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To assess how well MHAS meets the service specification
To ascertain areas of good practice
To examine whether the referral form is being used in an appropriate manner
To elucidate areas of good communication and whether any improvement can be made
Launched in 2012, MHAS is the single point of access service for mental health services for patients aged 16–65 years, with a general practitioner (GP) in Dudley, who are not currently open to secondary care. Assessments are completed by a medic, community psychiatric nurse or jointly. It aims to identify the most appropriate care pathway for patients. This audit was a comprehensive assessment of how effective MHAS is at ensuring patients are adequately triaged.
10 cases from each month between April 2018 and March 2019 were randomly selected from all 980 anonymised MHAS referrals. A proforma was developed based on current practice, previous audits and service specification. A team of four doctors assisted in the data collection and only electronic health records (EHR) were reviewed.
88.3% of referrals were recorded on the EHR. Only 61.7% of referrals used the proforma with the other referrals mostly being in the form of a letter, which often missed out information vital to the triaging process. Only 4.2% of referrals are from Primary Care Mental Health Nurses (PCMHN) with 85.8% arising from GPs. Urgent referrals were not discussed with MHAS via telephone contact in about 60% of cases. The majority of patients had telephone screening completed the same day and were then discussed the next working day at the daily referral meeting. Although a brief summary for the GP was being sent the same day in all cases, over half of the comprehensive assessments were not being sent within the five day timeframe.
All referrals must be uploaded to the EHR and completed using the service's proforma. PCMHNs may be currently under-utilised or effectively doing their jobs at managing mental health patients in primary care. GPs regularly referring via letter require further training and support to use the proforma. The proforma may require simplification to make it easier to complete. The service specification requires review as it makes unrealistic demands of the service. All referrals must be discussed at the daily referral meeting. Further investigation is required to understand why MHAS is struggling to meet timeframes for appointments and letters.
This study aimed to identify a well-fitting and theoretically justified item-level latent factor structure for the Wechsler Memory Scales (WMS)-IV verbal paired associates (VerbalPA) subtest to facilitate the ease and accuracy of score interpretations for patients with lateralized temporal lobe epilepsy (TLE).
Archival data were used from 250 heterogeneous neurosciences patients who were administered the WMS-IV as part of a standard neuropsychological assessment. Three theoretically motivated models for the latent structure of VerbalPA were tested using confirmatory factor analysis. The first model, based on cognitive principles of semantic processing from hub-and-spoke theory, tested whether performance is related to specific semantic features of target words. The second, motivated by the Cattell–Horn–Carroll (CHC) model of cognitive abilities, investigated whether the associative properties of items influence performance. A third, Hybrid model tested whether performance is related to both semantic and associative properties of items. The best-fitting model was tested for diagnostic group effects contrasting the heterogeneous neuroscience patients with subsets of left and right TLE (n = 51, n = 26, respectively) patients.
The Hybrid model was found to have the best fit. Patients with left TLE scored significantly less well than the heterogeneous neurosciences sample on selected semantic factor scores, although the effect size was small.
Future editions of the WMS may consider implementing a semantic scoring structure for the VerbalPA to facilitate test score interpretation. Additionally, these results suggest that principles of hub-and-spoke theory may be integrated into CHC cognitive ability taxonomy.
For the first time in four decades, leading business associations, corporations, and the corporate law and governance community are seriously debating moving beyond shareholder primacy toward some form of ‘stakeholder governance. But the how question unveils significant differences of opinion as well as difficulties. We focus on a pathway that complements the ambition of stakeholder governance, but which current reform proposals have largely overlooked. We draw on practical experience in the field of business and human rights, where leading companies are increasingly embedding human rights due diligence processes into their strategic decision-making. We contend that as human rights due diligence is made mandatory for companies, which it is in a growing number of jurisdictions, including for foreign firms with a significant business presence in them, risks to stakeholders become a material corporate governance issue. That makes it necessary for firms to address stakeholder concerns and to demonstrate that they are, with possible legal consequences for having failed to do where harm occurs. Such changes by themselves may not constitute a full-blown system of multi-fiduciary obligations, but they mark substantial strides on the path toward it, and they are doing it in the relatively near-term.
