Potato consumption linked to gestational diabetes

A study published in the BMJ has found a link between a woman’s pre-pregnancy consumption of potatoes and her chances of suffering gestational diabetes.

The researchers from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Harvard University tracked 15,632 women over a 10-year period, which resulted in 21,693 singleton pregnancies.

Of these pregnancies, 854 were affected by gestational diabetes.

After taking into account risk factors such as age, family history of diabetes, diet quality, physical activity and BMI, researchers found that higher total potato consumption was significantly associated with a risk of gestational diabetes.

The researchers found that if women substituted two servings of potatoes a week with other vegetables, wholegrains or legumes, there is a 9-12% lower risk of contracting gestational diabetes.

They say one explanation of the findings is that potatoes have a high glycaemic index which can trigger a rise in blood sugar levels thanks to the high starch content.

The most recent Australian dietary guidelines released in 2015 say Australians need to eat less starchy vegetables.

The authors of the study admit that the observational nature of their study means no definite conclusions can be drawn about cause and effect.

However, they conclude: “Higher levels of potato consumption before pregnancy are associated with greater risk of GDM, and substitution of potatoes with other vegetables, legumes, or whole grain foods might lower the risk.”

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Chromium supplements linked to carcinogens: research

An Australian research team has found concerns with the long-term use of nutritional supplements containing chromium.

UNSW and University of Sydney researchers say chromium partially converts into a carcinogenic form when it enters cells.

The findings are published in the chemistry journal Angewandte Chemie.

There are primarily two forms of chromium: chromium (III) forms such as trivalent chromium (III) picolinate are sold as nutritional supplements. Hexavalent chromium (VI) is its ‘carcinogenic cousin’.

The team was led by Dr Lindsay Wu from UNSW’s School of Medical Sciences and Professor Peter Lay from the University of Sydney’s School of Chemistry. It treated animal fat cells with chromium (III) in a labatory and created a map of every chemical element contained within the cell using a synchrotron’s X-ray beam.

Related: Supplement claims rejected

“The high energy X-ray beam from the synchrotron allowed us to not only see the chromium spots throughout the cell but also to determine whether they were the carcinogenic form,” said Dr Wu.

“We were able to show that oxidation of chromium inside the cell does occur, as it loses electrons and transforms into a carcinogenic form.

“This is the first time this was observed in a biological sample,” Dr Wu said.

Professor Lay said the finding raises concerns over possible cancer causing possibilities of chromium supplements.

“With questionable evidence over the effectiveness of chromium as a dietary supplement, these findings should make people think twice about taking supplements containing large doses of chromium,” Professor Lay said.

“However, additional research is needed to ascertain whether chromium supplements significantly alter cancer risk.”

There is controversy over whether the dietary form of chromium is essential.

Chromium supplements are sometimes used for the treatment of metabolic disorders however they are also commonly used for weight-loss and body building.

Australia’s current National Health and Medical Research Council Nutrient Reference Values, which are currently under review, recommend 25-35 micrograms of chromium daily as an adequate intake for adults.

Trace amounts of chromium (III) can be found in some foods however these findings are unlikely to apply.

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Nearly a third of cancer cases linked to inherited genes: study

A large twin study has found that in some families, there is a shared increased risk of any type of cancer.

Led by researchers at the Harvard T.H. Chan School of Public Health, the University of Southern Denmark, and the University of Helsinki, the study is the first to look at family risk estimates of common and rarer cancers.

The study, published in JAMA, looked at 23 different types of cancer and familial risk was seen for almost all cancers.

Co-lead author of the study Lorelei Mucci, associate professor of epidemiology at Harvard Chan School said: “Prior studies had provided familial risk and heritability estimates for the common cancers—breast, prostate, and colon—but, for rarer cancers, the studies were too small, or the follow-up time too short, to be able to pinpoint either heritability or family risk.”

Investigators looked at more than 200,000 identical and fraternal twins in Denmark, Finland, Norway, and Sweden, who were part of the Nordic Twin Study of Cancer. The twins were followed over an average of 32 years between 1943 and 2010.

One in three developed cancer in their lifetimes. Cancer was diagnosed in both twins for 3,316 pairs, 38% of identical twins had the same cancer compared to 25% of fraternal twins.

The researchers found that when one twin had been diagnosed with cancer, the fraternal twin’s risk of developing any cancer was 37%. Among identical twins, the risk jumped to 46%.

As fraternal twins are similarly genetically to other non-twin siblings, the study found that there is an increased cancer risk for families when one sibling contracts cancer.

Overall, the heritability of cancer was estimated at 33%. The cancers with the highest heritability were: skin melanoma (58%), prostate cancer (57%), non-melanoma skin cancer (43%), ovarian cancer (39%), kidney cancer (38%), breast cancer (31%), and uterine cancer (27%).

Co-author Jacob Hjelmborg, from the University of Southern Denmark said: “Because of this study’s size and long follow-up, we can now see key genetic effects for many cancers.

“Findings from this prospective study may be helpful in patient education and cancer risk counselling.”

Read the full study in JAMA.

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‘Get kids out of detention’

The Australian Medical Association has released its revised Position Statement on the Health Care of Asylum Seekers.

The statement reaffirmed a long-held believe that all asylum seeker children should be moved out of immigration detention.

AMA President Professor Brian Owler said they acknowledge the Government has significantly reduced the numbers of children in detention but more can be done.

“Detention has severe adverse effects on the health of all asylum seekers, but the harms in children are more serious.

“Some of the children have spent half their lives in detention, which is inhumane and totally unacceptable.

