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Introduction: The opioid crisis has reached epidemic levels in Canada, driven in large part by prescription drug use. Emergency physicians are frequent prescribers of opioids; therefore, the emergency department (ED) represents an important setting for potential intervention to encourage rational and safe prescribing. The objective of this study was to systematically review the literature on interventions aimed to influence opioid prescribing in the ED. Methods: Electronic searches of Medline and Cochrane were conducted and reference lists were hand-searched. All quantitative studies published in English from 2009 to 2019 were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible studies, the full texts of which were retrieved and assessed for inclusion. Outcomes of interest included opioid prescribing rate (proportion of ED visits resulting in an opioid prescription at discharge), morphine milligram equivalents per prescription and variability among prescribers. Results: The search strategy yielded 797 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 34 potentially relevant studies were retrieved in full text. Of these, 28 studies were included in the review. The majority (26, 92.9%) of studies were based in the United States and two (7.1%) were from Australia. Four (14.3%) were randomized controlled trials. The interventions were classified into six categories: prescribing guidelines (n = 10), regulation/rescheduling of opioids (n = 6), prescribing data transparency (n = 4), education (n = 4), care coordination (n = 3), and electronic medical record changes (n = 1). The majority of interventions reduced the opioid prescribing rate from the ED (21/28, 75.0%), although regulation/rescheduling of opioids had mixed effectiveness, with 3/6 (50%) studies reporting a small increase in the opioid prescribing rate post-intervention. Education had small yet consistent effects on reducing the opioid prescribing rate. Conclusion: A variety of interventions have attempted to improve opioid prescribing from the ED. These interventions include prescribing guidelines, regulation/rescheduling, data transparency, education, care coordination, and electronic medical record changes. The majority of interventions reduced the opioid prescribing rate; however, regulation/rescheduling of opioids demonstrated mixed effectiveness.
The aim of the study was to assess the experiences of discrimination as reported by people with mental health problems and to explore the impact of hospitalisation.
306 people with mental health problems provided sociodemographic data and data on discrimination using the discrimination and stigma scale version 12 (DISC-12) with the domains negative experienced discrimination, anticipated discrimination, overcoming stigma and discrimination, and positive experienced discrimination. Logistic regression analysis was used to test the impact of hospitalisation on discrimination, controlled for age, gender, education, employment, diagnosis and having been prescribed medication.
Hospitalisation had a major impact on negative discrimination: People were more likely to be treated unfairly in making or keeping friends, in marriage or divorce, by people in their neighbourhood, in social life, by mental health staff and in terms of privacy, if they had been hospitalised. They were also more likely to be avoided or shunned by people who knew about the mental health problem. People with a history of hospitalisation also reported more anticipated discrimination: They had stopped themselves more often from having a close personal relationship and concealed their mental health problem from others more often than those without a history of hospitalisation. However, people who had been hospitalised also experienced more positive discrimination in terms of being treated more positively in getting welfare benefits or disability pensions and in housing.
Findings suggest that treatment in hospital contributed to a higher extent to experienced discrimination than treatment in the community.
Conservation practitioners use a wide range of sources to inform decisions, but studies report that personal experience is usually most important; scientific papers and unpublished research are rarely referred to. For site-based conservation practitioners, day-to-day decisions are typically made within a context of earlier decisions taken at two levels: strategic decisions that define the aims and policies of the wider organisation; and management planning decisions which outline the objectives for a site and the actions needed to achieve them. Even where decisions are underpinned by scientific evidence, personal judgement is valuable in ensuring management actions are tailored to the specific site. The integration of scientific evidence into conservation decision-making could be improved. We suggest two main approaches. First, increase the synthesis, translation and exchange of scientific research into easily accessible, practical information. Second, ensure that decision-making processes involve skilled ecological advisors and scientists who keep up to date with relevant literature and are able to advise on site-specific evidence-based solutions.
This study investigated the attitudes of medical students towards psychiatry, both as a subject on the medical curriculum and as a career choice. Three separate questionnaires previously validated on medical student populations were administered prior to and immediately following an 8-week clinical training programme. The results indicate that the perception of psychiatry was positive prior to clerkship and became even more so on completion of training. On completion of the clerkship, there was a rise in the proportion of students who indicated that they might choose a career in psychiatry. Attitudes toward psychiatry correlated positively with the psychiatry examination results. Those that intended to specialise in psychiatry achieved significantly higher examination scores in the psychiatry examination.
