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Survivors of childhood trauma are at increased risk of complex post-traumatic stress disorder (CPTSD). The Recovering from Child Abuse Programme (RCAP) is a cognitive behavioural therapy (CBT) group promoting adaptive coping strategies which may help overcome CPTSD symptoms in adult survivors of childhood trauma. We sought to explore patient experiences of factors influencing treatment acceptability and potential mechanisms of therapeutic change in a sample of participants in the RCAP programme. As the group was delivered during the COVID-19 pandemic, necessitating a transition to remote therapy, we further aimed to capture experiences of the transition to telehealth delivery of the programme. A naturalistic sample of 10 women with CPTSD attending a specialist out-patient psychological trauma service participated in the study. Therapy sessions were recorded, transcribed verbatim and group members completed written feedback forms following each session. Reflexive thematic analysis was used to analyse the written feedback and transcripts. The RCAP was acceptable to group members and several themes were identified related to the experience of change in the group. Key themes centred on group solidarity; safety in the psychotherapeutic process; schema changes related to the self, others and future catalysed by the shifting of self-blame; increased emotional regulation to feel safer in the present; and increased future optimism. Therapeutic progress continued following the transition to telehealth, although face-to-face delivery was generally preferred. The programme was acceptable and led to cognitive change, enabling increased emotional regulation in the present and improved self-concept, thereby addressing key symptoms of CPTSD.
Key learning aims
(1) To identify potential mechanisms of therapeutic change related to participation in the Recovery from Childhood Abuse group CBT intervention.
(2) To understand factors influencing acceptability of the group intervention among women with CPTSD to childhood sexual abuse.
Heavy rainfall, storm surges, and tornadoes are hazards associated with hurricanes that can cause property damages and loss of life. Disaster-related mortality surveillance encounters challenges, such as timely reporting of mortality data. This review demonstrates how tracking hurricane-related deaths using online media reports (eg, news media articles, press releases, social media posts) can enhance mortality surveillance during a response. The Centers for Disease Control and Prevention used online media reports from 2012 to 2020 to characterize hurricane-related deaths from 10 hurricanes that were declared major disasters and the flooding related to Hurricane Joaquin in the contiguous United States. Media reports showed that drowning (n = 139), blunt force trauma (n = 89), and carbon monoxide poisoning (n = 58) were the primary causes of death. Online media and social media reports are not official records. However, media mortality surveillance is useful for hurricane responses to target messaging and current incident decision-making.
To describe the genomic analysis and epidemiologic response related to a slow and prolonged methicillin-resistant Staphylococcus aureus (MRSA) outbreak.
Design:
Prospective observational study.
Setting:
Neonatal intensive care unit (NICU).
Methods:
We conducted an epidemiologic investigation of a NICU MRSA outbreak involving serial baby and staff screening to identify opportunities for decolonization. Whole-genome sequencing was performed on MRSA isolates.
Results:
A NICU with excellent hand hygiene compliance and longstanding minimal healthcare-associated infections experienced an MRSA outbreak involving 15 babies and 6 healthcare personnel (HCP). In total, 12 cases occurred slowly over a 1-year period (mean, 30.7 days apart) followed by 3 additional cases 7 months later. Multiple progressive infection prevention interventions were implemented, including contact precautions and cohorting of MRSA-positive babies, hand hygiene observers, enhanced environmental cleaning, screening of babies and staff, and decolonization of carriers. Only decolonization of HCP found to be persistent carriers of MRSA was successful in stopping transmission and ending the outbreak. Genomic analyses identified bidirectional transmission between babies and HCP during the outbreak.
Conclusions:
In comparison to fast outbreaks, outbreaks that are “slow and sustained” may be more common to units with strong existing infection prevention practices such that a series of breaches have to align to result in a case. We identified a slow outbreak that persisted among staff and babies and was only stopped by identifying and decolonizing persistent MRSA carriage among staff. A repeated decolonization regimen was successful in allowing previously persistent carriers to safely continue work duties.
