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There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons.
To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD).
This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18–74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified.
Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI. Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12–1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34–1.69, P ≤ 0.001) but not with in-hospital mortality.
Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.
In sub-Saharan Africa, there are no validated screening tools for delirium in older adults, despite the known vulnerability of older people to delirium and the associated adverse outcomes. This study aimed to assess the effectiveness of a brief smartphone-based assessment of arousal and attention (DelApp) in the identification of delirium amongst older adults admitted to the medical department of a tertiary referral hospital in Northern Tanzania.
Consecutive admissions were screened using the DelApp during a larger study of delirium prevalence and risk factors. All participants subsequently underwent detailed clinical assessment for delirium by a research doctor. Delirium and dementia were identified against DSM-5 criteria by consensus.
Complete data for 66 individuals were collected of whom 15 (22.7%) had delirium, 24.5% had dementia without delirium, and 10.6% had delirium superimposed on dementia. Sensitivity and specificity of the DelApp for delirium were 0.87 and 0.62, respectively (AUROC 0.77) and 0.88 and 0.73 (AUROC 0.85) for major cognitive impairment (dementia and delirium combined). Lower DelApp score was associated with age, significant visual impairment (<6/60 acuity), illness severity, reduced arousal and DSM-5 delirium on univariable analysis, but on multivariable logistic regression only arousal remained significant.
In this setting, the DelApp performed well in identifying delirium and major cognitive impairment but did not differentiate delirium and dementia. Performance is likely to have been affected by confounders including uncorrected visual impairment and reduced level of arousal without delirium. Negative predictive value was nevertheless high, indicating excellent ‘rule out’ value in this setting.
Chapter 9 introduces the metaphor of a pendulum to characterize the sharp swings in Brandt’s policies toward European integration; the chancellor frequently backed ambitious EC projects that proved premature and unworkable. In 1970, fierce debates arose among the six EC members concerning how to pursue economic and monetary union (EMU). Brandt’s point person on Europe, Katharina Focke, sympathized with the French desire to tighten monetary cooperation among the EC partners right away. Bonn’s economy ministry under Karl Schiller took a more cautious line, insisting that macroeconomic convergence was necessary first. An EC agreement on EMU in early 1971 favored the French line; but soon thereafter a currency crisis prompted Brandt’s cabinet to “float” the mark, putting the EMU project on hold. Bonn’s policies helped the Nixon administration as it sought to stabilize the remnants of the Bretton Woods system – much to the dismay of French president Georges Pompidou. Afterwards Brandt worked to mend fences with France, and at a summit of the newly expanded EC in 1972 they pledged to form a European Union complete with a unified currency by 1980.
Drawing on the diary of Heinrich Krone, Chapter 1 opens by exploring social and cultural changes in West Germany at the end of Konrad Adenauer’s long ascendancy. The Christian Democratic milieu was losing its lock on politics, and the successes of German integration into Atlantic and European communities gave rise to new questions about whether NATO or the EEC had precedence; how German unity could be pursued in the face of détente; and what relationships were possible with the Soviet bloc. Adenauer’s choice was to intensify relations with de Gaulle’s France, with the 1963 Elysée Treaty defining the partnership between France and West Germany as a Cold War bulwark against détente and the USSR. This approach was challenged and significantly modified by the chancellor’s critics in the Bundestag, who feared alienating the United States and pushed for Ludwig Erhard to replace Adenauer. Foreign Minister Gerhard Schröder pushed for a “policy of movement,” intended to represent the cause of German unity more forcefully. Controversies over military aid, relations with Israel, and the Nuclear Test Ban Treaty showed that Adenauer’s long delay in resigning had left a vacuum of leadership.
