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The degree to which suicide risk aggregates in US families is unknown. The authors aimed to determine the familial risk of suicide in Utah, and tested whether familial risk varies based on the characteristics of the suicides and their relatives.
A population-based sample of 12 160 suicides from 1904 to 2014 were identified from the Utah Population Database and matched 1:5 to controls based on sex and age using at-risk sampling. All first through third- and fifth-degree relatives of suicide probands and controls were identified (N = 13 480 122). The familial risk of suicide was estimated based on hazard ratios (HR) from an unsupervised Cox regression model in a unified framework. Moderation by sex of the proband or relative and age of the proband at time of suicide (<25 v. ⩾25 years) was examined.
Significantly elevated HRs were observed in first- (HR 3.45; 95% CI 3.12–3.82) through fifth-degree relatives (HR 1.07; 95% CI 1.02–1.12) of suicide probands. Among first-degree relatives of female suicide probands, the HR of suicide was 6.99 (95% CI 3.99–12.25) in mothers, 6.39 in sisters (95% CI 3.78–10.82), and 5.65 (95% CI 3.38–9.44) in daughters. The HR in first-degree relatives of suicide probands under 25 years at death was 4.29 (95% CI 3.49–5.26).
Elevated familial suicide risk in relatives of female and younger suicide probands suggests that there are unique risk groups to which prevention efforts should be directed – namely suicidal young adults and women with a strong family history of suicide.
Demands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.
Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.
Health and social care face growing and conflicting pressures: mounting complex needs of an ageing population, restricted funding and a workforce recruitment and retention crisis. In response, in the UK the NHS Long Term Plan promises increased investment and an emphasis on better ‘integrated’ care. We describe key aspects of integration that need addressing.
Declaration of interest
D.K.T. and S.S.S. are on the editorial board of the British Journal of Psychiatry and executives of the Academic Faculty at the Royal College of Psychiatrists. A.J.B.J., H.P. and Z.M. have roles at the Royal College of Psychiatrists that include evaluation of integrated care systems. A.J.B.J. is married to Dr Sarah Wollaston, Member of Parliament for Totnes and Chair of the Health Select Committee.
We reviewed all patients who were supported with extracorporeal membrane oxygenation and/or ventricular assist device at our institution in order to describe diagnostic characteristics and assess mortality.
A retrospective cohort study was performed including all patients supported with extracorporeal membrane oxygenation and/or ventricular assist device from our first case (8 October, 1998) through 25 July, 2016. The primary outcome of interest was mortality, which was modelled by the Kaplan–Meier method.
A total of 223 patients underwent 241 extracorporeal membrane oxygenation runs. Median support time was 4.0 days, ranging from 0.04 to 55.8 days, with a mean of 6.4±7.0 days. Mean (±SD) age at initiation was 727.4 days (±146.9 days). Indications for extracorporeal membrane oxygenation were stratified by primary indication: cardiac extracorporeal membrane oxygenation (n=175; 72.6%) or respiratory extracorporeal membrane oxygenation (n=66; 27.4%). The most frequent diagnosis for cardiac extracorporeal membrane oxygenation patients was hypoplastic left heart syndrome or hypoplastic left heart syndrome-related malformation (n=55 patients with HLHS who underwent 64 extracorporeal membrane oxygenation runs). For respiratory extracorporeal membrane oxygenation, the most frequent diagnosis was congenital diaphragmatic hernia (n=22). A total of 24 patients underwent 26 ventricular assist device runs. Median support time was 7 days, ranging from 0 to 75 days, with a mean of 15.3±18.8 days. Mean age at initiation of ventricular assist device was 2530.8±660.2 days (6.93±1.81 years). Cardiomyopathy/myocarditis was the most frequent indication for ventricular assist device placement (n=14; 53.8%). Survival to discharge was 42.2% for extracorporeal membrane oxygenation patients and 54.2% for ventricular assist device patients. Kaplan–Meier 1-year survival was as follows: all patients, 41.0%; extracorporeal membrane oxygenation patients, 41.0%; and ventricular assist device patients, 43.2%. Kaplan–Meier 5-year survival was as follows: all patients, 39.7%; extracorporeal membrane oxygenation patients, 39.7%; and ventricular assist device patients, 43.2%.
This single-institutional 18-year review documents the differential probability of survival for various sub-groups of patients who require support with extracorporeal membrane oxygenation or ventricular assist device. The indication for mechanical circulatory support, underlying diagnosis, age, and setting in which cannulation occurs may affect survival after extracorporeal membrane oxygenation and ventricular assist device. The Kaplan–Meier analyses in this study demonstrate that patients who survive to hospital discharge have an excellent chance of longer-term survival.