“These children are suffering extreme physical and mental health issues, including severe anxiety and depression.

“Many of these conditions will stay with them throughout their lives,” Professor Owler said.

According to the latest Immigration Detention and Community Statistics Summary, as at 30 November 2015, there were 104 children held in immigration detention facilities within the Australian mainland, 70 children held in detention in Nauru, and 331 children in community detention.

The position statement also confirmed the AMA position that those who are seeking or have been granted asylum should have the right to appropriate medical care.

“Refugees and asylum seekers living in the community should have access to Medicare and the Pharmaceutical Benefits Scheme, state welfare and employment support, and appropriate settlement services,” Professor Owler said.

Other recommendations include:

There should be a maximum time that an asylum seeker can spend in detention
Those in detention should have access to appropriate specialist services
Anyone who has been in detention should be able to access their medical records after their release or deportation
Doctors treating asylum seekers who are transferred should be able to provide appropriate handover of relevant documents.
Doctors shouldn’t be obliged to artificially feed a hunger striker

Visit the AMA’s site to read their position statement.

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Genders experience pain differently, and women have it more

More women than men suffer from chronic pain, described as pain that persists for more than six months. In addition, much of this pain remains undiagnosed or untreated.

As well as the pain associated with menstruation or the bearing of children, waiting rooms of pain physicians, rheumatologists and gastroenterologists show clear majorities of women.

Research has found the only pain conditions more common in men are the relatively infrequent cluster headaches (where strong pain occurs on one side of the head), nerve pain after shingles, ankylosing spondylitis (a form of spinal arthritis) and migraine without perceptual disturbances of light and smell (called “aura”).

Everything else – from pelvic pain, irritable bowel syndrome, all other headaches, multiple sclerosis, rheumatoid arthritis, jaw pain, bladder pain syndrome, fibromyalgia, chronic regional pain syndrome to odontalgia (painful teeth) – is more common in women.

Men and women also describe pain differently. Research found women tended to use more descriptive, graphic language with a focus on sensory symptoms. Men were more likely to express anger or swear, but recalled the event more objectively.

Male subjects’ written responses were shorter and less detailed, with potential influences being gender role expectations of pain response, a male reticence to report painful sensations and feelings of embarrassment when reporting a pain experience.

History of thinking about pain

We understand pain in others best when we have real or imagined shared experience. Pain in women is frequently both unable to be visualised (unlike lacerations or other visible injuries) and outside the experience of their health professional.

How to view the female patient with pain that can’t be seen is a problem the Ancient Greeks pondered as early as 400 BC. Faced with a complex range of suffering and complaints in women, Ancient Greek physicians came up with a novel explanation: the “wandering womb”. The womb was believed to move upward in a woman’s body whenever it became hot and dry, searching for cool moist places, and causing stress and damage to her physical and mental well-being.

Hippocrates (460-370 BC) used the term “hysteria”, which derives from the Greek word “hysteros” for “womb”, to describe a wide variety of female emotional and physical conditions. By inference this labelled women in pain as weak, inferior or irrational. Parallel to their inferior social position in Ancient Greece, Aristotle (384-322) used the concept of hysteria in his book, The Nicomachean Ethics, as proof that women were unsuitable for public office.

Genders experience pain differently, and women have it more - Featured Image

There’s a common belief that women have a higher pain threshold so they can give birth, but actually men’s pain threshold is higher.

While such beliefs seem far-fetched today, the diagnosis of “hysteria” continued to be commonly used in European medical practice to describe a wide variety of symptoms in women for the next 2,000 years. Only in 1980 was it removed from the DSM III Manual of Psychiatric Disorders.

Unlike women, historical accounts of men’s pain have been influenced by their ability to withstand injuries incurred in warfare. As English poet William Cowper (1792) noted, incitements including “renown and glory” helped men disregard pain on the battlefield.

Research in pain

In 1977, with concern about the risk that new drugs might have on an undiagnosed pregnancy, the US Food and Drug Administration recommended that all women who were capable of becoming pregnant be excluded from drug trials. The presumption was that pain research in men would be applicable to both genders. While well intentioned, the consequence of this decision has been that the majority of pain research has been undertaken in male humans or male rodents.

This decision has since been reversed, and research into pain differences between the sexes has dramatically increased. While results have at times been conflicting, what we are learning is that females consistently show lower pain thresholds and increased pain following a painful stimulus than males. This doesn’t mean women are weaker than men or their pain isn’t real, but they feel pain more intensely than men.

Pains specifically associated with women, such as menstrual pain, may predispose women to feeling pain more acutely in other areas. Women’s brains produce less endorphin (which inhibits pain) following a pain stimulus than men. Yet when morphine is given to treat pain, it generally works equally well in either gender.

Clearly there is still a lot to learn about gender and pain. Newer thinking suggests that pain in men and women may even occur through entirely different mechanisms and pain pathways.

For example, microglia are cells from the immune system involved in chronic pain. Research in mice has shown that drugs that prevent activation of microglia are effective in reducing pain in male, but not female, mice.

So, the observed differences in ability to withstand acute pain on a battlefield (traditionally associated with males) and ability to withstand the pain of chronic disease (more commonly associated with females) may prove to have a physiological basis.

Every one of our cells knows whether we are male or female and responds accordingly. That there are differences between male and female pain should not be surprising.

This article was originally published on The Conversation. Read the original article. This article is part of a series focusing on Pain. Read other articles in the series here.

