bluuebunny/crossref_metadata_2025 huggingface dataset:
Intelligent machinery
Authors: Copeland Jack
Published: November 2020

This chapter explains why Turing is regarded as founding father of the field of artificial intelligence (AI), and analyses his famous method for testing whether a computer is capable of thought. In the weeks before his 1948 move from the National Physical Laboratory to Manchester, Turing wrote what was, with hindsight, the first manifesto of artificial intelligence (AI). His provocative title was simply Intelligent Machinery. While the rest of the world was just beginning to wake up to the idea that computers were the new way to do high-speed arithmetic, Turing was talking very seriously about ‘programming a computer to behave like a brain’. Among other shatteringly original proposals, Intelligent Machinery contained a short outline of what we now refer to as ‘genetic’ algorithms—algorithms based on the survival-of-the-fittest principle of Darwinian evolution—as well as describing the striking idea of building a computer out of artificial human nerve cells, an approach now called ‘connectionism’. Turing’s early connectionist architecture is outlined in Chapter 29. Strangely enough, Turing’s 1940 anti-Enigma bombe was the first step on the road to modern AI. As Chapter 12 explains, the bombe worked by searching at high speed for the correct settings of the Enigma machine—and once it had found the right settings, the random-looking letters of the encrypted message turned into plain German. The bombe was a spectacularly successful example of the mechanization of thought processes: Turing’s extraordinary machine performed a job, codebreaking, that requires intelligence when human beings do it. The fundamental idea behind the bombe, and one of Turing’s key discoveries at Bletchley Park, was what modern AI researchers call ‘heuristic search’. The use of heuristics—shortcuts or rules of thumb that cut down the amount of searching required to find the answer—is still a fundamental technique in AI today. The difficulty Turing confronted in designing the bombe was that the Enigma machine had far too many possible settings for the bombe just to search blindly through them until it happened to stumble on the right answer—the war might have been over before it produced a result. Turing’s brilliant idea was to use heuristics to narrow, and so to speed up, the search. Turing’s idea of using crib-loops to narrow the search was the principal heuristic employed in the bombe (as Chapter 12 explains).
Computer chess—the first moments
Authors: Copeland Jack , Prinz Dani
Published: November 2020

The electronic computer has profoundly changed chess. This chapter describes the birth of computer chess, from the very first discussions of computational chess at Bletchley Park during the war to the first chess moves ever calculated by an electronic computer. We cover a number of historic chess programs—including Turing’s own ‘Turochamp’—and recapture some of the atmosphere of those early days of computer chess. Albert Square, Manchester, 2012. The time was coming up to 9 o’clock on a grim summer morning, two days after what would have been Turing’s 100th birthday. Litter from the Olympic torch ceremony still scattered the ground. There were unusual numbers of chess enthusiasts and computer scientists in the square, hurrying past the awkwardly posturing statue of William Gladstone and up the steps at the entrance to Manchester Town Hall. Inside, they filed past more statues—chemist John Dalton, physicist James Joule—and took their seats in the crowded gothic-revival great hall. News of Turing’s centenary celebrations had reached over forty countries: fans in other time zones clicked to join the audience, watching their screens and waiting for the big event to start. Shortly after 9, a flawlessly groomed Garry Kasparov took the stage. Born in the Soviet Union in 1963, Kasparov (Fig. 31.1) became world chess champion at the age of only 22. He has gone down in history as the first reigning champion to be beaten by a computer. In a New York TV studio on the thirty-ninth floor of a Seventh Avenue skyscraper, IBM’s chess computer DeepBlue crushed Kasparov in 1997 (see Ch. 27). Fifteen years later he had come to Manchester to honour Turing, the first pioneer of computer chess. Seeming a bit nervous at first—until his natural ebullience reasserted itself—Kasparov haltingly told the crowd: ‘Apart from personal love of the game, Turing did serious work with chess as a model of mechanical thinking and machine intelligence’. Yet Turing, he said, ‘was a fairly terrible chess player’.
Mental disorder and you
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

