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Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.
To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.
A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.
In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).
Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.
North American studies show bipolar disorder is associated with elevated
rates of problem gambling; however, little is known about rates in the
different presentations of bipolar illness.
To determine the prevalence and distribution of problem gambling in
people with bipolar disorder in the UK.
The Problem Gambling Severity Index was used to measure gambling problems
in 635 participants with bipolar disorder.
Moderate to severe gambling problems were four times higher in people
with bipolar disorder than in the general population, and were associated
with type 2 disorder (OR = 1.74, P = 0.036), history of
suicidal ideation or attempt (OR = 3.44, P = 0.02) and
rapid cycling (OR = 2.63, P = 0.008).
Approximately 1 in 10 patients with bipolar disorder may be at moderate
to severe risk of problem gambling, possibly associated with suicidal
behaviour and a rapid cycling course. Elevated rates of gambling problems
in type 2 disorder highlight the probable significance of modest but
unstable mood disturbance in the development and maintenance of such
Methylation of the fragile X mental retardation 1 (FMR1) exon 1/intron 1 boundary positioned fragile X related epigenetic element 2 (FREE2), reveals skewed X-chromosome inactivation (XCI) in fragile X syndrome full mutation (FM: CGG > 200) females. XCI skewing has been also linked to abnormal X-linked gene expression with the broader clinical impact for sex chromosome aneuploidies (SCAs). In this study, 10 FREE2 CpG sites were targeted using methylation specific quantitative melt analysis (MS-QMA), including 3 sites that could not be analysed with previously used EpiTYPER system. The method was applied for detection of skewed XCI in FM females and in different types of SCA. We tested venous blood and saliva DNA collected from 107 controls (CGG < 40), and 148 FM and 90 SCA individuals. MS-QMA identified: (i) most SCAs if combined with a Y chromosome test; (ii) locus-specific XCI skewing towards the hypomethylated state in FM females; and (iii) skewed XCI towards the hypermethylated state in SCA with 3 or more X chromosomes, and in 5% of the 47,XXY individuals. MS-QMA output also showed significant correlation with the EpiTYPER reference method in FM males and females (P < 0.0001) and SCAs (P < 0.05). In conclusion, we demonstrate use of MS-QMA to quantify skewed XCI in two applications with diagnostic utility.
We use a WISE-2MASS-Pan-STARRS1 galaxy catalog to search for a supervoid in the direction of the Cosmic Microwave Background Cold Spot. We obtain photometric redshifts using our multicolor data set to create a tomographic map of the galaxy distribution. The radial density profile centred on the Cold Spot shows a large low density region, extending over 10's of degrees. Motivated by previous Cosmic Microwave Background results, we test for underdensities within two angular radii, 5°, and 15°. Our data, combined with an earlier measurement by Granett et al. 2010, are consistent with a large Rvoid=(192 ± 15)h−1 Mpc (2σ) supervoid with δ ≃ −0.13 ± 0.03 centered at z=0.22 ± 0.01. Such a supervoid, constituting a ∼3.5 σ fluctuation in the ΛCDM model, is a plausible cause for the Cold Spot.
An anonymous survey of Australian Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted with the aim of understanding current practice and attitudes toward population-based carrier screening for inherited conditions in the setting of routine pregnancy care. Of 1,121 Fellows invited to complete the online questionnaire by e-mail, 237 (21%) responded, and of these 156 were practicing obstetricians and completed the whole survey. Of the respondents, 83% expressed support for population-based carrier screening for at least some conditions, with 97% supporting carrier screening for β-thalassaemia, and 83% supporting carrier screening for cystic fibrosis (CF). A small proportion of obstetricians reported offering carrier screening as part of routine pregnancy care (20% for β-thalassaemia, 8% for CF, 5% for fragile X syndrome, and 2% for spinal muscular atrophy). The main practical barriers identified for screening were cost, time constraints, and availability of supporting services. Addressing these issues is crucial for the successful implementation of population-based carrier screening programs in Australia and internationally.
Recently, for many health economics researchers, empirical estimation of the monetary valuation of a quality-adjusted life year (QALY) has become an important endeavour. Different philosophical and practical approaches to this have emerged. On the one hand, there is a view that, with health-care budgets set centrally, decision-making bodies within the system can iterate, from observation of a series of previous decisions, towards the value of a QALY, thus searching for such a value. Alternatively, and more consistent with the approach taken in other public sectors, individual members of the public are surveyed with the aim of directly eliciting a preference-based – also known as a willingness-to-pay-based (WTP-based) – value of a QALY. While the former is based on supply-side factors and the latter on demand, both in fact suffer from informational deficiencies. Sole reliance on either would necessitate an acceptance or accommodation of chronic inefficiencies in health-care resource allocation. On the basis of this observation, this paper makes the case that in order to approach optimal decision making in health-care provision, a framework incorporating and thus, to a degree, reconciling these two approaches is to be preferred.
We develop a forward-looking version of the recursive dynamic MIT Emissions Prediction and Policy Analysis (EPPA) model, and apply it to examine the economic implications of proposals in the US Congress to limit greenhouse gas (GHG) emissions. We find that shocks in the consumption path are smoothed out in the forward-looking model and that the lifetime welfare cost of GHG policy is lower than in the recursive model, since the forward-looking model can fully optimize over time. The forward-looking model allows us to explore issues for which it is uniquely well suited, including revenue-recycling and early action crediting. We find capital tax recycling to be more welfare-cost reducing than labor tax recycling because of its long-term effect on economic growth. Also, there are substantial incentives for early action credits; however, when spread over the full horizon of the policy they do not have a substantial effect on lifetime welfare costs.
