the egg nucleus within 6 to 7 hr postpollination (hpp). Zygotic nuclear DNA levels began to increase at ~9 to 12 hpp in cultivar Alexis and at 12 to 15 hpp in cultivar Igri. The 4C DNA complement was reached in most zygotes by 22 to 26 hpp in cultivar Alexis and by 23 to 29 hpp in cultivar Igri. These data are fundamental to a better understanding of fertilization and zygote maturation in flowering plants. They are also relevant to studies in which the timing of zygotic DNA replication is of interest, such as ongoing investigations on genetic transformations in barley using the microinjection technique.

Genetic studies have demonstrated biparental inheritance of plastids in alfalfa. The ratio of paternal to maternal plastids in the progeny varies according to the genotypes of the parents, which can be classified as strong or weak transmitters of plastids. Previous cytological investigations of generative cells and male gametes have provided no consistent explanation for plastid inheritance patterns among genotypes. However, plastids in the mature egg cells of a strong female genotype (6–4) were found to be more numerous and larger than in mature eggs of a weak female genotype (CUF-B), and the plastids in 6–4 eggs are positioned equally around the nucleus. In CUF-B, the majority of plastids are positioned below (toward the micropyle) the mid level of the nucleus, which is the future division plane of the zygote. Since only the apical portion of the zygote produces the embryo proper, plastids in the basal portion were predicted to become included in the suspensor cells and not be inherited. In the present study, we examined zygotes and a two-celled proembryo from a cross between CUF-B and a strong male genotype (301), a cross that results in over 90% of the progeny possessing paternal plastids only. Our results indicate that the distribution of plastids observed in the CUF-B egg cell is maintained through the first division of the zygote. Further, paternal plastids are similarly distributed; however, within the apical portion of the zygote and in the apical cell of the two-celled proembryo, the number of paternal plastids is typically much greater than the number of maternal plastids. These findings suggest that maternal and paternal plastid distribution within the zygote is a significant factor determining the inheritance of maternal and paternal plastids in alfalfa.

Acropora and Porites corals are important reef builders in the Indo-Pacific and Caribbean. Bacteria associated with mucus produced by Porites spp. and Acropora spp. from Caribbean (Punta Maroma, Mexico) and Indo-Pacific (Hoga and Sampela, Indonesia) reefs were determined. Analysis of pyrosequencing libraries showed that bacterial communities from Caribbean corals were significantly more diverse (H′, 3.18 to 4.25) than their Indonesian counterparts (H′, 2.54 to 3.25). Dominant taxa were Gammaproteobacteria , Alphaproteobacteria , Firmicutes , and Cyanobacteria , which varied in relative abundance between coral genera and region. Distinct coral host-specific communities were also found; for example, Clostridiales were dominant on Acropora spp. (at Hoga and the Mexican Caribbean) compared to Porites spp. and seawater. Within the Gammproteobacteria , Halomonas spp. dominated sequence libraries from Porites spp. (49%) and Acropora spp. (5.6%) from the Mexican Caribbean, compared to the corresponding Indonesian coral libraries (Porites spp. from the Mexican Caribbean, there was also a ubiquity of Psychrobacter spp., which dominated Acropora and Porites libraries from Indonesia and Acropora libraries from the Caribbean. In conclusion, there was a dominance of Halomonas spp. (associated with Acropora and Porites [Mexican Caribbean]), Firmicutes (associated with Acropora [Mexican Caribbean] and with Acropora and Porites [Hoga]), and Cyanobacteria (associated with Acropora and Porites [Hoga] and Porites [Sampela]). This is also the first report describing geographically distinct Psychrobacter spp. associated with coral mucus. In addition, the predominance of Clostridiales associated with Acropora spp. provided additional evidence for coral host-specific microorganisms.

