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The COVID-19 pandemic forced the rapid implementation of changes to practice in mental health services, in particular transitions of care. Care transitions pose a particular threat to patient safety.
This study aimed to understand the perspectives of different stakeholders about the impact of temporary changes in practice and policy of mental health transitions as a result of coronavirus disease 2019 (COVID-19) on perceived healthcare quality and safety.
Thirty-four participants were interviewed about quality and safety in mental health transitions during May and June 2020 (the end of the first UK national lockdown). Semi-structured remote interviews were conducted to generate in-depth information pertaining to various stakeholders (patients, carers, healthcare professionals and key informants). Results were analysed thematically.
The qualitative data highlighted six overarching themes in relation to practice changes: (a) technology-enabled communication; (b) discharge planning and readiness; (c) community support and follow-up; (d) admissions; (e) adapting to new policy and guidelines; (f) health worker safety and well-being. The COVID-19 pandemic exacerbated some quality and safety concerns such as tensions between teams, reduced support in the community and increased threshold for admissions. Also, several improvement interventions previously recommended in the literature, were implemented locally.
The practice of mental health transitions has transformed during the COVID-19 pandemic, affecting quality and safety. National policies concerning mental health transitions should concentrate on converting the mostly local and temporary positive changes into sustainable service quality improvements and applying systematic corrective policies to prevent exacerbations of previous quality and safety concerns.
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.
Ecosystem modeling, a pillar of the systems ecology paradigm (SEP), addresses questions such as, how much carbon and nitrogen are cycled within ecological sites, landscapes, or indeed the earth system? Or how are human activities modifying these flows? Modeling, when coupled with field and laboratory studies, represents the essence of the SEP in that they embody accumulated knowledge and generate hypotheses to test understanding of ecosystem processes and behavior. Initially, ecosystem models were primarily used to improve our understanding about how biophysical aspects of ecosystems operate. However, current ecosystem models are widely used to make accurate predictions about how large-scale phenomena such as climate change and management practices impact ecosystem dynamics and assess potential effects of these changes on economic activity and policy making. In sum, ecosystem models embedded in the SEP remain our best mechanism to integrate diverse types of knowledge regarding how the earth system functions and to make quantitative predictions that can be confronted with observations of reality. Modeling efforts discussed are the Century ecosystem model, DayCent ecosystem model, Grassland Ecosystem Model ELM, food web models, Savanna model, agent-based and coupled systems modeling, and Bayesian modeling.
It is commonly thought that disability is a harm or “bad difference” because having a disability restricts valuable options in life. In his recent essay “Disability, Options and Well-Being,” Thomas Crawley offers a novel defense of this style of reasoning (formulated as the Options Argument) and argues that we and like-minded critics of this brand of argument are guilty of an inconsistency. Our aim in this article is to explain why our view avoids inconsistency, to challenge Crawley's positive defense of the Options Argument, and to suggest that this general line of reasoning employs a double standard.
Non-typhoidal Salmonella (NTS) serovars, sequences types and antimicrobial susceptibility profiles have specific associations with animal and human infections in Vietnam. Antimicrobial resistance may have an effect on the manifestation of human NTS infections, with isolates from asymptomatic individuals being more susceptible to antimicrobials than those associated with animals and human diarrhoea.
Infants with prenatally diagnosed CHD are at high risk for adverse outcomes owing to multiple physiologic and psychosocial factors. Lack of immediate physical postnatal contact because of rapid initiation of medical therapy impairs maternal–infant bonding. On the basis of expected physiology, maternal–infant bonding may be safe for select cardiac diagnoses.
This is a single-centre study to assess safety of maternal–infant bonding in prenatal CHD.