People’s attitudes to mental disorder vary widely. Often this is because of the extent of their personal experi­ence of mental illness. Some people have experienced a mental illness themselves while others may well have experience of mental illness in a friend or relative. If you have been lucky enough to avoid these personal experi­ences, it is almost inevitable that you will be exposed to one or the other during your lifetime, and, perhaps, several times. Of course, because you are reading this book, it is likely that you are, or want to be, a healthcare professional. In whatever area of healthcare you work, you will encounter hundreds or thousands of people with mental illness in your professional lifetime. The beliefs that you hold about mental illness and people with mental illness will influence how you respond. It is therefore important that you assess your existing be­liefs and, if necessary, consider changing some of them. Assessing and altering our beliefs is difficult. We all tend to assume that what we believe— about ourselves, others, or the world around us— is true. However, only some beliefs are facts. Despite this, our beliefs tend to be ‘static’ and resistant to change. One reason for this is the kind of cognitive biases that operate, uncon­sciously but persistently, to maintain our system of be­liefs. Cognitive therapists use a model which they call ‘the prejudice model’ to describe these biases: most evidence which conflicts with our core beliefs is either not noticed, or is altered in order to fit our core beliefs; whereas most evidence which fits with our core beliefs is noticed and used to bolster those beliefs. In this way, the beliefs that we hold tend to be stable through time. This section describes a short exercise for you to com­plete, with three stages: … 1 In Box 3.1, we list several common prejudices about mental illness. Rate each of those statements from 0 to 100 per cent, where the percentage is the extent to which you hold that belief. For example, if you believe that mental illness is a sign of weakness in most cases, you might answer 80 percent. It is important to be honest, rather than give what you believe to be the ‘correct’ answer.
Psychiatry and the law
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

In most of medicine, legal situations are rarely encoun­tered, typically related to complaints or complex eth­ical issues. Unusually, psychiatry is closely connected with the law, with most psychiatrists dealing with legal issues on a daily basis. There are three main areas of law which are relevant to psychiatry: … 1 Civil law relating to the involuntary admission and treatment of patients with mental disorders (in the UK, this is outlined in the Mental Health Act (MHA) 2007). 2 Civil law concerning issues of consent, capacity, and deprivation of liberty (Mental Capacity Act 2005 including Deprivation of Liberty Safeguarding (DoLS)). 3 Criminal law as it relates to individuals with mental disorders. … There are various reasons why knowledge of mental health legislation is helpful to all clinicians: … ● Laws and official guidelines provide backing to some aspects of ethical decision- making within medicine. ● The law regulates the circumstances under which treatment can be given without patients’ consent. All doctors may encounter situations in which patients refuse essential treatment, and may have to decide whether to invoke powers of compulsory admission and/ or best interest treatments. ● Doctors may be asked for reports used in legal decisions, such as the capacity to make a will or claims for compensation for injury. They may be asked for reports that set out the relationship between any psychiatric disorder and criminal behaviour. ● A minority of patients behave in ways that break the law. Doctors need to understand legal issues as part of their management of care. ● Victims of crime may suffer immediate and long-term psychological or physical consequences. … This chapter will describe the main principles of mental health legislation with particular reference to UK law. While some of the detail discussed (e.g. par­ticular definitions or legislative act numbers) may not be relevant to international readers, legal frameworks across the globe are broadly similar. Information of mental health legislation in most countries is now easily available online. The latter part of the chapter will provide an overview of the relationship between mental disorders and crime.
Managing acute behavioural disturbance
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

Acute behavioural disturbance is a common phenom­enon in mental health and acute general hospital settings and refers to agitation, aggression, and/ or violent behaviour towards property, self, or others. Behavioural disturbances may be due to mental or physical causes. In psychotic patients, agitation may be due directly to psychosis (e.g. paranoia or gran­diose delusions, or hallucinations) or accompanying non- psychotic symptoms (e.g. high levels of arousal or anxiety). In the UK, NICE published detailed guidance on the management of acute behavioural disturbance in 2015, but most hospitals and emergency rooms will also have local guidelines. A useful framework for thinking about managing be­havioural disturbance is as follows: … 1 Predicting the risk of behavioural disturbance. 2 Preventing behaviour escalating once a patient starts to become disturbed. 3 Intervening to prioritize safety of staff and patients. 4 Reviewing of events and planning for future risk reduction…. Many mental health trusts now have psychiatric intensive care units (PICUs), which specialize in pro­viding a safer and more secure environment for patients at high risk of acute behavioural disturbance. These wards are locked, have a higher ratio of staff to patients, and have facilities for physical restraint and seclusion. As a rule, patients are transferred to the PICU for the shortest time possible, before being ‘stepped down’ on to the open wards as soon as it is safe to do so. Predicting the likelihood of behavioural disturbance should be part of the overall risk assessment done when a patient is first seen and/ or admitted to hos­pital. This is frequently undertaken in mental health services, but rarely done in the general hospital. It is helpful to think of both the common causes of dis­turbed behaviour and the personal or situational vari­ables relating to the individual patient (Boxes 16.1 and 16.2). Simple measures such as searching the patient’s belongings and person for potential weapons and making sure that basic needs (e.g. warmth, hunger) are considered can reduce risks considerably.
Child and adolescent psychiatry: general aspects of care
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