Three cases of peripartum cardiomyopathy (PPCM) are presented, each illustrating a clinically important aspect of the disorder. One patient survived despite extreme haemodynamic deterioration, one died suddenly 2 months post partum although clinically recovered, and one died during a subsequent pregnancy. The cases demonstrate the severity and the unpredictable course of PPCM, which remains a challenge both to scientists and to clinicians.

The involvement of each of the two sperm cells from a pollen tube in separate fusion events characterizes double fertilization: a process that is illustrated in Figure 1. This process, which initiates the development of both the embryo (via the fusion of sperm and egg) and the endosperm (via the fusion of sperm and central cell), was discovered in angiosperms nearly acentury ago (Nawaschin, 1898; Guignard, 1899; reviewed in Russell, 1992). The application of the transmission electron microscope to the study of flowering plant embryogenesis in the early 1960s by Jensen and coworkers (reviewed in Jensen, 1973, 1974) marked the beginning of great strides that have been made in our understanding of embryogenesis since Maheshwari’s (1950) comprehensive review. Jensen and Fisher (1968,1970) confirmed the cellular nature of sperm cells and noted that sperm cells remain connected after their formation from the generative cell division. Jensen (1973,1974) also showed that the two synergids that typically flank the egg are active, functional cells that play a significant role in the fertilization process. More recent studies, also employing transmission electron microscopy but extending its use to the creation of three-dimensional, computer-generated reconstructions, have led to the concept of the male germ unit, which views the sperm cells and vegetative nucleus as a functional assemblage required for normal gamete transport, recognition, and fusion (see below; Dumas et al., 1984; reviewed in Mogensen, 1992). Because the sperms of a pair are dimorphic in some species, it also became apparent that double fertilization may not be a random event, i.e., that each sperm may be preprogrammed for fusion with either the egg or the central cell (Russell, 1985). Although the process of double fertilization offers unique opportunities for studying gamete interactions and control mechanisms, it also presents special problems not encountered in animals and nonangiospermous plants. A major deterrent to physiological, molecular, and experimental studies of embryogenesis in angiosperms has been the inaccessibility of the gametes. During the past few years, however, it has become possible in some angiosperm species to isolate male and female sex cells in large enough quantities to allow for the initial phases of such analyses.

Isolated egg cell protoplasts ofZea mays L., inbred line A 188, have been studied at the transmission electron microscope level. Their preparation for electron microscopy has been performed by embedding in ultra-low gelling agarose as a preliminary step. Five isolated egg cell protoplasts were serially ultrathin sectioned and studied in detail. One of these protoplasts was reconstructed in three dimensions to provide additional information on its structure. After enzymatic digestion and microdissection, isolated egg cells are true, highly vacuolized protoplasts. The structure of their organelles agrees with in situ observations, indicating an ultrastructural intactness after isolation: the mitochondria are polymorphic, form reticulate networks, and have well developed cristae; the plastids contain starch grains; and the spherical nucleus is euchromatic. As in situ, the organelles of the isolated egg cell protoplasts are aggregated near the nucleus. The complete picture provided by this work should serve as a comparative base for studies on in vitro fertilization products.

Asystole and electromechanical dissociation (EMD) are terminal conditions in advanced cardiac or other disease states. Both may also occur in less serious circumstances, reflecting a vast array of other pathophysiological conditions which may be potentially reversible. Consequently the prognosis will show very marked variations, from very poor in terminal conditions to fair when associated with a treatable or transient causative factor. It is vitally important to identify, understand and eliminate any underlying factor as soon as possible. If left untreated, asystole and EMD will lead to irreversible brain damage within a couple of minutes. Initial management always includes basic cardiopulmonary resuscitation (CPR) [ 11. Proper management also implies the early recognition - whenever possible - of those patients in whom resuscitation would not be appropriate. ‘Do-not-resuscitate’ orders given in advance help to clarify the clinical situation and should adhere to explicit standards. As a result of such a policy the quality of nursing care in advanced disease states may be improved [2]. Diagnosis Asystole and EMD may result from advanced myocardial deterioration and are then usually terminal conditions. Aystole can also reflect high levels of parasympathetic activity and is then usually transient [3]. Clinical circumstances aid in this differentiation. Asystole is an electrocardiographic diagnosis in clinical cardiac arrest. The possibility of technical error should be considered, amplification set at zero, disconnected leads etc. EMD is an electrocardiographic and clinical diagnosis - the absence of arterial pulses in the presence of QRS complexes - which usually but not always means complete circulatory standstill [a]. Clinical series of patients with both these conditions may be quite heterogenous. The outcomes may demonstrate large variations not necessarily refecting therapeutic efficacy but rather the lack of diagnostic categorisation.

