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Adhering to a Mediterranean Diet (MD) is associated with reduced cardiovascular disease (CVD) risk. This study aimed to explore methods of increasing MD adoption in a non-Mediterranean population at high risk of CVD, including assessing the feasibility of a developed peer support intervention. The Trial to Encourage Adoption and Maintenance of a MEditerranean Diet (TEAM-MED) was a 12-month pilot parallel group RCT involving individuals aged ≥40 y, with low MD adherence, who were overweight, and had an estimated CVD risk ≥20% over ten years. It explored three interventions, a peer support group, a dietician-led support group and a minimal support group to encourage dietary behaviour change and monitored variability in Mediterranean Diet Score (MDS) over time and between the intervention groups, alongside measurement of markers of nutritional status and cardiovascular risk. 118 individuals were assessed for eligibility, and 75 (64%) were eligible. After 12 months there was a retention rate of 69% (PSG 59%; DSG 88%; MSG 63%). For all participants, increases in MDS were observed over 12 months (p<0.001), both in original MDS data and when imputed data were used. Improvements in BMI, HbA1c levels, systolic and diastolic blood pressure in the population as a whole. This pilot study has demonstrated that a non-Mediterranean adult population at high CVD risk can make dietary behaviour change over a 12-month period towards a MD. The study also highlights the feasibility of a peer support intervention to encourage MD behaviour change amongst this population group and will inform a definitive trial.
As we arrive at ciu. Dei 21 and 22, we reach the final destination of the two cities after their long pilgrimage on earth. Book 21 deals with the final repudiation of the ciuitas terrena, the eternal punishment of the damned in Hell. Book 22 examines the ultimate fate of the ciuitas Dei, the eternal reward of the blessed in heaven. But, as I will argue in this chapter, one can also read the final books of the City of God as the endpoint of a specific intellectual journey on which Augustine had embarked decades earlier, one that led him to abandon much of the mental furniture of a late antique philosopher and to embrace – even to pioneer – a cosmology and a theological anthropology with specifically Christian contours.
To provide an answer to the question of whether we need global health ethics, we set ourselves three goals in this chapter. First, we explore a number of different ways that we might understand the term global health ethics. Second, we consider the arguments that could be used either to support or dismiss what we call substantive accounts of global health ethics. Finally, we make some suggestions in relation to what (if any) global obligations may bind us. Our discussions will use public health as an example throughout to illustrate our points. The reason for this focus is that, in our view, we ought to think of public health as providing systematic structural support for population health, with the key aim of fulfilling the basic requirements to protect health and prevent illness. This is not to suggest that other forms of healthcare are unimportant, just that public health will fulfill a primary role in any attempt to address questions of global justice in relation to existing health inequalities.
We use comparable 2005 and 2018 population data to assess threats driving the decline of lion Panthera leo populations, and review information on threats structured by problem tree and root cause analysis. We define 11 threats and rank their severity and prevalence. Two threats emerged as affecting both the number of lion populations and numbers within them: livestock depredation leading to retaliatory killing of lions, and bushmeat poaching leading to prey depletion. Our data do not allow determination of whether any specific threat drives declines faster than others. Of 20 local extirpations, most were associated with armed conflicts as a driver of proximate threats. We discuss the prevalence and severity of proximate threats and their drivers, to identify priorities for more effective conservation of lions, other carnivores and their prey.
Partnership working has been a long-standing objective of health and social policy, in recognition of the reality that few policy puzzles are simple and the preserve of any single agency or government department. ‘Wicked issues’ that display complex multiple causes in search of solutions that are intersectoral require joined up approaches at both national and local levels. Despite this awareness, in practice effective joint working remains the exception rather than the rule, and governments and their agents struggle to achieve success while remaining trapped in their silos and protecting their narrow interests (Hunter and Perkins, 2014; Perkins and Hunter, 2014).
How to do partnership working differently was behind the creation of health and wellbeing boards (HWBs) at the time of the 2012 NHS changes. At the time, there was much enthusiasm for these new entities and expectations ran high. Resources were made available to support boards and to help members consider how to create effective partnerships across local government and the National Health Service (NHS).
Sadly, some eight years later, the shine has gone off HWBs despite the fact that the issues they were set up to tackle remain as visible and deep-seated as ever. Indeed, after nearly a decade of austerity, which has contributed to a sharp rise in health inequalities and entrenched the North–South divide, and with the potential fallout from Brexit around the corner with as yet unknown but almost certainly negative consequences, the need for powerful HWBs that can bring about real change to improve the lot of ravaged communities has never been greater.