Child and adolescent psychiatry is a broad dis­cipline relevant to any health professional who has regular contact with young people. Childhood emotional, behavioural, and developmental prob­lems are common, especially in children with other medical or social difficulties. This chapter aims to provide an approach to child mental health diffi­culties, while Chapter 32 deals with common and/ or important psychiatric disorders that are specific to childhood. You may find it helpful to revise some basic child development— this can be found in any general paediatrics text (see ‘Further reading’). An overview of the differences between child and adult psychiatry is shown in Box 17.1. As in adult psychiatry, diagnosis of psychiatric dis­orders often relies on the clinician being able to recog­nize variants of and the limits of normal behaviour and emotions. In children, problems should be classified as either a delay in, or a deviation from, the usual pattern of development. Sometimes problems are due to an excess of what is an inherently normal characteristic in young people (e.g. anger in oppositional defiance disorder), rather than a new phenomenon (e.g. hallu­cinations or self- harm) as is frequently seen in adults. There are four types of symptoms that typically pre­sent to child and adolescent psychiatry services: … 1 Emotional symptoms: anxiety, fears, obsessions, mood, sleep, appetite, somatization. 2 Behavioural disorders: defiant behaviour, aggression, antisocial behaviour, eating disorders. 3 Developmental delays: motor, speech, play, attention, bladder/ bowels, reading, writing and maths. 4 Relationship difficulties with other children or adults…. There will also be other presenting complaints which fit the usual presentation of an adult disorder (e.g. mania, psychosis), and these are classified as they would be in an adult. Occasionally, there will also be a situ­ation where the child is healthy, but the problem is ei­ther a parental illness, or abuse of the child by an adult. Learning disorders are covered in Chapter 19. Table 17.1 outlines specific psychiatric conditions diagnosed at less than 18 years, and Box 17.2 lists general psychiatric conditions that are also commonly found in children.
Psychiatry of older adults
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

The provision of mental health services for older adults faces two main challenges: … 1 The world population is ageing, leading to increased numbers of elderly patients (Fig. 18.1). 2 These patients are more likely to present with multiple, complex co- morbidities which must be managed alongside acute or chronic psychiatric problems…. To provide effective care, services must combine treatment for mental, physical, and social needs of older people. The multidisciplinary team is key to delivering this, often in specialized environments such as a day centre programme. A huge number of physical, psychological, and social changes occur within the normal process of ageing. A basic understanding of these is necessary in order to identify those individuals in whom there is path­ology. Covering theories behind the ageing process is outside the scope of this text, but some references are given on p. 220. The following changes are seen in the brain during normal ageing: … ● The weight of the brain decreases by 5– 20 per cent between 70 and 90 years, with a compensatory increase in ventricular size. ● There is neuronal loss, especially in the hippocampus, cortex, substantia nigra, and cerebellum. ● Senile plaques are found in the neocortex, amygdala, and hippocampus. ● Tau proteins form neurofibrillary tangles, found normally only in the hippocampus. ● Lewy bodies are seen in the substantia nigra. ● Ischaemic lesions (reduced blood flow, lacunar infarcts) are seen in 50 per cent of normal people over 65 years…. From mid life there is a decline in intellectual func­tions, as measured with standard intelligence tests, together with deterioration of short- term memory and slowness. IQ peaks at about 25 years, remains stable until 60– 70 years, and then declines. Problem- solving reduces after about age 60. There may be alterations in personality and attitudes, such as increasing cautiousness, rigidity, and ‘disengagement’ from the outside world. Later life presents a series of major changes. Many individuals retire, lose partners, lose their physical health, and are forced to live on much lower incomes and in poorer- quality housing than younger people. These are difficult transitions which may predispose to mental illness. The majority of older people remain living at home: half with a partner, and 10 per cent with other family members. Those who live alone may be­come isolated and lonely.
People presenting with physical disorder
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

All healthcare professionals dealing primarily with physical disorder need a working knowledge of relevant psychological factors and psychiatric dis­orders. Despite the geographical and, often, cul­tural separation of most ‘general’ (i.e. physical) and psychiatric hospitals, there are close links (1) be­tween physical and psychological disorders, and (2) between physical and psychological factors in the aetiology, presentation, and management of all illness. This chapter aims to stimulate you to think about these issues in primary care and in the general hospital, and to equip you with the know­ledge required to think about them in an integrated, biopsychosocial way. The links between physical and psychological fac­tors are multiple. They include: … ● psychiatric and physical disorders occurring together by chance— as they are both common; ● psychiatric disorders causing physical symptoms— for example, depression is associated with low physical energy (anergia), amenorrhoea, and constipation; ● psychiatric disorder adversely affecting the outcome of physical disorder— for example, a depressive disorder might impair self- management of diabetes mellitus, because low motivation is a common symptom of depression, and may reduce adherence to self- monitoring of glucose; ● psychological factors increasing disability associated with physical disorder— for example, if a patient recovering from a myocardial infarction believes that it has led to a permanent reduction in their cardiac function, they are less likely to return to work, to take regular exercise, and to have a normal sex life; ● untreated psychological problems leading to the inappropriate use of medical resources and to poor compliance with medical advice— for example, people with panic disorder are more likely to attend emergency departments with acute ‘cardiac’ symptoms; ● physical symptoms and disorders having psychological consequences, which include psychiatric disorder— for example, hypothyroidism and cerebrovascular disease may lead to depression; ● physical disorder exacerbating unrelated psychiatric symptoms— for example, a viral infection could delay recovery from a depressive disorder, by impairing the person’s usual activities, at work and at home, which would otherwise provide therapeutic distraction and stimulation.
Child and adolescent psychiatry: specific disorders
Authors: McKnight Rebecca , Price Jonathan , Geddes John
Published: November 2020

