3027 results
Norms for neuropsychological tests in cognitively healthy French oldest old adults
- Eva Sizaret, Maxime Brachet, Alix Launay, Christophe Destrieux, Ilyess Zemmoura, Lucie Angel, the FIBRATLAS Consortium
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- Journal:
- Journal of the International Neuropsychological Society , First View
- Published online by Cambridge University Press:
- 18 September 2024, pp. 1-15
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Objective:
Normal aging often leads to cognitive decline, and oldest old people, over 80 years old, have a 15% risk of developing neurodegenerative diseases. Therefore, it is important to have appropriate tools to assess cognitive function in old age. The study aimed to provide new norms for neuropsychological tests used to evaluate the cognitive abilities in people aged 80 years and older in France, focusing on the impact of education and gender differences.
Method:107 healthy participants with an average age of 85.2 years, with no neurological history or major cognitive deficits were included. A comprehensive neuropsychological assessment was performed, covering several cognitive functions such as memory, visuospatial abilities, executive functions, attention, processing speed, and praxis.
Results:Individuals with lower levels of education performed poorly on some tests and took longer to complete. Gender differences were observed, with women outperforming men in verbal episodic memory, while men showed better performance in visuoconstructive tasks. The participants showed lower performance in verbal episodic memory compared to norms established in previous French studies. In relation to executive functions, participants were slower to perform complex tasks than participants in previous studies.
Conclusion:This study provides cognitive norms specifically adapted to the oldest old population, which differ from established norms for younger aging adults. It highlights the importance of including these norms in future clinical and scientific investigations. The findings underscore the importance of education on cognitive abilities and emphasize the need to consider gender differences when assessing cognitive functions in aging populations.
Outpatient Antibiotic Consumption Trends in Belgium: A Comparative Analysis of Reimbursement and Sales Data, 2013-2022
- Elena Damian, Laura Bonacini, Moira Kelly, Boudewijn Catry, Lucy Catteau
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- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 4 / Issue S1 / July 2024
- Published online by Cambridge University Press:
- 16 September 2024, pp. s152-s153
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Background: Antimicrobial resistance (AMR) is a global public health concern, necessitating close and timely monitoring of antibiotic consumption (AMC). In Belgium, AMC surveillance traditionally relies on reimbursement data, excluding over-the-counter non-reimbursed or imported products and involving a time lag. This study investigates disparities in AMC between reimbursement data and retail data, providing insights into AMC variations. Additionally this study seeks to critically evaluate the validity and representativeness of the reimbursed data in accurately reflecting the true extent of AMC in the country. Method: Utilizing reimbursement data from the National Institute for Health and Disability Insurance (NIHDI) and retail data (IQVIA Sales data; www.iqvia.com) for systemic antibacterials (ATC Group J01), outpatient consumption was estimated for the period 2013-2022. Volume of antimicrobials was measured in Defined Daily Doses (DDDs - WHO ATC/DDD Index 2023), while population data were extracted from Eurostat. Relative differences (RDs) in DDDs per 1000 inhabitants per day (DID) were computed, and validated through correlation analysis (Pearson’s r) and Bland–Altman plots. Result: J01 antibacterial sales declined from 23.10 DID (2013) to 20.85 (2022). Non-linear decreases, notably during the Covid-19 pandemic (21.54 DID in 2019 to 16.69 in 2020), followed by a rebound to pre-pandemic quantities in 2022 were observed (Figure 1). Reimbursement NIHDI data slightly underestimated IQVIA sales, with RDs ranging from 2% (2013) to 9% (2022). Notable differences, especially in recent years were attributed to quinolone reimbursement criteria changes implemented by law in Belgium in 2018, reducing the reimbursed proportion from 99% (2017) to 35% (2022). ATC-3 level analysis revealed disparities in low-DID groups (J01B, J01E and J01G). Notably, a small proportion of amphenicols (J01B) were reimbursed ( < 1 0%), with a congestion relieving combination product of tiamphenicol (+ N-acetylcysteine; Fluimucil®) frequently bought and remaining unreimbursed. Overall and across ATC3 groups, the correlation between NIDHI and IQVIA estimates was almost perfect across years and the Bland–Altman plots showed high agreement. Conclusion: Reimbursement data are reliable for outpatient AMC monitoring with slightly lower estimates than retail data across most categories. The 2018 quinolone reimbursement criteria change highlights the necessity of incorporating retail data for accurate assessments in this specific category. The synergistic use of reimbursement and retail datasets is crucial for a comprehensive understanding of consumption patterns, supporting effective AMR mitigation strategies in Belgium.