If West Germany had one unique asset, it was the bedrock stability of its currency, the Deutsche Mark. Chapter 4 introduces the principal defenders of German stability – the economy and finance ministries, the Bundesbank, and the Council of Economic Experts. In fall 1965, Chancellor Erhard identified the maintenance of price stability as the foundation of German policy – with enormous repercussions for foreign relations. In 1965-66, development aid programs, restitution to Israel, and offset purchases from the United States would all be scaled back in order to keep Bonn’s budget balanced and avoid stimulating inflation. German monetary experts worked closely with U.S. officials to uphold the Bretton Woods monetary system; but Lyndon Johnson was furious that Erhard had broken his offset pledges, particularly since West Germany remained reluctant to send personnel to Vietnam. In spring 1966, Erhard’s cabinet tried to unthaw relations with the USSR by issuing a “peace note” calling for mutual renunciation-of-force declarations; but the Soviet bloc rejected the approach as inadequate. When West Germany slipped into recession, Erhard’s coalition collapsed in failure.
Chapter 11 examines the steps needed to rescue Brandt’s Ostpolitik from its near-demise at the hands of a polarized Bundestag. Following a rash of back-channel diplomacy with Egon Bahr at the center, France, Britain, the United States, and the USSR finally reached a Quadripartite Agreement on Berlin; it guaranteed access to the city but failed to clarify West Berlin’s relationship to the Federal Republic, leaving room for future disputes. Brandt’s surprise visit to Brezhnev in Crimea deepened the relationship between these two leaders, but created suspicion in the Western camp that did not ease even with Brandt’s award of the Nobel Peace Prize. Rainer Barzel, leader of the CDU/CSU, insisted that the Warsaw and Moscow treaties must be renegotiated; he maneuvered in the Bundestag to overthrow the Brandt government. Outside observers feared that the entire course of détente was in jeopardy. Barzel’s bid for power failed, but he continued to seek concessions from the Soviets; the GDR did briefly take a softer line. The treaties passed without CDU/CSU support, and Brandt went on to win a decisive victory in the 1972 elections, affirming public backing for Ostpolitik.
The book’s introduction explains why the years 1963 to 1975 were a period of tremendous experimentation in German foreign relations. A succession of relatively weak chancellors gave scope for cabinet members to push in various directions, whether this involved voracious weapons procurement, a single-minded battle against inflation, more generous development aid, or a tighter commitment to European integration. Even in periods of political instability, developments in West Germany had great import for Europe and the world beyond. Historiographically, the introduction stresses the broader historical relevance of German foreign relations: its study reveals the contested values of postwar Germans and how those priorities came to shape the international environment. Methodologically, the chapter presents a brief discussion of constructivism as outlined by political scientists Alexander Wendt and Susan Strange. International relations theory informs the book’s core question – how West Germans shaped and were shaped by the international system.
With the forming of a Grand Coalition, headed by Kurt Kiesinger (CDU/CSU) as chancellor and Willy Brandt (SPD) as foreign minister, West Germany sought equidistance between France and the United States and pursued a new Ostpolitik in parallel with de Gaulle. As Chapter 5 explains, the project proved highly unstable; de Gaulle could do little to aid Bonn vis-à-vis Poland, and Brandt wound up preferring direct contacts with the Soviets. Disputes over Britain’s accession to the EEC further soured Franco-German relations, and Paris was hardly pleased at Bonn’s renewal of its offset promises toward London and Washington. But the U.S.–German relationship also came under strain as the United States and USSR negotiated a non-proliferation treaty (NPT) that would force West Germany to accept a permanently inferior status. Kiesinger and Brandt used their leverage with Washington to force significant changes to the NPT in the areas of nuclear research and commerce; but they also consulted with other nuclear have-nots, such as India and Iran, and contemplated Germany’s future as a middle-sized power. Increasingly, West Germans identified technology exports as a significant source of prestige.