This chapter describes common and/ or important mental health disorders seen in children and adoles­cents. More general information about classification, aetiology, assessment, and management is discussed in Chapter 17. Many of the psychiatric problems seen in adolescence are the common disorders of adult­hood; in the latter part of the chapter, these are briefly covered, identifying adolescent- specific presentation or treatment with reference to the general information in relevant chapters on adults. Mental disorders are very common in childhood and adolescence; meta- analysis data from international studies suggest a prevalence of 10 per cent in 5– 15- year- olds. It is difficult to get accurate epidemiology data for preschool- age children— partly as fewer studies have been done, but also because many be­havioural and emotional problems are short- lived and the child ‘grows out’ of them. Boys tend to be more prone to hyperactive, disruptive, and autistic spectrum disorders, while girls predominant the emotional dis­orders. Table 32.1 gives an overview of epidemiology of common mental health disorders. Common problems in preschoolers are shown in Table 32.2. Most problems are short- lived and whether they are reported to doctors depends on the attitudes of the parents as well as on the severity of the issue. The aetiology of these conditions is primarily related to individual variations in development and tempera­ment, but family problems can play a role in certain situations. In the UK, a health visitor is uniquely placed to assess the child and provide advice and support. Neurodevelopmental disorders are conditions that arise due to abnormalities in growth or development of the central nervous system. Some of these dis­orders cause emotional and behavioural difficulties or are highly associated with other mental disorders; it is these conditions that tend to present to psychiatry. A summary is shown in Table 32.3. They tend to pre­sent in early to mid childhood. Autistic spectrum disorders (ASD) are neurodevelopmental conditions characterized by deficits and delays in social and communicative development, which are associated with restricted patterns of interest and behaviour. As the name suggests, ASD are a spectrum of conditions, with individuals varying both in severity and form of the disorder. Due to this heterogeneity, the nomenclature and classifica­tion of ASD have been through various incarnations. Until recently they have been known as pervasive developmental disorders, with subtypes of child­hood autism, atypical autism, Rett’s syndrome, and Asperger’s syndrome.
Diagnosis and prevention of dental caries
Authors: Deery C , Toumba K J
Published: November 2020

Almost all research on the process of dental caries supports the chemoparasitic theory proposed by W.D. Miller in 1890. This is now more commonly known as the acidogenic theory of caries aetiology. The main features of the caries process are as follows. 1. Fermentation of carbohydrate to organic acids by micro-organisms in plaque on the tooth surface. 2. Acid production, which lowers the pH at the enamel surface below the level (the critical pH) at which enamel will dissolve. 3. When carbohydrate is no longer available to the plaque microorganisms, the pH within plaque will rise because of the outward diffusion of acids and their metabolism and neutralization in plaque, so that remineralization of enamel can occur; 4. Dental caries progresses only when the balance between demineralization and remineralization favours the former. The realization that demineralization and remineralization are in equilibrium is key to understanding the dynamics of the carious lesion and its prevention. One of the interesting features of an initial carious lesion of the enamel is that the lesion is subsurface, i.e. most of the mineral loss occurs beneath a relatively intact enamel surface. This contrasts strongly with the histological appearance of enamel after a clean tooth surface has been exposed to acid, where the surface is etched and there is no subsurface lesion. This dissolution of the surface of enamel, or etching, is a feature of enamel erosion caused, among other things, by dietary acids. Therefore the carious process and erosion differ completely, as erosion is a surface phenomenon. The explanation for the intact surface layer in enamel caries seems to lie in diffusion dynamics: the layer of dental plaque on the tooth surface acts as a partial barrier to diffusion. Further erosion occurs at much lower pH values (pH <4) than caries. Dental plaque forms on uncleaned tooth surfaces and is readily apparent if toothbrushing is stopped for 2–3 days. Contrary to popular opinion, plaque does not consist of food debris, but is a biofilm; 70% is comprised of micro-organisms—about 100 million organisms per milligram of plaque. When plaque is young cocci predominate, but as plaque ages the proportions of filamentous organisms and veillonellae increase.
Virological Diagnostic Methods
Authors: Oliver Anthony R.
Published: November 2020

