To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.
The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.
The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.
In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.
The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.
Experiencing traumatic life events is associated with an increased risk of common mental disorders (CMDs), but studies investigating this association within Indigenous populations are limited.
The aim of this study was to investigate associations between trauma and CMDs after controlling for other exposures.
Trauma exposures and CMD diagnoses were determined in a broadly representative sample of 544 Indigenous Australians, using a diagnostic clinical interview. Associations were determined by multivariate logistic regression.
Trauma exposure independently predicted CMDs. After adjustment for potential confounders, trauma exposure was associated with a 4.01-fold increased risk of a diagnosis of a CMD in the past 12 months. The increased risks were 4.38-, 2.65- and 2.78-fold of having an anxiety disorder, mood disorder or a substance use disorder, respectively. Trauma exposure and comorbid post-traumatic stress disorder was associated with a 4.53-fold increased risk of a diagnosis of a mood disorder, 2.47-fold increased risk of a diagnosis of a substance use disorder, and 3.58-fold increased risk of any diagnosis of a CMD, in the past 12 months. Experiencing both sexual and physical violence was associated with a 4.98-fold increased risk of a diagnosis of an anxiety disorder in the past 12 months.
Indigenous Australians experience significantly increased exposure to potentially harmful trauma compared with non-Indigenous Australians. Preventing and healing trauma exposure is paramount to reduce the high burden of CMDs in this population.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
As Ireland confronts the many challenges of broadening the introduction of early intervention services (EIS) for first episode psychosis (FEP) as national policy, this article describes Carepath for Overcoming Psychosis Early (COPE), the EIS of Cavan–Monaghan Mental Health Service, and presents prospective research findings during its first 5 years of operation.
COPE was launched as a rural EIS with an embedded research protocol in early 2012, following an education programme for general practitioners (GPs). Here, operational activities are documented and research findings presented through to late 2016.
During this period, 115 instances of FEP were incepted into COPE, 70.4% via their GP and 29.6% via the Emergency Department. The annual rate of inception was 24.8/100,000 of population aged > 15 years and was 2.1-fold more common among men than women. Mean duration of untreated psychosis was 5.7 months and median time from first psychotic presentation to initiation of antipsychotic treatment was zero days. Assessments of psychopathology, neuropsychology, neurology, premorbid functioning, quality of life, insight, and functionality compared across 10 DSM-IV psychotic diagnoses made at six months following presentation indicated minimal differences between them, other than more prominent negative symptoms in schizophrenia and more prominent mania in bipolar disorder.
COPE illustrates the actuality of introducing and the challenges of operating a rural EIS for FEP. Prospective follow-up studies of the 5-year COPE cohort should inform on the effectiveness of this EIS model in relation to long-term outcome in psychotic illness across what appear to be arbitrary diagnostic boundaries at FEP.
To derive scores for mental disorganization and impoverishment from commonly used rating scales, and test the hypothesis that disorganization and impoverishment, along with impaired cognition and role-function reflect a latent variable that is a plausible candidate for the putative core deficit.
For more than 100 years, disorganization and impoverishment of mental activity have been recognised as fundamental symptoms of schizophrenia. These symptoms may reflect a core brain process underlying persisting disability. Delusions and hallucinations have been regarded as accessory features. The psychopathological processes predisposing to persisting disability in schizophrenia are poorly understood. The delineation of a core deficit underlying persisting disability would be potentially of great value in predicting outcome and developing improved treatment.
Patients aged 18–55 years were included if: they satisfied DSM IV criteria for schizophrenia or schizoaffective disorder. Healthy controls were recruited by public advertisement and selected to match the patient group in age and sex. Study sample included 39 participants with schizophrenia, 1 with schizoaffective disorder and 44 matched healthy controls. We derived disorganization and impoverishment scores from three symptom scales: PANSS, SSPI and CASH. We computed composite scores for disorganization and for impoverishment and employed Confirmatory Factor Analysis to test the hypothesis that a single factor accounts for the relationships between disorganization, impoverishment, cognitive impairment and impaired role function. We assessed the relationship between this latent “core deficit” and diminished Post Movement Beta Rebound (PMBR), an electrophysiological measure from Magnetoencephalography (MEG), associated with persisting brain disorders.