The impact of influenza and pneumonia on individuals in clinical risk groups in England has not previously been well characterized. Using nationally representative linked databases (Clinical Practice Research Database (CPRD), Hospital Episode Statistics (HES) and Office for National Statistics (ONS)), we conducted a retrospective cohort study among adults (≥ 18 years) during the 2010/2011–2019/2020 influenza seasons to estimate the incidence of influenza- and pneumonia-diagnosed medical events (general practitioner (GP) diagnoses, hospitalisations and deaths), stratified by age and risk conditions. The study population included a seasonal average of 7.2 million individuals; approximately 32% had ≥1 risk condition, 42% of whom received seasonal influenza vaccines. Medical event incidence rates increased with age, with ~1% of adults aged ≥75 years hospitalized for influenza/pneumonia annually. Among individuals with vs. without risk conditions, GP diagnoses occurred 2–5-fold more frequently and hospitalisations were 7–10-fold more common. Among those with obesity, respiratory, kidney or cardiovascular disorders, hospitalisation were 5–40-fold more common than in individuals with no risk conditions. Though these findings likely underestimate the full burden of influenza, they emphasize the concentration of disease burden in specific age and risk groups and support existing recommendations for influenza vaccination.
The human large intestinal microbiota thrives on dietary carbohydrates that are converted to a range of fermentation products. Short-chain fatty acids (acetate, propionate and butyrate) are the dominant fermentation acids that accumulate to high concentrations in the colon and they have health-promoting effects on the host. Although many gut microbes can also produce lactate, it usually does not accumulate in the healthy gut lumen. This appears largely to be due to the presence of a relatively small number of gut microbes that can utilise lactate and convert it to propionate, butyrate or acetate. There is increasing evidence that these microbes play important roles in maintaining a healthy gut environment. In this review, we will provide an overview of the different microbes involved in lactate metabolism within the gut microbiota, including biochemical pathways utilised and their underlying energetics, as well as regulation of the corresponding genes. We will further discuss the potential consequences of perturbation of the microbiota leading to lactate accumulation in the gut and associated disease states and how lactate-utilising bacteria may be employed to treat such diseases.
There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.
This paper demonstrates that morphological change tends to involve the replacement of low frequency forms in inflectional paradigms by innovative forms based on high frequency forms, using Greek data involving the diachronic reorganisation of verbal inflection classes. A computational procedure is outlined for generating a possibility space of morphological changes which can be represented as analogical proportions, on the basis of synchronic paradigms in ancient Greek. I then show how supplementing analogical proportions with token frequency information can help to predict whether a hypothetical change actually took place in the language’s subsequent development. Because of the crucial role of inflected surface forms serving as analogical bases in this model, I argue that the results support theories in which inflected forms can be stored whole in the lexicon.
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.
Aims
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Method
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.
Results
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.
Conclusions
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.
The release of the Cumberlege Report in 2020 served as a reminder of the importance of informed consent for women when they are started on treatment that may affect their fertility or future pregnancies.
Our aim was to evaluate current performance with regards to advice given to women of childbearing age around contraception, impacts of psychotropic medication on fertility and future pregnancies, and availability of preconception counselling.
Method
Standard identified as NICE Guideline 192 (Antenatal and Postnatal Mental Health), sections 1.2 and 1.4.
60 female inpatients were selected by looking at the most recent discharges prior to 03/11/2020 from 3 local acute adult wards. All females aged between 18 and 48 years were included.
Electronic notes were reviewed for each patient. The discharge summary and last four ward round entries were reviewed, then key-word search of the patients’ records was performed using the terms “pregnan*”, “conception”, “contraception”, and “fertility”.
The following information for each patient was documented in a spreadsheet:
Discharge medication
Is there any discussion or advice around contraception?
