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The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.
We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.
Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.
To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.
The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.
Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.
A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.
41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.
The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.
This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.
For the last two decades, high-dimensional data and methods have proliferated throughout the literature. Yet, the classical technique of linear regression has not lost its usefulness in applications. In fact, many high-dimensional estimation techniques can be seen as variable selection that leads to a smaller set of variables (a “submodel”) where classical linear regression applies. We analyze linear regression estimators resulting from model selection by proving estimation error and linear representation bounds uniformly over sets of submodels. Based on deterministic inequalities, our results provide “good” rates when applied to both independent and dependent data. These results are useful in meaningfully interpreting the linear regression estimator obtained after exploring and reducing the variables and also in justifying post-model-selection inference. All results are derived under no model assumptions and are nonasymptotic in nature.
Intrauterine preeclampsia exposure affects the lifelong cardiometabolic health of the child. Our study aimed to compare the growth (from birth to 6 months) of infants exposed to either a normotensive pregnancy or preeclampsia and explore the influence of being born small for gestational age (SGA). Participants were children of women participating in the Post-partum, Physiology, Psychology and Paediatric follow-up cohort study. Birth and 6-month weight and length z-scores were calculated for term and preterm (<37 weeks) babies, and change in weight z-score, rapid weight gain (≥0.67 increase in weight z-score) and conditional weight gain z-score were calculated. Compared with normotensive exposed infants (n = 298), preeclampsia exposed infants (n = 84) were more likely to be born SGA (7% versus 23%; P < 0.001), but weight gain from birth to 6 months, by any measure, did not differ between groups. Infants born SGA, irrespective of pregnancy exposure, were more likely to have rapid weight gain and had greater increases in weight z-score compared with those not born SGA. Preeclampsia exposed infants born SGA may benefit from interventions designed to prevent future cardiometabolic disease.
With no approved treatments for COVID-19 initially available, the Food and Drug Administration utilized multiple preapproval pathways to provide access to investigational agents and/or medical devices: Expanded Access, Emergency Use Authorizations, and Clinical Trials. Regulatory units within an Academic Medical Center (AMC), including those part of the Clinical and Translational Science Award (CTSA) consortium, have provided support for clinicians in navigating these options prior to the pandemic. As such, they were positioned to be a resource for accessing therapies during the COVID-19 public health emergency.
A small survey and a follow-on poll of the national Investigational New Drug (IND)/Investigational Device Exemption (IDE) Workgroup were conducted in October and December 2020 to determine whether CTSA regulatory units assisted in facilitating access to COVID-19 therapies and the extent of pandemic-related challenges these units faced.
Fifteen survey and 21 poll responses were received, which provided insights into the demands placed on these regulatory support units due to the pandemic and the changes required to provide critical support during this and future crises. Key changes and lessons learned included the importance of regulatory knowledge to support the institutional response, the critical need for electronic submission capacity for Food and Drug Administration (FDA) documents, and the nimble reallocation of regulatory and legal resources to support patient access to investigational agents and/or medical devices during the pandemic.
AMC- and CTSA-based regulatory units played a meaningful role in the COVID-19 pandemic but further unit modifications are needed for enabling more robust regulatory support in the future.
Agency is the human capacity to freely choose one’s thoughts, motivations and actions without undue internal or external influences; it is distinguished from decisional capacity. Four well-known conditions that can deeply affect agency are depression, demoralization, existential distress, and family dysfunction. The study reviews how they may diminish agency in persons whose circumstances may lead them to consider or request euthanasia or assisted suicide. Since agency has been a relatively neglected dimension of autonomous choice at the end of life, it is argued that to respect the autonomy of individuals, it is essential to establish their agency.
