To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
The author reflects on the conclusions of the contributors to the edited volume and, based on his prior research, provides his own perspective on the main topic. His prior analysis of 395 ISDS rulings – and how they reference WTO law and European human rights law – throws cold water on the proposition that the trade and investment regimes, which some see as wrongly separated at birth, are converging around substantive common principles, standards or rules. Firstly, if significant trade-investment law convergence exists, it is not occurring through explicit reliance on WTO law by ISDS arbitrators. Secondly, the references to WTO law that he finds were narrow not only with respect to the numbers of IIAs involved; they were narrow with respect to the kinds of issues on which trade law was deemed relevant. The author furthermore acknowledges the limitations of citation studies, such as those conducted by him, as the two regimes may engage in other ways, apart from what happens at the final public stage of formal dispute settlement.
The coronavirus disease 2019 (COVID 19) is a new viral zoonosis of global concern that could cause psychological sequelae. We examined the levels of psychological distress, anxiety, depression, and stress during the COVID-19 outbreak in a Mexican sample.
An online survey was applied which collected information on demographic and financial status data, physical status, contact history, knowledge, concerns, and precautionary measures concerning COVID-19. Impact of Event Scale-Revised and Depression, Anxiety and Stress Scale were included.
50.3% of respondents rated psychological distress as moderate-severe; 15.7% reported moderate-severe depressive symptoms; 22.6% reported moderate-severe anxiety symptoms; and 19.8% reported moderate-severe stress levels. Female gender, older age, divorced status, lack confidence related to security of the test, lower satisfaction of health information concerning COVID-19, history of direct or indirect contact with a COVID-19 confirmed case, live with just one other person and spent >9h per day at home were associated with greater psychological distress and/or higher levels of stress, anxiety, and depression. By contrast, precautionary measures as hand hygiene and wearing masks were associated with lower levels of psychological distress, depression, anxiety, and stress.
COVID-19 outbreak results in considerable psychological effects among the Mexican sample.
This chapter’s analysis of Aluna Theatre’s RUTAS and CAMINOS festivals in Toronto, Canada, examines the ways in which these grassroots festivals harness the power of an interactional, mass gathering to generate a ‘theatrical commons’ grounded in a heterogeneous, intercultural Americas. Since their inauguration in 2012, the festivals feature and foster co-productions with Latin American, Latinx, Indigenous, and Afro-Caribbean artists from across the Americas as a way of generating alternative producing structures to foster hemispheric work and, in turn, alternative genealogies of Canadian performance history. The ‘theatrical commons’ generated by the alternating biennials of RUTAS and CAMINOS produces new social relations grounded in interculturalization rather than internationalization, offering a model of how festivals might advance forms of interculturalization as an ‘inter-epistemology’ with the potential to unravel colonial thinking and domination. These festivals play a critical role in reshaping the Canadian performance landscape and demonstrating how festivals can redirect transnational flows of knowledge and artistic production towards more inclusive practices.
To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.
Interrupted time series.
The study was conducted in an 865-bed academic medical center.
Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).
Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).
Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.
Systematic analysis shows that the Southern Hemisphere bivalve genus Retrotapes includes the Antarctic species R. antarcticus, R. newtoni, and R. robustus and recognizes for the first time the presence of Katelysia represented by K. florentinoi. Two new genera were erected in this study: Marciachlys new genus to include M. inflata new combination, and Adelfia new genus, which includes A. austrolissa new combination and A. omega new species from the Eocene of Antarctica, and the late Eocene Chilean A. arenosa new combination. Eurhomalea carlosi was synonymized with K. florentinoi; Cyclorismina marwicki with R. antarcticus; Gomphina iheringi was considered an indeterminate species; and Cockburnia lunulifera was excluded from the Tapetinae. These systematic assignments are supported by a phylogenetic analysis, which recognizes an Austral clade of Tapetinae, comprising all the genera mentioned above, along with Marcia, Paleomarcia, Atamarcia, and Protapes.