Early life exposures affect health and disease across the life course and potentially across multiple generations. The Clinical and Translational Research Institutes (CTSIs) offer an opportunity to utilize and link existing databases to conduct lifespan research.
A survey with Lifespan Domain Taskforce expert input was created and distributed to lead lifespan researchers at each of the 64 CTSIs. The survey requested information regarding institutional databases related to early life exposure, child-maternal health, or lifespan research.
Of 64 CTSI, 88% provided information on a total of 130 databases. Approximately 59% (n=76/130) had an associated biorepository. Longitudinal data were available for 72% (n=93/130) of reported databases. Many of the biorepositories (n=44/76; 68%) have standard operating procedures that can be shared with other researchers.
The majority of CTSI databases and biorepositories focusing on child-maternal health and lifespan research could be leveraged for lifespan research, increased generalizability and enhanced multi-institutional research in the United States.
We use data from hypothetical and nonhypothetical choice-based conjoint analysis to estimate willingness to pay for local food products. The survey was administered to three groups: consumers from a buying club with experience with local and grass-fed production markets, a random sample of Maryland residents, and shoppers at a nonspecialty Maryland supermarket. We find that random-sample and supermarket shoppers are willing to pay a premium for local products but view local and grass-fed production as substitutes. Conversely, buying-club members are less willing to pay for local production than the other groups but do not conflate local and grass-fed production.
Radio-glaciological parameters from the Moore’s Bay region of the Ross Ice Shelf, Antarctica, have been measured. The thickness of the ice shelf in Moore’s Bay was measured from reflection times of radio-frequency pulses propagating vertically through the shelf and reflecting from the ocean, and is found to be 576 ± 8 m. Introducing a baseline of 543 ± 7m between radio transmitter and receiver allowed the computation of the basal reflection coefficient, R, separately from englacial loss. The depth-averaged attenuation length of the ice column, 〈L〉 is shown to depend linearly on frequency. The best fit (95% confidence level) is 〈L(ν)〉= (460±20) − (180±40)ν m (20 dB km−1), for the frequencies ν = [0.100–0.850] GHz, assuming no reflection loss. The mean electric-field reflection coefficient is (1.7 dB reflection loss) across [0.100–0.850] GHz, and is used to correct the attenuation length. Finally, the reflected power rotated into the orthogonal antenna polarization is <5% below 0.400 GHz, compatible with air propagation. The results imply that Moore’s Bay serves as an appropriate medium for the ARIANNA high-energy neutrino detector.
Kitchen gardens may improve family food security and nutrition. While these gardens are the domain of women in Afghanistan, women face unique challenges accessing training and resources to maximize small-scale agricultural output. The University of Maryland's Women in Agriculture Project builds capacity among female extension educators to work with vulnerable women to implement and maintain kitchen gardens. Extension educators use experiential methods to teach vegetable gardening, apiculture, small-scale poultry production, post-harvest handling and processing, nutrition and marketing through workshops, demonstration gardens and farmer field schools. This paper explores contextual factors related to women's food security and agricultural opportunities, describes key project activities and approaches and discusses project success and challenges, sustainability and implications for future programs.
Correlative light and electron microscopy (CLEM) has facilitated study of intracellular trafficking. Routine application of CLEM would be advantageous for many laboratories but previously described techniques are particularly demanding, even for those with access to laser scanning confocal microscopy (LSCM) and transmission electron microscopy (TEM). We describe streamlined methods for TEM of green fluorescent protein (GFP)-labeled organelles after imaging by LSCM using gridded glass bottom imaging dishes. GFP-MAP 1A/1B LC3 (GFP-LC3) transfected cells were treated with rapamycin, fixed and imaged by LSCM. Confocal image stacks were acquired enabling full visualization of each GFP-LC3 labeled organelle. After LSCM, cells were embedded for TEM using a simplified two step method that stabilizes the glass bottom such that the block can be separated from the glass by mild heating. All imaging and TEM processing are performed in the same dish. The LSCM imaged cells were relocated on the block and serial sectioned. Correlation of LSCM, DIC, and TEM images was facilitated by cellular landmarks. All GFP labeled structures were successfully reidentified and imaged by serial section TEM. This method could make CLEM more accessible to nonspecialized laboratories with basic electron microscopy expertise and could be used routinely to confirm organelle localization of fluorescent puncta.
