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In Canada, recreational use of cannabis was legalized in October 2018. This policy change along with recent publications evaluating the efficacy of cannabis for the medical treatment of epilepsy and media awareness about its use have increased the public interest about this agent. The Canadian League Against Epilepsy Medical Therapeutics Committee, along with a multidisciplinary group of experts and Canadian Epilepsy Alliance representatives, has developed a position statement about the use of medical cannabis for epilepsy. This article addresses the current Canadian legal framework, recent publications about its efficacy and safety profile, and our understanding of the clinical issues that should be considered when contemplating cannabis use for medical purposes.
Compulsory admission is commonly regarded as necessary and justified for patients whose psychiatric condition represents a severe danger to themselves and others. However, while studies on compulsory admissions have reported on various clinical and social outcomes, little research has focused specifically on dangerousness, which in many countries is the core reason for compulsory admission.
To study changes in dangerousness over time in adult psychiatric patients admitted by compulsory court order, and to relate these changes to these patients' demographic and clinical characteristics.
In this explorative prospective observational cohort study of adult psychiatric patients admitted by compulsory court order, demographic and clinical data were collected at baseline. At baseline and at 6 and 12 month follow-up, dangerousness was assessed using the Dangerousness Inventory, an instrument based on the eight types of dangerousness towards self or others specified in Dutch legislation on compulsory admissions. We used descriptive statistics and logistic regression to analyse the data.
We included 174 participants with a court-ordered compulsory admission. At baseline, the most common dangerousness criterion was inability to cope in society. Any type of severe or very severe dangerousness decreased from 86.2% at baseline to 36.2% at 6 months and to 28.7% at 12 months. Being homeless at baseline was the only variable which was significantly associated with persistently high levels of dangerousness.
Dangerousness decreased in about two-thirds of the patients after court-ordered compulsory admission. It persisted, however, in a substantial minority (approximately one-third).
The aim of this study was to explore lameness and the associations between lameness and health/production measures of animal welfare in commercial broiler production, using the Welfare Quality® protocol for broilers. A total of 50 flocks were included in the sample and farm visits were conducted for lameness scoring at a mean age of 28.9 days. The percentage of animals (n=7500) in the six different gait score (GS) categories were GS0: 2.53%, GS1: 44.19%, GS2: 33.84%, GS3: 16.32%, GS4: 2.36% and GS5: 0.53%. Production and other welfare data were collected for each flock after slaughter. Higher gait scores were associated with increased hock burn score (P<0.02), increased footpad dermatitis score (P<0.01), reduced bird cleanliness score (P<0.01) and peat litter (P<0.01). Although not statistically significant, there was a tendency for increased flock gait score being associated with wet litter (P=0.07). In addition, condemnations at postmortem inspection were associated with increasing gait scores (P<0.05), indicating that at least a portion of the lameness cases display pathological changes on the carcasses. In conclusion, 19%of the birds showed moderate-to-severe lameness, which was associated with several production or health and welfare observations including feather cleanliness and condemnations as unfit for human consumption at slaughter. Although stocking density and growth rate are already known key factors for lameness, associations of lameness with hock burns, footpad dermatitis and cleanliness of the birds suggest that a suboptimal physical environment (e.g. litter- and air quality) may be detrimental to leg health. Further studies are needed to explore these associations in more detail.
When speaking in any language, speakers must conceptualize what they want to say before they can formulate and articulate their message. We present two experiments employing a novel experimental paradigm in which the formulating and articulating stages of speech production were kept identical across conditions of differing conceptualizing difficulty. We tracked the effect of difficulty in conceptualizing during the generation of speech (Experiment 1) and during the abandonment and regeneration of speech (Experiment 2) on speaking fluency by Dutch native speakers in their first (L1) and second (L2) language (English). The results showed that abandoning and especially regenerating a speech plan taxes the speaker, leading to disfluencies. For most fluency measures, the increases in disfluency were similar across L1 and L2. However, a significant interaction revealed that abandoning and regenerating a speech plan increases the time needed to solve conceptual difficulties while speaking in the L2 to a greater degree than in the L1. This finding supports theories in which cognitive resources for conceptualizing are shared with those used for later stages of speech planning. Furthermore, a practical implication for language assessment is that increasing the conceptual difficulty of speaking tasks should be considered with caution.
