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Our aim: To reduce the number of Level 1* violent incidents in Ward 4 by 30% by April 2020
*Level 1 is defined as “Behaviour involving force, which causes or is intended to cause physical harm to others; but excludes assault on objects, threats or verbal abuse”
Ward 4 is Belfast Health and Social Care Trust's only PICU, with a total of 6 beds. Our project took place on the background of a recent move to a new purpose-built inpatient unit, as well as a trust-wide initiative to address levels of violence across inpatient psychiatry services.
We divided our project into 3 main areas:
We identified and implemented a number of change ideas, using Plan-Do-Study- Act methodology, regularly meeting to review progress and plotting our data on a run chart.
Key patient interventions included a “Mutual Respect” exercise and regular “Community Meetings”.
Staff interventions included use of Safety Crosses, Daily Safety Briefings and the Broset Violence Checklist (BVC).
Environmental factors were continually assessed and escalated as appropriate.
We raised awareness of our project and gained feedback by creating a dedicated notice board, providing a staff information session and including it as an agenda item at ward meetings.
Our project measures were identified as:
Outcome: Number of level 1 violent incidents occurring per week
Balancing: Number of incidents in other categories; Patient satisfaction
Process: Staff safety rating; Engagement with interventions
Unfortunately, we were unable to meet our initial goal and there continued to be considerable variation in the number of weekly incidents.
We believe this was attributable to several factors, including the level of acuity within the ward during the project timeframe. It was noted that a relatively small number of patients contributed to a large proportion of the total incidents. Our results, therefore, did not reflect the success of interventions with other patients on the ward.
Despite this, we noted improvements in terms of patient and staff engagement with the project, including subjective reports of staff safety during shifts.
The unpredictable and complex nature of the PICU setting cannot be under-estimated and this ultimately impacted on achieving our intended outcome.
We do feel, however, that the project has had a positive impact and we hope we can build on this progress over the coming months.
Further interventions are being explored, including personalised daily activity schedules and attempts to reduce levels of continuous observations.
Food security status is a continuum ranging from high to very low food security. While marginal food security falls next to high food security on the spectrum, new quantitative research indicates marginal food security status is associated with negative health outcomes and poor academic performance among college students. Qualitative research focusing on college students experiencing marginal food security has not been conducted. The current study aims to qualitatively explore experiences of college students with marginal food security and to identify themes to better understand and provide context regarding how marginal food security impacts students.
Students were recruited for semi-structured interviews with questions designed to study the challenges associated with students’ food situations. All interviews were recorded and transcribed with themes identified via an inductive approach.
A large public university on the US west coast.
Thirty college students.
Key themes that emerged: purchasing cheap unhealthy foods, insufficient time to prepare and eat meals on a regular basis, stress and anxiety around the inability to eat healthy food and future health issues, self-perception of health when eating poorly along with physical symptoms and low academic motivation by not fully participating in their courses due to few healthy food options or missing meals.
Marginal food security can potentially diminish students’ health and their capacity to learn and succeed in their coursework. The results emphasise that students experiencing marginal food security should not be grouped with students experiencing high food security.
A large amount of literature surrounds the differences between dissociative neurological symptom disorder with non-epileptic seizures (DNSD-S) and epilepsy.
To explore the research gap on phenotypic differences between DNSD-S and other psychiatric disorders.
We conducted a case–control study of 1860 patients (620 patients with DNSD-S and 1240 controls with other psychiatric disorders) seen at the South London and Maudsley Hospital NHS Trust between 2007 and 2019.
