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Because of its inherent multidisciplinarity and conceptual flexibility, trauma theory has, from the start, been subject to ongoing revisions and redefinitions. This essay expands the notion of trauma as resulting from unassimilable, life-threatening, past events by conceptualizing trauma as resulting from the envisaged imminent annihilation of the known world. This apocalyptic trauma is embedded in American literature and closely tied to the politics of mourning dramatized in narratives of loss and melancholia but also in narratives of political activism and regeneration. This essay discusses apocalyptic expressions related to the trauma of the loss of the culture of the Old South in William Faulkner’s work, to the trauma of dispossession and cultural erasure in Chicano/a literature, and to the trauma of envisaged global annihilation in American eco-poetry.
Coronavirus disease 2019 (Covid-19), caused by severe acute respiratory syndrome coronavirus (SARS-CoV)-2, exerts far-reaching effects on public health and socio-economic welfare. The majority of infected individuals have mild to moderate symptoms, but a significant proportion develops respiratory failure due to pneumonia. Thrombosis is another frequent manifestation of Covid-19 that contributes to poor outcomes. Vitamin K plays a crucial role in the activation of both pro- and anticlotting factors in the liver and the activation of extrahepatically synthesised protein S which seems to be important in local thrombosis prevention. However, the role of vitamin K extends beyond coagulation. Matrix Gla protein (MGP) is a vitamin K-dependent inhibitor of soft tissue calcification and elastic fibre degradation. Severe extrahepatic vitamin K insufficiency was recently demonstrated in Covid-19 patients, with high inactive MGP levels correlating with elastic fibre degradation rates. This suggests that insufficient vitamin K-dependent MGP activation leaves elastic fibres unprotected against SARS-CoV-2-induced proteolysis. In contrast to MGP, Covid-19 patients have normal levels of activated factor II, in line with previous observations that vitamin K is preferentially transported to the liver for activation of procoagulant factors. We therefore expect that vitamin K-dependent endothelial protein S activation is also compromised, which would be compatible with enhanced thrombogenicity. Taking these data together, we propose a mechanism of pneumonia-induced vitamin K depletion, leading to a decrease in activated MGP and protein S, aggravating pulmonary damage and coagulopathy, respectively. Intervention trials should be conducted to assess whether vitamin K administration plays a role in the prevention and treatment of severe Covid-19.
Purine metabolism encompasses the metabolic pathways involved in the synthesis, interconversion, salvage, and degradation of purine-based nucleosides and nucleotides. These metabolic pathways are involved in many essential cellular processes, including energy transfer, oxidative phosphorylation, synthesis of DNA and RNA, and signal transduction. A nucleoside is a nitrogenous base linked to a 5-carbon sugar (either ribose or deoxyribose). For purines, this nitrogenous base is either adenine, guanine, or hypoxanthine. When nucleosides are covalently linked to one or more phosphate groups, they are referred to as nucleotides.
This chapter addresses the harmonization of trademark laws, both substantive law and administrative procedures, within different regional organizations. The topic of regional harmonization and procedural integration of laws is relevant in today’s geopolitical and economic framework considering the importance of trademarks for regional trade as well as the relevance of regional organizations as alternative fora for advancing trade and intellectual property (IP)-related negotiations instead of (or in addition to) multilateral negotiations at the World Trade Organization (WTO) and the World Intellectual Property Organization (WIPO). In particular, this chapter compares four distinct regional organizations in order to highlight different levels of regional harmonization and cooperation in these areas – from full harmonization, including the establishment of supranational rights and supranational institutions ruling on the interpretation of national and regional laws, to less integrated approaches based on the cooperation of national or regional offices regarding trademark registrations, and related administrative procedures.
To examine the associations of dietary diversity with anaemia and iron status among primary school-aged children in South Africa.
An analysis was conducted with pooled individual data from the baseline surveys from three previously conducted independent intervention studies. Two different dietary diversity scores (DDS) were calculated based on data from 1-day (1-d) and 3-day (3-d) dietary recall periods, respectively. Logistic regression analysis was performed to examine the associations of dietary diversity with anaemia and iron status.
KwaZulu-Natal and North West provinces, South Africa.
Children (n 578) 5- to 12-year-old.
