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COVID-19 can spread rapidly in psychiatric inpatient settings. Previous studies have found that patients have a higher risk of hospitalisation and death than adults in the community. The aim of this project was to improve the care of patients with COVID-19 in psychiatric inpatient settings.
A baseline audit was conducted of care COVID-19 patients received in wards that experienced outbreaks in January 2021 in a London Mental Health Trust. Clinical notes were reviewed for management plans, including clear documentation of risk of serious illness, frequency of vitals monitoring, and thresholds for escalation to medical teams.
A new protocol was subsequently developed and implemented at one inpatient unit: “COVID-19: Early Identification of Risk and Management”. This included an adjusted 4C mortality score to determine risk of deterioration, and schedules for observation monitoring based on this outcome. Each schedule specified separate frequencies of monitoring of critical observations (oxygen saturations, respiratory rate) and routine observations, thus minimising unnecessary staff exposure. It prompted venous thromboembolism (VTE) assessment and documentation of escalation criteria.
44 patients were identified across three working age (WAA, n = 29) and two older age (OA, n = 15) adult wards. 7.5% of WAA and 33.3% of OA patients were hospitalised. 20% of OA patients died following a positive test. 58% of patients had a documented management plan for COVID-19, but only 56% mentioned observation frequency, 19% escalation criteria, and 9% risk of serious disease. No patient received a repeat VTE assessment following diagnosis. The audit identified inconsistent approaches to COVID-19 management between wards, and found no relationship between risk of deterioration and frequency of observation monitoring. Following implementation of this protocol, 100% (n = 4) of patients had a robust plan for COVID-19 management, and 100% received a VTE assessment.
The audit supported previous findings that psychiatric inpatients are at risk of serious COVID-19 infection. This highlights an urgent clinical and ethical need to optimise COVID-19 care in psychiatric inpatient settings. The results of this audit suggest that risk factors for severe infection and elements of routine care are not widely understood or implemented by clinical staff. Introducing evidence-based protocols to support clinicians in managing the physical healthcare of these patients may be one way of promoting best practice. The improvement in care observed in the pilot study has resulted in this protocol being rolled out across the Trust in an ongoing quality improvement project.
Objectives: The purpose of this study was to investigate the longitudinal trajectory of self- and informant-subjective cognitive complaints (SCC), and to determine if SCC predict longitudinal changes in objective measures (OM) of cognitive function. Methods: The study included healthy and cognitively normal late middle-aged adults enriched with a family history of AD who were evaluated at up to three visits over a 4-year period. At each visit (Visit 1–3), self- and informant-SCC and OM were evaluated. Linear mixed models were used to determine if the longitudinal rate of change of self- and informant-SCC were associated with demographic variables, depressive symptoms, family history (FH), and apolipoprotein epsilon 4 (APOE4) status. The same modeling approach was used to examine the effect of Visit 1 SCC on longitudinal cognitive change after controlling for the same variables. Results: At Visit 1, more self-SCC were associated with fewer years of education and more depressive symptoms. SCC were also associated with poorer performance on cognitive measures, such that more self-SCC at Visit 1 were associated with poorer performance on memory and executive functioning measures at Visit 1, while more informant-SCC were associated with faster rate of longitudinal decline on a measure of episodic learning and memory. FH and APOE4 status were not associated with SCC. Discussion: Self- and informant-SCC showed an association with OM, albeit over different time frames in our late middle-aged sample. Additional longitudinal follow-up will likely assist in further clarifying these relationships as our sample ages and more pronounced cognitive changes eventually emerge. (JINS, 2017, 23, 617–626)
Objectives: Intraindividual cognitive variability (IICV) has been shown to differentiate between groups with normal cognition, mild cognitive impairment (MCI), and dementia. This study examined whether baseline IICV predicted subsequent mild to moderate cognitive impairment in a cognitively normal baseline sample. Methods: Participants with 4 waves of cognitive assessment were drawn from the Wisconsin Registry for Alzheimer’s Prevention (WRAP; n=684; 53.6(6.6) baseline age; 9.1(1.0) years follow-up; 70% female; 74.6% parental history of Alzheimer’s disease). The primary outcome was Wave 4 cognitive status (“cognitively normal” vs. “impaired”) determined by consensus conference; “impaired” included early MCI (n=109), clinical MCI (n=11), or dementia (n=1). Primary predictors included two IICV variables, each based on the standard deviation of a set of scores: “6 Factor IICV” and “4 Test IICV”. Each IICV variable was tested in a series of logistic regression models to determine whether IICV predicted cognitive status. In exploratory analyses, distribution-based cutoffs incorporating memory, executive function, and IICV patterns were used to create and test an MCI risk variable. Results: Results were similar for the IICV variables: higher IICV was associated with greater risk of subsequent impairment after covariate adjustment. After adjusting for memory and executive functioning scores contributing to IICV, IICV was not significant. The MCI risk variable also predicted risk of impairment. Conclusions: While IICV in middle-age predicts subsequent impairment, it is a weaker risk indicator than the memory and executive function scores contributing to its calculation. Exploratory analyses suggest potential to incorporate IICV patterns into risk assessment in clinical settings. (JINS, 2016, 22, 1016–1025)
For a well-read medieval monk, as Guillaume de Deguileville must have been, remembering what he read involved memory techniques centered on the visualization of unusual, if not bizarre and startling, scenes and figures. Thus, as a writer who wanted his writing to be remembered, Deguileville conveyed the content of his three Pèlerinages through vivid and detailed descriptions of unusual figures and scenes, including interactions between personifications and biblical characters, which beg for visualization. Apparently unwilling to rely entirely on the reader's ability to create these memory-images in the imagination, the author himself planned for some illustrations, though we cannot know whether he devised complete programs of miniatures or supervised the production of any illustrated manuscripts. Each of his three French pilgrimage poems appeared individually with illustrations, but manuscripts that collect all three Pèlerinages include some of the most ambitious programs of illustration. It is as if the desire for uniformity stimulated designers and artists to continue the dense level of visualization frequently found in manuscripts of the PVH into the other two poems. Images, in fact, provide the most striking evidence for the high level of familiarity with Deguileville's three Pèlerinages from the late fourteenth to mid-fifteenth centuries: in the book of hours known as the Hours of Isabella Stuart (Cambridge, Fitzwilliam Museum MS 62), picture cycles for each of the poems – in the unusual sequence PJC, PVH, PA – accompany not Deguileville's poems but the familiar cycle of texts found in this personal book of hours, an indication that the images alone enabled readers to recall the poems.