Compared with the controls, the patients with DNSD-S were more likely to be female (76 v. 47%, P < 0.001), of White ethnicity (77 v. 60%, P < 0.001), married (34 v. 14%, P < 0.001) and living in areas of lower socioeconomic status (−3.79, 95% CI −2.62 to −4.96, P < 0.001). Two peaks for age at diagnosis were observed for DNSD-S: the early 20s and late 40s. After 31 years of age, men's chance of being diagnosed with DNSD-S increased from 19 to 28% (P = 0.009). People with DNSD-S presented more commonly with a history of a neurological episodic or paroxysmal disorder (OR = 12, 95% CI 7.82–20.26), another dissociative disorder (OR = 10, 95% CI 1.64– 65.95) or unclassified signs or symptoms (OR = 4, 95% CI 2.61–6.43). Neither anxiety, depression nor other somatoform disorders predicted subsequent diagnosis of DNSD-S, and controls had a larger proportion of preceding psychiatric diagnoses than patients with DNSD-S (65 v. 49%, P < 0.001).
This is the first study comparing demographic and phenotypic correlates of patients with DNSD-S against a large cohort of psychiatric patients. These data will inform development and drive service needs in psychiatry for people with DNSD-S.
This chapter studies the four branches of the Athenian armed forces. For each branch, it discusses the legal and social positions of branch members, the means by which they were recruited and called up, and the history and the organization of their branch.
Patients with depression are more susceptible to cardiovascular illness including vascular surgeries. However, health outcomes after vascular surgery among patients with depression is unknown. This study aimed to investigate associations of depression with post-operative health outcomes for vascular surgical patients.
A retrospective observational study was conducted using data from a large mental healthcare provider and linked national hospitalization data for the same south London geographic catchment. OPCS-4 codes were used to identify vascular procedures. Health outcomes were compared between those with/without depression including length of hospital stay (LOS), inpatient mortality, and 30 day emergency hospital readmissions. Predictors of these health outcomes were also assessed.
Vascular surgery was received by 9,267 patients, including 446 diagnosed with depression. Patients with depression had a higher risk of emergency admission for vascular surgery (odds ratio [OR] 1.28; 1.03, 1.59), longer index LOS (IRR 1.38; 1.33–1.42), and a higher risk of 30-day emergency readmission (OR 1.82; 1.35–2.47). Patients with depression had higher inpatient mortality after adjustment for sociodemographic status (1.51; 1.03, 2.23) but not on full adjustment, and had longer emergency readmission LOS (1.13; 1.04, 1.22) after adjustment for sociodemographic factors and cardiovascular disease. Correlates of vascular surgery hospitalization among patients with depression included admission through emergency route for longer LOS, inpatient mortality, and 30-day hospital readmission.
Patients with depression undergoing vascular surgery have substantially poorer health outcomes. Screening for depression prior to surgery might be indicated to target preventative measures.
The Rapid ASKAP Continuum Survey (RACS) is the first large-area survey to be conducted with the full 36-antenna Australian Square Kilometre Array Pathfinder (ASKAP) telescope. RACS will provide a shallow model of the ASKAP sky that will aid the calibration of future deep ASKAP surveys. RACS will cover the whole sky visible from the ASKAP site in Western Australia and will cover the full ASKAP band of 700–1800 MHz. The RACS images are generally deeper than the existing NRAO VLA Sky Survey and Sydney University Molonglo Sky Survey radio surveys and have better spatial resolution. All RACS survey products will be public, including radio images (with
15 arcsec resolution) and catalogues of about three million source components with spectral index and polarisation information. In this paper, we present a description of the RACS survey and the first data release of 903 images covering the sky south of declination
made over a 288-MHz band centred at 887.5 MHz.
This chapter explores two influential conceptions of the role of common sense in philosophical theorizing from early analytical philosophy, due to G. E. Moore and Ludwig Wittgenstein. Both approaches set out an important function for our everyday certainties to play in the epistemological enterprise, albeit in very different ways. For Moore, our common-sense certainties serve as a kind of reasonable stopping point in philosophical disputes. In particular, where common sense confronts philosophical theory, we can reasonably side with common sense. While Moore claims that our common-sense certainties have an epistemic weight simply in virtue of being common-sense certainties, for Wittgenstein the certainty that attaches to these commitments entails that they have no rational status at all. Nonetheless, this doesn’t prevent them from having a crucial import to epistemological questions. By setting these two philosophical approaches side by side, we gain an important perspective on how common sense might be appealed to in philosophical theorizing.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting.