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Hospital doctors’ Opinions regarding educational Utility, public Sentiment and career Effects of Medical television Dramas: the HOUSE MD study

A career in medicine has long been considered an apprenticeship, with mentors providing guidance to their trainees. The word mentor finds its origins in Greek mythology. In Homer’s Odyssey, the confidant of king Odysseus, Mentor, was trusted to guide his son and oversee his education while Odysseus fought in the Trojan War.1

The modern practice of medicine, with an emphasis on shift work, has made the classical mentor–mentee relationship more challenging,2 but the modelling of one’s practice on observed social and clinical traits of a mentor or role model remains.3 Moreover, such exposures can be factors in students’ decisions to pursue a career in medicine and even in their subsequent choice of specialty.4

The eventual choice of role model is often a personal one and may not even involve one’s own supervising senior, although it is often based on clinical experiences.5 While knowledge and clinical competence have been cornerstones of role model selection, growing evidence suggests that factors relating to personality such as compassion, good communication and enthusiasm may in fact have more influence on the expanding minds of trainees.6 Further compounding this, in some educational situations, less than half of senior clinicians were subsequently identified as being excellent role models.7

While social interactions with parents, teachers or even peers may impact on personality, outlook and practice, other media such as literature and television (TV) have been demonstrated to be significant components of this role model hypothesis.8

Medical TV programs have grown in popularity from the 1960s onwards and are now considered a staple of primetime TV.9 It has only been in more recent years that the effects of these health and illness TV narratives have been studied in greater detail.

Although their true purpose has been one of entertainment, much of their appeal is based on the perception that they are an accurate reflection of reality.10

It has been well accepted that TV can have an impact on society, increasing knowledge and influencing behaviour.11 TV medical dramas have also been shown to be of educational worth to patients12 and even doctors.13

However, they have occasionally come under criticism for unrealistic medical content, ranging from demonstration of intubation technique14 to cardiopulmonary resuscitation (CPR).15 Frequently, in CPR situations on TV compared with actual practice, there is a higher volume of trauma cases as an underlying aetiology. Further, these scenarios often show considerably younger patients than those seen in routine CPR and survival to discharge is much better than clinically encountered.16 Concerns that this may influence the attitudes of members of the public who watch these dramas for educational purposes remain.

More recently, there has been a growing emphasis on the use of these programs as educational resources.17 In particular, some of the established role model personality traits such as ethical astuteness, communication and empathy have been sufficiently demonstrated in these series to warrant use in undergraduate teaching videos.18 Although much of the learning that can be gleaned from observing the practices of TV doctors has focused on perceived softer undergraduate educational domains,19 their use in postgraduate settings is also increasing.20

TV is a medium through which many health care workers not only take their minds off work, but also reflect both consciously and unconsciously on experiences. Students and doctors do indeed watch these programs at least as often as the general public does and, when questioned, are quite positive regarding them.21 Although not yet demonstrated, watching these series may form an early part of any role modelling or identification with certain character traits that both trainee and established medical practitioners may have.

Methods

A structured questionnaire was distributed among doctors of all grades and specialties in three large teaching hospitals in Wales, United Kingdom (Morriston Hospital, Singleton Hospital and Princess of Wales Hospital) within the Abertawe Bro Morgannwg (ABM) University Health Board, to allow capture of data from a diverse range of specialties. These were disseminated through various different locations, including departmental meetings and on-call rooms.

Questions related to respondents’ gender, specialty and grade, whether they watched medical TV dramas and their opinions regarding them, and whether they identified with characters from these programs (and if so, who) or with a non-fictional doctor encountered during their clinical careers.

Hospital grades were summarised as consultant, specialist trainee (registrar), core trainee (resident medical officer [RMO]), and foundation doctor (intern). For simplification, specialties was separated into medical, surgical, acute (eg, accident and emergency, intensive care unit, etc) and non-acute (eg, pathology, radiology, etc), although note was made of individual subspecialty answers from within these broader categories.

Statistical analysis

A cumulative odds ordinal logistic regression with proportional odds was run to determine the effect of grade and specialty on the choice and frequency of viewing of medical TV dramas. Statistical significance was set at P < 0.05. Statistical calculations were performed using SPSS Statistics, version 21.0 (IBM).

Ethics approval

Ethics approval was granted by the ABM University Health Board Research and Development Joint Scientific Review Committee.

Results

Three hundred and seventy-two questionnaires were disseminated and 200 completed questionnaires were returned (response rate, 54%). Forty-six per cent of individuals completing questionnaires were women and 88% had graduated from a UK medical school. Grades and specialties of respondents are presented in Box 1.

How often do clinicians watch TV medical dramas?

One hundred and twenty-nine doctors (65%) surveyed admitted to watching TV medical dramas on more than one occasion and 14% considered themselves to be regular viewers; 15% of respondents felt that watching them as a school student positively influenced their decision to pursue a medical career.

Junior doctors were five times more likely to have watched these programs as medical students compared with more senior doctors (odds ratio [OR], 5.2; 95% CI, 2.5–10; P < 0.01). The ORs for RMOs and specialist trainees were 3.1 and 2.5, respectively, in relation to consultants (P < 0.05). Further, UK graduates were five times more likely to have watched these medical TV dramas as medical students compared with non-UK graduates (OR, 4.8; 95% CI, 2.4–9.6; P < 0.01).

The most commonly watched TV programs were Scrubs (49%), House MD (35%) and ER (21%). Most doctors who admitted to watching medical dramas did so for entertainment purposes (69%); 19% watched because there was nothing else on TV; 5% for insight into media perceptions of medical practice; and 8% for educational purposes.

Clinicians’ opinions regarding TV medical dramas

We asked individuals if they felt that TV medical dramas were educational, gave doctors a bad name, accurately showed the doctor–nurse relationship, and represented the spectrum of illnesses commonly encountered.

