Conceptualizing Sexual Wellbeing: A Qualitative Investigation to Inform Development of a Measure (Natsal-SW)

Despite increasing scientific and policy interest in sexual wellbeing, it remains poorly conceptualized. Many studies purporting to measure it instead measure related but distinct concepts, such as sexual satisfaction. This lack of conceptual clarity impedes understanding, measuring, and improving sexual wellbeing. We present qualitative research from multi-stage, mixed-methods work to develop a new measure of sexual wellbeing (Natsal-SW) for the fourth British National Survey of Sexual Attitudes & Lifestyles. Literature review and discussion generated a conceptual framework with seven proposed domains: respect, self-esteem, comfort, self-determination, safety and security, forgiveness, and resilience. Semi-structured interviews with 40 adults aged 18-64 then explored whether and how these domains aligned with participants' own understandings, experiences, and language of sexual wellbeing. Data were analyzed thematically. Participants conceptualized sexual wellbeing as distinct from sexual satisfaction and sexual health and as multidimensional, dynamic, and socially and structurally influenced. All seven proposed domains resonated with accounts of sexual wellbeing as a general construct. The personal salience of different domains and their dimensions varied between individuals (especially by gender and sexual orientation) and fluctuated individually over time. This study clarifies dimensions of domains that participants considered important, providing an empirical basis to inform development of a new measure of sexual wellbeing.

Salivary Testosterone and Sexual Function and Behavior in Men and Women: Findings from the Third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Using data from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) we examined associations between salivary testosterone (Sal-T) and sexual function and behavior. Single morning saliva samples were self-collected from a subsample of participants aged 18-74 years and analyzed using mass spectrometry. 1,599 men and 2,123 women were included in the analysis (40.6% of those invited to provide a sample). We adjusted for confounders in a stepwise manner: in model 1 we adjusted for age only; model 2 for age, season and relationship status, and model 3 we added BMI and self-reported health. In the fully adjusted models, among men, Sal-T was positively associated with both partnered sex (vaginal sex and concurrent partners) and masturbation. Among women, Sal-T was positively associated with masturbation, the only association with partnered sex was with ever experience of same-sex sex. We found no clear association between Sal-T and sexual function. Our study contributes toward addressing the sparsity of data outside the laboratory on the differences between men and women in the relationship between T and sexual function and behavior. To our knowledge, this is the first population study, among men and women, using a mass spectrometry Sal-T assay to do so.

Does the number of doses matter? A qualitative study of HPV vaccination acceptability nested in a dose reduction trial in Tanzania

Background

The multi-dose regimen is a known barrier to successful human papillomavirus (HPV) vaccination. Emerging evidence suggests that one vaccine dose could protect against HPV. While there are clear advantages to a single dose schedule, beliefs about vaccine dosage in low and middle income countries (LMICs) are poorly understood. We investigated acceptability of dose-reduction among girls, and parents/guardians of girls, randomised to receive one, two or three doses in an HPV vaccine dose-reduction and immunobridging study (DoRIS trial) in Tanzania.

Methods

Semi-structured interviews with girls (n = 19), and parents/guardians of girls (n = 18), enrolled in the study and completing their vaccine course.

Results

Most participants said they entrusted decisions about the number of HPV vaccine doses to experts. Random allocation to the different dose groups did not feature highly in the decision to participate in the trial. Given a hypothetical choice, girls generally said they would prefer fewer doses in order to avoid the pain of injections. Parental views were mixed, with most wanting whichever dose was most efficacious. Nonetheless, a few parents equated a higher number of doses with greater protection.

Conclusion

Vaccine trials and programmes will need to employ careful messaging to explain that one dose offers sufficient protection against HPV should emerging evidence from ongoing dose-reduction clinical trials support this.

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We interviewed girls, and parents/carers of girls, enrolled in an HPV Vaccine dose reduction trial.

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We found that enrolling in the trial in the context of community rumours required trust in the trial scientists.

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Scientists were trusted to decide on dosage; thus randomisation by dosage was not an acceptability issue.

