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Posttraumatic stress disorder (PTSD) has been associated with advanced epigenetic age cross-sectionally, but the association between these variables over time is unclear. This study conducted meta-analyses to test whether new-onset PTSD diagnosis and changes in PTSD symptom severity over time were associated with changes in two metrics of epigenetic aging over two time points.
Methods
We conducted meta-analyses of the association between change in PTSD diagnosis and symptom severity and change in epigenetic age acceleration/deceleration (age-adjusted DNA methylation age residuals as per the Horvath and GrimAge metrics) using data from 7 military and civilian cohorts participating in the Psychiatric Genomics Consortium PTSD Epigenetics Workgroup (total N = 1,367).
Results
Meta-analysis revealed that the interaction between Time 1 (T1) Horvath age residuals and new-onset PTSD over time was significantly associated with Horvath age residuals at T2 (meta β = 0.16, meta p = 0.02, p-adj = 0.03). The interaction between T1 Horvath age residuals and changes in PTSD symptom severity over time was significantly related to Horvath age residuals at T2 (meta β = 0.24, meta p = 0.05). No associations were observed for GrimAge residuals.
Conclusions
Results indicated that individuals who developed new-onset PTSD or showed increased PTSD symptom severity over time evidenced greater epigenetic age acceleration at follow-up than would be expected based on baseline age acceleration. This suggests that PTSD may accelerate biological aging over time and highlights the need for intervention studies to determine if PTSD treatment has a beneficial effect on the aging methylome.
Interprofessional teams in the pediatric cardiac ICU consolidate their management plans in pre-family meeting huddles, a process that affects the course of family meetings but often lacks optimal communication and teamwork.
Methods:
Cardiac ICU clinicians participated in an interprofessional intervention to improve how they prepared for and conducted family meetings. We conducted a pretest–posttest study with clinicians participating in huddles before family meetings. We assessed feasibility of clinician enrollment, assessed clinician perception of acceptability of the intervention via questionnaire and semi-structured interviews, and impact on team performance using a validated tool. Wilcoxon rank sum test assessed intervention impact on team performance at meeting level comparing pre- and post-intervention data.
Results:
Totally, 24 clinicians enrolled in the intervention (92% retention) with 100% completion of training. All participants recommend cardiac ICU Teams and Loved ones Communicating to others and 96% believe it improved their participation in family meetings. We exceeded an acceptable level of protocol fidelity (>75%). Team performance was significantly (p < 0.001) higher in post-intervention huddles (n = 30) than in pre-intervention (n = 28) in all domains. Median comparisons: Team structure [2 vs. 5], Leadership [3 vs. 5], Situation Monitoring [3 vs. 5], Mutual Support [ 3 vs. 5], and Communication [3 vs. 5].
Conclusion:
Implementing an interprofessional team intervention to improve team performance in pre-family meeting huddles is feasible, acceptable, and improves team function. Future research should further assess impact on clinicians, patients, and families.
Functional decline following hospitalization remains an important problem in health care, especially for frail older adults. Modifiable factors related to reduction in harms of hospitalization are not well described. One particularly pervasive factor is emergency department (ED) boarding time; time waiting from decision to admit, until transfer to an in-patient medical unit. We sought to investigate how the functional status of frail older adults correlated with the length of time spent boarded in the ED. We found that patients who waited for 24 hours or more exhibited functional decline in both the Barthel Index and Hierarchical Assessment of Balance and Mobility and an increase in the Clinical Frailty Scale from discharge to 6 months post discharge. In conclusion, there is a need for additional investigation into ED focused interventions to reduce ED boarding time for this population or to improve access to specialized geriatric services within the ED.
The right to freedom of thought, conscience and religion in Article 9 of the European Convention on Human Rights (ECHR) has become increasingly significant and contested. Through an examination of ECHR Article 9, its drafting history, and the related jurisprudence of the European Court of Human Rights (ECtHR), Caroline K. Roberts challenges the classic approach to this right in the literature. Roberts argues that claims that there is, or should be, a clear binary and hierarchical distinction between the absolutely protected internal realm and the qualified external realm in this right are not founded textually or jurisprudentially. Rather, the primary materials suggest that the internal and external aspects are deeply interrelated, and this is reflected in the ECtHR's nuanced and holistic approach to ECHR Article 9 protection. This comprehensive, rigorous and up-to-date reappraisal of ECHR Article 9 and the related ECtHR jurisprudence will be essential reading for academics and practitioners.
The introduction sets out the context, aims and approach of this book. It explains that over the past thirty years, the number of cases before the ECtHR concerning freedom of thought, conscience and religion has increased significantly and interest in this right in the literature has grown exponentially. It notes that ECtHR jurisprudence relating to ECHR Article 9 has been heavily criticised by commentators but there has been very little interrogation of the core premises that underpin doctrinal analyses of Article 9 in recent years. In particular, the fundamental question—what is the law in relation to freedom of religion or belief?—has not been fully explored. The introduction explains that this book aims to address this important question in relation to ECHR Article 9 and, in doing so, it challenges the classic approach to freedom of thought, conscience and religion in the literature and offers an alternative interpretation of ECHR Article 9 and the related ECtHR jurisprudence. The detailed overview of the structure of this book in the introduction details the approach which will be taken, and sets out the the materials which form the basis for the analysis.
