To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Clostridioides difficile infection (CDI) is the most frequently reported hospital-acquired infection in the United States. Bioaerosols generated during toilet flushing are a possible mechanism for the spread of this pathogen in clinical settings.
To measure the bioaerosol concentration from toilets of patients with CDI before and after flushing.
In this pilot study, bioaerosols were collected 0.15 m, 0.5 m, and 1.0 m from the rims of the toilets in the bathrooms of hospitalized patients with CDI. Inhibitory, selective media were used to detect C. difficile and other facultative anaerobes. Room air was collected continuously for 20 minutes with a bioaerosol sampler before and after toilet flushing. Wilcoxon rank-sum tests were used to assess the difference in bioaerosol production before and after flushing.
Rooms of patients with CDI at University of Iowa Hospitals and Clinics.
Bacteria were positively cultured from 8 of 24 rooms (33%). In total, 72 preflush and 72 postflush samples were collected; 9 of the preflush samples (13%) and 19 of the postflush samples (26%) were culture positive for healthcare-associated bacteria. The predominant species cultured were Enterococcus faecalis, E. faecium, and C. difficile. Compared to the preflush samples, the postflush samples showed significant increases in the concentrations of the 2 large particle-size categories: 5.0 µm (P = .0095) and 10.0 µm (P = .0082).
Bioaerosols produced by toilet flushing potentially contribute to hospital environmental contamination. Prevention measures (eg, toilet lids) should be evaluated as interventions to prevent toilet-associated environmental contamination in clinical settings.
Against the backdrop of mounting calls for the global scaling-up of mental health services – including quality care and prevention services – there is very little guidance internationally on strategies for scaling-up such services. Drawing on lessons from scale-up attempts in six low- and middle-income countries (LMICs), and using exemplars from the front-lines in South Africa; we illustrate how health reforms towards people-centred chronic disease management provide enabling policy window opportunities for embedding mental health scale-up strategies into these reforms. Rather than going down the oft-trodden road of vertical funding for scale-up of mental health services, we suggest using the policy window that stresses global policy shifts towards strengthening of comprehensive integrated primary health care systems that are responsive to multimorbid chronic conditions. This is indeed a substantial opportunity to firmly locate mental health within these horizontal health systems strengthening funding agendas. While this approach will promote systems more enabling of scaling up of mental health services, implications for donor funders and researchers alike is the need for increased time commitments, resources and investment in local control.
The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare.
A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice.
To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries.
We focused on the involvement of policy planners, managers, patients and carers.
Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project.
This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.
There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The ‘Emerging mental health systems in low- and middle-income countries (LMICs)’ (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.
To provide a set of proposed recommendations for mental health system strengthening in LMICs.
The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012–2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.
The proposed recommendations align closely with the World Health Organization's key health system strengthening ‘building blocks’ of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.
These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.
This article attempts to highlight the challenges and possibilities for hearing healthcare through technology and aural rehabilitation in a resource-constrained setting, using South Africa as an example.
Results and conclusion
The authors argue that it is possible to enhance service delivery by using free resources and maximising the limited existing resources. In order to provide a sustainable hearing healthcare service in developing countries, it is pertinent to understand the context where the services are needed, and not just adopt an approach developed for a different context. Audiologists in such settings need to employ strategies to develop context-specific tools, and adapt existing tools to serve the needs of the local population. Some examples, although not exhaustive, are provided in the article.
Morphology of male genitalia of culicids is generally species-specific and often used as a taxonomic marker. However, some characters of the male genitalia vary intraspecifically and are not taxonomically diagnostic. This might be the case of Aedes scapularis, a Neotropical culicid with vector competence for arboviruses and filarial worms. Males of this species may or not present a retrorse process (RP) in the genitalic claspette filaments, which led authors to suspect that this variance might be indicative of population divergence or incipient speciation process. This suspicion has not been investigated hitherto and it is not known if there are variable patterns of RPs. We hypothesized that the presence of the RP varies intraspecifically in Ae. scapularis and then we statistically evaluated the variability of this character in a single population. To this study the genitalia of 73 males of Ae. scapularis were prepared, and their RPs were meristically quantified and categorized according to the phenotypes observed. We noted that the presence or RPs is a polymorphic character because it varied inter and intra-individually. The presence of a single RP on each claspette filament was the predominant pattern (77%), but absent or multiple RPs in each filament were also found either in bilateral symmetry or asymmetry. Thus, we conclude that the presence of RPs owing to its high variability is not indicative of populational divergence or diagnostic of species complex within Ae. scapularis.