The metacestode of Echinococcus multilocularis is the etiological agent of alveolar echinococcosis. The metacestode stage used for research is maintained in rodents by serial passages. In order to determine whether cryopreservation of E. multilocularis metacestodes would be suitable for long-term maintenance and replace serial passages, isolates of different geographic origin were cryopreserved in 1984–1986. The aim of the current study was to test the viability of cryopreserved isolates following long-term cryopreservation (up to 35 years) and to determine the phylogenetic clades these isolates belonged to. Cryopreserved isolates were tested for viability in vitro and in vivo in gerbils. In vitro results of 5 isolates indicated protoscolex survival in 13 of 17 experiments (76%) and metacestode survival in 5 of 12 (42%) in vivo experiments. In vivo results showed ‘abortive lesions’ in 13 of the 36 animals, 15 were negative and 8 harboured proliferating metacestode tissue containing protoscoleces. Genetic analysis confirmed the isolates belonged to European, Asian and North-American clades. In conclusion, the results of the current study indicate that metacestodes of E. multilocularis are able to survive long-term cryopreservation. Therefore, cryopreservation is a suitable method for long-term storage of E. multilocularis metacestode isolates and reduces the number of experimental animals.
To analyse the consequences of broadening DSM-IV criteria for generalized anxiety disorder (GAD) on the utilization of health care resources and corresponding costs.
Multicentre, prospective and observational study conducted in outpatient psychiatric clinics selected at random and weighted by geographical density of population. Patients with GAD according to DSM-IV criteria and subjects with anxiety symptoms fulfilling broader criteria were compared. Broadening criteria was considered 1-month of excessive or non-excessive worry and only 2 associated symptoms listed on DSM-IV for GAD. Socio-demographic data, medical history and health care resources and corresponding costs were recorded during a 6-month period.
A total of 3,549 patients were systematically recruited; 12.8% excluded because not fulfilling inclusion criteria, 1,815 patients in DSM-IV criteria group (DG) and 1,264 in broad criteria group (BG). Both groups were similar on their sociodemographic characteristics at baseline. Type of treatments prescribed at psychiatric clinics during the study were similar in frequency; anti-depressives (77.0% in DG vs. 75.3% in BG, ns), benzodiazepines (71.5% vs. 67.2% respectively, ns), and anti-convulsants (72.1% vs. 67.0% respectively, ns). Health care resources utilization were statistically reduced to a similar extent in both groups as a consequences of treatments yielding to a cost-of-illness in the 6-month period of 1,196 (1,158) and 1,112 (874), respectively; p=0.304.
In a large sample of subjects, broadening of GAD criteria could lead to earlier diagnosis that would not be associated necessarily to an increase in health care resources utilization or costs to the National Health System.
Deep brain stimulation (DBS) of the subcallosal cingulate gyrus (SCG) has been suggested to improve depressive symptoms in treatment-resistant depression (TRD). We now report preliminary results of DBS and one-year follow up in six patients.
Six patients with severe TRD (Thase Resistance Index>4) underwent DBS surgery and subsequent monthly assessments. DBS response was defined as ≥50% reduction in the 17-item Hamilton Depression Rating Scale (HDRS) or HDRS< 8 (remission). Electrodes location was assessed in each patient by means of pre/post-DBS MRIs co-registration.
DBS led to early and late reductions of average HDRS (from 22.5 to 9.8 and 6.25 respectively, see Figure 1 for evolution of HDRS mean scores). One month after surgery 16.7% of patients met criteria for response and for remission. Three months after response rates increased to 66.7% while remission rates were maintained. At six months, 66.7% of patients were responders. After 9 months, response rates arose up to 83.4% and these rates were largely maintained at 12 months. Remission rates showed similar growth over follow-up. No substantial differences were observed in electrodes location, and they were not found to be related to response or remission rates. The number of serious adverse effects was small with no patient experiencing permanent deficits.