One hundred and three respondents (52%) felt that these shows displayed no educational value whatsoever, 52 (26%) were unsure, and 45 (23%) believed there were some educational benefits from watching them.

Evaluating the spectrum of illness represented in these dramas, 82% felt that those shown were unrealistic of daily practice. However, 20 respondents (10%) thought that they accurately portrayed reality. Most of these positive responses (16/20) were from junior doctors. No associations between the belief that medical dramas portrayed realistic life situations and specialty or frequency of viewing were observed.

Grade, specialty and country of qualification had no effect on whether a doctor believed that the programs represented current medical practice. Neither did current frequent watching or having been a regular viewer at undergraduate level.

Twenty-seven per cent of doctors surveyed felt that these programs gave doctors a bad name, although no significant differences were observed between any of the groups.

Only 13% of respondents felt that medical dramas accurately portrayed the doctor–nurse relationship, most of whom were self-admitted non-regular viewers (P = 0.01) and general practitioners or GP trainees (19/25; P = 0.05).

Outcomes of watching TV medical dramas

Thirty per cent of foundation doctors (interns) and 25% of core trainees (RMOs) felt that watching medical TV programs may have affected their career choice (to any extent) compared with more senior doctors (18%).

Compared with consultants, the OR for interns considering that watching medical TV dramas had any effect on their subsequent career choices was 4.8 (95% CI, 1.6–13.7; P = 0.013); for RMOs and specialist trainees, the ORs were 2.5 (95% CI, 1.3–5.8) and 2.7 (95% CI, 1.3–5.8) respectively; P = 0.09 and 0.13).

Specialty and country of qualification did not influence doctors’ beliefs that watching medical dramas had an effect on their career choice.

Clinicians’ identification with doctors in TV medical dramas?

A total of 121 respondents (61%) role modelled aspects of their practice on another doctor (fictional and non-fictional).

Junior doctors, particularly interns and RMOs were more likely to find commonality in their practice with fictional TV characters compared with more senior doctors (OR, 2.7; 95% CI, 1.3–5.8; P = 0.008).

Consultants were most likely not to specify any role models and, if they did so, were more likely to identify themselves with non-fictional characters (32/55) compared with other doctors, particularly interns (4/49).

Medical doctors were more likely to identify themselves with a fictional TV character (OR, 3.2; 95% CI, 1.08–9.43; P = 0.035). This was followed by 19% of acute specialty doctors and 14% of surgical specialty doctors. Non-acute specialty doctors were least likely to identify themselves with a fictional TV doctor.

The top five most popular fictional role models are shown in Box 2. Leonard McCoy (Star Trek) and Quincy (Quincy ME) were the most popular choices among consultants; the majority of positive responders were anaesthetists and pathologists. A more varied response was seen among physicians and surgeons, but note was made of a peculiar popular choice: Dr Evil (from the Austin Powers film series, Box 3) was named by four trainees, all surgical (three orthopaedic and one general surgery).

Discussion

There is a known association between clinical role models in undergraduate medicine and career choice.22 Therefore, TV medical dramas could potentially influence doctors’ and students’ opinions and have been found to be a source of entertainment for both health care professionals as well as the wider public.23

Fictional doctors have evolved into television heroes and much of their appeal is their on-screen personality as well as, in some cases, their absolute prioritisation of scientific challenge over social relationships.24 Further, much of their appeal is their ability to navigate through difficult ethical dilemmas, to make decisions that are often perceived by clinical trainees as being positive ones.25

Although clinicians watching these programs appear to do so predominantly for entertainment purposes, we found that those who watch for educational reasons show that junior trainees exposed to this genre of TV entertainment are more influenced by these series than their more senior counterparts. Interestingly, all respondents who admitted to watching TV medical dramas for educational reasons watched House MD (Box 4), perhaps suggesting that they value its learning input.

In keeping with previous studies,14–16 most doctors felt that a large proportion of what was televised may not be a true representation of clinical practice; however, suggestions that more junior trainees believe this to be so could be explained by their relative lack of clinical experiences to date.

Identifying aspects of one’s practice with witnessed exposures has been a cornerstone of the role modelling theory, but data generated from this questionnaire-based study suggest some interesting differences between specialties. Doctors who answered negatively to currently viewing or having ever viewed this type of program were least likely to admit to having been influenced into a career in medicine on the basis of TV medical dramas, thus validating the data.

It is to be assumed that consultants may look on their past seniors as role models to identify commonality of practice but the high proportion of respondents among all grades who admitted to being influenced, at least in part, by medical TV dramas suggests a much higher effect than anticipated.

Further, differences between specialities — for example, medical doctors identifying more with TV doctors compared with their surgical peers — might be explained by the sizeable volume of medically themed programs as opposed to more surgical ones. It is plausible, however, that some of the core learning traits seen in physicianly specialties, particularly regarding difficult diagnostics and ethical dilemmas, strike a chord with this group of clinicians. Specific choice of TV doctor hero as a potential role model will require further evaluation. Motivations for the popular choice of a Star Trek character among anaesthetists may include an interest in futuristic technology. Likewise, the interesting preference for Dr Evil among some surgical trainees may be due to an interest in world and/or career domination, or it may be suggestive of professional ambition rather than a display of true megalomaniac traits.

While we may be some years from continuing medical education creditation obtained from Saturday evening viewing, this study does suggest that the current generation of junior doctors relies on medical TV dramas for entertainment and education in parallel. Further observation may show some interesting effects during career progression, particularly regarding the atypical answers we received to our questions about TV doctor identification.

