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The case for perinatal psychiatry as a subspecialty is strong. In the context of perinatal mental illness consideration has to be given to; differences in presentation, the need to account for mother and baby and the risks associated with inadequate treatment. Specialist services improve outcomes, reduce risks and save money. Despite the government's agenda of preventative healthcare, service provision has been inequitable across the UK. Here we detail the journey towards the development of new Community Perinatal Mental Health Services in Northern Ireland (NI).
Methods
In NI the first embers of a perinatal service were ignited by Dr Janine Lynch approximately 15 years ago when she established a small community perinatal team in Belfast Health and Social Care Trust (BHSCT). Her commitment and foresight regarding training inspired others, resulting in high levels of interest among trainees. From this grew a dedicated group of consultants committed to supporting service development across NI.
A multidisciplinary regional perinatal mental health forum was formed leading the development of a Northern Ireland Care Pathway in 2012. In partnership with women with lived experience, this forum led the bid for perinatal service development across the province.
Results
Following years of campaigning the need for services was recognised in both the Bamford Review (2012) and RQIA Perinatal Review (2017). A commitment for funding for specialist teams, across all five health and social care trusts, was outlined in the Mental Health Action Plan in May 2020. Funding was finally approved in January 2021.
Significant work has gone into training to ensure there is a workforce ready to deliver services with focus on upskilling all professionals who deliver care to mums during the perinatal period. A competency framework has been developed to compliment this.
It is important to recognise the support and commitment of many members of the college Perinatal Faculty throughout this journey.
Conclusion
Community perinatal mental health services are at an exciting juncture in NI. Each of the trusts have made a commitment to the development of services under the co-ordination of the Public Health Agency. Several have progressed to recruitment of key staff with the aspiration for services to go live before the end of the year. There will be an overarching, integrated approach, co-ordinated by the new Regional Perinatal Network.
As newly recruited consultants we look forward to working in partnership to address this long-standing health inequality and improve the outcome for women and their babies in NI.
Background: Seizures in childhood absence epilepsy (CAE) are typically easily controlled with anti-seizure medications (ASMs). Factors predictive of treatment resistance remain unclear. Our objectives were to assess prevalence of neuropsychiatric problems and factors influencing treatment resistance in a cohort of CAE at a single centre. Methods: We retrospectively reviewed patients with CAE diagnosed between January 1999 and December 2016 with at least 1-year follow-up. Treatment resistance was defined as failure to respond to two appropriate ASMs. Exclusion criteria included eyelid myoclonia with absence, myoclonic absence, and generalized tonic-clonic (GTC) seizures prior to absence seizures. Results: The study population comprised 164 patients (65 males) with mean age at seizures onset of 6.1years. 21% had treatment-resistant seizures. The first ASM was Ethosuximide (63.4%), Valproic acid (23.2%), and Lamotrigine (6.7%). 32.9% of children had learning disabilities, 28.7% ADHD, and 12.8 % anxiety.
A stepwise binary logistic regression analysis identified GTC seizures, learning disability (LD) and ongoing general spike and wave on EEG as predictors of treatment resistance. At last follow-up (average of 5.4 years), 43.3% of children were seizure-free off ASMs. Conclusions: 21% of children with CAE had treatment-resistant seizures. LD, GTC and failure of normalization of the EEG were associated with treatment resistance.
Over the last 25 years, radiowave detection of neutrino-generated signals, using cold polar ice as the neutrino target, has emerged as perhaps the most promising technique for detection of extragalactic ultra-high energy neutrinos (corresponding to neutrino energies in excess of 0.01 Joules, or 1017 electron volts). During the summer of 2021 and in tandem with the initial deployment of the Radio Neutrino Observatory in Greenland (RNO-G), we conducted radioglaciological measurements at Summit Station, Greenland to refine our understanding of the ice target. We report the result of one such measurement, the radio-frequency electric field attenuation length $L_\alpha$. We find an approximately linear dependence of $L_\alpha$ on frequency with the best fit of the average field attenuation for the upper 1500 m of ice: $\langle L_\alpha \rangle = ( ( 1154 \pm 121) - ( 0.81 \pm 0.14) \, ( \nu /{\rm MHz}) ) \,{\rm m}$ for frequencies ν ∈ [145 − 350] MHz.
