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The Management and Supervision Tool (MaST) helps NHS mental health care professionals identify patients who are most likely to need psychiatric hospital admission or home treatment, due to severe mental illness, through a Risk of Crisis (RoC) algorithm driven by electronic health record (EHR) data analytics. We describe the derivation and validation of the MaST RoC algorithm, and its implementation to support preventative mental healthcare in the NHS.
The RoC algorithm was developed and evaluated with EHR data from six UK NHS trusts using Ordered Predictor List propensity scores informed by a priori weightings from pre-existing literature, as well as real-world evidence evaluating the associations of clinical risk factors with mental health crisis using NHS EHR data. Mental health crisis was defined as admission to a psychiatric hospital or acceptance to a community crisis service within a 28-day period. Predictor variables included age, gender, accommodation status, employment status, Mental Health Act (MHA) status (under section or Community Treatment Order), and previous mental health service contacts (including hospital admissions and crisis services). Data were analysed using Ordered Predictor List propensity scores. The algorithm was derived using structured EHR data from 2,620 patients in a single NHS trust and externally validated using data from 107,879 patients in five other NHS trusts. Qualitative and quantitative data on feasibility, acceptability and system efficiency impacts of MaST implementation were obtained through staff surveys and local audits.
The factors associated with greatest propensity for mental health crisis included recent previous crisis, multiple previous crises, higher number of mental health service contacts in recent weeks, MHA section, accommodation status and employment status. The RoC algorithm identified 64% and 80% crises in its top quintile. Sentiment analysis of staff surveys suggested that the use of MaST improved productivity by reducing time taken to access patient information to support caseload management that was previously difficult to obtain through manual review of EHRs. The systems efficiency audit revealed a reduction in duration of crisis and inpatient admissions following MaST implementation.
The MaST RoC algorithm supports the identification of people more likely to use crisis services in NHS mental health trusts, is feasible to implement, and improves systems efficiency. EHR-derived algorithms can support real-world clinical practice to improve outcomes in people receiving NHS mental healthcare.
There is a lack of publicly available information covering the practices insurers employ to manage their exposure to reinsurance recapture risk. A working party was set-up to shed light on the different approaches insurers use to mitigate this complicated to manage risk. This report is intended to form part of a publicly available information repository that market practitioners can refer to and reflect on as best practice evolves and develops.
This historiographical review offers an overview of new approaches to the global history of the First World War. It first considers how, over the last decade, there has been a move to emphasize the war's imperial dimensions: in reconsiderations of the war in Africa, the experience of soldiers and workers from across Europe's colonial empires, and the German ‘global strategy’ of fomenting unrest within the Allied empires. It then suggests that new global histories of the First World War give further attention to its economic aspects, particularly in two ways: first, by recovering understudied global financial aspects of the war, including the effects of the 1914 financial crisis and wartime inflation on economies and societies far outside of Europe; and second, by investigating wartime histories of primary production, both in colonial territories and sovereign states in Latin America, Africa, and Southeast Asia. It argues that these approaches can offer an important corrective to common assumptions that the First World War led to a dramatic break with pre-war globalizing trends.
This chapter explores current research on how young people make judgements about the information they encounter. There will be a discussion on why some young people appear to trust, without question, online information whilst others show remarkable powers of insight and critique. Evidence on how this might affect their physical and mental well-being will be provided. Why this is important both in educational and political terms is discussed. There will then be an exploration of the approaches that can be employed to help young people develop a more discerning approach to engaging with the information they see, hear and read in any context.
The discussion put forward here is based upon a synthesis of research findings involving three groups of young people from the UK – 16–17-year-olds, at a secondary school, 18–19-year-old university students in their first undergraduate year and finally 18–24-year-old men recruited for an experiment, mostly undergraduates – all carried out in the UK. For the first two groups there was a concern voiced by teachers and academic tutors respectively that their students exhibited a noticeable lack of the necessary capabilities to make well-calibrated judgements in order to select good-quality information to support their work for assignments. The 16–17-year-olds were working towards gaining their Extended Project Qualification (EPQ)1 – a mini-dissertation in addition to their A-level study. Walton et al. (2018a) provide a comprehensive reflection of these studies. The 18–19-year-olds were working towards completing their first assignment and had to find good quality information about a sporting issue of their choice (see Walton and Hepworth, 2011; 2013 for a more detailed account). These two groups are quite similar in their context and we will see that their comments and experiences and our analyses align in an encouraging way. How? They both appear to indicate that most (but by no means all) students present with remarkably poor capabilities in making judgements about information, which prevent them from making the most suitable choices. The third group were recruited to find out whether the cognitive process of information discernment has a physiological component. Why? We wanted to find out whether being good at information discernment is related to positive responses to stress.
