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As the novel coronavirus disease 2019 changed patient presentation, this study aimed to prospectively identify these changes in a single ENT centre.
A seven-week prospective case series was conducted of urgently referred patients from primary care and accident and emergency department.
There was a total of 133 referrals. Referral rates fell by 93 per cent over seven weeks, from a mean of 5.4 to 0.4 per day. Reductions were seen in referrals from both primary care (89 per cent) and the accident and emergency department (93 per cent). Presentations of otitis externa and epistaxis fell by 83 per cent, and presentations of glandular fever, tonsillitis and peritonsillar abscess fell by 67 per cent.
Coronavirus disease 2019 has greatly reduced the number of referrals into secondary care ENT. The cause for this reduction is likely to be due to patients’ increased perceived risk of the virus presence in a medical setting. The impact of this reduction is yet to be ascertained, but will likely result in a substantial increase in emergency pressures once the lockdown is lifted and the general public's perception of the coronavirus disease 2019 risk reduces.
Our objective was to integrate lessons learned from perinatal collaborative care programs across the United States, recognizing the diversity of practice settings and patient populations, to provide guidance on successful implementation.
Collaborative care is a health services delivery system that integrates behavioral health care into primary care. While efficacious, effectiveness requires rigorous attention to implementation to ensure adherence to the core evidence base.
Implementation strategies are divided into three pragmatic stages: preparation, program launch, and program growth and sustainment; however, these steps are non-linear and dynamic.
The discussion that follows is not meant to be prescriptive; rather, all implementation tasks should be thoughtfully tailored to the unique needs and setting of the obstetric community and patient population. In particular, we are aware that implementation on the level described here assumes commitment of both effort and money on the part of clinicians, administrators, and the health system, and that such financial resources are not always available. We conclude with synthesis of a survey of existing collaborative care programs to identify implementation practices of existing programs.
Improving the quality of care on psychiatric inpatient wards has been a major focus in recent mental health policy, a recurrent criticism being that contact between staff and patients is limited in time and therapeutic value. Change is unlikely to be achieved without recruitment and retention of a high quality and well-motivated work force.
The NHS commissioned national inpatient mental health staff morale study is intended to inform service planning and policy by delivering evidence on the morale of the inpatient mental health workforce and the clinical, organisational, architectural and human resources factors that influence it.
100 wards in 17 area ‘Trusts’ are participating in the study, in addition to 40 community teams. The study will take place over two years, and has 6 modules:
1. A quantitative questionnaire for all staff in participating wards and
2. A comparison group in 20 community mental health teams and 20 crisis teams.
3. Case studies of 10 wards scoring in the top and bottom quartile for indicators of morale.
4. Repeated questionnaires for 20 wards in the second year to investigate how morale changes over time.
5. Staff who leave the wards in the course of the first year will be asked their reasons for leaving.
6. Links between rates of staff sickness and morale will be investigated.
Questionnaires have been distributed to 3,500 staff with a response rate of 65%, results from which will be presented in 2009.
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.
In 2011 the Incidence Assay Critical Path Working Group reviewed the current state of HIV incidence assays and helped to determine a critical path to the introduction of an HIV incidence assay. At that time the Consortium for Evaluation and Performance of HIV Incidence Assays (CEPHIA) was formed to spur progress and raise standards among assay developers, scientists and laboratories involved in HIV incidence measurement and to structure and conduct a direct independent comparative evaluation of the performance of 10 existing HIV incidence assays, to be considered singly and in combinations as recent infection test algorithms. In this paper we report on a new framework for HIV incidence assay evaluation that has emerged from this effort over the past 5 years, which includes a preliminary target product profile for an incidence assay, a consensus around key performance metrics along with analytical tools and deployment of a standardized approach for incidence assay evaluation. The specimen panels for this evaluation have been collected in large volumes, characterized using a novel approach for infection dating rules and assembled into panels designed to assess the impact of important sources of measurement error with incidence assays such as viral subtype, elite host control of viraemia and antiretroviral treatment. We present the specific rationale for several of these innovations, and discuss important resources for assay developers and researchers that have recently become available. Finally, we summarize the key remaining steps on the path to development and implementation of reliable assays for monitoring HIV incidence at a population level.
There are no existing longitudinal studies of inflammatory markers and atopic disorders in childhood and risk of hypomanic symptoms in adulthood. This study examined if childhood: (1) serum interleukin-6 (IL-6) and C-reactive protein (CRP); and (2) asthma and/or eczema are associated with features of hypomania in young adulthood.
Participants in the Avon Longitudinal Study of Parents and Children, a prospective general population UK birth cohort, had non-fasting blood samples for IL-6 and CRP measurement at the age of 9 years (n = 4645), and parents answered a question about doctor-diagnosed atopic illness before the age of 10 years (n = 7809). These participants completed the Hypomania Checklist at age 22 years (n = 3361).
