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The introduction of new legislation in 2006 brought about changes to the way citizenship applications were considered in the UK. Over the intervening years, several hundred children born in the UK have been denied British citizenship as a result of changes to the ‘good character’ requirement in the legislation – namely its extension to cover all those aged 10 years or older applying for citizenship, including individuals who were born in the UK. As a result of the formulaic way in which this requirement is assessed, citizenship can be denied on the basis of historical patterns of behaviour or offending from childhood. This article will consider whether the current approach to assessment of character in the context of applications for British citizenship is meaningful or appropriate, given developments in our understanding of normative psychological and neurological development and also the impact of psychosocial adversity, trauma, and broader psychopathological or neurodevelopmental conditions.
To understand the prescribing habits and trends of clinicians in a large ADHD clinic and the medication journey of patients from point of diagnosis to the point of agreeing a shared care plan with primary care services.
Methods
This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. Following approval by the Clinical Governance body of the practice, in June 2023, all patients with a SCP between the years 2019 and 2021 were identified. Data collected included patient demographics, date that medication was started, discontinued, or switched along with associated reasons. Additionally, to better understand the time taken to gain publication of a SCP, the amount of clinician-patient facing time was recorded, including the number of brief follow-up appointments, number of repeat prescriptions and number of clinician to patient emails. Patient data was fully anonymised and any identifiable data removed.
Results
All but one patient was started on a stimulant medication immediately following diagnosis, in line with national prescribing guidance. Atomoxetine was the medication of choice for a patient with a previous history of stimulant intolerance. 74% (n = 95) of patients were started on lisdexamfetamine, 20% (n = 25) were started on methylphenidate long-acting formulations and five patients on short-acting methylphenidate agent.
Of the 95 patients initiated on lisdexamfetamine, 78 (82.1%) were continued on lisdexamfetamine until the point of publication of their Shared Care Policy (SCP), nine (9.5%) patients switched medication, 10 patients initiated additional fast-acting dexamfetamine tablets and two had a second agent added to their therapy (atomoxetine n = 1, methylphenidate n = 1).
Of 25 patients initiated on methylphenidate long acting, 18 (72%) continued this medication at the point of publication of SCP. Of 25 patients initiated on methylphenidate long acting, seven (28%) patients switched medication and two patients were initiated on an additional fast acting methylphenidate.
To successfully stabilise and publish 134 patients on a SCP, 404 brief follow up appointments of 15-minute duration were utilised, which totals 6060 minutes of patient facing time. Of 134 patients, most n = 41 (30.6%) had 2 brief follow-up appointments; 32 (23.9%) had 3 brief follow up appointments and 22 (16.4%) had 4 appointments. Two patients did not attend a follow up appointment, and one patient had 11 brief follow up appointments.
Conclusion
Stimulant medications were typically used as first line treatment however, of these 74% were started on lisdexamfetamine while only 20% were initiated on long acting methylphenidate. Those started on lisdexamfetamine were more likely to continue on this medication to the point shared care agreement than those started on methylphenidate, 28% of whom switched to an alternative, for a variety of reasons. Mean time to reading a shared care agreement was longer for those initiated on methylphenidate long acting compared to lisdexamfetamine.
The data show that for most patients the journey from initiation of a stimulant medication to a shared care agreement was a straightforward one, with the majority having either two or three follow up appointments.
More research is needed to better understand the apparent differences in pathway for those commenced on lisdexamfetamine and long acting methylphenidate.
This study aimed to assess the perception of radiographers on the difficulties encountered during the delineation of organs at risk (OARs) for radiotherapy planning and the methods that could be used to facilitate this process.
Methodology:
A self-designed questionnaire was distributed to all radiographers (n = 29) employed at the radiotherapy department in Malta. The survey assessed the challenges faced by the radiographers during the delineation of various OARs and inquired about the perceived effectiveness of specific measures that could be used to facilitate the delineation process using a Likert scale ranging from 1 (not difficult/effective) to 5 (very difficult/effective).
Results:
The response rate was 79%. Overall, the delineation of OARs was rated as slightly difficult (mean score 1.95 ± 0.33). Nevertheless, some OARs, such as the parotid, stomach and brain stem, were deemed more difficult to contour with a mean score of 3 or higher. The implementation of peer review was perceived as the most influential factor in reducing delineation difficulty (mean score 4.59 ± 0.58), followed by contouring training (mean score 4.48 ± 0.58) and training on artificial intelligence (AI) (mean score 4.35 ± 0.48).