Box 1 –
Grade and specialty of respondents (n = 200)

Grade and specialty

No. (%)

Grade

Intern

49 (24.5%)

Core trainee (RMO)

60 (30.0%)

Registrar (specialist trainee)

36 (18.0%)

Consultant

55 (27.5%)

Specialty

Medical

83 (41.5%)

Surgical

36 (18.0%)

Acute non-medical

27 (13.5%)

Non-acute

20 (10.0%)

GP or GP trainee

34 (17.0%)

RMO = resident medical officer.

Box 2 –
Most popular fictional television doctor role models

Rank

Doctor

Show

The psychopathology of James Bond and its implications for the revision of the DSM-(00)7

The release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been controversial.1,2 One concern is that the DSM-5 promotes overdiagnosis, encouraging the unnecessary use of medications and potential stigmatisation through diagnostic labelling that does not necessarily lead to better treatment outcomes.3 The lack of consideration for local philosophical, cultural and professional practice needs has also been raised.4 The American Psychiatric Association (APA) should be commended for providing the first thorough revision of the DSM in more than 30 years.5 However, the resulting document is now a more complicated, thicker tome than the original version published in 1952, and literally adds weight to psychiatric diagnosis. A lighter, easier-to-use DSM would be welcomed.

Given the vocal debate that has ensued following the release of DSM-5, the authors of this article feel there is some merit in making the DSM more concise, while still ensuring that the criteria are effective when diagnosing complex cases. It was agreed that revised, more parsimonious DSM criteria were required. The authors were concerned that the APA would already be preparing the DSM-6, and therefore decided to begin with the DSM-(00)7. This paper describes the development of a novel diagnosis (the Bond Adequacy Disorder), new screening criteria (the Bond Additive Descriptors of Anti-Sociality Scale), and our proposed version of the DSM-(00)7.

Methods

James Bond was selected by the authors as a suitable subject on whom to base our study of psychopathology because of his widespread acceptance among both men and women as an aspirational role model, his documented problems with both alcohol and violence,6,7 and the large amount of observational data that was accessible without exceeding our research budget (NZ$80).

Our requests for a diagnostic interview with Commander Bond and for key informant interviews with his colleagues (M, Q and Miss Moneypenny) were turned down (we assume) by MI6 on the grounds that these people were allegedly not known at that address. We were, however, able to gain access to the 50th edition boxset of James Bond video observations.8 This provided more than 45 hours of video records of the subject over a 50-year period (1962–2012), and therefore represented a unique dataset in the history of psychiatry. The observations were not limited to unrepresentative research or clinical settings, but included many opportunities for observing the subject in a range of situations, including settings of considerable stress, intimacy and confrontation, and also in a wide range of cultural settings. This dataset has previously been described in greater detail by other authors on the Amazon.com website.

We also considered the many written observational records prepared by Fleming, Amis, Gardner, Benson and Faulks. However, we found their observations to be surprisingly inconsistent with the video recordings, which we feel must take precedence. The named researchers cannot, unfortunately, be regarded as reliable observers, and seem to have applied journalistic rather than scientific approaches in their work.

In order to catalogue the behaviours exhibited by James Bond, it was agreed that the investigation team would view all 23 Bond video observational records. An initial coding framework was developed, and each observation was reviewed and the behaviours categorised. This methodology was adapted from previously published studies on James Bond; one examined the books to evaluate alcohol consumption,6 another evaluated violence in the films.7

The reviewers were also asked to note any other extreme behaviours that might be suitable for establishing a DSM diagnosis. This included behaviours that are not currently included in the DSM but might be considered criteria for the diagnosis of Bond Adequacy Disorder (BAD: a good diagnosis has at least three words in the title and a catchy acronym).

Each reviewer watched between two and ten movies, depending on the reviewer’s ability to manage what, in some cases, were quite troubling recordings. Because of distress that initial views of the material caused the first author of this article, reviewers were prescribed anxiolytics (of the ethanol class) that they could take on an as-required basis. Eight observations were viewed twice to ensure inclusion of the newly identified criteria, and one recording (“Skyfall”) was viewed in a group setting by five of the reviewers.

The initial categorisations and the newly proposed behaviours were then analysed using a general inductive approach.9 We looked for behavioural themes, and developed an initial list of potentially defining characteristics for BAD. Although we considered using statistical techniques to define behavioural categories, we found that all the behaviours were highly correlated with each other. We therefore used the Delphi method to develop the final criteria for BAD. The initial round of discussions was undertaken by e-mail; when there was significant disagreement over the appropriateness of particular behaviours, the group met to discuss and resolve these questions.

Results

The initial review of the films identified 32 significant behaviours; the list was then refined, identifying 13 key behavioural themes (Box 1).

The Delphi process was used to select the eight behaviours that were consistent with a diagnosis of BAD: sense of entitlement, use of bad puns and sexual innuendos, craving for admiration and self-centredness, sexual promiscuity, excessive fighting, taking risks with one’s own life or those of others, excessive thrill seeking, and murder. All eight behaviours must be present for the diagnosis to be confirmed. If the individual presents with further symptoms listed in Box 1, it merely reflects increased severity of the diagnosed disorder.

We elected to further simplify diagnosis by defining just two categories: BAD and Normality Disorder (ie, everyone not meeting the criteria for BAD). The Bond Additive Descriptors of Anti-Sociality Scale (BADASS) tool was created to simplify screening for BAD and Normality Disorder (Box 2).

Discussion

In the resource-limited health settings that many countries face, there is a need to increase efficiencies, including that of diagnostic screening. We have used a novel approach to refine the DSM criteria so that less time need be spent diagnosing patients and more time directed to managing their care appropriately.