The Scaling-up Health-Arts Programme: Implementation and Effectiveness Research (SHAPER) project is the world's largest hybrid study on the impact of the arts on mental health embedded into a national healthcare system. This programme, funded by the Wellcome Trust, aims to study the impact and the scalability of the arts as an intervention for mental health. The programme will be delivered by a team of clinicians, research scientists, charities, artists, patients and healthcare professionals in the UK's National Health Service (NHS) and the community, spanning academia, the NHS and the charity sector. SHAPER consists of three studies – Melodies for Mums, Dance for Parkinson's, and Stroke Odysseys – which will recruit over 800 participants, deliver the interventions and draw conclusions on their clinical impact, implementation effectiveness and cost-effectiveness. We hope that this work will inspire organisations and commissioners in the NHS and around the world to expand the remit of social prescribing to include evidence-based arts interventions.
To examine children’s sugar-sweetened beverage (SSB) and water intakes in relation to implemented intervention activities across the social ecological model (SEM) during a multilevel community trial.
Children’s Healthy Living was a multilevel, multicomponent community trial that reduced young child obesity (2013–2015). Baseline and 24-month cross-sectional data were analysed from nine intervention arm communities. Implemented intervention activities targeting reduced SSB and increased water consumption were coded by SEM level (child, caregiver, organisation, community and policy). Child SSB and water intakes were assessed by caregiver-completed 2-day dietary records. Multilevel linear regression models examined associations of changes in beverage intakes with activity frequencies at each SEM level.
US-Affiliated Pacific region.
Children aged 2–8 years (baseline: n 1343; 24 months: n 1158).
On average (± sd), communities implemented 74 ± 39 SSB and 72 ± 40 water activities. More than 90 % of activities targeted both beverages together. Community-level activities (e.g. social marketing campaign) were most common (61 % of total activities), and child-level activities (e.g. sugar counting game) were least common (4 %). SSB activities across SEM levels were not associated with SSB intake changes. Additional community-level water activities were associated with increased water intake (0·62 ml/d/activity; 95 % CI: 0·09, 1·15) and water-for-SSB substitution (operationalised as SSB minus water: –0·88 ml/d/activity; 95 % CI: –1·72, –0·03). Activities implemented at the organization level (e.g. strengthening preschool wellness guidelines) and policy level (e.g. SSB tax advocacy) also suggested greater water-for-SSB substitution (P < 0·10).
Community-level intervention activities were associated with increased water intake, alone and relative to SSB intake, among young children in the Pacific region.