The principal aim of this study was to optimize the diagnosis of canine neuroangiostrongyliasis (NA). In total, 92 cases were seen between 2010 and 2020. Dogs were aged from 7 weeks to 14 years (median 5 months), with 73/90 (81%) less than 6 months and 1.7 times as many males as females. The disease became more common over the study period. Most cases (86%) were seen between March and July. Cerebrospinal fluid (CSF) was obtained from the cisterna magna in 77 dogs, the lumbar cistern in f5, and both sites in 3. Nucleated cell counts for 84 specimens ranged from 1 to 146 150 cells μL−1 (median 4500). Percentage eosinophils varied from 0 to 98% (median 83%). When both cisternal and lumbar CSF were collected, inflammation was more severe caudally. Seventy-three CSF specimens were subjected to enzyme-linked immunosorbent assay (ELISA) testing for antibodies against A. cantonensis; 61 (84%) tested positive, titres ranging from <100 to ⩾12 800 (median 1600). Sixty-one CSF specimens were subjected to real-time quantitative polymerase chain reaction (qPCR) testing using a new protocol targeting a bioinformatically-informed repetitive genetic target; 53/61 samples (87%) tested positive, CT values ranging from 23.4 to 39.5 (median 30.0). For 57 dogs, it was possible to compare CSF ELISA serology and qPCR. ELISA and qPCR were both positive in 40 dogs, in 5 dogs the ELISA was positive while the qPCR was negative, in 9 dogs the qPCR was positive but the ELISA was negative, while in 3 dogs both the ELISA and qPCR were negative. NA is an emerging infectious disease of dogs in Sydney, Australia.
Effective community engagement in T3–T4 research is widespread, however, similar stakeholder involvement is missing in T1–T2 research. As part of an effort to embed community stakeholders in T1–T2 research, an academic community partnered team conducted discussion groups with researchers to assess perspectives on (1) barriers/challenges to including community stakeholders in basic science, (2) skills/training required for stakeholders and researchers, and (3) potential benefits of these activities. Engaging community in basic science research was perceived as challenging but with exciting potential to incorporate “real-life” community health priorities into basic research, resulting in a new full-spectrum translational research model.
Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC.
Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test.
Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope –0.43 to –0.26, p = 0.055; sodium slope –2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%).
Significance of results
QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.
Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother–infant bonding problems.
The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3–9. VIHCS enrolment began in 2006 (when participants were aged 28–29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother–infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum.
Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20–29) reported higher levels of perinatal depressive symptoms and mother–infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted β = 5.40, 95% confidence interval (CI) 3.42–7.39; mother–infant bonding problems adjusted β = 7.51, 95% CI 3.09–11.92]. There was no evidence that self-harm in adolescence (ages 15–17) was associated with either perinatal outcome.
Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother–infant bonding problems.
Both childhood maltreatment and insecure attachment are known to be associated with depression in adulthood. The extent insecure attachment increases the risk of adult clinical depression over that of parental maltreatment among women in the general population is explored, using those at high risk because of their selection for parental maltreatment together with an unselected sample.
Semi-structured interviews and investigator-based measures are employed.
Insecure attachment is highly associated with parental maltreatment with both contributing to the risk of depression, with attachment making a substantial independent contribution. Risk of depression did not vary by type of insecure attachment, but the core pathways of the dismissive and enmeshed involved the whole life course in terms of greater experience of a mother's physical abuse and their own anger as an adult, with both related to adult depression being more often provoked by a severely threatening event involving humiliation rather than loss. By contrast, depression of the insecure fearful and withdrawn was more closely associated with both current low self-esteem and an inadequately supportive core relationship. In terms of depression taking a chronic course, insecure attachment was again a key risk factor, but with this now closely linked with the early experience of a chaotic life style but with this involving only a modest number of women.
Both insecure attachment and parental maltreatment contribute to an increased risk of depression with complex effects involving types of insecure attachment.
Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples.
Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.
Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.
Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms of C. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.
Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.
