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Longitudinal studies of patterns of healthcare contacts in those who die by suicide to identify those at risk are scarce.
To examine type and timing of healthcare contacts in those who die by suicide.
A population-based electronic case–control study of all who died by suicide in Wales, 2001–2017, linking individuals’ electronic healthcare records from general practices, emergency departments and hospitals. We used conditional logistic regression to calculate odds ratios, adjusted for deprivation. We performed a retrospective continuous longitudinal analysis comparing cases’ and controls’ contacts with health services.
We matched 5130 cases with 25 650 controls (5 per case). A representative cohort of 1721 cases (8605 controls) were eligible for the fully linked analysis. In the week before their death, 31.4% of cases and 15.6% of controls contacted health services. The last point of contact was most commonly associated with mental health and most often occurred in general practices. In the month before their death, 16.6 and 13.0% of cases had an emergency department contact and a hospital admission respectively, compared with 5.5 and 4.2% of controls. At any week in the year before their death, cases were more likely to contact healthcare services than controls. Self-harm, mental health and substance misuse contacts were strongly linked with suicide risk, more so when they occurred in emergency departments or as emergency admissions.
Help-seeking occurs in those at risk of suicide and escalates in the weeks before their death. There is an opportunity to identify and intervene through these contacts.
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.
Antibiotic overuse and misuse is a common problem in nursing homes. Antibiotic time-out (ATO) interventions have led to improvements in antibiotic uses in hospitals, but their impact in nursing homes remain understudied.
To evaluate the impact of a stewardship intervention, promoting use of ATOs on the frequency and types of antibiotic change events (ACEs) in nursing homes.
Controlled before-and-after intervention study.
Nursing homes in Wisconsin and Pennsylvania.
Data on antibiotic prescriptions in 11 nursing homes were collected for 25 months. We categorized ACEs as (1) early discontinuation, (2) class modification, or (3) administration modification. Class modification ACEs were further classified based on whether the change narrowed, expanded, or had no effect on bacterial spectrum coverage. Analyses were performed using a difference-in-difference (DiD) approach.
Of 2,647 antibiotic events initiated in study nursing homes, 376 (14.2%) were associated with an ACE. The overall proportion of ACEs did not significantly differ between intervention and control nursing homes. Early discontinuation ACEs increased in intervention nursing homes (DiD, 2.5%; P = .01), primarily affecting residents initiated on broad-spectrum antibiotics (DiD, 2.9%; P < .01). Class modification ACEs decreased in intervention nursing homes but remained unchanged in control nursing homes.
The impact of an ATO intervention in study nursing homes was mixed with increases in early discontinuation ACEs offset by reductions in class modification ACEs. More research on the potential value of ATO interventions in nursing homes is warranted.
Retinoblastoma is the most common primary intraocular tumor of childhood with >95% survival rates in the US. Traditional therapy for retinoblastoma often included enucleation (removal of the eye). While much is known about the visual, physical, and cognitive ramifications of enucleation, data are lacking about survivors' perception of how this treatment impacts overall quality of life.
Qualitative analysis of an open-ended response describing how much the removal of an eye had affected retinoblastoma survivors' lives and in what ways in free text, narrative form.
Four hundred and four retinoblastoma survivors who had undergone enucleation (bilateral disease = 214; 52% female; mean age = 44, SD = 11) completed the survey. Survivors reported physical problems (n = 205, 50.7%), intrapersonal problems (n = 77, 19.1%), social and relational problems (n = 98, 24.3%), and affective problems (n = 34, 8.4%) at a mean of 42 years after diagnosis. Three key themes emerged from survivors' responses; specifically, they (1) continue to report physical and intrapersonal struggles with appearance and related self-consciousness due to appearance; (2) have multiple social and relational problems, with teasing and bullying being prominent problems; and (3) reported utilization of active coping strategies, including developing more acceptance and learning compensatory skills around activities of daily living.
Significance of results
This study suggests that adult retinoblastoma survivors treated with enucleation continue to struggle with a unique set of psychosocial problems. Future interventions can be designed to teach survivors more active coping skills (e.g., for appearance-related issues, vision-related issues, and teasing/bullying) to optimize survivors' long-term quality of life.
Although efficacious treatments for major depression are available, efficacy is suboptimal and recurrence is common. Effective preventive strategies could reduce disability associated with the disorder, but current options are limited. Cognitive bias modification (CBM) is a novel and safe intervention that attenuates biases associated with depression. This study investigated whether the delivery of a CBM programme designed to attenuate negative cognitive biases over a period of 1 year would decrease the incidence of major depression among adults with subthreshold symptoms of depression.
