We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
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 coreplatform@cambridge.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.
Recent shifts in political support to populist parties worldwide have been linked to the changing preferences of “left behind communities.” Based on apparently growing “left behind” support for populists, some commentators have argued for policy changes including tightened immigration rules coupled with increasing investment in economically deprived areas, particularly in health care. However, left behind communities’ policy preferences are unclear from existing research due to a series of methodological challenges associated with researching polarization and stigmatization. We complement existing research with an innovative photo elicitation methodology covering five field sites in the United Kingdom during 2019, focusing on left behind communities’ policy preferences concerning Brexit. Photo elicitation overcomes methodological challenges associated with emotional attachment and stigmatization. Drawing on 418 interviews with 489 participants, we find that interviewees rejected elite framings suggesting a logical link between Brexit and health care investment, instead articulating policy preferences for health care investment drawing on personal experiences.
Hemorrhage control prior to shock onset is increasingly recognized as a time-critical intervention. Although tourniquets (TQs) have been demonstrated to save lives, less is known about the physiologic parameters underlying successful TQ application beyond palpation of distal pulses. The current study directly visualized distal arterial occlusion via ultrasonography and measured associated pressure and contact force.
Methods:
Fifteen tactical officers participated as live models for the study. Arterial occlusion was performed using a standard adult blood pressure (BP) cuff and a Combat Application Tourniquet Generation 7 (CAT7) TQ, applied sequentially to the left mid-bicep. Arterial flow cessation was determined by radial artery palpation and brachial artery pulsed wave doppler ultrasound (US) evaluation. Steady state maximal generated force was measured using a thin-film force sensor.
Results:
The mean (95% CI) systolic blood pressure (SBP) required to occlude palpable distal pulse was 112.9mmHg (109-117); contact force was 23.8N [Newton] (22.0-25.6). Arterial flow was visible via US in 100% of subjects despite lack of palpable pulse. The mean (95% CI) SBP and contact force to eliminate US flow were 132mmHg (127-137) and 27.7N (25.1-30.3). The mean (95% CI) number of windlass turns to eliminate a palpable pulse was 1.3 (1.0-1.6) while 1.6 (1.2-1.9) turns were required to eliminate US flow.
Conclusions:
Loss of distal radial pulse does not indicate lack of arterial flow distal to upper extremity TQ. On average, an additional one-quarter windlass turn was required to eliminate distal flow. Blood pressure and force measurements derived in this study may provide data to guide future TQ designs and inexpensive, physiologically accurate TQ training models.
The UK's relationship with the European Union (EU) is now embodied in two principal legal instruments: the EU–UK Trade and Cooperation Agreement, which formally entered into force on 1 May 2021; and the Withdrawal Agreement, with its Protocol on Ireland/Northern Ireland, which continues to apply. Using a ‘building blocks’ framework for analysis of national health systems derived from the World Health Organisation, this article examines the likely impacts in the UK of this legal settlement on the National Health Service (NHS), health and social care. Specifically, we determine the extent to which the trade, cooperation and regulatory aspects of those legal measures support positive impacts for the NHS and social care. We show that, as there is clear support for positive health and care outcomes in only one of the 17 NHS ‘building blocks’, unless mitigating action is taken, the likely outcomes will be detrimental. However, as the legal settlement gives the UK a great deal of regulatory freedom, especially in Great Britain, we argue that it is crucial to track the effects of proposed new health and social care-related policy choices in the months and years ahead.
Background: Healthcare facilities have experienced many challenges during the COVID-19 pandemic, including limited personal protective equipment (PPE) supplies. Healthcare personnel (HCP) rely on PPE, vaccines, and other infection control measures to prevent SARS-CoV-2 infections. We describe PPE concerns reported by HCP who had close contact with COVID-19 patients in the workplace and tested positive for SARS-CoV-2. Method: The CDC collaborated with Emerging Infections Program (EIP) sites in 10 states to conduct surveillance for SARS-CoV-2 infections in HCP. EIP staff interviewed HCP with positive SARS-CoV-2 viral tests (ie, cases) to collect data on demographics, healthcare roles, exposures, PPE use, and concerns about their PPE use during COVID-19 patient care in the 14 days before the HCP’s SARS-CoV-2 positive test. PPE concerns were qualitatively coded as being related to supply (eg, low quality, shortages); use (eg, extended use, reuse, lack of fit test); or facility policy (eg, lack of guidance). We calculated and compared the percentages of cases reporting each concern type during the initial phase of the pandemic (April–May 2020), during the first US peak of daily COVID-19 cases (June–August 2020), and during the second US peak (September 2020–January 2021). We compared percentages using mid-P or Fisher exact tests (α = 0.05). Results: Among 1,998 HCP cases occurring during April 2020–January 2021 who had close contact with COVID-19 patients, 613 (30.7%) reported ≥1 PPE concern (Table 1). The percentage of cases reporting supply or use concerns was higher during the first peak period than the second peak period (supply concerns: 12.5% vs 7.5%; use concerns: 25.5% vs 18.2%; p Conclusions: Although lower percentages of HCP cases overall reported PPE concerns after the first US peak, our results highlight the importance of developing capacity to produce and distribute PPE during times of increased demand. The difference we observed among selected groups of cases may indicate that PPE access and use were more challenging for some, such as nonphysicians and nursing home HCP. These findings underscore the need to ensure that PPE is accessible and used correctly by HCP for whom use is recommended.
