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Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS.
Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale – Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample).
Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms.
These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.
To audit completed liaison service high risk care plans against local and national guidelines.
Sample comprised of a snapshot of all liaison patients currently on the case load on 14th December 2021. Electronic notes were reviewed to identify High Risk Care Plans (HRCPs) and audit completion against local guidance. Currently there is no national guidelines.
In addition staff from the liaison team were surveyed to consider their confidence in completing HRCPs in order to direct staff training. Acute hospital staff were also surveyed to ascertain positive and negative aspects of the current HRCPs, in order to suggest quality improvements ahead of the upcoming integration of new Digital notes system.
Sample size 284. High Risk Care Plans completed 11, with an additional 2 required but not found in the notes.
Non pharmacological deescalation advice was specified in only 2/11.
Regular medication was documented in 5/11.
Specialist rapid tranquillisation medication advice in 8/11.
8/11 made reference to the local rapid tranquillisation policy, which was not made available in the notes.
Absconsion risk is documented in 8/11 and advised level of observation 10/11.
According to local guidelines High Risk Care Plans were appropriate for 4.6% of the liaison case load, but record was included in the notes for 3.9%. Of those completed mandatory fields including non pharmacological deescalation and rapid tranquillisation advice were not always complete. Reference to rapid tranquillisation policy not immediately available in the notes is largely unhelpful in an emergency.
Our local target is for 100% completion of appropriate high risk care plans and full documentation for each of the mandatory fields in the high risk care plan. Improved training and record keeping is required.
Staff survey suggested unfamiliarity with document and unclear boundaries between standard and patient specific information impaired utility of high risk care plans. We recommend familiarising staff with the document and encourage highlighted font for key information.
Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.
We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).
Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother–infant interaction quality and safeguarding outcome.
Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86–1.04, P = 0.29; an absolute difference of −5%, 95% CI −14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.
We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes.
This paper illustrates the potential impacts of climate change on financial markets, focusing on their long-term significance. It uses a top-down modelling tool developed by Ortec Finance in partnership with Cambridge Econometrics that combines climate science with macro-economic and financial effects to examine the possible impacts of three plausible (not extreme) climate pathways. The paper first considers the impact on gross domestic product (GDP), finding that GDP is lower in all three pathways, with the most severe reduction in the Failed Transition Pathway where the Paris Agreement climate targets are not met. The model then translates these GDP impacts into financial market effects. In the Failed Transition Pathway, cumulative global equity returns are approximately 50% lower over the period 2020–2060 than in the climate-uninformed base case. For the other two pathways where the Paris Agreement targets are met, the corresponding figures are 15% and 25% lower returns than in the base case. Results are provided for other asset classes too. These demonstrate that climate change represents a significant market risk, with implications for financial planning, modelling and regulation.
This paper demonstrates how climate scenario analysis can be used for forward-looking assessment of the risks and opportunities for financial institutions, using a case study for a UK defined benefit pension scheme. It uses a top-down modelling tool developed by Ortec Finance in partnership with Cambridge Econometrics to explore the possible impacts of three plausible (not extreme) climate pathways of the scheme’s assets and liabilities. It finds that the funding risks are greater under all three climate pathways than under the climate-uninformed base scenario. In the absence of changes to the investment strategy or recovery plan, the time taken to reach full funding is increased by three to nine years. Given that most models currently used by actuaries do not make explicit adjustments for climate change, these modelled results suggest it is quite likely that pension schemes are systematically underestimating the funding risks they face.
Liturgy has often served as a source for studying the identities of medieval religious communities through examining local saints and special chants or ceremonies. This article deepens such approaches by considering the practice of liturgical coordination, which required each convent to reconcile the obligations imposed upon it by the order to which it belonged, the diocese in which it lay, and the personal networks of its sisters. The shifting dates of the Easter cycle created a wide variety of possible calendrical conflicts and necessitated that each convent's liturgical practice be organized anew every year. Focusing on German-language liturgical manuals from Observant Dominican convents, this article introduces these sources and examines the various obligations, authorities, and sources of advice that Dominican sisters coordinated when planning each year's liturgy. It then turns to the concrete example of a major calendrical conflict on May 1, 1519, which illustrates how convents negotiated their networked obligations and defended their decisions. Supplementing traditional sources such as chronicles and charters, liturgical administrative documents reveal how each convent's liturgical identity was both iterative and networked and how the tensions between these features opened up spaces for assertive decision-making.
