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There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects.
To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms.
Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert.
Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned.
Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.
There are concerns that price promotions encourage unhealthy dietary choices. This review aims to answer the following research questions (RQ1) what is the prevalence of price promotions on foods in high-income settings, and (RQ2) are price promotions more likely to be found on unhealthy foods?
Systematic review of articles published in English, in peer-review journals, after 1 January 2000.
Included studies measured the prevalence of price promotions (i.e. percentage of foods carrying a price promotion out of the total number of foods available to purchase) in retail settings, in upper-mid to high-income countries.
‘Price promotion’ was defined as a consumer-facing temporary price reduction or discount available to all customers. The control group/comparator was the equivalent products without promotions. The primary outcome for this review was the prevalence of price promotions, and the secondary outcome was the difference between the proportions of price promotions on healthy and unhealthy foods.
Nine studies (239 344 observations) were included for the meta-analysis for RQ1, the prevalence of price promotions ranged from 6 % (95 % CI 2 %, 15 %) for energy-dense nutrient-poor foods to 15 % (95 % CI 9 %, 25 %) for cereals, grains, breads and other starchy carbohydrates. However, the I-squared statistic was 99 % suggesting a very high level of heterogeneity. Four studies were included for the analysis of RQ2, of which two supported the hypothesis that price promotions were more likely to be found on unhealthy foods.
The prevalence of price promotions is very context specific, and any proposed regulations should be supported by studies conducted within the proposed setting(s).
Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects.
To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems.
We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications.
A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues.
Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.
Peripheral vascular injury (PVI) is a major concern in the Emergency Department (ED). According to the CDC, there were 33,594 mortalities related to firearms in 2014.1 There were 803,007 cases of aggravated assault that occurred in 2016. Nearly 24% of these (190,000) were performed with firearms and 16% (120,000) with cutting instruments.2 Inevitably, many of these result in damage to the vasculature, leading to blood loss and presentation to the ED. While some forms of injury are immediately life threatening and require emergent intervention, some present asymptomatically, which can lead to delayed or missed diagnoses. Emergency physicians should be well versed in the diagnosis, management, and disposition of these patients. This chapter will focus on the management of penetrating extremity trauma with vascular injury.
New radiocarbon (14C) dates suggest a simultaneous appearance of two technologically and geographically distinct axe production practices in Neolithic Britain; igneous open-air quarries in Great Langdale, Cumbria, and from flint mines in southern England at ~4000–3700 cal BC. In light of the recent evidence that farming was introduced at this time by large-scale immigration from northwest Europe, and that expansion within Britain was extremely rapid, we argue that this synchronicity supports this speed of colonization and reflects a knowledge of complex extraction processes and associated exchange networks already possessed by the immigrant groups; long-range connections developed as colonization rapidly expanded. Although we can model the start of these new extraction activities, it remains difficult to estimate how long significant production activity lasted at these key sites given the nature of the record from which samples could be obtained.
The early Middle Ages saw a major expansion of cereal cultivation across large parts of Europe thanks to the spread of open-field farming. A major project to trace this expansion in England by deploying a range of scientific methods is generating direct evidence for this so-called ‘Medieval Agricultural Revolution’.
Syndromic surveillance is a form of surveillance that generates information for public health action by collecting, analysing and interpreting routine health-related data on symptoms and clinical signs reported by patients and clinicians rather than being based on microbiologically or clinically confirmed cases. In England, a suite of national real-time syndromic surveillance systems (SSS) have been developed over the last 20 years, utilising data from a variety of health care settings (a telehealth triage system, general practice and emergency departments). The real-time systems in England have been used for early detection (e.g. seasonal influenza), for situational awareness (e.g. describing the size and demographics of the impact of a heatwave) and for reassurance of lack of impact on population health of mass gatherings (e.g. the London 2012 Olympic and Paralympic Games).We highlight the lessons learnt from running SSS, for nearly two decades, and propose questions and issues still to be addressed. We feel that syndromic surveillance is an example of the use of ‘big data’, but contend that the focus for sustainable and useful systems should be on the added value of such systems and the importance of people working together to maximise the value for the public health of syndromic surveillance services.
