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Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.
To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).
Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.
All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.
The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.
Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.
To explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders.
Six online focus groups with 19 young people aged 16–25 years with existing or past eating disorders and 11 parents.
Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to ‘truly specialist’; (c) enhance peer and family support.
Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.
Bowel cancer risk is strongly influenced by lifestyle factors including diet and physical activity. Several studies have investigated the effects of adherence to the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) cancer prevention recommendations on outcomes such as all-cause and cancer-specific mortality, but the relationships with molecular mechanisms that underlie the effects on bowel cancer risk are unknown. This study aimed to investigate the relationships between adherence to the WCRF/AICR cancer prevention recommendations and wingless/integrated (WNT)-pathway-related markers of bowel cancer risk, including the expression of WNT pathway genes and regulatory microRNA (miRNA), secreted frizzled-related protein 1 (SFRP1) methylation and colonic crypt proliferative state in colorectal mucosal biopsies. Dietary and lifestyle data from seventy-five healthy participants recruited as part of the DISC Study were used. A scoring system was devised including seven of the cancer prevention recommendations and smoking status. The effects of total adherence score and scores for individual recommendations on the measured outcomes were assessed using Spearman’s rank correlation analysis and unpaired t tests, respectively. Total adherence score correlated negatively with expression of Myc proto-oncogene (c-MYC) (P=0·039) and WNT11 (P=0·025), and high adherers had significantly reduced expression of cyclin D1 (CCND1) (P=0·042), WNT11 (P=0·012) and c-MYC (P=0·048). Expression of axis inhibition protein 2 (AXIN2), glycogen synthase kinase (GSK3β), catenin β1 (CTNNB1) and WNT11 and of the oncogenic miRNA miR-17 and colonic crypt kinetics correlated significantly with scores for individual recommendations, including body fatness, red meat intake, plant food intake and smoking status. The findings from this study provide evidence for positive effects of adherence to the WCRF/AICR cancer prevention recommendations on WNT-pathway-related markers of bowel cancer risk.
The history of psychiatry is the history of therapeutic enthusiasm with all of the triumph and tragedy, hubris and humility that this brings. As a result, the emergence of any new diagnosis, such as attention-deficit hyperactivity disorder (ADHD), needs to be greeted with caution, rigour and scientific objectivity, as well as compassion, therapeutic engagement and optimism. Although there is now little doubt that ADHD is a valid, useful diagnostic concept, and progress has been made, there is still considerable work to be done to establish its incidence, prevalence and biological underpinnings, as well as optimal therapeutic strategies. As with all mental illnesses, it is likely that knowledge will develop over many decades and diagnostic criteria will be refined in parallel. In the absence of definitive biological understanding, there should be particular caution about over-exuberant diagnostic expansionism unless it is accompanied by compelling evidence of therapeutic benefit for those diagnosed.
Despite evidence for the effectiveness of structured psychological
therapies for bipolar disorder no psychological interventions have been
specifically designed to enhance personal recovery for individuals with
recent-onset bipolar disorder.
A pilot study to assess the feasibility and effectiveness of a new
intervention, recovery-focused cognitive–behavioural therapy (CBT),
designed in collaboration with individuals with recent-onset bipolar
disorder intended to improve clinical and personal recovery outcomes.
A single, blind randomised controlled trial compared treatment as usual
(TAU) with recovery-focused CBT plus TAU (n = 67).
Recruitment and follow-up rates within 10% of pre-planned targets to
12-month follow-up were achieved. An average of 14.15 h (s.d. = 4.21) of
recovery-focused CBT were attended out of a potential maximum of 18 h.
Compared with TAU, recovery-focused CBT significantly improved personal
recovery up to 12-month follow-up (Bipolar Recovery Questionnaire mean
score 310.87, 95% CI 75.00–546.74 (s.e. = 120.34), P =
0.010, d=0.62) and increased time to any mood relapse
during up to 15 months follow-up (χ2 = 7.64,
P<0.006, estimated hazard ratio (HR) = 0.38, 95%
CI 0.18–0.78). Groups did not differ with respect to medication
Recovery-focused CBT seems promising with respect to feasibility and
potential clinical effectiveness. Clinical- and cost-effectiveness now
need to be reliably estimated in a definitive trial.