A recent study (led by the author of this chapter) of HWBs in England established in 2012, when responsibility for public health transferred to local government, found that, with few exceptions, HWBs punched below their weight and were not the powerful system leaders that had been hoped for (Hunter et al, 2017). Similar findings were reported in a series of reviews conducted by Shared Intelligence in the early years of HWBs (Shared Intelligence, 2013, 2014, 2015). With the advent of sustainability and transformation programmes (STPs) and integrated care partnerships (ICPs) following the introduction in 2014 of a major programme of reform within the NHS (NHSE, 2014), an opportunity for HWBs to become key drivers for a new integrated approach with local government at its centre has largely been missed.
We can, together, reimagine our place in this world. As human beings we all have the outrageous fortune to be here on this planet at this moment of extreme consequence.
Christiana Figueres is adamant that this is the moment in which we are collectively writing the future of humanity. Christiana Figueres is worth listening to. She is the Costa Rican who was one of the architects of the Paris Agreement. We are constantly writing humanity's future (and living the future others have written for us). However, as existential risks swirl around us, threatening to combine in a perfect tornado, it feels more important than ever that we step into our role as authors of our collective destiny.
This authorship involves a creative imagining and a vivid communicating and is achieved, most powerfully, through stories. Stories set humans apart from other living organisms on the planet. They have the capacity to shift the minds and moods of nations, yet in turn are influenced and affected by the particular language (down to individual words) with which we choose to communicate them.
This chapter looks at archetypal elements of the great stories. It identifies the story that has dominated human culture over recent generations and some other stories it has ignored. It engages with the remarkable rewriting that has been taking place during the COVID-19 crisis, the language used and the lessons this offers for us as we build a new narrative and share the stories that flow from it to create the future we want for our descendants.
This chapter tells its story from the perspective of its teller, so is a white, Western, privileged version of where we have been and where we are going. It focuses on a possible positive future, but in describing some of the positive effects of the pandemic only, it is not intended to be dismissive of the enormous pain and disturbance many have suffered. It offers one reality, by no means the only one, but hopefully one that contains sufficient traces of universality to offer something for all readers.
The magic ingredients
The following table identifies, with reference to The Wizard of Oz, the core elements found in most of the great stories, as distilled by the Stronger Stories initiative.
Clozapine is uniquely effective in treatment-resistant psychosis but remains underutilised, partly owing to psychotic symptoms leading to non-adherence to oral medication. An intramuscular formulation is available in the UK but outcomes remain unexplored.
This was a retrospective clinical effectiveness study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis over a 3-year period.
Successful initiation of oral clozapine after intramuscular prescription was the primary outcome. Secondary outcomes included all-cause clozapine discontinuation 2 years following initiation, and 1 year after discharge. Discontinuation rates were compared with a cohort prescribed only oral clozapine. Propensity scores were used to address confounding by indication.
Among 39 patients prescribed intramuscular clozapine, 19 received at least one injection, whereas 20 accepted oral clozapine when given an enforced choice between the two. Thirty-six (92%) patients successfully initiated oral clozapine after intramuscular prescription; three never transitioned to oral. Eight discontinued oral clozapine during the 2-year follow-up, compared with 83 out of 162 in the comparator group (discontinuation rates of 24% and 50%, respectively). Discontinuation rates at 1-year post-discharge were 21%, compared with 44% in the comparison group. Intramuscular clozapine prescription was associated with a non-significantly lower hazard of discontinuation 2 years after initiation (hazard ratio 0.39, 95% CI 0.14–1.06) and 1 year after discharge (hazard ratio 0.37, 95% CI 0.11–1.24). The only reported adverse event specific to the intramuscular formulation was injection site pain and swelling.
Intramuscular clozapine prescription allowed transition to oral maintenance in an initially non-adherent cohort. Discontinuation rates were similar to patients only prescribed oral clozapine and comparable to existing literature.
This chapter argues that the emergence of marriage as a symbol and its relation to marriage as ‘sacrament’ were connected to a third factor, namely the emergence of a ‘priestly’ identity for the Western clergy. Hunter shows first that a tradition developed in the third to the fifth centuries in which the single marriage of the clergy (i.e. the prohibition of digamists from ordination) became a privileged symbol of divine–human union, and eventually the union of Christ and the Church; second, that this tradition of single marriage was directly connected to the increased sacralizing of marriage in liturgical practice; and, third, that both of these developments contributed to the identification of the Western clergy as ‘priests’.