This study suggests that DBS is relatively safe and provides significant improvement in patients with TRD. Improvement on average seems to be linearly progressive and, once melioration is achieved, it is maintained for at least one year. The procedure is well tolerated.
Suicide is a major public health problem, one of the leading causes of death and one of the first causes of years of life lost. It is a voluntary act that can be carried out by men and women, children and adults, rich and poor, people of every race and religion.
The aim of this text is to outline the most popular suicides and briefly discuss the representation of suicide in art. Painters such as Vincent Van Gogh, Edvard Munch, Jackson Pollock, musicians as Kurt Cobain, Jim Morrison, Janis Joplin, Jimi Hendrix, the actresses Lupe Vélez, Carole Landis, Pier Angeli, Capucine, Marylin Monroe, Lucy Gordon and the actors Heath Ledger and Freddie Prinze decided the end of their lives in different ways and at different stages.
In the literary field, we find the world renowned suicides of Socrates, Seneca and Caton. Other famous and more recent suicidal writers are Ernest Hemingway, Dylan Thomas, Virginia Woolf, Yukio Mishima, Alfonsina Stormi and Cesare Pavese among others.
Suicide has been represented in several plays and operas, not only people of flesh and blood kill themselves but also fictional characters. the love-death of Liu in Turandot and Tosca in the opera of the same name Are noteworthy, both were composed by Giacomo Puccini. In Hamlet, tragedy written by William Shakespeare, is Ophelia who dies drowning at the sea.
Oxidative stress suposses an imbalance between oxidants and antioxidants molecules. Negative and positive family environment have been related with worse and better outcomes respectively in schizophrenic patients.
Our objetive is to determine antioxidant defense in healthy controls and unaffected relatives of early onset psychosis patients and to asses its relationship with familiar environment.
We included 82 healthy controls (HC) and 14 healthy controls with second degree family history of psychosis (HCWFHP), aged between 9 to 17.
Total antioxidant status and lipid peroxidation test were determined in plasma and antioxidant enzime activities and glutathione levels were determined in erytrocytes.
We used the Global Assesment Functioning scale (GAF) and the Family Environment Scale (FES). The FES is made up of ten subscales: cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural, social, moral, organization and control.
The analyses showed a significant decrease in total antioxidant level in HCWFHP compared with the HC (U Mann Withney = 281.00, p=0.009, effect size= -0.78).
HC and HCWFHP did not differ in the GAF scale, nevertheless the scores of HCWFHP were significantly higher in cohesion and intellectual-cultural dimensions of the FES (p=0.007, p=0.025).
Adjusting by this two FES dimensions, antioxidant status remained significantly different between groups: OR= 10.86, p=0.009.
Although we cannot induce causative relations, we can state that family environment is not playing a role in inducing oxidative stress in these subjects. It could be hypothesized that families with affected relatives protect themselves with positive envionmental factors such as cohesion and intellectual-cultural activities.
To elucidate the consequences of broadening DSM-IV criteria for generalized anxiety disorder (GAD), we examined the evolution of GAD symptoms in two groups of newly diagnosed patients; one group according to DSM-IV criteria and the other, according to broader criteria.
Multicentre, prospective and observational study conducted in outpatient psychiatric clinics. Patients with GAD according to DSM-IV criteria and subjects with anxiety symptoms fulfilling broader criteria were compared. Broadening criteria was considered 1-month of excessive or non-excessive worry and only 2 associated symptoms listed on DSM-IV for GAD. Socio-demographic data, medical history and functional outcome measures were collected three times during a 6-month period.
3,549 patients were systematically recruited; 12.8% excluded because not fulfilling inclusion criteria, 1,815 patients in DSM-IV group (DG) and 1,264 in broad group (BG). Both groups were similar on their sociodemographic characteristics at baseline and most patients (about 80%), even newly diagnosed were exposed previously to pharmacological therapies (mainly benzodiazepines) of their anxiety symptoms. As a result of treatment at psychiatric clinics, the percentage of patients without symptoms of anxiety as per HAM-A scale were 49.0% and 58.0%, respectively at the 6 month visit (p=0.261). Similarly, responder rate (≥ 50% reduction of baseline scoring) were, respectively, 59.7% and 67.7% (p=0.103). Improvement in MADRS scores were observed in both group to a similar extent; 12.1 and 12.5 points average reduction respectively (p=0.264).