Antimicrobial Use in Belgian Acute Care Hospitals : Results of the 2022 ECDC Point Prevalence Survey
- Lucy Catteau, Katrien Latour, Morgan Pearcy, Boudewijn Catry
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- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 4 / Issue S1 / July 2024
- Published online by Cambridge University Press:
- 16 September 2024, pp. s150-s151
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Background: Point prevalence surveys (PPS) organized by the European Centre for Disease Prevention and Control (ECDC) play a crucial role in assessing healthcare-associated infections (HAIs) and antimicrobial use (AU) in European acute care hospitals. In 2017, a crude prevalence of 28.1% (95% CI 27.3-29.0%) of inpatients receiving at least one antimicrobial was recorded in Belgium (patients ≥65 years: 29.6% (95% CI 28.5-30.7%), < 6 5 years : 26.5% (95%CI 25.3-27.6%)) . Following the challenges posed by the COVID-19 pandemic, the 2022 ECDC-PPS aimed to reassess AU levels. Method: A cross-sectional study was conducted between September and November 2022 in 57 representative acute care Belgian hospital sites (35 mergers), following the ECDC-PPS protocol version 6.0. All patients present in surveyed wards at 8 a.m. on the PPS day and not discharged at that time were included. Infection prevention and control teams collected comprehensive data on hospitals, wards, and AU, including agents and indications. Results: Among the 10,142 included inpatients, 29.3% (95%CI 28.4-30.2) were receiving at least one antimicrobial (patients ≥65 years: 31.1% (95% CI 29.7-32.4%), < 6 5 years : 27.1% (95%CI 25.6-28.6%)). Intensive care units (56.3%), surgical (38.7%), and medical wards (33.1%) demonstrated the highest AU prevalence, while psychiatric wards exhibited the lowest (3.0%). A total of 3,549 antimicrobials were recorded, commonly prescribed for treating community-acquired infections (48.6%) and HAIs (30.3%, including 4.2% of long-term care facility acquired infections), as well as for surgical and medical prophylaxis (12.4 and 6.6%, respectively). Notably, only 22.7% of surgical prophylaxis courses (n=100/440) lasted more than one day. The top three most used antimicrobial agents consisted of amoxicillin in combination with a beta-lactamase inhibitor (J01CR02, 20.0%), cefazolin (J01DB04, 9.8%) and piperacillin in combination with a beta-lactamase inhibitor (J01CR05, 9.6%). The most frequently reported diagnoses for medical antimicrobial treatment were pneumonia (25.7%) and urinary tract infections (17.1%). The reason for AU was available in 80.0% of the medical notes. Conclusion: The 2022 PPS reveals an increased AU prevalence (+1.2%) in Belgian acute care hospitals, especially in patients over 65 years of age (+1.5%). This increase was less pronounced in younger patients (< 6 5y) (+0.6%). Future investigations are crucial to delve into prescription attitudes and modifiable practices, emphasizing the urgent need for robust antimicrobial stewardship programs in these healthcare settings.
Trends in Hospital Antibacterial Consumption in Belgium (2017-2021): Evaluating the Impact of the COVID-19 Pandemic
- Laura Bonacini, Elena Damian, Boudewijn Catry, Lucy Catteau
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- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 4 / Issue S1 / July 2024
- Published online by Cambridge University Press:
- 16 September 2024, pp. s149-s150
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This study aimed to evaluate the impact of the COVID-19 pandemic on antimicrobial consumption (AMC) in Belgian hospitals from 2017 to 2021, using data from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) and the Belgian Hospitals Surveillance of Antimicrobial Consumption (BeH-SAC). Antimicrobial volume was quantified in Defined Daily Doses (DDDs), and AMC was expressed in DDDs/1000 inhabitants/day (DIDs), DDDs/1000 patient days and DDDs/1000 admissions. Linear regressions were employed to analyze 5-year trends for the ATC J01 group, at the ATC-3 level and for broad-spectrum antimicrobials. Broad-spectrum antibiotics included combinations of penicillins, incl. beta-lactamase inhibitors (J01CR), second-generation cephalosporins (J01DC), third-generation cephalosporins (J01DD), macrolides, lincosamides and streptogramins (J01F, excluding erythromycin J01FA01), and fluoroquinolones (J01MA). The compound annual growth rate (CAGR) calculated for the years preceding the pandemic was used to forecast 2020 and 2021 AMC, enabling a comparison with the actual use. Hospital AMC measured as DIDs decreased by 12% from 2019 to 2020. In contrast, when expressed as DDDs/1000 patient days and DDDs/1000 admissions, a 5% and 7% increase was observed, respectively. Antibacterials for systemic use (J01) showed a significant decrease over the 5 years only when expressed in DIDs. Notable trends included a negative trend for quinolone antibacterials (J01M) when expressed in the three incidence units, as for amphenicols (J01B) when using hospital denominators only. Positive trends were observed for sulfonamides and trimethoprim (J01E) using hospital denominators and for other beta-lactam antibacterials (J01D) with the ‘patient days’ denominator. While the consumption of all J01 antimicrobial subclasses deviated negatively from predicted use both in 2020 and 2021 when expressed in DIDs, positive deviations were recorded using hospital denominators, except for macrolides (J01F). The use of broad-spectrum antimicrobials showed a notable decrease between 2017 and 2021 when expressed in DIDs. However, when using hospital denominators, the observed use of broad-spectrum antimicrobials exceeded the forecasted values in 2020, to regress below the forecasted levels in 2021 (Figure 1). Contrary to results obtained using the widely applied country’s population as the denominator, a notable surge in AMC, particularly for broad-spectrum antimicrobials, was observed in 2020 when using hospital-specific denominators. This increase coincided with the onset of the COVID-19 crisis. These findings emphasize the need for a national hospital surveillance system that uses denominators that accurately represent the specific population being monitored. Implementing robust hospital-specific surveillance mechanisms would improve the precision of evaluations and facilitate targeted interventions aimed at optimizing antimicrobial utilization.