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Girls preferred fewer vaccine doses in order to avoid injection-related pain.

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Parents/guardians generally wanted whichever dose regimen was most efficacious.

Validating Biobehavioral Technologies for Use in Clinical Psychiatry

The last decade has witnessed the development of sophisticated biobehavioral and genetic, ambulatory, and other measures that promise unprecedented insight into psychiatric disorders. As yet, clinical sciences have struggled with implementing these objective measures and they have yet to move beyond "proof of concept." In part, this struggle reflects a traditional, and conceptually flawed, application of traditional psychometrics (i.e., reliability and validity) for evaluating them. This paper focuses on "resolution," concerning the degree to which changes in a signal can be detected and quantified, which is central to measurement evaluation in informatics, engineering, computational and biomedical sciences. We define and discuss resolution in terms of traditional reliability and validity evaluation for psychiatric measures, then highlight its importance in a study using acoustic features to predict self-injurious thoughts/behaviors (SITB). This study involved tracking natural language and self-reported symptoms in 124 psychiatric patients: (a) over 5-14 recording sessions, collected using a smart phone application, and (b) during a clinical interview. Importantly, the scope of these measures varied as a function of time (minutes, weeks) and spatial setting (i.e., smart phone vs. interview). Regarding reliability, acoustic features were temporally unstable until we specified the level of temporal/spatial resolution. Regarding validity, accuracy based on machine learning of acoustic features predicting SITB varied as a function of resolution. High accuracy was achieved (i.e., ~87%), but only when the acoustic and SITB measures were "temporally-matched" in resolution was the model generalizable to new data. Unlocking the potential of biobehavioral technologies for clinical psychiatry will require careful consideration of resolution.

Frontal alpha asymmetry in schizotypy: electrophysiological evidence for motivational dysfunction

Introduction: Schizotypy is defined as personality traits reflecting an underlying risk for schizophrenia-spectrum disorders. As yet, there is a dearth of suitable objective markers for measuring schizotypy. Frontal alpha asymmetry, characterised by reduced left versus right frontal region activity, reflects trait-like diminished approach-related systems and has been found in schizophrenia. Methods: The present study used electroencephalography (EEG) recorded on a consumer-grade mobile headset to examine asymmetric resting-state frontal alpha, beta, and gamma power within the multidimensional schizotypy (e.g. positive, negative, disorganised) during a three-minute "eyes closed" resting period in college undergraduates (n=49). Results: Findings suggest that schizotypy was exclusively related to reduced left versus right-lateralised power in the alpha frequency (8.1-12.9 Hz., R²= .16). Follow-up analysis suggested that positive schizotypy was uniquely associated with increased right alpha activity, indicating increased withdrawal motivation. Conclusions: Frontal asymmetry is a possible ecologically valid objective marker for schizotypy that may be detectable using easily accessible, consumer-grade technology.

Blunted vocal affect and expression is not associated with schizophrenia: A computerized acoustic analysis of speech under ambiguous conditions

INTRODUCTION

Patients with schizophrenia are consistently rated by clinicians as having high levels of blunted vocal affect and alogia. However, objective technologies have often failed to substantiate these abnormalities. It could be the case that negative symptoms are context-dependent.

OBJECTIVES

The present study examined speech elicited under conditions demonstrated to exacerbate thought disorder.

METHODS

The Rorschach Test was administered to 36 outpatients with schizophrenia and 25 nonpatient controls. Replies to separate "perceptual" and "memory" phases were analyzed using validated acoustic analytic methods.

RESULTS

Compared to nonpatient controls, schizophrenia patients did not display abnormal speech expression on objective measure of blunted vocal affect or alogia. Moreover, clinical ratings of negative symptoms were not significantly correlated with objective measures.

CONCLUSIONS

These findings suggest that in patients with schizophrenia, vocal affect/alogia is generally unremarkable under ambiguous conditions. Clarifying the nature of blunted vocal affect and alogia, and how objective measures correspond to what clinicians attend to when making clinical ratings are important directions for future research.