Background: Antimicrobial stewardship (AMS) is recommended in hospital, postacute, and outpatient settings. Transitions of care (TOC) are important in each of these settings; however, AMS efforts during TOC have been limited. Beginning in October 2018, we sequentially implemented a pharmacist-led multidisciplinary review of oral antimicrobial therapy prescribed at hospital discharge from general and specialty medicine wards across a health system. Pharmacists facilitated data input of discharge prescriptions following early identification and collaborative discussion of patients to be discharged on oral antimicrobials The purpose of this study was to evaluate the impact of AMS during TOC. Methods: This project was an IRB-approved stepped-wedge, quasi-experimental study in a 5-hospital health system that included hospitalized adults with skin, urinary, intra-abdominal, and respiratory tract infections who had been discharged from general and specialty wards with oral antimicrobials. Patients with complicated infections, neutropenia, or who were transferred from an outside hospital were excluded. The primary end point was optimization of antimicrobial therapy at time of hospital discharge, defined by correct selection, dose, and duration according to institutional guidance. Outcomes were compared before and after the intervention. Results: In total, 800 patients were included: 400 in the preintervention period and 400 in the postintervention period. Among this cohort, 252 (63%) received the intervention by a pharmacist per protocol during TOC. Patients had similar comorbid conditions before and after the intervention. Preintervention patients were more likely to be discharged from community hospitals. Before the intervention, 36% of discharge regimens were considered optimized, compared to 81.5% after the intervention (P < .001); this difference was largely driven by a reduction in patients receiving a duration of therapy beyond the clinical indication (44.5 vs 10%; P < .001). We observed similar clinical resolution, 30-day readmission, and adverse drug events (ADEs) between the pre- and postintervention periods. Postdischarge antimicrobial duration of therapy was reduced from 4 days (range, 3–5) to 3 days (range, 2–4) (P < .001) Severe ADEs occurred more frequently in the preintervention group (9 vs 3.3%; P = .001), which was driven by isolation of multidrug-resistant pathogens (7 vs 2.5%; P = .003) and Clostridioides difficile (1.8 vs 0.5%; P = .094). Patients who received optimal therapy at discharge were less likely to develop an ADE (aOR, 0.530; 95% CI, 0.363–0.773). Conclusions: Implementation of an AMS TOC protocol reduced antimicrobial days, optimized therapy selection, and reduced duration. This intervention was associated with improved safety without compromise of clinical effectiveness. To increase patient safety, AMS programs should target antimicrobial optimization during TOC.
Funding: This work was completed under CDC contract number 200-2018-02928.
The Eating Assessment in Toddlers FFQ (EAT FFQ) has been shown to have good reliability and comparative validity for ranking nutrient intakes in young children. With the addition of food items (n 4), we aimed to re-assess the validity of the EAT FFQ and estimate calibration factors in a sub-sample of children (n 97) participating in the Growing Up Milk – Lite (GUMLi) randomised control trial (2015–2017). Participants completed the ninety-nine-item GUMLi EAT FFQ and record-assisted 24-h recalls (24HR) on two occasions. Energy and nutrient intakes were assessed at months 9 and 12 post-randomisation and calibration factors calculated to determine predicted estimates from the GUMLi EAT FFQ. Validity was assessed using Pearson correlation coefficients, weighted kappa (κ) and exact quartile categorisation. Calibration was calculated using linear regression models on 24HR, adjusted for sex and treatment group. Nutrient intakes were significantly correlated between the GUMLi EAT FFQ and 24HR at both time points. Energy-adjusted, de-attenuated Pearson correlations ranged from 0·3 (fibre) to 0·8 (Fe) at 9 months and from 0·3 (Ca) to 0·7 (Fe) at 12 months. Weighted κ for the quartiles ranged from 0·2 (Zn) to 0·6 (Fe) at 9 months and from 0·1 (total fat) to 0·5 (Fe) at 12 months. Exact agreement ranged from 30 to 74 %. Calibration factors predicted up to 56 % of the variation in the 24HR at 9 months and 44 % at 12 months. The GUMLi EAT FFQ remained a useful tool for ranking nutrient intakes with similar estimated validity compared with other FFQ used in children under 2 years.
Prescribing metrics, cost, and surrogate markers are often used to describe the value of antimicrobial stewardship (AMS) programs. However, process measures are only indirectly related to clinical outcomes and may not represent the total effect of an intervention. We determined the global impact of a multifaceted AMS initiative for hospitalized adults with common infections.
Single center, quasi-experimental study.
Hospitalized adults with urinary, skin, and respiratory tract infections discharged from family medicine and internal medicine wards before (January 2017–June 2017) and after (January 2018–June 2018) an AMS initiative on a family medicine ward were included. A series of AMS-focused initiatives comprised the development and dissemination of: handheld prescribing tools, AMS positive feedback cases, and academic modules. We compared the effect on an ordinal end point consisting of clinical resolution, adverse drug events, and antimicrobial optimization between the preintervention and postintervention periods.
