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An increasing number of patients are being prescribed direct oral anticoagulants (DOACs), while the patients who remain on warfarin are becoming more complex. There is currently a lack of a standardised anticoagulation review for patients in primary care, resulting in potentially preventable harm events. Our aim was to implement a new service, where a standardised review is carried out by a specialist multidisciplinary secondary care anticoagulation team. Overall, the implementation of a standardised review resulted in better optimisation of anticoagulation management for patients taking either a DOAC or a warfarin. Of the 172 eligible patients prescribed warfarin, 47 (27%) chose to switch a DOAC. The average time in therapeutic range for patients on warfarin before and after the pilot increased from 73.5% to 75%. Of 482 patients taking a DOAC, 35 (7%) were found to be on incorrect dose. In 32 (91%) of 35 patients, the dose was amended after notifying the patient’s general practitioner. We also found a significant number of patients inappropriately prescribed concomitant medication such as antiplatelet or non-steroidal anti-inflammatory drugs, potentially putting the patients at an elevated risk of bleeding. While further research is needed; we believe the results of this pilot can be used to help build a case to influence the commissioning of anticoagulation services. Secondary care anticoagulation teams, like our own, may be well-placed to provide or support such services, by working across the primary care and secondary care interface to support our primary care colleagues.
To utilise a community-based participatory approach in the design and implementation of an intervention targeting diet-related health problems on Navajo Nation.
A dual strategy approach of community needs/assets assessment and engagement of cross-sectorial partners in programme design with systematic cyclical feedback for programme modifications.
Navajo Nation, USA.
Navajo families with individuals meeting criteria for programme enrolment. Participant enrolment increased with iterative cycles.
The Navajo Fruit and Vegetable Prescription (FVRx) Programme.
A broad, community-driven and culturally relevant programme design has resulted in a programme able to maintain core programmatic principles, while also allowing for flexible adaptation to changing needs.
This paper explores the complex story of a particular style of rock art in western Arnhem Land known as ‘Painted Hands’. Using new evidence from recent fieldwork, we present a definition for their style, distribution and place in the stylistic chronologies of this region. We argue these motifs played an important cultural role in Aboriginal society during the period of European settlement in the region. We explore the complex messages embedded in the design features of the Painted Hands, arguing that they are more than simply hand stencils or markers of individuality. We suggest that these figures represent stylized and intensely encoded motifs with the power to communicate a high level of personal, clan and ceremonial identity at a time when all aspects of Aboriginal cultural identity were under threat.
The ‘jumping to conclusions’ (JTC) bias is associated with both psychosis and general cognition but their relationship is unclear. In this study, we set out to clarify the relationship between the JTC bias, IQ, psychosis and polygenic liability to schizophrenia and IQ.
A total of 817 first episode psychosis patients and 1294 population-based controls completed assessments of general intelligence (IQ), and JTC, and provided blood or saliva samples from which we extracted DNA and computed polygenic risk scores for IQ and schizophrenia.
The estimated proportion of the total effect of case/control differences on JTC mediated by IQ was 79%. Schizophrenia polygenic risk score was non-significantly associated with a higher number of beads drawn (B = 0.47, 95% CI −0.21 to 1.16, p = 0.17); whereas IQ PRS (B = 0.51, 95% CI 0.25–0.76, p < 0.001) significantly predicted the number of beads drawn, and was thus associated with reduced JTC bias. The JTC was more strongly associated with the higher level of psychotic-like experiences (PLEs) in controls, including after controlling for IQ (B = −1.7, 95% CI −2.8 to −0.5, p = 0.006), but did not relate to delusions in patients.
Our findings suggest that the JTC reasoning bias in psychosis might not be a specific cognitive deficit but rather a manifestation or consequence, of general cognitive impairment. Whereas, in the general population, the JTC bias is related to PLEs, independent of IQ. The work has the potential to inform interventions targeting cognitive biases in early psychosis.
