To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
This edition of Irish Journal of Psychological Medicine is a Special Themed Issue on Autism Spectrum Disorders (ASD). Mental health services are not currently meeting the needs of autistic people across the lifespan. We have limited evidence based treatments for core symptoms and comorbidities and there is lack of awareness and under-recognition of ASD, particularly in adults and certain groups of individuals. The key themes in this edition focus on challenges with recognition and diagnosis and address these from both clinical and research perspectives. Co-occurring conditions also feature, which are also under-recognised and can contribute to less optimal outcomes. New and existing research developments in stratification for clinical trials and neuroimaging are also discussed. We hope this Issue highlights relevant current issues in ASD, and provides insights which can help address the challenges in providing evidence based pathways to better meet the needs of autistic people into the future.
Antibiotic stewardship initiatives usually occur in the inpatient setting and should be optimized during transitions of care. In this study, we assessed the appropriateness of oral antibiotic treatment duration at the time of discharge from our institution based on national guidelines and clinical parameters for common infections.
The relationship between major depressive disorder (MDD) and personality disorders is complex, with implications for diagnosis and treatment. We sought to explore the relationship between these disorders quantitatively in an inpatient setting.
We conducted a structured observational study exploring symptoms of depression and selected neurocognitive functions over the span of an inpatient admission in those with depression and personality disorders. Sixty inpatients presenting with symptoms of depression completed ratings of mood and neurocognitive function. Diagnosis was confirmed by structured clinical interview (SCID-5-RV) at discharge and used to allocate patients to one of the two groups for analysis: those with MDD-only and those with a personality disorder (with or without MDD).
On admission, observer-based ratings of depression were significantly higher in the MDD-only group while subjective ratings were higher in the personality disorder group. Depression rating scores lessened in both groups during the admission, but at discharge, the personality disorder group continued to report higher subjective ratings. The personality disorder group also rated themselves as more cognitively impaired than the MDD-only group and unlike the MDD-only group, they did not report subjective improvements in cognitive function over the course of admission. Objective assessment of cognitive function demonstrated improvements in both groups.
In this study, the presence of a personality disorder was associated with greater subjective severity of depressive symptomatology and selected neurocognitive functioning, despite similar or lower objective severity in comparison with those with MDD. This finding has implications for understanding the patient journey through health care settings.
To describe the epidemiology of patients with nonintestinal carbapenem-resistant Enterobacterales (CRE) colonization and to compare clinical outcomes of these patients to those with CRE infection.
A secondary analysis of Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae 2 (CRACKLE-2), a prospective observational cohort.
A total of 49 US short-term acute-care hospitals.
Patients hospitalized with CRE isolated from clinical cultures, April, 30, 2016, through August 31, 2017.
We described characteristics of patients in CRACKLE-2 with nonintestinal CRE colonization and assessed the impact of site of colonization on clinical outcomes. We then compared outcomes of patients defined as having nonintestinal CRE colonization to all those defined as having infection. The primary outcome was a desirability of outcome ranking (DOOR) at 30 days. Secondary outcomes were 30-day mortality and 90-day readmission.
Of 547 patients with nonintestinal CRE colonization, 275 (50%) were from the urinary tract, 201 (37%) were from the respiratory tract, and 71 (13%) were from a wound. Patients with urinary tract colonization were more likely to have a more desirable clinical outcome at 30 days than those with respiratory tract colonization, with a DOOR probability of better outcome of 61% (95% confidence interval [CI], 53%–71%). When compared to 255 patients with CRE infection, patients with CRE colonization had a similar overall clinical outcome, as well as 30-day mortality and 90-day readmission rates when analyzed in aggregate or by culture site. Sensitivity analyses demonstrated similar results using different definitions of infection.
Patients with nonintestinal CRE colonization had outcomes similar to those with CRE infection. Clinical outcomes may be influenced more by culture site than classification as “colonized” or “infected.”
The search for biomarkers for autism spectrum disorder (henceforth autism) has received a lot of attention due to their potential clinical relevance. The clinical and aetiological heterogeneity of autism suggests the presence of subgroups. The lack of identification of a valid diagnostic biomarker for autism, and the inconsistencies seen in studies assessing differences between autism and typically developing control groups, may be partially explained by the vast heterogeneity observed in autism. The focus now is to better understand the clinical and biological heterogeneity and identify stratification biomarkers, which are measures that describe subgroups of individuals with shared biology. Using stratification approaches to assess treatment within pre-defined subgroups could clarify who may benefit from different treatments and therapies, and ultimately lead to more effective individualised treatment plans.
