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Nonmedical opioid use (NMOU) has been associated with opioid overdose deaths. This pattern of misuse can be seen in those using opioids for cancer-associated pain. We present a case that highlights the complexities associated with NMOU and a patient’s care at the end of life.
Cases Description
A patient with a metastatic solid tumor malignancy along with co-occurring history of polysubstance abuse was admitted to an acute palliative and supportive care unit (APSCU). The patient demonstrated behaviors concerning for NMOU during her hospital stay but had increased symptom expression concerning for worsening dyspnea while in the APSCU. Unfortunately, she used home opioids, which was unknown to the team at the time along with requesting for higher doses of opioids that were being prescribed. This caused a worsening respiratory status and affected her care. Using an interdisciplinary approach, the providers managed her symptoms and discharged her safely to see her child.
Conclusion
This highlights the complexities of the alleviation of suffering in those with NMOU. It is important to continue to manage NMOU at the end of life due to its effects on quality of life. A multimodal approach is recommended to identify and care for these patients.
Thirty years after the discovery of an Early Neolithic timber hall at Balbridie in Scotland was reported in Antiquity, new analysis of the site's archaeobotanical assemblage, featuring 20 000 cereal grains preserved when the building burnt down in the early fourth millennium BC, provides new insights into early farming practices. The results of stable isotope analyses of cereals from Balbridie, alongside archaeobotanical and stable isotope results from three other sites, indicate that while cereals were successfully cultivated in well-established plots without manuring at Balbridie, a variety of manuring strategies was implemented at the other sites. These differences reinforce the picture of variability in cultivation practices across Neolithic North-west Europe.
Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost.
Methods
We recruited 32 boys and 30 girls (aged 13–19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0–2 weeks after IPT), and follow-up (8–10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective.
Results
Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70–95); functional impairment decreased by 288% (249–351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity.
Conclusions
School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.
There has been a significant increase in presentations of people with eating disorders (ED) within CAMHS in relation to the pandemic with a significant pressure on services to continue to provide evidence-based treatments for an expanding number of severely unwell patients. The first aim was to assess the quality of referrals received for patients with suspected ED and to then implement an intervention regarding the way that referrals are handled. The second aim was to establish a process for handling and monitoring patients already open to the service.
Methods
An initial and repeat survey was sent to staff within the team. The survey included the Mental Health Professional Stress Scale (MHPSS). An audit was conducted to establish the quality of referrals from GPs based on the Junior Marsipan guidelines. Data were collected on physical measures and the written content of referrals for March 2020–21 and March 2021–22.
Duty clinicians were asked to screen referrals and prompt GPs to submit recordings of physical parameters for the referrals to be triaged. In addition, a weekly meeting in a “board round” format was implemented to discuss new referrals and 40–50 existing patients each week depending on risk. We developed a physical health monitoring clinic once per week.
Results
MHPSS scores remained high between initial and follow-up surveys, with slightly increased mean scores for workload, organisational structure and processes, and lack of resources. Referrals from 2020–2021 (N = 26) and those from 2021–2022 (N = 39) were screened. The majority had a diagnosis of anorexia nervosa. Most referrals had records of height and weight (73.1 to 82.1%). 53.8% of referrals in the re-audit period required prompting for physical recordings to be submitted. There was no change in the written content of referrals at re-audit, with only 46.2% recording risk, 51.3% recording estimated onset and 56.4% documenting body image.
There was a slight reduction in the mean time between referral and diagnosis from 44.1 to 34.2 days. The weekly board round received positive feedback (N = 10) with 70–100% answering agree/strongly agree to statements such as manage patients’ care safely, obtaining urgent advice and physical monitoring.
Conclusion
The processes summarised above have been successful in improving the efficiency surrounding the management of patients with ED. Unfortunately, there has been no improvement in the stress levels of staff; we hope to conduct a focus group to better understand this. A referral proforma should be developed by the wider service for GPs to complete.
Although it is well known that parental depression is transmitted within families across generations, the etiology of this transmission remains unclear. Our goal was to develop a novel study design capable of explicitly examining the etiologic sources of intergenerational transmission. We specifically leveraged naturally-occurring variations in genetic relatedness between parents and their adolescent children in the 720 families participating in the Nonshared Environment in Adolescent Development (NEAD) study, 58.5% of which included a rearing stepparent (nearly always a stepfather). Results pointed squarely to the environmental transmission of psychopathology between fathers and children. Paternal depression was associated with adolescent depression and adolescent behavior problems (i.e., antisocial behavior, headstrong behavior, and attention problems) regardless of whether or not fathers and their children were genetically related. Moreover, these associations persisted to a subset of “blended” families in which the father was biologically related to one participating child but not to the other, and appeared to be mediated via father–child conflict. Such findings are not only fully consistent with the environmental transmission of psychopathology across generations, but also add to extant evidence that parent–child conflict is a robust and at least partially environmental predictor of adolescent psychopathology.