Gathered here in alphabetical order are four short works that, like the COMMENTARIES, were written to help others understand scripture but that lack the sustained arguments of Bede's exegesis. It would, of course, have been possible to include many other works here as well. Most obviously, the CHAPTER DIVISIONS and PROLOGUES for books of the Bible are in some ways similar to the COLLECTIO PSALTERII in that they distil complex texts into more understandable forms. Moreover, while M.L.W. Laistner (1939 p xxxvii) is somewhat dismissive of the NOMINA REGIONUM ET LOCORUM DE ACTIBUS APOSTOLORUM, calling it “a not very distinguished performance,” we are more impressed by Bede's systematic study of diverse materials in order to acquire the knowledge he needed in order to understand God's unfolding plan. The three geographical works included here appear to be like his early study of time that led to DE TEMPORIBUS and the COMMENTARIUS IN APOCALYPSIM.
COLLECTIO PSALTERII [BEDA.Coll.Psalt.]: CPL 1371.
ed.: Browne 2001.
MSS – Quots/Cits
This little florilegium consists of, usually, one to a dozen key verses selected from each of the Psalms. Noting ALCUIN's “dicitur” in the reference listed above – which will be discussed in more detail in a moment – and the lack of any mention of this work in Bede's list of his writings at the end of the HISTORIA ECCLESIASTICA GENTIS ANGLORUM (ed. Lapidge 2010 2.480-84), Michael Gorman (1998 pp 230-31) casts doubt on the attribution. Alcuin's remark is, however, less ambiguous than Gorman suggests, and the work is, as he notes, identified as Bede's in the three ninth-century manuscripts in which it survives.
In a more extensive study of “Bede and the Psalter,” Benedicta Ward (1991 p 10) discusses Bede's method in compiling the work:
He selected the best text he knew, JEROME's third psalter, iuxta hebriacos. From this, he selected verses from each psalm which could be used as direct prayer or praise, as food for meditation, plea for mercy, protest, contrition, or adoration and exultation. Sometimes one verse alone was used, sometimes several. The verses were also selected so that a sense of the meaning of the psalm as whole was retained; it would be possible to recall the whole psalm from these clues.
Bede's list in HISTORIA ECCLESIASTICA GENTIS ANGLORUM V.xxiv (ed. Lapidge 2010.480-84) establishes not only what he had written up to 731 but, more remarkably, what he considered a work to be even though here he ingeniously avoided using any word to characterize his own compositions. From it Michael Lapidge (2010 1.xliv-xlvi) enumerates 30 items. While most can be identified with a simple reference to the Clavis Patrum Latinorum, a few problems, to which we will turn in a moment, appear. Lapidge then lists nine “altre opere” that can be attributed to Bede “con certezza.” While we accept Lapidge's judgement that Bede composed them, we would point out that he might not have considered all to be, as we do, opera. Clearly, the EPISTOLA AD ECGBERCTUM is both a work and was considered one by Bede, as the slight but significant evidence of a fifteenth-century manuscript now in Merton College Oxford indicates: after he wrote it in 734, he placed a copy into his LIBER EPISTOLARUM. Would he, however, have viewed the MAGNUS CIRCULUS SEU TABULA PASCHALIS ANNIS DOMINI DXXXII AD MLXIII and the PAGINA REGULARUM, tables designed to help students as they studied DE TEMPORUM RATIONE, opera? That we do calls attention to perhaps other lost handouts, other lost letters that Bede must have sent, other verse that he might have included in his LIBER HYMNORUM and his LIBER EPIGRAMMATUM, and three are listed there: other HOMILIES that he probably preached. Two more potentially lost works were mentioned by CUTHBERT in his EPISTOLA DE OBITU BEDAE (ed. and trans. Colgrave and Mynors 1969 pp 580-87), a translation of John's Gospel (to 6:9) and selections from ISIDORE's DE NATURA RERUM.
That there are so few lost works is a mark of the respect Bede has been given over the centuries. While the work of editing, translating, and interpreting the corpus is ongoing, identifying what Bede wrote has been largely accomplished, as several recent discoveries may make clear. Paul Meyvaert and Carmela Vircillo Franklin (1982) pick out the PASSIO ANASTASII that Bede mentioned in Historia ecclesiastica V.xxiv from among the anonymous versions of this work; Franklin (2004) edits and analyzes it. Lapidge (1996c) has identified the first version of the VITA CUTHBERTI METRICA, which he will edit in Bede's Latin Poetry.
