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 firstname.lastname@example.org
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.
Today it often appears as though the European Union has entered existential crisis after decades of success, condemned by its adversaries as a bureaucratic monster eroding national sovereignty: at best wasteful, at worst dangerous. How did we reach this point and how has European integration impacted on ordinary people's lives – not just in the member states, but also beyond? Did the predecessors of today's EU really create peace after World War II, as is often argued? How about its contribution to creating prosperity? What was the role of citizens in this process, and can the EU justifiably claim to be a “community of values”? Kiran Klaus Patel's bracing look back at the myths and realities of integration challenges conventional wisdoms of Europhiles and Eurosceptics alike and shows that the future of Project Europe will depend on the lessons that Europeans derive from its past.
Second-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.
After reading this article you will be able to:
•understand the relative incidence of cardiotoxic side-effects of the various SGAs
•perform preliminary investigations to diagnose the common cardiotoxic side-effects of SGAs
•understand the treatments for these cardiac side-effects and the role of cardiologists involved the care of these patients.
Anecdotal evidence suggests the use of bolus tube feeding is increasing in long term home enteral tube feed (HETF) patients. A cross-sectional survey to assess the prevalence of bolus tube feeding and to characterise these patients was undertaken. Dietitians from 10 centres across the UK collected data on all adult HETF patients on the dietetic caseload receiving bolus tube feeding, (n=604, 60% male, age 58years). Demographic data, reasons for tube and bolus feeding, tube and equipment types, feeding method and patients’ complete tube feeding regimens were recorded. Over a third of patients receiving HETF used bolus feeding (37%). Patients were long-term tube fed (4.1years tube feeding, 3.5years bolus tube feeding), living at home (71%) and sedentary (70%). The majority were head and neck cancer patients (22%) who were significantly more active (79%) and lived at home (97%), while those with cerebral palsy (12%) were typically younger (age 31years) but sedentary (94%). Most patients used bolus feeding as their sole feeding method (46%), because it was quick and easy to use, as a top up to oral diet or to mimic meal times. Importantly, oral nutritional supplements (ONS) were used for bolus feeding in 85% of patients, with 51% of these being compact-style ONS (2.4kcal/ml, 125ml). This survey shows that bolus tube feeding is common amongst UK HETF patients, is used by a wide variety of patient groups and can be adapted to meet the needs of a variety of patients, clinical conditions, nutritional requirements and lifestyles.
The lightest element has carried a heavy burden for half a century. Expectations for the hydrogen economy, first proposed in the 1970s, have been high. But hydrogen as a renewable, low-carbon fuel for vehicles, heating, and energy storage has remained evasive, held back by high costs, low efficiency, and a lack of infrastructure and storage technologies.
Numerous interventions to address posttraumatic stress (PTS) in youth exposed to mass trauma have been delivered and evaluated. It remains unclear, however, which interventions work for whom and under what conditions. This report describes a meta-analysis of the effect of youth mass-trauma interventions on PTS to determine if interventions were superior to inactive controls and describes a moderator analysis to examine whether the type of event, population characteristics, or income level of the country where the intervention was delivered may have affected the observed effect sizes. A comprehensive literature search identified randomized controlled trials (RCTs) of youth mass-trauma interventions relative to inactive controls. The search identified 2,232 references, of which 25 RCTs examining 27 trials (N = 4,662 participants) were included in this meta-analysis. Intervention effects were computed as Hedge’s g estimates and combined using a random effects model. Moderator analyses were conducted to explain the observed heterogeneity among effect sizes using the following independent variables: disaster type (political violence versus natural disaster); sample type (targeted versus non-targeted); and income level of the country where the intervention was delivered (high- versus middle- versus low-income). The correlation between the estimates of the intervention effects on PTS and on functional impairment was estimated. The overall treatment effect size was converted into a number needed to treat (NNT) for a practical interpretation. The overall intervention effect was statistically significant (g = 0.57; P < .0001), indicating that interventions had a medium beneficial effect on PTS. None of the hypothesized moderators explained the heterogeneity among the intervention effects. Estimates of the intervention effects on PTS and on functional impairment were positively correlated (Spearman’s r = 0.90; P < .0001), indicating a concomitant improvement in both outcomes. These findings confirm that interventions can alleviate PTS and enhance functioning in children exposed to mass trauma. This study extends prior research by demonstrating improvement in PTS with interventions delivered to targeted and non-targeted populations, regardless of the country income level. Intervention populations and available resources should be considered when interpreting the results of intervention studies to inform recommendations for practice.