It is estimated that a third of people in the United Kingdom with signs of dementia are living without a formal diagnosis. In Wales, the proportion is nearly half. Some explanations for the gap between prevalence of dementia and number of diagnoses include living with a long-term partner/spouse and systemic barriers to diagnosis. This study recruited participants from the Cognitive Function and Ageing Studies-Wales (CFAS-Wales) cohort, randomly selected from people aged over 65 living in two areas of Wales, who met study criteria for a diagnosis of dementia and did not have a record of a formal diagnosis in general practice records. We aimed to understand more about the contexts and circumstances of people who live with and cope with cognitive difficulties without having a formal diagnosis of dementia. We conducted qualitative interviews with six participants and their spouses, and additionally with four family members of three invited people who were unable to take part. Themes were generated using thematic analysis. We present the argument that there is an adaptive response to low service levels and a complex interaction between the expectations of levels of service, perceptions of the legitimacy of cognitive problems and the right to make demands on services. This paper concludes that more could be done to address barriers to diagnosis and treatment services for those living with symptoms of dementia, but that the value placed on diagnosis by some individuals might be lower than anticipated by government policy.
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.
Psychotropic medication is commonly used in people with Intellectual disabilities (ID). This may be attributed in part to an increased prevalence of mental illness in this population and the presence of challenging behaviour which has been shown to increase rates of prescribing. Whilst there are a number of studies looking at regularly prescribed medication there are few studies on “as and when” required (PRN) medication.
Psychotropic medication continues to be used to manage behavioural disturbances in people with ID. Where there is no clear cut psychiatric illness, the role of psychotropic medication is an adjunct to a comprehensive multimodal treatment plan.
The aim is to find out if prn psychotropic medication for behavioural disturbance is being used appropriately and safely in these individuals.
Files and PRN protocols of individuals known to be using prn psychotropic medications for the management of acute episodes of agitation and behavioural problems and supported by professional staff teams was studied.
We collected the data by contacting the residential homes, carers, Collecting details from case notes, from the Staff nurse who made the protocol for their patients
A questionnaire based on the standards mentioned above was developed and files and prn protocols were marked against these standards.
The standards from the medical file were 100 % achieved. Thus indicating the importance of the psychotropic prn medication and documentation of the same.
However, the protocol that needs to be with the patient/carers had some lacuna/deficits. Overall only in 53% of the case, standards were achieved. This needs to be highlighted to the team.
The Audit gave an insight into what needs to be improved.
THE FOLLOWING AREAS NEEDED IMPROVEMENT
1. There should be a prn protocol/ similar instruction to the staff about the use of prn medication(written by appropriately trained professional)
2. Prn protocol should be accessible to direct care staff
3. There should be a description of when to use the prn medication
4. There should be a description of what non-pharmacological de-escalation methods ought to be tried before using prn/ is there a detailed behaviour support plan available
5. Protocol should describe what the medication is expected to do
6. Protocol should describe the minimum time between doses if the first dose has not worked
7. Protocol should state the maximum dose in 24 hour period
8. Use of prn should be recorded
I hope this audit will help in improving the patient care with the right psychotropic prn medication, with correct doses and further details as mentioned in the standards of the protocol.
We also hope to ensure that in our area, prn psychotropic medication used for agitation and behavioural disturbance is used safely, appropriately and consistently by staff teams. This would be in accordance with the guidelines.
The aim is to find out if the physical health monitoring is adhered to in accordance with NICE guidelines in individuals with Intellectual disability who are on mood stabilisers and known to LD services.
We sought to explore if the physical health monitoring for prescribing mood stabilisers in a sample of people with ID was consistent with good practice guidelines.