The goal of this study was to perform in situ electrochemical polymerization of poly(3,4-ethylenedioxythiophene) (PEDOT) in peripheral nerves to create a soft, precisely located injectable conductive polymer electrode for bi-directional communication. Intraneural PEDOT polymerization was performed to target both outer and inner fascicles via custom fabricated 3D printed cuff electrodes and monomer injection strategies using a combination electrode-cannula system. Electrochemistry, histology, and laser light sheet microscopy revealed the presence of PEDOT at specified locations inside of peripheral nerve. This work demonstrates the potential for using in situ PEDOT electrodeposition as an injectable electrode for recording and stimulation of peripheral nerves.
Surgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.
To examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRS
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011–2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.
Of 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
The primary outcome of interest was 30-day SSI rate.
A total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23–2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09–1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06–2.53; P=.02), and longer duration of procedure were associated with development of SSI.
Patients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.
The ability to interface electronic materials with the peripheral nervous system is required for stimulation and monitoring of neural signals. Thus, the design and engineering of robust neural interfaces that maintain material-tissue contact in the presence of material or tissue micromotion offer the potential to conduct novel measurements and develop future therapies that require chronic interface with the peripheral nervous system. However, such remains an open challenge given the constraints of existing materials sets and manufacturing approaches for design and fabrication of neural interfaces. Here, we investigated the potential to leverage a rapid prototyping approach for the design and fabrication of nerve cuffs that contain supporting features to mechanically stabilize the interaction between cuff electrodes and peripheral nerve. A hybrid 3D printing and robotic-embedding (i.e., pick-and-place) system was used to design and fabricate silicone nerve cuffs (800 µm diameter) containing conforming platinum (Pt) electrodes. We demonstrate that the electrical impedance of the cuff electrodes can be reduced by deposition of the conducting polymer poly(3,4-ethylenedioxythiophene) polystyrene sulfonate (PEDOT:PSS) on cuff electrodes via a post-processing electropolymerization technique. The computer-aided design and manufacturing approach was also used to design and integrate supporting features to the cuff that mechanically stabilize the interface between the cuff electrodes and the peripheral nerve. Both ‘self-locking’ and suture-assisted locking mechanisms are demonstrated based on the principle of making geometric alterations to the cuff opening via 3D printing. Ultimately, this work shows 3D printing offers considerable opportunity to integrate supporting features, and potentially even novel electronic materials, into nerve cuffs that can support the design and engineering of next generation neural interfaces.
Feature tracking of approximately annually separated Landsat-7 ETM+ imagery acquired from 1999 to 2010 and speckle tracking of 24-day separated RADARSAT-2 imagery acquired from 2009 to 2015 reveal that motion of the major tidewater glaciers of Devon Ice Cap is more variable than previously described. The flow of almost half (six of 14) of the outlet glaciers slowed over the observation period, while that of the terminus regions of three of 14 of the glaciers sped up in the most recent years of observation. The North Croker Bay Glacier of southern Devon Ice Cap showed the greatest variability in motion, oscillating between multi-year (three or more) periods of slower and faster flow and exhibited a pattern of velocity variability that is different from that of the rest of the ice cap's outlet glaciers. Comparisons between areas of dynamic variability and glacier bed topography indicate that velocity variability is largely restricted to regions where the glacier bed is grounded below sea level. Derived velocities are combined with measurements of ice thickness at the fronts of tidewater glacier to determine a mean annual (2009; 2011–15) dynamic ice discharge of 0.41 ± 0.11 Gt a−1 for Devon Ice Cap. The Belcher Glacier is becoming a larger source of mass loss via ice discharge.
Nurses and respiratory therapists are seldom allowed to use automated external defibrillators (AED) during in-hospital cardiac arrest. This can result in significant time delays before defibrillation occurs and lower survival for cardiac arrest victims. We sought to identify barriers and facilitators to AED use by nurses and respiratory therapists.
We conducted semi-structured qualitative interviews with a purposeful sample of nurses and respiratory therapists. We developed the interview guide based on the constructs of the theory of planned behaviour, which elicits salient attitudes, social influences, and control beliefs potentially influencing the intent to use an AED. Interviews were recorded, transcribed verbatim, and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging categories and themes, and ranked them by frequency of the number of participants stating the topic.
Demographics for the 24 interviewees include mean age 40.5, 79.2% female, 87.5% performed cardiopulmonary resuscitation (CPR), 29.2% defibrillated a patient. Identified attitudes pertained to the timeliness of defibrillation, patient survival, simplicity of AED use, accuracy of rhythm recognition, and harm to self or others. Social influences consisted of physician and hospital administration support of AED use. Control beliefs included training on AED use, policy allowing AED use, familiarity with AED, and task burden during resuscitation.