Have women taking antipsychotic medication been given advice regarding the possible impact on fertility?
Has the potential impact of psychotropic medication on a future pregnancy been discussed?
Has advice been given about the availability of preconception counselling should they plan a pregnancy in future?
Result
On discharge, a total of 33 women were taking one or more antipsychotics and 14 were prescribed a benzodiazepine. 24 women were discharged with antidepressants and 10 women were using a mood stabilising agent. 8 women were discharged without any psychotropic medication.
Overall, 4 women received advice about contraception, and a further 8 women were already using contraception. The impact of taking an antipsychotic on fertility was not discussed with any patient. No women were advised about pre-conception counselling. The impact of taking psychotropic medication on a future pregnancy was discussed with one woman.
Conclusion
Current practice falls well below the standard set by NICE. Opportunities to inform women are being missed, and this has implications for the wellbeing of the patient and, potentially, future children.
Action plan;
Present findings at teaching.
Deliver local teaching covering preconception counselling and the role of adult mental health teams when managing women of childbearing age.
Produce a poster for inpatients wards and an information leaflet for women of childbearing age to aid with discussions.
Create a poster for doctors’ offices to remind about NICE standards and documentation.
This monograph closes with a reading of Sterne’s extra-textual collaboration with Joshua Reynolds and William Hogarth, on frontispieces for his Sermons of Mr. Yorick as well as for Tristram Shandy. These images were both free-standing as well as bookish ones bound within Sterne’s works, and served as important marketable visuals to prospective buyers. This final discussion of design elements beyond the narrative proper of Tristram Shandy demonstrates how, for Sterne, his literary project spanned print media, constructing an image of the man and the book as a print commodity.
This chapter reveals Sterne theorising his own experimentation with the visual appearance of the novel through images of the hand and handwriting. It measures the extent of Sterne’s innovation with the typographic manicule and his representation of script in print, comparing his innovations with those of Samuel Richardson a decade earlier while identifying the first known instance of printed strikethrough. Sterne inscribed his work with innovative examples of real and fictional handwriting, signing each copy of his novel and commissioning an original woodcut device to create the strikethrough. The chapter explores Sterne’s use of existing print practices or processes of book production in unusual and surprising ways. It establishes Sterne’s position in the print shop and his desire for his works to have specific material attributes, identifying also his anxiety over the potential invasion of his copyright. In revealing the author’s attempts to control every aspect of book production and his engagement with copyright debates, this chapter positions Sterne as a book designer well versed in codices from multiple disciplines and their varied modes of presenting printed data.
When Sterne (unsuccessfully) pitched to Robert Dodsley the first two volumes of Tristram Shandy, he was directing his novel to the very man whose career had been built on writing and publishing texts which sat on generic boundaries, such as his play The Toy-Shop (1735). Through an analysis of experimental texts in this tradition, including novels such as Jane Collier and Sarah Fielding’s The Cry: A Dramatic Fable (1754) and Richardson’s Sir Charles Grandison (1753), which imported dramatic devices into mid-century prose, this chapter contextualises Sterne’s mise en page experimentation within a wider mid-century fascination with hybrid print forms. Sterne was arguably aware of the theatrical heritage of sermon punctuation when he displaced these typographic characteristics from his professional work into his fiction, where such visual markers appeared innovative and surprising. By analysing Sterne’s sermonic punctuation and linking it to his development of a mid-century aesthetics of typesetting the novel, I suggest that Sterne drew from Anglican works published from within his professional context while responding to a 1750s fashion for printing closet drama and dramatic novels.
The introduction to the book historicises early responses to Sterne’s pioneering visual devices and establishes the rarity of illustrated first edition novels at mid-eighteenth century. It provides an insight into Sterne’s remarkable contribution to the history of the novel while justifying the scope of this project, which is to tackle mid-century book design more broadly. If first edition novels did not traditionally include visuals, what kind of books did? It also provides a brief outline of the contents.
