Academic literature on the topic '"Brought to you by a team of medical experts'

Aim/Purpose: The complexity of scientific problems has spurred the development of transdisciplinary science, in which experts are brought together to collaborate across disciplinary and practice boundaries. These knowledge diverse teams can produce novel solutions, but they often fail to achieve their potential. Background: Leaders have a crucial role to play in enabling effective collaboration among these diverse experts. We propose that a critical predictor of whether a newly formed interdisciplinary team will perform well is the leader’s multidisciplinary breadth of experience, which we define as a leader’s possession of significant experience in multiple areas of research and practice. We suggest that these leaders will have the capability to skillfully manage the interactions within the team. Methodology: We test our prediction in a sample of 52 newly formed interdisciplinary medical research teams. We also observe and examine the communication patterns in a subset of these teams. Contribution: There is a lack of systematic study of the impact leaders have on newly formed interdisciplinary science teams whose members have little or no prior collaborative experience with each other, possess specialized knowledge, and have limited overlapping expertise. This study combines quantitative and qualitative methods to examine the effect of leader multidisciplinary experience on team communication patterns and innovation. Findings: Our study finds that teams are more innovative when their leader has a moderate breadth of multidisciplinary expertise. Exploration of team communication patterns suggests that leaders with moderate multidisciplinary breadth of experience actively stimulated information sharing across expert domains by choosing cross-cutting topics and drew individuals’ attention to the knowledge and approaches of others in the team. Recommendations for Practitioners: Insights from this work can have practical implications regarding how to best select and train leaders to facilitate cross-boundary collaboration in transdisciplinary science. This study elucidates a variety of communication strategies that leaders can to enhance the team innovativeness. Recommendation for Researchers: Further investigation into the underlying psychological states that these communication strategies elicit is needed. Future research should investigate psychological mediators such as knowledge consideration, perspective taking, and cognitive flexibility. Impact on Society: Transdisciplinary science is needed to solve society’s most complex problems. The more insight we gather about factors that can help these knowledge diverse teams to be successful, but more society will benefit. Future Research: More research is needed on team formation, leader experience, and team outcomes in transdisciplinary science teams in a variety of contexts.

Background: This study is based on the tragic firework accident, with the highest death toll in India, that occurred in Puttingal Devi Temple, Kollam District, Kerala, at 3.30 am on 10/04/2016. Around 1500 people were injured. On the spot death toll was 109 and 12 others died in hospitals later. 1039 were treated as OP case and 410 as inpatients in various secondary and tertiary care hospitals in Kollam and Thiruvananthapuram with the help of the team of experts from AIIMS, Delhi. The aim was to study the clinical profile of inpatients admitted with trauma and/or burns following the incident and to formulate a Medical action- plan of in such eventualities.Methods: The present study is descriptive in nature with study setting in secondary and tertiary care hospitals in Kollam and Thiruvananthapuram districts. The study subjects were all the inpatient victims of the firework tragedy. The study method used analysis of relevant patient details collected from hospitals records. Results: 410 inpatients of various hospitals were analysed. Majority of the victims were males. (95.6%) Major age group affected is 20-50 years (66.1%). 79.5% of patients were treated in wards and 20.5% in various ICUs. 54.4% in secondary care centres and 45.6% in tertiary care centres. 78.2% of patients had traumatic injuries alone, 19.8% had trauma and burn injuries and 2% had burn injuries alone. 37.3% had major injuries, 21.5% had multiple fractures and 39.1% had minor injuries. 29% of patients had to undergo various surgeries. Hospital stay -76.4% of patients <2 weeks, 16.6% 2-4 weeks and 7.1% more than 30 days. Outcome: 70.7% were completely cured, 21.5% had temporary disability, 4.9% developed permanent disability. Mortality was 2.9%.Conclusions: Dedicated team work and inter-disciplinary care at Secondary and tertiary care centres of Kollam and Trivandrum districts with the timely help of medical team from Delhi has brought down the mortality rate to 2.9% in a major firework disaster with 1500 victims, which is comparable with the international standards.

In its 2017 guideline, ASCO challenged members to integrate palliative care into their standard oncology practices for all patients, throughout their cancer trajectory. However, partnering with palliative care experts alone will not be enough to achieve that goal; there are too few experts now, and there will not be enough in the future to meet the needs of patients with cancer and their families. Other strategies are required. Oncologists can develop new communication skills that were not included in their fellowship curricula, skills that integrate into their visits the subjects that palliative care clinicians discuss routinely with patients referred to them. In this review, Dr. Back offers three questions matched to communication skills that can help oncologists explore key areas: (1) What is happening? (2) How do you (and I) feel? and (3) What is important? and discusses the “REMAP” strategy for making urgent medical decisions. Dr. Friedman reviews the impact of community-based palliative care resources and telehealth on care quality, patient centeredness, and reducing costs. Community-based palliative care services and telehealth are available to patients and families at home, during active treatment. Dr. Abrahm reviews how patient-reported outcomes (PROs) completed at home can enhance patients’ symptom control, quality of life, and toleration of treatment and decrease unplanned emergency visits by alerting clinicians to patients’ severe symptoms, making appropriate referrals, or suggesting patients contact their oncology team. She also provides an update on using PROs and natural language processing with clinical decision support to create sophisticated palliative care assessments and treatment options in the electronic health record during patients’ office visits.