It is estimated that a third of the world’s adult population suffers from a mental health disorder.10 This means that efforts to streamline care for mental health would be of benefit for patients, clinicians and health care systems in general. We have used innovative methods to define two diagnostic categories for the DSM-(00)7. There are numerous advantages to this concept, as outlined in Box 3. We cannot see any disadvantages, but nevertheless expect some to be raised in letters to the editor following the publication of our proposal.

Our findings need to be considered in the light of some limitations. The members of our Delphi group had a tendency to be conflict avoiders, so that there was 100% agreement on all questions. It would have been ideal for each observation to have been examined by at least two enthusiastic reviewers. Unfortunately, as several reviewers stated that the movies did not live up to their childhood memories, the idea of recruiting additional reviewers and ruining their childhood spy fantasies seemed cruel and perhaps unethical. It was decided each observation would initially be viewed once, with repeat views only if necessary.

Our research team is not the first to turn to James Bond for insights into personality and emotional states.11–14 The popular media is awash with characters who manifest the personality traits of the dark triad of attributes exhibited by Bond. This triad is complex, comprising subclinical narcissism, psychopathy and Machiavellianism, and is traditionally associated with “bad boys” and antiheroes.13 Bond cold-bloodedly murders with a gun or even with bare hands, and this lack of empathy suggests an underlying psychopathy. His short-term relationships with women involve mate-poaching and manipulation, and his narcissism is manifested by expensive suits, perfect hair, driving expensive cars, and the ability to nonchalantly fix his tie as he walks away from a fatal scuffle or explosion.13 The development of DSM-(00)7 will make identifying and managing these types of individual more straightforward.

While we anticipate gratitude from the APA, we think it unlikely that we will be invited to contribute to the DSM-8. However, our vision for this document is to revive the diagnostic creep of past versions, albeit from the low (two-category) baseline of the DSM-(00)7. Such categories as normality disorder with psychosis, normality disorder with depression, normality disorder not otherwise specified etc would be possible and much more socially acceptable. This will have great appeal for the research community, as they will be able to build research teams (and empires) for receiving large research grants to validate the new diagnostic categories and to invent even more; eg, normality disorder with borderline traits. Our endeavours will also benefit the world of treatment. New medications and psychotherapies will need to be invented and tested to determine whether people can be made supernormal (ie, more normal than normal) or moved from being marginally normal to having a full normality disorder. The old definition of a normal person being someone you don’t know very well will be abandoned, as we will now have criteria for a positive diagnosis of normality disorder, the new normal.

The DSM-4 was followed a few years later by a revised version. To pre-empt this possibility for our new edition, we will publish a revised version of the DSM-(00)7 together with the actual DSM-(00)7. The revised DSM-(00)7 will allow people to make their own diagnosis, and will provide 140 ready-made character tweets (eg, “My BADASS says I have Normality Disorder #gettested #licencetothrill”), quizzes for Facebook, and badges that advertise a BADASS status for dating profiles. We think this will be welcomed by the anti-psychiatry lobby and by regular humans, who will now be able to self-diagnose and self-actualise with the help of the DSM-(00)7. We also believe this will broaden the considerable economic interest in the DSM, and reap even bigger profits than those generated by the DSM-5, as clinicians will feel the pressure to purchase both versions simultaneously. If the projected economic outcomes are not realised, we would be willing to revise the revised edition at a later date. We are interested only in the science of our undertaking, and making mental health understandable for the general public; we will donate any profits to the APA. We expect the APA will incorporate many aspects of the DSM-(00)7 into its later editions, and while credit is always appreciated, a complimentary copy of the DSM-8 is expected.

Areas for future research include reducing the size of other tomes that also keep expanding; for instance, we suggest reducing the size of the dictionary, which is simply too verbose.

Box 1 –
A summary of the key behaviours exhibited by James Bond in each of the 23 video observations

Deceit

Sexual contact

Risking life (self)

Risking life (others)

Attracted to women with unusual names

Entitled behaviour

Exploiting others

Lack of empathy/emotional detachment

Illegal activity*

Killing (self-defence and murder)

Fighting

Bad puns

Patronising/sexual innuendo

Dr. No

From Russia with Love

Goldfinger

Thunderball

You Only Live Twice

On Her Majesty’s Secret Service

Diamonds Are Forever

Live and Let Die

The Man with the Golden Gun

The Spy Who Loved Me

Moonraker

For Your Eyes Only

Octopussy

A View to a Kill

The Living Daylights

Licence to Kill

GoldenEye

Tomorrow Never Dies

The World is Not Enough

Die Another Day

Casino Royale

Quantum of Solace

Skyfall

*Includes stealing, breaking and entering etc.

Box 2 –
Bond Additive Descriptors of Anti-Sociality Scale (BADASS)

Box 3 –
Advantages of the DSM-(00)7

Domain

Advantage

Patient- and caregiver-focused

There would be little or no stigma attached to a mental health diagnosis. Indeed, we feel the community may wish to embrace their normality disorder: it will be easy, even encouraged, to Google and self-diagnose it.Parents would feel more comfortable about their children’s behaviour probably reflecting normality disorder, so that there would be no need to fret. Those parents who wanted to fret could entertain a diagnosis of BAD for their child.

Clinician-focused

Diagnosis would be simpler.Clinicians could ignore psychosocial complications.Mental health clinicians would benefit, as their consultations could focus on therapy rather than spending too much time on diagnosis. This will leave them more time to have coffee with their colleagues, helping with their lifelong learning.New categories could be developed for dual diagnosis; eg, normality disorder with psychosis, normality disorder with depression and anxiety. This would have the added benefit of normalising these conditions.

