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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.
Historians tend to think of the nobility as a military class – as indeed they would ultimately have defined themselves – and also as the social and cultural elite, as courtiers and councillors in relation to the crown, as inheritors and transmitters of their patrimony, but rarely as men of business. A mention of Anthony Wydeville, Earl Rivers, might conjure up in the modern mind an image of a chivalric jouster or a courtier/politician, but usually not an image of a man very much on top of his business affairs, despite the fact that his surviving correspondence shows him to be all of these things. The extent to which lords and ladies were involved with their estates and finances is a question that is often tentatively addressed by individual studies of landlords and landladies but less frequently by historians in a more general sense, despite the pithy remarks of K.B. McFarlane on the subject, although those that do tend to infer some lordly involvement in estate and financial management. This lack of investigation is in some contrast to consideration of the lesser gentry, where historians have argued for ‘personal decision making and the lightness of bureaucracy’. Clearly, the participation of greater landowners in the administration of their estates would have varied from individual to individual, but the evidence makes both case studies and any attempt at generalisations about the attitudes and expectations of the whole class rather difficult. The evidence tends to come in two forms. One is the manuals of instruction drawn up for lords and ladies detailing how they should conduct themselves in every aspect of their lives, including in their role as landlords and heads of households. While these shed light on how (some) contemporaries considered the question of the extent to which lords ought to be involved in their estates and finances, such works of instructions were idealistic and in part unrealistic, as indeed Dorothea Oschinsky, who worked extensively on these manuals in the mid twentieth century, admits. Yet the second type of evidence, the financial records of estate administration, is even more difficult to interpret, as these usually deliberately obscured agency behind the formal veil of lordly authority and on a number of levels require the historian to spend considerable time distinguishing fiction from reality.
Urothelial carcinoma (UCC) develops in both humans and dogs and tracks to regions of high industrial activity. We hypothesize that dogs with UCC may act as sentinels for human urothelial carcinogen exposures. The aim of this pilot study was to determine whether healthy people and dogs in the same households share urinary exposures to potentially mutagenic chemical carcinogens.
We measured urinary concentrations of acrolein (as its metabolite 3-HPMA), arsenic species, 4-aminobiphenyl, and 4-chlorophenol (a metabolite of the phenoxyherbicide 2,4-D) in healthy dogs and their owners. We assessed possible chemical sources through questionnaires and screened for urothelial DNA damage using the micronucleus assay.
Biomarkers of urinary exposure to acrolein, arsenic, and 4-chlorophenol were found in the urine of 42 pet dogs and 42 owners, with 4-aminobiphenyl detected sporadically. Creatinine-adjusted urinary chemical concentrations were significantly higher, by 2.8- to 6.2-fold, in dogs compared to humans. Correlations were found for 3-HPMA (r = 0.32, P = 0.04) and monomethylarsonic acid (r = 0.37, P = 0.02) between people and their dogs. Voided urothelial cell yields were inadequate to quantify DNA damage, and questionnaires did not reveal significant associations with urinary chemical concentrations.
Healthy humans and pet dogs have shared urinary exposures to known mutagenic chemicals, with significantly higher levels in dogs. Higher urinary exposures to acrolein and arsenic in dogs correlate to higher exposures in their owners. Follow-up studies will assess the mutagenic potential of these levels in vitro and measure these biomarkers in owners of dogs with UCC.
Liquid phase (or liquid cell) transmission electron microscopy (LP-TEM) has been established as a powerful tool for observing dynamic processes in liquids at nanometer to atomic length scales. However, the simple act of observation using electrons irreversibly alters the nature of the sample. A clear understanding of electron-beam-driven processes during LP-TEM is required to interpret in situ observations and utilize the electron beam as a stimulus to drive nanoscale dynamic processes. In this article, we discuss recent advances toward understanding, quantifying, mitigating, and harnessing electron-beam-driven chemical processes occurring during LP-TEM. We highlight progress in several research areas, including modeling electron-beam-induced radiolysis near interfaces, electron-beam-induced nanocrystal formation, and radiation damage of soft materials and biomolecules.