Fit indices for the single factor model from CFA indicated a good fit: χ2(2) = 1.817, p = .403; RMSEA <.001 GFI = .979. PMBR was significantly reduced in the schizophrenia group compared to healthy controls, t (68) = 3.55, p < .001. Within the patient group, PMBR was significantly and negatively correlated with the CFA factor scores representing the Core Deficit score, r=−.543, p < .01, indicating that high core deficit scores were associated with reduced PMBR. PMBR was significantly correlated with the composite Disorganization score, r=−.521, p < .001.
Our findings demonstrate that the shared variance between impoverishment (psychomotor poverty); disorganization; cognitive impairment; and impaired role function can be accounted for by a latent variable that can reasonably be described as the core deficit of classical schizophrenia. The demonstration that the severity of the putative core deficit is correlated with the reduction in PMBR provides evidence that the core deficit is associated with an identifiable abnormality of brain dysfunction.
Benzodiazepine (BZD) prescription rates have increased over the past decade in the United States. Available literature indicates that sociodemographic factors may influence diagnostic patterns and/or prescription behaviour. Herein, the aim of this study is to determine whether the gender of the prescriber and/or patient influences BZD prescription.
Cross-sectional study using data from the Florida Medicaid Managed Medical Assistance Program from January 1, 2018 to December 31, 2018. Eligible recipients ages 18 to 64, inclusive, enrolled in the Florida Medicaid plan for at least 1 day, and were dually eligible. Recipients either had a serious mental illness (SMI), or non-SMI and anxiety.
Total 125 463 cases were identified (i.e., received BZD or non-BZD prescription). Main effect of patient and prescriber gender was significant F(1, 125 459) = 0.105, P = 0 .745, partial η2 < 0.001. Relative risk (RR) of male prescribers prescribing a BZD compared to female prescribers was 1.540, 95% confidence intervals (CI) [1.513, 1.567], whereas the RR of male patients being prescribed a BZD compared to female patients was 1.16, 95% CI [1.14, 1.18]. Main effects of patient and prescriber gender were statistically significant F(1, 125 459) = 188.232, P < 0.001, partial η2 = 0.001 and F(1, 125 459) = 349.704, P < 0.001, partial η2 = 0.013, respectively.
Male prescribers are more likely to prescribe BZDs, and male patients are more likely to receive BZDs. Further studies are required to characterize factors that influence this gender-by-gender interaction.
Patients unsuccessfully treated by neurostimulation may represent a highly intractable subgroup of depression. While the efficacy of intravenous (IV) ketamine has been established in patients with treatment-resistant depression (TRD), there is an interest to evaluate its effectiveness in a subpopulation with a history of neurostimulation.
This retrospective, posthoc analysis compared the effects of four infusions of IV ketamine in 135 (x̄ = 44 ± 15.4 years of age) neurostimulation-naïve patients to 103 (x̄ = 47 ± 13.9 years of age) patients with a history of neurostimulation. The primary outcome evaluated changes in depression severity, measured by the Quick Inventory for Depression Symptomatology-Self Report 16-Item (QIDS-SR16). Secondary outcomes evaluated suicidal ideation (SI), anxiety severity, measured by the Generalized Anxiety Disorder 7-Item (GAD-7), and consummatory anhedonia, measured by the Snaith–Hamilton Pleasure Scale (SHAPS).
Following four infusions, both cohorts reported a significant reduction in QIDS-SR16 Total Score (F (4, 648) = 73.4, P < .001), SI (F (4, 642) = 28.6, P < .001), GAD-7 (F (2, 265) = 53.8, P < .001), and SHAPS (F (2, 302) = 45.9, P < .001). No between-group differences emerged. Overall, the neurostimulation-naïve group had a mean reduction in QIDS-SR16 Total Score of 6.4 (standard deviation [SD] = 5.3), whereas the history of neurostimulation patients reported a 4.3 (SD = 5.3) point reduction.
IV ketamine was effective in reducing symptoms of depression, SI, anxiety, and anhedonia in both cohorts in this large, well-characterized community-based sample of adults with TRD.