Studies utilizing restriction analysis of plastid DNA, as well as those employing chlorophyll-deficient mutants, have shown a high frequency of paternal plastid transmission in alfalfa. Recent research has also shown that plastid inheritance patterns among alfalfa genotypes and are under genetic control. In a previous study we were unable to detect any correlations between qualitative, three-dimensional ultrastructure of generative cells and male plastid transmission strength in certain genotypes. In the present study we used serial ultrathin sectioning, computerized reconstruction and quantitation, and stereology to further analyze generative cells within mature pollen. Measurements included volumes and surface areas of cells, nuclei, and organelles, as well as organelle number and distribution. Three genotypes were investigated, one that is a strong transmitter of male plastids (genotype 301), one that is a weaker transmitter of male plastids (genotype 7W), and a third that is an even weaker male plastid transmitter (genotype MS-5). Our results show that genotype MS-5 has significantly fewer plastids/generative cell than either of the other genotypes, which may account for it being a relatively poor transmitter of male plastids. However, plastid number does not explain known differences in male plastid inheritance between genotypes 301 and 7W, since plastid number does not differ significantly between these two genotypes. Regarding the other features of generative cells measured in this study, no consistent correlations were found that might account for differences in male plastid inheritance patterns between genotypes. Plastid distribution is equal in each end of the spindle-shaped generative cell in all genotypes studied. Similar relative results were found with regard to mitochondria within generative cells; however, comparative genetic data are not available on mitochondrial transmission patterns in alfalfa genotypes.

Contains fulltext : 172046.pdf (Publisher’s version ) (Open Access) BACKGROUND: Entrustable Professional Activities (EPAs) are increasingly used as a focus for assessment in graduate medical education (GME). However, a consistent approach to guide EPA design is currently lacking, in particular concerning the actual content (knowledge, skills and attitude required for specific tasks) for EPAs. This paper describes a comprehensive five stage approach, which was used to develop two specialty-specific EPAs in emergency medicine focused on the first year of GME. METHODS: The five stage approach was used to gain consensus on the task, content and entrustment scale for two specialty-specific EPAs in emergency medicine. The participants consisted of twelve clinical supervisors working in the emergency department. The five stages were: 1) Selecting the EPA topic; 2) Developing the EPA content by collecting data from participants using focus group and individual interviews; 3) Drafting the EPAs based on analysis of collected data; 4) Seeking feedback on the draft EPAs from the participants and other stakeholders; 5) Refining and finalising the EPAs based on feedback. RESULTS: Two specialty-specific EPAs were developed using the five stage approach. The participants reached consensus on the specific tasks and criteria for performance for the two EPAs. They also agreed that both day-to-day (ad hoc) and formal (summative) entrustment decisions were put into practice through the intensity of supervision provided to PGY1 doctors. As a result, a three level entrustment and supervision scale consisting of direct active, indirect active, passive was developed reflecting the shift in the intensity of supervision from close supervision to minimal supervision. CONCLUSIONS: The five stage approach described in this paper was used successfully to develop two specialty-specific EPAs in emergency medicine along with a three level entrustment scale.We propose that the five stage approach is transferable to a range of medical training contexts to design specialty-specific EPAs.