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Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre.
After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019.
An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients.
Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns.
Introduction: Providing comfort care support at home without transport to hospital has not traditionally been part of paramedic practice. The innovative Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to share goals of care, and palliative care training. This study aimed to determine essential elements for scale and spread of this model of care through the application of an implementation science model, the Consolidated Framework for Implementation Research (CFIR). Methods: Deliberative dialogue sessions were held with paramedic, palliative care, primary care, and administrative experts in a province that had the Program (Nova Scotia, March 2018) and one that had not (British Columbia, July 2018). Sessions were audio recorded and transcribed. The CFIR was used as the foundation for a framework analysis, which was conducted by four team members independently. Themes were derived by consensus with the broader research team. Results: Inter-sectoral communication between paramedics and other health care providers was key, and challenging due to privacy concerns. Relationships with health care providers are critical to promoting the new model of care to patients, managing expectations, and providing follow up/ongoing care. Training was an essential characteristic of the intervention that can be adapted to suit local needs, although cost is a factor. There were challenges due to the culture and implementation climate as a shift in the mindset of paramedics away from traditional roles is required to implement the model. Paramedic champions can play an important role in shifting the mindset of paramedics towards a new way of practice Conclusion: The CFIR construct of cosmopolitanism, emphasizing the importance of breaking down silos and engaging diverse stakeholders, emerged as one of the most important. This will be helpful for successful scale and spread of the program.
ICD-10 delineates Acute and Transient Psychotic Disorders (ATPD, F 23) as distinct from schizophrenia and affective psychosis. We investigated the descriptive epidemiology of ATPD and predictive validity of the diagnosis, compared its three-year outcomes with affective psychosis and schizophrenia, and explored whether acute onset and early remission identify a distinct good outcome subgroup in non-affective psychoses.
Between 1992-1994, all first-episode psychosis patients in Nottingham were identified and assigned an intake ICD-10 diagnosis. Patients were assessed three years later using established outcome measures and longitudinal diagnosis assigned. Multivariate analyses were conducted to determine whether acute onset and early remission predicted favourable three-year outcome in non-affective psychotic disorders.
Of 168 cases of first-episode psychosis, 112 received an intake diagnosis of non-affective psychoses (F20-29) and 32 (19%) of ATPD (F23). ATPD diagnosis was stable in women over three years, but not in men. Outcomes of ATPD were better than schizophrenia and similar to affective psychosis. In non-affective psychoses, favourable outcomes were a function of gender and good premorbid functioning rather than acute onset and early remission.
ICD-10 ATPD criteria identify a diagnostically unstable group of disorders consisting of ‘good outcome’ schizophrenia, affective psychosis and a very small group of ‘true’ non-affective, non-schizophrenic acute and transient psychoses. Although ATPD have a better outcome than schizophrenia, in non-affective psychoses, acute onset and early remission do not independently predict favourable outcome over three years.
The utility of questionnaire based self-report measures for non-clinical psychotic symptoms is unclear and there are few reliable data about the nature and prevalence of these phenomena in children. The study aimed to investigate psychosis-like symptoms (PLIKS) in children utilizing both self-report measures and semi-structured observer rated assessments.
The study was cross-sectional; the setting being an assessment clinic for members of the ALSPAC birth cohort in Bristol, UK. 6455 respondents were assessed over 21 months, mean age 12.9 years. The main outcome measure was: 12 self-report screening questions for psychotic symptoms followed by semi-structured observer rated assessments by trained psychology graduates. The assessment instrument utilised stem questions, glossary definitions, and rating rules adapted from DISC-IV and SCAN items.
The 6-month period prevalence for one or more PLIKS rated by self-report questions was 38.9 % (95% CI = 37.7-40.1). Prevalence using observer rated assessments was 13.7% (95% CI = 12.8-14.5). Positive Predictive Values for the screen questions versus observer rated scores were low, except for auditory hallucinations (PPV=70%; 95% CI = 67.1-74.2). The most frequent observer rated symptom was auditory hallucinations (7.3%); in 18.8% of these cases symptoms occurred weekly or more. The prevalence of DSM-IV ‘core’ schizophrenia symptoms was 3.62%. Rates were significantly higher in children with low socio-economic status.
With the exception of auditory hallucinations, self-rated questionnaires are likely to substantially over-estimate the frequency of PLIKS in 12-year-old children. However, more reliable observer rated assessments reveal that PLIKS occur in a significant proportion of children.
Venous thromboembolism (VTE) is a potentially fatal condition. Hospital-associated VTE leads to more than 25,000 deaths per year in the UK. Therefore identification of at-risk patients is crucial. Psychiatric in-patients have unique factors which may affect their risk of VTE (antipsychotic prescription, restraint) however there are currently no UK guidelines which specifically address VTE risk in this population.