Organisational culture of institutions providing care for older people is increasingly recognised as influential in the quality of care provided. There is little research, however, that specifically examines the processes of care home culture and how these may be associated with quality of care. In this paper we draw from an empirical study carried out in the United Kingdom (UK) investigating the relationship between care home culture and residents' experience of care. Eleven UK care homes were included in an in-depth comparative case study design using extensive observation and interviews. Our analysis indicates how organisational cultures of care homes impact on the quality of care residents receive. Seven inter-related cultural elements were of key importance to quality of care. Applying Schein's conceptualisation of organisational culture, we examine the dynamic relationship between these elements to show how organisational culture is locally produced and shifting. A particular organisational culture in a care home cannot be achieved simply by importing a set of organisational values or the ‘right’ leader or staff. Rather, it is necessary to find ways of resolving the everyday demands of practice in ways that are consistent with espoused values. It is through this everyday practice that assumptions continuously evolve, either consistent with or divergent from, espoused values. Implications for policy makers, providers and practitioners are discussed.
Consumer health organisations (CHOs), which operate outside the mainstream healthcare system with a specific focus on supporting people to self-manage their health conditions, have become widespread. Yet, there has been little systematic research into CHOs, including their perceived benefits and barriers, which encourage or deter their access by people with a variety of chronic health conditions.
This study explored the benefits of CHOs in self-management and also the barriers that inhibit their access, from the perspective of people with chronic conditions and their unpaid carers.
In-depth, semi-structured interviews were completed with 97 participants across four regions of Australia. The sample included a high representation of people from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander people as well as non-indigenous Australians.
Three inter-related themes were identified that represented the benefits of involvement and participation in CHOs: knowledge and information, connection and support and experiential learning. However, limited access pathways emerged as a barrier that inhibited a person’s entry into CHOs. Furthermore, the person’s beliefs and experiences about their own health condition(s) also inhibited their continued participation in CHO programmes.
Although our findings confirm that CHOs are a valuable resource in alleviating the ‘work of being a patient’ for some people, there seems to be some barriers that prevent their full access and utilisation. Structured integration systems to increase the reliable delivery and accessibility of CHOs are needed to ensure that people who would benefit from accessing them can do so.
This paper draws on two data sources (Kelly's ethnographic study and a British Broadcasting Corporation television programme) to explore the practice of bodywork in the care of frail people with dementia in institutional settings. It explores the complexity of engaging in bodywork, particularly work that is distasteful to the care-worker, and shows how non-recognition of the selfhood of the person with dementia can result in practices that are demeaning and potentially abusive to those in receipt of such work. In contrast to a person-centred approach that urges practitioners to acknowledge people with dementia as unique individuals, with unique needs, wishes, abilities and desires, this paper argues for the use of Sabat's Selfs 1–3 construct to look for commonalities of selfhood, enabling care workers to recognise aspects of themselves in their patients as they carry out care, thereby facilitating care that empathically respects their patients' dignity and potential for vulnerability. Thus, it aims to advance theory and improve practice by arguing for the necessity of putting selfhood at the forefront of bodywork in order to facilitate respectful care that dignifies rather than objectifies the person.
On March 11, 2011, Japan experienced the largest earthquake in its history. The undersea earthquake launched a tsunami that inundated much of Japan's eastern coastline and damaged nuclear power plants, precipitating multiple reactor meltdowns. We examined open-source disaster situation reports, news accounts, and disaster-monitoring websites to gather event-specific data to conduct a trauma signature analysis of the event.
The trauma signature analysis included a review of disaster situation reports; the construction of a hazard profile for the earthquake, tsunami, and radiation threats; enumeration of disaster stressors by disaster phase; identification of salient evidence-based psychological risk factors; summation of the trauma signature based on exposure to hazards, loss, and change; and review of the mental health and psychosocial support responses in relation to the analysis.
Exposure to this triple-hazard event resulted in extensive damage, significant loss of life, and massive population displacement. Many citizens were exposed to multiple hazards. The extremity of these exposures was partially mitigated by Japan's timely, expert-coordinated, and unified activation of an evidence-based mental health response.
The eastern Japan disaster was notable for its unique constellation of compounding exposures. Examination of the trauma signature of this event provided insights and guidance regarding optimal mental health and psychosocial responses. Japan orchestrated a model response that reinforced community resilience. (Disaster Med Public Health Preparedness. 2013;0:1-14)
Few studies have focused on the mental health consequences of indirect exposure to disasters caused by naturally occurring hazards. The present study assessed indirect exposure to the 2010 earthquake in Haiti among Haitian-Americans now living in Miami; these subjects had no direct exposure to the earthquake, but retained their cultural identity, language, and connection to family and friends in Haiti.