Risk Factors for Multi-Drug Resistant Gram-negative Infections across a Pediatric Hospital System
- Aarika Young, Elizabeth Tocco, Tjin Koy, Grant Stimes, Judith Campbell, Lucy Marquez, Catherine Foster
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- Antimicrobial Stewardship & Healthcare Epidemiology / Volume 4 / Issue S1 / July 2024
- Published online by Cambridge University Press:
- 16 September 2024, p. s109
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Background: Infections due to antibiotic resistant bacteria are increasing worldwide and while, the epidemiology of these pathogens is well described in adults, pediatric specific data are lacking. We sought to gain an understanding of the risk factors for multi-drug resistant Gram-negative (MDRGN) infections in our pediatric population. Methods: We performed a retrospective review of pediatric patients seen at a pediatric hospital system in 2022 who had a culture-positive MDRGN, which was defined as a gram-negative bacteria resistant or intermediate to at least 1 antibiotic in ≥ 3 antibiotic groups. Repeat positive cultures for the same MDRGN were considered a single infection episode if occurring within a 14-day period. Demographic, clinical, and microbiologic data was obtained from the electronic medical record. Fisher’s exact was used for analysis. Results: One hundred and seventy-nine children had 237 infection episodes during the study period. Eighty-one patients (45%) were male and the median age was 5.3 years. The most prevalent MDRGNs included: Escherichia coli (154, 65%), Klebsiella spp (52, 22%), and Enterobacter spp (16, 7%). Escherichia coli was significantly more likely than other pathogens to be isolated from the urine (P = 0.008). Compared to multi-drug resistant E. coli, patients with a non-E. coli MDRGN were significantly more likely to have an underlying medical condition, recent hospitalization and antibiotic use (P≤0.001 for each, Table 1). A carbapenem was administered in 32% (75/237) of infection episodes. There were only 6 carbapenem resistant organisms. Conclusions: In our study, E. coli was the most frequent MDRGN. Most patients with a non-E. coli MDRGN infection episode had an underlying medical condition, recent hospitalization and antibiotic use. Carbapenem resistance was infrequent, though surveillance studies are needed to identify changing antibiotic resistance patterns and to direct prevention measures.
Developing, delivering and evaluating a university-led cognitive behavioural therapy service for students
- Lucy J. Robinson, Ellen Marshall, Alyson Dodd, Mma Yeebo, Rochelle Morrison, Claire Lomax
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- The Cognitive Behaviour Therapist / Volume 17 / 2024
- Published online by Cambridge University Press:
- 12 September 2024, e20
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Demand for student mental health services is growing, as is the complexity of presentations to university student wellbeing services. There is a need for innovative service delivery models to prevent students falling in the gaps of existing provision, where outcomes from traditional talking therapies services have been shown to be poorer for students than non-student peers. In 2018, Newcastle University established a pilot in-house cognitive behavioural therapy (CBT) service to provide high-intensity CBT for students at the university, harnessing the expertise of qualified and training staff from the psychological professions. This subsequently expanded into the Psychological Therapies Training and Research Clinic, appointing additional clinical staff. Here we present the journey of the clinic, from inception to implementation and expansion. We also present a descriptive evaluation of the first three years of operation, reporting on clinical activity, clinical outcomes and client experiences of the service. Data are presented from 605 referrals. Over 70% of referrals were assessed and over 60% transitioned into treatment. The treatment completion rate was 50%, with an overall recovery rate of 47.3% [using the same definition of recovery as NHS Talking Therapies for Anxiety and Depression (NHS TTAD)]. Satisfaction, measured by the Patient Evaluation Questionnaire, was high. These outcomes are commensurate or better than seen in NHS TTAD services for students and young adults. Overall, the clinic has been a successful addition to the wellbeing offer of the university and has provided a number of positive further opportunities for both research and the clinical training programmes.
Key learning aims(1) To understand the process followed to establish a university-run cognitive behavioural therapy service for students and enable other institutions to replicate this model.
(2) To identify whether universities can deliver safe, effective mental health services that are fully evaluated and result in commensurate clinical outcomes to other service contexts.
(3) To reflect on key learning, challenges and ethical considerations in establishing such services.
Alterations in fear learning as a mechanism linking childhood exposure to violence with PTSD symptoms: a longitudinal study
- Laura Machlin, Margaret A. Sheridan, Lucy A. Lurie, Steven W. Kasparek, Stephanie Gyuri Kim, Matthew Peverill, John McClellan France, Madeline M. Robertson, Tanja Jovanovic, Liliana J. Lengua, Katie A. McLaughlin
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- Psychological Medicine , First View
- Published online by Cambridge University Press:
- 09 September 2024, pp. 1-9
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Background
Fear learning is a core component of conceptual models of how adverse experiences may influence psychopathology. Specifically, existing theories posit that childhood experiences involving childhood trauma are associated with altered fear learning processes, while experiences involving deprivation are not. Several studies have found altered fear acquisition in youth exposed to trauma, but not deprivation, although the specific patterns have varied across studies. The present study utilizes a longitudinal sample of children with variability in adversity experiences to examine associations among childhood trauma, fear learning, and psychopathology in youth.
MethodsThe sample includes 170 youths aged 10–13 years (M = 11.56, s.d. = 0.47, 48.24% female). Children completed a fear conditioning task while skin conductance responses (SCR) were obtained, which included both acquisition and extinction. Childhood trauma and deprivation severity were measured using both parent and youth report. Symptoms of anxiety, externalizing problems, and post-traumatic stress disorder (PTSD) were assessed at baseline and again two-years later.
ResultsGreater trauma-related experiences were associated with greater SCR to the threat cue (CS+) relative to the safety cue (CS−) in early fear acquisition, controlling for deprivation, age, and sex. Deprivation was unrelated to fear learning. Greater SCR to the threat cue during early acquisition was associated with increased PTSD symptoms over time controlling for baseline symptoms and mediated the relationship between trauma and prospective changes in PTSD symptoms.
ConclusionsChildhood trauma is associated with altered fear learning in youth, which may be one mechanism linking exposure to violence with the emergence of PTSD symptoms in adolescence.
Testing maternal effects of vitamin-D and omega-3 levels on offspring neurodevelopmental traits in the Norwegian Mother, Father and Child Cohort Study
- Robyn E. Wootton, Kyle Dack, Hannah J. Jones, Lucy Riglin, Paul Madley-Dowd, Carolina Borges, Panagiota Pagoni, Christine Roth, Anne Lise Brantsæter, Elizabeth C. Corfield, Camilla Stoltenberg, Anne-Siri Øyen, George Davey Smith, Helga Ask, Anita Thapar, Evie Stergiakouli, Alexandra Havdahl
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- Psychological Medicine , First View
- Published online by Cambridge University Press:
- 09 September 2024, pp. 1-11
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Background
Maternal vitamin-D and omega-3 fatty acid (DHA) deficiencies during pregnancy have previously been associated with offspring neurodevelopmental traits. However, observational study designs cannot distinguish causal effects from confounding.