Interest in organic grain production is increasing in the United States but there is limited information regarding the economic performance of organic grain and forage production in the mid-Atlantic region. We present the results from enterprise budget analyses for individual crops and for complete rotations with and without organic price premiums for five cropping systems at the US Department of Agriculture–Agricultural Research Service (USDA–ARS) Beltsville Farming Systems Project (FSP) from 2000 to 2005. The FSP is a long-term cropping systems trial established in 1996 to evaluate the sustainability of organic and conventional grain crop production. The five FSP cropping systems include a conventional, three-year no-till corn (Zea mays L.)–rye (Secale cereale L.) cover crop/soybean (Glycine max (L.) Merr)–wheat (Triticum aestivum L.)/soybean rotation (no-till (NT)), a conventional, three-year chisel-till corn–rye/soybean–wheat/soybean rotation (chisel tillage (CT)), a two-year organic hairy vetch (Vicia villosa Roth)/corn–rye/soybean rotation (Org2), a three-year organic vetch/corn–rye/soybean–wheat rotation (Org3) and a four- to six-year organic corn–rye/soybean–wheat–red clover (Trifolium pratense L.)/orchard grass (Dactylis glomerata L.) or alfalfa (Medicago sativa L.) rotation (Org4+). Economic returns were calculated for rotations present from 2000 to 2005, which included some slight changes in crop rotation sequences due to weather conditions and management changes; additional analyses were conducted for 2000 to 2002 when all crops described above were present in all organic rotations. Production costs were, in general, greatest for CT, while those for the organic systems were lower than or similar to those for NT for all crops. Present value of net returns for individual crops and for full rotations were greater and risks were lower for NT than for CT. When price premiums for organic crops were included in the analysis, cumulative present value of net returns for organic systems (US$3933 to 5446 ha−1, 2000 to 2005; US$2653 to 2869 ha−1, 2000 to 2002) were always substantially greater than for the conventional systems (US$1309 to 1909 ha−1, 2000 to 2005; US$634 to 869 ha−1, 2000 to 2002). With price premiums, Org2 had greater net returns but also greater variability of returns and economic risk across all years than all other systems, primarily because economic success of this short rotation was highly dependent on the success of soybean, the crop with the highest returns. Soybean yield variability was high due to the impact of weather on the success of weed control in the organic systems. The longer, more diverse Org4+ rotation had the lowest variability of returns among organic systems and lower economic risk than Org2. With no organic price premiums, economic returns for corn and soybean in the organic systems were generally lower than those for the conventional systems due to lower grain yields in the organic systems. An exception to this pattern is that returns for corn in Org4+ were equal to or greater than those in NT in four of six years due to both lower production costs and greater revenue than for Org2 and Org3. With no organic premiums, present value of net returns for the full rotations was greatest for NT in 4 of 6 years and greatest for Org4+ the other 2 years, when returns for hay crops were high. Returns for individual crops and for full rotations were, in general, among the lowest and economic risk was, in general, among the highest for Org2 and Org3. Results indicate that Org4+, the longest and most diverse rotation, had the most stable economic returns among organic systems but that short-term returns could be greatest with Org2. This result likely explains, at least in part, why some organic farmers in the mid-Atlantic region, especially those recently converting to organic methods, have adopted this relatively short rotation. The greater stability of the longer rotation, by contrast, may explain why farmers who have used organic methods for longer periods of time tend to favor rotations that include perennial forages.
We investigate nutrient trading for point and non-point sources for the Bay Restoration Fund in Maryland. We demonstrate how to use the proceeds from the tax revenue to mimic a market by trading high-cost upgrades of sewage treatment plants for low-cost winter cover crops. Under an optimistic assumption about costs for non-point sources and naïve assumptions about the lag from planting cover crops to changes in nitrogen load, we calculate that 100 percent of abatement could be achieved at 56 percent of total costs, while in a pessimistic scenario, 100 percent of abatement could be could be achieved at 83 percent of total costs.
Using trout producer survey data and the contingent valuation method, we estimate willingness to pay for a potential insurance policy. The survey was conducted in 2005 across the United States; 268 producers completed the survey instrument, resulting in a response rate of 81 percent. Design of the contingent valuation method takes into account two coverage levels and four premium rates. Using standard willingness-to-pay techniques, we assess the premium rate that producers with varying practices and regions are willing to pay for two different coverage levels of insurance. In general, trout producers appear willing to pay premium rates of 2 to 11 percent for these coverage levels.
Early studies in population cohorts proposed that perturbation of the environment in utero and in early life gives rise to marked and permanent alteration in offspring cardiovascular homeostasis, leading to increased risk of cardiovascular and metabolic disease in later life (reviewed in this volume). Clinical outcomes focused on the incidence of heart disease and hypertension in relation to birthweight, with little detailed investigation of other parameters of cardiovascular risk or outcome. More recent studies have given insight into underlying aetiological pathways, and the development of the different animal models of developmental plasticity has provided an opportunity to assess parameters of cardiovascular function at a depth which is not feasible, or indeed practicable, in humans.
