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Medical assistance in dying (MAiD) (which includes euthanasia and assisted suicide) is available in an increasing number of countries. In Belgium, The Netherlands and Switzerland (and was due to be implemented in Canada from 2024) eligibility includes mental suffering in the absence of any physical disorder. There are particular ethical and legal issues when considering MAiD for those involuntarily detained in prisons and hospitals. We describe four recent cases that illustrate these complexities, and highlight issues of equivalence of healthcare and self-determination against concerns about the criteria for determining eligibility of those with non-terminal conditions as well as the objections raised by victims and families and the demands for justice.
The Minnesota Longitudinal Study of Risk and Adaptation (MLSRA) is a landmark prospective, longitudinal study of human development focused on a sample of mothers experiencing poverty and their firstborn children. Although the MLSRA pioneered a number of important topics in the area of social and emotional development, it began with the more specific goal of examining the antecedents of child maltreatment. From that foundation and for more than 40 years, the study has produced a significant body of research on the origins, sequelae, and measurement of childhood abuse and neglect. The principal objectives of this report are to document the early history of the MLSRA and its contributions to the study of child maltreatment and to review and summarize results from the recently updated childhood abuse and neglect coding of the cohort, with particular emphasis on findings related to adult adjustment. While doing so, we highlight key themes and contributions from Dr Dante Cicchetti’s body of research and developmental psychopathology perspective to the MLSRA, a project launched during his tenure as a graduate student at the University of Minnesota.
Patients with Fontan failure are high-risk candidates for heart transplantation and other advanced therapies. Understanding the outcomes following initial heart failure consultation can help define appropriate timing of referral for advanced heart failure care.
Methods:
This is a survey study of heart failure providers seeing any Fontan patient for initial heart failure care. Part 1 of the survey captured data on clinical characteristics at the time of heart failure consultation, and Part 2, completed 30 days later, captured outcomes (death, transplant evaluation outcome, and other interventions). Patients were classified as “too late” (death or declined for transplant due to being too sick) and/or “care escalation” (ventricular assist device implanted, inotrope initiated, and/or listed for transplant), within 30 days. “Late referral” was defined as those referred too late and/or had care escalation.
Results:
Between 7/2020 and 7/2022, 77 Fontan patients (52% inpatient) had an initial heart failure consultation. Ten per cent were referred too late (6 were too sick for heart transplantation with one subsequent death, and two others died without heart transplantation evaluation, within 30 days), and 36% had care escalation (21 listed ± 5 ventricular assist device implanted ± 6 inotrope initiated). Overall, 42% were late referrals. Heart failure consultation < 1 year after Fontan surgery was strongly associated with late referral (OR 6.2, 95% CI 1.8–21.5, p=0.004).
Conclusions:
Over 40% of Fontan patients seen for an initial heart failure consultation were late referrals, with 10% dying or being declined for transplant within a month of consultation. Earlier referral, particularly for those with heart failure soon after Fontan surgery, should be encouraged.
Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development.
Aims
To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security.
Method
A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire.
Results
Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score.
Conclusions
Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.
Public stigma and fear are heightened in cases of extreme violence perpetrated by persons with serious mental illness (SMI). Prevention efforts require understanding of illness patterns and treatment needs prior to these events unfolding.
Aims
To examine mental health service utilisation by persons who committed homicide and entered into forensic care, to investigate the adequacy of mental healthcare preceding these offences.
Method
Forensic patients across two mental health hospitals in Ontario with an admitting offence of homicide between 2011 and 2021 were identified (n = 112). Sociodemographic, clinical and offence-related variables were coded from the health record and reports prepared for the forensic tribunal.
Results
Most patients (75.7%) had mental health contacts preceding the homicide, with 28.4% having a psychiatric in-patient admission in the year prior. For those with service contacts in the year preceding, 50.9% had had only sporadic contact and 70.7% were non-adherent with prescribed medications. Victims were commonly known to the individual (35.7%) and were often family members in care-providing roles (55.4%). Examination of age at onset of illness and offending patterns suggested that most persons admitted to forensic care for homicide act in the context of illness and exhibit a low frequency of pre-homicide offending.
Conclusions
Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Effective responses to reduce and manage risk should encompass services that proactively address illness-related (e.g. earlier access and better maintenance in care) and criminogenic (e.g. substance use treatment, employment and psychosocial supports) domains.
The COVID pandemic caused an unprecedented public health crisis and adversely impacted children’s well-being. It has negatively affected children’s mental health due to social isolation, human losses, and remote learning. Our goal is to learn about the challenges and factors that these children and young adults face upon returning to school and college, which could further decline their mental health. We also need to understand parents’ concerns about this transition to a back-to-school routine.