‘Some editors are failed writers, but so are most writers.’ TS Eliot (1888–1965) Have you ever wondered what medical journal editors do? Most editors in the medical field are unpaid and the work is part of the wider culture of service provided by so many in the medical profession. Together with the editorial board and the publisher, an editor will decide the direction of the journal. For instance, decisions are made about what sort of material should be published. One of the most common tasks, however, is the daily screening of manuscripts submitted for publication, many of which are rejected without peer review owing to poor quality, redundant material or the subject of the article being beyond the scope of the journal. After deciding which peer reviewers to send an article to, the editor must make a final decision on a manuscript, which may not necessarily concur with the advice given by the reviewers. With this comes a huge amount of personal responsibility and one to the organisation the editor represents. Take the example of George Lundberg, the editor of JAMA: The Journal of the American Medical Association, who was fired from his position after 17 years with the alleged faux pas of rushing to publish an article to coincide with the Clinton impeachment hearings ‘to extract political leverage.’ Lundberg published research showing that 60% of college students surveyed in 1991 did not think that engaging in oral sex was classed as actually ‘having sex.’ 1 While neither the methods used in the survey nor the results were disputed, the timing of the publication at an awkward political juncture was. Extrapolating this, editors are therefore not just responsible for the content of what is published but also the impact of publications in the wider arena. Editors must also handle a great deal of correspondence, including author queries and complaints, and respond to them in a timely manner. Communication with the team, the publisher, authors and readers is a vital skill. Finally, the editor needs to deal with the journal’s ethical policy when examples of plagiarism, author disputes or other forms of misconduct are evident. Breaches of publication ethics are forms of scientific misconduct that can undermine science and challenge editors, many of whom have little formal training in this field. In this respect, the Committee on Publication Ethics (COPE), founded in 1997 as a voluntary body, has become a central player. COPE provides a discussion forum and advice as well as guidelines for scientific editors with the aim of finding practical ways to deal with forms of misconduct. The Annals is a member of COPE and follows its code of conduct for journal editors. 2 It is a privilege that the current chair of COPE, Dr Barbour, and her colleagues have written this final article in the medical publishing series about challenges in publication ethics. I hope you have found this series useful and enjoyed reading the range of articles we have published from many experts in their fields. JYOTI SHAH Commissioning Editor References 1. Sanders SA , Reinisch JM . Would you say you ‘had sex’ if…? JAMA 1999 ; 281 : 275 – 277 . 2. Committee on Publication Ethics . Code of Conduct and Best Practice Guidelines for Journal Editors . Harleston, UK : COPE ; 2011 .

Background Biopharmaceutical products have become an important sector of the pharmaceutical industry in the United States (U.S.). This fast-growing sector is in a critical position in which therapeutic biological products represent over a third of all new drugs in clinical trials or awaiting approval from the U.S. Food and Drug Administration (FDA) (International Trade Administration, n.d.). The development and review of a new therapeutic biological product is a complex process that requires considerable monetary and time investment. This process takes, on average, twelve years, and the estimated average cost of taking a new drug from concept to market exceeds $1 billion (Van Norman, 2016a). After the significant expenditure of manufacturer time and resources, many drugs fail to achieve FDA approval late in the process. Criticism has arisen from the fact that the increasingly complex regulatory environment and expense associated with drug development have caused a lag in the release of new pharmaceuticals to the drug market. Advocacy groups and experts in the area are demanding a more rapid approval and release of new products because they consider the current process to be risk averse, slow, and inefficient (Ty Williams, 2016; Van Norman, 2016a). The FDA has created programs to expedite the approval of drugs and biological products (FDA, 2018). Despite all of these efforts, FDA scrutiny remains a long, costly, and risky process. The goal of this work is the exploration of the factors and gaps relevant to the FDA review and approval process which contribute to process inefficiencies, as well as proposed methods and solutions to address such gaps. Review Findings Researchers who investigated the FDA review and approval operations have identified challenges and constraints in the process (e.g. Baylor, 2014; Conner et al., 2014; Kinch, 2016; Ty Williams, 2016; Van Norman, 2016a, 2016b). Van Norman (2016a) and Ty Williams (2016) emphasizes that the main challenges for the pharmaceuticals are in terms of cost and time. Complexities in the flow of information and the communications network have been identified due to the fact that the process involves multiple FDA resources and constant communication with the applicant. Additionally, complexities could arise from the review team not only having to deal with the flow of new submissions but also with the flow of resubmitted applications, which puts a strain on FDA normal operations by having to share resources between both types of submissions. Other relevant challenges are in terms of bias due to the user fees collected from sponsors and drug manufacturers to support the drug approval process (Ty Williams, 2016) and lack of transparency of non-published drug trial data (Van Norman, 2016b). The review of methods and solutions to address such challenges and constraints has identified a lack of research activity in studying the approval process from the regulatory agency point of view (i.e. from FDA internal operations). Most research efforts are directed toward the incorporation of modeling tools to the drugs development and production practices (e.g. Gernaey & Gani, 2010; Horner, Joshi, & Waghmare, 2017). Reform models to the current FDA review and approval process have been published with the purpose of providing flexible approaches to change the way medical products are brought to market (Thierer & Wilt, 2016; Williams, Joffe, & Slonim, 2016; Klein & Tabarrok, 2016; Conko & Madden, 2000; Gulfo, Briggeman, & Roberts, 2016). The implementation of any of these reform models may imply a shift in the responsibilities of the FDA and therefore may change the organizational structure of the regulatory agency – something that must be addressed and measured for effectiveness. Conclusions Suggesting changes to the review and approval of therapeutic biological products is a challenging task. To the best of our knowledge, none of the academic articles identified in this scoping review have modeled the FDA review and approval process to address issues related to the robustness, reliability and efficiency of its operations from an internal point of view. The reform models identified in the literature are limited in several aspects. For example, there is a general lack of application of scientific methodologies and modeling techniques in understanding FDA as a complex sociotechnical system. In addition, tools and methods to assess their efficacy before implementation are largely absent. Findings from this scoping review suggest an opportunity to employ Model-Based Systems Engineering (MBSE) approaches to provide a systems-oriented descriptive model of the FDA approval process for therapeutic biological products as a service network, with the objective of providing a method to support individual, team, and organizational decision-making to balance the process structure in terms of enforcement and in-formation. This holistic approach will serve several investigative purposes: (1) identify influential sources of variability that cause major delays including individual, team, and organiza-tional decision-making, (2) identify the human-system bottle-necks, (3) identify areas of opportunity for design-driven im-provements, (4) study the effect of induced changes in the sys-tem, and (5) assess the robustness of the structure of the FDA approval process in terms of enforcement and information sym-metry.