Among the 10 categories of personality disorders (PDs), interventions for antisocial and borderline personality disorder are best studied. However, the remaining PDs also pose major problems in everyday health care settings. People affected often additionally present with Axis-I disorders such as substance-related, mood or anxiety disorders, and are among those most difficult to treat. Cluster A PDs (paranoid, schizoid, schizotypal) are of particular significance as some authors argue that they may be part of a continuum of mental disorders and be considered as sub-syndrome of schizophrenia
In the context of Cochrane Collaboration reviews for Cluster A, B and C PDs, exhaustive literature searches were completed to identify the current RCT evidence for PD treatments. Retrievals were assessed and evaluated by two reviewers independently and trials for Cluster A PD were identified.
Only very few (under five) RCTs specifically for Cluster A PDs were identified. Some studies reported on mixed PD samples but it was not always possible to extract data specifically for Cluster A disorders. Participants mostly also suffered from Axis-I disorders. Reported outcomes also focus on Axis-I disorder outcomes or general measures such as overall functioning rather than specific PD symptoms.
The current evidence for psychpathological treatment of Cluster A PD is sparse and does not allow for distinct treatment recommendations. Symptom-driven treatment regimes as suggested by several guidelines are not supported by current evidence.
Limited to no literature exists on the association among sleep quality, obesity and depression in pediatric populations. This study aims to explore this association by examining the sleep quality of children and adolescents before and after a twelve-week comprehensive multidisciplinary pediatric obesity program.
Archival data from the pediatric obesity program included 71 children ages 6-17 (M=10.24, SD=2.74 ) who had been assessed pre and post intervention using the Children's Depression Inventory (CDI), a Sleep Questionnaire, and physician derived Body Mass Index (BMI). On all measures, higher scores indicate presence of symptoms of depression, sleep difficulties, or obesity.
High scores on the CDI proved to predict poor sleep quality both at intake and exit. Hierarchical regression exhibited change in BMI from intake to exit and predicted sleep quality. As BMI decreased from intake to exit, sleep quality increased.
The current study suggests that sleep quality is influenced by the level of depression in children and adolescents both at pre and post intervention measures. Both depression and BMI influenced sleep quality. When the effect of BMI was accounted for, depression significantly predicted sleep quality. The more depressed children/adolescents reported to be, the lower their quality of sleep. Thus, this study suggests the importance of sleep and depression in the treatment of pediatric obesity. This research supports the importance of a multidisciplinary approach to addressing pediatric obesity.
Cannabis is a widely used drug, which effects on human health remain controversial. Recent studies have found correlations between cannabis use and brain structural changes that may be related to ageing processes. Eotaxin-1 is a chemokine described as a marker of ageing, which also appear to increase with cognitive deficits and neurogenesis. Here, we aimed at characterising the effect of cannabis in accelerating normal ageing processes, by studying eotaxin-1 plasma levels in people who currently use cannabis, have used cannabis in the past, or have never used cannabis.
A total of 87 healthy volunteers participated in the study. Participants completed the Cannabis Experience Questionnaire, the General Practice Physical Activity Questionnaire, the Sociodemographic, Morphometric, Alcohol and Tobacco Questionnaire, and provided a blood sample. Eotaxin-1 was assessed by ELISA. The three groups were compared using one-way ANOVA to assess levels of eotaxin-1, and nonpaired Student t-tests to assess other factors effects.
Current users of cannabis (n=18) had significantly higher eotaxin-1 plasma levels compared to past users of cannabis (n=33) and individuals who never used cannabis (n=36). The latter two groups had similar eotaxin-1 levels. Higher eotaxin-1 plasma levels were not attributed to gender, age, body mass index, physical activity or use of other legal/illegal drugs.
These results suggest that cannabis use increases eotaxin-1 plasma levels and could result in accelerated brain ageing. However, the effects appear to be reversible when cannabis use ceases. These findings have important implications for treatment and care of mental health disorders, such as schizophrenia.
There has been increasing interest in the association between childhood trauma and psychosis. Proposals for potential mechanisms involved include affective dysregulation and appraisals of threat, yet few large-scale clinical studies exist in affective psychosis.
We hypothesise that within bipolar disorder (BD), childhood events will show a significant association with psychosis, and in particular with symptoms driven by dysregulation of mood or with a persecutory content.