Auditory Verbal Hallucinations (AVH) are a hallmark of psychosis, but affect many other clinical populations. Patients’ understanding and self-management of AVH may differ between diagnostic groups, change over time, and influence clinical outcomes.
We aimed to explore patients’ understanding and self-management of AVH in a young adult clinical population.
Method
35 participants reporting frequent AVH were purposively sampled from a youth mental health service, to capture experiences across psychosis and non-psychosis diagnoses. Diary and photo-elicitation methodologies were used – participants were asked to complete diaries documenting experiences of AVH, and to take photographs representing these experiences. In-depth, unstructured interviews were held, using participant-produced materials as a topic guide. Conventional content analysis was conducted, deriving results from the data in the form of themes.
Result
Three themes emerged:
(1) Searching for answers, forming identities – voice-hearers sought to explain their experiences, resulting in the construction of identities for voices, and descriptions of relationships with them. These identities were drawn from participants’ life-stories (e.g., reflecting trauma), and belief-systems (e.g., reflecting supernatural beliefs, or mental illness). Some described this process as active / volitional. Participants described re-defining their own identities in relation to those constructed for AVH (e.g. as diseased, 'chosen', or persecuted), others considered AVH explicitly as aspects of, or changes in, their personality.
(2) Coping strategies and goals – patients’ self-management strategies were diverse, reflecting the diverse negative experiences of AVH. Strategies were related to a smaller number of goals, e.g. distraction, soothing overwhelming emotions, 'reality-checking', and retaining agency.
(3) Outlook – participants formed an overall outlook reflecting their self-efficacy in managing AVH. Resignation and hopelessness in connection with disabling AVH are contrasted with outlooks of “acceptance” or integration, which were described as positive, ideal, or mature.
Conclusion
Trans-diagnostic commonalities in understanding and self-management of AVH are highlighted - answer-seeking and identity-formation processes; a diversity of coping strategies and goals; and striving to accept the symptom. Descriptions of “voices-as-self”, and dysfunctional relationships with AVH, could represent specific features of voice-hearing in personality disorder, whereas certain supernatural/paranormal identities and explanations were clearly delusional. However, no aspect of identity-formation was completely unique to psychosis or non-psychosis diagnostic groups. The identity-formation process, coping strategies, and outlooks can be seen as a framework both for individual therapies and further research.
Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.
Memory symptoms and objective impairment are common in HIV disease and are associated with disability. A paradoxical issue is that objective episodic memory failures can interfere with accurate recall of memory symptoms. The present study assessed whether responses on a self-report scale of memory symptoms demonstrate measurement invariance in persons with and without objective HIV-associated memory impairment.
Method:
In total, 505 persons with HIV completed the Prospective and Retrospective Memory Questionnaire (PRMQ). Objective memory impairment (n = 141) was determined using a 1-SD cutoff on clinical tests of episodic memory. PRMQ measurement invariance was assessed by confirmatory factor analyses examining a one-factor model with increasing cross-group equality constraints imposed on factor loadings and item thresholds (i.e., configural, weak, and strong invariance).
Results:
Configural model fit indicated that identical items measured a one-factor model for both groups. Comparison to the weak model indicated that factor loadings were equivalent across groups. However, there was evidence of partial strong invariance, with two PRMQ item thresholds differing across memory impairment groups. Post hoc analyses using a 1.5-SD memory impairment cutoff (n = 77) revealed both partial weak and partial strong invariance, such that PRMQ item loadings differed across memory groups for three items.
Conclusions:
The PRMQ demonstrated a robust factor structure among persons with and without objective HIV-associated memory impairment. However, on select PRMQ items, individuals with memory impairment reported observed scores that were relatively higher than their latent score, while items were more strongly associated with the memory factor in a group with greater memory impairment.