Cognitive functioning in schizotypy through the lens of the accessibility model

INTRODUCTION

Individuals with schizotypy self-report subjective cognitive complaints commensurate with deficits reported by individuals with schizophrenia. In contrast to schizophrenia, objective deficits in memory are modest in individuals with schizotypy, as compared to their self-reported cognitive complaints. It has been proposed that abnormalities in semantic memory systems may underlie this dysjunction.

METHODS

This study employed a modified verbal memory paradigm in a sample of 87 individuals with psychometrically defined schizotypy. Appraisals of memory performance were evaluated across global (i.e. drawing on semantic memory systems and assessing perceived typical performance) and situation-specific (i.e. drawing on episodic memory systems) epochs. Objective memory performance was assessed using a verbal recall paradigm.

RESULTS

Individuals with schizotypy did not differ in situation-specific appraisals or in objective memory performance. Global appraisals of memory performance predicted negative and disorganised schizotypy scores. No other measure of memory performance predicted any facet of schizotypy. Individuals with schizotypy appraised their global memory performance higher than controls at a medium effect.

CONCLUSIONS

Higher order global appraisals of cognitive performance, subsumed within semantic networks, may be important in the subjective-objective paradox in schizotypy, suggesting the importance of considering demand characteristics when assessing measures of neurocognitive performance in individuals with schizotypy.

Painful sex (dyspareunia) in women: prevalence and associated factors in a British population probability survey

Objective

To estimate the prevalence of painful sex among women in Britain, and to explore associated sexual, relationship and health factors that should be considered in assessment.

Design

Multi‐stage, clustered and stratified population probability sample survey, using computer‐assisted self‐interview. Sample frame was the British Postcode Address File.

Setting

Participants interviewed at home between 2010 and 2012.

Sample

A total of 15 162 adults aged 16–74 years (8869 women). Data reported from 6669 sexually active women.

Methods

Age‐adjusted logistic regressions to examine associations between painful sex and indicators of sexual, relational, mental and physical health.

Main outcome measure

Physical pain as a result of sex for ≥3 months in the past year, plus measures of symptom severity.

Results

Painful sex was reported by 7.5% (95% CI 6.7–8.3) of sexually active women, of whom one‐quarter experienced symptoms very often or always, for ≥6 months, and causing distress. Reporting painful sex was strongly associated with other sexual function problems, notably vaginal dryness (age adjusted odds ratio 7.9; 6.17–10.12), anxiety about sex (6.34; 4.76–8.46) and lacking enjoyment in sex (6.12; 4.81–7.79). It was associated with sexual relationship factors [such as not sharing same level of interest in sex (2.56; 1.97–3.33)], as well as with adverse experiences such as non‐volitional sex (2.17; 1.68–2.80). Associations were also found with measures of psychological and physical health, including depressive symptoms (1.68; 1.28–2.21).

Conclusion

Painful sex is reported by a sizeable minority of women in Britain. Health professionals should be supported to undertake holistic assessment and treatment which takes account of the sexual, relationship and health context of symptoms.

Tweetable abstract

Painful sex—reported by 7.5% of women in Britain—is linked to poorer sexual, physical, relational and mental health.

Painful sex–reported by 7.5% of women in Britain–is linked to poorer sexual, physical, relational and mental health.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14518.

Vocal expression in schizophrenia: Less than meets the ear

Abnormalities in nonverbal communication are a hallmark of schizophrenia. Results from studies using symptom rating scales suggest that these abnormalities are profound (i.e., 3-5 SDs) and occur across virtually every channel of vocal expression. Computerized acoustic analytic technologies, used to overcome practical and psychometric limitations with symptom rating scales, have found much more benign and isolated abnormalities. To better understand vocal deficits in schizophrenia and to advance acoustic analytic technologies for clinical and research applications, we examined archived speech samples from 5 separate studies, each using different speaking tasks (patient N = 309; control N = 117). We sought to: (a) use Principal Component Analysis (PCA) to identify independent vocal expression measures from a large set of variables, (b) quantify how patients with schizophrenia are abnormal with respect to these variables, (c) evaluate the impact of demographic and contextual factors (e.g., study site, speaking task), and (d) examine the relationship between clinically-rated psychiatric symptoms and vocal variables. PCA identified 7 independent markers of vocal expression. Most of these vocal variables varied considerably as a function of context and many were associated with demographic factors. After controlling for context and demographics, there were no meaningful differences in vocal expression between patients and controls. Within patients, vocal variables were associated with a range of psychiatric symptoms-though only pause length was significantly associated with clinically rated negative symptoms. The discussion centers on explaining the apparent discordance between clinical and computerized speech measures.