[Formula: see text] There is a growing desire amongst space-faring nations to venture beyond the Van Allen radiation belts to a variety of intriguing locations in our inner solar system. Mars is the ultimate destination. In two decades, we hope to vicariously share in the adventure of an intrepid crew of international astronauts on the first voyage to the red planet. This will be a daunting mission with an operational profile unlike anything astronauts have flown before. A flight to Mars will be a 50-million-kilometre journey. Interplanetary distances are so great that voice and data communications between mission control on Earth and a base on Mars will feature latencies up to 20 min. Consequently, the ground support team will not have real-time control of the systems aboard the transit spacecraft nor the surface habitat. As cargo resupply from Earth will be impossible, the onboard inventory of equipment and supplies must be planned strategically in advance. Furthermore, the size, amount, and function of onboard equipment will be constrained by limited volume, mass, and power allowances. With less oversight from the ground, all vehicle systems will need to be reliable and robust. They must function autonomously. Astronauts will rely on their own abilities and onboard resources to deal with urgent situations that will inevitably arise. The deep space environment is hazardous. Zero- and reduced-gravity effects will trigger deconditioning of the cardiovascular, musculoskeletal, and other physiological systems. While living for 2.5 years in extreme isolation, Mars crews will experience psychological stressors such as loss of privacy, reduced comforts of living, and distant relationships with family members and friends. Beyond Earth’s protective magnetosphere, the fluence of ionising radiation will be higher. Longer exposure of astronauts to galactic cosmic radiation could result in the formation of cataracts, impaired wound healing, and degenerative tissue diseases. Genetic mutations and the onset of cancer later in life are also possible. Acute radiation sickness and even death could ensue from a large and unpredictable solar particle event. There are many technological barriers that prevent us from carrying out a mission to Mars today. Before launching the first crew, we will need to develop processes for in-situ resource utilisation. Rather than bringing along large quantities of oxygen, water, and propellant from Earth, future astronauts will need to produce some of these consumables from local space-based resources. Ion propulsion systems will be needed to reduce travel times to interplanetary destinations, and we will need systems to land larger payloads (up to 40 tonnes of equipment and supplies for a human mission) on planetary surfaces. These and other innovations will be needed before humans venture into deep space. However, it is the delivery of health care that is regarded as one of the most important obstacles to be overcome. Physicians, biomedical engineers, human factors specialists, and radiation experts are re-thinking operational concepts of health care, crew performance, and life support. Traditional oversight of astronaut health by ground-based medical teams will no longer be possible, particularly in urgent situations. Aborting a deep space mission to medically evacuate an ill or injured crew member to Earth will not be an option. Future crews must have all of the capability and responsibility to monitor and manage their own health. Onboard medical resources must include imaging, surgery, and emergency care, as well as laboratory analysis of blood, urine, and other biospecimens. At least one member of the crew should be a broadly trained physician with experience in remote medicine. She/he will be supported by an onboard health informatics network that is artificial intelligence enabled to assist with monitoring, diagnosis, and treatment. In other words, health care in deep space will become more autonomous, intelligent, and point of care. The International Commission on Radiological Protection (ICRP) has dedicated a day of its 5th International Symposium in Adelaide to the theme of Mars exploration. ICRP has brought global experts together today to consider the pressing issues of radiation protection. There are many issues to be addressed: Can the radiation countermeasures currently used in low Earth orbit be adapted for deep space? Can materials of low atomic weight be integrated into the structure of deep space vehicles to shield the crew? In the event of a major solar particle event, could a safe haven shelter the crew adequately from high doses of radiation? Could Martian regolith be used as shielding material for subterranean habitats? Will shielding alone be sufficient to minimise exposure, or will biological and pharmacological countermeasures also be needed? Beyond this symposium, I will value the continued involvement of ICRP in space exploration. ICRP has recently established Task Group 115 to examine radiation effects on the health of astronaut crew and to recommend exposure limits. This work will be vital. Biological effects of radiation could not only impact the health, well-being, and performance of future explorers, but also the length and quality of their lives. While humanity has dreamed of travel to the red planet for decades, an actual mission is finally starting to feel like a possibility. How exciting! I thank ICRP for its ongoing work to protect radiation workers on Earth. In the future, we will depend on counsel from ICRP to protect extraterrestrial workers and to enable the exploration of deep space.

Perfect vision for the path ahead? As I write this editorial it seems that once again, we stand on the threshold of yet another significant date. The fortieth anniversary of ISCPES and also that of this journal, that has been the voice of the society’s contribution over that period, has been and gone. This time it is 2020 that looms on the near horizon. It is a date that has long been synonymous with perfect vision. Many may perhaps see this as somewhat ironic, given the themes surrounding change and the directions it has taken, that have been addressed previously in these pages. Perfect vision and the clarity it can bring seem a far cry away from the turbulent world to which we seem to be becoming accustomed. So many of the divisions that we are facing today seem to be internal in nature and far different from the largely: nation against nation; system against system strife, we can remember from the cold war era. The US, for example, seems to be a nation perpetually at war with itself. Democrats v Republicans, deplorables v elites - however you want to label the warring sides - we can construct a number of divisions which seem to put 50% of Americans implacably opposed to the other 50%. In the UK, it has been the divide around the referendum to leave the European Union – the so-called Brexit debate. Nationally the division was 52% to 48% in favour of leaving. Yet the data can be reanalysed in, it seems, countless ways to show the splits within a supposedly ‘United’ Kingdom. Scotland v England, London and the South East v the English regions, young v old are just some of the examples. Similar splits seem to be increasing within many societies. Hong Kong has recently been the focus of world interest We have watched this erstwhile model of an apparently successful and dynamic compromise between two ‘diverse’ systems, appear to tear itself apart on our television screens. Iran, Brazil, Venezuela are just three further examples of longstanding national communities where internal divisions have bubbled to the surface in recent times. These internal divisions frequently have no simple and single fault line. In bygone times, social class, poverty, religion and ethnicity were simple universal indicators of division. Today ways of dividing people have become far more complex and often multi-dimensional. Social media has become a means to amplify and repeat messages that have originated from those who have a ‘gripe’ based in identity politics or who wish to signal to all and sundry how extremely ‘virtuous’ and progressive they are. The new technologies have proved effective for the distribution of information but remarkably unsuccessful in the promotion of communication. This has been exemplified by the emergence and exploitation of Greta Thunberg a sixteen-year-old from Sweden as a spokesperson for the ‘Extinction Rebellion’ climate change lobby. It is a movement that has consciously eschewed debate and discussion in favour of action. Consequently, by excluding learning from its operation, it is cutting itself off from the possibility of finding out what beneficial change will look like and therefore finding a way by which to achieve it. Put simply, it has predetermined its desired goal and defined the problem in inflexible terms. It has ignored a basic tenet of effective problem solving, namely that the key lies in the way you actually frame the problem. Unfortunately, the movement has adopted the polarised labelling strategies that place all humans into the category of either ‘believers’ or ‘deniers’. This fails to acknowledge and deal with the depth and complexity of the problem and the range of our possible responses to it. We are all the losers when problems, particularly given their potential significance, become addressed in such a way. How and where can human behaviour learn to rise above the limits of the processes we see being followed all around us? If leadership is to come, it must surely come from and through a process of education. All of us must assume some responsibility here – and certainly not abdicate it to elite and powerful groups. In other words, we all have a moral duty to educate ourselves to the best of our ability. An important part of the process we follow should be to remain sceptical of the limits of human knowledge. In addition, we need to be committed to applying tests of truth and integrity to the information we access and manage. This is why we form and support learned societies such as ISCPES. Their duty is to test, debate and promote ideas and concepts so that truth and understanding might emerge from sharing and exploring information, while at the same time