In total, 256 subjects were included before and after an AMS intervention. Excessive durations of therapy were reduced from 40.3% to 22% (P < .001). Patients without an optimized antimicrobial course were more likely to experience clinical failure (OR, 2.35; 95% CI, 1.17–4.72). The likelihood of a better global outcome was greater in the family medicine intervention arm (62.0%, 95% CI, 59.6–67.1) than in the preintervention family medicine arm.
Collaborative, targeted feedback with prescribing metrics, AMS cases, and education improved global outcomes for hospitalized adults on a family medicine ward.
The aim of this study is to determine the response of home-based primary care programs to the fall 2017 Atlantic hurricane season.
This study examines the experiences of 9 Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) programs in their responses to Hurricanes Harvey, Irma, and Maria. Thirty-four phone interviews with HBPC leadership and staff were conducted from April to July 2018.
The total census of impacted HBPC programs was 3118. No program reported loss of life due to these hurricanes. Early preparedness was key to an effective program response. Response included prompt tracking of the patients. In the most affected areas, respondents noted limited resources to support basic patient needs.
Medically complex patients served by programs such as the VHA’s HBPC program represent a subset of the population, yet they have an outsized impact on health care resources that could be exacerbated by inadequate disaster preparedness. HBPC programs serve a unique role in supporting the “older old.” They are tasked with supporting disaster preparedness activities of patients. Understanding what is involved in actualizing their requirements shows communities how to effectively engage with these programs.
Poor diet and physical inactivity are leading modifiable causes of death and chronic disease. Robust evidence confirms that the Mediterranean diet (MedDiet) reduces mortality and cardiovascular disease risk, and promotes healthy longevity. However, MedDiet interventions are typically resource intensive, requiring regular face-to-face visits, in a one-on-one or small group setting. The rapid growth of Artificial-Intelligence (chatbot) technology has created new possibilities for low-cost, personalised health behaviour programs. We aimed to assess whether a 12-week MedDiet and physical activity intervention delivered entirely via technology (chatbot, website, wrist-worn activity tracker) could result in health behaviour change in 30 adults aged 57 ± 8 years. Volunteers’ height, body weight, waist circumference and blood pressure were measured in clinic at baseline, week 6 and 12. Introduction of the MedDiet and physical activity recommendations were conducted through a website with short videos and written sections assisted by the chatbot. Participants were encouraged to interact with the chatbot program at least weekly for 12-weeks. The MedDiet component of the program was modelled on the MedLey trial, whilst physical activity used step count goal-setting using a Garmin Vivofit 4 wrist-worn tracker. Diet and self-reported physical activity outcomes were measured using the 14-point MedDiet questionnaire and Active Australia Survey. The study achieved 93% retention over the 12-weeks and with excellent user engagement and satisfaction. There was a significant increase in the MedDiet score from 3 ± 3.5 (out of 14) at baseline, to 11 ± 3 at weeks 6 and 12, (p < 0.001). Weekly moderate-to-vigorous physical activity minutes increased from 135 ± 196 at baseline, to 210 ± 233 and 300 ± 433 mins, at weeks 6 and 12, respectively, (p < 0.001). Waist circumference decreased from 99 ± 28 to 98 ± 27 and 96 ± 25 cm, at weeks 6 and 12, respectively, (p < 0.001). BMI decreased from 29 ± 10 to 28 ± 9 at week 6 and 28 ± 10 at week 12 (P < 0.05). There was no change in blood pressure. Our pilot data confirm that the chatbot together with informational website and wearable intervention approach achieved excellent user satisfaction and preliminary efficacy of behaviour change across a 12-week period. Further research employing a randomized-controlled design, and high quality outcome measures is warranted to confirm efficacy and sustainability of behaviour change. However, these early results suggest that this innovative, comprehensive chatbot-based approach may be an appealing and feasible strategy suitable for mass-dissemination to assist dietary and physical activity related behaviour, leading to a widespread reduction in risk factors for chronic disease.