Salivary Testosterone Levels and Health Status in Men and Women in the British General Population: Findings from the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

CONTEXT

Salivary T (Sal-T) measurement by liquid chromatography-tandem mass spectroscopy resents the opportunity to examine health correlates of Sal-T in a large-scale population survey.

OBJECTIVE

This study sought to examine associations between Sal-T and health-related factors in men and women age 18-74 years.

DESIGN AND SETTING

Morning saliva samples were obtained from participants in a cross-sectional probability-sample survey of the general British population (Natsal-3). Self-reported health and lifestyle questions were administered as part of a wider sexual health interview.

PARTICIPANTS

Study participants included 1599 men and 2123 women.

METHODS

Sal-T was measured using liquid chromatography-tandem mass spectroscopy. Linear regression was used to examine associations between health factors and mean Sal-T.

RESULTS

In men, mean Sal-T was associated with a range of health factors after age adjustment, and showed a strong independent negative association with body mass index (BMI) in multivariable analysis. Men reporting cardiovascular disease or currently taking medication for depression had lower age-adjusted Sal-T, although there was no association with cardiovascular disease after adjustment for BMI. The decline in Sal-T with increasing age remained after adjustment for health-related factors. In women, Sal-T declined with increasing age; however, there were no age-independent associations with health-related factors or specific heath conditions with the exception of higher Sal-T in smokers.

CONCLUSIONS

Sal-T levels were associated, independently of age, with a range of self-reported health markers, particularly BMI, in men but not women. The findings support the view that there is an age-related decline in Sal-T in men and women, which cannot be explained by an increase in ill health. Our results demonstrate the potential of Sal-T as a convenient measure of tissue androgen exposure for population research.

How can we objectively categorise partnership type? A novel classification of population survey data to inform epidemiological research and clinical practice

Background

Partnership type is a determinant of STI risk; yet, it is poorly and inconsistently recorded in clinical practice and research. We identify a novel, empirical-based categorisation of partnership type, and examine whether reporting STI diagnoses varies by the resulting typologies.

Methods

Analyses of probability survey data collected from 15 162 people aged 16–74 who participated in Britain's third National Survey of Sexual Attitudes and Lifestyles were undertaken during 2010–2012. Computer-assisted self-interviews asked about participants' ≤3 most recent partners (N=14 322 partners/past year). Analysis of variance and regression tested for differences in partnership duration and perceived likelihood of sex again across 21 ‘partnership progression types’ (PPTs) derived from relationship status at first and most recent sex. Multivariable regression examined the association between reporting STI diagnoses and partnership type(s) net of age and reported partner numbers (all past year).

Results

The 21 PPTs were grouped into four summary types: ‘cohabiting’, ‘now steady’, ‘casual’ and ‘ex-steady’ according to the average duration and likelihood of sex again. 11 combinations of these summary types accounted for 94.5% of all men; 13 combinations accounted for 96.9% of all women. Reporting STI diagnoses varied by partnership-type combination, including after adjusting for age and partner numbers, for example, adjusted OR: 6.03 (95% CI 2.01 to 18.1) for men with two ‘casual’ and one ‘now steady’ partners versus men with one ‘cohabiting’ partner.

Conclusions

This typology provides an objective method for measuring partnership type and demonstrates its importance in understanding STI risk, net of partner numbers. Epidemiological research and clinical practice should use these methods and results to maximise individual and public health benefit.