The present functional magnetic resonance imaging (fMRI) study investigated neural changes in relation to mood biased processing in depression, before and after cognitive behavioral therapy (CBT) using an emotional Stroop task.
Sixteen unmedicated patients (mean age 40 years), fulfilling DSM-IV diagnosis for unipolar major depression underwent fMRI, prior to and after 16 once-weekly sessions of CBT. Sixteen matched healthy volunteers were scanned at similar time intervals. In an emotional Stroop task negative and neutral words were presented in various colors and volunteers had to name the color of words. Latencies were recorded to determine behavioral emotional interference effects. MRI images were acquired using clustered image acquisition. Whole-brain and region of interest analysis examined the neural basis of interference and mood biased processing.
At baseline patients displayed increased latencies during color naming negative words, in comparison to neutral words and in relation to healthy volunteers. After treatment, latencies did not significantly differ between groups. With regard to neural activity, depressed patients showed increased activation at baseline in amygdala, dorsolateral prefrontal cortex (DLPFC), and ventrolateral prefrontal cortex (VLPFC), which normalized after CBT. Additionally, hyperactivation in the rostral anterior cingulate at baseline was positively correlated with symptom reduction after CBT.
Evidence was found for an emotional interference effect during acute states of depression which improved following CBT. The neural basis is associated with increased activity in the amygdala, DLPFC and VLPFC which normalized after treatment. CBT seems to affect behavioral biases and neural circuits involved in processing negative information.
Although genetic and environmental factors operating before or around the time of birth have been demonstrated to be relevant to the aetiology of the major psychoses, a seasonal variation in the rates of admission of such patients has long been recognised. Few studies have compared first and readmissions. This study examined for seasonal variation of admission in the major psychoses, and compared diagnostic categories by admission status. Patients admitted to Irish psychiatric inpatient facilities between 1989 and 1994 with an ICD-9/10 diagnosis of schizophrenia or affective disorder were identified from the National Psychiatric Inpatient Reporting System (NPIRS). The data were analysed using a hierarchical log linear model, the chi-square test, a Kolmogorov-Smirnov (KS) type statistic, and the method of Walter and Elwood. The hierarchical log linear model demonstrated significant interactions between the month of admission and admission order (change in scaled deviance 28.77, df = 11, P < 0.003). Both first admissions with mania, and readmissions with bipolar affective disorder exhibited significant seasonality. In contrast, only first admissions with schizophrenia showed significant seasonal effects. Although first admissions with mania and readmissions with bipolar disorder both show seasonality, seasonal influences appear to be more relevant to onset of schizophrenia than subsequent relapse.
We sought to explore whether obstetric complications (OCs) are more likely to occur in the presence of familial/genetic susceptibility for schizophrenia or whether they themselves represent an independent environmental risk factor for schizophrenia.
The presence of OCs was assessed through maternal interview on 216 subjects, comprising 36 patients with schizophrenia from multiply affected families, 38 of their unaffected siblings, 31 schizophrenic patients with no family history of psychosis, 51 of their unaffected siblings and 60 normal comparison subjects. We examined the familiality of OCs and whether OCs were commoner in the patient and sibling groups than in the control group.
OCs tended to cluster within families, especially in multiply affected families. Patients with schizophrenia, especially those from multiply affected families, had a significantly higher rate of OCs compared to normal comparison subjects, but there was no evidence for an elevated rate of OCs in unaffected siblings.
Our data provides little evidence for a link between OCs and genetic susceptibility to schizophrenia. If high rates of OCs are related to schizophrenia genes, this relationship is weak and will only be detected by very large sample sizes.
P300 wave anomalies correlate with genetic risk for schizophrenia and constitute a plausible endophenotype for the disease. The COMT gene is thought to influence cognitive performance and to be a susceptibility gene for schizophrenia. Unlike two previous studies, we found no significant influence of the COMT gene on P300 amplitude or latency in 189 individuals examined. The well-supported role of the COMT gene both in dopamine catabolism as well as in prefrontal cognition makes a strong theoretical case for the influence of COMT Val158Met polymorphism on P300 endophenotypes. However, the available neurophysiologic evidence suggests that any such association, if present, must be very subtle.