Most nurses and respiratory therapists intended to use an AED if permitted to do so by a medical directive. Successful implementation would require educational initiatives focusing on safety and efficacy of AEDs, support from physicians and hospital administrators, and additional training on AED use.
This chapter explores how the major powers of Europe and the USA mobilized their economies when war came in 1939, and how at the end of the Second World War they once again wrestled with the problem of how to restore economic peace. Viewed in terms of strictly economic metrics it is conventional to draw a sharp line in 1945 separating the troubled interwar era from the 'post-war' era of triumphant growth. In terms of economic success the difference is undeniable. But the moniker of 'post-war' is seriously misleading when applied to the 1950s, a period of intense military confrontation in the early Cold War and violent decolonization struggles. Alongside the famous welfare state initiatives of the 1940s, the warfare states that had first taken shape in the First World War were more entrenched than ever. Recognizing this casts new light on the nature of the 'post-war' international economic order.
Before his death in 1987, Jacob Taubes played an important role in postwar German academic philosophy and religious thought. Best known for his leftist political theology and scholarship on the history of Western eschatology, Taubes's thought was influential on mid-twentieth-century debates in Germany about secularization and modern political theology. Outside his relationship with Carl Schmitt, however, Taubes has received little attention in histories of postwar European thought, and few attempts have been made to understand his idiosyncratic work on its own terms. This essay presents new contexts for understanding Taubes and his political-theological critique of the ideological dominance of liberalism in postwar Germany. By analyzing Taubes's thought through the lens of his intellectual quarrel with Hans Blumenberg over secularization, it reassesses his contributions to postwar debates about the political temporality appropriate to a secular and non-utopian social theory, and the consequences of these debates for broader critiques of political liberalism.
This chapter deals with important considerations with regard to pre-procedure, peri-procedure, and post-procedure patient assessment and pain management strategies. Practitioner training and experience in administering sedation is an important consideration. For most patients, pain assessments and establishment of pain treatment goals can be performed by a non-anesthesiologist. Appropriate assessment of pain increases caregiver awareness of pain status, allows for the delivery of appropriate interventions, provides for feedback, decreases both patient and caregiver frustration, and improves patient satisfaction. The chapter outlines the most common pain assessment tools in current use in general and special populations. In the general population, which includes mature children, adults, and the cognitively intact elderly, the use of self-report scales has been validated as the most reliable indicator of pain. With appropriate vigilance, planning, and continuous communication between team members, many of the barriers involved in planning and executing an effective pain management strategy can be overcome.
Evidence suggests that schizophrenia may have a better outcome for
individuals living in low- and middle-income countries compared with
To determine the frequency of symptom and functional remission in
out-patients with schizophrenia in different regions of the world.
Using data from the Worldwide-Schizophrenia Outpatient Health Outcomes
(W-SOHO) study we measured clinical and functional remission in
out-patients with schizophrenia in different regions of the world, and
examined sociodemographic and clinical factors associated with these
outcomes. The 11 078 participants analysed from 37 participating
countries were grouped into 6 regions: South Europe, North Europe,
Central and Eastern Europe, Latin America, North Africa and Middle East,
and East Asia.
In total, 66.1% achieved clinical remission during the 3-year follow-up
(range: 60.1% in North Europe to 84.4% in East Asia) and 25.4% achieved
functional remission (range: 17.8% in North Africa and Middle East to
35.0% in North Europe). Regional differences were not explained by
participants' clinical characteristics. Baseline social functioning,
being female and previously untreated were consistent predictors of
remission across regions.
Clinical outcomes of schizophrenia seem to be worse in Europe compared
with other regions. However, functional remission follows a different
Ultrasmall paramagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) imaging is a promising noninvasive method to identify high-risk atheromatous plaques. Iron oxide particles function as contrast-enhancing agents by creating a large dipolar magnetic field gradient that acts on the water molecules that diffuse close to the particles. Howarth reported that USPIO appeared to show a dual contrast effect with signal enhancement being seen in plaques with little inflammation and large fibrous caps. The contralateral side of symptomatic patients given USPIO were also analyzed. It was found that 95% patients showed bilateral USPIO uptake suggesting an inflammatory burden within their carotid atheroma bilaterally. Three different approaches have been adopted to make the seemly impossible task a reality: ultrashort echo times (uTE), inversion recovery on-resonance water suppression (IRON) imaging, and Gradient echo acquisition for superparamagnetic particles with positive contrast (GRASP).