Conclusion:
The introduction of peer review, training and AI could facilitate the delineation of OARs.
Ever since the publication of “The Imperialism of Free Trade” by John Gallagher and Ronald Robinson in 1953, “informal empire” has been a key term for historians. It has, however, always been contentious. The central issue was whether imperial historians were prepared to accept a new concept of empire. This article explains the paradox of informal empire by creating a stronger provenance for the term. Since the early nineteenth century, imperial metaphors have been used to characterize Britain's position in the world economy. Gallagher and Robinson—like their immediate predecessors, Charles Fay and Keith Hancock—wanted to understand British imperialism in the broader context of European expansion while also formulating an alternative to the radical liberal and neo-Marxist interpretations widely current after World War I. Ultimately, the difficulty of using “empire” as a single category led Gallagher and one of his most influential successors to choose an alternative term.
Coronavirus disease 2019 (COVID-19) spread globally, including across Europe, resulting in different morbidity and mortality outcomes. The aim of this study was to explore the progression of the COVID-19 pandemic over 18 mo in relation to the effect of COVID-19 vaccination at a population level across 35 nations in Europe, while evaluating the data for cross-border epidemiological trends to identify any pertinent lessons that can be implemented in the future.
Methods:
Epidemiological data were obtained from European Centre for Disease Prevention and Control and Our World in Data databases while Ministry of Health websites of each respective country and local newspapers were used for COVID-19-related vaccination strategies. Case, mortality, and vaccination incidence comparative analyses were made across neighboring countries.
Results:
Similar morbidity and mortality outcomes were evident across neighboring countries over 18 mo, with a bidirectional relationship evident between cumulative fully vaccinated population and case fatality rates.
Conclusion:
Countries’ COVID-19 outcome is related on national mitigative measures, vaccination rollouts, and neighboring countries’ actions and COVID-19 situations. Mass population vaccination appeared to be effective in reducing COVID-19 case severity and mortality rates. Vaccination equity and pan-European commitment for cross-border governance appear to be the way forward to ensure populations’ return to “normality.”
Asphyxia describes any condition that results in oxygen deprivation and, in the unborn or soon-to-be-born infant, may occur prenatally in utero, during delivery or postnatally [1]. In cases of intrapartum asphyxia, the duration of oxygen deprivation may vary and is critical to the ensuing insult to the infant’s vital organs and, especially, to the brain. Oxygen deficiency at tissue level (hypoxia, see Box 60.1) is often accompanied by glucose and nutrient deprivation, and is further compounded by pre-existing or complicating factors in the mother, especially pyrexia, and in the infant such as sepsis or congenital anomalies, the concomitant degree of metabolic derangement (e.g. extent of hypoglycaemia or metabolic acidosis), and the time to delivery and effective resuscitation. All of these factors will potentially compound any hypoxic injury and the extent of any ensuing brain damage, described as hypoxic ischaemic encephalopathy (HIE, Box 60.1). Attempts to assign an HIE ‘grade’ may help to correlate early symptoms and signs with the degree and likelihood of long-term sequelae [2], although accurate prognostication of asphyxial brain damage remains difficult.
On January 27, 2021, the United Nations Human Rights Committee (HRC or Committee) published two separate decisions in response to communications brought against Malta and Italy. Both decisions concerned the same incident, which occurred on October 11, 2013, where over 200 migrants drowned in a shipwreck in the Mediterranean. The first complaint brought against Malta was dismissed by the Committee on procedural grounds. In the second case, A.S., D.I., O.I. and G.D. v. Italy, the HRC found that Italy had failed to protect the right to life of the migrants under the International Covenant on Civil and Political Rights (ICCPR). This introductory note discusses the significance of the Committee's findings in this decision and its ramifications with respect to the protection of human rights at sea.
‘Negative mechanical materials / metamaterials’ refer to materials and/or engineered systems that exhibit anomalous macroscopic thermo-mechanical properties that emerge due to the structure of their subunits, rather than the specific chemical composition. As a result of their design/construction, they may exhibit anomalous macroscopic properties such as zero or negative Poisson’s ratios (auxetic), moduli and/or indices. Such zero/negative properties are not normally manifested by their conventional counterparts and may thus potentially be used in applications where typical materials cannot. This work will look into some of the more recent developments made in this field, focusing on how existing materials (e.g. crystals) are providing the blueprint for the design and manufacture of novel ’negative materials’. In particular, this work looks at how wine-rack like crystalline materials which are typically studied for their negative thermal expansion and/or negative compressibility properties can be modified so as to generate negative Poisson’s ratio through a novel mechanism involving forcing elements to move out-of-plane to generate giant out-of-plane auxeticity.
Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.
LEARNING OBJECTIVES:
After reading this article you will be able to:
• understand the mechanism of gastrointestinal hypomotility in those taking clozapine
• improve the monitoring of clozapine-induced constipation
• understand prophylactic laxative treatment and the use of less commonly prescribed laxatives in patients who experience clozapine-induced constipation.
Background: Almost all patients admitted at acute crisis to a psychiatric ward experience clinically significant symptoms of insomnia. Ward environments pose challenges to both sleep and the delivery of therapy. Despite this, there is no description of how to adapt cognitive behavioural therapy (CBT) for insomnia to overcome these challenges. Aims: (i) To describe the key insomnia presentations observed in the Oxford Ward Sleep Solution (OWLS) trial and (ii) outline key adaptations aimed to increase accessibility and hence effectiveness of CBT for insomnia for a ward setting. Methods: Trial therapists collaboratively agreed the key insomnia presentations and therapy adaptations based on their individual reflective logs used during the trial. Results: Three key insomnia presentations are outlined. These are used to illustrate the application of 10 CBT for insomnia therapy adaptations. These include use of sleep monitoring watches to engage patients in treatment, stabilizing circadian rhythms, reducing the impact of night-time observations and managing discharge as a sleep challenge. Conclusions: Whilst inpatient wards bring challenges for sleep and therapy delivery, creative adaptations can increase the accessibility of evidence based CBT for insomnia techniques. This therapy has proven popular with patients.
When patients are admitted onto psychiatric wards, sleep problems are highly prevalent. We carried out the first trial testing a psychological sleep treatment at acute admission (Oxford Ward sLeep Solution, OWLS).
Methods
This assessor-blind parallel-group pilot trial randomised patients to receive sleep treatment at acute crisis [STAC, plus standard care (SC)], or SC alone (1 : 1). STAC included cognitive–behavioural therapy (CBT) for insomnia, sleep monitoring and light/dark exposure for circadian entrainment, delivered over 2 weeks. Assessments took place at 0, 2, 4 and 12 weeks. Feasibility outcomes assessed recruitment, retention of participants and uptake of the therapy. Primary efficacy outcomes were the Insomnia Severity Index and Warwick–Edinburgh Mental Wellbeing Scale at week 2. Analyses were intention-to-treat, estimating treatment effect with 95% confidence intervals.
Results
Between October 2015 and July 2016, 40 participants were recruited (from 43 assessed eligible). All participants offered STAC completed treatment (mean sessions received = 8.6, s.d. = 1.5). All participants completed the primary end point. Compared with SC, STAC led to large effect size (ES) reductions in insomnia at week 2 (adjusted mean difference −4.6, 95% CI −7.7 to −1.4, ES −0.9), a small improvement in psychological wellbeing (adjusted mean difference 3.7, 95% CI −2.8 to 10.1, ES 0.3) and patients were discharged 8.5 days earlier. One patient in the STAC group had an adverse event, unrelated to participation.
Conclusions
In this challenging environment for research, the trial was feasible. Therapy uptake was high. STAC may be a highly effective treatment for sleep disturbance on wards with potential wider benefits on wellbeing and admission length.
We present solutions to nonzero-sum games of optimal stopping for Brownian motion in [0, 1] absorbed at either 0 or 1. The approach used is based on the double partial superharmonic characterisation of the value functions derived in Attard (2015). In this setting the characterisation of the value functions has a transparent geometrical interpretation of 'pulling two ropes' above 'two obstacles' which must, however, be constrained to pass through certain regions. This is an extension of the analogous result derived by Peskir (2009), (2012) (semiharmonic characterisation) for the value function in zero-sum games of optimal stopping. To derive the value functions we transform the game into a free-boundary problem. The latter is then solved by making use of the double smooth fit principle which was also observed in Attard (2015). Martingale arguments based on the Itô–Tanaka formula will then be used to verify that the solution to the free-boundary problem coincides with the value functions of the game and this will establish the Nash equilibrium.