Geologists and archaeologists have long known that the bluestones of Stonehenge came from the Preseli Hills of west Wales, 230km away, but only recently have some of their exact geological sources been identified. Two of these quarries—Carn Goedog and Craig Rhos-y-felin—have now been excavated to reveal evidence of megalith quarrying around 3000 BC—the same period as the first stage of the construction of Stonehenge. The authors present evidence for the extraction of the stone pillars and consider how they were transported, including the possibility that they were erected in a temporary monument close to the quarries, before completing their journey to Stonehenge.
The aim of this study was to determine what clinically important events occur in ST-elevation myocardial infarction (STEMI) patients transported for primary percutaneous coronary intervention (PCI) via a primary care paramedic (PCP) crew, and what proportion of such events could only be treated by advanced care paramedic (ACP) protocols.
We conducted a health record review of STEMI transports by PCP-only crews and those transferred from PCP to ACP crews (ACP-intercept) from 2011 to 2015. A piloted data collection form was used to extract clinically important events, interventions during transport, and mortality.
We identified 214 STEMI bypass cases (118 PCP-only and 96 ACP-intercept). Characteristics were mean age 61.4 years; 44.4% inferior infarcts; mean response time 6 minutes, 19 seconds; total paramedic contact time 29 minutes, 40 seconds; and, in cases of ACP-intercept, 7 minutes, 46 seconds of PCP-only contact time. A clinically important event occurred in 127 (59.3%) of cases: SBP < 90 mm Hg (26.2%), HR < 60 (30.4%), HR > 100 (20.6%), arrhythmias 7.5%, altered mental status 6.5%, airway intervention 2.3%. Two patients (0.9%) arrested, both survived. Of the events identified, 42.5% could be addressed differently by ACP protocols. The majority related to fluid boluses for hypotension (34.6%). In the ACP-intercept group, ACPs acted on 51.6% of events. There were six (2.8%) in-hospital deaths.
Although clinically important events are common in STEMI bypass patients, a smaller proportion of events would be addressed differently by ACP compared with PCP protocols. The majority of clinically important events were transient and of limited clinical significance. PCP-only crews can safely transport STEMI patients directly to primary PCI.
The use of the advanced manufacturing technique of strain annealing for nanocomposite magnetic ribbons enables control of relative permeabilities and spatially dependent permeability profiles. Tuned permeability profiles enable enhanced control of the magnetic flux throughout magnetic cores, including the concentration or dispersion of the magnetic flux over specific regions. Due to the correlation between local core losses and temperature rises with the local magnetic flux, these profiles can be tuned at the component level for improved losses and reduced steady-state temperatures. We present analytical models for a number of assumed permeability profiles. This work shows significant reductions in the peak temperature rise with overall core losses impacted to a lesser extent. Controlled strain annealing profiles can also adjust the location of hotspots within a component for optimal cooling schemes. As a result, magnetic designs can have improved performance for a range of potential operating conditions.
The Pediatric Heart Network designed a career development award to train the next generation of clinician scientists in paediatric-cardiology-related research, a historically underfunded area. We sought to identify the strengths/weaknesses of the programme and describe the scholars’ academic achievements and the network’s return on investment.
Survey questions designed to evaluate the programme were sent to applicants – 13 funded and 19 unfunded applicants – and 20 mentors and/or principal investigators. Response distributions were calculated. χ2 tests of association assessed differences in ratings of the application/selection processes among funded scholars, unfunded applicants, and mentors/principal investigators. Scholars reported post-funding academic achievements.
Survey response rates were 88% for applicants and 100% for mentor/principal investigators. Clarity and fairness of the review were rated as “clear/fair” or “very clear/very fair” by 98% of respondents, but the responses varied among funded scholars, unfunded applicants, and mentors/principal investigators (clarity χ2=10.85, p=0.03; fairness χ2=16.97, p=0.002). Nearly half of the unfunded applicants rated feedback as “not useful” (47%). “Expanding their collaborative network” and “increasing publication potential” were the highest-rated benefits for scholars. Mentors/principal investigators found the programme “very” valuable for the scholars (100%) and the network (75%). The 13 scholars were first/senior authors for 97 abstracts and 109 manuscripts, served on 22 Pediatric Heart Network committees, and were awarded $9,673,660 in subsequent extramural funding for a return of ~$10 for every scholar dollar spent.
Overall, patient satisfaction with the Scholar Award was high and scholars met many academic markers of success. Despite this, programme challenges were identified and improvement strategies were developed.