Two months following the earthquake a sample of Haitian-Americans was surveyed inquiring about: (1) their psychological reactions to the quake; (2) types of exposures experienced by their family members and friends in Haiti; and (3) symptom levels of (a) major depression, (b) generalized anxiety disorder, (c) complicated grief, (d) mental health status, and (e) physical health status.
Haitian-Americans living in Miami experienced a broad spectrum of indirect exposures to the 2010 earthquake in Haiti. These exposures were strongly associated with psychological distress, trauma-related mental health consequences, and diminished health status. Most notable was the multiplicity of indirect exposures to the on-scene experiences of multiple family members and friends in Haiti.
Consideration should be given to the psychological impact and needs for support among indirectly-exposed populations with strong affiliation to directly-impacted victims.
Shultz JM, Besser A, Kelly F, Allen A, Schmitz S, Hausmann V, Marcelin LH, Neria Y. Psychological consequences of indirect exposure to disaster due to the Haiti earthquake. Prehosp Disaster Med. 2012;27(4):1-10.
Early medieval stone sculpture is the most important archaeological evidence we currently have for identifying the process of conversion to Christianity and the development and distribution of ecclesiastical foundations and related sites in Wales before the twelfth century. Moreover, close examination of the sculpture – including quantification, and consideration of its archaeological and historical context, geology, form, function, ornament and inscriptions – also allows us to study it as an important manifestation of material, economic and social investment and consequently to pose other interesting questions concerning cultural contacts, wealth and patronage, the ownership of land and the relationship between secular rulers and the Church.
To date, research on the early medieval sculpture of north-west Wales has tended to focus on the inscribed memorial stones of the fifth to seventh centuries. Though some of the later monuments have been discussed, notably by H. Harold Hughes and C. A. R. Radford, a number were not noted in Nash-Williams's Early Christian Monuments of Wales and several others have come to light more recently. The aim of this paper is to focus on the Viking-Age sculpture of northwest Wales, especially Anglesey, which is broadly datable from the tenth to early twelfth centuries, and to examine the complete range of carved stone monuments, not just the large-scale, free-standing decorated crosses, particularly those at Penmon, which have tended to receive most attention in the past.
Christian iconography is not so plentiful in the post-Roman states of Britain that we can afford to ignore a varied and interesting range of crosses and other motifs from a period when we are otherwise heavily dependent on epigraphic evidence, a tradition that was largely peculiar to the far west and north. The problem is the source: like Dean Swift's island of Laputa, a substantial body of hanging-bowls floats above the cultural landscape of seventh-century Britain. Often labelled ‘Anglo-Saxon’ from their usual find-places in furnished burials in eastern England, considerable ingenuity has been expended in the past in arguing for a Germanic context for the manufacture of these distinctive vessels, despite their late Celtic decoration. Most hanging-bowls are demonstrably not made for or by Germanic owners and in their ornament they bear unique witness to the pretensions, changing tastes and religion of the Celtic patrons for whom most of these luxury items were originally manufactured. The tally of early bowls is now well over 150 and steadily rising through metal-detecting and controlled excavations, but is certainly an underestimate because the parts that survive best are the applied mounts, comprising suspension hooks with a decorated plate, separate appliqués or basal plates attached to the inside or outside of the vessel. Otherwise unrecorded bowl-mounts pass through coin fairs and appear on Internet sale sites.
In the first preface to the Descriptio Kambriae, completed in 1194, Gerald of Wales makes two related assertions: he had written a work of history, and he had sought to imitate the example of Gildas. Although by no means ignored, both statements have remained at the margins of scholarly discussion, which has tended to concentrate on the Descriptio's novelty as a remarkably detailed, albeit partial, account of a medieval country and people as well as on what it reveals of its author's attitude towards Wales and the Welsh. The emphasis on the work as an original contribution to ethnographic writing strongly coloured by its author's complex relationship with Wales remains highly illuminating. However, this essay will argue that, in order to appreciate the nature of that contribution, Gerald's presentation of the Descriptio as a piece of historical writing needs to be taken very seriously, for it was central to his purpose. In particular, it will suggest that, just as Bede's account of the seventh- and eighth-century Britons was informed by a reading of Gildas, so too was Gerald's description of the Welsh. After a brief introduction to the Descriptio Kambriae the discussion will consider how Gerald uses the past in the work in general before moving on to explore the implications of his specific identification with Gildas.