We assessed VTE risk among psychiatric inpatients in Cardiff and Vale university health board, Wales, UK, and whether proformas currently provided for VTE risk assessment were being completed.
All acute adult in-patient and old age psychiatric wards were assessed by a team of medical students and a junior doctor over three days. We used the UK department of health VTE risk assessment tool which was adapted to include factors specific for psychiatric patients. We also assessed if there were concerns about prescribing VTE prophylaxis (compression stockings or anticoagulants), because of a history of self-harm or ligature use.
Of the 145 patients included, 0% had a completed VTE risk assessment form. We found 38.6% to be at an increased risk of VTE and there were concerns about prescribing VTE prophylaxis in 31% of patients.
Our findings suggest that VTE risk assessment is not being carried out on psychiatric wards. Staff education is needed to improve awareness of VTE. Specific guidance for this population is needed due to the presence of unique risk factors in psychiatric in-patients and concerns regarding VTE prophylaxis.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Cognitive dysfunction is an important aspect of depression that includes problems with thinking, concentration and memory. Research suggests that the cognitive aspect of depression is highly prevalent and has a significant impact on patient functioning. Currently, cognitive dysfunction in depression is largely unrecognised, unmonitored and untreated.
We aim to define cognitive dysfunction in clinical depression (major depressive disorder) and explore its detection and management in the UK, highlighting priority areas to be addressed.
A modified Delphi method was used as the process to gain consensus. A multi-stakeholder steering committee of depression experts (including psychiatrists, psychologists, primary care physicians, and representatives from occupational therapy and a depression charity) provided the key themes and, through round-table discussion, developed draft statements. The main areas of focus were burden, detection and management of cognitive dysfunction in depression. These statements formed a questionnaire to be reviewed by 150–200 health-care professionals with an involvement in the management of depression, with level of agreement noted as ‘strongly disagree’, ‘disagree’, ‘don’t know/uncertain’, ‘agree’ or ‘strongly agree’. Responses to the questionnaire will be analysed (very high agreement [> 66%] or very low agreement [< 33%]) and the steering committee will revise and finalise the consensus statements, and identify priority areas for future consideration. The steering committee was initiated and supported by the pharmaceutical company Lundbeck Ltd, through an educational grant. Lundbeck Ltd did not influence content.
Results of the questionnaire and the evolution of the final consensus statements will be presented.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Polygenic risk scores (PRS) incorporate many small genetic markers that are associated with conditions. This technique was first used to investigate mental illnesses in 2009. Since then, it has been widely used.
We wanted to explore how PRS have been used to the study the aetiology of psychosis, schizophrenia, bipolar disorder and depression.
We aimed to conduct a systematic review, identifying studies that have examined associations between PRS for bipolar disorder, schizophrenia/psychosis and depression and psychopathology-related outcome measures.
We searched EMBASE, Medline and PsychInfo from 06/08/2009 to 14/03/2016. We hand-searched the reference lists of related papers.
After removing duplicates, the search yielded 1043 publications. When irrelevant articles were excluded, 33 articles remained. We found 24 studies using schizophrenia PRS, three using bipolar PRS and nine using depression PRS. Many studies successfully used PRS to predict case/control status. Some studies showed associations between PRS and diagnostic sub-categories. A range of clinical phenotypes and symptoms has been explored. For example, specific PRS are associated with cognitive performance in schizophrenia, psychotic symptoms in bipolar disorder, and frequency of episodes of depression. PRS have also demonstrated genetic overlap between mental illnesses. It was difficult to assess the quality of some studies as not all reported sufficient methodological detail.
PRS have enabled us to explore the polygenic architecture of mental illness and demonstrate a genetic basis for some observed features. However, they have yet to give insights into the biology, which underpin mental illnesses.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Short-term peripheral venous catheter–related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.
Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.
We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).
PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.
Two major outstanding questions in microbiome research ask what microbes are present in a community and how they interact with each other and their hosts. Recent, rapid improvements in nucleic acid (DNA and RNA) sequencing allow us to study the composition and function of microbiomes in unprecedented detail, leading to a step change in our understanding of host–microbe interactions. This chapter gives a broad overview of the basic toolkit available to modern microbiologists and microbial ecologists, exploring their application to key questions about microbiome structure and function. We cover tools based on nucleic acid sequencing (e.g. amplicon sequencing, metagenomics, metatranscriptomics) as well as approaches targeting larger molecules such as metabolomics and proteomics. We discuss the use of microbial culture as a means of measuring functional capacity of individual microbes, or building artificial communities to understand emergent properties of consortia. We emphasise the advantages of combining multiple techniques alongside robust experimental design to garner powerful quantitative estimates of microbiome structure, and how this relates to host–microbe interactions.