In total, 157 fetuses with prenatally diagnosed CHD were reviewed. On the basis of cardiac diagnosis, 91 fetuses (58%) were prenatally approved for bonding and successfully bonded, 38 fetuses (24%) were prenatally approved but deemed not suitable for bonding at delivery, and 28 (18%) were not prenatally approved to bond. There were no complications attributable to bonding. Those who successfully bonded were larger in weight (3.26 versus 2.6 kg, p<0.001) and at later gestation (39 versus 38 weeks, p<0.001). Those unsuccessful at bonding were more likely to have been delivered via Caesarean section (74 versus 49%, p=0.011) and have additional non-cardiac diagnoses (53 versus 29%, p=0.014). There was no significant difference regarding the need for cardiac intervention before hospital discharge. Infants who bonded had shorter hospital (7 versus 26 days, p=0.02) and ICU lengths of stay (5 versus 23 days, p=0.002) and higher survival (98 versus 76%, p<0.001).
Fetal echocardiography combined with a structured bonding programme can permit mothers and infants with select types of CHD to successfully bond before ICU admission and intervention.
We present an interesting and rare case of traumatic Gerbode ventricular septal defect and complete heart block. The multimodality images illustrate the diagnosis well. This case is an excellent demonstration of the diagnostic utility of multimodality imaging.
Fontan survivors have depressed cardiac index that worsens over time. Serum biomarker measurement is minimally invasive, rapid, widely available, and may be useful for serial monitoring. The purpose of this study was to identify biomarkers that correlate with lower cardiac index in Fontan patients.
Methods and results
This study was a multi-centre case series assessing the correlations between biomarkers and cardiac magnetic resonance-derived cardiac index in Fontan patients ⩾6 years of age with biochemical and haematopoietic biomarkers obtained ±12 months from cardiac magnetic resonance. Medical history and biomarker values were obtained by chart review. Spearman’s Rank correlation assessed associations between biomarker z-scores and cardiac index. Biomarkers with significant correlations had receiver operating characteristic curves and area under the curve estimated. In total, 97 cardiac magnetic resonances in 87 patients met inclusion criteria: median age at cardiac magnetic resonance was 15 (6–33) years. Significant correlations were found between cardiac index and total alkaline phosphatase (−0.26, p=0.04), estimated creatinine clearance (0.26, p=0.02), and mean corpuscular volume (−0.32, p<0.01). Area under the curve for the three individual biomarkers was 0.63–0.69. Area under the curve for the three-biomarker panel was 0.75. Comparison of cardiac index above and below the receiver operating characteristic curve-identified cut-off points revealed significant differences for each biomarker (p<0.01) and for the composite panel [median cardiac index for higher-risk group=2.17 L/minute/m2 versus lower-risk group=2.96 L/minute/m2, (p<0.01)].
Higher total alkaline phosphatase and mean corpuscular volume as well as lower estimated creatinine clearance identify Fontan patients with lower cardiac index. Using biomarkers to monitor haemodynamics and organ-specific effects warrants prospective investigation.
This short piece highlights a current spurt in queer researcher–practitioners doing practice as research (PaR) in higher education and explores potential reasons why PaR is so vital, appealing, useful and strategic for queer research. As a starting point, we offer the idea of messiness and messing things up as a way of describing the methods of PaR. Queer mess is to do with asserting the value and pleasure of formations of knowledge that sit outside long-standing institutional hierarchies of research. The latter places what Robin Nelson calls ‘hard knowledge’ above tacit, quotidian, haptic and embodied knowledge. The methodological and philosophical impulses of PaR make space for a range of research methods inherently bound up with the researcher as an individual and the materiality of lived experience within research. Yet, in our experience, although each PaR project is individual, PaR projects follow certain shared modes evolving largely from embodied and heuristic research methods adapted from social sciences, such as (auto)ethnography, participant observation, phenomenology and action research. PaR methodology in theatre and performance is composed of a bricolage of these openly embodied methods, which makes PaR, as an embodied resistance to sanitary boundaries, somewhat queer in academic terms already. It is unsurprising, then, that PaR is so attractive to queer practitioner–researchers bent on queering normative hierarchies of knowledge.