We collected the data by reviewing the clinical records of individuals with LD who were under the care of mental health services in the CLDT- Wrexham and prescribed a mood stabiliser drug. We also contacted the patient's carers who came to outpatients and by calling the GP surgery and enquiring about the details. We also assessed the Welsh clinical portal in order to assess the blood tests.
Data were collected by trainee doctors in Psychiatry. This was a retrospective audit, looking at data from Learning Disability psychiatry caseload. We identified about 16 patients on mood stabilisers.
Physical health monitoring for prescribing mood stabilisers was almost consistent with good practice guidelines. This has shown that the majority of the monitoring has complied. There are few lacunae, such as Thyroid function not being monitored every 6 months for patients on Lithium, Serum Carbamazepine levels not being monitored as per guidelines with 1 patient not having blood done at all whilst on Carbamazepine. Moreover, the details are not readily available for the Consultant/ team when needed, thus making it very tedious for them to search/ contact the GP, etc.
Medications such as mood stabilisers can increase the risk further if the patient's physical health is not monitored regularly. This can lead to compromised quality of life for the patient and in some cases increased morbidity. Hence we have come up with a proforma that can be attached to patient case notes. This will serve as a record for us and prompt for physical monitoring. We will keep a database online with reminders set. This is to ensure a continuity of care for the patients.
To establish whether physical health monitoring for CYP on ADHD medication is according to NICE guidance (2018).
To determine the impact of COVID-19 pandemic restrictions on physical health monitoring for CYP on ADHD medication.
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, characterised by a persistent pattern of inattention and/or hyperactivity-impulsivity, directly impacting on academic, occupational, or social functioning. It affects between 1-5% of children and young people (CYP) most often presenting in early-mid childhood.
Pharmacological treatment can be considered in CYP if certain criteria are met, where licensed medications include methylphenidate, dexamfetamine, lisdexamfetamine, atomoxetine and guanfacine. Stimulant and non-stimulant medications require frequent physical health monitoring due to their side effects including an increase in blood pressure and/or heart rate, loss of appetite, growth restriction and tics.
Standards and criteria were derived from the NICE guidance (2018), whilst local trust policies were reviewed, demonstrating discrepancies. Standards were expected to be met for 100% of patients.
Electronic patient records were reviewed retrospectively from a representative cohort of CYP reviewed by clinicians in a community CAMHS service during March-November 2020. Data were entered manually into a spreadsheet for evaluation.
A total of 27 CYP records were reviewed, average age 13yo, on a range of stimulant/non-stimulant preparations.
5 (19%) had height checked every 6 months, with 4 delayed to 7-8 months.
For those >10yo, only 5 (19%) had weight checked every 6 months.
Only 2 (7%) had their height and weight plotted on a growth chart and reviewed by the healthcare professional responsible for treatment.
Just 4 (15%) had heart rate and blood pressure recorded before and after each dose change, whilst similarly only 4 (not the same) had these parameters recorded every 6 months.
17 patients were reviewed by telephone/video call, where 5 patients provided physical health parameters (measured at home).
Across all parameters, standards are not being met for the required physical health monitoring for CYP on ADHD medication.
The COVID-19 pandemic has significantly changed the working conditions for community teams, impacting face to face reviews, creating challenges for physical health monitoring.
Our ongoing implementations for change include the use of a proforma for physical health measurements, improving psychoeducation for families, exploring potential barriers with senior colleagues and collaborating with pharmacy colleagues to update local guidelines in accordance with the latest NICE recommendations. We aim to re-audit in June 2021.
Social anxiety disorder (SAD) is a prevalent chronic condition with a large demand for treatment. This community outpatient study examined the effectiveness of a group intervention version of the established one-to-one cognitive therapy derived from the Clark and Wells model for SAD. Questionnaires were completed pre-treatment and post-treatment for SAD symptoms (Social Phobia Scale, Social Interaction Anxiety Scale), depressive symptoms (BDI-II), self-focused attention, safety behaviours (Social Phobia Weekly Summary Scale and Subtle Avoidance Frequency Examination), and impaired functioning (Work and Social Adjustment Scale). From an initial sample of 159 participants, 101 completed at least seven of the nine weekly group sessions (Mage = 34.1 years, SDage = 10.8 years, 53% female). Significant improvements were demonstrated on all measures. Large effect sizes were found for social anxiety symptoms and safety behaviour use. Self-focused attention, depressive symptoms, and impaired functioning had moderate effect sizes. Effect sizes for anxiety (d = 1.00 and 1.32) and mood measures (d = 0.71) were as high, or in some cases, higher than previous group treatment studies. Results suggest group cognitive therapy for SAD based on the Clark and Wells model is effective in a clinical setting for individuals with moderate/severe and treatment-resistant social anxiety.