A DDS ≤ 4 was associated with higher odds of being anaemic (1-d P = 0·001; 3-d P = 0·006) and being iron deficient (ID) (3-d P < 0·001). For both recall periods, consumption of ‘vegetables and fruits other than vitamin A-rich’ and ‘animal-source foods (ASF)’ was associated with lower odds of being anaemic (both P = 0·002), and ‘organ meats’ with lower odds of being ID (1-d P = 0·045; 3-d P < 0·001). Consumption of ‘meat, chicken and fish’ was associated with lower odds of being anaemic (P = 0·045), and ‘vegetables and fruits other than vitamin A-rich’, ‘legumes, nuts and seeds’ and ‘ASF’ with lower odds of being ID for the 3-d recall period only (P = 0·038, P = 0·020 and P = 0·003, respectively).
In order to improve anaemia and iron status among primary school-aged children, dietary diversification, with emphasis on consumption of vegetables, fruits and ASF (including organ meats), should be promoted.
With the increasing availability of large amounts of data in the livestock domain, we face the challenge to store, combine and analyse these data efficiently. With this study, we explored the use of a data lake for storing and analysing data to improve scalability and interoperability. Data originated from a 2-day animal experiment in which the gait score of approximately 200 turkeys was determined through visual inspection by an expert. Additionally, inertial measurement units (IMUs), a 3D-video camera and a force plate (FP) were installed to explore the effectiveness of these sensors in automating the visual gait scoring. We deployed a data lake using the IMU and FP data of a single day of that animal experiment. This encompasses data from 84 turkeys for which we preprocessed by performing an ‘extract, transform and load’ (ETL-) procedure. To test scalability of the ETL-procedure, we simulated increasing volumes of the available data from this animal experiment and computed the ‘wall time’ (elapsed real time) for converting FP data into comma-separated files and storing these files. With a simulated data set of 30 000 turkeys, the wall time reduced from 1 h to less than 15 min, when 12 cores were used compared to 1 core. This demonstrated the ETL-procedure to be scalable. Subsequently, a machine learning (ML) pipeline was developed to test the potential of a data lake to automatically distinguish between two classses, that is, very bad gait scores v. other scores. In conclusion, we have set up a dedicated customized data lake, loaded data and developed a prediction model via the creation of an ML pipeline. A data lake appears to be a useful tool to face the challenge of storing, combining and analysing increasing volumes of data of varying nature in an effective manner.
Investigate protein intake patterns over the day and their association with total protein intake in older adults.
Cross-sectional study utilising the dietary data collected through two non-consecutive, dietary record-assisted 24-h recalls. Days with low protein intake (n 290) were defined using the RDA (<0·8 g protein/kg adjusted BW/d). For each day, the amount and proportion of protein ingested at every hour of the day and during morning, mid-day and evening hours was calculated. Amounts and proportions were compared between low and high protein intake days and related to total protein intake and risk of low protein intake.
739 Dutch community-dwelling adults ≥70 years.
The mean protein intake was 76·3 (sd 0·7) g/d. At each hour of the day, the amount of protein ingested was higher on days with a high protein intake than on days with a low protein intake and associated with a higher total protein intake. The proportion of protein ingested during morning hours was higher (22 v. 17 %, P < 0·0001) on days with a low protein intake, and a higher proportion of protein ingested during morning hours was associated with a lower total protein intake (P < 0·0001) and a higher odds of low protein intake (OR 1·04, 95 % CI 1·03, 1·06). For the proportion of protein intake during mid-day or evening hours, opposite but weaker associations were found.
In this sample, timing of protein intake was associated with total protein intake. Additional studies need to clarify the importance of these findings to optimise protein intake.
In middle-aged and older patients in whom antidepressant use increased in last decades, patterns of use might be of concern The objective of this study was to investigate the patterns of prevalence, incidence and duration of antidepressant use in an ageing population.
All participants (aged > 45 years) from the population-based Rotterdam Study were followed from January 1st 1991 until death, loss to follow-up, or end of the study period (December 31st 2011). Antidepressant drug dispensing, based on pharmacy records, were subdivided into Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs) and other antidepressants. One-year prevalence, 5-year incidence and duration of antidepressant use were calculated.
Yearly prevalence of antidepressant use increased from 3.9% in 1991 to 8.3% of the population in 2011. The increase in SSRI use was 5.8-fold, whereas use of other antidepressants doubled and TCA use remained stable over time. Incidence of all antidepressants decreased from 23.9 to 14.2 per 1000 person-years between 1992 and 2011. The duration of a first treatment episode increased over time.