What do we really know about blunted vocal affect and alogia? A meta-analysis of objective assessments

Deficits in nonverbal vocal expression (e.g., blunted vocal affect, alogia) are a hallmark of schizophrenia and are a focus of the Research Domain Criteria initiative from the National Institute of Mental Health. Results from studies using symptom rating scales suggest that these deficits are profound; on the order of four to six standard deviations. To complement this endeavor, we conducted a meta-analysis of studies employing objective analysis of natural speech in patients with schizophrenia and nonpsychiatric controls. Thirteen studies, collectively including 480 patients with schizophrenia and 326 nonpsychiatric controls, were identified. There was considerable variability across studies in which aspects of vocal communication were examined and in the magnitudes of deficit. Overall, speech production (reflecting alogia) was impaired at a large effects size level (d=-.80; k=13), whereas speech variability (reflecting blunted affect) was much more modest (d=-.36; k=2). Regarding the former, this was largely driven by measures of pause behavior, as opposed to other aspects of speech (e.g., number of words/utterances). On the other hand, ratings of negative symptoms across these studies suggested profound group differences (d=3.54; k=4). These data suggest that only certain aspects of vocal expression are affected in schizophrenia, and highlight major discrepancies between symptom rating and objective-based measures. The discussion centers on advancing objective analysis for understanding vocal expression in schizophrenia and for identifying and defining more homogenous patient subsets for study.

Comparison of Ha-ras mutational spectra of N-methyldibenzo[c,g]carbazole and 7H-dibenzo[c,g]carbazole-induced mouse skin tumors

Carcinogenic N-heterocyclic aromatic hydrocarbons are formed during the incomplete combustion of fossil fuels as well as cigarette smoke. N-Methyldibenzo[c,g]carbazole (NMeDBC) and 7H-dibenzo[c,g]carbazole (DBC) are members of this group. DBC induces mouse skin and liver tumors, whereas NMeDBC induces only mouse skin tumors. The objective of this study was to elucidate the mechanism of action of these compounds in skin by assessing the Ha-ras mutational spectra induced by a two-stage initiation-promotion protocol. NMeDBC (200 nmol) or DBC (200 nmol) was applied to the back skin of 24 female Hsd:ICR(Br) mice (12 per group) once. 12-O-tetradecanoylphorbol-13-acetate (TPA) (2 microg) was then applied twice weekly for 28 wk. Tumors were screened for Ha-ras mutations using enriched polymerase chain reaction and mutations defined by dideoxy sequencing. In DBC animals 58% produced papillomas, of which 71% had codon 61 mutations, 4% had codon 12 mutations, 4% had codon 13 mutations, and 21% had no Ha-ras mutations. In NMeDBC animals 92% produced papillomas, of which 73% had codon 61 mutations and 27% had no Ha-ras mutations. All of the codon 61 mutations, from both NMeDBC and DBC, were CAA-->CTA transversions. The DBC-induced tumors with the codon 12 mutation had a GGA-->GAA transition, and the codon 13 mutation was a GGC-->GTC transversion. These results suggest that NMeDBC is a more potent tumor inducer than DBC, but the resulting H-ras mutations in each group were predominantly in codon 61, and, therefore, mutation induction in skin by each chemical appears to proceed by a similar mechanism.

Frequent Ha-ras mutations in murine skin and liver tumors induced by 7H-dibenzo[c,g]carbazole

7H-dibenzo[c,g]carbazole (DBC) is a potent liver and skin carcinogen when topically applied to the back skin of mice. This compound is found in complex mixtures produced during incomplete combustion of fossil fuels as well as in wood and tobacco smoke. The objective of this study was to elucidate the mechanism of action of this compound by assessing the Ha-ras mutational spectra of skin and liver tumors induced in a mouse model system. Low doses (50 nmol) and high doses (100 nmol) of DBC were applied topically to the backs of Hsd:ICR(Br) mice twice weekly. No treatment and solvent application were used as controls. After the mice were killed, the skin and liver tumors were removed, DNA was isolated, and tumor DNA was screened for Ha-ras codon 12, 13, and 61 mutations by using an enriched polymerase chain reaction method. Mutations were confirmed by reverse cyclic dideoxy sequencing. No mutations were found in codons 12 and 13 of DBC-induced tumors, whereas one acetone-control tumor had a codon 13 mutation. Sixty-seven percent of skin tumors and 45% of liver tumors induced by high doses of DBC and 67% of skin tumors induced by low doses of DBC contained codon 61 mutations, whereas liver tumors induced by low doses of DBC did not. The codon 61 mutations were exclusively A:T-->T:A transversions within the second base (CAA-->CTA). These results indicate that DBC is a unique polycyclic aromatic hydrocarbon in that it induces both skin and liver tumors upon topical application and that the mutational spectra are the same in tumors from two target organs, skin and liver, yet different from tumors from a third target organ, lung.