By mid-century, novel readers began to expect a printed framework for reading prose narrative consisting of cues such as page numbers, catchwords, chapter divisions and notes. This chapter tells the backstory of this navigational framework of the eighteenth-century novel that Sterne disrupts, before analysing his experimentation with mise en page. This study of Sterne’s manipulation of seemingly untouchable conventions of the printed page, such as pagination and catchwords, complements an approach to his more widely recognised interference with footnotes and chapters, and reveals the full extent of Sterne’s pioneering disruption of the format of the eighteenth-century book. I argue that Sterne’s innovations with footnotes, catchwords, chapters and pagination combine aspects of Scriblerian satire with more recent but perhaps lesser-known interventions in the codex by Thomas Amory in John Buncle (1756). Unlike Swift and Pope, however, and like Amory, Sterne deploys footnotes in the first edition of Tristram Shandy, encouraging the reader to approach at once all sections of the page in search of meaning and raising questions about literary authority from the outset.
The second chapter deals with the black page commemorating the death of parson Yorick, often perceived as the pre-eminent symbol of Stern’s experimentation. This chapter suggests that with the black page, Sterne references a longstanding tradition of woodcut ornaments and mourning typography in funeral publications from the seventeenth to the eighteenth centuries, but which had reached their peak in the 1612 commemorations of the death of Henry, Prince of Wales. But he comments on how far this form of typographic commemoration has become clichéd by drawing from two recent typesetting trends: the representation of major funeral processions in newspapers and gravestone-like pages in the mid-century novel, as evidenced in Tom Jones (1749), Peregrine Pickle (1751) and William Toldervy’s Two Orphans (1756). Through considering the rarely studied mourning borders around Yorick’s epitaph alongside the black page’s double-sided covering of black ink, this chapter sees Sterne engaging with past and contemporary clichés of mourning iconography while playing upon – and pushing to its limits – the novelistic epitaph’s self-conscious manipulation of the printed page.
The final chapter considers Sterne’s use of engraved lines as illustrations of digression. Contextualising the print history of lines, the chapter examines the history of the dance manual, which, like that of Tristram Shandy, is one of innovation. Dance manuals were visual texts that had to be ever more experimental in their attempt to instruct by means of the printed page. Tristram Shandy shares with Beauchamp-Feuillet manuals diagrams which become demystified through labelling: the four plotlines closing volume 6 and Trim’s flourish in volume 9. Sterne defers annotating these lines to encourage the reader to encounter the digressive text in a looping and non-linear manner. Trim’s flourish is remarkably like the symbols which in the Beauchamp-Feuillet dance notation system represent arm movements or dance steps, and the serpentine, Hogarthian progress of a dance like the minuet, one of the most popular dances of the mid-eighteenth century. Like Sterne’s use of dance in Tristram Shandy, Trim’s flourish, when read alongside eighteenth-century dance notation, signifies both the one-off movement of his stick and the inability of anyone in Sterne’s novel to progress in a straight line.
The third volume of Tristram Shandy opens with Tristram’s eventual arrival into the Shandy family, when his nose is crushed during a bungled forceps delivery, causing Walter to throw himself prostrate on the bed. Sterne inserts his most startling innovation, the marbled page, within a volume almost entirely concerned with the publication and collection of medical books. This chapter situates Sterne’s remarkable visual device within a history of colour book illustration dominated by scientific works of the kind treasured by Walter Shandy. It also recounts the history of marbled paper, commonly recognised as book binding material but lesser known as medical packaging for nostrums prescribed to treat wounds and ailments. As a colour illustration in the instalment of Tristram Shandy addressing a wounded nose, for eighteenth-century readers the colour and dimensions of the marbled leaf would have simultaneously recalled colour-illustrated medical books and distinctively packaged branded remedies. The marbled page, therefore, references a full range of paper materials seeking to theorise, diagnose and treat malfunctioning bodies.