Despite the prevalence of antidepressant use increased over time, incidence did not, which is most likely explained by a longer treatment duration and recurrent episodes.
Suicide remains the leading cause of premature death in patients with psychotic disorders. The lifetime suicide risk for schizophrenia is approximately 10%.
This study aims to compare the suicide risk over the past decade following recent onset psychosis to findings from the eighties and nineties in the same catchment area and to identify predictors of suicide in the context of the Psychosis Recent Onset Groningen – Survey (PROGR-S).
A medical file search was carried out to determine the current status of all patients admitted between 2000 and 2009. The suicide rate was compared with a study executed in 1973-1988 in the same catchment area. Predictors of suicide were investigated using Cox regression.
The status of 424 of the 614 patients was known in July 2014. Suicide occurred in 2.4% of the patients with psychotic disorders (n=10; mean follow-up 5.6 years); 6 out of 10 suicides took place within two years. Within two decades, the suicide rate dropped from 11% (follow-up 15 years, 8.5% after 5 years) to 2.4%. The Standardized Mortality Rate (SMR) of suicides compared with the general population was 41.6. A higher age was the only significant predictor for suicide. Neuroticism, living situation, disorganized and negative symptoms, and passive coping style showed a trend for significance. A significant reduction in the suicide rate was found for people with psychosis over the past decades.
A considerable drop in suicide rate was found. Given the high SMR, suicide research should have the highest priority.
In the Netherlands, there is an increased incidence of non-affective psychotic disorders (NAPD) among first- and second-generation migrants from Turkey, Morocco, Surinam and the Netherlands Antilles.
The purpose of this population-based study was to compare the risk of suicide in Dutch natives and immigrants with or without NAPD. We examined the influence of NAPD, ethnicity and history of migration (first or second generation).
Cases of NAPD (n = 12,580) from three Dutch psychiatric registers were linked to the cause of death register of Statistics Netherlands and compared to matched controls (n = 124,547) from the population register, who had no such diagnosis. Hazard ratios (HRs) of suicide were estimated and adjusted for age and gender by Cox regression analysis.
The presence of NAPD was strongly associated with suicide risk in each ethnic group.
However, for most ethnic minority groups the HRs were somewhat lower than among Dutch natives, for whom the HR was 30.4 (95%; 22.8–40.7). A closer examination revealed that suicide risk was influenced by history of migration. While the risk for immigrants of the first generation, diagnosed with NAPD, was significantly lower than that for native Dutch patients (HR = 0.44; 95% CI: 0.27–0.72), the risk for those of the second generation was similar to that for the Dutch (HR = 0.81; 95% CI: 0.48–1.38). The same pattern was found among first- and second-generation immigrants not diagnosed with NAPD.
Immigrants of the first generation appear to be protected against suicide, whereas this protection is waning among those of the second generation.
Studies in the general population show cannabis use has a beneficial effect on metabolic disorders. Given the increased cardiometabolic risk in patients with psychotic disorders, as well as their prevalent use of cannabis, we aim to investigate whether such effects are also evident in these patients.
3176 patients with chronic psychotic disorders from mental health institutions in the Netherlands were included in the study. With multivariate regression analyses we examined the effects of cannabis use on metabolic risk factors; BMI, waist circumference, blood pressure (BP), cholesterol, HDL-C, LDL-C, triglycerides, glucose and HbA1c. Age, sex, smoking, alcohol use and antipsychotic drugs were included as confounders. Next, we examined change in metabolic risk factors after one-year follow up for cannabis users, non-users, discontinuers and starters.
We found a significant negative association between cannabis use and BMI (p=0.003), waist circumference (p>0.001), diastolic BP (p=0.015) and HbA1c (0.004). One year later, patients who had discontinued their cannabis use had a greater increase of BMI (p=0.002) and waist circumference (p=0.011) than other patients. They also had a greater increase of diastolic BP than non-users (p=0.036) or starters (p=0.004).
Discontinuation of cannabis use increased metabolic risk. To stop cannabis use is often an important treatment goal, because it reduces psychotic symptoms. However, physicians should be aware of the increased metabolic risk in patients who discontinue the use of cannabis. Extra attention should be paid to monitoring and treatment of metabolic parameters in these patients to prevent cardiovascular diseases and premature cardiovascular mortality.