Impaired working memory is a core feature of schizophrenia and is linked with altered engagement the lateral prefrontal cortex. Although altered PFC activation has been reported in people with increased risk of psychosis, at present it is not clear if this neurofunctional alteration differs between familial and clinical risk states and/or increases in line with the level of psychosis risk. We addressed this issue by using functional MRI and a working memory paradigm to study familial and clinical high-risk groups. We recruited 17 subjects at ultra-high-risk (UHR) for psychosis, 10 non-affected siblings of patients with schizophrenia (familial high risk [FHR]) and 15 healthy controls. Subjects were scanned while performing the N-back working memory task. There was a relationship between the level of task-related deactivation in the medial PFC and precuneus and the level of psychosis risk, with deactivation weakest in the UHR group, greatest in healthy controls, and at an intermediate level in the FHR group. In the high-risk groups, activation in the precuneus was associated with the level of negative symptoms. These data suggest that increased vulnerability to psychosis is associated with a failure to deactivate in the medial PFC and precuneus during a working memory task, and appears to be most evident in subjects at clinical, as opposed to familial high risk.
Recent literature suggests that over 70% of cases of antibody-mediated encephalitis present to psychiatry services with features of psychosis predominantly.
To investigate the seroprevalence of N-Methyl-D-Aspartate receptor antibodies (NMDAr-Ab) in patients with first episode psychosis (FEP)
Following ethical approval, all cases meeting entry criteria were invited to participate. Participants were interviewed with SCID to obtain a DSM diagnosis. NMDAr-Ab were identified in serum by cell based assay using co-transfected Human Embryonic Kidney (HEK)cells. Positive cases were reviewed by clinical neurology. Decision to treat with immunotherapy was made on a case by case basis.
85/115 (72%) of patients with FEP entered the study. 49 (58%) participants were male, mean age (SD) 37 (15.7) years. 42 (52%) were outpatients at the time of assessment. Four cases (5%) were serum NMDAr-Ab positive. 3 of these cases were male, age 48 (16.3) years. All four were admitted as inpatients with normal brain MRI imaging. One case (female, 55) was confirmed as NMDAr-Ab encephalitis based on case presentation, EEG demonstrating bilateral cerebral dysfunction and NMDAr-Ab in CSF. Immunotherapy treatment lead to clinical improvement. In remaining cases, EEG was normal and CSF negative. All 3 of these cases showed clinical improvement following psychiatric treatment as usual.
Our findings support the current estimates as to NMDAr-Ab prevalence in FEP. Increased awareness has lead to rapid treatment of florid cases of NMDAr-Ab encephalitis in our service. Additional seropositive cases are being followed with neuro-cognitive testing for any evidence of decline.
Australian conservation cropping systems are practiced on very large farms (approximately 3,000 ha) where herbicides are relied on for effective and timely weed control. In many fields, though, there are low weed densities (e.g., <1.0 plant 10 m−2) and whole-field herbicide treatments are wasteful. For fallow weed control, commercially available weed detection systems provide the opportunity for site-specific herbicide treatments, removing the need for whole-field treatment of fallow fields with low weed densities. Concern about the sustainability of herbicide-reliant weed management systems remain and there has not been interest in the use of weed detection systems for alternative weed control technologies, such as targeted tillage. In this paper, we discuss the use of a targeted tillage technique for site-specific weed control in large-scale crop production systems. Three small-scale prototypes were used for engineering and weed control efficacy testing across a range of species and growth stages. With confidence established in the design approach and a demonstrated 100% weed-control potential, a 6-m wide pre-commercial prototype, the “Weed Chipper,” was built incorporating commercially available weed-detection cameras for practical field-scale evaluation. This testing confirmed very high (90%) weed control efficacies and associated low levels (1.8%) of soil disturbance where the weed density was fewer than 1.0 plant 10 m−2 in a commercial fallow. These data established the suitability of this mechanical approach to weed control for conservation cropping systems. The development of targeted tillage for fallow weed control represents the introduction of site-specific, nonchemical weed control for conservation cropping systems.