Objectives
1) To learn about the mental health challenges for children, adolescents, and young adults returning to school after the beginning of the COVID pandemic.
2) To identify the factors and challenges that parents and caregivers face during the COVID regarding the return of their children to school.
Methods
We conducted a literature search using relevant medical subject heading (MeSH) terms in PubMed, PubMed Central, Web of Science, and Medline databases. We identified all published relevant articles until June 4, 2021. After a thorough review of relevant published articles until October 30, 2022, we included 5 articles in our qualitative synthesis.
Results
A cross-sectional study in China measured depression, anxiety, and social support in back-to-school students via PHQ-9, GAD-7, and SSQ, respectively. They found a significant rise in anxiety and depression among these students. This correlation was weak at higher social support. Data collected from 15 children’s hospitals found that students want to participate actively in returning to school and the recovery process as they are concerned about their future, family, and society. Another 2021 cross-sectional study in Texas revealed that parents are concerned about their children’s health and prefer an onsite-virtual hybrid learning setup over in-person learning (Limbers C. A. et al. The Journal of school health 2021; 91(1), 3–8.). Parents in Italy favored school reopening with reduced student numbers (70.1%), social distancing within classes (45.3%), and masks as they were concerned about their children due to COVID (Pierantoni, L et al. 2021; Acta paediatrica (Oslo, Norway : 1992), 110(3), 942–943 ). Fewer White parents were supportive of a mask mandate for students and staff members (62.5%) than parents of ethnicities like Hispanic (79.5%, p= 0.026) and other racial/ethnic groups (66.9%, p = 0.041) (Gilbert, L. K. et al. MMWR. Morbidity and mortality weekly report 2020; 69(49), 1848–1852).
Conclusions
The return to school after COVID is challenging for students and parents due to the rise in anxiety and depression in children. Social support has been found to be protective of children’s mental health. Future well-designed studies should identify challenges and factors that can help safeguard children’s mental health and develop appropriate policies.
Public health authorities recommend symptom monitoring of healthcare personnel (HCP) after defined exposures to monkeypox. We report on the rapid development and implementation of mobile responsive survey solutions for notification of possible exposure, exposure risk assessment and stratification, and symptom monitoring.
Setting:
An academic health center in Boston, Massachusetts, after admission of first diagnosed case of monkeypox in the United States during the current global outbreak.
Participants:
Research Electronic Data Capture (REDCap) design and programmers, infection control, occupational health, and emergency preparedness specialists, and HCP with possible exposure to monkeypox.
Interventions:
Design and deployment of REDCap tools to identify HCP with possible exposure to monkeypox, to perform exposure risk assessment and stratification for postexposure prophylaxis (PEP), and to conduct symptom monitoring during the exposure window. Project enhancements included dashboards for HCP tracking and short message service (SMS text) reminders for symptom monitoring.
Results:
Tools to support the contact tracing and exposure investigation were deployed within 24 hours of identification of a patient with suspected monkeypox, with the full suite in production within 4 days of confirmation of the monkeypox diagnosis. Clinical follow-up of HCP was integrated into the design, and real-time versioning allowed for improvements in HCP symptom monitoring compliance and enhanced tracking.
Conclusions:
During the current monkeypox outbreak, timely and comprehensive evaluation of potential HCP exposures is necessary but presents logistical challenges. Rapid development of monkeypox-specific solutions using REDCap facilitated flexibility in design and approach, and integration of targeted clinical support enhanced functionality.
Intimate kissing is often viewed as a preliminary or ancillary behaviour in studies exploring sexual interactions. There is a lack of research that focuses on differentiating the types of intimate kisses, including the contexts in which they occur, and desirable and undesirable features. The current study was designed to assess memories of first, best, forbidden and worst kisses. Participants were 691 U.S. adults (mean age 32.27 years; 55% identified as male) who completed an online survey addressing kissing attitudes and experiences using both structured and open-ended survey tools. Four themes emerged through content analysis: physical components, connection to the partner, context, and emotions evoked; and these are discussed for all four types of kissing memories. Findings are discussed in terms of embodiment that intimate kisses capture, their role as a metric of one's attraction to a partner, and the means by which kissing experiences might solidify a sense of oneself as a sexual person.