One of the many subjects on which Thomas Charles-Edwards has immeasurably broadened our understanding over the years is that of early Irish legal education. Through his work we have been invited to contemplate not merely what, but how, budding lawyers were being taught in the schools. No tract addresses the issue of instructional method specifically; however, given the traditional understanding of the extant law tracts as textbooks for junior jurists, it seems only reasonable to imagine that one might be able to infer something about this from the texts that remain. Particularly difficult to reconstruct from this distance are the oral aspects of early legal instruction, though one tract in the corpus has always seemed to me especially promising in this respect. Berrad Airechta, an early-eighth-century tract on suretyship and contract (and the first text I ever read with Professor Charles-Edwards thirty years ago at Oxford), is well known among specialists for the large amount of purportedly oral material it contains. Not only is it one of our most important sources for sayings attributed to the traditional oral law known as Fénechas, but at the core of the tract are replicated what purport to be the ritualised oral exchanges used by creditor and debtor in contracting obligations. Equally intriguing are the ten quotations not ascribed to Fénechas but introduced in the text by expressions such as is de asberr, ‘it is regarding this that this is said’, or cid dia nepir, ‘why is this said?’
A cartulary of the Benedictine cathedral priory of Bath, which on the evidence of its script has been dated to around the mid-twelfth century, contains an indulgence granted by Marcus Cluanensis episcopus to the ‘truly penitent’ who with alms and prayers would visit the church at Bath on the feast of the Exaltation of the Cross (14 September). The text, which is printed in Appendix 1,2 is preceded in the cartulary by similar indulgences from Theobald, archbishop of Canterbury (1138–61), and Robert, bishop of Bath (1136–66), and followed by one from Nicholas, bishop of Llandaff (1148–83). As is usual in texts of indulgences, none contains a witness-list and this makes dating difficult, with the added consequence in the case of Marcus that his very identity remains obscure. The four indulgences evidently form a series, as in each the period of remission is twenty days and is linked to the celebration of the same feast. However, there are also differences in the wording of the four texts which may indicate that they were not necessarily issued on the same occasion. The indulgence of Robert, bishop of Bath, recorded that he had consecrated a cross in the cathedral church on the feast of the Exaltation of the Cross, and it was the acquisition of this new cross which appears to have occasioned the indulgences. It is conceivable that Robert may have been assisted at the consecration ceremony by one or more of the other bishops who also granted indulgences.
Cyfraith Hywel, the law of Hywel, was the system of law followed in Wales throughout the Middle Ages; attributed to Hywel ap Cadell (Hywel Dda), d. 949 or 950, it survives in some forty manuscripts dating from the mid-thirteenth century to the fifteenth century. It was a native legal system, distinct from both English law and Canon Law; had the system survived to this day, it would be a third class of law in the United Kingdom, a Volksrecht-system to join the Scottish civil law tradition and the English common law.
The manuscripts of Welsh law divide into three Welsh groups or redactions, named after eminent lawyers noted in the prologues of each redaction: Iorwerth, Blegywryd and Cyfnerth. The Latin manuscripts form a separate group. There are eight manuscripts in the Iorwerth redaction, and they take up the first letters of the alphabet in the sigla assigned to them by Aneurin Owen. They are: Aberystwyth, National Library of Wales, Peniarth 29 (The Black Book of Chirk, Owen's A); London, British Library, Cotton Titus D.ii (B); BL Cotton Caligula A.iii (C); NLW Peniarth 32 (D); BL Additional MS. 14931 (E); NLW Peniarth 35 (G); NLW Peniarth 40 (K); and NLW Peniarth 39 (named Lew by William Maurice, it was not known to Owen). Llyfr Colan, NLW Peniarth MS 30, is a revised version of the Iorwerth redaction. The Iorwerth redaction is from north Wales and includes some of the earliest manuscripts of Welsh law; the text itself can be linked to the kingdom of Gwynedd during the time of Llywelyn ap Iorwerth and Llywelyn ap Gruffudd.