This article examines how older adults make decisions about their medications through interconnected axes of trust that operate across social networks. Trust is negotiated by older adults enrolled in a deprescribing programme which guides them through the process of reducing medications to mitigate risks associated with polypharmacy. Habermas’ work on the significance of communicative action in negotiating trust within social relationships informs our analysis, specifically in-depth semi-structured interviews with older adults about their medication use and the role of social networks in managing their health. Participants were age 70+ and experiencing polypharmacy. Our analysis discusses the social nature of medication practices and the importance of social networks for older adults’ decision-making. Their perspective reflects the critique of late-modern society put forward by Habermas. Negotiating trust in pharmaceutical decision-making requires navigating tensions across and between system networks (health-care professionals) and life-world networks (family and friends). This study contributes to our knowledge of how distinct forms of trust operate in different social spheres, setting the context for the way health-care decisions are made across social networks. Our analysis reinforces the need for older adults to engage meaningfully in health-care decision-making such that a convergence between system-world and life-world structures is encouraged. This would improve deprescribing programmes’ efficacy as older adults optimise their medication use and improve overall quality of life.
Shanidar Cave in Iraqi Kurdistan became an iconic Palaeolithic site following Ralph Solecki's mid twentieth-century discovery of Neanderthal remains. Solecki argued that some of these individuals had died in rockfalls and—controversially—that others were interred with formal burial rites, including one with flowers. Recent excavations have revealed the articulated upper body of an adult Neanderthal located close to the ‘flower burial’ location—the first articulated Neanderthal discovered in over 25 years. Stratigraphic evidence suggests that the individual was intentionally buried. This new find offers the rare opportunity to investigate Neanderthal mortuary practices utilising modern archaeological techniques.
We read with interest the recent editorial, “The Hennepin Ketamine Study,” by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton’s editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton’s editorial, and to the lay media stories on which it appears to be based.
Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators’ reply. Prehosp Disaster Med. 2019;34(2):111–113
In Alcimus Ecdicius Avitus's sixth-century biblical poem De spiritalishistoriae gestis, Satan boasts that after tempting Eve to eat the forbidden fruit he enjoys a better claim over the first couple than God himself:
En, diuina manet promissae gloria laudis!
Quicquid scire meum potuit, iam credite uestrum est:
omnia monstraui sensumque per abdita duxi,
et quodcumque malum sollers natura negabat,
institui dextrisque dedi coniungere laeuum.
Istinc perpetua uosmet mihi sorte dicaui.
Nec Deus in uobis, quamquam formauerit ante,
iam plus iuris habet: teneat, quod condidit ipsae;
quod docui meum est; maior mihi portio restat.
Multa creatori debetis, plura magistro.
Behold, the godlike glory of the praise I promised abides with you. Whatever knowledge was within my grasp, trust now that it is yours. I have shown you everything, have guided your senses through what was hidden, and whatever evil ingenious nature had denied to you, this I have taught, allowing man to join left and right, foul and fitting. And so your fate is sealed forever and I have consecrated you to myself. Nor does God, although He formed you earlier, have greater rights in you. Let Him hold what He Himself made. What I taught is mine, and the greater portion remains with me. You owe much to your Creator but more to your teacher.
This passage lacks a direct analogue in Paradise Lost, but its conception of the devil as a teacher resonates powerfully within Milton's epic, because education ranks among his most central and sustained interests: as Margaret Olofson Thickstun remarks, Paradise Lost is “a poem about the education of its main characters and at the same time dedicated to the education of its readers.” Having served as a schoolmaster himself during the 1640s, Milton knew firsthand the pleasure and perils of teaching, a vocation that he seems to have considered “parallel, if not quite equal, to preaching and poesy.” Over the past fifty years, many scholars have contributed to a deepening understanding of Miltonic learning, often employing his tractate Of Education (1644) as a framework for assessing the methods and success of Raphael, Michael, and the Father in guiding Adam and Eve's progress towards true knowledge in Paradise Lost.