Having established the terms and features of the soul’s journey, our task now is to locate the body within Bonaventure’s soteriology – something which, as I have already explained, Bonaventure’s thirteenth-century context does not compel him to do overtly. While this chapter draws together many well-known threads from Bonaventure’s system, a few components will require constructive development. Very clear in Bonaventure’s corpus is the body’s role as gatherer of sensory data for the soul to contemplate. Also explicit is the notion that human bodies contain a perfect proportion of corporeal elements, and the idea that, as body-soul composites, human beings stand between pure corporeality and uncreated Spirituality, and are tasked with uniting the two through contemplation.
We come now to the central, Christological chapter of this study. We have seen how the self’s failure to contemplate creation disrupts its salvific journey, severing body from soul and abandoning corporeality to an irreversible “dimness.” Now the question begs asking: If in this world corporeality must always bear the marks of abandonment, how is it possible to speak of its redemption? If redemption is possible, what can it look like? How can there be beauty in a body that must die?
We have established the Trinitarian shape of Bonaventure’s soteriology, and some of the key features that mark the self’s pilgrimage to Beauty. Our next two chapters follow the interaction of these themes first through the stages of the soul’s becoming, and next through the ascent of its corresponding body. Bonaventure’s presentation of material makes the distinction necessary. The typically premodern priority he gave to the soul’s capacity to know and love led him to pen several works dedicated explicitly to its ascent, with the Collations on the Six Days reflecting his most mature and complex soteriological vision. Embarking on a close reading of this text in the chapter at hand will allow us to appreciate the organic shape and dynamism of the soul’s journey as Bonaventure himself conceives it. Understanding how the body participates in this journey, for Bonaventure, will take more constructive work in Chapter 3.
In preceding chapters I have proposed that while premodern theologians including Bonaventure have tended to emphasize the body’s rebellion against the soul’s headship when speaking of sin’s effect on the human person, in our own period it may be more helpful to emphasize the soul’s abandonment of the body at the fall, together with the whole corporeal world it represents. Journeying to glory under the aesthetic terms initiated by the fall invites humanity to reclaim the corporeality it estranged when it tried to possess created goods divorced from the whole of uncreated Beauty. But this, as we saw in Chapters 3 and 4, can only occur as believers come to locate their bodily diminishment within the glorified corporeality of the resurrected Christ. Relating to diminishment in this way can enable humans to direct the movement of their bodies toward death in a way that leads to transfiguration. While bouts of perplexity and feelings of bodily estrangement may linger (an experience we can read into the ambiguous relationship Francis maintains with his own body throughout the Major Life, as we shall soon see), Bonaventure’s theological framework can teach believers to encounter the unintelligibility of their bodies and of the whole corporeal world with the same tender care Francis exhibits after receiving counsel from the brother just described: “Cheer up Brother Body, and forgive me,” Francis responds, “for I will now gladly do as you please, and gladly hurry to relieve your complaints!” As the body is reclaimed by the soul in this way, the fractured “parts” of fallen humanity may once again come, in hiddenness, to exercise the beauty of proportion, and to participate in the generative work of the One who leads all things to glory.
It was Eastertide of 1273 that Bonaventure began delivering his final set of lectures, the Collations on the Six Days. He would never finish them. Trained in scholasticism at the university in Paris, Bonaventure was called to serve as Minister General of the young Franciscan order in 1257, and spent the next sixteen years balancing pastoral and administrative responsibilities while his Dominican counterpart in Paris, Thomas Aquinas, busied himself with the Summa. Although Bonaventure’s academic career was cut short, having a base in Paris for the eight years before his death afforded him the opportunity to participate in the university’s intellectual life. There his brilliant mind and clerical concern fused to produce a number of rich theological works, but these particular collations were his crowning achievement. Elected Cardinal on Pentecost of 1273, Bonaventure was once again called away from Paris, and he died a year later at the second Council of Lyon, his masterpiece unfinished.