We cross-sectionally investigated irregular breakfast consumption and food timing patterns in relation to weight status and inflammation among 644 participants in the Cancer Prevention Study-3 Diet Assessment Sub-study. Breakfast consumption, and the individual means and the intra-individual standard deviation (iSD) of time at first intake of the day, duration of daily intake window, and midpoint of daily intake window were collected via six 24-hour recalls and examined in relation to body mass index (BMI), waist circumference (WC), and inflammation (GlycA). Compared to consuming breakfast on all six recalls, linear regression models showed those who consumed breakfast on 5 or 4 of the days had a 1.29 (95% CI: 0.19, 2.38) and 1.64 kg/m2 (95% CI: 0.12, 3.16) higher BMI; no association for consuming breakfast ≤3 days. 1-hour later in the average time of first intake was associated with a 0.44 kg/m2 higher BMI (95% CI: 0.04, 0.84). A 1-hour increase in the iSD of first intake, was associated with a 1.12 (95% CI: 0.49, 1.75) higher BMI; iSD in duration and midpoint of intake window were significant prior to additional adjustment for iSD in first intake. 1-hour increases in iSD for first intake time (β: 0.15; 95% CI: 0.04, 0.26) and midpoint of intake window (β: 0.16; 95% CI: 0.02, 0.31) were associated with higher GlycA. No associations were observed for WC independent of BMI. The results provide evidence that irregularity in breakfast consumption and daily intake timing patterns, particularly early in the day, may be related to weight status and inflammation.
Schools are important settings for increasing reach and uptake of adolescent mental health interventions. There is limited consensus on the focus and content of school-based mental health services (SBMHSs), particularly in low-resource settings. This study elicited the views of diverse stakeholders in two urban settings in India about their priorities and preferences for SBMHSs.
We completed semi-structured interviews and focus group discussions with adolescents (n = 191), parents (n = 9), teachers (n = 78), school counsellors (n = 15), clinical psychologists/psychiatrists (n = 7) in two urban sites in India (Delhi and Goa). Qualitative data were obtained on prioritized outcomes, preferred content and delivery methods, and indicated barriers.
All stakeholders indicated the need for and acceptability of SBMHSs. Adolescents prioritized resolution of life problems and exhibited a preference for practical guidance. Parents and teachers emphasized functional outcomes and preferred to be involved in interventions. In contrast, adolescents' favored limited involvement from parents and teachers, was related to widespread concerns about confidentiality. Face-to-face counselling was deemed to be the most acceptable delivery format; self-help was less frequently endorsed but was relatively more acceptable if blended with guidance or delivered using digital technology. Structured sensitization was recommended to promote adolescent's engagement. Providers endorsed a stepped care approach to address different levels of mental health need among adolescents.
SBMHSs are desired by adolescents and adult stakeholders in this setting where few such services exist. Sensitization activities are required to support implementation. School counsellors have an important role in identifying and treating adolescents with different levels of mental health needs, and a suite of interventions is needed to target these needs effectively and efficiently.
There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.
In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.
Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35–0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13–0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.
An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.