applying the criteria developed by the wisdom and experience of those who have gone before. And so, we come to the processes of change and disruption as we are currently experiencing them at International Sports Studies. Throughout our history we have followed the traditional model of a scholarly journal. That is, our reason for existence is to provide a scholarly forum for colleagues who wish to contribute to and develop understanding within the professional and academic field of Comparative Physical Education and Sport. As the means of doing this, we encourage academics and professionals in our field to submit articles which are blind reviewed by experts. They then advise the editor on their quality and suitability for publication. As part of our responsibility we particularly encourage qualified authors from non-English speaking backgrounds to publish with us, as a means of providing a truly international forum for ideas and development. Where possible the editorial team works with contributors to assist them with this process. We have now taken a step further by publishing the abstracts in Portuguese, Spanish and Chinese on the website, in order to spread the work of our contributors more widely. Consistent with international changes in labelling and focus over the years, the title of the society’s journal was changed from the Journal of Comparative Physical Education and Sport to International Sports Studies in 1989. However, our aim has remained to advance understanding and communication between members of the global community who share a professional, personal or scholarly interest in the state and development of physical education and sport around the world. In line with the traditional model, the services of our editorial and reviewing teams are provided ex gratia and the costs of publication are met by reader and library subscriptions. We have always offered a traditional printed version but have, in recent years, developed an online version - also as a subscription. Over the last few years we have moved to online editorial support. From 2020 will be adopting the practice of making articles available online immediately following their acceptance. This will reduce the wait time experienced by authors in their work becoming generally available to the academic community. Readers will no doubt be aware of the current and recent turbulence within academic publishing generally. There has been a massive increase in the university sector globally. As a result, there has been an increasing number of academics who both want to and need to publish, for the sake of advancement in their careers. A number of organisations have seen this as providing a business opportunity. Consequently, many academics now receive daily emails soliciting their contributions to various journals and books. University libraries are finding their budgets stretched and while they have been, up until now, the major funders of scholarly journals through their subscriptions, they have been forced to limit their lists and become much more selective in their choices. For these reasons, open access has provided a different and attractive funding model. In this model, the costs of publication are effectively transferred to the authors rather than the readers. This works well for those authors who may have the financial support to pursue this option, as well as for readers. However, it does raise a question as to the processes of quality control. The question arises because when the writer becomes the paying customer in the transaction, then the interests of the merchant (the publisher) can become more aligned to ensuring the author gets published rather than guaranteeing the reader some degree of quality control over the product they are receiving. A further confounding factor in the scenario we face, is the issue of how quality is judged. Universities have today become businesses and are being run with philosophies similar to those of any business in the commercial world. Thus, they have ‘bought into’ a series of key performance indicators which are used to compare institutions one with another. These are then added up together to produce summative scores by which universities can be compared and ranked. There are those of us that believe that such a process belittles and diminishes the institutions and the role they play in our societies. Nonetheless it has become a game with which the majority appear to have fallen in line, seeing it as a necessary part of the need to market themselves. As a result, very many institutions now pay their chief executives (formerly Vice-Chancellors) very highly, in order to for them to optimise the chosen metrics. It is a similar process of course with academic journals. So it is, that various measures are used to categorise and rank journals and provide some simplistic measure of ‘quality’. Certain fields and methodologies are inherently privileged in these processes, for example the medical and natural sciences. As far as we are concerned, we address a very significant element in our society – physical education and sport - and we address it from a critical but eclectic perspective. We believe that this provides a significant service to our global community. However, we need to be realistic in acknowledging the limited and restricted nature of that community. Sport Science has become dominated by physiology, data analytics, injury and rehabilitation. Courses and staff studying the phenomenon of sport and physical education through the humanities and social sciences, seem to be rarer and rarer. This is to the great detriment of the wellbeing and development of the phenomenon itself. We would like to believe that we can make an important difference in this space. So how do we address the question of quality? Primarily through following our advertised processes and the integrity and competence of those involved. We believe in these and will stick with them. However, we appreciate that burying our heads in the sand and remaining ‘king of the dinosaurs’ does not provide a viable way forward. Therefore, in our search for continuing strategy and clear vision in 2020, we will be exploring ways of signalling our quality better, while at the same time remaining true to our principles and beliefs. In conclusion we are advising you, as our readers, that changes may be expected as we, of necessity, adapt to our changing environment while seeking sustainability. Exactly what they will be, we are not certain at the time of going to press. We believe that there is a place, even a demand for our contribution and we are committed to both maintaining its standard and improving its accessibility. Comments and advice from within and outside of our community are welcome and we remain appreciative, as always, of the immense contribution of our international review board members and our supportive and innovative publisher. So, to the contributors to our current volume. Once again, we would point with some pride to the range of articles and topics provided. Together, they provide an interesting and relevant overview of some pertinent current issues in sport and physical education, addressed from the perspectives of different areas across the globe. Firstly, Pill and Agnew provide an update to current pedagogical practices in physical education and sport, through their scoping review of findings related to the use of small-sided games in teaching and coaching. They provide an overview of the empirical research, available between 2006 and 2016, and conclude that the strategy provides a useful means of achieving a number of specific objectives. From Belgium, Van Gestel explores the recent development of elite Thai boxing in that country. He draws on Elias’ (1986) notion of ‘sportization’ which describes the processes by which various play like activities have become transformed into modern sport. Thai boxing provides an interesting example as one of a number of high-risk combat sports, which inhabit an ambiguous area between the international sports community and more marginalised combat activities which can be brutal in nature. Van Gestel expertly draws out some of the complexities involved in concluding that the sport has experienced some of the processes of sportization, but in this particular case they have been ‘slight’ in impact rather than full-blown. Abdolmaleki, Heidari, Zakizadeh XXABSTRACT De Bosscher look at a topic of considerable contemporary interest – the management of a high-performance sport system. In this case their example is the Iranian national system and their focus is on the management of some of the resources involved. Given that the key to success in high performance sport systems would appear to lie in the ability to access and implement some of the latest and most effective technological information intellectual capital would seem to be a critical component of the total value of a competitive high performance sport system Using a model developed by a Swedish capital services company Skandia to model intangible assets in a service based organisation, Abdolmaleki and his associates have argued for the contribution of human, relational and structural capital to provide an understanding of the current place of intellectual capital in the operations of the Iranian Ministry of Sport and Youth. An understanding of the factors contributing to the development of these assets, contributes to the successful operation of any organisation in such a highly competitive and fast changing environment. Finally, from Singapore, Chung, Sufri and Wang report on some of the exciting developments in school based physical education that have occurred over the last decade. In particular they identify the increase in the placement of qualified physical education teachers as indicative of the progress that has been made. They draw on Foucault’s strategy of ‘archaeological analysis’ for an explanation of how these developments came to be successfully put in place. Their arguments strongly reinforce the importance of understanding the social and political context in order to achieve successful innovation and development. May I commend the work of our colleagues to you and wish you all the best in the attempt to achieve greater clarity of vision for 2020!