Broadening of GAD criteria could lead to earlier diagnosis that will benefit patients by starting appropriate treatment sooner.
Suicide is one of the most frequent causes of death. In 1993, Bleuler emphasized its importance in his “Suicidal behavior is the most serious symptom of schizophrenia”. Since then, various studies have confirmed importance of suicide in schizophrenia, and today it's clear that his research and knowledge is one of the great challenges of psychiatry.
- Establish clinical-socio-demographic profile and risk factors for psychotic people with autolytic behaviors.
- Determine frequency of suicides in psychotic disorders in our area of care.
Material and methods
Retrospective study(3 years evolution) that includes psychotic patients(diagnosed according DSM IV-TR) admitted to the HCU of Valladolid. With data provided by hospital medical records, analyzed socio-demographic variables and clinics. Study consists of two groups:group of cases(those patients who have suicidal behavior) and control group (those that haven't autolytic gesture during the study period). Statistical evaluation was performed with SPSS.
- The sample includes 191 patients:41(21%) have attempted suicide.
- Of them:73% are males;88% singles;51% have basic studies;61% we re unemployed;37% were 31-40 aged;54% started disease 21-30 aged and 63.5% are schizophrenic.
- Considering statistical study we find that suicidal patient profile is male(p = 0.039),diagnosed with schizophrenia(p = 0.033),with previous suicide attempts(p = 0.009)and lack of social support(p = 0.007).
- 21% of hospitalized psychotic patients have presented some autolytic attempt.
- Profile of suicidal psychotic patient is a male, single, 21-40 aged, primary education, unemployed, with a primary diagnosis of schizophrenia, particularly paranoid, with ten years evolution,without acceptable social support, number of revenues higher than non-suicidal psychotic and a personal history of previous autolytic attempts.
Electroconvulsive therapy (ECT) cannot always be effective for Treatment Resistant Depression. Deep brain stimulation (DBS), a procedure that involves the direct implantation of stimulation electrodes in localized brain regions with the aim of modulating local and connected abnormal activity, has recently been gaining momentum as an alternative treatment modality for the most severe TRD patients. However, there is minimal experience with ECT in patients who have undergone DBS procedures.
We present two cases of patients who remitted from TRD after SCG-DBS, and some months after they suffered a relapse that was treated with ECT.
Before DBS intervention, ECT was not capable to sustain response more than two weeks beyond and was even bad tolerated by these patients. DBS was effective for both patients until a severe relapse occurred (after 4 and 14 months, respectively). Optimization of medication did not elicit response, given the seriousness of symptoms and their previous treatment resistance. Therefore, neurostimulator was turned off in order to administer ECT to both patients. After usual series of sessions set at corresponding parameters over 3 weeks, using bitemporal electrode placement, the episode remitted. Deep brain stimulator was turned on again, and they were in remission until the present moment.
The use of ECT proved to be effective without adverse effects to the patients or to the DBS hardware. The modulation of SCG activity and its downstream targets might also serve as a trigger for the therapeutic effect of formerly useful or even never-effective antidepressant strategies.
To analyse the effect of Pregabalin (PGB) on anxiety and depression symptoms in patients with refractory-severe Generalized Anxiety Disorder (GAD) and severe concomitant depressive disorder.
Post-hoc analysis of a multicentre, prospective and observational study conducted in outpatient psychiatric clinics to ascertain the impact of broadening GAD criteria. Men and women above 18 years, with GAD (DSM-IV criteria), PGB naïve and refractory to a previous course of benzodiazepines and/or anti-depressive drugs (minimum 3 months) and severe symptoms of anxiety (HAM-A ≥ 24) and depression (MADRS ≥ 35) were included. Changes in HAM-A and MADRS were assessed after 6 months of receiving PGB as per psychiatrist's judgement.