Contemporary scholarship on fandom explores how communities are created through affinities of taste. Drawing on that work, this chapter argues that Cicero’s account in De Finibus and Pro Archia of his and his fellow Romans’ investment in and debt to Athenian literature experiments with the effects of passionately identifying with another culture – thus opening up ways of thinking and feeling about citizenship as an aesthetic property that transcends the limits of ethnic or linguistic identity. Hellenistic literature, organiSed in part around the trope of Athens as a universalist model of human excellence – a trope used first by Athenian writers and appropriated by writers in both Greek and Latin in the first century BCE – helps make the concept of universal citizenship thinkable, not only for Romans like Cicero but for readers over centuries (including scholars and students of 'classics' today) who shared and sustained his investment in the Athenian Greek past. This fantasy of cultural belonging obscures the violence of Roman imperial reality and helps explain the persistent appeal of 'classical' Greek literature.
We investigated two potential mechanisms facilitating local food procurement in schools, food hubs, and funded farm to school policies. Using all three waves of the USDA’s farm to school census, we assessed the factors that support school districts that have stated an intention of beginning a farm to school program. We find that neither food hubs nor funded policies have an impact on farm to school programming. Instead, it is large-scale farms that play a role in the farm to school supply chain. Coupled with the positive impact of school size and receipt of increased federal funding, this suggests that while both cost and transactional barriers impact school procurement, current policy solutions are insufficient. This study improves our understanding of the role of facilitation mechanisms on farm to school implementation in the United States.
Schizophrenia-related, health, social, and fiscal consequences are substantial, affecting patients, caregivers, and society. The incidence of health, social, and fiscal outcomes are frequently reported for the overall schizophrenia population, not stratified by remission or relapse status.
Objectives
This study aimed to assess healthcare resource use, employment status, and housing circumstances for patients with schizophrenia in remission or relapse, compared to the overall schizophrenia population.
Methods
The Adelphi Schizophrenia Disease Specific Programme was a point-in-time survey conducted across the USA between July and October 2019. Remission was defined using Clinical Global Impression-Severity (CGI-S) score of 1-3 (stable), with relapse defined as a CGI-S score of 4-7 (unstable). Outcome-specific rate ratios were calculated by dividing the cumulative incidence for those in remission or relapse by the cumulative incidence of the overall schizophrenia population. Ratios greater than 1 indicate a higher probability of the event.
Results
Psychiatrists (n = 124) provided data for 409 patients in remission and 609 patients in relapse. Patients with schizophrenia in remission were more likely to be employed (1.66, 95% confidence interval [1.46-1.90]) and to live with a partner or family (1.08 [1.01-1.17]) compared to the overall schizophrenia population, whereas patients in relapse were more likely to experience hospitalizations in the previous 12 months (1.34 [1.19-1.15]), disability-related unemployment (1.38 [1.25-1.51]), sick leave absences (1.23 [0.66-2.31]), need to support housing (1.39 [1.08-1.79]), and homelessness (1.47 [0.95-2.27]).
Conclusions
Schizophrenia patients in relapse were more likely to experience hospitalizations, unemployment, and have unfavorable housing circumstances compared to the overall schizophrenia population. Identifying patients at risk of relapse may aid physicians in targeting interventional support, thereby reducing the burden of schizophrenia.
The involvement of citizens in the production and creation of public services has become a central tenet for administrations internationally. In Scotland, co-production has underpinned the integration of health and social care via the Public Bodies (Joint Working) (Scotland) Act 2014. We report on a qualitative study that examined the experiences and perspectives of local and national leaders in Scotland on undertaking and sustaining co-production in public services. By adopting a meso and macro perspective, we interviewed senior planning officers from eight health and social care partnership areas in Scotland and key actors in national agencies. The findings suggest that an overly complex Scottish governance landscape undermines the sustainability of co-production efforts. As part of a COVID-19 recovery, both the implementation of meaningful co-production and coordinated leadership for health and social care in Scotland need to be addressed, as should the development of evaluation capacities of those working across health and social care boundaries so that co-production can be evaluated and report to inform the future of the integration agenda.
Proper testing of evidence, including witness testimony, is key to ensuring due process and procedural fairness, and affirms the legitimacy of systems of international dispute settlement resolution. In this regard, commentators have emphasised that, in international dispute settlement, less weight should be given to witness testimony that has not ‘undergone the interrogation of the court and the cross-examination by the opposing party’. The WTO dispute settlement system sees some of the most active and complex litigation across international tribunals. Yet, the WTO’s standard procedural rules provide no opportunity for the adjudicator or parties to (1) request the appearance of a witness, or (2) pose live questions to the witness. Consequently, most WTO disputes do not involve any in-person testing of witnesses. In this context, this chapter sets out to suggest an approach to fill the gap in the WTO rules on in-person witness testing.