After adjusting for age, sex, ethnicity, socio-economic status, past psychological and behavioural problems, body mass index and maternal postnatal depression, participants in the top third of IL-6 values at 9 years, compared with the bottom third, had an increased risk of hypomanic symptoms by age 22 years [adjusted odds ratio 1.77, 95% confidence interval (CI) 1.10–2.85, p < 0.001]. Higher IL-6 levels in childhood were associated with adult hypomania features in a dose–response fashion. After further adjustment for depression at the age of 18 years this association remained (adjusted odds ratio 1.70, 95% CI 1.03–2.81, p = 0.038). There was no evidence of an association of hypomanic symptoms with CRP levels, asthma or eczema in childhood.
Higher levels of systemic inflammatory marker IL-6 in childhood were associated with hypomanic symptoms in young adulthood, suggesting that inflammation may play a role in the pathophysiology of mania. Inflammatory pathways may be suitable targets for the prevention and intervention for bipolar disorder.
Parasites are considered to be an important selective force in host evolution but ecological studies of host-parasite systems are usually short-term providing only snap-shots of what may be dynamic systems. We have conducted four surveys of helminths of bank voles at three ecologically similar woodland sites in NE Poland, spaced over a period of 11 years, to assess the relative importance of temporal and spatial effects on helminth infracommunities. Some measures of infracommunity structure maintained relative stability: the rank order of prevalence and abundance of Heligmosomum mixtum, Heligmosomoides glareoli and Mastophorus muris changed little between the four surveys. Other measures changed markedly: dynamic changes were evident in Syphacia petrusewiczi which declined to local extinction, while the capillariid Aonchotheca annulosa first appeared in 2002 and then increased in prevalence and abundance over the remaining three surveys. Some species are therefore dynamic and both introductions and extinctions can be expected in ecological time. At higher taxonomic levels and for derived measures, year and host-age effects and their interactions with site are important. Our surveys emphasize that the site of capture is the major determinant of the species contributing to helminth community structure, providing some predictability in these systems.
In traditional transit timing variations (TTVs) analysis of multi-planetary systems, the individual TTVs are first derived from transit fitting and later modelled using n-body dynamic simulations to constrain planetary masses. We show that fitting simultaneously the transit light curves with the system dynamics (photo-dynamical model) increases the precision of the TTV measurements and helps constrain the system architecture. We exemplify the advantages of applying this photo-dynamical model to a multi-planetary system found in K2 data very close to 3:2 mean motion resonance, K2-19. In this case the period of the larger TTV variations (libration period) is much longer (>1.5 years) than the duration of the K2 observations (80 days). However, our method allows to detect the short period TTVs produced by the orbital conjunctions between the planets that in turn permits to uniquely characterise the system. Therefore, our method can be used to constrain the masses of near-resonant systems even when the full libration curve is not observed.
Little is known about the relative extent of crime against people with
severe mental illness (SMI).
To assess the prevalence and impact of crime among people with SMI
compared with the general population.
A total of 361 psychiatric patients were interviewed using the national
crime survey questionnaire, and findings compared with those from 3138
general population controls participating in the contemporaneous national
Past-year crime was experienced by 40% of patients v.
14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0–3.8); and
violent assaults by 19% of patients v. 3% of controls
(adjusted OR = 5.3, 95% CI 3.1–8.8). Women with SMI had four-, ten- and
four-fold increases in the odds of experiencing domestic, community and
sexual violence, respectively. Victims with SMI were more likely to
report psychosocial morbidity following violence than victims from the
People with SMI are at greatly increased risk of crime and associated
morbidity. Violence prevention policies should be particularly focused on
people with SMI.
Domestic and sexual violence are significant public health problems but little is known about the extent to which men and women with severe mental illness (SMI) are at risk compared with the general population. We aimed to compare the prevalence and impact of violence against SMI patients and the general population.
Three hundred and three randomly recruited psychiatric patients, in contact with community services for ⩾1 year, were interviewed using the British Crime Survey domestic/sexual violence questionnaire. Prevalence and correlates of violence in this sample were compared with those from 22 606 general population controls participating in the contemporaneous 2011/12 national crime survey.
Past-year domestic violence was reported by 27% v. 9% of SMI and control women, respectively [odds ratio (OR) adjusted for socio-demographics, aOR 2.7, 95% confidence interval (CI) 1.7–4.0], and by 13% v. 5% of SMI and control men, respectively (aOR 1.6, 95% CI 1.0–2.8). Past-year sexual violence was reported by 10% v. 2.0% of SMI and control women respectively (aOR 2.9, 95% CI 1.4–5.8). Family (non-partner) violence comprised a greater proportion of overall domestic violence among SMI than control victims (63% v. 35%, p < 0.01). Adulthood serious sexual assault led to attempted suicide more often among SMI than control female victims (53% v. 3.4%, p < 0.001).
Compared to the general population, patients with SMI are at substantially increased risk of domestic and sexual violence, with a relative excess of family violence and adverse health impact following victimization. Psychiatric services, and public health and criminal justice policies, need to address domestic and sexual violence in this at-risk group.