The legislation of active voluntary euthanasia in Australia: will the slippery slope prove fatal?

At 2.00 am on the morning of May 24, 1995 the Northern Territory Legislative Assembly Australia passed the Rights of the Terminally Ill Act by the narrow margin of 15 votes to 10. The act permits a terminally ill patient of sound mind and over the age of 18 years, and who is either in pain or suffering, or distress, to request a medical practitioner to assist the patient to terminate his or her life. Thus, Australia can lay claim to being the first country in the world to legalise voluntary active euthanasia. The Northern Territory's act has prompted Australia-wide community reaction, particularly in South Australia, Tasmania and the Australian Capital Territory where proposals to legalise euthanasia have already been defeated on the floor of parliament. In New South Wales (NSW) the AIDS Council of NSW has prepared draft euthanasia legislation to be introduced into the Upper House as a Private Member's Bill some time in 1996. In this paper, we focus on a brief description of events as they occurred and on the arguments for and against the legalisation of euthanasia which have appeared in the media.

'These sorts of people don't do very well': race and allocation of health care resources

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed.

Teaching clinical ethics as a professional skill: bridging the gap between knowledge about ethics and its use in clinical practice

Ethical reasoning and decision-making may be thought of as 'professional skills', and in this sense are as relevant to efficient clinical practice as the biomedical and clinical sciences are to the diagnosis of a patient's problem. Despite this, however, undergraduate medical programmes in ethics tend to focus on the teaching of bioethical theories, concepts and/or prominent ethical issues such as IVF and euthanasia, rather than the use of such ethics knowledge (theories, principles, concepts, rules) to clinical practice. Not surprisingly, many students and clinicians experience considerable difficulty in using what they know about ethics to help them make competent ethical decisions in their day-to-day clinical practice. This paper describes the development of a seminar programme for teaching senior medical students a more systematic approach to ethical reasoning and analysis and clinical decision-making.

Ethical reasoning and decision-making in the clinical setting: assessing the process

Clinical ethical reasoning and analysis are skills as central to good patient care as the efficient application of biomedical knowledge to diagnosis and prognosis. However, experience in teaching clinical ethics to senior medical students has indicated that simply trying to 'apply' the knowledge learnt about ethical theories, principles, concepts and rules in the clinical setting does not ensure ethical competence in clinical decision-making. In 1992, we developed and piloted a three-session programme that focused on a more systematic approach to the way students identified and attempted to manage ethical issues in their clinical practice. This programme was modified and improved in 1993 and further expanded in 1994. Our experience suggests that many students are now better able to bridge what has been called the 'gap' between the possession of ethical knowledge and its actual use in clinical decision-making. The remaining problem was assessment. How do you assess clinical ethical reasoning and decision-making? In the preclinical years of medical education, knowledge-based assessment tools, like the modified essay question (MEQ), provide a means for assessing the sensitivity of students to ethical issues. However, such tools permit neither an appraisal of how students actually make clinical ethical decisions, nor which factors students perceive as important in making an actual clinical decision. In order to make this type of appraisal, we developed a format for a written case report that facilitated our assessing the process as well as the end-product, the decision.(ABSTRACT TRUNCATED AT 250 WORDS)

Guidelines for no-CPR orders

A no-CPR decision is not synonymous with abandonment and does not, of itself, rescind the obligations of the health care team to provide the highest quality care. Rather, a no-CPR order is best seen as one element of a comprehensive and dynamic management plan which should be reviewed and changed as the patient's medical condition warrants. A no-CPR order, therefore, offers an opportunity to rethink the goals of therapy in the light of discussions with the critically ill patient and his or her family.