Trends in structural and chemical leaf traits along a chronosequence of semi-evergreen tropical forest and their correlation with litter production and decomposition and associated carbon (C) and nitrogen (N) fluxes were assessed. Leaves of 15 dominant species in each plot were collected to measure leaf area, specific leaf area (SLA), C and N concentration and C:N ratio. Litterfall was measured and litter decomposition experiments were set up in 16 experimental plots in a chronosequence of secondary and mature forest. All five leaf traits combined discriminated the secondary forests from mature forest. SLA, N and C:N were significantly correlated to litter decomposition rates. Litter decomposition was significantly slower in mature forest compared with secondary forests. The N concentration of litter was lowest during the dry season, when litterfall was highest. N concentration in fresh leaves was higher than in litter, indicating that N is re-absorbed before leaf abscission. Leaf dynamics and associated nutrient cycling differ significantly between secondary forests and mature forest. Ecosystem-level leaf structural and chemical traits are good predictors of the stage of the forest and explain well the differences in decomposition rates between secondary and primary forests.
The aim of this study was to evaluate the cost-effectiveness of exposure in vivo (EXP, a cognitive-behavioral treatment targeting pain-related fear) in Complex Regional Pain Syndrome Type I (CRPS-I), as compared to pain-contingent physical therapy (PPT).
Data from a randomized controlled trial were used to compare the cost-effectiveness of EXP versus PPT from a societal perspective. Intervention costs, other healthcare costs, costs to patient and family, and productivity losses were included. The main outcomes were changes in the SF-36 physical component scale and quality-adjusted life-years. Changes were followed until 6 months after treatment. Uncertainty was estimated using nonparametric bootstrap analysis, cost-effectiveness acceptability curves and cost-effectiveness planes. Sensitivity analyses were performed to check robustness of findings.
Forty-six patients were randomized and thirty-eight completed the study. Over 6 months, EXP resulted in greater improvement in physical health-related quality of life and quality-adjusted life-years than PPT. Despite higher initial treatment costs, EXP showed a tendency to reduce all costs compared with PPT; healthcare costs were significantly reduced. Furthermore, the cost-effectiveness planes were in favor of EXP. Sensitivity analyses, for different program costs and complete cases only, confirmed robustness of these findings.
EXP, a cognitive-behavioral treatment, seems more cost-effective than PPT in CRPS patients with pain-related fear. The initial higher costs for EXP are offset by a long-term reduction of costs for healthcare use, and a tendency to lower work absenteeism and reduced societal costs. Due to low sample sizes, replication of findings is required to confirm results.
Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.
This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).
Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.
On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.
Although judicial decisions in tort law primarily determine the (correlative) responsibilities and liabilities of the proceeding parties, they also have regulatory effects on non-litigants. In this contribution, these regulatory consequences of tort law will be analysed in light of a court’s quest when it decides a tort claim involving (uncertain) risks. It will be argued that decisions in tort law about uncertain risks involve the possible occurrence of a false positive (eg accepting liability for a non-existing risk) and a false negative (eg denying liability for a real risk). False positives and false negatives have adverse consequences for the parties to the proceedings but, bearing in mind the regulatory effects of tort adjudication, potentially also for non-litigants. While courts might want to avoid both, scientific uncertainties and complexities make it difficult for them to assess to what extent there is a chance of either a false positive or a false negative occurring. Therefore, they necessarily need to determine which party bears the risk of the involved errors. In addition, the question arises whether courts should also take the potential regulatory consequences of their rulings into account and, if yes, how? To that purpose, they can employ a bipolar reasoning style and a multipolar reasoning style. Although tort law is about determining the applicable rights and obligations between the plaintiff and defendant (bipolar reasoning), in light of the regulatory implications of tort law and developments in several tort systems, the relevance of considerations transcending this bipolar relationship (multipolar reasoning) is increasing. However, the possibilities for courts to engage in multipolar reasoning are restrained by the bipolar nature of tort law which gives rise to information and specialism deficits. This will be illustrated by referring to issues in relation to setting the standard of care and examining causation.
The vulnerability hypothesis suggests that impairments after remission of depressive episodes reflect a pre-existing vulnerability, while the scar hypothesis proposes that depression leaves residual impairments that confer risk of subsequent episodes. We prospectively examined vulnerability and scar effects in mental and physical functioning in a representative Dutch population sample.