Between 1270 and 1870 Britain slowly progressed from the periphery of the European economy to centre-stage of an integrated world economy. In the process it escaped from Malthusian constraints and by the eighteenth century had successfully reconciled rising population with rising living standards. This final chapter reflects upon this protracted but profound economic transformation from the perspective of the national income estimates assembled in Part I and analysed in Part II of this book. Because Britain’s economic rise did not unfold in isolation, account is taken of the broader comparative context provided by the national income reconstructions now available for several other Eurasian countries: Spain from 1282, Italy from 1310 and Holland from 1348, plus Japan from 725, China from 980 and India from 1600. All are output-based estimates but have been derived via a range of alternative approaches according to the nature of the available historical evidence. Several make ingenious use of real wage rates and urbanisation ratios (Malanima, 2011; Álvarez-Nogal and Prados de la Escosura, 2013), two economic indicators often used as surrogates for estimates of GDP per head. Only the GDP estimates for Holland, like these for Britain, have been made the hard way, by summing the weighted value-added outputs of the agricultural, industrial and service sectors and then dividing the results by estimates of total population obtained by reconciling time-series and cross-sectional demographic data. Methodologically, the British and Dutch national income estimates are therefore the most directly comparable. Each is free from overdependence upon any single or narrow range of data series and, instead, they encapsulate variations in the wide range of economic indicators, appropriately weighted in line with their importance in overall economic activity, from which they have been reconstructed.
Agriculture was for long the single largest component of the English and British economies, both in terms of its share of employment and the value of its output. The latter was a function of the amount of land under cultivation, the uses to which it was put, the productivities of crops and animals and their respective prices. The main purpose of this chapter is to describe the methods used to derive the areas under arable and grass and, in particular, the total sown acreage. The crops produced and animals stocked are the subjects of the following chapter. Along the way, it will be demonstrated that claims that the peak arable area in the medieval period may have exceeded 20 million acres (Clark, 2007a: 124) are unrealistic, since, on the best available evidence, the combined total under field crops and fallow could not have been more than 12.75 million acres. In the absence of significant food imports, this limited both the population that could be supported and the supply of kilocalories per head needed for survival. It also shaped the production choices made by agricultural producers.
Comprehensive national agricultural statistics were collected annually from 1866 and provide the starting point for calculating the acreages of arable and grass (Anon, 1968; Coppock, 1984). Together with the tithe files, which provide a precise but incomplete guide to the share of land in each county devoted to arable production during the 1830s (Kain, 1986; Overton, 1986), they are used to provide a nineteenth-century benchmark. The chapter proceeds as follows. After a discussion of the potential agricultural area of England in Section 2.2, Section 2.3 reviews the arable acreage by county from the tithe files of the 1830s and from the agricultural statistics of 1871. Section 2.4 then examines changes in land use between 1290 and 1871, while Section 2.5 presents county-level estimates of the arable acreage in 1290. Section 2.6 provides a further cross-check by examining changes in land use between 1086 and 1290. Finally, Section 2.7 provides estimates of land use for a number of benchmark years between 1270 and 1871.
Economic growth can be either extensive or intensive. Extensive growth arises where more output is produced in line with a growing population but living standards remain constant, while intensive growth arises where more output is produced by each person. In the former case, there is no economic development, as the economy simply reproduces itself on a larger scale: in the latter, living standards rise as the economy goes through a process of economic development. To understand the long-run growth of the British economy reaching back to the thirteenth century therefore requires knowledge of the trajectories followed by both population and GDP. Of particular interest is whether periods of intensive growth, distinguished by rising GDP per head, were accompanied by expanding or contracting population. For it is one thing for living standards to rise during a period of population decline, such as that induced by the recurrent plagues of the second half of the fourteenth century, when survivors found themselves able to add the land and capital of those who had perished to their own stocks, but quite another for living standards and population to rise together, particularly given the emphasis of Malthus  on diminishing returns. Indeed, Kuznets (1966: 34–85) identified simultaneous growth of population and income per head (i.e. the concurrence of intensive and extensive growth) as one of the key features that distinguished modern from pre-industrial economic growth.