Randomised double-blind controlled trial delivered an active CBM intervention or a control intervention over 52 weeks. Two hundred and two community-dwelling adults who reported subthreshold levels of depression were randomised (100 intervention, 102 control). The primary outcome of interest was the incidence of major depressive episode assessed at 11, 27 and 52 weeks. Secondary outcomes included onset of clinically significant symptoms of depression, change in severity of depression symptoms and change in cognitive biases.
Adherence to the interventions was modest though did not differ between conditions. Incidence of major depressive episodes was low. Conditions did not differ in the incidence of major depressive episodes. Likewise, conditions did not differ in the incidence of clinically significant levels of depression, change in the severity of depression symptoms or change in cognitive biases.
Active CBM intervention did not decrease the incidence of major depressive episodes as compared to a control intervention. However, adherence to the intervention programme was modest and the programme failed to modify the expected mechanism of action.
The Australian prehospital profession has not yet facilitated a comprehensive discussion regarding paramedic role and responsibility during disasters. Whether paramedics have a duty to treat under extreme conditions and what acceptable limitations may be placed on such a duty require urgent consideration. The purpose of this research is to encourage discussion within the paramedic profession and broader community on this important ethical and legal issue.
The authors employed qualitative methods to gather paramedic and community member perspectives in Victoria, Australia.
These findings suggested that both paramedic and community member participants agree that acceptable limitations on paramedic duty to treat during disaster are required. These limitations should be based on consideration of the following factors: personal health circumstances (eg, pregnancy for female paramedics); pre-existing mental health conditions (eg, posttraumatic stress disorder/PTSD); competing personal obligations (eg, paramedics who are single parents); and unacceptable levels of personal risk (eg, risk of exposure and infection during a pandemic).
It is only with the engagement of a more broadly representative segment of the prehospital profession and greater Australian community that appropriate guidance on limiting standards of care under extreme conditions can be developed and integrated within prehospital care in Australia.
SmithE, BurkleFM Jr., GebbieK, FordD, BensimonC. Acceptable Limitations on Paramedic Duty to Treat During Disaster: A Qualitative Exploration. Prehosp Disaster Med. 2018;33(5):466–470.
Disasters place unprecedented demands on emergency medical services and can test paramedics personal commitment as health care professionals. Despite this challenge, guidelines and codes of ethics are largely silent on the issue, providing little to no guidance on what is expected of paramedics or how they ought to approach their duty to treat in the face of risk. The objective of this research is to explore how paramedics view their duty to treat during disasters.
The authors employed qualitative methods to gather Australian paramedic perspectives.
Our findings suggest that paramedic decisions around duty to treat will largely depend on individual perception of risk and competing obligations. A code of ethics for paramedics would be useful, but ultimately each paramedic will interpret these suggested guidelines based on individual values and the situational context.
Coming to an understanding of the legal issues involved and the ethical-social expectations in advance of a disaster may assist paramedics to respond willingly and appropriately. (Disaster Med Public Health Preparedness. 2019;13:191–196)
Current understanding of climate change impacts, adaptation and vulnerability among Inuit in the Arctic is relatively static, rooted in the community and time that case studies were conducted. This paper captures the dynamism of Inuit–climate relationships by applying a longitudinal approach to assessing vulnerability to climate change among Inuit in Ulukhaktok, Northwest Territories, Canada. Data were collected in 2005 and 2016 following a consistent methodology and analytical framework. Findings from the studies are analysed comparatively together with longitudinal datasets. The data reveal that many of the climatic changes recorded in 2005 that adversely affected hunting activities have been observed to be persisting or progressing, such as decreasing sea ice thickness and extent, and stronger and more consistent summer winds. Inuit are responding by altering travel routes and equipment, taking greater pre-trip precautions, and concentrating their efforts on more efficient and accessible hunts. Increasing living and subsistence costs and time-constraints, changes in the generation and transmission of environmental knowledge and land skills, and the concentration of country food sharing networks were identified as key constraints to adaptation. The findings indicate that the connections between subsistence activities and the wage economy are central to understanding how Inuit experience and respond to climate change.
Giant ragweed has been increasing as a major weed of row crops in the last
30 yr, but quantitative data regarding its pattern and mechanisms of spread
in crop fields are lacking. To address this gap, we conducted a Web-based
survey of certified crop advisors in the U.S. Corn Belt and Ontario, Canada.