We summarize some of the past year's most important findings within climate change-related research. New research has improved our understanding of Earth's sensitivity to carbon dioxide, finds that permafrost thaw could release more carbon emissions than expected and that the uptake of carbon in tropical ecosystems is weakening. Adverse impacts on human society include increasing water shortages and impacts on mental health. Options for solutions emerge from rethinking economic models, rights-based litigation, strengthened governance systems and a new social contract. The disruption caused by COVID-19 could be seized as an opportunity for positive change, directing economic stimulus towards sustainable investments.
Technical summary
A synthesis is made of ten fields within climate science where there have been significant advances since mid-2019, through an expert elicitation process with broad disciplinary scope. Findings include: (1) a better understanding of equilibrium climate sensitivity; (2) abrupt thaw as an accelerator of carbon release from permafrost; (3) changes to global and regional land carbon sinks; (4) impacts of climate change on water crises, including equity perspectives; (5) adverse effects on mental health from climate change; (6) immediate effects on climate of the COVID-19 pandemic and requirements for recovery packages to deliver on the Paris Agreement; (7) suggested long-term changes to governance and a social contract to address climate change, learning from the current pandemic, (8) updated positive cost–benefit ratio and new perspectives on the potential for green growth in the short- and long-term perspective; (9) urban electrification as a strategy to move towards low-carbon energy systems and (10) rights-based litigation as an increasingly important method to address climate change, with recent clarifications on the legal standing and representation of future generations.
Social media summary
Stronger permafrost thaw, COVID-19 effects and growing mental health impacts among highlights of latest climate science.
We examined whether intraindividual variability (IIV) across tests of executive functions (EF-IIV) is elevated in Veterans with a history of mild traumatic brain injury (mTBI) relative to military controls (MCs) without a history of mTBI. We also explored relationships among EF-IIV, white matter microstructure, and posttraumatic stress disorder (PTSD) symptoms.
Method:
A total of 77 Veterans (mTBI = 43, MCs = 34) completed neuropsychological testing, diffusion tensor imaging (DTI), and PTSD symptom ratings. EF-IIV was calculated as the standard deviation across six tests of EF, along with an EF-Mean composite. DSI Studio connectometry analysis identified white matter tracts significantly associated with EF-IIV according to generalized fractional anisotropy (GFA).
Results:
After adjusting for EF-Mean and PTSD symptoms, the mTBI group showed significantly higher EF-IIV than MCs. Groups did not differ on EF-Mean after adjusting for PTSD symptoms. Across groups, PTSD symptoms significantly negatively correlated with EF-Mean, but not with EF-IIV. EF-IIV significantly negatively correlated with GFA in multiple white matter pathways connecting frontal and more posterior regions.
Conclusions:
Veterans with mTBI demonstrated significantly greater IIV across EF tests compared to MCs, even after adjusting for mean group differences on those measures as well as PTSD severity. Findings suggest that, in contrast to analyses that explore effects of mean performance across tests, discrepancy analyses may capture unique variance in neuropsychological performance and more sensitively capture cognitive disruption in Veterans with mTBI histories. Importantly, findings show that EF-IIV is negatively associated with the microstructure of white matter pathways interconnecting cortical regions that mediate executive function and attentional processes.
Prior work has robustly suggested that social processes in the neighborhood (i.e. informal social control, social cohesion, norms) influence child conduct problems (CP) and related outcomes, but has yet to consider how these community-level influences interact with individual-level genetic risk for CP. The current study sought to do just this, evaluating neighborhood-level social processes as etiologic moderators of child CP for the first time.
Methods
We made use of two nested samples of child and adolescent twins within the Michigan State University Twin Registry (MSUTR): 5649 families who participated in in the Michigan Twins Project (MTP) and 1013 families who participated in the Twin Study of Behavioral and Emotional Development (TBED-C). The neighborhood social processes of informal social control, social cohesion, and norms were assessed using neighborhood sampling techniques, in which residents of each twin family's neighborhood reported on the social processes in their neighborhood. Standard biometric GxE analyses evaluated the extent to which they moderated the etiology of CP.
Results
The ‘no moderation’ model provided the best fit to the data in nearly all cases, arguing against neighborhood social processes as etiologic moderators of youth CP.
Conclusions
The neighborhood social processes evaluated here do not appear to exert their effects on child CP via etiologic moderation. The documented links between neighborhood social processes and child CP are thus likely to reflect a different etiologic process. Possibilities include environmental main effects of neighborhood social processes on child CP, or genotype-environment correlations.