We assessed whether paternal demographic, anthropometric and clinical factors influence the risk of an infant being born large-for-gestational-age (LGA). We examined the data on 3659 fathers of term offspring (including 662 LGA infants) born to primiparous women from Screening for Pregnancy Endpoints (SCOPE). LGA was defined as birth weight >90th centile as per INTERGROWTH 21st standards, with reference group being infants ⩽90th centile. Associations between paternal factors and likelihood of an LGA infant were examined using univariable and multivariable models. Men who fathered LGA babies were 180 g heavier at birth (P<0.001) and were more likely to have been born macrosomic (P<0.001) than those whose infants were not LGA. Fathers of LGA infants were 2.1 cm taller (P<0.001), 2.8 kg heavier (P<0.001) and had similar body mass index (BMI). In multivariable models, increasing paternal birth weight and height were independently associated with greater odds of having an LGA infant, irrespective of maternal factors. One unit increase in paternal BMI was associated with 2.9% greater odds of having an LGA boy but not girl; however, this association disappeared after adjustment for maternal BMI. There were no associations between paternal demographic factors or clinical history and infant LGA. In conclusion, fathers who were heavier at birth and were taller were more likely to have an LGA infant, but maternal BMI had a dominant influence on LGA.
Bohdanowiczite was first described in 1967 but incomplete data prevented its acceptance as a new mineral at that time. Additional data on the same material now characterize bohdanowiczite as a new species with the formula:
The mineral occurs in intimate intergrowths with clausthalite and wittichenite in polymetallic mineralization at Kletno in Poland. In reflected light bohdanowiczite has a creamy-yellow colour and short polysynthetic twinning is frequently observed. Cell parameters indexed on a hexagonal lattice are a = 4.183±0.008 Å and c = 19.561± 0.016 Å. Pm1 is the most likely space group. The strongest lines of the powder pattern are 2.91(100), 2.03(30), 3.40(20), 6.54(20), 2.09(18), 3.26(18). The calculated density is 7.72 gm/cm3 and the VHN between 63 and 96 kg/mm2.
Empirical studies are incompatible with the proposal that neonatal imitation is arousal driven or declining with age. Nonhuman primate studies reveal a functioning brain mirror system from birth, developmental continuity in imitation and later sociability, and the malleability of neonatal imitation, shaped by the early environment. A narrow focus on arousal effects and reflexes may grossly underestimate neonatal capacities.
Previous research suggests that the experience of abuse and neglect in childhood has negative implications for physical health in adulthood. Using data from the Minnesota Longitudinal Study of Risk and Adaptation (N = 115), the present research examined the predictive significance of childhood physical abuse, sexual abuse, and physical/cognitive neglect for multilevel assessments of physical health at midlife (age 37–39 years), including biomarkers of cardiometabolic risk, self-reports of quality of health, and a number of health problems. Analyses revealed that childhood physical/cognitive neglect, but not physical or sexual abuse, predicted all three health outcomes in middle adulthood, even when controlling for demographic risk factors and adult health maintenance behaviors. We discuss possible explanations for the unique significance of neglect in this study and suggest future research that could clarify previous findings regarding the differential impact of different types of abuse and neglect on adult health.
In 2011, 14 Midwest trial locations evaluated tolerance of an AAD-1 and glyphosate-resistant corn hybrid to a 2,4-D choline+glyphosate premix formulation applied single and sequential POST at V4 and/or V7 corn with and without a PRE application of 2,4-D dimethylamine (DMA). Herbicides were applied at 1X and 2X maximum use rates with 1X rates of 1120 g ae ha−1 for glyphosate and 2,4-D DMA and 1065+1120 g ae ha−1 for the 2,4-D choline+glyphosate premix, respectively. Crop response was greatest 2 d after 2X rate applications, resulting in 4 to 10% visible injury to corn across application timings. No brace root injury or effect on corn grain yield were observed.
As survival after cardiac surgery continues to improve, an increasing number of patients with hypoplastic left heart syndrome are reaching school age and beyond, with growing recognition of the wide range of neurodevelopmental challenges many survivors face. Improvements in fetal detection rates, coupled with advances in fetal ultrasound and MRI imaging, are contributing to a growing body of evidence that abnormal brain architecture is in fact present before birth in hypoplastic left heart syndrome patients, rather than being solely attributable to postnatal factors. We present an overview of the contemporary data on neurodevelopmental outcomes in hypoplastic left heart syndrome, focussing on imaging techniques that are providing greater insight into the nature of disruptions to the fetal circulation, alterations in cerebral blood flow and substrate delivery, disordered brain development, and an increased potential for neurological injury. These susceptibilities are present before any intervention, and are almost certainly substantial contributors to adverse neurodevelopmental outcomes in later childhood. The task now is to determine which subgroups of patients with hypoplastic left heart syndrome are at particular risk of poor neurodevelopmental outcomes and how that risk might be modified. This will allow for more comprehensive counselling for carers, better-informed decision making before birth, and earlier, more tailored provision of neuroprotective strategies and developmental support in the postnatal period.