Keywords: digamus; remarriage (or second marriage); clergy; single marriage; priesthood
The two conferences hosted by the Norwegian Institute in Rome during the summers of 2014 and 2016 provided a welcome opportunity to reflect on the character of marriage as a symbol and its functions in late antique and early medieval Christianity. As participants, we were invited to consider the relationship between construing marriage as a symbol of a divine/human union (e.g. Christ and the Church) and the impact of this symbolization on the developing notion of marriage as ‘sacrament’. In my contribution, which is presented here, I suggest that these two developments – the use of marriage as a symbol and the increased recognition of marriage as some kind of sacred union – were connected to a third factor, namely the emergence of a ‘priestly’ identity for the Western Christian clergy.
Restrictions on the sexual and marital lives of the Christian clergy emerged only very gradually in both East and West. Permanent sexual abstinence for the higher clergy (bishops, presbyters, and deacons) became a canonical requirement in the West in the late fourth century, and by the late eleventh and early twelfth centuries a complete separation of clergy and marriage had become central to the agenda of the Gregorian Reform. But prior to these developments, an earlier tradition of restricting ordination to men who had been married only once existed in both the Eastern and the Western Churches.
The music-theatrical benefit is an open acknowledgement of the role that audiences play in the economy of the musical and theatrical worlds. Ostensibly put on as a means to provide performers or other playhouse personnel with a direct reward from audiences, the occasions also serve as a means for performers to reward audiences for their attentiveness, fidelity, and participation throughout the season. To conceive of benefits without audiences is as impossible as it is to conceive of them without performers. As part of the panoply of patronal relationships common before and during the long eighteenth century, the benefit is still with us and plays the same role, notwithstanding the variety of ways in which we chose to cloak it these days. By examining the structure of who, when, where, how much, and how often, through examination of original archival materials, published correspondence, commentary in the London Stage volumes, and other sources, including both straightforward and satirical portrayals in poems, novels, plays, and cartoons, I examine the ecology of the benefit to reveal its extent, its boundaries, and its value.
By 1918, Japan had achieved lofty goals conceived more than fifty years previously by those known in the West as the oligarchs, and in Japan as genro (elder statesmen). Over the next twenty-five years, these gains were lost as Japan experienced crises at home and launched disastrous military adventures abroad. In Japan, power had long adhered to those close to the emperor, who, himself, seldom ruled and who stood for no particular ideology. Japanese society consisted of many autonomous, competing groups. The father of the Imperial Japanese Army (IJA), Yamagata Aritomo, equipped it with several advantages in this competition, allowing it to eventually seize control of the state. The IJA led the nation into war with Manchuria, then China, and then the Allies. Its organizational culture produced tough, proficient, and courageous soldiers, who won three conventional conflicts. But its culture left it unable to deal with military losses; it was a culture that prized reputation over public honesty, ritualized death and placed its own judgment above question. According to its own creed, the IJA should have “done its utmost to protect the state.” Instead its soldiers are remembered in Japan and much of the world as “beasts.”
Residual herbicides are routinely applied to control troublesome weeds in pumpkin production. Fluridone and acetochlor, Groups 12 and 15 herbicides, respectively, provide broad-spectrum PRE weed control. Field research was conducted in Virginia and New Jersey to evaluate pumpkin tolerance and weed control to PRE herbicides. Treatments consisted of fomesafen at two rates, ethalfluralin, clomazone, halosulfuron, fluridone, S-metolachlor, acetochlor emulsifiable concentrate (EC), acetochlor microencapsulated (ME), and no herbicide. At one site, fluridone, acetochlor EC, acetochlor ME, and halosulfuron injured pumpkin 81%, 39%, 34%, and 35%, respectively, at 14 d after planting (DAP); crop injury at the second site was 40%, 8%, 19%, and 33%, respectively. Differences in injury between the two sites may have been due to the amount and timing of rainfall after herbicides were applied. Fluridone provided 91% control of ivyleaf morningglory and 100% control of common ragweed at 28 DAP. Acetochlor EC controlled redroot pigweed 100%. Pumpkin treated with S-metolachlor produced the most yield (10,764 fruits ha–1) despite broadcasting over the planted row; labeling requires a directed application to row-middles. A separate study specifically evaluated fluridone applied PRE at 42, 84, 126, 168, 252, 336, and 672 g ai ha–1. Fluridone resulted in pumpkin injury ≥95% when applied at rates of ≥168 g ai ha–1; significant yield loss was noted when the herbicide was applied at rates >42 g ai ha–1. We concluded that fluridone and acetochlor formulations are unacceptable candidates for pumpkin production.