Every clinical virologist must step back and ask what the aim of diagnostics is, in general, i.e. the ‘who/ what/ when/ where’ questions. Broadly, the clinical virologists of today must answer a limited set of questions because that is what current technology allows: ● Is this person currently infected with a virus? ● Has this person ever been infected/ exposed to a virus? ● This person has a confirmed virus infection— how is it progressing with or without intervention? ● From whom was this virus infection contracted? However, currently many questions remain remarkably difficult to answer with existing diagnostics. Increasingly the focus of diagnostics is moving from interest solely in the virus itself to how a given virus interacts with a given host pre/ post infection, e.g. HIV host co- receptor testing. Nearly all virological diagnostic methods rely on two fundamental technical principles— target and signal amplification, which both allow the visualization of virus- specific antigen/antibody or nucleic acid. Luckily, some clinical samples, e.g. stool, do not require amplification in order to detect significant virus infections, but even in these situations it is impossible to visualize the presence of viruses or their host antibodies without highly specialized equipment and chemistry. Most viruses are < 200nm in size, and therefore it is impossible to resolve virus particles even with the best optical microscopes. Nearly all of the methodologies detect surrogate markers. It is of note that viable virus numbers do not equal nucleic acid copies, which do not equal virus capsids visible by electron microscopy: these are apples and elephants when trying to compare their quantity. Diagnostic technology operates in two phases or realms; detection or screening, and characterization. For example, asking if a patient has an Influenza A virus infection, followed by asking what is the haemagglutinin/neuraminidase type (e.g. H1N1).
Key Communicable Diseases of Public Health Significance and UK Legislation
Authors: Basarab Marina
Published: November 2020

Timely reporting to public health authorities of certain infections which are transmissible between individuals and/or are likely to have been acquired from a contaminated source is essential to prompt immediate action to reduce further spread. In England, Health Protection Teams (HPTs) effect health protection actions at local level. They act as the ‘proper officer’ carrying out the function of receiving notifications in relation to the statutory regulations for both attending registered medical practitioners and diagnostic laboratories (see Section 14.6 and Section 14.7). Notification to public health authorities is a legal requirement. It is critical to the control and prevention of outbreaks of communicable diseases and is an integral part of wider local and national infection surveillance. Clinical recognition is the first step and public health authorities should be notified on clinical suspicion before obtaining laboratory test results to look for causative pathogens. As soon as a notification has been made, public health risk assessment and appropriate measures can be initiated. These may include preventing others being exposed to cases or a possible source of contamination, offering chemoprophylaxis, vaccination, education, and closing down of premises. The intervention will depend on the clinical syndrome, the confirmed or presumed infectious agent involved, and any further supporting or refuting diagnostic laboratory results. Time is of the essence; there should be no delay in notifications. Health protection legislation is set out in the Health Protection (Notification) Regulations 2010. It requires both registered medical practitioners (RMPs) and laboratories to notify cases of infection or contamination that could present a significant risk to human health, on the basis of clinical suspicion or laboratory confirmation. The medical doctor (and no other healthcare professional) attending the patient with possible or probable or confirmed infection is responsible for notification to the public health authorities.
Common Organisms Responsible for Healthcare-associated Infection (HCAI)
Authors: Jacob George , Cummins Martina N.
Published: November 2020

MRSA are S. aureus which become methicillin resistant by the acquisition of the mec A gene which is on a mobile chromosomal determinant called staphylococcal cassette chromosome mec (SCC mec). The mec A gene encodes for a penicillin- binding protein (PBP2a) which has a low affinity for isoxazolyl-penicillins (MICs to oxacillin/ meticillin ≥ 4μg/ ml) and is resistant to all classes of beta-lactam antibiotics. Current Department of Health (DOH) guidance (2014) recommends that mandatory MRSA screening be streamlined to include only: ● All patient admissions to high- risk units; ● Healthcare workers; and ● All patients previously identified as colonized or infected with MRSA. The guidance also advises Trusts to follow local risk assessment policies to identify other potential high- risk units or units with a history of high endemicity of MRSA; and The guidance also recommends regular auditing of compliance with MRSA screening policy. The 2006 guideline for the control and prevention of MRSA in healthcare facilities recommends the following four measures. ● Isolation MRSA- positive patients should be nursed in a single room or if none is available, cohorting into a bay after risk assessment. Patient movement, and the number of staff and visitors looking after the patient, should be minimized. ● Hand hygiene and use of personal protective equipment (PPE) All staff and visitors should decontaminate their hands with soap and water/or an alcohol rub before and after contact with the patient or their immediate surroundings. Single-use disposable gloves and aprons/non- permeable gowns should be used by staff and visitors if there is a risk of contamination with body fluids. ● Disposal of waste and laundry All waste from colonized/ infected patients should be placed in the infectious waste stream. All linen and bedding from patients colonized/infected with MRSA should be considered as contaminated and processed as infected linen. ● Cleaning and decontamination The patient’s room should be cleaned/disinfected daily with an appropriate detergent/disinfectant as per local policy. On discharge of the patient, the room needs to be terminally cleaned before it is reused. All patient equipment should either be single-patient use or be cleaned, disinfected, and sterilized.
Sepsis—Recognition, Diagnosis, and Management in Adult Patients
Authors: Melzer Mark
Published: November 2020