MethodsFirst, we conducted Mendelian randomisation (MR) using genetic instruments for vitamin-D and DHA identified in independent genome-wide association studies (GWAS). Outcomes were (1) GWAS for traits related to autism and ADHD, generated in the Norwegian mother, father, and child cohort study (MoBa) from 3 to 8 years, (2) autism and ADHD diagnoses. Second, we used mother–father–child trio-MR in MoBa (1) to test causal effects through maternal nutrient levels, (2) to test effects of child nutrient levels, and (3) as a paternal negative control.
ResultsAssociations between higher maternal vitamin-D levels on lower ADHD related traits at age 5 did not remain after controlling for familial genetic predisposition using trio-MR. Furthermore, we did not find evidence for causal maternal effects of vitamin-D/DHA levels on other offspring traits or diagnoses. In the reverse direction, there was evidence for a causal effect of autism genetic predisposition on lower vitamin-D levels and of ADHD genetic predisposition on lower DHA levels.
ConclusionsTriangulating across study designs, we did not find evidence for maternal effects. We add to a growing body of evidence that suggests that previous observational associations are likely biased by genetic confounding. Consequently, maternal supplementation is unlikely to influence these offspring neurodevelopmental traits. Notably, genetic predisposition to ADHD and autism was associated with lower DHA and vitamin-D levels respectively, suggesting previous associations might have been due to reverse causation.
Morphodynamics and management challenges for beaches in modified estuaries and bays
- Ana Vila-Concejo, Thomas E. Fellowes, Shari Gallop, Irene Alejo, Donatus B. Angnuureng, Javier Benavente, Jorn W. Bosma, Emmanuel K. Brempong, Pushpa Dissanayake, Md Yousuf Gazi, Rita González-Villanueva, Ricardo Guimarães, David M. Kennedy, John L. Largier, Marlies A. van der Lugt, Juan Montes, Mara Orescanin, Charitha B. Pattiaratchi, Luci Cajueiro Carneiro Pereira, Remo Luan Marinho da Costa Pereira, Timothy Price, Maryam Rahbani, Laura del Río, Michael Rosenthal, Matthieu de Schipper, Anne M. Ton, Lukas WinklerPrins, Zhongyuan Chen
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- Journal:
- Cambridge Prisms: Coastal Futures / Volume 2 / 2024
- Published online by Cambridge University Press:
- 27 August 2024, e11
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There is a relative lack of research, targeted models and tools to manage beaches in estuaries and bays (BEBs). Many estuaries and bays have been highly modified and urbanised, for example port developments and coastal revetments. This paper outlines the complications and opportunities for conserving and managing BEBs in modified estuaries. To do this, we focus on eight diverse case studies from North and South America, Asia, Europe, Africa and Australia combined with the broader global literature. Our key findings are as follows: (1) BEBs are diverse and exist under a great variety of tide and wave conditions that differentiate them from open-coast beaches; (2) BEBs often lack statutory protection and many have already been sacrificed to development; (3) BEBs lack specific management tools and are often managed using tools developed for open-coast beaches; and (4) BEBs have the potential to become important in “nature-based” management solutions. We set the future research agenda for BEBs, which should include broadening research to include greater diversity of BEBs than in the past, standardising monitoring techniques, including the development of global databases using citizen science and developing specific management tools for BEBs. We must recognise BEBs as unique coastal features and develop the required fundamental knowledge and tools to effectively manage them, so they can continue providing their unique ecosystem services.
Significant Global Improvements for Opioid Dependent Patients Receiving 8 Sessions of Flexible Trauma Informed Psychological Therapies Whilst on Long Acting Injectable Buprenorphine: 9 Month Findings
- Jan Melichar, Lucie James, James Tucker, Lewis Jones, Emma Dennie
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S196-S197
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Aims
Opioid dependence is associated with adverse physical health, mental health and social consequences. Daily oral opiate substitutes offer some treatment gains but several negative associations including daily dosage fluctuations, long-term reliance on services and negative impact on ability to work.
Long-acting injectable buprenorphine (LAIB) is a new treatment option, extensively used in Wales since 2020. We have shown the many gains, including increased treatment retention, reduced service reliance, improved patient satisfaction and increased capacity for people to move on in their recoveries, are likely to be due to LAIBs unique combination of allostatic μ-opioid receptor agonism (craving reduction) and sustained κ-receptor antagonism (anxiolysis). However, ~50% experience resurfacing of mental health and/or trauma symptoms on LAIB that impedes recovery. The Buvidal Psychological Support Service, commissioned by Welsh Government, seeks to develop the evidence base for provision of rapidly accessible, tiered psychological support alongside LAIB to address this. Here we present initial 9-month findings.
MethodsTier 1 of the service offers 8 weekly individual therapy sessions, delivered flexibly over 2–6 months, with an experienced trained therapist focused on psychoeducation, co-production of a trauma and compassioned based formulation, and the development of skills to manage current mental health or trauma symptoms.
Pre- and post-evaluation programme assessed efficacy including: EQ5D-5L, Work and Social Adjustment Scale (WSAS), Clinical Global Impressions (CGI), PRO Severity and Clinical Outcomes in Routine Evaluation –10 (CORE-10).
ResultsThe service launched in March 2023 with 100 referrals in the first 9 months.
35 patients have completed Tier 1, taking between 2 and 6 months to complete.
Patients who completed Tier 1 showed clinically significant reductions in psychological distress and improvements in global functioning, quality of life and perceived mental health difficulties.
These were statistically significant at p < 0.001 for all measures (EQ5D, ICECAPS, WSAS, CGI, PRO, CORE-10) (28< = n <=34).
