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.
Alcohol use disorders (AUD) are common, particularly in patients attending mental health services. Clinicians are often hesitant to explore with patients their relationship with alcohol and the role that it has in their presenting complaint, despite being ideally placed to optimise on a ‘teachable moment’ and initiate treatment, where necessary. This article provides an overview of AUD and their identification and management options.
After reading this article you will be able to:
•understand key concepts and definitions of alcohol use disorders
•recognise and assess alcohol use disorders
•manage alcohol use disorders in clinical settings.
There are few topics that divide public opinion as sharply as the use of psychoactive substances and it is easy to see why. Substance use is complex and can be examined from numerous perspectives, including legal, health, economic, cultural and ethical. These varying approaches can lead to a range of different conclusions. Here we explore some of the common approaches adopted towards drug policy and suggest a number of principles, which may inform a psychiatrist's own view.
Human curation has earned itself a permanent place in the streaming media world, though it wasn’t always clear whether or how that would happen. For a time, it seemed like tech didn’t want to justify the use of human labour if the future could be won without it. That time seems to have passed, and with handmade playlists and other editorial products, human curators have a unique ability to help the widest-ever audiences find great music. People from different backgrounds are more able now to hear each other’s sounds than ever before. Whether the streamlining of these services matters to a given user is wholly subjective, since the joy of discovering new music is often so inefficient and chaotic. It was never clear that this same sense of joy would make it into streaming products – for many of us, it cannot. And that’s okay. Services offer only what they can.
Addictions are challenging health and social problems that need to be addressed to preserve and promote good mental health and ensure that individuals within society lead healthy and productive lives. Tackling addictions is complex and requires communities, public health, specialist services, and local and national government to act in unison and implement evidence-based interventions. This editorial raises systemic issues that need attention and proposes a range of systemic options.
Declaration of interest
K.S.B. is Editor-in-Chief of the British Journal of Psychiatry. The other authors declare no conflict of interest.
Background: Electroconvulsive therapy (ECT) involves the induction of a generalized seizure with an electrical current and has been used worldwide when treating medically refractory psychiatric illness. Here we describe a patient with no prior history or risk factors for epilepsy who developed temporal lobe epilepsy after chronic treatment of ECT. Methods: A 16-year-old right-handed boy with severe refractory depression received ECT treatment every 10 days for 8 months. Six months into his ECT treatment, the patient developed seizures and was admitted to a pediatric epilepsy monitoring unit. Results: Initial clinical events included lightheadedness, diaphoresis, and nausea with associated kaleidoscopic vision changes. Seizures progressed to confusion, fear and paranoia by the time the patient was admitted for monitoring. Long-term video EEG captured many focal seizures with impaired awareness, all originating from both temporal lobes. MRI was normal. ECT was terminated and the patient started on carbamazepine. He has been seizure free for the past 2 years on medication Conclusions: While rare, we present a case of a patient with no prior risk factors for epilepsy who developed temporal lobe epilepsy after chronic ECT treatment. Although ECT is an indispensable treatment for many medically refractory psychiatric illnesses, we suggest caution in young patient undergoing ECT.
Background: There are few published reports on the safety and efficacy of stereoelectroencephalography (SEEG) in the presurgical evaluation of pediatric drug-resistant epilepsy. Our objective was to describe institutional experience with pediatric SEEG in terms of (1) insertional complications, (2) identification of the epileptogenic zone and (3) seizure outcome following SEEG-tailored resections. Methods: Retrospective review of 29 patients pediatric drug resistant epilepsy patients who underwent presurgical SEEG between 2005 – 2018. Results: 29 pediatric SEEG patients (15 male; 12.4 ± 4.6 years old) were included in this study with mean follow-up of 6.0 ± 4.1 years. SEEG-related complications occurred in 1/29 (3%)—neurogenic pulmonary edema. A total of 190 multi-contact electrodes (mean of 7.0 ± 2.5per patient) were implanted across 30 insertions which captured 437 electrographic seizures (mean 17.5 ± 27.6 per patient). The most common rationale for SEEG was normal MRI with surface EEG that failed to identify the EZ (16/29; 55%). SEEG-tailored resections were performed in 24/29 (83%). Engel I outcome was achieved following resections in 19/24 cases (79%) with 5.9 ± 4.0 years of post-operative follow-up. Conclusions: Stereoelectroencephalography in presurgical evaluation of pediatric drug-resistant epilepsy is a safe and effective way to identify the epileptogenic zone permitting SEEG-tailored resection.
