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This chapter argues that as Shakespeare was canonised as Britain’s national poet from 1660 through to the end of the eighteenth century, so editors and critics increasingly presented him as bourgeois and respectable, minimising the plays’ barbarous violence, ghosts and witches – their ‘Gothic’ elements. Between 1764 and 1768, Horace Walpole wrote The Castle of Otranto (a novel/romance hybrid), Historic Doubts on the Life and Reign of King Richard the Third (a revisionist history) and The Mysterious Mother (a Shakespearean blank-verse tragedy), three different genres that variously appropriate and rework Shakespeare. Confronting the national poet, the argument holds, enabled him to work through his fears of illegitimacy, the sense that he had no claim to being the trueborn son of the powerful Sir Robert Walpole and the implied adultery of his beloved mother. His reading of Hamlet’s anger and loathing of his mother Gertrude’s behaviour unconsciously facilitated Horace Walpole’s invention of ‘Gothic Story’, which he located within the walls of an ancient castle haunted by the family secrets generated by the laws of patriarchy.
As W. C. Sellar and R. J. Yeatman wrote, long ago, ‘History is not what you thought. It is what you can remember.’ I myself would go a little further: ‘history is what people want you to remember’, and if that sounds paranoid, a little paranoia never did anyone any harm and is, as far as historians are concerned, a healthy addition to their professional repertoire. The point can be illustrated by considering the posthumous reputation of King Harold II Godwineson, whose defeat at Hastings provided Sellar and Yeatman with the title of their work. Harold's fall meant the loss not only of the battle, his kingdom and his life, but also his good name, and the almost unanimous strictures on him and on his family from both medieval and modern historians warrant examination.
Harold's claim to the kingship was threefold: he had been chosen by the previous king, elected by the English magnates and consecrated in the coronation ritual. Even in near-contemporary sources there is some doubt about the first element, the designation by King Edward. All three recensions of the Anglo-Saxon Chronicle, written within a few years of the Conquest, say that Edward chose Harold as his heir, and the claim is grudgingly accepted in the panegyric on Duke William penned by William of Poitiers in the early 1070s. The Bayeux Tapestry is more ambiguous. In its scene depicting King Edward's deathbed only the dying king is identified by name, and the text says merely that he is speaking to his faithful companions (hic Eadwardus rex iniecto alloquit fideles), with no hint of what he is actually saying. The other participants in the scene can be identified from the more or less contemporary description of the king's deathbed in the Life of King Edward who Rests at Westminster. Here the Tapestry's ‘faithful companions’ appear as Queen Edith, ‘who was sitting on the floor warming [Edward’s] feet in her lap’, Earl Harold, Robert fitzWymarc and Archbishop Stigand, all of whom the king had summoned to hear his prophetic dream of England as a green tree, cut down and carried three furlongs from its stump before regrowing and fruiting once again.
Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI.
Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors.
Five urban, academic medical centers, part of the New York City Clinical Data Research Network.
Potential patients were age <22 years who were seen between October 2010 and September 2015.
In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1–6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics.
Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.
This study investigated subjective memory complaints in older adults and the roles of setting, response bias, and personality.
Cognitively normal older adults from two settings completed questionnaires measuring memory complaints, response bias, and personality.
(A) Neuroimaging study with community-based recruitment and (B) academic memory clinic.
Cognitively normal older adults who (A) volunteer for research (N = 92) or (B) self-referred to a memory clinic (N = 20).
Neuropsychological evaluation and adjudication of normal cognitive status were done by the neuroimaging study or memory clinic. This study administered self-reports of subjective memory complaints, response bias, five-factor personality, and depressive symptoms. Primary group differences were examined with secondary sensitivity analyses to control for sex, age, and education differences.
There was no significant difference in over-reporting response bias between study settings. Under-reporting response bias was higher in volunteers. Cognitive complaints were associated with response bias for two cognitive complaint measures. Neuroticism was positively associated with over-reporting in evaluation-seekers and negatively associated with under-reporting in volunteers. The relationship was reversed for Extraversion. Under-reporting bias was positively correlated with Agreeableness and Conscientiousness in volunteers.