Introduction Such symptoms as hard, complex, bodily or mental feelings, that turn our everyday life into a hell, at first, lead us to a doctor, and then - to a psychotherapist. A sick man is keen to get rid of a symptom. A doctor prescribes medication, that is ought to eliminate a symptom. A psychotherapist searches for a reason of the problem that needs to be removed. There is such an idea that a neurotic symptom, in particular, an anxiety - is a pathological (spare or extra) response of a body. It is generally believed that such anxiety doesn’t have some real, objective reasons and that it is the result of a nervous system disorder, or some disruption of a cognitive sphere etc. Meanwhile, it is known that in the majority of cases, medical examinations of anxious people show that they don’t have any organic damages, including nervous system. It often happens that patients even wish doctors have found at least any pathology and have begun its treatment. And yet - there is no pathology. All examinations indicate a high level of functionality of a body and great performance of the brain's work. Doctors throw their hands up, as they can't cure healthy people. One of my clients told me her story of such medical examinations (which I’ll tell you with her permission). She said that it was more than 10 years ago. So, when she told her doctor all of her symptoms - he seemed very interested in it. He placed a helmet with electrodes on her head and wore some special glasses, when, according to her words, he created some kind of stressful situation for her brain, as she was seeing some flashings of bright pictures in her eyes. She said that he had been bothered with her for quite a long time, and at the end of it he had told her that her brain had been performing the best results in all respects. He noted that he’d rarely got patients with such great health indicators. My client asked the doctor how rare that was. And he answered: “one client in two or three months.” At that moment my client didn’t know whether to be relieved, flattered or sad. But since then, when someone told her that anxiety was a certain sign of mental problems, or problems with the nervous system, or with a body in general, she answered that people who had anxiety usually had already got all the required medical examinations sufficiently, and gave them the advice to go through medical screening by themselves before saying something like that. Therefore, we see a paradoxical situation, when some experts point to a neurotic anxiety as if it is a kind of pathology, in other words - some result of a nervous system disorder. Other specialists in the same situation talk about cognitive impairments. And some, after all the examinations, are ready to send such patients into space Main text I don’t agree with the statement that any neurotic anxiety that happens is excessive and unfounded. It often happens that there is objective, specific and real causes for appearance of anxiety conditions. And these causes require solutions. And it’s not about some organic damages of the brain or nervous system. The precondition that may give a rise to anxiety disorder is the development of such a life story that at some stage becomes too toxic - when, on the one hand, a person interacts with the outside world in a way that destroys his or her personality, and, on the other hand, this person uses repression and accepts such situation as common and normal. Repression - is an essential condition for the development of a neurotic symptom. Sigmund Freud was the first who pointed this out. Repression is such a defense mechanism that helps people separate themselves from some unpleasant feelings of discomfort (pain) while having (external or internal) irritations. It is the situation when, despite the presence of irritations and painful feelings, a person, however, doesn't feel any of it and is not aware of them in his or her conscious mind. Repression creates the situation of so-called emotional anesthesia. As a result, a displacement takes place, so a body starts to signal about the existing toxic life situation via a symptom. Anxiety disorder is usually an appropriate response (symptom) of a healthy body to an unhealthy life situation, which is seen by a person as normal. And it’s common when such a person is surrounded by others (close people), who tend to benefit from such situation, and so they actively maintain this state of affairs, whether it is conscious for them or not. At the beginning of a psychotherapy almost all clients insist that everything is good in their lives, even great, as it is like in everyone else’s life. They say that they have only one problem, which is that goddamn symptom. So they focus all of their attention on that symptom. They are not interested in all the other aspects of their life, and they show their irritation when it comes to talking about it. People want to get rid of it, whatever it takes, but they often tend to keep their lives the way that it was. In such cases a psychotherapist is dealing with the resistance of clients, trying to turn their attention from a symptom to their everyday situation that includes their way of thinking, interactions with themselves and with others and with the external world in order to have the opportunity to see the real problem, to live it through, to rethink and to change the story of their lives. For better understanding about how it works I want to tell you three allegorical tales. The name of the first tale is “A frog in boiling water”. There is one scientific anecdote and an assumption (however, it is noted that such experiments were held in 19 century), that if we put a frog in a pot with warm water and start to slowly heat the water, then this frog get used to the temperature rise and stays in a hot water, the frog doesn’t fight the situation, slowly begins to lose its energy and at the last moment it couldn’t find enough strength and energy to get out of that pot. But if we throw a frog abruptly in hot water - it jumps out very quickly. It is likely that a frog, that is seating in boiling water, will have some responses of the body (symptoms). For example, the temperature of its body will rise, the same as the color of it, etc., that is an absolutely normal body response to the existing situation. But let us keep fantasizing further. Imagine a cartoon where such a frog is the magical cartoon hero, that comes to some magical cartoon doctor, shows its skin, that has changed the color, to the doctor, and asks to change the situation by removing this unpleasant symptom. So the doctor prescribes some medication to return the natural green color of the frog’s skin back. The frog gets back in its hot water. For some period of time this medication helps. But then, after a while, the frog’s body gets over the situation, and the redness of the frog's skin gets back. And the magical cartoon doctor states that the resistance of the body to this medication has increased, and each time prescribes some more and more strong drugs. In this example with the frog it is perfectly clear that the true solution of the problem requires the reduction of the water temperature in that pot. We could propose that magical cartoon frog to think and try to realize that: 1) the water in that pot is hot, and that is the reason why the skin is red; 2) the frog got used to this situation and that is why it is so unnoticeably for this frog; 3) if the temperature of the water in the pot still stay so hot, without any temperature drop, then all the medication works only temporarily; 4) if we lower the temperature in that pot - the redness disappears on its own, automatically and without any medication. Also this cartoon frog, that will go after the doctor to some cartoon physiotherapist, will face the necessity to give itself some answers for such questions as: 1) What is going on? Who has put this frog in that pot? Who is raising the temperature progressively? Who needs it? And what is the purpose or benefit for this person in that? Who benefits? 