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We examine epidemiological evidence for the central role of inequalities (principally economic) in driving the onset of mental disorders, physical ill health and premature mortality. We locate the search for solutions in current UK contexts, and include known and likely effects of the COVID-19 pandemic. Prevention of mental disorders and adverse outcomes such as premature mortality must begin with efforts to mitigate rising poverty-inequality.
Demands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.
Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.
Recent investigations now suggest that cerebrovascular reactivity (CVR) is impaired in Alzheimer’s disease (AD) and may underpin part of the disease’s neurovascular component. However, our understanding of the relationship between the magnitude of CVR, the speed of cerebrovascular response, and the progression of AD is still limited. This is especially true in patients with mild cognitive impairment (MCI), which is recognized as an intermediate stage between normal aging and dementia. The purpose of this study was to investigate AD and MCI patients by mapping repeatable and accurate measures of cerebrovascular function, namely the magnitude and speed of cerebrovascular response (τ) to a vasoactive stimulus in key predilection sites for vascular dysfunction in AD.
Thirty-three subjects (age range: 52–83 years, 20 males) were prospectively recruited. CVR and τ were assessed using blood oxygen level-dependent MRI during a standardized carbon dioxide stimulus. Temporal and parietal cortical regions of interest (ROIs) were generated from anatomical images using the FreeSurfer image analysis suite.
Of 33 subjects recruited, 3 individuals were excluded, leaving 30 subjects for analysis, consisting of 6 individuals with early AD, 11 individuals with MCI, and 13 older healthy controls (HCs). τ was found to be significantly higher in the AD group compared to the HC group in both the temporal (p = 0.03) and parietal cortex (p = 0.01) following a one-way ANCOVA correcting for age and microangiopathy scoring and a Bonferroni post-hoc correction.
The study findings suggest that AD is associated with a slowing of the cerebrovascular response in the temporal and parietal cortices.
Following a series of high-profile attacks in Beijing, Kunming and Urumqi by Uyghur militants, the Chinese party-state declared a “war on terror” in 2014. Since then, China's Xinjiang region has witnessed an unprecedented build-up of what we describe as a multi-tiered police force, turning it into one of the most heavily policed regions in the world. This article investigates the securitization of Xinjiang through an analysis of official police recruitment documents. Informal police jobs, which represent the backbone of recent recruitment drives, have historically carried inferior pay levels. Yet, advertised assistant police positions in Xinjiang now offer high salaries despite low educational requirements, thereby attracting lesser-educated applicants, many of whom are ethnic minorities. Besides co-opting Uyghurs into policing their own people, the resulting employment is in itself a significant stability maintenance strategy. While the known numbers of violent attacks have subsided, China's heavy-handed securitization approach risks alienating both minority and Han populations.
Our purpose was to determine the effectiveness and harms of vaccination in patients with any sexual history to prevent the prevalence of papillomavirus infection. A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE and LILACS databases. Searches were also conducted in other databases and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration's tool. Analysis of fixed effects was conducted. The primary outcome was the infection by any and each human papillomavirus (HPV) genotype, serious adverse effects and short-term adverse effects. The measure of the effect was the risk difference (RD) with a 95% confidence interval (CI). The planned interventions were bivalent vaccine/tetravalent/nonavalent vs. placebo/no intervention/other vaccines. We included 29 studies described in 35 publications. Bivalent HPV vaccine offers protection against HPV16 (RD −0.05, 95% CI −0.098 to −0.0032), HPV18 (RD −0.03, 95% CI −0.062 to −0.0004) and HPV16/18 genotypes (RD of −0.1, 95% CI −0.16 to −0.04). On the other side, tetravalent HPV vaccine offered protection against HPV6 (RD of −0.0500, 95% CI −0.0963 to −0.0230), HPV11 (RD −0.0198, 95% CI −0.0310 to −0.0085). Also, against HPV16 (RD of −0.0608, 95% CI −0.1126 to −0.0091) and HPV18 (RD of −0.0200, 95% CI −0.0408 to −0.0123). There was a reduction in the prevalence of HPV16, 18 and 16/18 genotypes when applying the bivalent vaccine, with no increase in adverse effects. Regarding the tetravalent vaccine, we found a reduction in the prevalence of HPV6, 11, 16 and 18 genotypes, with no increase in adverse effects.
As bottom water warms, destabilisation of gas hydrates may increase the extent of methane-rich sediments. The authors present an assessment of organic carbon processing by the benthic community in methane-rich sediments, including one of the first investigations of inorganic C fixation in a non-hydrothermal vent setting. This topic was previously poorly studied, and there is much need to fill the gaps in knowledge of such ecosystems. The authors hypothesized that benthic C fixation would occur, and that a high biomass macrofaunal community would play a substantial role in organic C cycling. Experiments were conducted at a 257 m deep site off South Georgia. Sediment cores were amended with 13C and 15N labelled algal detritus, or 13C labelled bicarbonate solution. In the bicarbonate experiment, labelling of bacteria-specific phospholipid fatty acids provided direct evidence of benthic C fixation, with transfer of fixed C to macrofauna and dissolved organic carbon (DOC). In the algae experiment, macrofauna played an active role in organic carbon cycling. Compared to similar experiments, low temperature supressed the rates of community respiration and macrofaunal C uptake. While benthic C fixation occurred, the biological processing of organic carbon was dominantly controlled by low temperature and high photic zone productivity.