Prior studies have indicated that both high and low school achievement are associated with development of bipolar disorder (BD). We believe that the latter association may be due to the confounding effect of family history of mental disorder.
To further investigate the association between school achievement and subsequent development of BD by adding adjustment for family history of mental disorder.
We are conducting a historical prospective cohort study based on data from nationwide Danish registers. The cohort consists of all individuals born in Denmark 1986–97 of Danish-born parents, who were alive and living in Denmark at age 16 years, and who have completed final examinations in 9th grade between 2002 and 2014 (n = 578,247). The cohort members will be followed until death, emigration, development of bipolar disorder, or end of study, whichever comes first. Hazard rate ratios for bipolar disorder will be calculated in a Cox model using the z-score for examination grades as unit of exposure. The regression analyses will be adjusted for a series of potential confounders including family history of mental disorder.
We expect to find a positive association between high school achievement and development of BD. In contrast, we expect to demonstrate that the association between low school achievement and BD detected in prior studies is due to confounding by family history of mental disorder. The results will be shown at the conference.
By further testing the potential link between eminence and BD, we hope to contribute to a more balanced perception of BD.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Cobalt (Co) is essential for rumen microbial metabolism to synthesize methane, acetate and methionine. It also serves as a structural component of vitamin B12 (cobalamin), which functions as a coenzyme in energy metabolism. A study was conducted to determine if Co form (carbonate v. glucoheptonate) supplemented above the National Research Council requirements would improve digestibility of a low-quality forage diet and change serum cobalamin concentrations. Nineteen ruminally cannulated cows (577 ± 13 kg) were fed individually in a completely randomized experimental design. Cows were fed a grass hay diet that contained (79·2 g/kg crude protein, 565 g/kg total digestible nutrients, 633·2 g/kg neutral detergent fibre (NDF), 874·2 g/kg dry matter) at a rate of 0·02% of body weight on a as fed basis for a 62-day study, which consisted of three periods; acclimation (AC), treatment (TR) and residual (RE). Measurements taken in the AC period were used as covariates for analysis in the TR and RE periods. Cows were stratified by age (5 ± 0·4 years) and lactational history, and assigned to receive 12·5 mg supplemental Co in one of two forms: (1) 27·2 mg of Co carbonate (CC, n = 11 cows) or (2) 50 mg of Co glucoheptonate (CGH, n = 8 cows). Supplement was administered daily via a gelatin capsule placed directly into the rumen 2 h after feeding. During the last 96 h of each period, forage digestibility was measured using an in situ nylon bag technique. Blood samples were collected 4 and 6 h following feeding, and 24 h before the end of each period. A treatment × period interaction was detected for in situ organic matter (OM) disappearance at 96 h; (TR period: 684 and 708 ± 81 g/kg; RE period: 676 and 668 ± 75 g/kg, for CC and CGH, respectively). Once inclusion of Co in the CGH group was removed, OM disappearance was reduced by 4·01% compared with 0·82% in the CC cows. The NDF disappearance (OM basis) was less for the TR compared with the RE at 48 h (629 and 652 ± 39 g/kg, respectively). However, by 96 h NDF disappearance was greater for TR than the RE (704 and 689 ± 44 g/kg; respectively). No differences were detected for cobalamin serum concentrations or rate of fibre fermentation. The outcomes of the current research signify that there may be a slight residual effect of Co supplementation on fermentation; there was also an indication that Co source may enhance the overall extent of fermentation.
Individuals with anxiety disorders exhibit a ‘vigilance-avoidance’ pattern of attention to threatening stimuli when threatening and neutral stimuli are presented simultaneously, a phenomenon referred to as ‘threat bias’. Modifying threat bias through cognitive retraining during adolescence reduces symptoms of anxiety, and so elucidating neural mechanisms of threat bias during adolescence is of high importance. We explored neural mechanisms by testing whether threat bias in adolescents is associated with generalized or threat-specific differences in the neural processing of faces.