2) Why did the frog get into the pot? What are the benefits in it for the frog? Or why did the frog agree to that? 3) What does the frog lose when it gets out of this pot? What are the consequences of it for the frog? What does the frog have to face? What are the possible difficulties on the way? Who would be against the changes? With whom the frog may confront? 4) Is the frog ready to take control over its own pot in its own hands and start to regulate the temperature of the water by itself, so to make this temperature comfortable for itself? Is this frog ready to influence by itself on its own living space, to take the responsibility for it to itself? The example “A frog in boiling water” is often used as a metaphorical portrayal of the inability of people to respond (or fight back) to significant changes that slowly happen in their lives. Also this tale shows that a body, while trying to adjust to unfavorable living conditions, will react with a symptom. And it is very important to understand this symptom. Symptom - is the response of a body, it’s a way a body adjusts to some unfriendly environment. Symptom, on the one hand, informs about the existence of a problem, and from the other hand - tries to regulate this problem, at least in some way (like, to remove or reduce), at the level on which it can do it. The process is similar to those when, for example, in a body, while it suffers from some infectious disease, the temperature rises. Thus, on the one hand, the temperature informs about the existence of some infection. On the other hand, the temperature increase creates in a body the situation that is damaging for the infection. So, it would be good to think about in what way does an anxiety symptom help a body that is surrounded by some toxic life situation. And this is a good topic for another article. Here I want to emphasize that all the attempts to remove a symptom without a removal of a problem, without changing the everyday life story, may lead to strengthening of the symptom in the body. Even though the removal of a symptom without elimination of its cause has shown success, it only means that the situation was changed into the condition of asymptomatic existence of a problem. And it is, in its essence, a worse situation. For example, it can cause an occurrence of cancer. The tale “A frog in boiling water” is about the tendency of people to treat a symptom, instead of seeing their real problems, as its cause, and trying to solve it. People don’t want to see their problems, but it doesn’t mean that the problem doesn’t exist. The problem does exist and it continues to destroy a person, unnoticeably for him or her. A person with panic disorder could show us anxiety that is out of control (fear, panic), which, by its essence, seems to exist without any logical reason. Meanwhile the body of such a person could be in such processes that are similar to those that occur in the conditions of some real dangers, when the instinct for self-preservation is triggered and an automatic response of a body to fight or flight implements for its full potential. We can see or feel signs of this response, for example, in cases when some person tries to avoid some real or imaginary danger via attempts to escape (the feeling of fear), or tries to handle the situation by some attempts to fight (the feeling of anger). As I mentioned before, many doctors believe that such fear is pathological, as there is no real reason for such intense anxiety. They may see the cause of the problem in worrisome temper, so they try to remove specifically anxiety rather than help such patients to understand specific reason of their anxiety, they use special psychotherapeutic methods that are designed to help clients to develop logical thinking, so it must help them to realize the groundlessness of their anxiety. In my point of view, such anxiety often has specific, real reasons, when this response of a body, fight or flight, is absolutely appropriate, but not excessive or pathological. Inadequacy, in fact, is in the unconsciousness, but not in the reactions of a body. For a better understanding of the role of anxiety in some toxic environment, that isn’t realized, I want to tell you another allegorical tale called “The wolf and the hare”. Let us imagine that two cages were brought together in one room. The wolf was inside one cage and the hare was in another. The cages were divided by some kind of curtain that makes it impossible for them to see each other. At this point a question arises whether the animals react to each other in some way in such a situation, or not? I think that yes, they will. Since there are a lot of other receptors that participate in the receiving and processing of the sensory information. As well as sight and hearing, we have of course a range of other senses. For example, animals have a strong sense of smell. It is well known that people, along with verbal methods of communicating information, like language and speaking, also have other means of transmitting information - non-verbal, such as tone of voice, intonation, look, gestures, body language, facial expressions etc., that gives us the opportunity to receive additional information from each other. The lie detector works by using this principle: due to detecting non-verbal signals, it distinguishes the level of the accuracy of information that is transmitted. It is assumed, that about 30% of information, that we receive from the environment, comes through words, vision, hearing, touches etc. This is the information that we are aware of in our consciousness, so we could consciously (logically) use it to be guided by. And approximately 70% of everyday information about the reality around us we receive non-verbally, and this information in the majority of cases could remain in us without any recognition. It is the situation when we’ve already known something, and we even have already started to respond to it via our body, but we still don’t know logically and consciously that we know it. We can observe the responses of our own body without understanding what are the reasons for such responses. We can recognize this unconscious information through certain pictures, associations, dreams, or with the help of psychoanalysis. Psychoanalysis is a great tool that can help to recognize the information from the unconscious mind, so that it can be logically processed further on, in other words, a person then receives the opportunity to indicate the real problems and to make right decisions. But let us return to the tale where the hare and the wolf stay in one room and don’t see each other, and, maybe, don’t hear, though - feel. These feelings (in other words - non-verbal information that the hare receives) activate a certain response in the hare’s body. And it reacts properly and adequately to the situation, for instance, the body starts to produce adrenaline and runs the response “fight or flight”. So the hare starts to behave accordingly and we could see the following symptoms: the hare is running around his cage, fussing, having some tremor and an increased heart rate, etc.. And now let us imagine this tale in some cartoon. The hare stays in its house, and the wolf wanders about this house. But the hare doesn’t see the wolf. Though the body of the hare gives some appropriate responses. And then that cartoon hare goes to a cartoon doctor and asks that doctor to give it some pill from its tremor and the increased heart rate. And in general asks to treat in some way this incomprehensible, confusing, totally unreasonable severe anxiety. If we try to replace the situation from this fairy-tale to a life story, we could see that it fits well to the script of interdependent relationships, where there are a couple “a victim and