Three waves were used from the Netherlands Mental Health Survey and Incidence Study-2, a population-based study with a 6-years follow-up. Mental and physical functioning were assessed with the Medical Outcomes Study Short Form (SF-36). Major depressive disorder (MDD) was assessed with the Composite International Diagnostic Interview 3.0. Vulnerability effects were examined by comparing healthy controls (n = 2826) with individuals who developed a first-onset depressive episode during first follow-up but did not have a lifetime diagnosis of MDD at baseline (n = 181). Scarring effects were examined by comparing pre- and post-morbid functioning in individuals who developed a depressive episode after baseline that was remitted at the third wave (n = 108).
Both mental (B = −5.4, s.e. = 0.9, p < 0.001) and physical functioning (B = −8.2, s.e. = 1.1, p < 0.001) at baseline were lower in individuals who developed a first depressive episode after baseline compared with healthy controls. This effect was most pronounced in people who developed a severe episode. No firm evidence of scarring in mental or physical functioning was found. In unadjusted analyses, physical functioning was still lowered post-morbidly (B = −5.1, s.e. = 2.1, p = 0.014), but this effect disappeared in adjusted analyses.
Functional impairments after remission of depression seem to reflect a pre-existing vulnerability rather than a scar.
A substantial proportion of persons with mental disorders seek treatment from complementary and alternative medicine (CAM) professionals. However, data on how CAM contacts vary across countries, mental disorders and their severity, and health care settings is largely lacking. The aim was therefore to investigate the prevalence of contacts with CAM providers in a large cross-national sample of persons with 12-month mental disorders.
In the World Mental Health Surveys, the Composite International Diagnostic Interview was administered to determine the presence of past 12 month mental disorders in 138 801 participants aged 18–100 derived from representative general population samples. Participants were recruited between 2001 and 2012. Rates of self-reported CAM contacts for each of the 28 surveys across 25 countries and 12 mental disorder groups were calculated for all persons with past 12-month mental disorders. Mental disorders were grouped into mood disorders, anxiety disorders or behavioural disorders, and further divided by severity levels. Satisfaction with conventional care was also compared with CAM contact satisfaction.
An estimated 3.6% (standard error 0.2%) of persons with a past 12-month mental disorder reported a CAM contact, which was two times higher in high-income countries (4.6%; standard error 0.3%) than in low- and middle-income countries (2.3%; standard error 0.2%). CAM contacts were largely comparable for different disorder types, but particularly high in persons receiving conventional care (8.6–17.8%). CAM contacts increased with increasing mental disorder severity. Among persons receiving specialist mental health care, CAM contacts were reported by 14.0% for severe mood disorders, 16.2% for severe anxiety disorders and 22.5% for severe behavioural disorders. Satisfaction with care was comparable with respect to CAM contacts (78.3%) and conventional care (75.6%) in persons that received both.
CAM contacts are common in persons with severe mental disorders, in high-income countries, and in persons receiving conventional care. Our findings support the notion of CAM as largely complementary but are in contrast to suggestions that this concerns person with only mild, transient complaints. There was no indication that persons were less satisfied by CAM visits than by receiving conventional care. We encourage health care professionals in conventional settings to openly discuss the care patients are receiving, whether conventional or not, and their reasons for doing so.
Research suggests that in environments where community conflict and violence are chronic or cyclical, caregiving can impact how children may begin to reproduce violence throughout the various stages of their lives. The aim of this study is to understand how caregiving affects processes of reproducing violence and resilience among children in conflict-affected Burundi.
We combined a socio-ecological model of child development with a child-actor perspective. We operationalized the core concepts ‘vulnerable household’, ‘resilience’, and ‘caregiving’ iteratively in culturally relevant ways, and put children's experiences at the center of the inquiry. We carried out a comparative case study among 74 purposively sampled vulnerable households in six collines in three communes in three provinces in the interior of Burundi. Burundian field researchers conducted three consecutive interviews; with the head of the household, the main caregiver, and a child.
Our findings reveal a strong congruence between positive caregiving and resilience among children. Negative caregiving was related to negative social behavior among children. Other resources for resilience appeared to be limited. The overall level of household conditions and embedment in communities attested to a generalized fragile ecological environment.