Establishing the role of active galactic nuclei (AGN) during the formation of galaxies remains one of the greatest challenges of galaxy formation theory. Towards addressing this, we summarise our recent work investigating: (1) the physical drivers of ionised outflows and (2) observational signatures of the impact by jets/outflows on star formation and molecular gas content in AGN host galaxies. We confirm a connection between radio emission and extreme ionised gas kinematics in AGN hosts. Emission-line selected AGN are significantly more likely to exhibit ionised outflows (as traced by the [O iii] emission line) if the projected linear extent of the radio emission is confined within the spectroscopic aperture. Follow-up high resolution radio observations and integral field spectroscopy of 10 luminous Type 2 AGN reveal moderate power, young (or frustrated) jets interacting with the interstellar medium. We find that these sources live in highly star forming and gas rich galaxies. Additionally, by combining ALMA-derived dust maps with integral field spectroscopy for eight host galaxies of z ≈ 2 X-ray AGN, we show that Hα emission is an unreliable tracer of star formation. For the five targets with ionised outflows we find no dramatic in-situ shut down of the star formation. Across both of these studies we find that if these AGN do have a negative impact upon their host galaxies, it must be happening on small (unresolved) spatial scales and/or an observable galaxy-wide impact has yet to occur.
In this chapter we examine linguistic and language-encoded cultural data from two indigenous groups of South Siberia. Both groups practice a traditional lifeway of hunting and gathering accompanied by herding of domesticated reindeer. Both speak languages that arose through in situ language shift and belong to the Siberian areal group of the Turkic family.
The Square Kilometre Array (SKA) is a planned large radio interferometer designed to operate over a wide range of frequencies, and with an order of magnitude greater sensitivity and survey speed than any current radio telescope. The SKA will address many important topics in astronomy, ranging from planet formation to distant galaxies. However, in this work, we consider the perspective of the SKA as a facility for studying physics. We review four areas in which the SKA is expected to make major contributions to our understanding of fundamental physics: cosmic dawn and reionisation; gravity and gravitational radiation; cosmology and dark energy; and dark matter and astroparticle physics. These discussions demonstrate that the SKA will be a spectacular physics machine, which will provide many new breakthroughs and novel insights on matter, energy, and spacetime.
Drawing on the work of Mark Siderits, Jay Garfield, and others, I introduce a global approach to the philosophy of religion that is inspired by ‘fusion’, ‘engagement’, or ‘confluence’ philosophy. To globalize the philosophy of religion requires more than expanding its traditional disciplinary scope or broadening its range of questions; it requires philosophers who are conversant in more than one philosophical tradition. I argue that this approach offers a viable way to develop the discipline by providing a platform for deep and authentic engagement in philosophical inquiry that crosses traditional religious and philosophical boundaries.
Stability of a solitary wave disturbed by a submerged flat sill is investigated experimentally. For sills narrow compared with the solitary wave, the transmitted waves are found to be unaffected in waveform and amplitude. A wider sill disturbs the solitary wave resulting in the formation of a dispersive wavetrain following the transmitted wave. In some cases, the wave amplitude recovers, despite being perturbed, to the state of an unobstructed solitary-wave state at a certain distance beyond the sill. Wider sills cause wave breaking that occurs over the sill or, in some cases, after the wave passes through the sill. Details of waveform transformation leading toward the breaking and subsequent energy dissipation are discussed.
How landscapes respond to, and evolve from, large jökulhlaups (glacial outburst floods) is poorly constrained due to limited observations and detailed monitoring. We investigate how melt of glacier ice transported and deposited by multiple jökulhlaups during the 2010 eruption of Eyjafjallajökull, Iceland, modified the volume and surface elevation of jökulhlaup deposits. Jökulhlaups generated by the eruption deposited large volumes of sediment and ice, causing significant geomorphic change in the Gígjökull proglacial basin over a 4-week period. Observation of these events enabled robust constraints on the physical properties of the floods which informs our understanding of the deposits. Using ground-based LiDAR, GPS observations and the satellite-image-derived ArcticDEMs, we quantify the post-depositional response of the 60 m-thick Gígjökull sediment package to the meltout of buried ice and other geomorphic processes. Between 2010 and 2016, total deposit volume reduced by −0.95 × 106 m3 a−1, with significant surface lowering of up to 1.88 m a−1. Surface lowering and volumetric loss of the deposits is attributed to three factors: (i) meltout of ice deposited by the jökulhlaups; (ii) rapid melting of the buried Gígjökull glacier snout; and (iii) incision of the proglacial meltwater system into the jökulhlaup deposits.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.