2019 participants were recruited as part of our programme of research into the genetic and non-genetic determinants of BD (www.bdrn.org). Data on lifetime ever presence of psychosis and specific psychotic symptoms were determined by detailed structured interview with case note review. Childhood events were recorded after self-report questionnaire and case note information.
There was no relationship between childhood events, or childhood abuse, and psychosis per se. Childhood events were not associated with increased risk of persecutory or other delusions. Significant associations were found between childhood abuse and auditory hallucinations, strongest between sexual abuse and mood congruent or abusive voices. These relationships remain significant after controlling for lifetime ever cannabis misuse.
Within affective disorder, the relationship between childhood events and psychosis appears to be relatively symptom-specific. It is possible that the pathways leading to psychotic symptoms differ, with delusions and non-hallucinatory symptoms being influenced less by childhood or early environmental experience.
1. Upthegrove R, Chard C, Jones, L, Gordon –Smith K, Forty L, Jones I and Craddock N. Adverse Childhood Events and Psychosis in Bipolar Affective Disorder. BJPsych In press BJP/2014/152611
There are limited amount of studies comparing time trends of incidence and risk factors of psychosis.
To compare time trends of incidence of psychosis in two population samples.
To study 1) onset age and cumulative incidence of psychoses in two Northern Finland Birth Cohorts (NFBC), 2) changes in type of diagnosis and risk factors.
The NFBC 1966 (N=12,058) and NFBC 1986 (N=9,432) are prospective cohorts of the two provinces of Finland with the live born children followed since pregnancy. The data for psychosis and risk factors were collected from variety of nationwide registers and earlier collected data of the NFBCs. The follow-up time was in both cohorts in average 26.5 years.
Proportion of all psychoses was higher in NFBC 1986 than in the NFBC 1966 (1.81% vs 1.0%). There were more affective psychoses in NFBC 1986 (0.5% vs 0.1%), but incidence of schizophrenia was the same (0.4%) in both cohorts. The age of onset was lower in NFBC 1986 than in NFBC 1966 and majority of this cases were females. Only parental psychosis was a significant risk factor predicting psychosis (Hazard Ratios >3.0) in both cohorts.
In conclusion, two birth cohorts within 20 years covering altogether about 40 years showed changes in terms of incidence, age of onset, and type of psychosis.
Our aim was to investigate how age of achieving early motor developmental milestones differ among subjects with and without a history of parental psychosis and whether parental psychosis may alter the effects of the age of achievement on the risk of schizophrenia.
The study sample comprised 10,307 individuals from the prospective Northern Finland Birth Cohort 1966. A total of 139 (1.3%) cohort members suffered from schizophrenia by the age of 46 years. Out of them 19 (13.7%) had a parent with a history of psychosis, while among the non-psychotic cohort members this figure was 524 (5.2%).
Out of eight different motor milestones investigated, parental psychosis associated (p>0.05) with later learning of holding head up, grabbing object, and walking without support. In the parental psychosis group, significant risk factors for schizophrenia included later learning of holding head up and touching thumb with index finger. In the non-parental psychosis group risk estimates were lower and statistical significant milestones were different i.e. turning over, sitting without support, standing up, standing and walking without support. Interactions between parental psychosis and touching thumb with index finger and walking without support was found.
Although parental psychosis associated with delays in motor milestones in the first year of life, it does not explain the association between late achievement of motor milestones and later risk for schizophrenia
Schizophrenia is a serious mental illness that carries a significant burden for families providing care.
The ADHES carers' survey canvassed opinions of families/friends of patients with schizophrenia across Europe.
To ascertain carer attitudes towards schizophrenia, its treatment and treatment adherence.
The survey was conducted from January-April 2011 in 16 European countries, comprising 10 questions relating to the respondents' understanding of schizophrenia, attitudes towards schizophrenia treatments, and perception of the family's/friend's role in supporting patients with schizophrenia.