Participants were asked questions regarding giant ragweed and crop
production practices for the county of their choice. Responses were mapped
and correlation analyses were conducted among the responses to determine
factors associated with giant ragweed populations. Respondents rated giant
ragweed as the most or one of the most difficult weeds to manage in 45% of
421 U.S. counties responding, and 57% of responding counties reported giant
ragweed populations with herbicide resistance to acetolactate synthase
inhibitors, glyphosate, or both herbicides. Results suggest that giant
ragweed is increasing in crop fields outward from the east-central U.S. Corn
Belt in most directions. Crop production practices associated with giant
ragweed populations included minimum tillage, continuous soybean, and
multiple-application herbicide programs; ecological factors included giant
ragweed presence in noncrop edge habitats, early and prolonged emergence,
and presence of the seed-burying common earthworm in crop fields. Managing
giant ragweed in noncrop areas could reduce giant ragweed migration from
noncrop habitats into crop fields and slow its spread. Where giant ragweed
is already established in crop fields, including a more diverse combination
of crop species, tillage practices, and herbicide sites of action will be
critical to reduce populations, disrupt emergence patterns, and select
against herbicide-resistant giant ragweed genotypes. Incorporation of a
cereal grain into the crop rotation may help suppress early giant ragweed
emergence and provide chemical or mechanical control options for
late-emerging giant ragweed.
National Institute for Health and Care Excellence have recommended faecal calprotectin (FC) testing as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected and it is used to support a diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome. York Hospital and Vale of York Clinical Commissioning Group have developed an evidence-based care pathway to support this recommendation for use in primary care. It incorporates a higher FC cut-off value, a ‘traffic light’ system for risk and a clinical management pathway.
To evaluate this care pathway.
The care pathway was introduced into five primary care practices for a period of six months and the clinical outcomes of patients were evaluated. Negative and positive predictive values (NPV and PPV) were calculated. GP feedback of the care pathway was obtained by means of a web-based survey. Comparator gastroenterology activity in a neighbouring trust was obtained.
The care pathway for FC in primary care had a 97% NPV and a 40% PPV. This was better than GP clinical judgement alone and doubled the PPV compared with the standard FC cut-off (<50 mcg/g), without affecting the NPV. In total, 89% of patients with IBD had an FC>250 mcg/g and were diagnosed by ‘straight to test’ colonoscopy within three weeks. The care pathway was considered helpful by GPs and delivered a higher diagnostic yield after secondary care referral (21%) than the conventional comparator pathway (5%).
A care pathway for the use of FC that incorporates a higher cut-off value, a ‘traffic light’ system for risk and supports clinical decision making can be achieved safely and effectively. It maintains the balance between a high NPV and an acceptable PPV. A modified care pathway for the use of FC in primary care is proposed.
Scriptural Reasoning is the study and discussion of Tanakh, Bible and Qur'an together, usually by Jews, Christians and Muslims. On its Christian side it has had strong Anglican participation since it began in the mid-1990s. This article recounts its origins and development (including its spread beyond the academy and to many countries, including China); offers guidelines for its practice; discusses four key publications that offer Anglican theological understandings of it; summarizes its significance; and proposes that it be practised more widely in the Anglican Communion. The article concludes with meditative and prophetic postscripts.
The settlement of Australia on a continental scale was unimaginable in 1820. Yet by 1850 the continent had been transformed by Europeans and their domesticated animals, and the Australian colonies ranked, with other Anglophone settler societies, among the fastest growing economies in history. Rapid expansion in Australia was neither organic nor inevitable. It was contingent on ecological limits and global political and economic contexts, and was contested by imperial and colonial governments, by excluded settlers and, most of all, by Indigenous people.
Early expansion, 1822–27
In New South Wales, vital groundwork for expansion was laid during the administration of Governor Lachlan Macquarie (1810–21). First, at the end of the Napoleonic wars, Britain appeared to rediscover its convict colony; an influx of convict transports after 1815 increased the tiny local workforce dramatically. Second, there had been important geographic discoveries in the Macquarie era. Driven by overstocking, drought and caterpillar plagues, settlers had crossed the Cowpastures and moved south-west into the cooler climes of Bargo Brush and Sutton Forest, and then beyond, towards the foot-hills of the southern tablelands. Isolated pockets of coastal settlement had also proliferated, to the south on the Illawarra plains and north at Newcastle, where the colony's old penal settlement had grown into an industrial centre supporting around 1,000 prisoners. An overland route from the Hawkesbury River to the lower Hunter Valley, north of Newcastle, paved the way for expansion into what would soon be one of the colony's most productive agricultural districts. Most important, however, was the breaching of the Blue Mountains west of Sydney, that great physical and perceptual boundary that had long defined the colony's horizon. By 1818 a long, sinuous road had been carved across the sandstone ridges of the Great Dividing Range, descending onto the Bathurst plains where two great waterways, the Lachlan and Macquarie rivers, flowed enticingly inland.