The availability of colonizable substrate is an important driver of the temporal dynamics of sessile invertebrates on coral reefs. Increased dominance of algae and, in some cases, sponges has been documented on many coral reefs around the world, but how these organisms benefit from non-colonized substrate on the reef is unclear. In this study, we described the temporal dynamics of benthic organisms on an Indonesian coral reef across two time periods between 2006 and 2017 (2006–2008 and 2014–2017), and investigated the effects of colonizable substrate on benthic cover of coral reef organisms at subsequent sampling events. In contrast with other Indonesian reefs where corals have been declining, corals were dominant and stable over time at this location (mean ± SE percentage cover 42.7 ± 1.9%). Percentage cover of turf algae and sponges showed larger interannual variability than corals and crustose coralline algae (CCA) (P < 0.001), indicating that these groups are more dynamic over short temporal scales. Bare substrate was a good predictor of turf cover in the following year (mean effect 0.2, 95% CI: 0–0.4). Algal cover combined with bare space was a good predictor of CCA cover the following year generally, and of sponge cover the following year but only at one of the three sites. These results indicate that turf algae on some Indonesian reefs can rapidly occupy free space when this becomes available, and that other benthic groups are probably not limited by the availability of bare substrate, but may overgrow already fouled substrates.
Thromboembolism (TE) in pediatrics is relatively rare compared with adults, with an estimated venous thromboembolism (VTE) incidence of 0.07–0.14/10,000 children [1, 2]. A bimodal age distribution has been well demonstrated in the pediatric VTE population and children less than 1 year of age, especially those less than 1 month of age, are most commonly affected [1, 2]. The incidence of VTE in this very young population, particularly when hospitalized, is increasing [3–6]. Between 1997 and 2018, up to a 13-fold increase in neonatal TE incidence has been described in all live births and a greater than six-fold increase in neonatal TE incidence has been described for neonatal intensive care unit (NICU) admissions [4–7]. This increase has been attributed to improving survival rates in critically ill and/or premature neonates, the increased utilization of central venous catheters (CVC), and a much greater awareness of VTE and the associated risk factors in this population [3, 6, 8, 9]. The aim of this chapter is to review the congenital and acquired risk factors associated with neonatal TE and to discuss the clinical presentation, diagnosis, and management of this rare complication that has been shown to significantly impact the morbidity and mortality rates of those afflicted [1–3, 8].
As the pathophysiology of Covid-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.
Results
During the first wave of the Covid-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status.
Conclusion
Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with Covid-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.
Although we commonly work with patients with emotionally unstable personality disorder (EUPD) in community mental health teams (CMHTs), only some enter evidence-based psychological therapies. Many patients are not considered ready to engage in specialist treatments and remain in CMHTs without any clear focus or structure to their treatment, which is unsatisfactory for patients, clinicians and services. We present a fictional case and synthesise available literature and lived experience to explore readiness and ways to promote it. We highlight relevant issues for trainees to consider in practice. Patients with EUPD who have not received specialist treatment can be considered in terms of the transtheoretical model's stages of change. Identifying a patient's stage can help guide how to increase readiness for referral and decide when to refer. Interventions available to all healthcare professionals which may promote readiness include: psychoeducation, personal formulations, crisis planning, goal-setting, peer support, distress tolerance skills, motivational interviewing and mindfulness.
Tourniquets (TQs) save lives. Although military-approved TQs appear more effective than improvised TQs in controlling exsanguinating extremity hemorrhage, their bulk may preclude every day carry (EDC) by civilian lay-providers, limiting availability during emergencies.
Study Objective:
The purpose of the current study was to compare the efficacy of three novel commercial TQ designs to a military-approved TQ.
Methods:
Nine Emergency Medicine residents evaluated four different TQ designs: Gen 7 Combat Application Tourniquet (CAT7; control), Stretch Wrap and Tuck Tourniquet (SWAT-T), Gen 2 Rapid Application Tourniquet System (RATS), and Tourni-Key (TK). Popliteal artery flow cessation was determined using a ZONARE ZS3 ultrasound. Steady state maximal generated force was measured for 30 seconds with a thin-film force sensor.
Results:
Success rates for distal arterial flow cessation were 89% CAT7; 67% SWAT-T; 89% RATS; and 78% TK (H 0.89; P = .83). Mean (SD) application times were 10.4 (SD = 1.7) seconds CAT7; 23.1 (SD = 9.0) seconds SWAT-T; 11.1 (SD = 3.8) seconds RATS; and 20.0 (SD = 7.1) seconds TK (F 9.71; P <.001). Steady state maximal forces were 29.9 (SD = 1.2) N CAT7; 23.4 (SD = 0.8) N SWAT-T; 33.0 (SD = 1.3) N RATS; and 41.9 (SD = 1.3) N TK.