In southern Australia, annual sowthistle and prickly lettuce have become more prevalent following the adoption of reduced tillage cropping systems. They are especially problematic in lentil and other pulse crops, which are weakly competitive and have few herbicide options available for POST control of broadleaf weeds. This study aimed to evaluate the influence of management in a previous cereal crop on weed densities in a subsequent crop. At two field sites, crop seeding density and POST herbicide treatments (a conventional choice that included metsulfuron-methyl and MCPA; and a proactive choice that included bromoxynil, picolinafen, and MCPA) were applied to a wheat crop, and weed density was assessed at the beginning of the following season to measure for a legacy effect of the treatments. Study site populations were also screened for herbicide resistance and were found to have high (≥90% survival) ALS inhibitor resistance. Crop competition treatments had no effect on weed populations, and effects of herbicide treatment were significant at only one of the sites. At this site, both herbicide treatments had lower weed densities than the nontreated in the first year, but the legacy effect was only significant for annual sowthistle density in the proactive treatment. At both sites, even where weeds were extremely sparse or completely controlled following herbicide treatment in the first year, moderate densities were observed the following year, indicating that colonization from the seedbank or adjacent areas could be contributing to weed numbers. Weed density assessments and accurate knowledge of the herbicide resistance status of target weeds should guide herbicide selection to maximize control.
Higher body mass index (BMI) has been found to predict greater antidepressant response to intravenous (IV) ketamine treatment. We evaluated the association between BMI and response to repeat-dose IV ketamine in patients with treatment-resistant depression (TRD).
Adults (N = 230) with TRD received four infusions of IV ketamine at a community-based clinic. Changes in symptoms of depression (ie, Quick Inventory for Depressive Symptomatology-Self-Report 16; QIDS-SR16), suicidal ideation (SI; ie, QIDS-SR16 SI item), anxiety (ie, Generalized Anxiety Disorder-7 Scale), anhedonic severity (ie, Snaith–Hamilton Pleasure Scale), and functioning (ie, Sheehan Disability Scale) following infusions were evaluated. Participants were stratified by BMI as normal (18.0-24.9 kg/m2; n = 72), overweight (25-29.9 kg/m2; n = 76), obese I (30-34.9 kg/m2; n = 47), or obese II (≥35.0 kg/m2; n = 35).
Similar antidepressant effects with repeat-dose ketamine were reported between BMI groups (P = .261). In addition, categorical partial response (P = .149), response (P = .526), and remission (P = .232) rates were similar between the four BMI groups.
The findings are limited by the observational, open-label design of this retrospective analysis. Pretreatment BMI did not predict response to IV ketamine, which was effective regardless of BMI.
In the Introduction to his Treatise of Human Nature, David Hume credits “my Lord Shaftesbury” as one of the “philosophers in England, who have begun to put the science of man on a new footing.” I describe aspects of Shaftesbury’s philosophy that justify the credit Hume gives him. I focus on Shaftesbury’s refutation of psychological egoism, his examination of partiality, and his views on how to promote impartial virtue. I also discuss Shaftesbury’s political commitments, and raise questions about recent interpretations that have taken his Characteristicks to be a polemic, partisan text.
Recent literature suggests that over 70% of cases of antibody-mediated encephalitis present to psychiatry services with features of psychosis predominantly.
To investigate the seroprevalence of N-Methyl-D-Aspartate receptor antibodies (NMDAr-Ab) in patients with first episode psychosis (FEP)
Following ethical approval, all cases meeting entry criteria were invited to participate. Participants were interviewed with SCID to obtain a DSM diagnosis. NMDAr-Ab were identified in serum by cell based assay using co-transfected Human Embryonic Kidney (HEK)cells. Positive cases were reviewed by clinical neurology. Decision to treat with immunotherapy was made on a case by case basis.
85/115 (72%) of patients with FEP entered the study. 49 (58%) participants were male, mean age (SD) 37 (15.7) years. 42 (52%) were outpatients at the time of assessment. Four cases (5%) were serum NMDAr-Ab positive. 3 of these cases were male, age 48 (16.3) years. All four were admitted as inpatients with normal brain MRI imaging. One case (female, 55) was confirmed as NMDAr-Ab encephalitis based on case presentation, EEG demonstrating bilateral cerebral dysfunction and NMDAr-Ab in CSF. Immunotherapy treatment lead to clinical improvement. In remaining cases, EEG was normal and CSF negative. All 3 of these cases showed clinical improvement following psychiatric treatment as usual.
Our findings support the current estimates as to NMDAr-Ab prevalence in FEP. Increased awareness has lead to rapid treatment of florid cases of NMDAr-Ab encephalitis in our service. Additional seropositive cases are being followed with neuro-cognitive testing for any evidence of decline.