Part III draws together the central threads in the preceding chapters and takes the analysis a step further. Chapter 8 draws particular attention to the importance of context in ECtHR jurisprudence relating to ECHR Article 9, contending that in taking different approaches and reaching different outcomes in ostensibly similar Article 9 cases, the ECtHR is not necessarily being inconsistent. Rather, its approach can be explained by recognising the significance of the facts; the facts help the ECtHR identify what is at stake in a particular case and respond accordingly. In developing this, this chapter explores the importance placed on contextual differences between, and within, Member States by the ECtHR in Article 9 cases, and refers to the major role of the facts in cases concerning other ECHR Articles. Finally, it explores some of the broader cultural, social and political factors the ECtHR may legitimately take into account in Article 9 assessments, and considers the impact of the increased focus on the local context in declarations on reform of the ECHR system on the ECtHR.
Chapters 6 and 7 examine cases which one would expect to fall in the middle circle in the loose concentric circles model, where both forum internum relevance and countervailing factors may both be strong or both be weak and, as such, for the degree of protection offered to depend heavily on the way in which the ECtHR balances the factors. Chapter 6 explores cases concerning limitations on proselytism, and the wearing of religious clothing and symbols. It seeks to show that, again, the ECtHR’s approach is consistent with its general principles concerning Article 9 as the ECtHR balances factors indicating a violation (primarily, but not only, forum internum relevance) with countervailing factors indicating no violation, in order to reach its decision. Given that such cases are highly fact sensitive, the degree of forum internum protection offered ranges from a high to a low degree depending on the particular circumstances of the case.
This conclusion summarises the arguments presented in the chapters in Parts I, II and III. It also explores some of the implications of the reappraisal of ECHR Article 9 and the related ECtHR jurisprudence in this book for academics and legal practitioners alike.
Chapter 2 focuses on the text of ECHR Article 9 and other international provisions protecting the right to freedom of thought, conscience and religion including Article 18 of the Universal Declaration of Human Rights (UDHR), Article 18 of the International Covenant on Civil and Political Rights (ICCPR), and Article 1 of the Declaration on the Elimination of all Forms of Intolerance and of Discrimination based on Religion or Belief (1981 Declaration). It also explores the drafting history of these Articles through an examination of the relevant travaux préparatoires. By analysing this material, and drawing upon a recent, deeply valuable contribution to the understanding of ICCPR Article 18, Chapter 2 seeks to demonstrate that it is more faithful to these text of the ECHR Article 9 and the relevant travaux préparatoires to understand the forum internum and forum externum aspects of the right to freedom of thought, conscience and religion in terms of a relationship rather than in terms of a binary and hierarchical distinction.
Chapter 3 focuses on the ECtHRs general principles concerning ECHR Article 9 in its jurisprudence. It contends that the ECtHR recognises the forum internum and forum externum relationship, intuitively understanding that, because actions flow from the forum internum, the forum internum is always relevant to some degree in Article 9 cases. As such, this chapter recommends conceptualising the forum internum and forum externum aspects of the right on a continuum. Whilst, this chapter argues, forum internum relevance is the principal factor weighing in favour of the applicant, it contends that it is not the only factor the ECtHR takes into consideration in Article 9 cases; the ECtHR balances in all Article 9 cases, weighing up factors pointing to a violation of Article 9 (primarily, but not forum internum relevance) with countervailing factors pointing away from a violation, to reach its decision. Given the ECtHR offers a range of protection as a result, this chapter suggests that a useful way of grouping Article 9 cases for analysis is a loose concentric circles model, comprising three circles, as this better reflects the ECtHR jurisprudence than a binary and hierarchical framework.
Chapter 5 focuses on cases in which States have restricted the activities of individuals or communities due to concerns about religiously motivated harm. Firstly, it explores cases concerning sexual relations with minors, corporal punishment of children, compulsory vaccination refusal, and ceremonial use of illegal substances. These are the kinds of cases one would expect fall into the outermost circle in the loose concentric circles model, where there is weakest forum internum relevance and strongest countervailing factors and, thus a very low degree of forum internum protection. This chapter seeks to demonstrate that the ECtHR’s approach in such cases is as expected. Secondly, through an analysis of cases concerning allegations of threats to national security, challenges to rights and freedoms of members, and transgressions of health and safety laws, this chapter also aims to show that where the ECtHR considers the harm in question is not substantiated, or State actions are disproportionate, the ECtHR can, and does, give greater weight to forum internum relevance than to countervailing factors, and offer a higher degree of protection.