Health care organisations

Planners would like it, as they would not need to provide as many mental health resources.Insurance billing codes would be simpler and payment quicker.

Commercial entities

Normality disorder would need treating, so new drugs could be developed to improve the quality of life for those with normality disorder.Big Pharma would appreciate a new diagnostic category being created by someone else for a change.

Other

It provides a boon to the research community working on projects related to diagnosis and treatment.The concept provides more fodder for editorials about the latest controversies; this will please editors.

Red Dust, dingoes, trauma and Sepsis

Dr Chris Edwards of EMJourney recounts his time as a remote retrieval registrar based in Alice Springs. Follow him on twitter @EMtraveller

I’ve had the privilege to work as a Retrieval Registrar for the Alice Springs Hospital Retrieval Service in Central Australia for the last 6 months. How to describe it – words that spring to mind include:

Challenging (unlike many other retrieval jobs, you often are intimately involved in the logistics planning)
Satisfying (providing ICU level care to the most remote parts of Australia)
Scary (providing ICU level care to the most remote parts of Australia!)
Clinical character forming (Brown underpants occasionally needed)
Interesting (When a potassium > 7 and severe rheumatic heart disease no longer turns your head)
Scenic (people pay money to see Uluru from the air, I get paid)

The Central Australian Retrieval service retrieves patients mainly by fixed wing aircraft over a catchment area of 1.6 million square km. We also perform inter-hospital transfers to Adelaide and Darwin (that’s 3.5 hours, one way, either way!) Let me try to put the sheer size of our catchment area and distance from our tertiary referral centres into perspective…

Here is Australia, our tertiary referral centres and our catchment area roughly outlined…

I think you get the idea – this is a huge catchment area! With one other small hospital in Tennant Creek, the rest of our primary retrievals are to remote health clinics, staffed by RANs (Remote Area Nurses).

In our primary retrieval we don’t have sub-specialty retrieval teams so we do it all, although we do occasionally take a paediatrician with us. Common conditions, mostly from our indigenous population but occasionally a grey nomad or overly adventurous backpacker, include:

Trauma (usually penetrating or MVA)
Sepsis (and sometimes overwhelming septic shock)
Snake bites/stick bites
Renal disease – Missed dialysis with APO and/or hyperkalaemia
Threatened/established/imminent/delivered labours at term/pre-term (I mentioned the brown underpants right?)
Paediatrics – URTIs, LRTIs, infected scabies, post-streptococcal glomerulonephritis

Mostly our patient population is young, less than 50 years old – I haven’t retrieved a single NOF fracture since I got here!

Then there’s the inter-hospital retrievals; Mostly to Adelaide, we take intubated patients on inotropes, trauma patients with chest drains and vacmat with spinal precautions, recently lysed STEMIs, including failed thrombolysis with ongoing arrhythmia for rescue PCI (52 shocks is my current record); I’ve even taken two patients so far with intra-cranial bleeds and extra-ventricular drains (first time I had even seen one).

Equipment and Staff

The plane we use is the Pilatus PC-12, a single-engine turboprop made by the Swiss. It has a cruising speed of approximately 500km/hr and a maximum service ceiling of 30,000ft with cabin pressurization of <8000ft. We operate with a single pilot and flight nurse. The passenger cabin is modified to carry two stretchers and 3 seats. The plane also comes with a hydraulic stretcher loader in the rear exit – maximum load of 182kg. The PC-12 is ideal for our environment – it can land on shorter strips and can be flown with only one pilot – keeping our take-off and landing weights down.

Interior of the PC-12

On the plane, we carry the doctor’s bag, which contains central lines, arterial lines, fast trach intubating LMAs, rapid infusion catheters, EZ-IO, scalpels, bougies and other useful gear. We also have onboard a standalone intubation kit, cannulation kit, equipment for infusions, syringe drivers, pump sets, a full cold and warm drug box, an Oxylog 3000, a Zoll X-series monitor/defibrillator/pacer and of course the most important – coffee/tea bag. Additional equipment we can carry includes a maternity pack, trauma pack, neonatal pack, a vacmat, a humidicrib, paediatric ventilator, surfactant, a Sonosite M-Turbo and 2-4 units of packed RBCs.

Our Flight Nurses are the backbone of the clinical service. Trained in both critical care and midwifery they have a broad skill set and a lot of experience. They have invaluable clinical and logistical knowledge and when it comes to obstetric cases, my general approach is to ‘Remain Above The Navel’ and do what I’m told!

The Retrieval Doctors have a varied background – some are Rural and Remote Medicine trained, some are budding intensivists, but the majority are Emergency trainees. What we all need to have in common is the ability to be flexible and manage a difficult airway or an unstable patient on your own, supported by the FACEM in ED and Retrieval specialists.

Typical Day

No such thing as a typical day in this job. You might be heading to Adelaide with an ICU patient – if you do, that’s your whole day, because it’s a 3 hour one way trip. If you aren’t tasked to an inter-hospital transfer, at some point you will likely get an SMS from RFDS operations with a job. You check the email system and read the clinical information – then you call the clinic and speak to the RAN – get the latest details, suggest management or procedures and try to get a feel of how sick the patient is and what equipment you might need to bring. Then it’s a trip into the hospital if you aren’t already there, grabbing your gear and driving or taking a taxi out to the RFDS hanger.