The present study aimed to clarify the neuropsychological profile of the emergent diagnostic category of Mild Cognitive Impairment with Lewy bodies (MCI-LB) and determine whether domain-specific impairments such as in memory were related to deficits in domain-general cognitive processes (executive function or processing speed).
Patients (n = 83) and healthy age- and sex-matched controls (n = 34) underwent clinical and imaging assessments. Probable MCI-LB (n = 44) and MCI-Alzheimer’s disease (AD) (n = 39) were diagnosed following National Institute on Aging-Alzheimer’s Association (NIA-AA) and dementia with Lewy bodies (DLB) consortium criteria. Neuropsychological measures included cognitive and psychomotor speed, executive function, working memory, and verbal and visuospatial recall.
MCI-LB scored significantly lower than MCI-AD on processing speed [Trail Making Test B: p = .03, g = .45; Digit Symbol Substitution Test (DSST): p = .04, g = .47; DSST Error Check: p < .001, g = .68] and executive function [Trail Making Test Ratio (A/B): p = .04, g = .52] tasks. MCI-AD performed worse than MCI-LB on memory tasks, specifically visuospatial (Modified Taylor Complex Figure: p = .01, g = .46) and verbal (Rey Auditory Verbal Learning Test: p = .04, g = .42) delayed recall measures. Stepwise discriminant analysis correctly classified the subtype in 65.1% of MCI patients (72.7% specificity, 56.4% sensitivity). Processing speed accounted for more group-associated variance in visuospatial and verbal memory in both MCI subtypes than executive function, while no significant relationships between measures were observed in controls (all ps > .05)
MCI-LB was characterized by executive dysfunction and slowed processing speed but did not show the visuospatial dysfunction expected, while MCI-AD displayed an amnestic profile. However, there was considerable neuropsychological profile overlap and processing speed mediated performance in both MCI subtypes.
We surveyed acute-care hospitals on strategies to reduce inappropriate C. difficile testing and treatment of colonized patients. Decision support during C. difficile test ordering was common, but “hard stops” to prevent placement of inappropriate orders and active intervention of antimicrobial stewardship programs on positive C. difficile test reports were infrequent.
As part of the roundtable, “The Responsibility to Protect in a Changing World Order: Twenty Years since Its Inception,” this essay asks the reader to consider the role that trust, distrust, and ambivalence play in enabling and constraining the use of force under pillar three of the Responsibility to Protect (RtoP). Drawing on interdisciplinary studies on trust, it analyzes the 2011 military intervention in Libya for evidence on how trust, distrust, and ambivalence help explain the positions taken by member states on the United Nations Security Council. In so doing, it challenges the mainstream view that the fallout over Libya represents a shift from trust to distrust. We find this binary portrayal problematic for three reasons. First, it fails to take into account the space in between trust and distrust, which we categorize as ambivalence and use to make sense of the position of Russia and China. Second, it is important to recognize the role of bounded trust, as those that voted in favor of going into Libya did so on certain grounds. Third, it overemphasizes the political fallout, as six of the ten elected member states continued to support the intervention. Learning lessons from this case, we conclude that it is highly unlikely that the Security Council will authorize the use of force to fulfill the RtoP anytime soon, which may have detrimental implications for the RtoP as a whole.
The coronavirus disease 2019 (COVID-19) pandemic has resulted in shortages of personal protective equipment (PPE), underscoring the urgent need for simple, efficient, and inexpensive methods to decontaminate masks and respirators exposed to severe acute respiratory coronavirus virus 2 (SARS-CoV-2). We hypothesized that methylene blue (MB) photochemical treatment, which has various clinical applications, could decontaminate PPE contaminated with coronavirus.
The 2 arms of the study included (1) PPE inoculation with coronaviruses followed by MB with light (MBL) decontamination treatment and (2) PPE treatment with MBL for 5 cycles of decontamination to determine maintenance of PPE performance.
MBL treatment was used to inactivate coronaviruses on 3 N95 filtering facepiece respirator (FFR) and 2 medical mask models. We inoculated FFR and medical mask materials with 3 coronaviruses, including SARS-CoV-2, and we treated them with 10 µM MB and exposed them to 50,000 lux of white light or 12,500 lux of red light for 30 minutes. In parallel, integrity was assessed after 5 cycles of decontamination using multiple US and international test methods, and the process was compared with the FDA-authorized vaporized hydrogen peroxide plus ozone (VHP+O3) decontamination method.
Overall, MBL robustly and consistently inactivated all 3 coronaviruses with 99.8% to >99.9% virus inactivation across all FFRs and medical masks tested. FFR and medical mask integrity was maintained after 5 cycles of MBL treatment, whereas 1 FFR model failed after 5 cycles of VHP+O3.