ConclusionRates of retention in treatment are greater than expected amongst this complex client group and the significant global improvements support the notion that those on LAIB present with increased stability and ability to engage in therapy, and that a tiered flexible approach to therapy can promote psychological safety and engagement and sustained recovery.
We propose that a tiered trauma-focused psychology service is well placed to meet the needs of people on LAIB and should be a core component of LAIB treatment in the UK.
Revisiting Dental Care and Mental Health: A Quality Improvement Project of Dental Care for Patients With Severe Mental Illness Living in a Community Rehabilitation Centre
- Yuepeng Wang, Sukhdev Singh, Lucy Duah, Serge Salih, Matthew Allin
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S177
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The Care Quality Commission report (Smiling matters: oral health care in care homes) showed that too many people living in care homes were not being supported to maintain and improve their oral health. Lime Tree Garden is a purpose-built care home for up to 24 adults with mental health needs supporting people with enduring mental health illness to develop basic life skills so they can live supported in the community.
This is a quality improvement project aiming to improve oral health and to reduce the burden of oral diseases in people with mental disorders and ensure timely access to dental treatment in Lime Tree Gardens through meeting the NICE quality standards of care.
MethodsAuditing current implementing status of oral health procedures in place and comparing with NICE guidelines and quality standards: 1) Adults who move into a care home have their mouth care needs assessed on admission; 2) Adults living in care homes have their mouth care needs recorded in their personal care plan; 3) Adults living in care homes are supported to clean their teeth twice a day and to carry out daily care for their dentures. For each patient, their dental care plan is recorded and compared with NICE guideline.
ResultsThere are challenges and space for improvement while implementing Oral health toolkit for adults in care homes at Lime Tree Gardens. A significant amount of patients (>90%) have unmet needs in terms having oral health.
ConclusionThere is a need to address the dental health challenges in this vulnerable population with recurrent and enduring mental illness. It is important to integrate and highlight dental health, as an important part of physical heath into the overall medical management of patients with severe mental illness in residential rehabilitation psychiatry.
An Evaluation of the Costs and Benefits of the New Psychological Support Service for Patients On Long-Acting Injectable Buprenorphine
- Jan Melichar, Lucie James, Rosemary Greenwood
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S197
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Long-acting injectable buprenorphine (LAIB) is an opiate substitution therapy which controls cravings and other symptoms for at least 28 days. Using this medication eliminates daily visits to the pharmacy, the risk of deviation or overdose from OST and death from overdosing with opiates. Many of those on LAIB return to the lives they left before they became addicted to opiates, but some require additional support from a new bespoke psychological service.
The new service with funds for two years opened in March 2023. An evaluation of the service is required before funding ends to ensure renewal. Here we discuss the costs, benefits and assumptions we have used to demonstrate cost effectiveness.
MethodsPatients referred to the service are asked questionnaires and clinical outcomes at the start and end of the programme. We have used the EQ5D throughout as from this we can calculate the QALYs that NICE uses to value cost effectiveness. We have extrapolated that the benefit will last 4 years based on the COBALT study (Wiles 2016). We will be following the patients up at 12 months to test this but have no funds to follow up to 4 years. We have assumed that patients would have remained the same without this therapy.
ResultsThe service has a budget of £23,812 a month and 5.17 patients a month (n = 31 July to December 2023) completed treatment. The average gain in EQ5D utility score per patient (n = 33) at discharge was 0.234 [0.140, 0.328]. If the quality-of-life score (EQ5D) at discharge is maintained in the same way as that for CBT in the COBALT study, the total number of QALYs gained from referral to 4 years would be 0.876. The cost-effectiveness ratio is therefore £5,261 per QALY gain. If the assumptions are correct and the patients retain this benefit this could be easily offset by savings elsewhere that have not been estimated in this evaluation.
ConclusionOur analysis shows we are cost effective, but we may be cost neutral due to the potential savings accrued due to less substance misuse – currently costed at £58K per user per year (Home Office). The use of additional questionnaires for assessing NHS resource use or criminal activity could derail the success by overburdening participants. Evaluating roll out to other sites needs to be costed and proportional.
With thanks to all who have helped with an infectious enthusiasm – we may be cost-effective.
Use of Treatment Escalation Plans to Guide Care Planning on a Specialist Dementia Unit
- Charlotte Russell, Lucy Calvert
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S223
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This audit reviewed the use of Treatment Escalation Plans (TEPs) on the Borders Specialist Dementia Unit (BSDU). We aimed to use data on completion rates and quality to adapt the TEP form to both improve practice and develop a more specialised form for use in inpatient old age psychiatry.
TEPs improve clinical decision-making in frail and elderly patient populations, and are commonly used on medical wards. However, these forms are primarily orientated towards acute medical environments and may not be appropriate for use in psychiatric inpatient settings, despite the clear benefits they could provide in this patient group.
MethodsThis retrospective audit reviewed completion rates and quality of completed TEP forms for 10 BSDU inpatients in December 2023. Data was gathered by reviewing TEPs and using a data collection form to collate information on completion rates and quality of information provided. Both the TEP form and the ReSPECT form were used to review what information would be relevant to include when completing TEP forms for new admissions to BSDU.
ResultsSome sections of TEP forms were consistently well-completed – typically those that were quick to complete e.g. tick boxes. However, limitations of the existing TEP form reduced these sections’ usefulness in practice. Most significantly, the form does not indicate whether “ward level care” refers to care on the old age psychiatry ward, or transfer to a medical ward. The “Additional Information” section, which could be used to clarify the patient's ceiling of care and transfer status, was only completed in 40% of cases, despite being particularly relevant to the BSDU patient population. In addition, this audit highlighted that there is no process for reviewing TEPs to ensure they remain appropriate for the patient, which is particularly relevant for old age psychiatry inpatient populations due to their advancing frailty and quickly changing clinical picture.