Reading through the chapters in this volume with a view to responding to it and looking to the future, I have been immediately struck by two things.
The first is the debt of gratitude owed to Rowan Williams, then Archbishop of Canterbury, for opening up the question of shariʽa in Britain in the way he did. It was courageous to face the issue so squarely in his 2008 lecture; in the media storm that followed, the basis for which is so helpfully described by Robin Griffith-Jones, even greater courage was required to hold his ground and respond so patiently and thoroughly to many critics. In retrospect, it seems the sort of statesmanlike contribution to public debate that few others could have made and that exemplifies a healthy way of addressing issues surrounding religion in the life of the nation. It is not that his way of handling the question of shariʽa in Britain can now, after the misrepresentations have been identified, be seen as uncontroversial; rather, he has placed the question firmly on the table in a way that, if one returns to his original lecture, helps to ensure that it can be debated with appropriate categories and concepts, and without the sorts of misunderstandings (not least about the nature of shariʽa ) that are widespread (even in pronouncements of the European Court of Human Rights (ECtHR)). Not least among the benefits of his lecture has been the impetus for drawing together the distinguished contributors to this volume, producing an expert, multi-faceted approach to the topic that should make it required reading far beyond Britain.
The Nicodemus story can be read as a distillation of the Gospel of John and an example of many of its key features. John 3:1–21 poses a wide range of the problems raised by this most distinctive and mysterious of the four gospels. It shows characteristic practices of John as a reader, writer and teacher. In line with John's theology of the Spirit ‘leading into all the truth’, it also shows him as a daring theologian, opening up fresh interpretations and ways of doing theology beyond the Septuagint and the Synoptic Gospels and even beyond his own Prologue (itself a remarkably daring piece of theology). That same Spirit means that John also expects his readers to be led into further truth, and to improvise on his theology as he himself did on the Septuagint and on the Synoptic traditions. His ways of reading, writing and teaching encourage such a response in the Spirit by creating a work rich in intertextuality, imagery and conceptuality which has a ‘deep plain sense’, superabundant in meaning and always inviting the reader to reread, learn more and interpret afresh. So one challenge for readers now is whether they are open not only to thinking along with John but also to thinking beyond him, in ways appropriate to different people and contexts. But this transformation in thought and imagination is not all: it is inseparable from doing the truth ‘in God’. The mutual involvement of seeing, believing/trusting, knowing and living in love is above all communicated in the drama of John's Gospel, whose backbone is a series of meetings with Jesus and the injunction to follow Jesus. More embracing and fundamental than, for example, doctrinal theology or existential decision-making, is the dramatic reality of encountering other people and following Jesus in all the complexities of life in specific contexts. In John 3:1–21 the encounter of Jesus with Nicodemus is the dramatic heart of the passage, blending into a discourse which itself culminates in the ultimate drama of ‘deeds done in God’. But to stop interpretation there would be to refuse the Johannine invitation to enter into more truth with a view to ‘doing greater things’. So the article ends with two midrashic interpretations of Nicodemus for today.
To evaluate the first phase of a specialist weight management programme provided entirely within the UK National Health Service.
Prospective cohort study using multiple logistic regression analysis to report odds of ≥5 kg weight loss in all referrals and completers, and odds of completion, with 95 % confidence intervals. Anxiety and depression ‘caseness’ were measured by the Hospital Anxiety and Depression Scale.
Glasgow and Clyde Weight Management Service (GCWMS) is a specialist multidisciplinary service, with clinical psychology support, for patients with BMI ≥35 kg/m2 or BMI ≥30 kg/m2 with co-morbidities.
All patients referred to GCWMS between 2004 and 2006.
Of 2976 patients referred to GCWMS, 2156 (72·4 %) opted into the service and 809 completed phase 1. Among 809 completers, 35·5 % (n 287) lost ≥5 kg. Age ≥40 years, male sex (OR = 1·39, 95 % CI 1·05, 1·82), BMI ≥ 50 kg/m2 (OR = 1·70, 95 % CI 1·14, 2·54) and depression (OR = 1·81, 95 % CI 1·35, 2·44) increased the likelihood of losing ≥5 kg. Diabetes mellitus (OR = 0·55, 95 % CI 0·38, 0·81) and socio-economic deprivation were associated with poorer outcomes. Success in patients aged ≥40 years and with BMI ≥50 kg/m2 was associated with higher completion rates of the programme. Patients from the most deprived areas were less likely to lose ≥5 kg because of non-completion of the programme.
Further improvements in overall effectiveness might be achieved through targeting improvements in appropriateness of referrals, retention and effective interventions at specific populations of patients.