We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24–36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression.
There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2–7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7–13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4–7.9; p < 0.0001).
In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.
Depression is associated with lower educational attainment, but there has been little investigation of long-term educational trajectories in large cohorts with diagnosed depression.
To describe the educational attainment trajectories of children with a depression diagnosis in secondary care, and to investigate whether these trajectories vary by sociodemographic characteristics.
We identified new referrals to South London and Maudsley's NHS Foundation Trust between 2007 and 2013 who received a depression diagnosis at under 18 years old. Linking their health records to the National Pupil Database, we standardised their performance on three assessments (typically undertaken at ages 6–7 years (school Year 2), 10–11 (Year 6) and 15–16 (Year 11)) relative to the local reference population in each academic year. We used mixed models for repeated measures to estimate attainment trajectories.
In our sample of 1492 children, the median age at depression diagnosis was 15 years (interquartile range = 14–16). Their attainment showed a decline between school Years 6 and 11. Attainment was consistently lower among males and those eligible for free school meals. Black ethnic groups also showed lower attainment than White ethnic groups between Years 2 and 6, but showed a less pronounced drop in attainment at Year 11.
Those who receive a depression diagnosis during their school career show a drop in attainment in Year 11. Although this pattern was seen among multiple sociodemographic groups, gender, ethnicity and socioeconomic status predict more vulnerable subgroups within this clinical population who might benefit from additional educational support or more intensive treatment.
Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs.
This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures.
Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system.
Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = −8.099, P < 0.0001).
This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.
Clozapine, an antipsychotic with unique efficacy in treatment-resistant psychosis, is associated with increased susceptibility to infection, including pneumonia.
To investigate associations between clozapine treatment and increased risk of COVID-19 infection in patients with schizophrenia-spectrum disorders who are receiving antipsychotic medications in a geographically defined population in London, UK.
Using information from South London and Maudsley NHS Foundation Trust (SLAM) clinical records, via the Clinical Record Interactive Search system, we identified 6309 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders and were taking antipsychotics at the time of the COVID-19 pandemic onset in the UK. People who were on clozapine treatment were compared with those on any other antipsychotic treatment for risk of contracting COVID-19 between 1 March and 18 May 2020. We tested associations between clozapine treatment and COVID-19 infection, adjusting for gender, age, ethnicity, body mass index (BMI), smoking status and SLAM service use.
Of 6309 participants, 102 tested positive for COVID-19. Individuals who were on clozapine had increased risk of COVID-19 infection compared with those who were on other antipsychotic medication (unadjusted hazard ratio HR = 2.62, 95% CI 1.73–3.96), which was attenuated after adjusting for potential confounders, including clinical contact (adjusted HR = 1.76, 95% CI 1.14–2.72).
These findings provide support for the hypothesis that clozapine treatment is associated with an increased risk of COVID-19 infection. Further research will be needed in other samples to confirm this association. Potential clinical implications are discussed.
Support is canvassed for a new way of approaching some core epistemic issues: anti-risk epistemology. It is explained how anti-risk epistemology differs from anti-luck epistemology by examining some of the subtle (but epistemologically significant) differences between the notions of luck and risk. It is argued that anti-risk epistemology, while essentially an adaption of anti-luck epistemology, can nonetheless resolve some motivational issues that face the latter proposal. In the process, it can provide other important benefits, such as enabling a broader range of epistemic assessments, including capturing the complexity of some important epistemic assessments involving collaborative inquiry. Our ultimate concern, however, is to examine how anti-risk epistemology fits into a wider virtue-theoretic account of knowledge, one that replaces anti-luck virtue epistemology with anti-risk virtue epistemology. As we will see, the latter proposal inherits all the strengths of the former but none of its flaws. It is also better placed to explain why knowledge is never compatible with unsafe belief, and to provide us with a diagnostic handle on the path taken by post-Gettier epistemology.