MBL treatment decontaminated respirators and masks by inactivating 3 tested coronaviruses without compromising integrity through 5 cycles of decontamination. MBL decontamination is effective, is low cost, and does not require specialized equipment, making it applicable in low- to high-resource settings.
To examine the rates of antipsychotic prescribing in the Irish paediatric and young adult population enrolled in the Irish General Medical Services Scheme pharmacy claims database from the Health Service Executive Primary Care Reimbursement Services database, with a focus on age and sex differences. To examine concomitant prescribing of certain other related medicines in this population.
Data were obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive (HSE) – Primary Care Reimbursement Services (PCRS). Participants included children aged <16 years and youth aged 16–24 years availing of medicines under the HSE-PCRS GMS scheme between January 2005 and December 2015. Outcome measures included prescribing rates of antipsychotics from 2005 to 2015, differences in prescribing rates between different ages and sexes, and percentage of concomitant prescriptions for antidepressants, psychostimulants, anxiolytics and hypnosedatives.
Overall the trend in prescribing rates of antipsychotic medications was stable at 3.94/1000 in 2005 compared with 3.97/1000 in 2015 for children <16 years, and 48.37/1000 eligible population in 2005 compared to 39.64/1000 in 2015 for those aged 16–24. There was a significant decrease in prescribing rates for males in the 16–24 age group.
While rates of antipsychotic prescribing have decreased or remained stable over the timeframe of the study, we did find a significant proportion of this population were prescribed antipsychotics. This study also shows that co-prescribing of antidepressants increased and highlights the need for guidelines for antipsychotic prescribing in children and youth in terms of clinical indication, monitoring, co-prescribing and treatment duration.
Factors that facilitate transfer of training in paediatric echocardiography remain poorly understood. This study assessed whether high-variation training facilitated successful transfer in paediatric echocardiography.
A mixed-methods study of transfer of technical and interpretive skill application amongst postgraduate trainees. Trainees were randomised to a low or high-variation training group. After a period of 8 weeks intensive echocardiography training, we video-recorded how trainees completed an echocardiogram in a complex cardiac lesion not previously encountered. Blinded quantitative analysis and scoring of trainee performance (echocardiogram performance, report, and technical proficiency) were performed using a validated assessment tool by a blinded cardiologist and senior cardiac physiologist. Qualitative interviews of the trainees were recorded to ascertain trainee experiences during the training and transfer process.
Sixteen trainees were enrolled in the study. For the cumulative score for all three components tested (echocardiogram performance, report, and technical proficiency), χ2 = 8.223, p = .016, which showed the high-variation group outperformed the low-variation group. Two common themes which assisted in the transfer emerged from interviews are as follows: (1) use of strategies described in variation theory to describe abnormal hearts, (2) the use of formative live feedback from trainers during hands-on training.
Training strategies exposing trainees to high-variation training may aid transfer of paediatric echocardiography skills.
Background: Antimicrobial resistance (AMR) is an increasingly critical global public health challenge. An initial step in prevention is the understanding of resistance patterns with accurate surveillance. To improve accurate surveillance and good clinical care, we developed training materials to improve the appropriate collection of clinical culture samples in Ethiopia. Methods: Specimen-collection training materials were initially developed by a team of infectious diseases physicians, a clinical microbiologist, and a monitoring and evaluation specialist using a training of trainers (ToT) platform. Revisions after each training session were provided by Ethiopian attendees including the addition of regional and culturally relevant material. The training format involved didactic presentations, interactive practice sessions with participants providing feedback and training to each other and the entire group as well as assessments of all training activities. Results: Overall, 4 rounds of training were conducted from August 2017 to September 2019. The first 2 rounds of training were conducted by The Ohio State University (OSU) staff, and Ethiopian trainers conducted the last 2 rounds. Initial training was primarily in lecture format outlining use of microbiology laboratory findings in clinical practice and steps for collecting specimens correctly. Appropriate specimen collection was demonstrated and practiced. Essential feedback from this early audience provided input for the final development of the training manual and visual aids. The ToT for master trainers took place in July 2018 and was conducted by OSU staff. In sessions held in February and August 2019, these master trainers provided training to facility trainers, who provide training to personnel directly responsible for specimen collection. In total, 144 healthcare personnel (including physicians, nurses, and laboratory staff), from 12 representative Ethiopian public and academic hospitals participated in the trainings. Participants were satisfied with the quality of the training (typically ranked >4.5 of 5.0) and strongly agreed that the objectives were clearly defined and that the information was relevant to their work. Posttraining scores increased by 23%. Conclusions: Training materials for clinical specimen collection have been developed for use in low- and middle-resource settings and with initial pilot testing and adoption in Ethiopia. The trainings were well accepted, and Ethiopian personnel were able to successfully lead the trainings and improve their knowledge and skills regarding specimen collection. The materials are being finalized in an online format for easier open access dissemination. Further studies are planned to determine the effectiveness of the trainings in improving the quality of clinical specimen submissions to the microbiology laboratory.