Results were obtained from 138 respondents. 76% of carers recognized the importance of medication to help patients get better, improve their quality of life (77%) and relationships (74%). 67% of carers responded that they believed schizophrenia treatment damages patients' general health. Two-thirds of the carers reported that treatment adherence was a burden for the patient and over a third of carers indicated that it was a daily struggle to get patients to take their medication. 50% of carers considered the benefits offered by long-acting injectable antipsychotics as very/quite important and thus, could provide a valuable tool in improving treatment adherence. 92% of carers agreed on the importance of family support to boost treatment adherence with education/information deemed important for families and patients alike.
Carers recognize the issues they face in caring for patients with schizophrenia and their role in improving partial/non-adherence to medication, especially to avoid suboptimal treatment outcomes. The important role of family carers should be considered by healthcare professionals when treating patients with schizophrenia.
A clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, and how this relates to other symptom dimensions, is essential for developing interventions to reduce risk. The studies presented here investigate whether depression and suicidal thinking are predictable, how they relate to the early course of psychotic symptoms and develop over time.
92 patients with first episode psychosis recruited from the Birmingham Early Intervention Service completed measures of depression, including an prodromal depression, psotove and negative symptoms, self-harm, duration of untreated psychosis, insight and illness appraisals. Follow up took place over 12 months.
Depression occurred in 80% of patients at one or more phase of illness; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of selfharm. Post psychotic depression unheralded by previous depressive episodes was rare. Depression and suicidal thinking in the acute and post psychotic phases is associated with higher levels of loss and shame, and subordination to persecutors and malevolent voices.
Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking, and related to the personal significance and impact of positive symptom dimensions. Efforts to predict and reduce depression and self-harm in psychosis may need to target this early phase to reduce later risk.
This paper reports on the findings of three qualitative research studies undertaken within, respectively, medium and low secure units in one UK region, and a high secure mental health hospital in England (UK). The first study investigated alliance based involvement practices. The second explored service user and staff views and sense making of the notion of recovery. The third study is ongoing into service user and staff experiences of extreme coercive measures, such as forms of restraint and long-term seclusion or segregation. All studies utilised either semi-structured interviews or focus groups. All data was subject to thematic analysis.
Selected and emergent themes include:
– the importance of relationships and communication; security first; involvement as pacification;
– different understandings of recovery; the importance of meaningful occupation; staff-service user relationships; recovery journeys and dialogue with the past; and recovery as personal responsibility;
– good and bad coercion; cooperation, resistance and recalcitrance; and alternatives to coercion.
Findings suggest that cooperation is largely framed by services in terms of compliance with a bio-medical model. The impact of the secure environment, whilst ever-present, is not an absolute constraint on the realisation of recovery or involvement objectives. The availability of extreme coercive measures raises some seemingly paradoxical understandings from both service user and staff perspectives. Critical social theory is drawn on to illuminate the tensions between cooperation and recalcitrance and suggest further exploration of their respective legitimacy.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The native rat lungworm (Angiostrongylus mackerrasae) and the invasive rat lungworm (Angiostrongylus cantonensis) occur in eastern Australia. The species identity of A. mackerrasae remained unquestioned until relatively recently, when compilation of mtDNA data indicated that A. mackerrasae sensu Aghazadeh et al. (2015b) clusters within A. cantonensis based on their mitochondrial genomes (mtDNA). To re-evaluate the species identity of A. mackerrasae, we sought material that would be morphologically conspecific with A. mackerrasae. We combined morphological and molecular approaches to confirm or refute the specific status of A. mackerrasae. Nematodes conspecific with A. mackerrasae from Rattus fuscipes and Rattus rattus were collected in Queensland, Australia. Morphologically identified A. mackerrasae voucher specimens were characterized using amplification of cox1 followed by the generation of reference complete mtDNA. The morphologically distinct A. cantonensis, A. mackerrasae and A. malaysiensis are genetically distinguishable forming a monophyletic mtDNA lineage. We conclude that A. mackerrasae sensu Aghazadeh et al. (2015b) is a misidentified specimen of A. cantonensis. The availability of the mtDNA genome of A. mackerrasae enables its unequivocal genetic identification and differentiation from other Angiostrongylus species.
To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).
An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.
Four hospitals in an academic healthcare network.
All patients with a C. difficile order after hospital day 3.
Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”).
Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73–0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98–1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61–1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93–0.97).
An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.