Background: West syndrome (WS) is characterized by the onset of epileptic spasms usually within the first year of life. Global developmental delay with/without regression is common. Advances in high-throughput sequencing have supported the genetic heterogeneity of this condition. To better understand the genetic causes of this disorder, we investigated the results of targeted exome sequencing in 29 patients with WS. Methods: Whole exome sequencing (WES) was performed on an Ion ProtonTM and variant reporting was restricted to sequences of 620 known epilepsy genes. Diagnostic yield and treatment impact are described for 29 patients with WS. Results: A definitely/likely diagnosis was made in 10 patients (34%), which included 10 different genes (ALG13, PAFAH1B1, SLC35A2, DYNC1H1, ADSL, DEPDC5, ARX, CDKL5, SCN8A, STXBP1) known to be associated with epilepsy or WS. Most variants were de novo dominant (X-linked/autosomal) except for ARX (X-linked recessive) and ADSL (autosomal recessive). 4 out of 10 (40%) had a genetic diagnosis with potential treatment implications. Conclusions: These results emphasize the genetic heterogeneity of WS. The high diagnostic yield, along with the significant genetic variability, and the potential for treatment impact, supports the early use of this testing in patients with unexplained WS.
Background: To assess the response to high dose daily nocturnal diazepam (HDD) in children with encephalopathy associated with electrical status epilepticus in sleep (ESES). Methods: A prospective cohort of patients (4-12 years), newly diagnosed with ESES, initiated on the first course HDD, was followed for ≤ 1-year. Sleep EEG scores (SES) pre and post HDD were evaluated. An EEG grading system based on both sleep spike wave index (sSWI) (Grade: 1-4) and distribution of epileptiform discharges (Grade: 0-4) was used and summed to yield an aggregate SES (ASES) (Grade: 1-8). Results: Eighteen eligible children (M:F 12:6; median age, 7.6 years) were initiated on first course HDD (median, 0.5 mg/kg/d). sSWI decreased from 85.7% (mean, SD 13.9) to 32.6% (mean, SD 37.1) at subsequent EEG (95% CI = -70.60- -35.62; p < 0.001). ASES decreased from 6.5 (SD 1.3) to 3.1 (SD 1.9) (95% CI = -4.17- -2.60; p < 0.001). EEG relapse after a period of improvement occurred in 10 children. Minimal response to HDD occurred in 2 children. Five patients manifested mild side effects; behavior (2), hyperactivity (2), and lethargy (1). Conclusions: HDD safely and significantly reduces both SWI and aggregate sleep EEG score in children with ESES.
Background: Seizures in childhood absence epilepsy (CAE) are usually easily controlled with anti-seizure medications (ASMs). Factors predictive of treatment resistance remain unclear. Our objectives were to assess prevalence of neuropsychiatric problems and factors influencing refractoriness in a cohort of CAE at a single centre. Methods: We retrospectively reviewed patients with CAE (ILAE 2017 classification) diagnosed between January 1999 and December 2016 with at least 1-year follow-up. Treatment resistance was defined as failure to respond to two or more appropriate ASMs. Exclusion criteria included eyelid myoclonia with absence, myoclonic absence, and generalized tonic-clonic (GTC) seizure before developing absences. Results: The study population comprised 164 patients (65 males) 6.25-year-old on average at absence onset. 22% had treatment-resistant seizures. The first ASM was Ethosuximide in 63.4%, Valproic acid in 23.2%, and Lamotrigine in 6.7%. Statistical differences between response groups included developing a second seizure type specifically GTC, the second and third ASM, and absence of EEG normalization. At last follow-up, 43.3% of children were seizure-free off ASMs. 32.9% of children had learning disabilities, 28% ADHD, and 12.8 % anxiety. Conclusions: 22% of children with CAE had treatment-resistant seizures. Photoparoxysmal response was not predictive of treatment resistance. Neuropsychiatric problems were common with learning disabilities increased with refractory absences.