Sepsis is defined as life- threatening organ dysfunction caused by a detrimental host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular abnormalities are profound enough to substantially increase mortality. Septic shock is characterized by: ● The need for vasopressors to maintain mean arterial pressure (MAP) > 65mmHg despite adequate volume resuscitation. ● A serum lactate > 2mmol/L In lay terms, it is hypoperfusion with evidence of metabolic derangement. The mortality for both criteria is ~40%, compared to 20–30% for a single item. Please also refer to: https:// www.nice.org.uk/ guidance/indevelopment/gid-cgwave0686 The old definitions of sepsis described a heterogeneous group of patients and did not discriminate between infectious and non- infectious causes such as pancreatitis and trauma. The new definitions also allow easier recognition, based on a combination of symptoms and signs. Key parameters include: decreased level of consciousness, rigors, severe myalgia, high or low temperature, pulse > 130/min, systolic blood pressure < 90mmHg, respiratory rate (RR) > 25/ min, creatinine > 170μmol/ L, platelets < 100 x 109/l and bilirubin > 33μmol/ L. The Clinical Quality Commission recommend that NHS trusts use the national early warning score (NEWS), and a score > 5 is an indication to consider moving a patient to critical care. SIRS is defined as any of the two following criteria: acutely altered mental state, temperature < 36°C or > 38°C, pulse > 90/ min, RR > 20/ min, WCC > 12 or < 4 x 109/L and hyperglycaemia in the absence of diabetes mellitus. In the former definitions (1991 and 2001), sepsis was defined as infection plus SIRS. SIRS, however, was not good at separating infected patients who died from those who recovered from infection. SIRS was often an appropriate reaction to infection and many hospitalized patients meet the SIRS criteria. Also, as many as one in eight patients admitted to critical care units with infection and new organ failure did not have two SIRS criteria required to fulfil the sepsis definition. SIRS is no longer part of the new definitions.
Laboratory Diagnosis and Monitoring of HIV Infection
Authors: Jeffery- Smith Anna , William Tong C. Y.
Published: November 2020

In the majority of UK laboratories initial testing for HIV is now performed using a fourth generation test, which is a combination test for antibody to HIV and p24 antigen. These tests should be able to detect antibody to both HIV-1 and HIV-2. In addition, due to the heterogeneity of the virus they should be able to reliably detect antibody to the main circulating subtypes of HIV-1, i.e. group M (Major), O (Outlier), and N (non-M, non-O). The p24 antigen is an HIV capsid protein which is produced in large quantities during initial infection, prior to seroconversion. The sensitivity and specificity of fourth generation tests is typically > 99%. However, all positive results need further confirmation tests, as discussed below. Third generation laboratory assays only test for the presence of antibody to HIV. Though it includes the detection of IgM (which is not included in second generation assays), they do not detect early infection with isolated HIV antigen prior to seroconversion. Point-of-care testing for HIV is performed in the clinic or at bedside. Like laboratory based assays these tests can be either third or fourth generation. The sensitivity and specificity of point-of-care tests is considered lower than that of laboratory tests, and all positive results require confirmation with a laboratory assay. The window period is the length of time following infection with HIV until the appearance of laboratory markers of HIV infection in the blood. This period varies depending on which marker, i.e. antibody or antigen, is being tested for. The window period for fourth-generation tests is between eleven days and one month. Patients being counselled prior to this testing should be advised that a negative result does not cover risk exposures in the preceding month. These patients should be advised to have repeat testing if they have any further exposure risks in the preceding month prior to testing. For third-generation tests the window period is up to three months, correlating with the amount of time it may take for antibodies to HIV to develop.
Opportunistic Infections in HIV Infection
Authors: Williams Elizabeth
Published: November 2020