Health and social care face growing and conflicting pressures: mounting complex needs of an ageing population, restricted funding and a workforce recruitment and retention crisis. In response, in the UK the NHS Long Term Plan promises increased investment and an emphasis on better ‘integrated’ care. We describe key aspects of integration that need addressing.
Declaration of interest
D.K.T. and S.S.S. are on the editorial board of the British Journal of Psychiatry and executives of the Academic Faculty at the Royal College of Psychiatrists. A.J.B.J., H.P. and Z.M. have roles at the Royal College of Psychiatrists that include evaluation of integrated care systems. A.J.B.J. is married to Dr Sarah Wollaston, Member of Parliament for Totnes and Chair of the Health Select Committee.
Excavations from 2013 to 2015 at the site of Shishan Marsh 1 (SM1) in the Azraq Basin of eastern Jordan have yielded substantial late middle Pleistocene lithic assemblages in association with faunal remains. Faunal preservation is poor, but multiple taxa have been identified, including cf. Panthera leo, Gazella sp., Bos cf. primigenius, Camelus sp., Equus spp., cf. Stephanorhinus hemitoechus, Palaeoloxodon cf. recki, and Elephas cf. hysudricus. The overall Azraq habitat may have been most similar to a savanna ecosystem, with a mixture of open grassland/shrub habitats and more closed vegetation along the wetlands margins. These taxa were drawn to the relatively lush oasis environment, where they were a dietary resource of the hominin groups exploiting the wetlands resources.
Labour standards provisions within the Trade and Sustainable Development (TSD) chapters of EU Free Trade Agreements (FTAs) are presented as a key element of the EU's commitment to a ‘value-based trade agenda’. But criticism of TSD chapters has led the European Commission to commit to improving their implementation and enforcement, creating a critical juncture in the evolution of the EU's trade–labour linkage. This contribution synthesizes findings from academic studies that have examined the effectiveness of labour standards provisions in EU FTAs. It then considers the reform agenda as presented by the European Commission, and explains how some of the proposals could tackle failures identified. However, it also argues that there are various limitations with the Commission's current proposals, and outlines how legal obligations and institutional mechanisms created by trade agreements could better be harnessed to improve working conditions and rights at work around the world.
Next-generation 21cm observations will enable imaging of reionization on very large scales. These images will contain more astrophysical and cosmological information than the power spectrum, and hence providing an alternative way to constrain the contribution of different reionizing sources populations to cosmic reionization. Using Convolutional Neural Networks, we present a simple network architecture that is sufficient to discriminate between Galaxy-dominated versus AGN-dominated models, even in the presence of simulated noise from different experiments such as the HERA and SKA.
The UK's Choosing Wisely campaign aims to tackle the pressing issue of overuse in healthcare (i.e. overdiagnosis and overtreatment) through improving awareness and promoting shared decisionmaking. This campaign involves medical societies developing lists of interventions that are of questionable value and so require a genuine discussion between doctors and patients about their use. This article is about the problem of overuse and the launch of the Royal College of Psychiatrists' Choosing Wisely campaign. It provides a critical review of why this might occur and whether Choosing Wisely is likely to be successful.
• Understand the aims of the Choosing Wisely programme
• Define overdiagnosis and overtreatment
• Develop a critical perspective on potential areas of overuse in your clinical practice
In this paper, we present the argument in favor of an open source, a royalty-free video codec that will keep pace with the evolution of video traffic. Additionally, we argue that the availability of a state-of-the-art, royalty-free codec levels the playing field, allowing small content owners, and application developers to compete with the larger companies that operate in this space.
Clinical audit is a central component of clinical governance and is the principal tool for providers and patients to find out if healthcare is being delivered to the required standard and continuously improves. It is defined by the National Institute for Health and Care Excellence (NICE) as:
‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.’ (NICE, 2002)
Participation in clinical audit by hospital doctors was made mandatory with the publication of A First Class Service (Department of Health, 1998) and is a requirement of Good Psychiatric Practice (Royal College of Psychiatrists, 2009). Psychiatrists should ‘participate in clinical audit to measure and improve clinical care provided by themselves and their team’. It is a prerequisite for revalidation (General Medical Council, 2012). Done well, it can lead to significant and sustained improvement in outcomes for users but at its worst it can be a time-consuming, demoralising waste, with no clear benefits, while diverting precious clinical time away from patients. The report of the public inquiry into Mid Staffordshire NHS Foundation Trust (Francis, 2013) marked a sentinel moment in quality improvement with a demand to put the quality of patient care, and especially patient safety, above all other aims; it reaffirmed the primacy of clinical audit in this process. Don Berwick asserted that mastery of quality and patient safety science and practices should be part of the initial preparation and lifelong education of not only healthcare professionals but also managers and executives (National Advisory Group on the Safety of Patients in England, 2013). He went on to highlight the ‘most single important change’ in the NHS would be for it to become ‘a system devoted to continual learning and improvement of patient care, top to bottom and end to end’.