ConclusionThis audit showed that the current TEP form is not ideally suited to old age psychiatry settings. However, this could be improved with simple adaptations such as distinguishing between psychiatric ward care and medical ward care, and adding a review date to ensure these forms are regularly updated in light of the advancing frailty of old age psychiatry inpatient populations. I would also recommend implementing an initial review of TEP forms shortly after patients are admitted, to ensure the information contained on them is accurate and that they are countersigned by the responsible consultant.
An Audit on Telephone Referrals to Beechcroft, a Step 5 Regional Child and Adolescent Mental Health Inpatient Unit
- Andrew Breakwell, Claire Kelly, Lucy Brakspear, Owen McMurray, Karolina Szczygiel
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S221
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To audit telephone referrals to Beechcroft inpatient unit.
Beechcroft inpatient unit is a step 5 regional child and adolescent mental health inpatient unit in Belfast. It receives a large volume of referrals from across all five health and social care trusts in Northern Ireland. The process of referral to Beechcroft can vary between trusts and clinicians; the majority of admissions are emergency. The demand for beds has risen by 30% since 2019. Emergency admissions are commonly telephone referrals whilst others submit written referrals. The referrals process is managed by the ward sisters, as there is no bed manager post. Referrals are discussed with a consultant psychiatrist.
Referrals received often lack key clinical information, which makes decisions around appropriateness of admission or prioritising multiple referrals difficult. Furthermore, as the admitting doctor relies on this information, missing clinical information could result in patient safety issues.
Methods24 telephone referrals were recorded between August to December 2023. 5 referrals were excluded for either no request for a bed (3) or telephone update following previous written referral (2). 19 telephone referrals were analysed across 7 different criteria as below, based on necessary information.
Criteria 1 Patient identifiable information
Criteria 2 Source of referral/referrer details
Criteria 3 Current location of patient
Criteria 4 Legal status
Criteria 5 Presenting symptoms
Criteria 6 Working diagnosis
Criteria 7 Risks warranting admission
ResultsYes No %Yes
Criteria 1 19 0 100
Criteria 2 19 0 100
Criteria 3 13 6 68
Criteria 4 14 5 74
Criteria 5 18 1 95
Criteria 6 2 17 11
Criteria 7 15 4 79
Total 100 33 75.2
Patient identifiable information and source was documented in all referrals. Only 10% of referrals included a working diagnosis. Location of patient, legal status and risks warranting admission were documented between 68 and 78%.
ConclusionCrucial information such as working diagnosis was missing in 90%. Risks or legal status missing in up to a quarter of referrals. This has an impact on timely access, bed flow and potentially patient safety.
A need for improvement in receiving and documenting telephone referrals has been identified. To aid improvement in patient safety and flow, a bed manager for in hours has now been appointed. A standardised proforma for recording data will be developed by inpatient staff in collaboration with community staff to include the above criteria. A re-audit will be carried out following these service improvements.
Weight Management Quality Improvement Project in Tower Hamlets Community Learning Disability Service
- Lucy Dundas, Irem Deniz, Genevieve Hirsz, David Prior, Nicole Eady
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S134
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Aims
The project's aim is to record up-to-date BMI readings of 70% or more of our service users by September 2024. We have identified barriers limiting current data collection, such as challenges weighing wheelchair bound clients or limited availability of weighing scales, and will action our change idea methods to reach our target in this time period.
Significant health inequalities have been identified in the learning disability population, with men and women in our cohort dying 23 years and 27 years younger respectively compared with the general population. Furthermore, people with learning disabilities are at increased risk of being overweight or obese compared with other cohorts, which itself leads to a range of health and social complications. A recent audit of our psychiatry caseload revealed the need to improve weight monitoring and subsequent management for our service users, to help reduce health inequalities identified.
MethodsWe have weekly project meetings with our MDT including psychiatrists, dietetics, occupational therapists, nurses and psychologists. We have arranged stakeholder involvement by inviting service users to these weekly meetings to contribute their own ideas to the project, and have organised focus groups for service users, carers and staff. We intend to generate change ideas by using quality improvement methodology to identify primary and secondary drivers. One of these already incorporated into the project is a machine in our waiting room monitoring our clients’ weight, height and blood pressure. Having identified obstacles in our service users obtaining their weight, we have successfully bid for funding for one of these machines.
ResultsWe will use Plan Do Study Act (PDSA) cycles to evaluate the effectiveness of our change ideas. Convenient sampling of our psychiatry caseload showed only 26.7% of 71 service users have an updated weight and BMI, and identified that we don't have a robust process for monitoring patients' weights (total project caseload is 1264).
ConclusionDuring the development of this project, we identified a variety of approaches to improve health outcomes for our service users including educating staff on incorporating weight monitoring into consultations and how to manage the results. This project comprises one part of East London Foundation Trust's overall Triple Aim: to improve population health; improve the quality and improve value for the system. Going forward, our intention is to incorporate weight management into our routine reviews and ensure staff are educated in the importance of regular weight monitoring, the health benefits and how to refer.
Designing a Virtual Reality Café to Treat Eating Disorders: A Thematic Analysis of Stakeholder Viewpoints
- Lydia Shackshaft, Laura Chapman, Lucy Biddle, Lucy Yardley, Helen Bould
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S80
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Aims
Eating disorders (ED) have significant physical and psychosocial impacts, and the highest mortality rates of any psychiatric illness. About a third of patients with Anorexia Nervosa or Bulimia Nervosa do not recover and develop persistent ED. Development of novel treatments is a priority to prevent adverse effects on young people's physical, relational and educational development. Virtual reality (VR) has shown promising efficacy as an innovative mental health treatment, and has potential therapeutic value within ED. People with lived experience (PWLE) and clinicians have demonstrated enthusiasm for a VR café intervention to practice social and food-related challenges. A VR café would enable gradual exposure to challenges in a protected environment, aiming to support people with ED to return to real-life cafés and social eating. This study aims to explore the opinions of key stakeholders to help inform the development of a VR café scenario as an adjunctive treatment for ED.