We report on strontium (87Sr/86Sr) isotope results from 91 modern trees growing on the Bahamas and Turks and Caicos Islands. The average 87Sr/86Sr ratio of 0.709169±0.000010 is consistent with the late Quaternary limestone of the islands and with the modern ocean value. The absence of any detectable influence of 87Sr-enriched Saharan dust is notable, given the known contribution of this material to both past and recent soils of the Caribbean. Our results indicate that the impact of Saharan dust to the modern biosphere of the Bahamian archipelago is at least an order of magnitude less than modeled in currently available strontium isoscapes for the circum-Caribbean. We suggest that the bioavailability of Sr in Saharan dust may be considerably less than previously thought. Nevertheless, further work could usefully be carried out in the Bahamian archipelago on plants with different rooting depths, growing on different soil types and on limestone of different ages. Our results have particular relevance for the refinement of existing strontium isoscapes and the archaeological provenience of artifacts, animals, and people in the circum-Caribbean.
The diagnosis of dementia remains inadequate, even within clinical settings. Data on rates and degree of impairment among inpatients are vital for service planning and the provision of appropriate patient care as Ireland's population ages.
Every patient aged 65 years and over admitted over a two-week period was invited to participate. Those who met inclusion criteria were screened for delirium then underwent cognitive screening. Demographic, functional, and outcome data were obtained from medical records, participants, and family.
Consent to participate was obtained from 68.6% of the eligible population. Data for 143 patients were obtained. Mean age 78.1 years. 27.3% met criteria for dementia and 21% had mild cognitive impairment (MCI). Only 41% of those with dementia and 10% of those with MCI had a previously documented impairment. Between-group analysis showed differences in length of stay (p = 0.003), number of readmissions in 12 months (p = 0.036), and likelihood of returning home (p = 0.039) between the dementia and normal groups. MCI outcomes were similar to the normal group. No difference was seen for one-year mortality. Effects were less pronounced on multivariate analysis but continued to show a significant effect on length of stay even after controlling for demographics, personal and family history, and anxiety and depression screening scores. Patients with dementia remained in hospital 15.3 days longer (p = 0.047). A diagnosis is the single biggest contributing factor to length of stay in our regression model.
Cognitive impairment is pervasive and under-recognized in the acute hospital and impacts negatively on patient outcomes.
Transient Ischaemic Attack (TIA) is a neurologic event with symptom resolution within 24 hours. Early specialist assessment of TIA reduces risk of stroke and death. National United Kingdom (UK) guidelines recommend patients with TIA are seen in specialist clinics within 24 hours (high risk) or seven days (low risk).
We aimed to develop a complex intervention for patients with low risk TIA presenting to the emergency ambulance service. The intervention is being tested in the TIER feasibility trial, in line with Medical Research Council (MRC) guidance on staged development and evaluation of complex interventions.
We conducted three interrelated activities to produce the TIER intervention:
•Survey of UK Ambulance Services (n = 13) to gather information about TIA pathways already in use
•Scoping review of literature describing prehospital care of patients with TIA
•Synthesis of data and definition of intervention by specialist panel of: paramedics; Emergency Department (ED) and stroke consultants; service users; ambulance service managers.
The panel used results to define the TIER intervention, to include:
1.Protocol for paramedics to assess patients presenting with TIA and identify and refer low risk patients for prompt (< 7day) specialist review at TIA clinic
2.Patient Group Directive and information pack to allow paramedic administration of aspirin to patients left at home with referral to TIA clinic
3.Referral process via ambulance control room
4.Training package for paramedics
5.Agreement with TIA clinic service provider including rapid review of referred patients
We followed MRC guidance to develop a clinical intervention for assessment and referral of low risk TIA patients attended by emergency ambulance paramedic. We are testing feasibility of implementing and evaluating this intervention in the TIER feasibility trial which may lead to fully powered multicentre randomized controlled trial (RCT) if predefined progression criteria are met.
Stonehenge is a site that continues to yield surprises. Excavation in 2009 added a new and unexpected feature: a smaller, dismantled stone circle on the banks of the River Avon, connected to Stonehenge itself by the Avenue. This new structure has been labelled ‘Bluestonehenge’ from the evidence that it once held a circle of bluestones that were later removed to Stonehenge. Investigation of the Avenue closer to Stonehenge revealed deep periglacial fissures within it. Their alignment on Stonehenge's solstitial axis (midwinter sunset–midsummer sunrise) raises questions about the early origins of this ritual landscape.