Trichotillomania has been found to be associated with mood disorders, particularly bipolar disorder. Trichotillomania has shared similarities with bipolar disorder by virtue of phenomenology, co-morbidity, and psychopharmacologic observations. In the past, trichotillomania with comorbid bipolar disorder was treated with lithium and sodium valproate. There has been little, if any, literature on using asenapine to augment treatment in patients with trichotillomania with comorbid bipolar disorder. A patient presented with hair-pulling episodes for a year, resulting in bald scalp patches. She had no mood symptoms prior to this. She developed low mood, anhedonia, poor sleep and poor appetite subsequently as she could not stop pulling her hair. She was started on escitalopram 10 mg daily for he depressive symptoms. Three years later, she developed hypomanic symptoms such as irritability and spending sprees. Her hair pulling behaviour worsened at this time. At this point, a diagnosis of bipolar disorder type 2 was considered and she was started on lithium 300 mg daily. Her escitalopram was discontinued. As her mood was still labile 10 months later, asenapine was added to augment lithium in the treatment of the bipolar disorder. With asenapine, her hair pulling frequency started to decrease rapidly. Asenapine was increased to 10 mg daily and her hair pulling ceased. Her mood also stabilized and she no longer had erratic periods of mood lability. In conclusion, asenapine augmentation of lithium has potential to be used in patients who have trichotillomania with comorbid bipolar disorder due to its unique receptor profile.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Waardenburg syndrome (WS) is a rare genetic disorder characterised by varying degrees of sensorineural deafness, dystopia canthorum, musculokeletal defects, pigmentation anomalies such as bright blue iris, greying hair and in some cases intestinal pathology.
A 21-year-old Chinese gentleman, diagnosed with WS type 1 (Figs. 1 and 2) at the age of two, presented at the emergency unit with manic symptoms for the past one month such as irritability, grandiosity, flight of ideas and reduced need for sleep. With regards to social integration, he had features suggestive of autism spectrum disorder (ASD). He often played by himself and was fixated on particular toys. He was eventually admitted to the psychiatric ward for acute management of mania. He was stabilised on olanzapine 10 mg BD and sodium valproate 600 mg BD. His sodium valproate was cross-titrated with lithium in the ward and his manic features gradually subsided. He was discharged well after 2 weeks of admission with lithium 300 mg BD and olanzapine 10 mg BD. WS type 1 has been localised to the locus 2q35 and researchers have identified that a tetranucleotide repeat marker on 2q35 is strongly associated with recurrent mood symptoms.
In conclusion, it is important to note that individuals with WS may be at higher risk to develop ASD and mood disorders.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Diet modifies the risk of colorectal cancer (CRC), and inconclusive evidence suggests that yogurt may protect against CRC. We analysed the data collected from two separate colonoscopy-based case–control studies. The Tennessee Colorectal Polyp Study (TCPS) and Johns Hopkins Biofilm Study included 5446 and 1061 participants, respectively, diagnosed with hyperplastic polyp (HP), sessile serrated polyp, adenomatous polyp (AP) or without any polyps. Multinomial logistic regression models were used to derive OR and 95 % CI to evaluate comparisons between cases and polyp-free controls and case–case comparisons between different polyp types. We evaluated the association between frequency of yogurt intake and probiotic use with the diagnosis of colorectal polyps. In the TCPS, daily yogurt intake v. no/rare intake was associated with decreased odds of HP (OR 0·54; 95 % CI 0·31, 0·95) and weekly yogurt intake was associated with decreased odds of AP among women (OR 0·73; 95 % CI 0·55, 0·98). In the Biofilm Study, both weekly yogurt intake and probiotic use were associated with a non-significant reduction in odds of overall AP (OR 0·75; 95 % CI 0·54, 1·04) and (OR 0·72; 95 % CI 0·49, 1·06) in comparison with no use, respectively. In summary, yogurt intake may be associated with decreased odds of HP and AP and probiotic use may be associated with decreased odds of AP. Further prospective studies are needed to verify these associations.
When a man of business enters into life and action, he is more apt to consider the characters of men, as they have relation to his interest, than as they stand in themselves; and has his judgement warped on every occasion by the violence of his passion. When a philosopher contemplates characters and manners in his closet, the general abstract view of the objects leaves the mind so cold and unmoved, that the sentiments of nature have no room to play, and he scarce feels the difference between vice and virtue. History keeps in a just medium betwixt these extremes, and places the objects in their true point of view. The writers of history, as well as the readers, are sufficiently interested in the characters and events, to have a lively sentiment of blame or praise; and, at the same time, have no particular interest or concern to pervert their judgment.