Once there you load up the plane and head off. Most of our retrieval locations are within 1 hour’s flight from Alice Springs, with a few outliers like Elliot and Kiwirrkurra taking 2 hours. Flight time will usually include discussing the plan with your flight nurse and finding out any logistical challenges from your pilot (eg. Day strip only, weights permissible, pilot hours remaining).

Occasionally you may instead be tasked to go to a cattle station, roadhouse or the side of the road but in most cases you will be going to a clinic in a remote community. When you arrive, someone will meet you in a car to take you and your gear to the clinic. The clinics vary in size and equipment but most will have at least a small ‘Emergency’ room.

Typical remote emergency room

It’s hard to really describe accurately the first time you arrive at a remote community clinic. I remember being surprised by all the dogs (and the occasional donkey and camel) and the hurried advice from the flight nurse not to try and pet them. I remember the flies being everywhere (we carry mortein in the plane) and I remember the crowd that greeted us, largely children ages 5-12, mostly with crusty noses and curious smiles and scattered amongst them would be one or two proud elders. I even remember one time where I heard a commotion outside the clinic and popped my head outside to see several children beating a snake with a water bottle, right near where we would be loading the stretcher…

So, at the clinic, you assess your patient(s), perform therapy as necessary and package for transfer. It’s important in this job to not spend unnecessary time on the ground – because you, the plane and the crew are an important resource for a large area of Australia. Once you are ready, you load your patient into the ‘Troopy’.

The Toyota Land Cruiser 70 Troop Carrier, affectionally known as a ‘Troopy’ is the ubiquitous remote area 4wd transport all over the globe. In Central Australia they have been modified to carry one or two stretchers. Having ridden in the back of many of them now, I can definitely say that they are a bumpy ride, but they’re very reliable and spare parts are easy to get.

After arriving at the plane, you load the patient, with or without an escort and head back to Alice Springs – unless another job comes through whilst you are in the air and nearby!

Airstrip intubation due to deterioration – note the fuel barrel table

What is it like to live in Alice Springs

Alice Springs is great. Many of the junior hospital staff are on temporary placements as well – young trainees keen to explore the area. From social nights at the local pubs (Monte’s being the most popular), to bike rides, local hikes and camping trips. The mountain biking and trail running is truly world class with several professional class races held here and the rock climbing hides some real gems and capacity for endless new development.

Within 4 hours driving there are a host of great hiking and camping spots, many with large permanent water holes (some locals have canoes!)– Ormiston Gorge, Palm Valley, Kings Canyon and of course you can’t miss out on a trip to Uluru and you can take a plane there or drive.

Uluru in a rare rainstorm

Local events are varied and the peak season for events and tourists is in Winter. There’s the Finke Desert Race (which I was involved with as a medical officer at Finke), the Beanie Festival, Wide Open Spaces, the typically Territorian Henley on Todd, the Alice Springs Show, Territory Day (the one day of the year you get to buy and use fireworks) and the Camel Races.

Finke Desert Race

Sounds exciting? Well I had a blast. It was a challenging job and I think it begins shaping you as a future consultant. The friends I made and the adventures I had were all great experiences. I urge anyone who might be interested to consider a 6 month rotation up here as a Retrieval Registrar – you’ll get a lot out of it!

This blog was previously published on Life in the Fast Lane and has been republished with permission. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

Other doctorportal blogs

What GPs can do to help curb rising STI rates

Despite years of safe sex promotion, rates of sexually transmitted infections continue to rise and there are concerns infections are becoming resistant to antibiotics.

Gonorrhoea notifications have almost doubled between 2008 and 2012, rates of HIV infection have increased and in 2013, the highest number of syphilis cases was ever recorded.

However in good news, chlamydia rates in 2013 decreased for the first time in 15 years and genital warts in young women is also declining thanks to the introduction of the HPV vaccine.

Dr Catriona Ooi and Professor David Lewis from the Western Sydney Sexual Health Centre say that more needs to be done in a primary health setting to prevent, identify and treat these infections.

They say: “GPs have an important role in caring for patients with sexually transmitted infections, in educating patients about unsafe sex, and encouraging regular screening for people at risk of infection. The whole community needs to acknowledge and tackle the rising rates of sexually transmitted infection.”

In an article published in Australian Prescriber, they write a detailed update about STIs and what doctors can do to help diagnose and treat them.

According to NSW STI Unit, people should be offered STI screening if they meet the following criteria:

Anyone requesting a screen
Sexually active people under 29 years
Men who have sex with men
Sex workers
People who inject drugs

Social media campaign for World AIDS day

World AIDS Day was 1st December and Durex used the day to launch a social media campaign “”to create the first official safe sex emoji”, asking users to use #CondomEmoji hashtag.

They said their research had told them that 80% of 16-25-year-olds could express themselves better using Emojis. 84% of young people felt more comfortable using icons when talking about sex.

Durex said it was sending the emoticon to developer Unicode following ‘resounding global support’ for the campaign.

Latest news:

National licensing scheme for medicinal cannabis: Ley

Minister for Health Sussan Ley has announced there will be a nationally controlled licensing scheme regulating the cultivation of medical marijuana.

This scheme would reduce the need for states and territories to set up individual schemes and ensure laws are consistent for growers.

“Allowing controlled cultivation locally will provide the critical “missing piece” for a sustainable legal supply of safe medicinal cannabis products for Australian patients in the future,” she said.

There has been consultation with state and territory governments and law enforcement agencies over the past month,

“We want to not only ensure these legislative amendments are rock solid, but that we can all work together to pass them in a bipartisan fashion as quickly as possible,” Ms Ley said.

“The important point is legislative changes are drafted and we’ve hit the start button for change.”

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