In conflict-affected socio-ecological environments, caregiving can impact children's functioning and their role in reproducing violence. Interventions that support caregivers in positive caregiving are promising for breaking cyclical violence.
Depressive patients can present with complex and different symptom patterns in clinical care. Of these, some may report patterns that are inconsistent with typical patterns of depressive symptoms. This study aimed to evaluate the validity of person-fit statistics to identify inconsistent symptom reports and to assess the clinical usefulness of providing clinicians with person-fit score feedback during depression assessment.
Inconsistent symptom reports on the Inventory of Depressive Symptomatology Self-Report (IDS-SR) were investigated quantitatively with person-fit statistics for both intake and follow-up measurements in the Groningen University Center of Psychiatry (n = 2036). Subsequently, to investigate the causes and clinical usefulness of on-the-fly person-fit alerts, qualitative follow-up assessments were conducted with three psychiatrists about 20 of their patients that were randomly selected.
Inconsistent symptom reports at intake (12.3%) were predominantly characterized by reporting of severe symptoms (e.g. psychomotor slowing) without mild symptoms (e.g. irritability). Person-fit scores at intake and follow-up were positively correlated (r = 0.45). Qualitative interviews with psychiatrists resulted in an explanation for the inconsistent response behavior (e.g. complex comorbidity, somatic complaints, and neurological abnormalities) for 19 of 20 patients. Psychiatrists indicated that if provided directly after the assessment, a person-fit alert would have led to new insights in 60%, and be reason for discussion with the patient in 75% of the cases.
Providing clinicians with automated feedback when inconsistent symptom reports occur is informative and can be used to support clinical decision-making.
Elemental, chemical, and structural analysis of polycrystalline materials at the micron scale is frequently carried out using microfocused synchrotron X-ray beams, sometimes on multiple instruments. The Maia pixelated energy-dispersive X-ray area detector enables the simultaneous collection of X-ray fluorescence (XRF) and diffraction because of the relatively large solid angle and number of pixels when compared with other systems. The large solid angle also permits extraction of surface topography because of changes in self-absorption. This work demonstrates the capability of the Maia detector for simultaneous measurement of XRF and diffraction for mapping the short- and long-range order across the grain structure in a Ni polycrystalline foil.
Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors.
The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD.
20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2–0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66–55% v. 43%) and later-recovery (75–68% v. 39%).
We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.
In the Welfare Quality® assessment protocol for broilers, the touch test is included to assess the human–animal relationship in the flock. The test is designed to measure the animals’ fear of humans, assuming that broilers will withdraw from the observer if they are fearful. However, many broilers close to slaughter age have impaired walking ability, and the results from the touch test may thus be biased by lameness and poor leg health. As the touch test is currently being used in several countries to assess human–animal relationship in broilers, there is an urgent need to examine this potential relationship for a further validation of the test. In the present study, fear of humans was assessed in 50 randomly selected Norwegian broiler flocks, using the touch test as described in the Welfare Quality® protocol for ty broilers. Leg health was assessed by examining the gait of 150 random birds in each of the flocks, using a six-point gait score scale from 0 to 5. The coefficient for the relationship between touch test score and gait score was 0.034 (P<0.001), indicating that the animals express less fear as assessed by the touch test when the gait scores increase. This implies that the touch test may be confounded by impaired walking ability and therefore might be a suboptimal method of assessing fear of humans and human–animal relationship in broilers. In conclusion, the results from this study suggests that the touch test must be further validated in broilers and perhaps be replaced with a fear test that doesn’t rely on walking ability.
4MOST is a new wide-field, high-multiplex spectroscopic survey facility for the VISTA telescope of ESO. Starting in 2022, 4MOST will deploy 2400 fibres in a 4.1 square degree field-of-view using a positioner based on the tilting spine principle. In this contribution we give an outline of the major science goals we wish to achieve with 4MOST in the area of Galactic Archeology. The 4MOST Galactic Archeology surveys have been designed to address long-standing and far-reaching problems in Galactic science. They are focused on four major themes: 1) Near-field cosmology tests, 2) Chemo-dynamical characterisation of the major Milky Way stellar components, 3) The Galactic Halo and beyond, and 4) Discovery and characterisation of extremely metal-poor stars. In addition to a top-level description of the Galactic surveys we provide information about how the community will be able to join 4MOST via a call for Public Spectroscopic Surveys that ESO will launch.