Background: Children with pathogenic variations in SCN8A can present with early infantile epileptic encephalopathy-13, benign familial infantile seizures-5 or intellectual disability alone without epilepsy. In this case series, we discuss six children with variants in SCN8A managed at BC Children’s Hospital. Methods: We describe clinical and genetic results on six individuals with SCN8A variants identified via clinical or research next-generation sequencing. Functional consequences of two SCN8A variants were assessed using electrophysiological analyses in transfected cells. Results: Clinical findings ranged from normal development with well-controlled epilepsy to significant developmental delay with treatment-resistant epilepsy. Phenotypes and genotypes in our cohort are described in the table below. Functional analysis supported gain-of-function in P2 and loss-of-function in P4. Conclusions: Our cohort expands the clinical and genotypic spectrum of SCN8A-related disorders. We establish functional evidence for two missense variants in SCN8A, including LoF variant in a patient with intellectual disability, and autism spectrum disorder without seizures.
Table for P.120
Patients
Age/Sex
Development
Age of
seizure onset
Epilepsy type
Current antiseizure medication
Seizure frequency
Gene variant/Function
Inheritance
P1
14y/F
Profound GDD
5m
Infantile spasms, LGS, hyperkinetic movements
Clobazam
Daily
c.1238C>A (p.Ala413Asp)
De novo
P2
6y/F
Normal
3-7m
Focal epilepsy
Carbamazepine
Seizure free
c.5630A>G (p.Asn1877Ser)/GoF
Paternal
P3
4y/F
Normal
12m
Focal epilepsy
Clobazam, topiramate
Seizure free
c.4447G>A (p.Glu1483Lys)
De novo
P4
6y/F
GDD, autism
3y - EEG abnormality only
-
Sodium valproate (discontinued)
No clinical seizure
c.971G>A (p.Cys324Tyr)/LoF, VUS in KCNQ3
De novo
P5
7y/M
GDD
5m
Generalized seizures
Ethosuximide, acetazolamide
Daily
c.773C>T (p.Thr258Ile)
De novo
P6
19y/F
Normal
10y
Focal epilepsy
Carbamazepine
Seizure free
c.986A>G (p.Asp329Gly)
De novo
Abbreviations: *Father with similar history, y Years, m Months, GDD Global developmental delay, LGS Lennox-Gastaut syndrome, VUS Variant of unknown significance, LoF Loss-of-function, GoF Gain-of-function, EEG Electroencephalogram, F - Female, M - Male, CBD - Cannabidiol
To understand the conflicts in many of Roth’s novels, it is important to situate his narratives within the context of class conflict, in particular. Class identity – particularly, Jewish middle-class identity – is an influential factor in the development of Roth’s protagonists. As Ruth Wisse points out in her article “Philip Roth Then and Now,” “Roth’s fictional interpretation of American Jews as a regnant bourgeoisie disturbed as much as it amused,” as it addressed an anxiety about materialism and upper class assimilation, particularly in works like Goodbye, Columbus. Moreover, the striving of a character like the Swede in American Pastoral and the identity of Faunia Farley in The Human Stain can be further understood when considered in light of American class structure the assumptions and promises proffered by American liberalism.
Support for social distancing measures was, globally, high at the early stages of the COVID-19 pandemic but increasingly came under pressure. Focusing on the UK, this article provides a rigorous exploration of the drivers of public support for social distancing at their formative stage, via mixed methods. Synthesizing insights from crisis management and securitization theory, thematic analysis is employed to map the main frames promoted by the government and other actors on the nature/severity, blame/responsibility, and appropriate response to the pandemic, which ‘follows the science’. The impact of these on public attitudes is examined via a series of regression analyses, drawing on a representative survey of the UK population (n = 2100). Findings challenge the prevailing understanding that support for measures is driven by personal health considerations, socio-economic circumstances, and political influences. Instead, crisis framing dynamics, which the government is well-positioned to dominate, have the greatest impact on driving public attitudes.
To improve postgraduate psychiatry education and training in Northern Ireland.
Background
Historically within Northern Ireland there has been a postgraduate Member of the Royal College of Psychiatrists (MRCPsych) teaching programme delivered to core trainees in preparation for MRCPsych examinations. There has been no official teaching programme for higher trainees. Northern Ireland Medical and Dental Training Agency (NIMDTA), in collaboration with the Royal College of Psychiatrists in Northern Ireland and all five Trusts developed the novel idea of introducing Postgraduate Education Fellows, to oversee and improve core training, and to develop a bespoke higher training programme.