This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.
We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.
Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.
These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.
Alcohol misuse is common in bipolar disorder and is associated with worse outcomes. A recent study evaluated integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder and alcohol misuse with promising results in terms of the feasibility of delivering the therapy and the acceptability to participants.
Here we present the experiences of the therapists and supervisors from the trial to identify the key challenges in working with this client group and how these might be overcome.
Four therapists and two supervisors participated in a focus group. Topic guides for the group were informed by a summary of challenges and obstacles that each therapist had completed at the end of therapy for each individual client. The audio recording of the focus group was transcribed and data were analysed using thematic analysis.
We identified five themes: addressing alcohol use versus other problems; impact of bipolar disorder on therapy; importance of avoidance and overcoming it; fine balance in relation to shame and normalising use; and ‘talking the talk’ versus ‘walking the walk’.
Findings suggest that clients may be willing to explore motivations for using alcohol even if they are not ready to change their drinking, and they may want help with a range of mental health problems. Emotional and behavioural avoidance may be a key factor in maintaining alcohol use in this client group and therapists should be aware of a possible discrepancy between clients’ intentions to reduce misuse and their actual behaviour.
Objectives: Caregivers of youth with heavy prenatal alcohol exposure report impaired communication, which can significantly impact quality of life. Using data collected as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD), we examined whether cognitive variables predict communication ability of youth with histories of heavy prenatal alcohol exposure. Methods: Subjects (ages 10–16 years) comprised two groups: adolescents with heavy prenatal alcohol exposure (AE) and non-exposed controls (CON). Selected measures of executive function (NEPSY, Delis-Kaplan Executive Function System), working memory (CANTAB), and language were tested in the child, while parents completed communication ratings (Vineland Adaptive Behavior Scales – Second Edition). Separate multiple regression analyses determined which cognitive domains predicted communication ability. A final, global model of communication comprised the three cognitive models. Results: Spatial Working Memory and Inhibition significantly contributed to communication ability across groups. Twenty Questions performance related to communication ability in the CON group only while Word Generation performance related to communication ability in the AE group only. Effects remained significant in the global model, with the exception of Spatial Working Memory. Conclusions: Both groups displayed a relation between communication and Spatial Working Memory and Inhibition. Stronger communication ability related to stronger verbal fluency in the AE group and Twenty Questions performance in the CON group. These findings suggest that alcohol-exposed adolescents may rely more heavily on learned verbal storage or fluency for daily communication while non-exposed adolescents may rely more heavily on abstract thinking and verbal efficiency. Interventions aimed at aspects of executive function may be most effective at improving communication ability of these individuals. (JINS, 2018, 24, 1026–1037)
The discovery of the ubiquity of filaments in the interstellar medium in the last two decades has begged the question: “What role do filaments play in star formation?” Here we describe how our automated filament finding algorithms can combine with both magnetic field measurements and high-resolution observations of dense cores in these filaments, to provide a statistically large sample to investigate the effect of filaments on star formation. We find that filaments are likely actively accreting mass from the interstellar medium, explaining why some 60% of stars, and all massive stars, form “on-filament”.
Biomass energy with carbon capture and storage (BECCS) is represented in many integrated assessment models as a keystone technology in delivering the Paris Agreement on climate change. This paper explores six key challenges in relation to large scale BECCS deployment and considers ways to address these challenges. Research needs to consider how BECCS fits in the context of other mitigation approaches, how it can be accommodated within existing policy drivers and goals, identify where it fits within the wider socioeconomic landscape, and ensure that genuine net negative emissions can be delivered on a global scale.