In Chapter 8, focus turns to the handiwork of Brandt’s Ostpolitik – the negotiation of the Moscow and Warsaw Treaties in 1970. Egon Bahr’s bargaining strategy in Moscow was hasty and dilettantish; he did not worry overly about the contents of the treaty with the USSR, since he saw the agreement as only one component of an interlocking series of treaties. When the substance of the “Bahr Paper” was leaked, his secretive approach and his failure to address the Berlin problem further polarized German politics. The CDU/CSU vehemently rejected Brandt’s policies and members of the coalition parties began to defect. The external resonance of German Ostpolitik was nonetheless enormous. Brandt’s meeting with Brezhnev in Moscow alerted the world to the ebbing of Soviet hostility, resulting in greater maneuvering room for Bonn. When the chancellor kneeled in Warsaw, it appeared to signal German acceptance of the moral weight of Nazi crimes. A closer view shows, however, that the Federal Republic was extremely hard-nosed toward Poland; it demanded emigration rights for ethnic Germans while refusing to offer restitution payments. Brandt’s Germany looked forward, not backward.
Chapter 7 depicts a severe cleft in German politics as the Grand Coalition headed toward Bundestag elections in September 1969. Chancellor Kiesinger tried to coax the USSR into softening its enmity toward West Germany, but his hard-line stances on Berlin and the NPT stalled progress. Egon Bahr, Willy Brandt’s controversial aide, urged the SPD to cast aside old ballast: Bonn should sign the NPT, stop isolating the GDR, and renounce territorial claims in Poland. Economy minister Karl Schiller, the SPD’s central figure in the 1969 campaign, insisted that the German mark should be revalued. Kiesinger’s CDU/CSU rejected all of these proposals, and the coalition cabinet proved incapable of decisive action for most of the year – causing economic havoc across Western Europe. The SPD–FDP coalition won the election only narrowly, but as Chancellor Willy Brandt acted decisively to revalue the mark and pledge German support for “deepening” and “widening” Europe at an EC summit in The Hague. On Ostpolitik, Brandt signed the NPT and authorized soundings with the USSR and Poland; but Bahr grew impatient and angled to open a back channel to the Kremlin.
Turning to the Middle East, Africa, and Latin America, Chapter 10 explores the challenges Bonn faced amidst the turmoil of the early 1970s. Tightened budgets, occasioned by worries about inflation, hampered efforts by aid minister Erhard Eppler to follow through on Brandt’s promises of expanding development aid to the Global South. Karl Schiller insisted that trade, not aid, was the better path forward. Bonn’s liberal, free-trade approach drew criticism from African leaders, as West Germany invested heavily in apartheid South Africa; Brandt’s government did, however, enact tighter restrictions on weapons exports outside NATO. German officials frowned upon Global South demands for a more balanced world trading order, but they played a mediating role at UNCTAD III, a global trade and development conference in Santiago, Chile. Confronted with a rash of kidnappings in Latin America and Palestinian terrorism on German soil, Brandt’s government opted repeatedly to appease the hostage-takers rather than prosecute them. This passive response contributed to the disaster at the Munich Olympics in 1972, when Israeli athletes were captured and murdered.
Chapter 13 documents a shift in leadership as hard-nosed pragmatist Helmut Schmidt moved to the fore. The 1973 “oil shock” provoked disarray among the EC-9 as European countries adopted egoistic strategies to secure oil supplies. Bonn responded by putting the EC Regional Development Fund on hold, touching off a crisis in British–EC relations. Schmidt aligned German positions more closely with the United States, ending capital controls and embracing Henry Kissinger’s plan for Western energy cooperation. When Brandt resigned over a spy scandal, Schmidt assumed control of a confident West Germany that was managing the oil price spike smoothly – and used its influence (and a Bundesbank loan) to urge austerity measures on Italy. Schmidt forged a tight partnership with French president Valéry Giscard d’Estaing, who endorsed many German economic views. Relations with the USSR soured due to disputes over Berlin, and also because of Bonn’s key role in thwarting communist gains in Portugal and Italy. As seen in German diplomacy toward Greece and Turkey over Cyprus, Schmidt’s Germany was defining a role as a stabilizing force on the European continent in cooperation with the United States.