Innovation in agronomy by large numbers of smallholder farmers will need to accelerate if global commitments to end hunger are to be achieved in the face of major climate and other global change that are both caused by, and impact, agriculture. Conventional research and development in agronomy have involved a research process that produces technologies, which are then promoted for uptake by large numbers of farmers through extension, with both research and extension phases being more or less participatory. Recent research, including key contributions to this special issue, reveals that the performance of many technology options varies hugely across the geographies over which development programmes operate, depending on social, economic and ecological context. This severely limits the value of attempting to produce recommendations for large areas and numbers of farmers and identifies the need for new ways of supporting innovation that address the real-world heterogeneity of farmer circumstances. Addressing this widespread phenomenon of option by context interaction (OxC) has profound implications for how agronomic research and development are organised. Papers in this special issue show the nature and implications of such interactions and suggest ways in which research and development systems need to respond in order to support locally relevant innovation. It is evident that a paradigm shift is well underway, with researchers embracing new modes of thinking and action required to address OxC interactions, but these also need to be taken up and further developed by extension and change agents in the public and private sector. It is only through continued co-development of methods involving both these constituencies, working closely with farmers that sufficient progress is likely to be made for smallholder farming to keep pace with global demand for food without further damaging the environmental resources upon which production is based.
Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification.
We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system.
Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0–2.08) for intervention patients and 9 minutes (5–18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8–14.5) faster for the intervention group.
A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.
Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.
After Mexican sugar producers gained unlimited, tariff-free access to the U.S. market in 2008, U.S. and Mexican governments bilaterally agreed to constrain Mexico’s sugar exports to the United States because of dumping allegations by U.S. producers in December 2014. This analysis employs a dynamic partial equilibrium model to estimate the price and welfare impacts of the U.S.-Mexico agreement by simulating the reimplementation of North American Free Trade Agreement sugar policies. Estimates suggest liberalizing the market would decrease U.S. sugar prices, translating to an average annual decrease in producer surplus of approximately $660 million and increase in consumer surplus of $1.67 billion across the simulation.
Very few practical frameworks exist to guide the formulation of recommendations at hospital-based health technology assessment (HTA) units. The objectives of our study were: (i) to identify decision criteria specific to the context of hospital-based health technologies and interventions, (ii) to estimate the extent to which the expert community agrees on the importance of the identified criteria, (iii) to incorporate the identified criteria into a decision-aid tool, and (iv) to illustrate the application of a prototype decision-aid tool.
Relevant decision criteria were identified using existing frameworks for HTA recommendations, our past experience, a literature search, and feedback from a survey of diverse stakeholders.
Based on the survey results, twenty-three decision criteria were incorporated into the final framework. We defined an approach that eschewed a scoring system, but instead relied on a visual means for arriving at a final recommendation, by juxtaposing the importance rating for each criterion against the results of the health technology assessment. For a technology to be approved, a majority of criteria considered important should also have received favorable findings.
We created a simple and practical decision-aid tool that incorporates all decision criteria relevant to a hospital-based HTA unit. With its ease of use and accessibility, our tool renders the subjective decision-making process more structured and transparent.
Objective: To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function. Methods: Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10–100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility. Results: The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (>50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits. Conclusions: Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.
A new species, Contarinia brassicola Sinclair (Diptera: Cecidomyiidae), which induces flower galls on canola (Brassica napus Linnaeus and Brassica rapa Linnaeus (Brassicaceae)), is described from Saskatchewan and Alberta, Canada. Larvae develop in the flowers of canola, which causes swelling and prevents opening, pod formation, and seed set. Mature larvae exit the galls, fall to the soil, and form cocoons. Depending on conditions, larvae will either pupate and eclose in the same calendar year or enter facultative diapause and emerge the following year. At least two generations of C. brassicola occur each year. Adults emerge from overwintering cocoons in the spring and lay eggs on developing canola flower buds. The galls produced by C. brassicola were previously attributed to the swede midge, Contarinia nasturtii (Kieffer) in Saskatchewan; here, we compare and list several characters to differentiate the two species.
The concept of cultural competence is a multifaceted construct that requires careful consideration as it raises questions as to whose ‘truth’ is being advocated. This paper draws on findings from a qualitative study which used an indigenous methodology of yarning to investigate early childhood educators’ understandings and perspectives of cultural competence. Adopting a poststructuralist approach to grounded theory, data were analysed to identify themes that reflected educators’ understandings and perspectives. This paper presents a snapshot of these themes along with a framework of positioning self in relationship to ways of knowing, being and doing cultural competence. I conclude by suggesting that this framework can provide opportunity for educators to disrupt normalised discourses and re-conceptualise cultural competence.