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Patients’ rights can be seen as a precondition to empowering people and moving to health systems that are more person-centred. They provide a foundation for citizens to be considered as actors in control of their own health care delivery process.
Increasingly, the challenges and potential solutions that health systems are facing are explored through a patients’ rights lens. Changes, such as the rapid ageing of the population and the rising burden of chronic conditions (including mental health problems), along with scientific and technological developments as well as cultural preferences, are creating new questions that are often debated within the context of fundamental rights, including self-determination, dignity and equality. The growing complexity of health care together with innovations in the fields of medicine (e.g. precision medicine) and of information and communication technology (ICT) (e.g. e-health), along with an increased focus on quality and safety, are likely to impact patients’ rights, especially with regard to privacy and equity.
Institutional investment in forestry has now exceeded US$100 billion, much of this in the United States. Many large institutional investors are considered ‘universal owners’ because they own a portion of all sectors, geographies and markets of the global economy through their investment portfolios. These large investors increasingly acknowledge that negative environmental and social externalities pose material risks to their long-term investments, with many beginning to consider the alignment of their portfolios with internationally agreed objectives on climate change and sustainable development. Efforts to measure and monitor ESG (environmental, social, governance) performance of forestry investments are now well established. We propose a framework of criteria to assess landscape-scale outcomes from forestry investment activities which we call Sustainable Landscape Investment. This framework can help address wicked forestry problems and the often-competing demands of investors, local communities, governments and NGOs.
The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England.
We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England.
There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40–49 years (30%) for men and 19–29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8−140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results.
The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.
The lower Mississippian Ballagan Formation of northern Britain is one of only two successions worldwide to yield the earliest known tetrapods with terrestrial capability following the end-Devonian mass extinction event. Studies of the sedimentary environments and habitats in which these beasts lived have been an integral part of a major research project into how, why and under what circumstances this profound step in the evolution of life on Earth occurred. Here, a new palaeogeographic map is constructed from outcrop data integrated with new and archived borehole material. The map shows the extent of a very low-relief coastal wetland developed along the tropical southern continental margin of Laurussia. Coastal floodplains in the Midland Valley and Tweed basins were separated from the marginal marine seaway of the Northumberland–Solway Basin to the south by an archipelago of more elevated areas. A complex mosaic of sedimentary environments was juxtaposed, and included fresh and brackish to saline and hypersaline lakes, a diverse suite of floodplain palaeosols and a persistent fluvial system in the east of the region. The strongly seasonal climate led to the formation of evaporite deposits alternating with flooding events, both meteoric and marine. Storm surges drove marine floods from the SW into both the western Midland Valley and Northumberland–Solway Basin; marine water also flooded into the Tweed Basin and Tayside in the east. The Ballagan Formation is a rare example in the geological record of a tropical, seasonal coastal wetland that contains abundant, small-scale evaporite deposits. The diverse sedimentary environments and palaeosol types indicate a network of different terrestrial and aquatic habitats in which the tetrapods lived.
The mental health outcomes of military personnel deployed on peacekeeping
missions have been relatively neglected in the military mental health
To assess the mental health impacts of peacekeeping deployments.
In total, 1025 Australian peacekeepers were assessed for current and
lifetime psychiatric diagnoses, service history and exposure to
potentially traumatic events (PTEs). A matched Australian community
sample was used as a comparator. Univariate and regression analyses were
conducted to explore predictors of psychiatric diagnosis.
Peacekeepers had significantly higher 12-month prevalence of
post-traumatic stress disorder (16.8%), major depressive episode (7%),
generalised anxiety disorder (4.7%), alcohol misuse (12%), alcohol
dependence (11.3%) and suicidal ideation (10.7%) when compared with the
civilian comparator. The presence of these psychiatric disorders was most
strongly and consistently associated with exposure to PTEs.
Veteran peacekeepers had significant levels of psychiatric morbidity.
Their needs, alongside those of combat veterans, should be recognised
within military mental health initiatives.
Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.
To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.
A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.
In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).
Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.
Children with cancer are potentially at a high risk of plasma 25-hydroxyvitamin D (25(OH)D) inadequacy, and despite UK vitamin D supplementation guidelines their implementation remains inconsistent. Thus, we aimed to investigate 25(OH)D concentration and factors contributing to 25(OH)D inadequacy in paediatric cancer patients. A prospective cohort study of Scottish children aged <18 years diagnosed with, and treated for, cancer (patients) between August 2010 and January 2014 was performed, with control data from Scottish healthy children (controls). Clinical and nutritional data were collected at defined periods up to 24 months. 25(OH)D status was defined by the Royal College of Paediatrics and Child Health as inadequacy (<50 nmol/l: deficiency (<25 nmol/l), insufficiency (25–50 nmol/l)), sufficiency (51–75 nmol/l) and optimal (>75 nmol/l). In all, eighty-two patients (median age 3·9, interquartile ranges (IQR) 1·9–8·8; 56 % males) and thirty-five controls (median age 6·2, IQR 4·8–9·1; 49 % males) were recruited. 25(OH)D inadequacy was highly prevalent in the controls (63 %; 22/35) and in the patients (64 %; 42/65) at both baseline and during treatment (33–50 %). Non-supplemented children had the highest prevalence of 25(OH)D inadequacy at every stage with 25(OH)D median ranging from 32·0 (IQR 21·0–46·5) to 45·0 (28·0–64·5) nmol/l. Older age at baseline (R −0·46; P<0·001), overnutrition (BMI≥85th centile) at 3 months (P=0·005; relative risk=3·1) and not being supplemented at 6 months (P=0·04; relative risk=4·3) may have contributed to lower plasma 25(OH)D. Paediatric cancer patients are not at a higher risk of 25(OH)D inadequacy than healthy children at diagnosis; however, prevalence of 25(OH)D inadequacy is still high and non-supplemented children have a higher risk. Appropriate monitoring and therapeutic supplementation should be implemented.
It has become widely accepted among musicologists that medieval music is most profitably studied from interdisciplinary perspectives that situate it within broad cultural contexts. The origins of this consensus lie in a decisive reorientation of the field that began approximately four decades ago. For much of the twentieth century, research on medieval music had focused on the discovery and evaluation of musical and theoretical sources. The 1970s and 1980s, by contrast, witnessed calls for broader methodologies and more fully contextual approaches that in turn anticipated the emergence of the so-called 'New Musicology'. The fifteen essays in the present collection explore three interrelated areas of inquiry that proved particularly significant: the liturgy, sources (musical and archival), and musical symbolism. In so doing, these essays not only acknowledge past achievements but also illustrate how this broad, interdisciplinary approach remains a source for scholarly innovation.