Little is known about who would benefit from Internet-based personalised nutrition (PN) interventions. This study aimed to evaluate the characteristics of participants who achieved greatest improvements (i.e. benefit) in diet, adiposity and biomarkers following an Internet-based PN intervention. Adults (n 1607) from seven European countries were recruited into a 6-month, randomised controlled trial (Food4Me) and randomised to receive conventional dietary advice (control) or PN advice. Information on dietary intake, adiposity, physical activity (PA), blood biomarkers and participant characteristics was collected at baseline and month 6. Benefit from the intervention was defined as ≥5 % change in the primary outcome (Healthy Eating Index) and secondary outcomes (waist circumference and BMI, PA, sedentary time and plasma concentrations of cholesterol, carotenoids and omega-3 index) at month 6. For our primary outcome, benefit from the intervention was greater in older participants, women and participants with lower HEI scores at baseline. Benefit was greater for individuals reporting greater self-efficacy for ‘sticking to healthful foods’ and who ‘felt weird if [they] didn’t eat healthily’. Participants benefited more if they reported wanting to improve their health and well-being. The characteristics of individuals benefiting did not differ by other demographic, health-related, anthropometric or genotypic characteristics. Findings were similar for secondary outcomes. These findings have implications for the design of more effective future PN intervention studies and for tailored nutritional advice in public health and clinical settings.
Little evidence exists to support pharmacotherapeutic strategies for heart failure management in paediatrics. A recent Europe-wide survey suggests that this translates into substantial variability in clinical practice.
To conduct a formal discussion among an expert group of paediatric cardiology physicians on controversial aspects regarding the pharmacotherapy of children heart failure, facilitate consensus, and highlight areas of agreement and disagreement.
A two-round modified Delphi process was conducted between July and August 2015. Topics addressed were predominantly selected from the results of a previous Europe-wide survey. Fourteen statements were presented for discussion grouped under three categories; Angiotensin-converting-enzyme-inhibitors: Considerations for optimal dosage; Angiotensin-converting-enzyme-inhibitors for the management of CHDs; Neurohumoral antagonists for the management of dilated cardiomyopathy-related heart failure.
A total of 13 paediatricians dedicated to cardiology from across Europe and the United States of America completed the study; of them, 92% had a working experience in the field of more than 10 years and were working in a specific paediatric cardiology unit. Agreement on the acceptance/rejection of 11 statements was achieved. Results show agreement on the importance of a set of topics relevant to the standardisation of the therapy as well as consensus upon specific therapeutic attitudes.
We have found areas of common thinking and motivation, which can provide a means of triggering scientific collaboration. Our results might also contribute to disseminate available paediatric evidence and promote reducing unjustified variability in everyday practice. Until solid evidence is available, other research methods can contribute to advancing the goal of safe and effective paediatric heart failure pharmacotherapy.
Introduction: There is increasing evidence to support the integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum currently exists. Using Delphi methodology, we aimed to identify and establish content validity evidence for EM curricular content best suited for simulation-based training to inform national postgraduate EM training. Methods: A national panel of experts in EM simulation-related education iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed and topics scoring <2/4 were removed. Remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics that were rated ≥3.5/4 were considered core curricular topics, while those rated 3.0-3.5 were considered extended curricular topics. Results: Forty-four experts from 13 Canadian centres participated. Two hundred and eighty potential curricular topics, in 29 domains, were generated from a systematic review of the literature, analysis of relevant educational documents and a survey of Delphi panelists. Three rounds of Delphi surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in 8 domains, reached consensus as core curricular topics. An additional 35 topics, in 14 domains, reached consensus as extended curricular topics. Conclusion: Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.
Introduction: Alcohol use disorder (AUD) is a chronic relapsing and highly comorbid disease. Patients suffering from AUD are frequently seen in the emergency department (ED) presenting intoxicated or in withdrawal. Brief interactions in the ED are often the only portal of entry to the healthcare system for many of these patients. Oral naltrexone and long acting injectable naltrexone are effective treatment options for AUD associated with decreased cravings, shorter length of hospital stay, and lower cost of healthcare utilization. This study's objective was to perform a systematic review of the literature evaluating initiation of naltrexone in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing initiation of naltrexone in patients (≥18 years) to standard care in the ED were included. Two reviewers independently screened titles and abstracts, reviewed full text articles for inclusion, assessed quality of the studies, and extracted data. Results: The search strategy yielded 183 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 10 articles were retrieved for full text review. There were no published RCTs that examined naltrexone initiation in the ED. There is one ongoing study being conducted in New York, which aims to assess naltrexone initiation in the ED and measure health outcomes and quality of life of study participants, as well as potential healthcare cost savings. Conclusion: The lack of published research in this area demonstrates a significant gap in knowledge. It is clear that well-designed RCTs are needed to evaluate the effectiveness of initiating naltrexone for those with AUD at the ED visit.