This second volume completes our survey of the reception of Bede's writings in Anglo-Saxon England. Reading Bede through the works of his immediate followers makes us aware of how useful he was to them, providing the tools they needed to carry on, most prominently, recording history and spreading the faith through preaching. With its entries on the HISTORIA ECCLESIASTICA GENTIS ANGLORUM and the two chronicles that are part of DE TEMPORIBUS and DE TEMPORUM RATIONE, volume one focused on the first topic. With those on HOMILIES and on the EXTRACTS from the COMMENTARIES on Mark and Luke, which served the same purpose, volume two is dominated by the latter. There is much else in both, but in these areas, geography, hagiography, metrics, orthography, rhetoric, and science, Bede primarily taught.
Bede's theology is only occasionally a focus of the entries in this volume, in part because he chose not to accentuate doctrinal differences. This is not to say he avoided these issues when they arose. As Faith Wallis (2013) and Peter Darby (2012) have demonstrated, it appears to have been his interest in combatting eschatological speculation around the year 700 that led to both his De temporibus and the COMMENTARIUS IN APOCALYPSIM. Similarly, his unprecedented commentaries on the tabernacle and the temple demonstrate the degree to which Bede pursued topics that caught his interest. Here the study of Conor O’Brien (2015) breaks new ground in our understanding of Bede's developing thought. Passing over much other scholarship, we would finally note the work of Benedicta Ward (1995) and Sarah Foot (2014) on Bede's understanding of prayer, particularly as it applied to female monastic communities. There is much more to be learned in these areas; and yet, for the moment, it appears that Bede stood out from his contemporaries in having the time and inclination to read deeply in the Fathers and engage with their work in order to produce original commentaries on the Bible.
So we return to Bede the preacher to conclude this introduction.
Although Bede is now known primarily as an historian, he considered himself foremost a biblical exegete, and most of his works are exegetical. He emphasized this role in the bio-bibliographic note at the end of the HISTORIA ECCLESIASTICA GENTIS ANGLORUM, which suggests that there were two overlapping phases in his study of the Bible. The first covered his entire intellectual and spiritual life, beginning when, at the age of seven, he was given to the abbey of Monkwearmouth (ed. Lapidge 2010 2.478-80; trans. Colgrave and Mynors 1969 p 567):
Qui natus in territorio eiusdem monasterii, cum essem annorum VII, cura propinquorum datus sum educandus reuerentissimo abbati Benedicto, ac deinde Ceolfrido, cunctumque ex eo tempus uitae in eiusdem monasterii habitatione peragens, omnem meditandis scripturis operam dedi, atque inter obseruantiam disciplinae regularis, et cotidianam cantandi in ecclesia curam, semper aut discere aut docere aut scribere dulce habui.
(I was born in the territory of this monastery. When I was seven years of age I was, by the care of my kinsmen, put into the charge of the reverend Abbot Benedict and then of Ceolfrith, to be educated. From then on I have spent all my life in this monastery, applying myself entirely to the study of the Scriptures; and amid the observance of the discipline of the Rule and the daily task of singing in the church, it has always been my delight to learn or to teach or to write.)
As this passage makes clear, his study of and meditation on scripture was a life-long occupation, fit in around his other duties in the monastery, observing the monastic rule, learning, teaching, and writing.
After describing his ordinations as a deacon and a priest at the ages of nineteen and thirty, Bede focused more specifically on his biblical commentaries: “ex quo tempore accepti presbyteratus usque ad annum aetatis meae LVIIII haec in scripturam sanctam meae meorumque necessitati ex opusculis uenerabilium patrum breuiter adnotare, siue etiam ad formam sensus et interpretationis eorum superadicere curaui” (ed. Lapidge 2010 2.480; “from the time I became a priest until the fifty-ninth year of my life I have made it my business for my own benefit and that of my brothers, to make brief extracts from the works of the venerable fathers on the holy Scriptures, or to add notes of my own to clarify their sense and interpretation,” trans.