Cognitive deficits affect a significant proportion of patients with bipolar disorder (BD). Problems with sustained attention have been found independent of mood state and the causes are unclear. We aimed to investigate whether physical parameters such as activity levels, sleep, and body mass index (BMI) may be contributing factors.
Forty-six patients with BD and 42 controls completed a battery of neuropsychological tests and wore a triaxial accelerometer for 21 days which collected information on physical activity, sleep, and circadian rhythm. Ex-Gaussian analyses were used to characterise reaction time distributions. We used hierarchical regression analyses to examine whether physical activity, BMI, circadian rhythm, and sleep predicted variance in the performance of cognitive tasks.
Neither physical activity, BMI, nor circadian rhythm predicted significant variance on any of the cognitive tasks. However, the presence of a sleep abnormality significantly predicted a higher intra-individual variability of the reaction time distributions on the Attention Network Task.
This study suggests that there is an association between sleep abnormalities and cognition in BD, with little or no relationship with physical activity, BMI, and circadian rhythm.
The present research aims to investigate what purpose[s] self-harm serves for male patients in a dangerous and severe personality disorder unit in Rampton high secure hospital. It is proposed that existing functional models of self-harm should be modified to suit this group due to environmental constraints and features of their diagnoses.
A model of self-harm was devised from interviews with patients, literature reviews and a pilot review of daily nursing notes, therapy notes and incident reports. The ten proposed functions for self-harm in this population were affect regulation, interpersonal influence, control, sensation seeking, psychosis, feeling generation, self-punishment, anti-suicide, revenge and the expression of aggressive intent. This was applied to data collected from incident reports and daily nursing notes on all incidents (n=386) of self-harm for all current patients (n=53) in the unit in December 2008, in order to establish the nature and context of the incidents, i.e. the location, time and method of self-harm, as well as the function of the behaviour.
The nature and context of self-harm was similar to that in other inpatient and secure settings, except the number of incidents, which did not vary according to time of day. The functions of self-harm were diverse, and there was evidence for those unique to this population.
Future research intends to develop a behavioural classification system for the assessment of motivations for self-harm that can be administered to staff and patients. The clinical impact of this work is discussed.
Admission to one of the Dangerous and Severe Personality Disordered (DSPD) services in England and Wales is heavily determined by risk status and monitoring of changes in risk over time is a core procedure. However, the extent to which DSPD services are effective in terms of reducing risk is one of the most important questions yet to be answered. This paper seeks to examine whether risk, as measured by the Historical-Clinical-Risk-20 (HCR-20) (Webster et al. 1997), posed by patients admitted to a high-secure psychiatric DSPD unit reduces according to length of time in the unit.
Admission and discharge/current treatment status HCR-20 measures were collected for 58 concurrent DSPD admissions for period 25th March 2004 to 22nd July 2009.
Overall longer ‘treatment’ times were associated with lower scores on the dynamic risk scales of the HCR-20 for a group of patients admitted to the high secure DSPD facility. Specifically, Clinical and Risk scores both reduced by .05 points (monthly). Historical risk did not change over time.
These changes are promising, since positive changes in a high-risk group of mentally disordered offenders on such factors as insight and impulsivity are known to be hard to accomplish. The results provide support for the proposition that the C and R scales of the HCR-20 are dynamic. Attention to whether risk reduction translates to lower institutional infractions and future recidivism is recommended.
Hypersexuality is an uncommon behavioral complication associated with traumatic brain injury (TBI) involving lesions to frontal basal, temporal, or diencephalic structures. Experimental brain injury in animals has produced hypersexual behaviors; however, there is comparative paucity of knowledge in humans. TBI with hypersexuality offers insights into neurological basis of aberrant sexual behaviors as well as potential treatments. This case report describes social/sexual disinhibition in a patient following neurosurgery for self-inflicted TBI.
Case analysis with literature review.