159 patients [69.2% women, 45.9 (12.6) years] fulfilled criteria for analysis. Respectively, 92% and 90% of subjects were previously exposed to benzodiazepines and anti-depressives before adding PGB [mean dose: 223.1 (126.3) mg/day]. PGB therapy reduced both anxiety and depressive baseline symptoms by a mean of, respectively in HAM-A and MADRS scales, 57.9% (from 35.5±5.8 to 14.8±9.4; p< 0.001, effect size: 3.57) and 58.1% (from 39.4±4.3 to 16.5±10.3; p< 0.001, effect size: 5.33). As a result, the percentages of patients without symptoms of both anxiety and depression were 34.4% and 40.9%, respectively at the 6 month visit (p< 0.001 in all cases). Similarly, responder rates (≥ 50% reduction of baseline scoring) were 63.1% and 62.9%.
Despite limitations, Pregabalin therapy had a meaningful and significant effect of symptoms of anxiety and depression in patients with severe refractory GAD and concomitant severe depressive disorder.
Alcoholism is a chronic relapsing disorder characterized by compulsive drinking, alcohol seeking, loss of control over alcohol consumption, and impaired social and occupational functioning. Treatment of Alcohol Dependence (AD) comprises two steps, detoxification and relapse prevention (RP). Traditionally, long half-life benzodiazepines have been the most widely used agents for alcohol detoxification. On the other hand, disulfiram, naltrexone and acamprosate are the three drugs that have been approved for relapse prevention. In the last decades, nevertheless, there is a growing interest in the use of anticonvulsant drugs in the management of both, detoxification and relapse prevention of alcohol.
To review the different pharmacological strategies in which an anticonvulsant was used in the management of AD.
We searched in MEDLINE and in the Cochrane Database System Review, selecting all studies from 1980 until present, in which a pharmacological intervention with anticonvulsant agents was made for alcohol detoxification or RP.
The most tested anticonvulsant drugs are the classical Carbamazepine and Valproate. Both have demonstrated to be efficacious in Alcohol Withdrawal Syndrome and RP. However, the use of these agents has been limited by their hepatic and hematologic toxicity. Novel anticonvulsants such as Gabapentin, Pregabalin, Topiramate, Oxcarbazepine and Zonisamide have also been found to be effective, with the advantage of rapid onset of action, lower toxicity and fewer side effects.
Anticonvulsants are efficacious and safe agents in the management of AD. Further randomized, double-blind, placebo-controlled trials are warranted to increase the evidence of the use of these agents.
Delusional disorder, also known as paranoia, is a low prevalence psychotic disorder in our environement. Usually, patients who have this disorder are very difficult to treat adequately besides its poor adherence to medical treatment, and the ineffectiveness of some therapies are well documented.
The aims of this study were to describe clinical, socio-demographic and pharmacological variables among a large stable sample in the community, and quantify the association between these variables and mental health care adherence.
Hospital Clinico San Carlos Hospital covers three local health areas; the sample was taken from one of them, wich provides health care to 268,000 people, approximately.We identified 130 out-patients with delusional disorder, but only 90 of these fulfilled DSM IV criteria. We recorded socio-demographic, clinical, pharmacological and legal data from 71 medical history patients. We also included number of visits and number of times patients didn't attend to an appointment among the total in one year. We defined mental health care adherence as good, irregular, or abandoned, in relation to missed appointments.
Delusional disorder incidence was 1,6 per 100,000 habitants, with a prevalence of 36 per 100,000 habitants, according to other studies results. Among all treatments, risperidone was the most prescribes neuroleptic. We found association almost significant between tratment with benzodiacepinesn and good adherence (x2 = 0,059).
These results give as a more realistic view of delusional disorder in our enviroment, and let us to reconsider aspects of mental health care adherence and a posible association with benzodiazepine treatment.