An infection is defined as opportunistic when it affects those with severe immunosuppression, i.e. takes a n opportunity to cause disease in a host with a weakened immune system. In people living with HIV it mainly affects those with a CD4 count < 200 although it is not impossible in those with CD4 count > 200. The CD4 percentage is also important as those with a CD4% < 14 are also more likely to have an OI. The lower the CD4 count the higher the risk of OIs, and some OIs are seen much more commonly with very low CD4 counts, e.g. cryptococcal meningitis in those with CD4 count of < 100. Before the introduction of antiretroviral therapy OIs were much more common than they are now, with previously up to 80% of those with AIDS having pneumocystis pneumonia (PCP). Since the introduction of antiretrovirals (ARVs) the rates of OIs has reduced greatly but unfortunately there are people who are still diagnosed late with an OI at diagnosis. Those with poor adherence or difficulty accessing ARVs are also more likely to be affected. In the UK in 2014, 40% of people diagnosed with HIV had a CD4 count of <350 which is defined as a late diagnosis (and 22% had a CD4 count of <200 which is defined as a very late diagnosis). In comparison to someone diagnosed with HIV early, those who are diagnosed late have a 10 times higher risk of dying in the year after they are diagnosed. This highlights the need for routine HIV testing so that people are diagnosed early to reduce the incidence of OIs further. The most common OIs seen in the UK are pneumocystis pneumonia (PCP), central nervous system (CNS) toxoplasmosis, cryptococcal meningitis, cytomegalovirus (CMV) retinitis, Mycobacterium avium intracellulare (MAI) infection and candidiasis. All those with HIV and a CD4 count ≤ 200, or with a CD4% < 14 should be given prophylaxis against PCP. Prophylaxis should also be recommended for those with oral candidiasis or a previous AIDs – defining illness. The options are co-trimoxazole 480mg od or 960mg 3x/week (960mg once daily can be given although does not confer any greater protection and has increased risk of side effects), dapsone 50mg once daily, or pentamidine nebulisers 300mg once every 4 weeks.
Fever in Returned Travellers
Authors: Hsu Desmond , Eltahir Babiker Zahir Osman
Published: November 2020

Travel-related problems have been reported in up to two-thirds of travellers to developing countries and approximately 10% of them seek medical advice during or after return from abroad. Furthermore, global migration from the developing to the developed world has increased over the past decades and these individuals may present with tropical infections soon after arrival in non-endemic settings. Fever, with or without localizing symptoms or signs, is a common presenting symptom in returning travellers. Most unwell travellers seek medical attention within one month of return from abroad. Travellers who visit friends and relatives (VFRs) in their countries of origin are disproportionately affected by the burden of imported infections, e.g. 70% of patients with imported malaria in the United Kingdom (UK) are VFRs. While most febrile travellers have common infections such as respiratory or urinary tract infection, it is of paramount importance not to miss potentially life-threatening tropical infections. Evaluation of fever in returning travellers requires an understanding of the geographical distribution of infectious diseases, risk factors for acquisition, incubation periods, and major clinical syndromes of travel-associated infections. The following points should be considered when assessing febrile international travellers: A. Travel dates: the relationship between the timing of the onset of symptoms and travel dates should be assessed. B. Geography: ● travel destination: a detailed itinerary is required. ● local setting: urban vs rural locations; type of accommodation, e.g. air-conditioned hotel room, outdoor camping, etc. C. Risk factors for acquiring infectious diseases: ● purpose of travel: visiting friends and family; social gatherings (e.g. funerals and weddings); mass gatherings (e.g. Hajj pilgrimage, Kumbh Mela religious festival, Olympic games, etc.); tourism; business; voluntary work. ● contact with unwell individuals. ● activities while abroad (examples): ■ food consumption: street food, seafood, raw food, unpasteurized dairy products, exotic foods, bush meat, etc. ■ contact with animals: visits to game parks, farms, caves, bites or scratches by bats or terrestrial animals, visits to ‘wet markets’, birding events, etc. ■ bites: ticks, insects, snakes, spiders, etc. ■ use of local healthcare system: dental or surgical procedures, blood transfusion, dialysis, tattoos, acupuncture.
Trauma and orthopaedics
Authors: Whymark Caroline , Junkin Ross , Ramsey Judith
Published: November 2020

To pass the written part of the FRCA, candidates must achieve the pass mark for the SAQs and the MCQ/ SBA papers combined. Therefore, doing particularly well in one paper, or one area, can compensate for another in which you have scored poorly. The 30 SBA questions is an area that candidates commonly find difficult. There is a feeling these questions are unjust and that it is impossible to second guess the examiners and choose the correct option. They feel further punished that four marks are awarded for each correct answer or lost for an incorrect choice. While this reflects the fact that four answers have been eliminated in the course of choosing the best answer, candidates often state it is an unfair ‘all or nothing’ way to mark these questions. They can commonly narrow the choice down to a final two options but report finding it difficult to then choose between them. They receive no credit having successfully eliminated three of the options and cite the SBA element as being the reason they failed the examination. These comments however are not supported by examination success data published by the RCoA. The pass rate for this paper was consistent at around 70% before and after the introduction of the SBA component in September 2011. We believe the concepts behind the SBAs are misunderstood by many. When asked to write a SBA question, candidates inevitably produce a five- part A to E multiple choice question but with only one correct answer. The finer points of SBA questions are lost among quickly written revision aids containing what the authors believe to be examination standard questions, when often they are not. Further, because SBAs are a relatively new element to the FRCA there is a limited bank of questions, and a highly restricted number in the public domain. Both these factors make practice of these questions difficult. Part of exam success is practice of the technique and question type in advance. We believe the practice of SBAs is an area to which candidates do not give enough attention.
Vascular and general
Authors: Whymark Caroline , Junkin Ross , Ramsey Judith
Published: November 2020