Outbreaks of cutaneous infectious disease in amphibians are increasingly being attributed to an overlooked group of fungal-like pathogens, the Dermocystids. During the last 10 years on the Isle of Rum, Scotland, palmate newts (Lissotriton helveticus) have been reportedly afflicted by unusual skin lesions. Here we present pathological and molecular findings confirming that the pathogen associated with these lesions is a novel organism of the order Dermocystida, and represents the first formally reported, and potentially lethal, case of amphibian Dermocystid infection in the UK. Whilst the gross pathology and the parasite cyst morphology were synonymous to those described in a study from infected L. helveticus in France, we observed a more extreme clinical outcome on Rum involving severe subcutaneous oedema. Phylogenetic topologies supported synonymy between Dermocystid sequences from Rum and France and as well as their distinction from Amphibiocystidium spp. Phylogenetic analysis also suggested that the amphibian-infecting Dermocystids are not monophyletic. We conclude that the L. helveticus-infecting pathogen represents a single, novel species; Amphibiothecum meredithae.
This paper examines how older men perceive, experience and internalise ageist prejudice in the context of their everyday lives. We draw on in-depth interviews with 29 community-dwelling Canadian men aged 65–89. Although one-third of our participants were unfamiliar with the term ageism, the majority felt that age-based discrimination was prevalent in Canadian society. Indicating that they themselves had not been personally subjected to ageism, the men considered age-based discrimination to be a socially distant problem. The men explained their perceived immunity to ageism in terms of their youthful attitudes and active lifestyles. The men identified three groups who they considered to be particularly vulnerable to age-based discrimination, namely women, older workers and frail elders residing in institutions. At the same time, the majority of our participants had internalised a variety of ageist and sexist stereotypes. Indeed, the men assumed that later life was inevitably a time of physical decline and dependence, and accepted as fact that older adults were grumpy, poor drivers, unable to learn new technologies and, in the case of older women, sexually unattractive. In this way, a tension existed between the men's assertion that ageism did not affect their lives and their own internalisation of ageist stereotypes. We consider our findings in relation to the theorising about ageism and hegemonic masculinity.
In this article, we draw upon interviews with 14 men and 15 women aged 51–92 to examine the embodied experiences of Canadian power mobility device users. In particular, we investigate how individuals ageing with mobility impairments perceived and experienced the practical impacts and symbolic cultural connotations of utilising a power mobility device. Our findings reveal that those participants who had begun to use their power mobility devices later in life were dismayed by and apprehensive about the significance of their diminishing physical abilities in the context of the societal privileging of youthful and able bodies. At the same time, the participants who had used a power mobility device from a young age were fearful of prospective bodily declines, and discussed the significance and consequences of being unable to continue to operate their power mobility devices autonomously in the future. We consider the ways in which the participants attempted to manage, mitigate and reframe their experiences of utilising power mobility devices in discriminatory environments. We discuss our findings in relation to on-going theoretical debates pertaining to the concepts of ‘biographical disruption’ and the third and fourth ages.
As a transformative service, aged care has the capacity to create uplifting changes and improvements to the quality of life for individuals and communities. Recent studies have, however, highlighted the pressures faced by aged care workers and the impact that these pressures have on employee wellbeing and quality of care. This paper explores the relationship between employee wellbeing and service quality. We present a model for the aged care sector which suggests that by identifying and implementing appropriate HRM strategies both employee wellbeing and service quality will be enhanced thus ensuring that this transformative service meets the needs of its many stakeholders. Essentially, we argue that employee wellbeing is directly linked to service delivery outcomes and overall business performance and that HR practices that address issues such as learning and development, employee voice and involvement and workplace health and safety play a significant role in enhancing and maintaining employee wellbeing.
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York
The history of the book is now recognized as a field of central importance for understanding the cultural changes that swept through Tudor England. This companion aims to provide a comprehensive guide to the issues relevant to theearly printed book, covering the significant cultural, social and technological developments from 1476 (the introduction of printing to England) to 1558 (the death of Mary Tudor). Divided into thematic sections (the printed booktrade; the book as artefact; patrons, purchasers and producers; and the cultural capital of print), it considers the social, historical, and cultural context of the rise of print, with the problems as well as advantages of the transmission from manuscript to print. the printers of the period; the significant Latin trade and its effect on the English market; paper, types, bindings, and woodcuts and other decorative features which create the packaged book; and the main sponsors and consumers of the printed book: merchants, the lay clientele, secular and religious clergy, and the two Universities, as well as secular colleges and chantries. Further topics addressed include humanism, women translators, and the role of censorship and the continuity of Catholic publishing from that time. The book is completed with a chronology and detailed indices. Vincent Gillespie is J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford; Susan Powell held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York. Contributors: Tamara Atkin, Alan Coates, Thomas Betteridge, Julia Boffey, James Clark, A.S.G. Edwards, Martha W. Driver, Mary Erler, Alexandra Gilespie, Vincent Gillespie, Andrew Hope, Brenda Hosington, Susan Powerll, Pamela Robinson, AnneF. Sutton, Daniel Wakelin, James Willoughby, Lucy Wooding
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York
Edited by
Vincent Gillespie, J.R.R. Tolkien Professor of English Literature and Language at the University of Oxford,Susan Powell, Held a Chair in Medieval Texts and Culture at the University of Salford, and is currently affiliated to the Universities of London and York