Four Western countries (Greece, Ireland, Italy and Portugal) with strong Orthodox and Catholic traditions have been associated with the underreporting of death by suicide, and underreported suicides are sometimes found among deaths recorded as ‘undetermined’ or ‘accidental’.
This population-based study tests whether there are any significant difference in patterns of suicides, undetermined deaths and accidental deaths between these four Western countries and 21 predominately Islamic countries.
World Health Organization age-standardised death rates per million population were used to compare suicide rates with combined undetermined death and accidental death (UnD+AccD) rates, from which odds ratios were calculated. Substantial odds ratios (OR > 2.0) were taken as indicative of likely underreporting of suicides. The Islamic countries come from four different historico-cultural regions, described as: less-traditional Islamic countries; former USSR countries; Gulf Arab states; and Middle Eastern and North African countries. χ2-tests were used to determine any significant differences between the Western comparator countries and the Islamic regions.
For the Western comparator countries, the average suicide rate was 66 per million population, the average undetermined death rate 56 per million and the average accidental death rate 58 per million, yielding a suicide:UnD+AccD odds ratio (OR) of 1.73. The average values for the other three groups were as follows. Less-traditional Islamic countries: suicide rate, 31 per million; UnD+AccD rate, 101 per million; suicide:UnD+AccD OR = 3.3. Former USSR countries: suicide rate, 61 per million; UnD+AccD rate, 221 per million; suicide:UnD+AccD OR = 3.6. Gulf Arab states: suicide rate, 10 per million; UnD+AccD rate, 76 per million; suicide:UnD+AccD OR = 8.6. Middle Eastern and North African countries: suicide rate, 6 per million; UnD+AccD rate, 151 per million; suicide:UnD+AccD OR = 25.2. The patterns of these mortalities in the Islamic countries was significantly different from Western comparator countries.
The results indicate underreporting of suicides in Islamic countries. This might inadvertently lead to reduced access to mental health preventive services in both Western and Islamic countries.
Desiccation-tolerant (DT) plant germplasm (i.e. seeds, pollen and spores) survive drying to low moisture contents, when cytoplasm solidifies, forming a glass, and chemical reactions are slowed. DT germplasm may survive for long periods in this state, though inter-specific and intra-specific variation occurs and is not currently explained. Such variability has consequences for agriculture, forestry and biodiversity conservation. Longevity was previously considered in the context of morphological features, cellular constituents or habitat characteristics. We suggest, however, that a biophysical perspective, which considers the molecular organization – or structure – within dried cytoplasm, can provide a more integrated understanding of the fundamental mechanisms that control ageing rates, hence the variation of longevity among species and cell types. Based on biochemical composition and physical–chemical properties of dried materials, we explore three types of the interplay between structural conformations of dried cytoplasm and ageing: (1) cells that lack chlorophyll and contain few storage lipids may exhibit long shelf life, with ageing probably occurring through slow autoxidative processes within the glassy matrix as it relaxes; (2) cells with active chlorophyll may die quickly, possibly because they are prone to oxidative stress promoted by the photosynthetic pigments in the absence of metabolic water and (3) cells that lack chloroplasts but contain high storage lipids may die quickly during storage at −20°C, possibly because lipids crystallize and destabilize the glassy matrix. Understanding the complex variation in structural conformation in space and time may help to design strategies that increase longevity in germplasm with generally poor shelf life.