As Fabienne Pomel's contribution to this volume demonstrates vividly, Deguileville's corpus reads like nothing so much as a collection of legal documents. The saga of Deguileville's poetic persona. Here distinguished by the Latinized name Guillermus de Deguilevilla, resembles a case file; both narrator and author are put on trial repeatedly, and poetic and juridical authority are closely related. Two instances of judgment stand out in particular, found respectively in PVH2 and in PA. First, in PVH2. Guillermus loses a judgment aboard the Ship of Religion, from which he is exiled as a result and deprived of his good name. Because of the poet's insistence on the (pseudo-) autobiographical nature of the episode, modern scholars have usually seen in it a reflection of Deguileville's own legal troubles, presumably at the hands of fellow monks at Chaalis. And because Deguileville linked this affair to the high-profile literary scandals of other authors – namely, Abelard and Ovid – it is plausible that he suffered for something he wrote. If so, this would doubtless have been the earlier PVH1, which the 1355 version (PVH2) was destined to correct and supplement.
The Castillian prose translation of PVH1, El pelegrino de la vida humana, underwent a number of transformations before even appearing in the workshop of Henrico Mayer Aleman in Toulouse, where it was eventually printed in 1490. The Spanish version is based on a French printed prose adaptation of PVH1, produced in Lyon by Mathis Husz in 1485 and reprinted in 1486, itself based on an anonymous prose adaptation of PVH1 produced for Jeanne de Laval in Angers in 1465. The translator is identified in Mayer's print as Vinçente de Maçuelo, who appears to have had close connections with the Dominican order and the university of Toulouse on the one hand, and with the Royal family of Castile and Aragon on the other. Indeed, a copy of Mayer's print was acquired by the Royal Family in 1492, presumably for the spiritual education of the young Prince John, whose training was entrusted to a fellow Dominican, Diego de Deza. The connections between Mayer, Maçuelo, the Dominican order and the Royal Family thus provide the main context for the reception of this work in Spain. Mayer's print also lends the text a more militant, combative tone, notably with the addition of a full-page frontispiece woodcut showing a hybrid figure of a pilgrim-knight. This addition may have heightened the book's appeal for an aristocratic readership, allowing the volume to serve as a ‘mirror for princes’ within the court.
This essay discusses how Croatian Renaissance literature reflects the influence of Deguileville's allegory of human life as a pilgrimage, looking in particular for possible borrowings from PVH. uncovering intertextual relations, this study also sheds light on how medieval poetic paradigms permeated Renaissance literature, bringing into focus dynamic continuities amid the shifting historical, cultural and linguistic contexts of Europe in this era. Croatia's position – suspended between Byzantine (Greek) and western (Latin) influence – invites us to look beyond traditional geographic boundaries as well as across the conceptual division of the ‘Middle Ages’ from the ‘Renaissance’. The openness of this literature to different forms of cultural translation is further enhanced by the linguistic complexities of late medieval Croatian culture, which is both trilingual (Latin, Croatian and Old Slavic languages) and triliterate (relying on Glagolitic, Cyrilic and Roman script).
Croatia's geographical position at the crossroads of Central Europe and the Mediterranean determined its role as an intermediary between the two large cultural arenas. During the fourteenth century, Croatian literature became increasingly receptive to the influence of western literature; in the fifteenth century, this influence became dominant, significantly contributing to the development of Croatian Renaissance culture. The fourteenth century – often considered the golden age of Croatian political history and court culture – witnessed the ascent of the French Angevin dynasty, the Capetian House of Anjou, to the Croatian-Hungarian throne (1301–1409).
Readers of the Pèlerinages encounter multiple embedded texts, presented as autonomous lyrics, letters, documents and prayers; such text disrupts the flow of the allegorical narrative on both a formal and a conceptual level, inviting readers to reflect on the authority of the allegorical narrative itself. These disruptions are marked in varied ways: shifts in metre, rhyme, or language; narrative presentation emphasising the material forms or extraneous uses of lyrics or prayers; even the use of acrostics that literally disrupt the linearity of the reading experience.
All these embedded texts identify specific speakers and/or addressees in a manner that suggests analogies with both medieval epistolary convention and judicial practice. Such formalised textual exchanges are characterised by an asymmetrical communication between different levels of authority, participating in a vertical system of exchange. In the case of the Pèlerinages, these texts also reciprocally connect different levels of reality, enabling a two-way system of communication between ordinary human agents and representatives of divine authority, absent or present. This creative emulation of epistolary and judicial models invites readers to explore the performative value of authorised speech and authorised text. Embedded text functions at once as language, as event and as object: it can be manifested as verbal performance and can also take on the material form of scrolls and letters, handled and exchanged within the narrative, thus intervening in the action of the poem.