MethodsWe conducted semi-structured focus groups and 1:1 interviews with PWLE aged 14–25 years (n = 15), parents/carers (n = 4), and clinicians (n = 6). Participants were recruited via social media, advertisement via ED charities, posters in public places, and snowballing. Following completion of an online screening survey, eligible individuals were invited to participate using purposive sampling to ensure diversity of ages, ethnicities, genders, ED diagnoses, and health professional roles. Data were analysed thematically.
ResultsPreliminary analysis indicates that PWLE, parents/carers and clinicians expressed mostly positive opinions regarding a VR café adjunctive treatment. Expressed concerns related to themes of intervention efficacy, translation of learnt skills to real life, and use of VR technology. Most participants agreed a VR café intervention should be a repeated experience (many suggested graded exposure), realistic, and maximally individualised. All stakeholder groups identified a similar range of challenges to experience within a VR café, with themes including choosing food, other people, eating socially or alone, and the café environment. Differences in specific aspects of the scenario that might make challenges harder or easier reflected the unique experiences of individual participants.
ConclusionThese findings build upon previous research demonstrating support from PWLE, parents/carers, and clinicians for the development of a VR café adjunctive treatment for ED. Themes identified are largely consistent across stakeholder groups and relate to the design of a VR café scenario and its implementation as a treatment. This analysis enables the perspectives of key stakeholders to be incorporated into the design of a novel VR café intervention to optimise efficacy and acceptability.
Evaluating Improvement Collaboratives in Quality Improvement Projects: Design Variations and Their Impact
- Geetika Singh, Mehtab Ghazi Rahman, Isaac Obeng, Lucy Palmer, Janet Seale
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S161
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Aims
Aim: To compare and evaluate three improvement collaboratives designs in terms of tangible and non-tangible benefits.
Background: Leading health systems have invested in substantial quality improvement capacity building, but little is known about the aggregate effect of these investments at the health system level.
Collaborative learning is one of the educational approaches of using groups to enhance learning through working together. Research shows that collaborative experiences that are active, social, contextual, engaging and student-owned leads to deeper learning.
MethodsCNWL organised three collaborative programmes with varying duration and distinct approaches to team selection, wrap-around support mechanisms, training design and post-collaborative QI support.
These three virtual collaborative programmes were co-designed with service users and carers to support 24 teams each in planning, delivering and sustaining improvements aligned with the Trust's Strategic Priorities.
All programmes provided knowledge on the Model for Improvement and co-production, enabling frontline ownership of safety solutions while building organisational QI capacity and capability.
Each collaborative was divided into Planning and Delivery phases. The evaluation, which covers a 3-year period, compares programme metrics to assess effectiveness, impact and identify areas for improvement.
ResultsIncorporating cognitive diversity is crucial in improving the learning process. Collaboratives play a vital role in achieving this, as they bring together different services, staff, and SU&C to drive improvement.
The benefits of collaborative work in quality improvement extend beyond the project data, as it can lead to positive unintended consequences such as a shift in team culture and the adoption of an improvement mindset. These outcomes gained on the journey should be evaluated and celebrated. Moreover, collaboration fosters a culture and platform for sharing and spreading learning beyond the team/service.
However, it is important to take the time to consider and compare different designs of collaboratives during the scoping phase. Factors such as the duration of the collaborative programme, the need for additional wrap-around support and the selection of measures to evaluate the programme should be carefully considered before proceeding.
Effects of changes
1. Comparing different collaborative designs identified the key enablers to a successful project. They were application process brought teams together that were ready and willing to improve; targeted wrap-around support to Sponsors, SU&Cs, Coaches and having decision gateways in design enabled focused and candid conversations about team progression.
2. Collaborative with longer time frame were more resource intensive but had a greater positive impact on safety culture, successful projects and sustained gains than the shorter duration.
3. CNWL Added Value framework evaluated tangible and non-tangible benefits, i.e. staff experience, safety and learning culture, patient experience, streamlined processes and efficiencies gained.
ConclusionIt is important to look at the local context when designing a collaborative with their clinical setting.
A consideration should be based on resources available to support the entire duration of collaborative and what are the desired outcomes of the collaborative.
Quality Improvement: The Power of Behavioural Change in Involvement
- Geetika Singh, Mehtab Ghazi Rahman, Isaac Obeng, Lucy Palmer, Janet Seale
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S162
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Aims
Aim:
80% of Central and North West London NHS Foundation Trust (CNWL) QI projects will have meaningful Service User & Carer involvement by August 2023 (baseline was 46%).
Background:
Service user and carer (SU&C) involvement is increasingly recognised as integral to healthcare improvement efforts. However, despite its many benefits, the meaningful involvement of service users and carers remains a challenge.
Thus, it is necessary to get an in-depth understanding of the barriers and enablers to embedding involvement in improvement practice at the individual, service and organisational levels. With this understanding and staff can then co-produce evidence-informed behaviour change interventions to improve SU&C involvement.
Patient representation and lived experience
This improvement work embraces a full and continuous partnership with SU&Cs.
SU&C worked with CNWL staff in the conception, execution, delivery and dissemination of this work including EbE Improvement Forum.
They, thus, serve as integral members of the project team where they provide valuable input based on their lived experiences and perspectives to help shape the direction of the work. As equal partners, it also helps foster a culture of mutual respect, collaboration, and trust between all the parties involved.