The mechanisms contributing to cardiovascular homeostasis are complex and interwoven; they range from central control of the heart rate and vascular tone to paracrine, autocrine and genomic influences on the vascular smooth muscle and function of the endothelium. Fluid and volume homeostatic pathways, as well as the intricacy of haemostatic control, also contribute to the status quo. The complexity is such that common disorders such as essential hypertension remain poorly understood despite decades of research. The scientist wishing to investigate developmental programming of, for example, metabolic syndrome faces a bewildering choice of avenues to explore. Without a firm understanding of the early aetiology of hypertension or of insulin resistance, he or she has little choice but to follow the well-trodden paths which characterise research into these disorders in humans.
In a series of focus groups during 2001 and 2002, organic farmers from different regions of the United States identified a wide range of risks to their operations. The focus groups were facilitated by the University of Maryland in cooperation with a research team from USDA's Economic Research Service, to explore the risks faced by organic farmers, how they are managed, and needs for risk management assistance. Contamination of organic production from genetically modified organisms was seen as a major risk, particularly by grain, soybean and cotton farmers. Focus-group participants producing grains and cotton—many of whom knew about and had obtained crop insurance—raised concerns about coverage offered, including the need for insurance to reflect the higher prices received for organic crops. Most fruit and vegetable producers participating in the focus groups had little knowledge of crop insurance. When provided with basic information about crop insurance, operators of small fruit and vegetable farms were skeptical about its usefulness for their type of operation.
This study investigated the potential influences of general processing capacity and sustained selective attention on the temporal processing of a group of children with specific language impairment (SLI) and a group of age-matched (CA) controls. Children completed a sustained selective auditory attention task and two speech processing tasks, the Speech Identification Task, representing a cognitively more complex task, and a standard speech discrimination task, representing a cognitively less complex task. The speech stimuli included two-formant, 40-ms transition [ba] and [da] consonant–vowel (CV) syllables and the nonstop CV syllable [sa]. We hypothesized, in accordance with Tallal's temporal processing deficit view, that if SLI children have a fundamental deficit in temporal processing, they should demonstrate poor performance on both speech processing tasks relative to CA children. By contrast, if the temporal processing problem of SLI children relates to a limitation in general processing capacity, the SLI children should show better performance on the discrimination task compared to the identification task. Alternatively, if poor sustained selective attention mediates SLI children's poor temporal processing, the SLI children should show poor performance on an independent measure of auditory attention, which in turn should account for a portion of the variance in any observed group differences in temporal processing. Results showed no group difference in sustained selective auditory attention. On the identification task, group, stimulus-type, and interaction effects emerged. SLI children performed more poorly than CA children, and stop CV syllables were identified less frequently than the nonstop CV syllable. On the discrimination task, there were no main effects or interactions for accuracy (Á score). For the reaction time analysis, only a stimulus-type effect was found, with children responding faster to the /sa/ syllable. Results were interpreted to suggest that these SLI children did not evidence a basic temporal processing deficit. Rather, the SLI children's poor identification task performance was interpreted to reflect an interaction between these children's more limited general processing capacity and the nature of the task.
Small farmers urgently need alternative marketing strategies if they are to achieve the goals of a more sustainable agriculture. This study was a survey of nine Pennsylvania wholesale produce auctions, all established between 1984 and 1998. The main goals of the auctions were to serve local communities, provide high-quality produce to local consumers and make profits. The results showed that the auctions typically employ an average of 7–10 people per growing season. The five most common commodities sold were cantaloupe, watermelon, tomato, pumpkin and sweet corn. Asparagus and onions were the least sold during a regular growing season. In terms of market share, roadside market operators purchased the largest proportion of produce (40%), followed by farmers (27%), chain food stores (16%), independent grocery stores (11%) and restaurants (6%), making up an average annual gross sale of $3.5 million per auction. The study revealed that the nine Pennsylvania produce auctions were successful in meeting their goals. The reasons for success included private ownership, excellent quality and freshness of produce, good location, local produce recognition, clientele availability and customer-oriented business. The auction managers identified some weaknesses, including inconsistent and poor grading, limited space in the auction facility, produce unavailability and limited volume, lack of cooling facility, price fluctuation and slow service. The study indicated that local wholesale produce auctions are a useful marketing alternative for small farmers in Pennsylvania, by providing marketing outlets and convenient shopping centers for sellers and buyers; by securing a source of fresh and locally grown produce not found in traditional wholesale terminal markets; and by allowing exchange and networking among farmers and buyers. Consequently, the wholesale produce auction can be a useful model for an alternative marketing strategy and can provide considerable benefits to small farm and rural communities.