Mitochondrial DNA (mtDNA) is has recently lost relevance especially when utilised to study species that are characterised with a history of several migrations. Nonetheless, mtDNA can still represents a useful additional tool in the study of molecular genetic diversity. The reason for the adoption of mtDNA is that it is easy to amplify because it appears in multiple copies in the cells and the mitochondrial gene content is strongly conserved across generations. Thousands of published studies have reached conclusions about population history, patterns of gene flow, genetic structure, and species limits, on the basis of mtDNA sequence variation. MtDNA has been used to study phylo-geographic structure of avian species, and to identify the number of maternal lineages and their geographic origins. Most studies of chicken mtDNA rely on sequences of partial control region but recent researches used the complete mtDNA genome to reconstruct the history of animal domestication. The first genetic study on mtDNA suggests that the Indochinese Red Junglefowl subspecies Gallus gallus gallus is the primary ancestor of the domestic chicken (Gallus gallus domesticus). Other studies showed that at least three subspecies of Gallus gallus were enrolled in the origin of domestic chicken breeds, and that there may be at least two domestication centres: one in Southeast Asia and one in the Indian subcontinent. The authors suggested nine highly divergent clades (named clade A-I) related to geographical distribution in a wide range of domestic chickens and Red Junglefowls across Eurasian regions. Understanding when chickens were transported out of domestication centres and the directions in which they were moved provides information about prehistoric human migration, trade routes and cultural diffusion. MtDNA has been used to infer regions of domestication and to identify the number of maternal lineages and their geographic origins in macroevolution studies.
This review is a first attempt to give a comprehensive historical account on the evolution of the Maltese Black chicken breed. The initiative consolidates available information to propose hypothesis on the origins of the breed, and to develop a comprehensive breed standard in conformity with the format of the American Breed Standard. The Maltese Black was established in 1950 as a rustic, dual purpose breed capable of producing adequate egg and chicken for consumption. In the 1960's, it was replaced with commercially available stock, marginalising the breed and restricting its existence to small dispersed populations. An initial attempt to have an in-situ conservation of the Maltese Black started in 1998 with a small flock of about 400 chickens that were later relocated to the Agricultural Research and Development Centre in Malta with the intention of maintaining a nucleus flock as a measure for a long term ex-situ conservation strategy. A recent survey highlights that the present population has drifted significantly away from standards first published in 1950. In efforts to consolidate the breed standard definition of the Maltese Black, the breed standards of related Mediterranean breeds, as confirmed by molecular markers, were consulted to translate and address the missing gaps in the previous breed standards. The updated breed standard presented will act as the bench mark against which all future breeding and selection programs are compared.
Objective: To assess the adequacy of the pediatric triage system in an acute care general hospital.
Methods: All children younger than 14 years of age who presented with a primary medical condition to the accident and emergency department (ED) during January to March 2009 were recruited. Suitability of the triage system was assessed according to the vital parameters taken and the priority code assigned. Triage workload was assessed from the number of children presenting to ED and the timing of presentation.
Results: Of 2269 children presenting to ED, 1617 (71.3%) were younger than 5 years, and 883 (38.9%) were younger than 2 years. Only 0.26% (6/2269) had four vital parameters crucial for priority assignment measured, and 19.3% (437/2269) had at least one parameter measured. A priority code was assigned to 10% (225/2269).
Conclusions: Our study revealed inadequacies in the pediatric triage system. A simple and objective triage system that is based on the measurement of crucial vital parameters and on prompt recognition of warning signs and symptoms to correctly identify high-risk groups has been introduced to ensure appropriate and effective triage of sick children.
(Disaster Med Public Health Preparedness. 2012;6:151–154)
To describe the characteristics of patients admitted over one year to two psychiatric intensive care units in one large mental health trust. To establish the number of admissions, reasons for admission, incidents on the PICU, bed days and destination after discharge. Differences in gender for these factors were explored. Secondary questions were whether patient factors predicted aggressive incidents or predicted requiring long term care.
Method
The electronic notes for one year of admissions to the PICUs in one trust were examined; sociodemographic and clinical details were recorded. Reasons for admission and incidents on the PICU were coded. Data was analysed to establish significant sociodemographic or clinical differences within the cohort.
Results
Men were much more likely to require PICU but women stayed longer. There was a trend for women to go on to long term secure placement. Aggression and sexually inappropriate behaviour were common but there were no demographic predictors of aggression. The only predictor of requiring long term placement was having been a long time on the PICU.
Conclusion
There is evidence that women and men use the PICU differently, with women staying longer. Further research is needed to see if this is a national trend.
Detailed post-mortem is crucial in infants who die suddenly and without a known cause. We report a rare case of histiocytoid cardiomyopathy with endocardial fibroelastosis, the second case in the world literature. The infant presented with sudden death, but the cardiac histological appearance was initially believed to be caused by Pompes disease.