Conclusion:
All novel TQ systems were non-inferior to the military-approved CAT7. Mean application times were less than 30 seconds for all four designs. The size of these novel TQs may make them more conducive to lay-provider EDC, thereby increasing community resiliency and improving the response to high-threat events.
This book has examined three case studies of policy areas in which it is possible to observe dynamics of hyper-active governance. In each area, politicians must manage the dual demands of relying upon ‘independent’ experts in delegated agencies – what Alasdair Roberts (2011) called the ‘logic of discipline’ – with a wish to impose democratically legitimated state authority – a ‘logic of democracy’. This tension is constantly managed, and the international analysis of developments in each policy area and process-tracing cases identify the distinctive dynamics in each area. These were summed up in terms of three styles: defence (the protection of expert independence), empowerment (the provision of resources to experts to tackle policy problems) and inclusion (the reform of agencies to include diverse stakeholders and conceptions of expertise). This chapter looks at how these styles can be distinguished more clearly from one another. In particular, it argues that the ‘defence’ style can operate alongside the ‘empowerment’ and ‘inclusion’ styles, both in the institutional design of agencies and how they work in practice.
This chapter looks empirically at the field of health technology assessment (HTA) and argues that it is possible to identify the ‘defence’ style of hyper-active governance posited in the previous chapter. HTA is the crucial expert policy area, involving deciding which drugs and other medical treatments are safe and cost-effective to be prescribed by a local doctor or hospital. HTA has been described by international organisations promoting its use as ‘the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decision making regarding health technologies’ (www.inahta.org). It is a process for making delicate decisions about whether a country will fund a medicine, often based on variants of cost–benefit analysis. In this sense, HTA is a classic arena of expert governance: it is the attempt to turn highly emotive decisions about life and death – about who gets access to new potentially life saving drugs and medical treatments – into rational, evidence-based questions of medical science.
In October 2016, The Guardian published a story about what it called ‘The Cult of the Expert’, which had dominated the first decade of the twenty-first century (Mallaby, 2016). Following the global financial crisis, the chair of the US Federal Bank, Ben Bernanke, was asked by a congressional committee whether he had $85 billion to inject into the economy. ‘I have $800 billion’, he replied. ‘Somehow’, the Guardian noted, ‘America’s famous apparatus of democratic checks and balances did not apply to the monetary priesthood. Their authority derived from technocratic virtuosity’. Scholars have noted since the 1990s how political issues have tended to be put in the hands of so-called experts; scientists, lawyers, clinicians, economists and the like (Fischer, 1990; Barker and Peters, 1993; Hoppe, 1999; Maasen and Weingart, 2006). As political scientist Alasdair Roberts argued in his evocative 2011 book The Logic of Discipline, ‘the pervading sense was that liberal democracies lacked the capacity to make hard choices and that mechanisms were necessary to force those choices or empower technocrat-guardians who would make them on society’s behalf’ (Roberts, 2011, p. 144). Following the fall of the Soviet Union and the rise of Francis Fukuyama’s famously flawed ‘End of History’ thesis, ‘by the turn of the 21st century, a new elite consensus had emerged: democracy had to be managed’ (Mallaby, 2016).
This book has shown that experts widely assumed to have been given much autonomy over governance over the past three decades are in fact intimately linked to the state. Governments defend them from public attack (see Chapter 3), empower them with more resources to fight crises (Chapter 4) and include a wider range of ‘experts’ in their working (Chapter 5). Successful areas of public policy widely claimed to be the domain of experts – monetary policy and electoral administration specifically – are designed to be closely connected with, and steered by, public authorities. This chapter turns to the theoretical implications of this argument and, in particular, delves deeper into explaining the ‘pathological’ aspects of the case studies, noted in Chapters 3–5.
This chapter looks empirically at the field of health technology assessment (HTA) and argues that it is possible to identify the ‘defence’ style of hyper-active governance posited in the previous chapter. HTA is the crucial expert policy area, involving deciding which drugs and other medical treatments are safe and cost-effective to be prescribed by a local doctor or hospital. HTA has been described by international organisations promoting its use as ‘the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decision making regarding health technologies’ (www.inahta.org). It is a process for making delicate decisions about whether a country will fund a medicine, often based on variants of cost–benefit analysis. In this sense, HTA is a classic arena of expert governance: it is the attempt to turn highly emotive decisions about life and death – about who gets access to new potentially life saving drugs and medical treatments – into rational, evidence-based questions of medical science.