32-year-old male was admitted with TBI following an unsuccessful suicide attempt, self-inflicted nail gun injury to the occiput. CT scan revealed 6.5cm nail that had entered the skull in right occiput, right parasagittal location with nail head right of vein of Galen, coursing through splenium of corpus callosum, right thalamus-hypothalamus-midbrain, with its tip at the suprasellar cistern. Occipital craniotomy with retrieval of foreign body was performed eleven days after admission. From post-operative day eight through twenty-seven, patient made inappropriate sexual comments to female medical student: asking her out repetitively, describing her physical appearance, enquiring about her suitors, and requesting her to call him upon his discharge. Prior psychiatric history was pertinent for major depression and social anxiety (especially women) with psychotropic noncompliance. During admission, patient was diagnosed with recurrent major depression, social anxiety by history, and impulse control disorder nos. On sertraline titrated to 100mg qhs, depression resolved with increased control over newly acquired sexual/social disinhibition noted.
TBI can lead to social disinhibition and hypersexuality. Sertraline may be a beneficial treatment.
The neurodevelopmental model of schizophrenia includes the etiological impact of fetal brain stressors possibly connected with birth seasonality. Specification of social class of origin (SES) as a related risk factor remains unexamined as does type of schizophrenia as an outcome variable. The objective of this study was to test for an interconnection between SES, type of schizophrenia and seasonality of birth.
Patients (N = 436) from a United States psychiatric hospital were separated into deficit/nondeficit presentation and bifurcated into poor/nonpoor SES. Birth seasonality was assessed by months hypothetically connected with winter-related trimesters of gestation.
Results showed that there is a significant difference (p = 0.0411) in the monthly birth patterns of poor vs. nonpoor patients and that the difference connects with the likelihood of deficit vs. nondeficit schizophrenia. Specifically, an elevated proportion of patients with deficit schizophrenia were born to impoverished women who likely conceived in January. Findings were confirmed by multiple levels of statistical assessment including log linear analysis.
The resultant model suggests the environmental location (lower SES) and timing (winter conception) of adult schizophrenia with poor outcome (deficit).
Prader-Willi Syndrome (PWS) is a genetically determined neurodevelopmental disorder which occurs in approximately 1 in 22000 births.
Parents of subjects with genetically confirmed PWS (participating in the First National Irish PWS study) were asked to fill in a demographic questionnaire, The Child Behaviour Checklist 6–18 (CBCL/6–18), Brief Symptom Inventory (BSI). The age, gender and IQ matched control group was collected through Special Schools.
Both groups (PWS and Controls) were comprised of 24 children. Internalizing problems score was higher in children with PWS than controls (T mean score (62.02 (SD = 10.17) vs. 58.13 (SD = 7.53) p < . 05). The comparison of PWS and control group along CBCL/6–18 syndromes profiles indicated that children with PWS had more sever somatic problems (mean T 63.50 SD = 8.41 vs. 56.13 SD = 6.31, p< .05), social problems (mean T 64.71 SD = 8.95 vs. 58.79 SD = 9.41, p < .05), thoughts problems (mean T 67.71 SD = 9.71 vs. 58.04 SD = 7.17, p < .05) and were more withdrawn/depressed (mean T 64.04 SD = 9.11 vs. 55.46 SD = 6.48, p < .05). Borderline difficulties were detected for the affective, somatic and ADHD CBCL DSM orientated subscales in PWS group with PWS children having significantly more somatic (mean T 63.05 SD = 8.33 vs. 52.00 SD = 6.48, P < .05) and affective (mean T 66.22 SD = 8.51, vs. 60.08 SD = 6.829 P < .05) problems than controls. The analysis of BSI scales revealed that parents of PSW children in comparison to controls had more somatization, phobic anxiety, obsessive compulsion, and anxiety problems.
PWS represents a complex psychological disorder with multiple areas of disturbances.
In New York City, a multi-disciplinary Mass Casualty Consultation team is proposed to support prioritization of patients for coordinated inter-facility transfer after a large-scale mass casualty event. This study examines factors that influence consultation team prioritization decisions.
As part of a multi-hospital functional exercise, 2 teams prioritized the same set of 69 patient profiles. Prioritization decisions were compared between teams. Agreement between teams was assessed based on patient profile demographics and injury severity. An investigator interviewed team leaders to determine reasons for discordant transfer decisions.
The 2 teams differed significantly in the total number of transfers recommended (49 vs 36; P = 0.003). However, there was substantial agreement when recommending transfer to burn centers, with 85.5% agreement and inter-rater reliability of 0.67 (confidence interval: 0.49–0.85). There was better agreement for patients with a higher acuity of injuries. Based on interviews, the most common reason for discordance was insider knowledge of the local community hospital and its capabilities.
A multi-disciplinary Mass Casualty Consultation team was able to rapidly prioritize patients for coordinated secondary transfer using limited clinical information. Training for consultation teams should emphasize guidelines for transfer based on existing services at sending and receiving hospitals, as knowledge of local community hospital capabilities influence physician decision-making.