There is a large mortality gap between patients with a non-affective psychotic disorder (NAPD) and the general population.
To assess whether mortality risks vary for different death causes according to duration since diagnosis and age in a large sample of NAPD patients.
To get insight into the risk of specific death causes along the treatment trajectory, important for interventions that are tailored to the patients' risk profile.
Data of NAPD patients (n=12,580) from three Dutch psychiatric registers were linked to the registers of Statistics Netherlands and compared to personally matched controls (n=124,143). Death rates were analysed by duration since the date of diagnosis of the (matched) patient and age using Poisson regression.
Among patients, the rates of all-cause death decreased with longer duration. This was explained by lower suicide rates. E.g., among those aged 40-60 years, the rate ratios (RRs) of suicide during 2-5 and >5 years compared to the early years after diagnosis were 0.52 and 0.46 (P=0.002). Compared with controls, patients experienced higher rates of natural death causes during all stages and in all age categories: RRs 2.35-5.04, P < 0.05. No increase in these RRs for patients compared to controls with increasing duration or increasing age was found.
The high risk of natural death causes among NAPD patients is not (only) an effect of accumulating risks induced by the chronic nature of the disorder and/or antipsychotic treatment, but is already present during the early stages of the treatment and at young age.
Routine Outcome Monitoring (ROM) is a new phenomenon in the mental healthcare system. Its introduction into daily clinical practice has not been straightforward. This study examines practical examples of the embedding of this innovation and its effective acceptance in clinical practice.
A case history illustrates how ROM was implemented in a large mental health hospital in The Netherlands. During implementation a number of weak points in the implementation process emerged. An intense analysis of the organization of the care process, in the context of care pathways and operations management, offered explanations of what went wrong in this case. Future improvements are suggested from an operations management viewpoint.
Results and conclusion
For the improved implementation of ROM in the mental healthcare sector implementation must be widely participatory, the process must be continuously monitored, and a leading, well-informed clinician must be appointed as process manager to guide the implementation process.
In adolescence, help-seeking is affected by different actors. The influence of each actor on help-seeking is often studied in isolation, or, if multiple informants are included, using only few assessments of adolescents’ mental health.
The aim of this study is to determine the extent to which self-, parent- and teacher-reported problem behavior predict secondary care in adolescence and to what extent the informants’ relative importance changes over time.
Data from the Dutch community-based cohort study tracking adolescents’ individual lives survey (TRAILS) were linked to administrative records of secondary care from 2000 (age 9) to 2011 (age 21). Internalizing and externalizing problems were assessed using the youth self-report, child behavior checklist and teacher checklist of psychopathology at ages 11, 13 and 16, and the adult self-report at age 19.
The annual incidence of secondary care fluctuated between 1.3% and 2.4%. In Cox regression analyses that adjusted for sociodemographic covariates and problem behavior, internalizing problems but not externalizing problems predicted secondary care. Secondary care between the ages 11 to 13 years was predicted best by teachers, between the ages 13 to 16 by parents, and between the ages 16 to 21 by adolescents.
The relative importance of informants for predicting secondary care shifts over time, which suggests that each informant is the driving force behind secondary care at a different phase of adolescence. The treatment gap may be reduced by improving problem recognition of teachers in secondary education and by educating young adults about mental health problems.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
There is an urgent need for an effective psychological treatment for patients with obsessive compulsive disorder (OCD) with poor insight, since this disorder is associated with severe suffering and a low quality of life. The inference based approach (IBA), a new psychotherapy for OCD specifically targets insight in OCD. In a randomized controlled multicentre trial, the effectiveness of IBA was compared to the effectiveness of CBT for treating patients with OCD with poor insight. In this study, 24 sessions of IBA were tested versus 24 sessions of CBT. Ninety patients with a main diagnosis of OCD with poor insight according to the DSM-IV criteria participated in the study. The primary outcome was reduction of the obsessive-compulsive symptoms.
In both conditions, a significant OCD symptom reduction was reached, but no condition effects were established. Post hoc, in a small subgroup of patients with the worst insight (n = 23), it was found that the patients treated with the IBA reached a significantly higher OCD symptom reduction than patients treated with CBT [estimated marginal mean = –7.77, t(219.45) = –2.4, P = 0.017]. Of patients treated with IBA, 41.9% were responder and 20.9% completely recovered. Of the patients treated with CBT, 42.6% were responder and 12.8% recovered.