India has gradually progressed into fertility transition over the last few decades. However, the timing and pace of this transition has varied notably in terms of both its geography and the demographic groups most affected by it. While much literature exists on the relationships between fertility level and its influence on demographic, economic, socio-cultural and policy-related factors, the potential spatial variations in the effects of these factors on the fertility level remain unaddressed. Using the most recent district-level census data (of 2011) for India, this nationwide study has identified plausible spatial dependencies and heterogeneities in the relationships between the district-wise Total Fertility Rates (TFRs) and their respective demographic, socioeconomic and cultural factors. After developing a geocoded database for 621 districts of India, spatial regression and Geographically Weighted Regression (GWR) models were used to decipher location-based relationships between the district-level TFR and its driving forces. The results revealed that the relationships between the district-level TFR and the considered selected predictors (percentage of Muslims, urbanization, caste group, female mean age at marriage, female education, females in the labour force, net migration, sex ratio at birth and exposure to mass media) were not spatially invariant in terms of their respective strength, magnitude and direction, and furthermore, these relationships were conspicuously place- and context-specific. This study suggests that such locality-based variations and their complexities cannot be explained simply by a single narrative of either socioeconomic advancement or government policy interventions. It therefore contributes to the ongoing debate on fertility research in India by highlighting the spatial dependence and heterogeneity of the impacts made by demographic, socioeconomic and cultural factors on local fertility levels. From a methodological perspective, the study also discerns that the GWR local model performs better, in terms of both model performance and prediction accuracy, compared with the conventional global model estimates.
There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).
To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.
Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.
Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.
Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.
Low-intensity psychosocial interventions have been effective in targeting perinatal depression, but relevant mechanisms of change remain unknown.
To examine three theoretically informed mediators of the Thinking Healthy Programme Peer-delivered (THPP), an evidence-based psychosocial intervention for perinatal depression, on symptom severity in two parallel, randomised controlled trials in Goa, India and Rawalpindi, Pakistan.
Participants included pregnant women aged ≥18 years with moderate to severe depression, as defined by a Patient Health Questionnaire 9 (PHQ-9) score ≥10, and were randomised to either THPP or enhanced usual care. We examine whether three prespecified variables (patient activation, social support and mother–child attachment) at 3 months post-childbirth mediated the effects of THPP interventions of perinatal depressive symptom severity (PHQ-9) at the primary end-point of 6 months post-childbirth. We first examined individual mediation within each trial (n = 280 in India and n = 570 in Pakistan), followed by a pooled analysis across both trials (N = 850).
In both site-specific and pooled analyses, patient activation and support at 3 months independently mediated the intervention effects on depressive symptom severity at 6 months, accounting for 23.6 and 18.2% of the total effect of THPP, respectively. The intervention had no effect on mother–child attachment scores, thus there was no evidence that this factor mediated the intervention effect.
The effects of the psychosocial intervention on depression outcomes in mothers were mediated by the same two factors in both contexts, suggesting that such interventions seeking to alleviate perinatal depression should target both social support and patient activation levels.
Many hospitals have established inpatient antibiotic stewardship programs (ASPs), but outpatient activities remain limited. In 2016, the United Hospital Fund (UHF), an independent nonprofit working to build a more effective healthcare system for every New Yorker, launched a 2-stage grant-funded initiative to evaluate outpatient antibiotic stewardship, focusing on adults with acute respiratory infections (ARIs). Conclusions from stage 1 included few outpatient antibiotic stewardship activities, variation in prescribing, macrolides as the most commonly prescribed antibiotic, and provider interest in improving prescribing.1
The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.
We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.
This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.
Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).
Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.
Declaration of interest
F.G. has received honoraria for advisory work and lectures or CME activity support from Roche, BMS, Lundbeck, Otsuka, Janssen and Sunovion, is a collaborator on an NHS Innovations project co-funded by Janssen and has a family member with professional links to Lilly and GSK, including shares. R.M.M. has received honoraria for lectures from Lundbeck, Otsuka, Janssen and Sunovian. M.D.F. has received honoraria for lectures from Janssen and Sunovian. Z.A. has received honoraria for advisory work and lectures from Roche, Sanofi, Lilly and Otsuka. O.H. has received investigator-initiated research funding from and/or participated in advisory/speaker meetings organised by Astra-Zeneca, Autifony, Biogen, BMS, Eli Lilly, Heptares, Jansenn, Lundbeck, Lyden-Delta, Otsuka, Servier, Sunovion, Rand and Roche. D.T. has received funding for lectures and research from Janssen, Otsuka, Servier, Lundbeck, Sunovion.