Thirty pyrite samples from a wide range of localities were analysed using relative comparator and k0 neutron activation analysis (NAA) techniques at the University of Missouri Research Reactor, Columbia, Missouri, USA (MURR) and the Australian Nuclear Science and Technology Organisation, Lucas Heights, NSW, Australia (ANSTO), respectively. Statistical analyses of the trace-element data produced by the two methods showed a generally good correlation, with the majority of elemental concentrations of paired data reported by MURR and ANSTO being indistinguishable at a 0.05 significance level. Trace-element analyses of pyrite from Navajún in Spain by both techniques compare well with published data. There is evidence for contamination by Al, Na and Ti in one set of samples, this is likely to have been introduced by contact with a plastic used in sample preparation.
Standard acute psychiatric care in the UK is costly but problematic. Alternatives to standard in-patient wards exist, but little is known about their effectiveness, implementation and sustainability. This paper explores successful features and limitations of five residential alternative services in England and factors that facilitate or impede their initial and sustained implementation and success.
Semi-structured interviews about the functioning of six alternative services were conducted with 36 mental health professionals with good working knowledge of, and various connections with these services. A group interview with study researchers was also conducted. Data were analysed using thematic analysis.
One service did not show evidence of operating as an alternative and was excluded from further analysis. The remaining five alternatives are valued for providing a more holistic style of care than standard services that confers many perceived benefits. However, they are seen as less appropriate for compulsorily detained or highly disturbed patients, and as providing less comprehensive treatment packages than hospital settings. Factors identified as important to successful implementation and sustainability are: responding to known shortcomings in local acute care systems; balancing role clarity and adaptability; integration with other services; and awareness of the alternative among relevant local health-care providers.
Residential alternatives can play an important role in managing mental health crises. Their successful implementation and endurance depend on establishing and maintaining a valued position within local service systems. Findings contribute to bridging the gap between research evidence on the problems of standard acute care and delivering improved crisis management services.
Key questions regarding residential alternatives to standard acute psychiatric care, such as crisis houses and short-stay in-patient units, concern the role that they fulfil within local acute care systems, and whether they manage people with needs and illnesses of comparable severity to those admitted to standard acute wards.
To study the extent to which people admitted to residential alternatives and to standard acute services are similar, and the role within local acute care systems of admission to an alternative service.
Our approach combined quantitative and qualitative methods. Consecutive cohorts of patients in six residential alternatives across England and six standard acute wards in the same areas were identified, and clinical and demographic characteristics, severity of symptoms, impairments and risks compared. Semi-structured interviews with key stakeholders in each local service system were used to explore the role and functioning of each alternative.
Being already known to services (OR = 2.6, 95% CI 1.3–5.2), posing a lower risk to others (OR = 0.49, 95% CI 0.31–0.78) and having initiated help-seeking in the current crisis (OR = 2.2, 95% CI 1.2–4.3) were associated with being admitted to an alternative rather than a standard service. Stakeholder interviews suggested that alternatives have a role that is similar but not identical to standard hospital services. They can divert some, but not all, patients from acute admission.
Residential alternatives are integrated into catchment area mental health systems. They serve similar, but not identical, clinical populations to standard acute wards and provide some, but not all, of the functions of these wards.
Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched.
To explore short-term outcomes and costs of admission to alternative and standard services.
Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services.
All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12–2.86), TAG (difference 1.40, 95% CI 0.39–2.51) and GAF functioning (difference 4.15, 95% CI 1.08–7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK£3832 v. £9850). Standard services cost an additional £2939 per unit HoNOS improvement.
The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.
Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched.
To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction.
Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored.
No significant difference was found in intensity of staff– patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives.
Similarities in care may be more marked than differences at alternative and standard services. Staff–patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.
Infection of domestic ruminants with bluetongue virus (BTV) is widespread in the Sudan but there are no records of vector species of Culicoides in that country. Therefore, light-trap collections of Culicoides for virus isolation procedures were made in the Khartoum and Um Benein areas of the Sudan during September–October 1982.
Two virus isolates were made from pools of unengorged, female Culicoides. An isolate from a pool of C. kingi (schultzei gp) is a member of the Epizootic Haemorrhagic Disease (EHD) serogroup. The other isolate from a pool of C. imicola, a known BTV vector in other parts of Africa, is type-5 BTV.
In laboratory experiments, the North American vector of BTV, C. variipennis, supported replication of both Sudanese isolates to a high titre and transmission occurred after 10 days' incubation.
This paper records the first isolation in the Sudan of arboviruses from Culicoides, with the identification of a BTV serotype and the presence of a member of the EHD (genus orbivirus, family Reoviridae) serogroup.
A wave basin experiment has been performed in the MARINTEK laboratories, in one of the largest existing three-dimensional wave tanks in the world. The aim of the experiment is to investigate the effects of directional energy distribution on the statistical properties of surface gravity waves. Different degrees of directionality have been considered, starting from long-crested waves up to directional distributions with a spread of ±30° at the spectral peak. Particular attention is given to the tails of the distribution function of the surface elevation, wave heights and wave crests. Comparison with a simplified model based on second-order theory is reported. The results show that for long-crested, steep and narrow-banded waves, the second-order theory underestimates the probability of occurrence of large waves. As directional effects are included, the departure from second-order theory becomes less accentuated and the surface elevation is characterized by weak deviations from Gaussian statistics.