Psychiatry has faced significant criticism for overreliance on the Diagnostic and Statistical Manual of Mental Disorders (DSM) and medications with purported disregard for empathetic, humanistic interventions.
To develop an empirically based qualitative theory explaining how psychiatrists use empathy in day-to-day practice, to inform practice and teaching approaches.
This study used constructivist grounded theory methodology to ask (a) ‘How do psychiatrists understand and use empathetic engagement in the day-to-day practice of psychiatry?’ and (b) ‘How do psychiatrists learn and teach the skills of empathetic engagement?’ The authors interviewed 17 academic psychiatrists and 4 residents and developed a theory by iterative coding of the collected data.
This constructivist grounded theory of empathetic engagement in psychiatric practice considered three major elements: relational empathy, transactional empathy and instrumental empathy. As one moves from relational empathy through transactional empathy to instrumental empathy, the actions of the psychiatrist become more deliberate and interventional.
Participants were described by empathy-based interventions which are presented in a theory of ‘empathetic engagement’. This is in contrast to a paradigm that sees psychiatry as purely based on neurobiological interventions, with psychotherapy and interpersonal interventions as completely separate activities from day-to-day psychiatric practice.
The mechanics of snow friction are central to competitive skiing, safe winter driving and efficient polar sleds. For nearly 80 years, prevailing theory has postulated that self-lubrication accounts for low kinetic friction on snow: dry-contact sliding warms snow grains to the melting point, and further sliding produces meltwater layers that lubricate the interface. We sought to verify that self-lubrication occurs at the grain scale and to quantify the evolution of real contact area to aid modeling. We used high-resolution (15 µm) infrared thermography to observe the warming of stationary snow under a rotating polyethylene slider. Surprisingly, we did not observe melting at contacting snow grains despite low friction values. In some cases, slider shear failed inter-granular bonds and produced widespread snow movement with no persistent contacts to melt (μ < 0.03). When the snow grains did not move and persistent contacts evolved, the slider abraded rather than melted the grains at low resistance (μ < 0.05). Optical microscopy revealed that the abraded particles deposited in air pockets between grains and thereby carried heat away from the interface, a process not included in current models. Overall, our results challenge whether self-lubrication is indeed the dominant mechanism underlying low snow kinetic friction.
The U.S. Food and Drug Administration (FDA) traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.
To develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.
In 2016-2017, we convened a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.
The team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.
The development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation.
Scarcely any turbulence, quarrels or disturbance ever occur there, but delinquents are punished with no other punishment than expulsion from communion with their society, which is a penalty they fear more than criminals elsewhere fear imprisonment and fetters. For a man once expelled from one of these societies is never received into the fellowship of any other of those societies. Hence the peace is unbroken and the conversation of all of them is as the friendship of united folk.
This was Sir John Fortescue's idealized account to the exiled prince of Wales, Edward of Lancaster, of the peace-loving nature of London's Inns of Court and Chancery in the mid-fifteenth century. Fortescue was not concerned with the reality, which, as he knew all too well, was different. He was concerned with impressing on his young pupil the perfection of the English law and the education of its practitioners, rather than the imperfections that existed in a society that the prince, as he explicitly told him, would never experience. Few who were familiar with the legal quarter that surrounded the Inns would have recognized the Arcadia that Fortescue described. Far from being the peaceful and well-ordered district that the former chief justice invoked, in the period when he wrote the area to the west of London's Temple Bar was a liminal space, populated by—among others—large numbers of young trainee lawyers, in whom the kind of unruly behaviour otherwise also associated with the early universities, not least the western suburb's Paris counterpart, the quartier latin to the south of the river Seine, was endemic. Among the most important factors that made it so was the very existence of the established, and to some extent tribal, all-male societies of the Inns of Court and of Chancery, at close quarters with the royal law courts and their heady mix of disputants and hired legal counsellors in permanent competition with each other.