Assessing the clinical ethical competence of undergraduate medical students

At the University of Newcastle, health law and ethics is taught and assessed in each year of the five-year curriculum. However, the critical question for assessment remains: 'Does teaching ethics have a measurable effect on the clinical activity of medical students who have had such courses?' Those responsible for teaching confront this question each year they sit down to construct their assessment tools. Should they assess what the student knows? Should they assess the student's moral reasoning, that is, what decisions the student makes, and, how these decisions are justified, or should they assess what the student actually does when dealing with patients in the clinical setting, and how he or she does it? From 1982 to 1991, assessment at Newcastle was primarily aimed at determining the quality of the students' ethics knowledge base. This paper describes the strengths and limitations of a purely knowledge-based method of evaluation and why in 1992, we are now attempting to redefine and assess, what we call 'clinical ethical competence' in terms of how students actually apply this knowledge base in a controlled clinical context.

Medical futility, treatment withdrawal and the persistent vegetative state

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient.

Problem solving in undergraduate medical students

In recent years the systematic development of the skill of clinical reasoning has come to assume a high priority as an explicit aim of medical education. Clinical reasoning, it is contended, is the application of general reasoning and problem-solving skills to the specific knowledge base of medicine. The results presented in this paper constitute a preliminary study designed to investigate the ability of first-year medical undergraduates to solve abstract problems using a simple nonmedical knowledge base. Further studies are being carried out and will continue to extend this into the specific medical knowledge base area. The potential implications for medical education and the development of clinical reasoning are discussed.

An investigation of the attitudes of medical students to physically disabled people

A study was carried out to investigate the change in attitudes towards physically disabled people of a group of fifty-eight medical students during the first 3 years of their course. The students attended a newly established medical school which has developed a curriculum without the traditional division into preclinical and clinical years and where contact with patients occurs from the first year. Results demonstrated that, as expected, at the start of the course the attitudes of females towards disabled people were more positive than those of males. Also, a significant change in attitudes was found after 3 years, both males and females demonstrating more positive attitudes toward physical disability. The differences between males and females were maintained. The relationship between these students' attitudes and their behaviour was discussed and proposals for further research to investigate this are outlined.

Student characteristics on entry to an innovative medical programme

The interests, attitudes and motivations of two groups of first-year medical undergraduates, one group from an innovative medical school and one group from a more traditional school were compared. Differences were found between the two groups in their reasons for studying medicine, their attitudes to medical education, and the role of the medical profession. The students from the innovative school placed more emphasis on the interpersonal and practical aspects of medicine as well as a sense of responsibility to the community. Reasons for these differences were discussed.

Identification and partial characterization of the secreted form of the fourth component of human complement: evidence that it is different from major plasma form

Immunoprecipitation of human C4 from plasma followed by NaDodSO4/polyacrylamide gel electrophoresis under reducing conditions revealed the expected alpha, beta, and gamma chains as well as a smaller quantity of a molecule containing an alpha chain (p98) approximately equal to 5,000 daltons heavier than the normal alpha chain. Further studies on p98 indicated that it covalently incorporated methyl-amine, was present at a concentration of approximately equal to 8% of the principal plasma form of the C4 alpha chain, and was found in highly purified C4 preparations. Hep G2, a human hepatoma-derived cell line, was found to secrete a C4 molecule in which the alpha chain had a molecular weight identical to that of the p98 protein found in plasma. The secreted C4 molecule possessed hemolytic activity. The 5,000-dalton difference in the alpha chain was localized to the COOH terminus and was attributed to an additional polypeptide. We propose that p98 is the alpha chain of the secreted form of C4, which is processed extracellularly by proteolytic cleavage to the principal C4 molecule found in plasma.