Evaluation-seekers do not show bias toward over-reporting symptoms compared to volunteers. Under-reporting response bias may be important to consider when screening for memory impairment in non-help-seeking settings. The Memory Functioning Questionnaire was less sensitive to reporting biases. Over-reporting may be a facet of higher Neuroticism. Findings help elucidate psychological influences on self-perceived cognitive decline and help seeking in aging and may inform different strategies for assessment by setting.
UK Biobank is a well-characterised cohort of over 500 000 participants including genetics, environmental data and imaging. An online mental health questionnaire was designed for UK Biobank participants to expand its potential.
Describe the development, implementation and results of this questionnaire.
An expert working group designed the questionnaire, using established measures where possible, and consulting a patient group. Operational criteria were agreed for defining likely disorder and risk states, including lifetime depression, mania/hypomania, generalised anxiety disorder, unusual experiences and self-harm, and current post-traumatic stress and hazardous/harmful alcohol use.
A total of 157 366 completed online questionnaires were available by August 2017. Participants were aged 45–82 (53% were ≥65 years) and 57% women. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status. Lifetime depression was a common finding, with 24% (37 434) of participants meeting criteria and current hazardous/harmful alcohol use criteria were met by 21% (32 602), whereas other criteria were met by less than 8% of the participants. There was extensive comorbidity among the syndromes. Mental disorders were associated with a high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The UK Biobank questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed because of selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
Current neurocognitive models suppose dysfunctions of associative and limbic cortico-basal ganglia circuits to be at the core of obsessive-compulsive disorder (OCD). As little is known about the state of underlying anatomical connections, we investigated whether these connections were reduced and/or not properly organised in OCD patients compared to control.
Diffusion magnetic resonance images were obtained in 37 OCD patients with predominant checking symptoms and 37 matched healthy controls. We developed indices to characterise the quantity (spatial extent and density) and the organisation (topography and segregation) of 24 anatomical connections between associative and limbic cortical (anterior cingulate, dorsolateral prefrontal, orbitofrontal cortices and the frontal pole), and subcortical (caudate nucleus, putamen and thalamus) areas in each hemisphere.
Associative and limbic cortico-basal-ganglia connections were reduced in OCD patients compared to controls: 19/24 connections had a reduced subcortical spatial extent, 9/24 had a reduced density. Moreover, while the general topography was conserved, the different cortical projection fields in the striatum and thalamus were hyper-segregated in OCD patients compared to controls.
These quantitative and qualitative differences of anatomical connections go beyond the current model of a reduced cortical control of automatic behaviour stored in the basal ganglia. The hyper-segregation in OCD could also impair the integration of cortical information in the thalamus and striatum and distort the subsequent behavioural selection process. This provides new working hypotheses for functional and behavioural studies on OCD.
In Baby-Led Weaning (BLW), infants are offered foods they can pick up and feed themselves from the start of complementary feeding. Infants who are fully BLW are not spoonfed at all by their parents, feeding themselves all their foods instead. The Baby-Led Introduction to SolidS (BLISS) study was a randomised controlled trial of the effect of a modified version of BLW5 on infant growth, iron status, and risk of choking, and provides an opportunity to investigate parents’ experiences of using a baby-led approach to infant feeding. Complementary feeding methods are usually chosen by parents, so it is important to ascertain whether parents find a baby-led method of introducing solids acceptable if they are assigned to follow it. This is both to determine whether it would be feasible to randomise them to follow BLW in future randomised controlled trials and because, if beneficial effects of BLW are shown, policy makers need to know whether parents would find it acceptable to follow BLW. The aim of this analysis was to determine the acceptability to parents of a baby-led approach to complementary feeding when their infant was 7 to 12 months of age. In total, 206 participants were randomised to Control (n = 101) or BLISS (n = 105) groups in the third trimester of pregnancy. When the infants were 7, 8, 9, and 12 months of age, questionnaires were administered to determine parents’ happiness and frustration with their feeding method, and attitudes regarding its convenience, mess, and expense. Food cost was estimated using supermarket prices linked to a 3-day weighed diet record collected at 7 months of age. Both groups reported high levels of happiness and convenience, but also reported finding complementary feeding very frustrating. There were two significant differences between the groups – the BLISS group reported less messiness, and were more likely to perceive their method as expensive. The actual food cost per day was not statistically significantly different between the two groups (NZ$1.70 for BLISS, NZ$1.90 for Controls). In conclusion, parents did not find a baby-led approach to introducing solids any less acceptable than control parents found standard infant feeding. It is, therefore, feasible to run studies where parents are randomised to follow a baby-led approach to complementary feeding and, should health advantages to BLW be identified, parents are likely to find BLW acceptable to follow.