MethodsThis work adopts the COM-B model. The approach to conduct semi-structured interviews (interview questions were based on COM-B model and behavioural change wheel) with frontline healthcare staff and SU&Cs. The interviews gave insights on the barriers and facilitators to SU&C involvement in healthcare improvement work.
This then generated operational-level and actionable change ideas to guide tailored strategies for enhancing involvement capabilities, widening involvement opportunities and enabling motivations using the model for Improvement. These change ideas were then co-tested with SU&C using the Model for Improvement approach.
This systematic approach enabled a cultural shift towards collaborative partnerships between healthcare staff and SU&C to contribute to the service improvement.
Measurement of improvement
1. Qualitative data to understand enablers and barriers to involvement in improvement work.
2. Percentage of all QI projects (registered on Life QI and scoring 1 or more on IHI Project Score) that have a SU&C involvement.
ResultsEffects of changes
Staff and SU&C interviews identified the key barriers as inadequate capability (lack of understanding and skills), limited opportunities (leadership, resources, access) and insufficient motivation (discomfort, inability, time limitations). Enablers included appreciating diverse perspectives, leadership support and buy-in, established processes, valuing insights and patient empowerment.
The outcome measure also showed an increase in the number of improvement projects at CNWL that have SU&C involvement from 46% to 80%.
ConclusionLesson Learnt:
This work has shown that by bringing multi-disciplinary staff and SU&Cs together generates cognitive diversity to the learning to drive improvement and sustain the gains. Furthermore, partnership working helped to create and establish learning culture within the healthcare service.
Message to others:
1. Strong executive sponsorship helps to drive involvement across the organisation.
2. By bringing staff and SU&Cs together generates cognitive diversity to the learning to drive improvement.
3. Using well-known and established behavioural change model, such as COM-B model, helped to identify, design and synthesize behaviour change interventions.
The clinical characteristics of autistic women with restrictive eating disorders
- Janina Brede, Charli Babb, Catherine R.G. Jones, Lucy Serpell, Laura Hull, James Adamson, Hannah Baker, John R.E. Fox, Will Mandy
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- Journal:
- BJPsych Open / Volume 10 / Issue 4 / July 2024
- Published online by Cambridge University Press:
- 26 July 2024, e131
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Background
Autistic women are at high risk of developing restrictive eating disorders (REDs), such as anorexia nervosa.
AimsThis study provides an overview of the clinical characteristics of autistic women with REDs to (i) enhance understanding of increased risk, and (ii) support the identification of autistic women in eating disorder services.
MethodWe compared self-reported autistic and disordered eating characteristics of: autistic participants with REDs (Autism + REDs; n = 57); autistic participants without REDs (Autism; n = 69); and women with REDs who are not autistic (REDs; n = 80). We also included a group of women with high autistic traits (HATs) and REDs, but no formal autism diagnosis (HATs + REDs; n = 38).
ResultsAutism + REDs participants scored similarly to Autism participants in terms of autistic characteristics and to REDs participants in terms of experiencing traditional disordered eating symptoms. Autism + REDs participants were distinguished from both groups by having more restricted and repetitive behaviours and autism-specific eating behaviours related to sensory processing, flexibility and social differences. HATs + REDs participants showed a similar pattern of scores to Autism + REDs participants, and both also presented with high levels of co-occurring mental health difficulties, particularly social anxiety.
ConclusionThe presentation of autistic women with REDs is complex, including both traditional disordered eating symptoms and autism-related needs, as well as high levels of co-occurring mental health difficulties. In eating disorder services, the REDs presentation of autistic women and those with HATs should be formulated with reference to autism-specific eating behaviours and co-occurring difficulties. Treatment adaptations should be offered to accommodate autistic characteristics and related needs.
12 - Queering the Castalian: James VI and I and ‘Narratives of Blood’
- Edited by Allan Kennedy, University of Dundee, Susanne Weston, University of Dundee
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- Book:
- Life at the Margins in Early Modern Scotland
- Published by:
- Boydell & Brewer
- Published online:
- 08 May 2024
- Print publication:
- 04 June 2024, pp 194-209
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Summary
This work began life as a call to arms for the discussion of bisexuality in the era of James VI and I. In the process of development, it has come to be a consideration of early modern Scottish scholarship itself, and the ways in which the truth can be obfuscated, made wilfully opaque, implied in the margins. It is an examination of the ways in which marginalised histories are maintained in the status quo through decades of scholarship which elides the obvious, shies away from the reality of lived queer experiences, and dares not to label or name that which is discusses.
Throughout this work, the term ‘queer’ will be utilised. In considering the use of this term, the following definition becomes useful:
Queer works as an umbrella term for a range of sexual and gender identities that are not ‘straight,’ or at least not normative. In a second sense, queer functions more as a verb than a noun, signaling a critical stance … skeptical of existing identity categories and more interested in understanding the production of normativity and its queer companion, nonnormativity.
When we erase queerness, we do more than just flatten our historical understanding. In the case of James, we eliminate the potential for consideration of the influence of his parents, Mary, Queen of Scots and Lord Darnley. We further limit the potential for deeper analysis of the complex and stylistically nuanced work of poets such as Alexander Montgomerie. We deny the full lived experience of the people who shape these narratives. We wilfully push to the margins.
Indeed, there is an ever-present pushback against the retrospective labelling of concepts such as homosexual or indeed bisexual. Michael B. Young states in James VI and the History of Homosexuality that ‘strictly speaking, in early modern Britain, no one was a homosexual because the word, and arguably the connotations that went with it, did not exist’. As such, at no point does Young's initial study of James, one of the only studies in which James’ sexuality is the focus rather than a hushed sidenote, name James as a homosexual. Nor, it should be said at the outset, will this chapter. Instead of focusing on the labels of homosexual or bisexual, I wish to reclaim and instate the concept of queerness at the court of James and in his personal life.