The Postgraduate Education Fellows met to collate information from various sources in relation to issues within the current teaching programme and address these along with the development of new initiatives. The fellows further act as a point of contact for all trainees within their Trust to provide advice and support with education if needed.
Method
One higher trainee was appointed to the role of Postgraduate Education Fellow in each Trust within the NIMDTA deanery for a term of 1 year.
The starting point was delivering the pre-established teaching timetable and gaining feedback from core trainees to identify areas for improvement. The next phase involved piloting traditional and contemporary methods of feedback. A further development was designing a mock paper A delivered under exam conditions. Two mock Clinical Assessment of Skills and Competencies (CASC) exams were organised under exam conditions, offering other trainees the opportunity to act as simulated patients and examiners.
The third aspect of this role involved creating a programme of higher trainee seminars. Baseline data were collated and identified key areas that higher trainees felt they needed further training and guidance in.
Result
Using baseline data on the current teaching programme and from higher trainees as well as incorporating quality improvement methodology, we have been making small changes to each aspect of the teaching programme and evaluating the changes made. The feedback from trainees has been positive as evidenced by quantitative and qualitative feedback. 8 candidates sat our first mock CASC with a 100% pass rate in their MRCPsych CASC examination. There has been a positive response to the higher trainee seminar programme.
Conclusion
This programme has produced good outcomes to date and sets foundations for the future development of post graduate psychiatry education in Northern Ireland.
To understand the prevalence, patterns and correlates of substance use among transgender adults.
Background
Minority stress theories suggest that the increasing rates of discrimination experienced by transgender people are precipitants of substance use. This is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which gender minority status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.
Method
In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, EMBASE and Global Health databases. Primary quantitative studies, published in the English language, that reported the prevalence, patterns or correlates/risk factors of substance use by trans people were included, with no restriction on methodological design.
Result
651 unique records were identified by the search and 40 studies were included in the synthesis. While there was some suggestion of excess risk of substance use among trans people, there was insufficient evidence to estimate prevalence or quantify the risk of substance use among transgender people, relative to a cisgender population. However, this review identified several gender minority related correlates of substance use which are of relevance to clinicians working with transgender patients, including transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.
Conclusion
There are currently significant gaps in the trans substance use literature, relating to the disproportionate investigation of transgender women with multiple intersectional disadvantages, who are not representative of the wider trans community. However, there is sufficient evidence to recommend screening for substance use when individuals report high levels of gender minority stress and to consider the use of integrated trauma-informed psychosocial interventions when managing problematic substance use in the transgender adult.
To review the existent literature base regarding Black and Minority Ethnic (BAME) groups care pathway into and experience of care and treatment within secure services. This includes any differences (between BAME and majority ethnic groups) in rates of sentencing, sectioning, length of stay, received treatment and use of restrictive practice. Our overarching aim is to highlight the severe lack of research in this area and the corresponding need for increased research to both consolidate and progress the existing evidence base in order to inform and improve culturally competent service provision.
Background
Research suggests that BAME groups have an increased risk of involuntary psychiatric care, longer-stays within services and higher rates of re-admission. Several explanations have been proposed for this observed disparity, however few of these proposed explanations have provided sufficient or consistent supporting evidence.
Method
A review of both quantitative and qualitative research regarding BAME groups within secure services was conducted. Approximately twenty journal articles, literature reviews and meta-analysis published between 1988 and 2019 were included. The current study should be considered a snapshot and not reflective of the full extent of published literature on the subject. For inclusion, studies should have been conducted in either a forensic mental health setting or a prison and differentiate a minimum of two ethnic groups
Conclusion
Research suggest that BAME individuals continue to experience an increased risk of involuntary psychiatric care, longer stays within secure services and higher rates of re-admission. Whilst many explanations for this disparity have been proposed, few have provided adequate supporting evidence. The ongoing lack of research within this field has led to a limited evidence base from which to inform culturally competent practice. The research which has been conducted has tended to produce inconsistent findings, in part due to the reliance on small scale studies with limited generalisability. Research within this area has been further complicated by varying definitions of culture and ethnicity across studies, leading to some suggestion that the issue of ethnic inequalities and pathways to care, has been misconceptualised. This highlights a critical need for increased research efforts to:
Understand why BAME individuals are at increased risk of involuntary psychiatric care, and how this disproportionate risk can be addressed
Explore potential disparities in the care and treatment of BAME individuals within services and how this might impact upon higher rates of re-admission
Ascertain how best to improve culturally competent service provision.