There are a variety of causes of acute heart failure in children including myocarditis, genetic/metabolic conditions, and congenital heart defects. In cases with a structurally normal heart and a negative personal and family history, myocarditis is often presumed to be the cause, but we hypothesise that genetic disorders contribute to a significant portion of these cases. We reviewed our cases of children who presented with acute heart failure and underwent genetic testing from 2008 to 2017. Eighty-seven percent of these individuals were found to have either a genetic syndrome or pathogenic or likely pathogenic variant in a cardiac-related gene. None of these individuals had a personal or family history of cardiomyopathy that was suggestive of a genetic aetiology prior to presentation. All of these individuals either passed away or were listed for cardiac transplantation indicating genetic testing may provide important information regarding prognosis in addition to providing information critical to assessment of family members.
Female family headship has strong implications for endemic poverty in the United States. Consequently, it is imperative to explore the chief factors that contribute to this problem. Departing from prior literature that places significant weight on welfare-incentive effects, our study highlights the role of male marriageability in explaining the prevalence of never-married female family headship for blacks and whites. Specifically, we examine racial differences in the effect of male marriageability on never-married female headship from 1980 to 2010. By exploiting data from IPUMS-USA (N = 4,958,722) and exogenous variation from state-level sentencing reforms, the study finds that the decline in the relative supply of marriageable males significantly increases the incidence of never-married female family headship for blacks but not for whites.
Falls prevention strategies can only be effective in reducing falls amongst older people if they are adopted and enacted in their daily lives. There is limited evidence identifying what older people in residential aged care (RAC) homes understand about falls and falls prevention, or what may limit or enable their adoption of strategies. This study was conducted in two countries and explored older people's knowledge and awareness of falls and their preferences, opportunities and motivation to undertake falls prevention strategies. A cross-sectional survey was administered to participants (N = 70) aged 65 years and over, living in six RAC homes in Perth, Australia and six RAC homes in Swansea, Wales, United Kingdom. Participants had limited knowledge about intrinsic falls risk factors and strategies to address these and frequently expressed self-blame regarding falling. Almost all (N = 67, 95.7%) participants felt highly motivated to maintain their current functional mobility and independence in everyday tasks. Key preferences for receiving falls prevention messages favoured a positive approach promoting wellness and independence (N = 41, 58.6%) via pictorial posters or brochures (N = 37, 52.9%) and small group discussions preferably with demonstrations (N = 18, 25.7%). Findings from this study may assist organisations and staff to more effectively engage with older people living in RAC about falls prevention and design targeted resources to address the motivations and preferences of this population.
Early life exposures affect health and disease across the life course and potentially across multiple generations. The Clinical and Translational Research Institutes (CTSIs) offer an opportunity to utilize and link existing databases to conduct lifespan research.
A survey with Lifespan Domain Taskforce expert input was created and distributed to lead lifespan researchers at each of the 64 CTSIs. The survey requested information regarding institutional databases related to early life exposure, child-maternal health, or lifespan research.
Of 64 CTSI, 88% provided information on a total of 130 databases. Approximately 59% (n=76/130) had an associated biorepository. Longitudinal data were available for 72% (n=93/130) of reported databases. Many of the biorepositories (n=44/76; 68%) have standard operating procedures that can be shared with other researchers.
The majority of CTSI databases and biorepositories focusing on child-maternal health and lifespan research could be leveraged for lifespan research, increased generalizability and enhanced multi-institutional research in the United States.
UK Biobank is a well-characterised cohort of over 500 000 participants that offers unique opportunities to investigate multiple diseases and risk factors.
An online mental health questionnaire completed by UK Biobank participants was expected to expand the potential for research into mental disorders.