The United States is moving closer to enacting comprehensive climate change policy. President Obama campaigned in 2008 in part on a platform of re-engaging in the international negotiations on climate policy and supported a U.S. cap-and-trade policy with 100 percent auctioning of permits. Congress moved rapidly in 2009, with the House of Representatives voting favorably on the American Clean Energy and Security Act of 2009 (H.R. 2454) in late June of that year. What will happen in the Senate is still unresolved as this is written.
H.R. 2454 establishes a cap-and-trade system to reduce greenhouse gas emissions 17 percent below 2005 levels by 2020 and 83 percent by 2050. Among other provisions, it contains new energy efficiency standards for various appliances and a renewable electricity standard that requires retail suppliers to meet 20 percent of their electricity demand through renewable sources and energy efficiency by 2020 (see Holt and Whitney  for a detailed description of the bill).
Cap-and-trade legislation acts like a tax in raising the price of carbon-based fuels and other covered inputs that release greenhouse gases. The monies involved in a cap-and-trade program are significant. The Congressional Budget Office estimated in June 2009 that H.R. 2454 would increase federal revenues by nearly $850 billion between 2010 and 2019. Because the bulk of permits are freely allocated in the early years of the program, spending would also increase over that period by roughly $820 billion.
Immediately after his successful conquest of Muslim Sicily (1060–92), Roger de Hauteville set about dividing the spoils amongst the small band of Norman, French and Italian knights who were his closest followers. This distribution of the land of Sicily and its inhabitants was in part based upon the fiscal documents of the Muslim administration, which were salvaged and adapted to post-conquest circumstances by a small cadre of Greek bureaucrats imported from Calabria. The documents were of two types: lists of tax-payers, known in Arabic as jarā 'id (sg. jarīda; Greek plateia; Latin plated); and descriptions of estate boundaries, known as hudud (sg. hadd; Greek periorismos; Latin divisa). These were the foundations of the Arabic administration of Norman Sicily.
Mammary gland protein metabolism, determined by an arteriovenous difference technique, was monitored in four Holstein-Friesian dairy cows in response to supplemental dietary protein (provided as rumen-protected soyabean meal) during late lactation (weeks 24–30). Each cow was offered two isoenergetic diets composed of grass silage (170 g crude protein/kg dry matter) plus either a low (108 g/kg) or medium (151 g/kg) crude protein concentrate in a single crossover design involving two 21 d periods. On day 21, arteriovenous measurements across the mammary gland were made during a 13 h continuous i.v. infusion of [1-13C]leucine and with frequent (2 hourly) milk sampling during the final 6 h. Although total milk yield was slightly increased (+1 kg/d) by protein supplementation, milk protein yield was not significantly affected. Whole body protein flux (protein synthesis plus oxidation) was not significantly affected by supplementation. Total mammary gland protein synthesis (milk plus non-milk protein) was also not affected by supplementation but on both diets gland synthesis was always greater (by 20–59%) than milk protein output. The fractional oxidation rate of leucine by the mammary gland was significantly increased by protein supplementation (0·047 v. 0·136). Although the enrichment of leucine in secreted milk protein continued to increase, the final value (at 13 h) was 0·94 of the arterial plasma free leucine plateau value (not significantly different), suggesting almost exclusive use of plasma free leucine for milk protein synthesis. Based on current feeding schemes for dairy cattle, a fixed proportion (0·65–0·75) of the additional protein intake (+490 g/d) should have been partitioned into milk protein. Instead, leucine oxidation by the mammary gland was increased. Whether oxidation of other amino acids was also enhanced is unknown but if amino acid oxidation and the ‘additional’ non-milk protein synthesis occurring in the gland are not crucial to milk synthesis, then by reducing such activities improvements in the efficiency of converting absorbed amino acid into milk protein can be achieved.
The hyperinsulinaemic euglycaemic insulin clamp technique was used to compare insulin sensitivity in lactating ewes at two levels of feeding. Clamps were performed at two (restricted intake) or three (ad libitum intake) stages of lactation and also 30 d after drying off. Dose response curves for insulin were constructed using the glucose metabolic clearance rate (MCR) as the measure of glucose metabolism and these were statistically compared between stages of lactation within the feeding levels, and also between feeding regimes. Animals on a restricted feed intake showed a weight loss throughout lactation, coupled with a lower insulin sensitivity, as measured by the ED50 (concentration of insulin required to produce a half maximal increase in MCR), while those on ad libitum feeding showed a weight gain and a decreased insulin sensitivity in the dry period. Endogenous glucose production was less sensitive to inhibition by insulin in the animals subjected to restricted food intake, compared with those on the ad libitum regime, which suggested a major role for the plane of nutrition in adjusting the homeorhetic control of metabolism during lactation.
This article is concerned with principles that might help to ensure that procedures and tools used in primary care are appropriate to people's needs and expectations. It urges attention, not first to technology, but to the broad range of purposes served by primary care and to the relevance of procedures to them. Other criteria for ensuring appropriateness are also proposed.
During the summer of 1967 willcmite was found for the first time in the Ilímaussaq alkaline intrusion, South Greenland. The willemite occurs in an albitite together with aegirine/acmite, albite, analcime, arfvedsonite, apatite, chkalovite, hemimorphite, microcline, monazite, natrolite, naujakasite, neptunite, sphalerite, and polylithionite. Analytical, optical, and X-ray data were obtained from the willemite. Willemite from a calcite vein at Franklin Furnace, New Jersey, and from a quartz vein at Mussartût, South Greenland, were also examined.
One of the willemite crystals from Ilimaussaq was a trilling on <100>. This is the first time willemite has been found as a trilling.