To pass the written part of the FRCA, candidates must achieve the pass mark for the SAQs and the MCQ/ SBA papers combined. Therefore, doing particularly well in one paper, or one area, can compensate for another in which you have scored poorly. The 30 SBA questions is an area that candidates commonly find difficult. There is a feeling these questions are unjust and that it is impossible to second guess the examiners and choose the correct option. They feel further punished that four marks are awarded for each correct answer or lost for an incorrect choice. While this reflects the fact that four answers have been eliminated in the course of choosing the best answer, candidates often state it is an unfair ‘all or nothing’ way to mark these questions. They can commonly narrow the choice down to a final two options but report finding it difficult to then choose between them. They receive no credit having successfully eliminated three of the options and cite the SBA element as being the reason they failed the examination. These comments however are not supported by examination success data published by the RCoA. The pass rate for this paper was consistent at around 70% before and after the introduction of the SBA component in September 2011. We believe the concepts behind the SBAs are misunderstood by many. When asked to write a SBA question, candidates inevitably produce a five- part A to E multiple choice question but with only one correct answer. The finer points of SBA questions are lost among quickly written revision aids containing what the authors believe to be examination standard questions, when often they are not. Further, because SBAs are a relatively new element to the FRCA there is a limited bank of questions, and a highly restricted number in the public domain. Both these factors make practice of these questions difficult. Part of exam success is practice of the technique and question type in advance. We believe the practice of SBAs is an area to which candidates do not give enough attention.
Introduction to dynamic programming
Authors: Fehr Hans , Kindermann Fabian
Published: November 2020

Dynamic optimization is widely used in many fields of economics, finance, and business management. Typically one searches for the optimal time path of one or several variables that maximizes the value of a specific objective function given certain constraints. While there exist some analytical solutions to deterministic dynamic optimization problems, things become much more complicated as soon as the environment in which we are searching for optimal decisions becomes uncertain. In such cases researchers typically rely on the technique of dynamic programming. This chapter introduces the principles of dynamic programming and provides a couple of solution algorithms that differ in accuracy, speed, and applicability. Chapters 8 to 11 show how to apply these dynamic programming techniques to various problems in macroeconomics and finance. To get things started we want to lay out the basic idea of dynamic programming and introduce the language that is typically used to describe it. The easiest way to do this is with a very simple example that we can solve both ‘by hand’ and with the dynamic programming technique. Let’s assume an agent owns a certain resource (say a cake or a mine) which has the size a0. In every period t = 0, 1, 2, . . . ,∞ the agent can decide how much to extract from this resource and consume, i.e. how much of the cake to eat or how many resources to extract from the mine.We denote his consumption in period t as ct. At each point in time the agent derives some utility from consumption which we express by the so-called instantaneous utility function u(ct). We furthermore assume that the agent’s utility is additively separable over time and that the agent is impatient, meaning that he derives more utility from consuming in period t than in any later period.We describe the extent of his impatience with the time discount factor 0 < β < 1.
Dynamic macro II: The stochastic OLG model
Authors: Fehr Hans , Kindermann Fabian
Published: November 2020

In Chapters 6 and 7 we discussed how to compute overlapping generations models and how to use them for policy analysis. The models developed there are completely deterministic in that they exclude both income and investment risk. While this ensured analytical tractability of the household problem and greatly facilitated computation, it certainly limit the scope of policy analysis. Consequently these chapters centred around clarifying the impact of public policy on the labour-supply and savings decisions of households and around evaluating its consequences for intergenerational redistribution. In practice, however, households face all kinds of risks that cannot be insured perfectly by the market. This opens up an additional channel through which the government could increase households’ welfare, namely by providing public insurance. In Chapter 10, we studied individual behaviour in an uncertain world, where individuals face idiosyncratic labour income and mortality risk as well as aggregate capital-market risk. The models therein are partial equilibrium models, meaning that prices are fixed and there is no need for the government to operate a balanced budget. In this chapter, we embed a household’s decision model with idiosyncratic labour-productivity risk and endogenous labour-supply decisions into a general equilibrium framework, which leads us to the stochastic OLG model. In this setup, factor prices respond to changes in individual behaviour and the government will be an explicit entity that collects revenue from taxes to finance its expenditure. Such a setup allows us to analyse both the distortionary and the risk-sharing effects of public policies. This chapter is organized in three main sections. The first two closely follow the setup of Chapter 6. We first explain the general structure of the stochastic OLG model with all its actors and conduct some steady-state policy analysis. We then discuss how to extend the model to include a transition path between steady states and to compute aggregate efficiency effects. In the last section, Section 11.3, we provide some policy applications where we analyse optimal tax schedules and the optimal size of the social-security system in more detail. In the following, we extend the life-cycle model with variable labour supply from Section 10.1.2 to a full general equilibrium setup with overlapping generations.