an aggressor”, and where such common for our traditional families’ occurrences as a domestic family violence, psychological and physical abuse take place. Only in 2019 a law was passed that follows the European norms and gives a legislative definition of such concepts as psychological domestic abuse, sexual abuse, physical abuse, bullying, that criminalizes all of these occurrences, establishes the punishment and directly points to people that could be a potential abuser. Among them are: a husband towards his wife, parents towards their children, a wife towards her husband, a superior towards a subordinate, a teacher towards his or her students, children towards each other etc.. When it comes to recognition of something as unacceptable, it seems more easy to put to that category such occurrences as physical and sexual abuse, as we could see here some obvious events. For example, beating or sexual harassment. Our society is ready to respond to these incidents in more or less adequate way, and to recognize them as a crime. But it is harder to deal with the recognition of psychological abuse as an offence. Psychological abuse in our families is common. Psychological abuse occurs through such situations, when one person, while using different psychological manipulations, such as violation of psychological borders, imposition of feeling of guilty or shame, etc., force another person to give up his or her needs and desires, and so in such a way make this person live another’s life. Such actions have an extremely negative effect on the mental health of these people, just as much as physical abuse. It can destroy a person from the inside, ruin self-esteem and a feeling of self-worth, create the situation of absolute dependence such victim from an abuser, including financial dependence etc.. It often happens that psychological abuse takes place against the backdrop of demonstrations of care and love. So you've got this story about the wolf and the hare, that are right next to each other, and the shield between two of them is a repression - a psychological defense mechanism, when a person turns a blind eye to such offences, that take place in his or her own life and towards him or her. And this person considers this as normal, doesn't realize, doesn't have a resource to realize, that it is a crime. Most importantly - doesn’t feel anything, as a repression takes place. But a body responds in a right way - from a certain point of the existence of such a toxic situation the response “fight or flight” is launched in a body at full, in other words - the fear and anxiety with the associated symptoms. The third allegorical tale I called “Defective suit”, which I read in the book of Clarissa Pinkola Estés with the name “Running With the Wolves". “Once one man came to a tailor and started to try on a suit. When he was standing in front of a mirror, he saw that the costume had uneven edges. - Don’t worry, - said the tailor. - If you hold the short edge of the suit by your left hand - nobody notices it. But then the man saw that a lapel of a jacket folded up a little bit. - It's nothing. You only need to turn your head and to nail it by your chin. The customer obeyed, but when he put on trousers, he saw that they were pulling. - All right, so just hold your trousers like this by your right hand - and everything will be fine, - the tailor comforts him. The client agreed with him and took the suit. The next day he put on his new suit and went for a walk, while doing everything exactly in the way that the tailor told him to. He waddled in a park, while holding the lapel by his chin, and holding the short edge of the suit by his left hand, and holding his trousers by his right hand. Two old men, who were playing checkers, left the game and started to watch him. - Oh, God! - said one of them. - Look at that poor cripple. - Oh, yes - the limp - is a disaster. But I'm wondering, where did he get such a nice suit?” Clarissa wrote: “The commentary of the second old man reflects the common response of the society to a woman, who built a great reputation for herself, but turned into a cripple, while trying to save it. “Yes, she is a cripple, but look how great her life is and how lovely she looks.” When the “skin” that we put on ourselves towards society is small, we become cripples, but try to hide it. While fading away, we try to waddle perky, so everyone could see that we are doing really well, everything is great, everything is fine”. As for me, this tale is also about the process of forming a symptom in a situation when one person tries very hard to match to another one, whether it is a husband, a wife or parents. It’s about a situation when such a person always tries to support the other one, while giving up his or her own needs and causing oneself harm in such a way by feeling a tension every day, that becomes an inner normality. And so this person doesn’t give oneself a possibility to relax, to be herself (or himself), to be spontaneous, free. As a result, in this situation the person, who was supported, looks perfect from the outside, but those who tried to match, arises some visible defect, like a limp - a symptom. And so this person lives like a cripple, under everyday stress and tension, trying to handle it, while sacrificing herself (or himself) and trying to maintain this situation, so not to lose the general picture of a beautiful family and to avoid shame. The tailor, who made this defective suit and tells how to wear the suit properly, in order to keep things going as they are going, often is a mother who raised a problematic child and then tells another person how to deal with her child in the right way. It is the situation when a mother-in-law tells her daughter-in-law how to treat her son properly. In other words, how to support him, when to keep silent, to handle, how to fit in, so that her problematic son and this relationship in general looks perfect. Or vice versa, when a mother-in-law tells her son-in-law how to support her problematic daughter, how to fit in etc.. When, for example, a woman acts like this in her marriage and with her husband, with these excessive efforts to fit in - then after a while everybody will talk like: “Look at this lovely man: he lives with his sick wife, and their family seems perfect!”. But when such a woman becomes brave enough to relax and to just let the whole thing go, everybody will see that the relationship in her marriage isn’t perfect, and it is the other one who has problems. Each time when someone tries excessively to match up to another one, while turning oneself in some kind of a cripple, - he or she, on the one hand, supports the comfort of that person, to whom he or she tries to match up, and on the other hand - such a situation always arises in that person such conditions as a continuous tension, anxiety, fear to act spontaneously. A symptom - is like a visible defect, that shows itself through the body (and may look like some kind of injury). It is the result of a hidden inner prison. As a result of evolution, a pain tells us about a problem that is needed to be solved. When we repress our pain we can’t see our needs and our problems at full. And then a body starts to talk to us via a symptom. Psychotherapy aims for providing a movement from a symptom to a resumption of sensitivity to feelings, a resumption of the ability to feel your psychological pain, so you can realize your own toxic story. In this perspective another fairy-tale looks interesting to analyze - it is Andersen's fairytale “Princess and the Pea”. In the tale a prince wanted to find a princess to marry. There was one requirement for women candidates, so the prince could select her among commoner - high level of sensitivity, as the real princess would feel a pea through the mountain of mattresses, and so she could have the ability to feel discomfort, to be in a good contact with her