Subjects were categorized into those with (n = 25) and without (n = 27) threat avoidance based on a dot-probe task at average age 12.9 years. Threat avoidance in this cohort has previously been shown to index threat bias. Brain response to individually presented angry and neutral faces was assessed in a separate session using functional magnetic resonance imaging.
Adolescents with threat avoidance exhibited lower activity for both angry and neutral faces relative to controls in several regions in the occipital, parietal, and temporal lobes involved in early visual and facial processing. Results generalized to happy, sad, and fearful faces. Adolescents with a prior history of depression and/or an anxiety disorder had lower activity for all faces in these same regions. A subset of results replicated in an independent dataset.
Threat bias is associated with generalized, rather than threat-specific, differences in the neural processing of faces in adolescents. Findings may aid in the development of novel treatments for anxiety disorders that use attention training to modify threat bias.
Recent media reports have focused on the large increase in antidepressants dispensed in England. We investigated this, focusing on selective serotonin reuptake inhibitors (SSRIs).
To examine the rate of initiation of SSRIs over time and changes over time in the duration of prescribing episodes.
We estimated initiation and duration of SSRI prescribing from 7 025 802 individuals aged over 18 years and registered with a general practice that contributed data to The Health Improvement Network.
Rates of SSRI initiation increased from 1.03 per 100 person-years in 1995 to 2.15 in 2001, but remained stable from then to 2012. The median duration of prescribing episodes increased from 112 to 169 days for episodes starting in 1995 to 2010.
Despite media reports describing an increasing rate of antidepressant prescribing, SSRI initiation rates have stabilised since 2001. However, our results suggest that individuals who take SSRIs are receiving treatment for longer.
Cardiovascular risk prediction tools are important for cardiovascular disease (CVD) prevention, however, which algorithms are appropriate for people with severe mental illness (SMI) is unclear.
To determine the cost-effectiveness using the net monetary benefit (NMB) approach of two bespoke SMI-specific risk algorithms compared to standard risk algorithms for primary CVD prevention in those with SMI, from an NHS perspective.
A microsimulation model was populated with 1000 individuals with SMI from The Health Improvement Network Database, aged 30–74 years without CVD. Four cardiovascular risk algorithms were assessed; (1) general population lipid, (2) general population BMI, (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those high-risk (> 10%) were assumed to be prescribed statin therapy, others received usual care. Individuals entered the model in a ‘healthy’ free of CVD health state and with each year could retain their current health state, have cardiovascular events (non-fatal/fatal) or die from other causes according to transition probabilities.
The SMI-specific BMI and general population lipid algorithms had the highest NMB of the four algorithms resulting in 12 additional QALYs and a cost saving of approximately £37,000 (US$ 58,000) per 1000 patients with SMI over 10 years.
The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of a SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The 2012 West Nile virus (WNV) epidemic was the largest since 2003 and the North Texas region was the most heavily impacted. We conducted a serosurvey of blood donors from four counties in the Dallas–Fort Worth area to characterize the epidemic. Blood donor specimens collected in November 2012 were tested for WNV-specific antibodies. Donors positive for WNV-specific IgG, IgM, and neutralizing antibodies were considered to have been infected in 2012. This number was adjusted using a multi-step process that accounted for timing of IgM seroreversion determined from previous longitudinal studies of WNV-infected donors. Of 4971 donations screened, 139 (2·8%) were confirmed WNV IgG positive, and 69 (1·4%) had IgM indicating infection in 2012. After adjusting for timing of sampling and potential seroreversion, we estimated that 1·8% [95% confidence interval (CI) 1·5–2·2] of the adult population in the Dallas–Fort Worth area were infected during 2012. The resulting overall estimate for the ratio of infections to reported WNV neuroinvasive disease (WNND) cases was 238:1 (95% CI 192–290), with significantly increased risk of WNND in older age groups. These findings were very similar to previous estimates of infections per WNND case, indicating no change in virulence as WNV evolved into an endemic infection in the United States.
There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.