Ambrosiaster, an early Christian exegete writing in Latin at the end of the fourth century in Rome, was a thinker whose mind was profoundly shaped by notions of law. He devoted considerable attention to questions of the relation between various kinds of law: the law of nature (lex naturalis), the Mosaic Law, Roman law, and Christian law (“the law of faith”). As an interpreter of the Pauline corpus, he was especially influenced by Paul’s discussion of law in the Epistle to the Romans, where the Apostle argued, “When Gentiles who have not the law do by nature what the law requires, they are a law to themselves” (Rom 2:14). Ambrosiaster saw contemporary Roman law as derived partly from natural law, partly from Mosaic law, and partly from the Greeks. As a result, he did not hesitate to justify both Christian doctrine and Christian practice by referring to Roman legal traditions. Because Ambrosiaster’s Pauline commentary was transmitted in the Middle Ages under the name of Ambrose, and because his Questions on the Old and New Testaments was ascribed to Augustine, he exerted great influence on the subsequent tradition, especially on medieval canon law.
Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.
To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).
Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.
All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.
The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.
Movement disorders associated with exposure to antipsychotic drugs are common and stigmatising but underdiagnosed.
To develop and evaluate a new clinical procedure, the ScanMove instrument, for the screening of antipsychotic-associated movement disorders for use by mental health nurses.
Item selection and content validity assessment for the ScanMove instrument were conducted by a panel of neurologists, psychiatrists and a mental health nurse, who operationalised a 31-item screening procedure. Interrater reliability was measured on ratings for 30 patients with psychosis from ten mental health nurses evaluating video recordings of the procedure. Criterion and concurrent validity were tested comparing the ScanMove instrument-based rating of 13 mental health nurses for 635 community patients from mental health services with diagnostic judgement of a movement disorder neurologist based on the ScanMove instrument and a reference procedure comprising a selection of commonly used rating scales.
Interreliability analysis showed no systematic difference between raters in their prediction of any antipsychotic-associated movement disorders category. On criterion validity testing, the ScanMove instrument showed good sensitivity for parkinsonism (90%) and hyperkinesia (89%), but not for akathisia (38%), whereas specificity was low for parkinsonism and hyperkinesia, and moderate for akathisia.
The ScanMove instrument demonstrated good feasibility and interrater reliability, and acceptable sensitivity as a mental health nurse-administered screening tool for parkinsonism and hyperkinesia.
OBJECTIVES/SPECIFIC AIMS: Listening effort is needed to understand speech that is degraded by hearing loss and/or a noisy environment. Effortful listening reduces cognitive spare capacity (CSC). Predictive contexts aid speech perception accuracy, but it is not known whether the use of context reduces or preserves CSC. Here, we compare the impact of predictive context and cognitive load on behavioral indices of CSC in elderly, hearing-impaired adults. METHODS/STUDY POPULATION: Elderly, hearing-impaired adults listened in a noisy background to spoken sentences in which sentence-final words were either predictable or not predictable based on the sentence context. Cognitive load was manipulated by asking participants to remember either short or long sequences of visually presented digits. Participants were divided into low or high cognitive capacity groups based on a pretest of working memory. Accuracy and response times were examined for report of both sentence-final words and digit sequences. RESULTS/ANTICIPATED RESULTS: Preliminary results indicate that accuracy and response times for both words and digits were facilitated by sentence predictability, suggesting that the use of predictive sentence context preserves CSC. Response times for both words and digits and accuracy for digits were impaired under cognitive load. Trends were similar across high and low cognitive capacity groups. The preliminary results support the idea that habilitation strategies involving context use could potentially support CSC in elderly, hearing-impaired adults. DISCUSSION/SIGNIFICANCE OF IMPACT: These preliminary results support the concept that habilitation strategies involving context use could potentially support CSC in elderly, hearing-impaired adults.
Amidst the NHS’s (National Health Service) success lies its major weakness, although one that Klein overlooks in his reflections on the NHS as it approaches 70. The focus on, and investment in, curing ill-health has been at the expense of attending to the public’s overall health and well-being. This preoccupation poses a greater threat to the NHS’s future than privatisation. Despite the weakness having been diagnosed decades ago, redressing the imbalance has proved stubbornly hard to achieve. Rhetoric has not been translated into reality. Yet, we may be on the cusp of a tipping point where in order to ensure a sustainable NHS, and one that is capable of meeting the 21st century challenges facing it, there is a renewed and overdue interest in promoting health and well-being in communities. But for this to succeed, the NHS will need to embrace its bete noire, local government.