Competitive micro, small and medium enterprises (MSMEs) are crucial to private sector development in Pacific islands countries (PICs). MSMEs confront significant challenges, however, including pervasive state engagement in markets, high input costs, and difficulty in accessing legal remedies. Competition policy and law have an important role to play in enhancing business conditions for MSMEs in PICs. This chapter examines the setting in which competition policy and law operates in PICs and considers possible directions for their future development in the Pacific region. Conventional conduct prohibitions and penalties are likely to be necessary but not sufficient. Effective competition policy and law must be geared to the particular circumstances and needs of PICs, including the need to facilitate MSME entry to markets that have hitherto been closed to them. The policy and legal responses that suit the circumstances and needs of MSMEs in PICs may have wider applications in small developed economies or economies that are larger but still developing.
Introduction
The governments of most Pacific islands countries (PICs) have embraced private sector development as central to their strategies for economic development. Competitive markets are perceived as essential to such private sector development. Accordingly, the governments of several PICs are taking steps toward implementing competition policies or reviewing their regulatory institutions (ADB 2014a). Economic activity in most PICs is dominated by state-owned enterprises (SOEs) and a handful of multinationals or large privately-owned domestic enterprises. In several PICs, policymakers have been pursuing the corporatization and privatization of SOEs. Typically, there is little competition in the major infrastructure-based industries (telecommunications is an exception) but active competition, at least in urban areas, occurs among smaller scale businesses with lower capital requirements.
Policymakers in PICs, as in other developing economies, are therefore looking to micro, small and medium enterprises (MSMEs) as major drivers of the private sector development that is needed to generate economic growth, create jobs, and alleviate poverty (McIntyre 2001). MSMEs are pivotal to the emergence of competitive markets in PICs but face significant constraints on their ability to compete. While MSMEs in the Pacific bear the substantial weight of development expectations, they are poorly equipped to apprehend the implications of competition laws, obtain independent legal advice, enforce their rights, participate in the policy process, or otherwise advance their legal interests.
It is well established that pregnant women are at an increased risk of Plasmodium falciparum infection when compared to non-pregnant individuals and limited epidemiological data suggest Plasmodium vivax risk also increases with pregnancy. The risk of P. falciparum declines with successive pregnancies due to the acquisition of immunity to pregnancy-specific P. falciparum variants. However, despite similar declines in P. vivax risk with successive pregnancies, there is a paucity of evidence P. vivax-specific immunity. Cross-species immunity, as well as immunological and physiological changes that occur during pregnancy may influence the susceptibility to both P. vivax and P. falciparum. The period following delivery, the postpartum period, is relatively understudied and available epidemiological data suggests that it may also be a period of increased risk of infection to Plasmodium spp. Here we review the literature and directly compare and contrast the epidemiology, clinical pathogenesis and immunological features of P. vivax and P. falciparum in pregnancy, with a particular focus on studies performed in areas co-endemic for both species. Furthermore, we review the intriguing epidemiology literature of both P. falciparum and P. vivax postpartum and relate observations to the growing literature pertaining to malaria immunology in the postpartum period.
There is evidence that headache response rates may be higher if triptans are used early when a migraine attack is still mild, as compared to when it is treated after pain has reached moderate or severe intensity.
Methods:
In this randomized, double blind, placebo controlled, parallel group clinical trial, 361 patients took either placebo, sumatriptan 50 mg, or sumatriptan 100 mg in a single attack study. The primary outcome measure was pain-free status at two hours.
Results:
In the intention to treat group, two hour pain free rates were 16%, 40%, and 50% in the placebo group, sumatriptan 50 mg group, and the sumatriptan 100 mg group respectively (p<0.001, active treatment groups vs. placebo).
Conclusions:
Both sumatriptan 50 mg and 100 mg were significantly superior to placebo for the pain-free end point at two hours. The pain-free response rates in this trial where sumatriptan was taken while the headache was still mild were generally higher than in older clinical trials where headache was treated after reaching a moderate or severe intensity.
Background: Repetitive transcranial magnetic stimulation (rTMS) is a new treatment with promise for resistant depression.
Objective: We tested the economic feasibility of this new method compared with electroconvulsive therapy (ECT).
Method: An economic decision analysis was used to compare the costs of three different treatment strategies for nonpsychotic severe depression. The strategies were: ECT alone; rTMS alone; and rTMS followed by ECT for nonresponders (rTMS-to-ECT). We calculated 12-month costs and quality adjusted life years (QALYs) for the three treatment options for all nonpsychotic, severely depressed United States patients who would have otherwise undergone ECT. A sensitivity analysis was performed to test the degree of change in outcome with various parameter changes.