In preparation for a multisite antibiotic stewardship intervention, we assessed knowledge and attitudes toward management of asymptomatic bacteriuria (ASB) plus teamwork and safety climate among providers, nurses, and clinical nurse assistants (CNAs).
Prospective surveys during January–June 2018.
All acute and long-term care units of 4 Veterans’ Affairs facilities.
The survey instrument included 2 previously tested subcomponents: the Kicking CAUTI survey (ASB knowledge and attitudes) and the Safety Attitudes Questionnaire (SAQ).
A total of 534 surveys were completed, with an overall response rate of 65%. Cognitive biases impacting management of ASB were identified. For example, providers presented with a case scenario of an asymptomatic patient with a positive urine culture were more likely to give antibiotics if the organism was resistant to antibiotics. Additionally, more than 80% of both nurses and CNAs indicated that foul smell is an appropriate indication for a urine culture. We found significant interprofessional differences in teamwork and safety climate (defined as attitudes about issues relevant to patient safety), with CNAs having highest scores and resident physicians having the lowest scores on self-reported perceptions of teamwork and safety climates (P < .001). Among providers, higher safety-climate scores were significantly associated with appropriate risk perceptions related to ASB, whereas social norms concerning ASB management were correlated with higher teamwork climate ratings.
Our survey revealed substantial misunderstanding regarding management of ASB among providers, nurses, and CNAs. Educating and empowering these professionals to discourage unnecessary urine culturing and inappropriate antibiotic use will be key components of antibiotic stewardship efforts.
The administration of naloxone therapy is restricted by scope of practice to Advanced Life Support (ALS) in many Emergency Medical Services (EMS) systems throughout the United States. In Delaware’s two-tiered EMS system, Basic Life Support (BLS) often arrives on-scene prior to ALS, but BLS providers were not previously authorized to administer naloxone. Through a BLS naloxone pilot study, the researchers sought to evaluate BLS naloxone administration and timing compared to ALS.
After undergoing specialized training, BLS providers would be able to appropriately administer naloxone to opioid overdose patients in a more timely manner than ALS providers.
This was a retrospective, observational study using data collected from February 2014 through May 2015 throughout a state BLS naloxone pilot program. A total of 14 out of 72 state BLS agencies participated in the study. Pilot BLS agencies attended a training session on the indications and administration of naloxone, and then were authorized to carry and administer naloxone. Researchers then compared vital signs and the time of BLS arrival to administration of naloxone by BLS and ALS. Data were analyzed using paired and independent sample t-tests, as well as chi-square, as appropriate.
A total of 131 incidents of naloxone administration were reviewed. Of those, 62 patients received naloxone by BLS (pilot group) and 69 patients received naloxone by ALS (control group). After naloxone administration, BLS patients showed improvements in heart rate (HR; P < .01), respiratory rate (RR; P < .01), and pulse oximetry (spO2; P < .01); ALS patients also showed improvement in RR (P < .01), and in spO2 (P = .005). There was no significant improvement in HR for ALS providers (P = .189).
There was a significant difference in arrival time of BLS to the time of naloxone administration between the two groups, with shorter times in the BLS group compared to the ALS group (1.9 minutes versus 9.8 minutes; P < .01); BLS administration was 7.8 minutes faster when compared to ALS administration (95% CI, 6.2-9.3 minutes).
Patients improved similarly and received naloxone therapy sooner when treated by BLS agencies carrying naloxone than those who awaited ALS arrival. All EMS systems should consider allowing BLS to carry and administer naloxone for an effective and potentially faster naloxone administration when treating respiratory compromise related to opiate overdose.