Juvenile nephronophthisis and medullary cystic disease--the same disease (report of a large family with medullary cystic disease associated with gout and epilepsy)

A large family with medullary cystic disease is described to show that juvenile nephronophthisis and medullary cystic disease should not be differentiated by age of onset and type of inheritance. The age at diagnosis of six family members with medullary cystic disease ranged from 4-32 years, and age at death from renal failure or commencement of dialysis from 7-48 years. A mother of two children with renal failure in early childhood has histological evidence of medullary cystic disease with normal renal function. We suggest that juvenile nephronophthisis and medullary cystic disease are the same conditions and that the disease be classified as medullary cystic disease, autosomal dominant or recessive form. When undertaking genetic counselling in the parents of children with medullary cystic disease, we suggest that renal biopsy may need to be considered even if their renal function is normal. Three patients presented with gout, and the possibility of an association with medullary cystic disease should be considered when more than one member of a family develops gout. Two patients died of status epilepticus, and epilepsy is probably an added association of medullary cystic disease.

Essential hypertension: subjects' estimation of blood pressure as an aid to response generalization

9 persons (5 men and 4 women) with essential hypertension made 5 daily estimates of blood pressure over 8 wk. and after 12 wk. Estimations improved for systolic blood pressure. Reductions in levels occurred. No change appeared for controls.

Behavioral treatment of presleep tension and intrusive cognitions in patients with severe predormital insomnia

Behavioral approaches to the treatment of predormital insomnia have assumed that hyperarousal is the underlying cause; thus presleep tension has been the most common target treated. A second indicator, presleep intrusive cognitions, has only recently been examined as a target for treatment. In the present study, 20 subjects were randomly assigned to three groups which focused on the treatment of either (1) presleep tension alone, (2) presleep tension and intrusive cognitions, of (3) perception of sleep. Four subjects acted as controls. The findings indicated that reductions in both presleep tension and intrusive cognitions were followed by a significantly greater reduction in latency to sleep onset and daytime impairment than reductions in presleep tension alone. The results obtained from modifying the individual's perception of sleep were not significantly different from those obtained from reductions in presleep tension alone. A 6 weeks follow-up revealed no change in the relative status of the three treatment groups.

Heterosexual social competence, anxiety, avoidance and self-judged physical attractiveness

The relationship between self-judged physical attractiveness and opposite-sex behavior was examined as part of a large survey on the interaction patterns of 963 college students. The findings suggest that a self-rated negative physical image is related to significantly high levels of heterosexual difficulties.

Note on treatment of heterosexual anxiety using short-term massed desensitization

Data from traditional and short-term desensitization procedures ( ns = 7, 8) showed decreased anxiety associated with paper-and-pencil measures of heterosexual interactions but the two desensitization groups were not significantly different nor did a relaxation and a no-treatment group ( ns = 9, 5) differ in reports.

A psychological approach to the treatment of migraine

Recently, Mitchell (1969) treated 16 migraine subjects using a combination of three specific behaviour therapy techniques namely, applied relaxation training, desensitization and assertive therapy. Migraine episodes for the treatment subjects decreased by an average of 89.5 per cent when compared with their pre-treatment base rate; no change was reported by six control subjects. The present investigation reports the comparative effectiveness of the three behaviour therapy techniques used previously. The specific therapeutic effectiveness of applied relaxation training was compared with that of combined desensitization (relaxation application, desensitization and assertive therapy). This comparison follows the conclusion by Cautela (1969), ‘… that relaxation can be considered a self-control technique in its own right: first, when it is used to reduce the overall anxiety level, and second, as a means of decreasing anxiety or tension whenever the patient is either involved in a readily identifiable anxiety-provoking situation, or is experiencing anxiety without being able to discern the antecedent conditions (p. 328.)’ It was predicted that combined desensitization would be more effective than the single-model procedure of applied relaxation training.

Note on treatment of migraine using behavior therapy techniques

3 college students were treated for migraine headaches by a combination of techniques. 3 students received no treatment. Over 8 wk. treated Ss reported fewer headaches and lessened pain.