Patients with OCD with poor insight improve significantly after psychological treatment. The results of this study suggest that both CBT and the IBA are effective treatments for OCD with poor insight. The IBA might be more promising than CBT for patients with more extreme poor insight.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Multidisciplinary guidelines in adolescent mental health care are based on RCTs, while treatment efficacy can be different from effectiveness seen in ‘the real world’. Studies in the real world conducted so far suggest that treatment has a negligible effect on follow-up symptomatology. However, these studies did not incorporate the pre-treatment trajectory of symptoms nor investigated a dose-response relationship.
To test whether future treatment users and non-users differed in emotional and behavioural problem scores, whether specialist mental health treatment (SMHT) was effective in reducing problem levels while controlling for pre-treatment trajectory, and to seek evidence of a dose-response relationship.
Six-year follow up data were used from the Tracking Adolescents’ Individual Lives Survey (TRAILS). We identified adolescents with a clinical level of problem behaviour on the Child Behaviour Checklist or Youth Self Report and first SMHT between the ages 13 and 16. Adolescents with a clinical level of problem behaviour but without SMHT use served as control group. A psychiatric case register provided data on number of treatment contacts. Using regression analysis, we predicted the effect of treatment on post-treatment problem scores.
Treated adolescents more often had a (severe) diagnosis than untreated adolescents. Pre-treatment trajectories barely differed between treated and untreated adolescents. Treatment predicted an increase in follow-up problem scores, regardless of the number of sessions.
The quasi-experimental design calls for modest conclusions. We might however need to take a closer look at real-world service delivery, and invest in developing treatments that can achieve sustainable benefits.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
To gain insight in Dutch food bank recipients’ perception on the content of the food parcels, their dietary intake and how the parcels contribute to their overall dietary intake.
Eleven semi-structured focus group discussions were conducted. Focus group topics were based on Andersons food insecurity definition: the lack of availability of nutritionally adequate foods and the assured ability to acquire foods in socially acceptable ways. Data were coded and analysed with Atlas.ti 7.0 software, using the framework approach.
Seven food banks throughout the Netherlands.
A total of 44 Dutch food bank recipients.
Food bank recipients were not always satisfied with the amount, quality, variation and type of foods in the food parcel. For the participants who could afford to, supplementing the food parcel was reported as main reason for buying foods, and price was the most important aspect in selecting these foods. Participants were not satisfied with their dietary intake; they mainly reported not having enough to eat. The content of the food parcel importantly influenced participants’ overall dietary intake. Finally, participants reported struggling with their feelings of dissatisfaction, while also being grateful for the foods they receive.
This study suggests that, despite their best efforts, food banks are not meeting food bank recipients’ needs. Our results provide valuable directions for improving the content of the food parcels by increasing the quantity, quality and variation in the foods supplied. Whether this also improves the dietary intake of recipients needs to be determined.
To examine mediation by (i) diet quality and (ii) diet quantity in the associations of mindful eating domains with 3-year change in depressive symptoms.
Depressive symptoms were measured with the Center for Epidemiologic Studies Depression scale at baseline and 3-year follow-up. Four mindful eating domains (Focused Eating; Eating in response to Hunger and Satiety Cues; Eating with Awareness; Eating without Distraction) were measured with the Mindful Eating Behavior Scale. Food intake was measured with a 238-item FFQ. Diet quality was defined as the Mediterranean Diet Score (MDS). Diet quantity was defined as total energy intake (kcal/d; 1 kcal = 4·184 kJ). Mediation analyses with percentile-corrected bootstrap confidence intervals were conducted to calculate indirect effects.
Longitudinal Aging Study Amsterdam.
Adults aged 55 years or above (n 929).
Diet quality (MDS) did not mediate associations of any of the four mindful eating domains with change in depressive symptoms. In contrast, total energy intake did mediate the associations with change in depressive symptoms for the mindful eating domains Eating with Awareness (indirect effects fully adjusted models: B = −0·014, 95 % CI −0·037, −0·002) and Eating without Distraction (B = −0·013, 95 % CI −0·033, −0·001), but not for the other two domains. Post hoc multiple mediation analyses showed similar results.
Higher scores on two mindful eating domains were associated with a decrease in depressive symptoms through lower total energy intake. Diet quantity, but not diet quality, could be a possible underlying mechanism in the associations between mindful eating and change in depressive symptoms.