An expert working group designed the questionnaire, using established measures where possible, and consulting with a patient group regarding acceptability. Case definitions were defined using operational criteria for lifetime depression, mania, anxiety disorder, psychotic-like experiences and self-harm, as well as current post-traumatic stress and alcohol use disorders.
157 366 completed online questionnaires were available by August 2017. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status than the general population across a range of indicators. Thirty-five per cent (55 750) of participants had at least one defined syndrome, of which lifetime depression was the most common at 24% (37 434). There was extensive comorbidity among the syndromes. Mental disorders were associated with high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed owing to selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
Declaration of interest
G.B. received grants from the National Institute for Health Research during the study; and support from Illumina Ltd. and the European Commission outside the submitted work. B.C. received grants from the Scottish Executive Chief Scientist Office and from The Dr Mortimer and Theresa Sackler Foundation during the study. C.S. received grants from the Medical Research Council and Wellcome Trust during the study, and is the Chief Scientist for UK Biobank. M.H. received grants from the Innovative Medicines Initiative via the RADAR-CNS programme and personal fees as an expert witness outside the submitted work.
To date no studies have explored the effectiveness of written cognitive–behavioural therapy (CBT) resources for low mood and stress delivered via a course of self-help classes in a community setting.
To assess the effectiveness of an 8-week community-based CBT self-help group classes on symptoms of depression, anxiety and social function at 6 months (trial registration: ISRCTN86292664).
In total, 142 participants were randomly allocated to immediate (n = 71) or delayed access to a low-intensity CBT intervention (n = 71). Measures of depression, anxiety and social function were collected at baseline and 6 months.
There was a significant improvement for the primary outcome of Patient Health Questionnaire-9 (PHQ-9) score (mean between-group difference: –3.64, 95% CI –6.06 to –1.23; P = 0.004). The percentage of participants reducing their PHQ-9 score between baseline and 6 months by 50% or more was 17.9% for the delayed access group and 43.8% for the immediate access group. Secondary outcomes also improved including anxiety and social function. The intervention was cost neutral. The probabilities of a net benefit at willingness to pay thresholds of £20 000, £25 000 or £30 000 were 0.928, 0.944 and 0.955, respectively.
Low-intensity class-based CBT delivered within a community setting is effective for reducing depression, anxiety and impaired social function at little additional cost.
Declaration of interest
C.W. is president of British Association for Behavioural & Cognitive Psychotherapies (BABCP) – the lead body for CBT in the UK. He is also author of a range of CBT-based resources available commercially. He is developer of the LLTTF classes evaluated in this study. He receives royalty, and is shareholder and director of a company that commercialises these resources.
Background: Functional neurological symptoms (FNS) are considered non-volitional and often very disabling, but are not explainable by neurological disease or structural abnormalities. Brief Augmented Psychodynamic Interpersonal Therapy (BAPIT) was adapted to treat the putative emotion processing deficits thought to be central to FNS aetiology and maintenance. BAPIT for FNS has previously been shown to improve levels of distress and functioning, but it is unknown whether improvements on such measures correlate with changes in emotion processing ‒ which this treatment focuses on. Aim: To determine (a) whether the recently developed Emotional Processing Scale-25 can be used to demonstrate BAPIT-associated changes in patients with FNS, and (b) whether changes in the EPS-25 are associated with changes in previously validated outcome measures. Method: 44 patients with FNS completed questionnaires including the EPS-25 and measures of clinical symptomology (health-related quality of life (SF-36), somatic symptoms (PHQ-15), psychological distress (CORE-10) and illness understanding (BIPQ)) pre- and post-therapy. Results: At group level, emotion processing improved following therapy (p = .049). Some measures of clinical symptomology also improved, namely health-related quality of life (p = .02) and illness understanding (p = .01). Improvements in the EPS-25 correlated with improvements in mental health-related quality of life and psychological distress. Conclusions: Emotion processing and some measures of clinical symptomology improved in patients with FNS following BAPIT. The EPS-25 demonstrated changes that correlated with previously validated outcome measures. The EPS-25 is a suitable measure of psychotherapy-associated change in the FNS patient population.