Introduction: Participation in Global Health (GH) electives can improve resourcefulness, cultural and ethical insight, and personal development. Risks to trainees, hosts and institutions may be minimized through pre-departure and post-elective training. In 2016 such training was mandatory in only 3 Canadian residency programs, however there is no published data specific to Canadian Emergency Medicine (EM) programs. This study sought to identify current GH elective requirements and related perceived gaps among Royal College EM programs. Methods: We conducted two cross-sectional surveys in 2019 (one each for Royal College EM PDs and residents) via email regarding training requirements for GH electives. Additionally, a survey link was distributed in the CAEP EM resident newsletter. We also contacted university PGME and/or global health offices to understand and collate university-wide requirements and resources. Results: Nine PDs responded, with 78% reporting having 1-5 residents participate in GH electives yearly. Many PDs were unsure of the requirements surrounding GH electives; two reported that pre-departure training was required, while none reported requiring post-departure debriefs. Overall, 67% of PDs felt that their residents were moderately prepared for GH electives and 33% felt they were unprepared to some degree. Thirty-three percent believed that improvements should be made to either pre-departure training or both pre- and post-departure training, while 56% were unsure if improvements were needed. Forty-seven out of an estimated 380 residents responded. Thirty-five percent of residents had completed a GH elective during residency. Of residents who participated in a GH elective, only one (6%) reported feeling very prepared; 18 residents (43%) reported there was a need to improve trainings. Residents reported a number of challenges during electives (lack of resources, inadequate supervision, safety issues) and identified priority topics for training. Conclusion: Although EM residents are participating in GH electives, the majority of EM residency programs do not require pre- or post-departure training. Some PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure/post-elective GH training or to encourage EM residents to access university-wide training.
Are restricted Women's Rights, i.e. limited access to family planning, including abortion, associated with Young Women's (YW)(15–24) suicides in two Catholic formal continents, Catholic Western Europe (CWE) and South American Countries (SAC).
WHO female Suicide rates per million (pm) were compared and ratios of YW to Total (All Age Suicides) calculated. To explore possibility that undetermined deaths, categorised as ‘Other-External-Causes of Death’ (OECD), might be a source of under-reported suicides, OECD and suicides are correlated. Each SAC mortality patterns, using chi square test and average CWE rates are compared to determine any differences between the two continents, sharing the same formal religious culture.
Total CWE suicides at 64pm and OECD 15pm were significantly different from SAC suicides 27pm and OECD 24pm rates.
Most SAC YW mortalities were higher than their Total rates, the reverse was true for the majority of CWE.
SAC Average YW to Total suicide ratios were 1.82: 1 compared to 0.54:1 in CWE and SAC YW to Total OECD ratios were 1.09: 1 and amongst the CWE 0.43:1. There were significant positive correlations between suicides and OECD rates for both CWE age bands but non-significant negative correlation for SAC, showing a marked disparity between the two continents.
SAC YW births rates correlated positively and significantly with their OECD rates.
In the majority of SAC patterns of YW suicide and OECD were significantly different from CWE and SAC YW OECD results might well contain more ‘hidden’ suicides possibly linked to restricted Women's Rights.
This study will be controversial as it highlights the continuing link of violent deaths of children and psychiatric disorder and the forgotten/ hidden psychiatric-criminological child protection interface.
We challenge the Child Protection assumption that there is a continuum of neglect into abuse that, at the extremes, leads to the death of a child. The avoidance of such tragedies has become the benchmark of the effectiveness of child protection, reflected in the high profile situations in every Western country.
This has led to a practice culture of fearing the ‘worst case scenario’ with inevitable defensive bureaucratisation, hence the importance of answering the question’who kill children’?
Based upon an analysis of the latest WHO mortality statistics in the 20 Western Countries, we juxtapose All forms of children’s (0–14) mortality against indices of relative poverty i.e. Income Inequalities, and answer the core question from a decade cohort of people who actually killed children,
We show that whilst child neglect is related to poverty, statistically poverty is Not related to child-abuse-related-deaths (CARD).
It will be shown that men with previous convictions for violence pose physical risk to children, followed by psychotic parents. Consequently, assailants’ problems are essentially ‘psychological/ criminological’, rather than socio-economic though poverty always compounds vulnerable situations.
A more accurate risk assessment would enable psychiatric and child protection practitioners to differentiate the neglect and poverty interface from CARD, enabling each discipline to offer an optimal practice intervention earlier and more effectively.