body, to tell about her discomfort without such feeling as shame and guilt, and to refuse that discomfort, so to have the readiness to solve her problems and to demand from others the respect for her needs. It is common for our culture that the expression “a princess on a pea” very often uses for a negative meaning. So people who are in good contact with their body and who can demand comfort for themselves are often called capricious. At the same time the heroes who are ready to suffer and to tolerate their pain, who are able to repress (stop to feel) their pain represents a good example to be followed in our society. So, we may see the next algorithm in cases of various anxiety disorders: the existence of some toxic situation that brings some danger to a person. And we need not to be confused: a danger exists not for a body, but for a personality. A toxic live situation as well as having a panic attack is not a threat for the health of a body (that is what medical examinations show), and vice versa - it’s like every day intensive sport training, that could be good for your health only to some degree. A toxic situation destroys a person as a personality, who longs for one self’s expression; the existence of such a defense mechanism as repression - it’s a life with closed eyes, in pink glasses, when there is inability (or the absence of the desire) to see its own toxic story; 3.the presence of a symptom - a healthy response of a body “fight or flight” to some toxic situation; displacement - it’s replacement of the attention from the situation to a symptom, when a person starts to see and search for the problem in some other place, not where it really is. A symptom takes as some spare, pathological reaction that we need to get rid of. The readiness to fight the symptom arises, and that is the goal of such methods of therapy as pharmacological therapy, CBT and many others; the absence of adequate actions that are directed towards the change of a toxic situation itself. The absence of the readiness to show aggression when it comes to protect its space. All of it is a mechanism of formation of primary anxiety and preparation for launch of secondary anxiety. A complete anxiety disorder is the interaction between a primary and a secondary anxiety.

Once again, 12 months seem to have f lown by and we find ourselves at the end of this journal’s 10th Anniversary year. So what will 2012 have in store for us? Will financial chaos send us spiralling into the abyss or will the Olympics and Diamond Jubilee bring back the long-awaited ‘feel good factor’? Maybe the England football team will finally win a trophy, and surely we are due for some decent weather. I prefer to stay optimistic, and believe predictions of ‘barbeque summers’, rather than those of Nostradamus! One thing we can certainly look forward to in 2012 is a ‘silver’ anniversary for SAM – as well as the first to be held overseas, the spring meeting in Dublin will be the 25th held by the Society. I hope that many UK readers will be able to make the short trip across the Irish Sea to attend this special event. The year’s end also brings the cluster of festive bank holidays – 3 in England and 4 for those North of the border, each co-inciding with weekends. Some will take this opportunity to recharge the batteries before the onslaught of January; for others the challenge of 7 day working will be brought back into sharp focus. Many readers will be familiar with the aftermath of these long holiday weekends when it often feels like the whole hospital has ground to a halt. Higher weekend mortality has attracted some Press attention during the past year; this has added weight to those arguing for greater levels of consultant cover outside of traditional working hours. The paper from Dublin, published in this edition, suggests that higher illness severity might contribute to this weekend mortality. The model of medical service is a little different to that which operates in most UK hospitals, but the findings are still of interest. Does this diminish the need to expand consultant cover? Absolutely not, in my view – sicker patients require more senior care, not less; whether this will inf luence outcome for these patients is yet to be proven, but the principle remains clear. We should strive to provide the same level of care for patients, irrespective of the day on which they are admitted. Achieving this is a bigger challenge – particularly in the current financial climate – which will require close cooperation between SAM and the Royal Colleges. Acute physicians will need to continue on rotas working alongside ‘general’ physicians to achieve this as the numbers gradually expand. Mark Temple, recently appointed as Acute Care Fellow at the Royal College of Physicians of London and writing in this edition, has reiterated the RCPL’s line on this issue; a ‘toolkit’ is being produced in collaboration with SAM to provide practical solutions to this problem. On a lighter note, I hope readers will enjoy the series of clinical articles to be found in this issue. Case reports from both sides of the world document some unusual causes of ‘collapse’, a common reason for admission on the AMU, requiring a broad differential. Serotonin syndrome and thyrotoxic periodic paralysis may not be top of the list of causes, but these articles highlight the need to keep an open mind in such cases. Our problem-based review series continues, with paracetamol overdose and pleural effusions being the subjects on this occasion. Although forming part of the ‘trainee’ section, I am certain that the content will also provide a useful insight into these topics for our many ‘trained’ readers. Finally, I would like to take this opportunity to thank all those who have contributed to the journal over this ‘anniversary’ year – and the previous nine. I am particularly grateful for the efforts of the editorial board in helping to make this a ‘quarterly’ publication in 2011. The numbers of contributions continues to rise, as does the quality of submissions, no doubt fuelled by the recent listing of the journal in Medline. As a consequence we are still looking to expand our pool of expert referees, so please contact me at the email address on this page, indicating any specific areas of interest / expertise, if you are able to help. Wishing all readers a happy Christmas and New Year

The requirements of state-of-the-art curricula and teaching processes in medical education have brought both new and improved the existing assessment methods. Recently, several promising methods have emerged, among them the Comprehensive Integrative Puzzle (CIP), which shows great potential. However, the construction of such questions requires high efforts of a team of experts and is time-consuming. Furthermore, despite the fact that English language is accepted as an international language, for educational purposes there is also a need for representing data and knowledge in native language. In this paper, we present an approach for automatic generation of CIP assessment questions based on using ontologies for knowledge representation. In this way, it is possible to provide multilingual support in the teaching and learning process because the same ontological concept can be applied to corresponding language expressions in different languages. The proposed approach shows promising results indicated by dramatic speeding up of construction of CIP questions compared to manual methods. The presented results represent a strong indication that adoption of ontologies for knowledge representation may enable scalability in multilingual domain-specific education regardless of the language used. High level of automation in the assessment process proven on the CIP method in medical education as one of the most challenging domains, promises high potential for new innovative teaching methodologies in other educational domains as well.