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Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.
To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.
Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.
Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient’s mental capacity at the time of writing), time constraints and significant legal/ethical complexities.
The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.
Declaration of interest
D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
2,4-dimethylamine salt (2,4-D) is a synthetic auxin herbicide used extensively in turfgrass for selective broadleaf weed control. Previous research has shown that 2,4-D can dislodge from treated turf, notably in the presence of canopy moisture. Practitioners commonly apply 2,4-D in combination with various commercially available surfactants to increase efficacy. Field research was completed to evaluate the effect of surfactant inclusion and sample collection time within a day on dislodgeable 2,4-D residue from perennial ryegrass. Research was initiated May 24, 2016 in Raleigh, NC and repeated in time to quantify dislodgeable 2,4-D following application (2.1 kg ae ha–1) either alone or with a nonionic surfactant (0.5% vol/vol). Sample collection occurred 1, 2, 3, 6, 12 or 24 d after treatment (DAT) at AM [7:00 AM Eastern Standard Time (EST)] and PM (2:00 PM EST) sample timings within a day. 2,4-D applied with surfactant (0.4% to 25.4% of applied) reduced dislodgeable foliar residue compared to 2,4-D applied alone (0.5% to 31.2%) from 1 through 6 DAT, whereas dislodgeable 2,4-D was not detected at 12 and 24 DAT. Regardless of surfactant inclusion or absence, samples collected in the AM resulted in a 5- to 10-fold increase in dislodgeable 2,4-D compared to samples collected in the PM from 1 through 6 DAT, suggesting that 2,4-D dislodgeability may be influenced by conditions favoring canopy moisture development. This research will improve turfgrass management practices and research designed to minimize human 2,4-D exposure.
Lake et al. underrate both the promise and the limitations of contemporary deep learning techniques. The promise lies in combining those techniques with broad multisensory training as experienced by infants and children. The limitations lie in the need for such systems to possess functional subsystems that generate, monitor, and switch goals and strategies in the absence of human intervention.
Archaeological fieldwork preceding housing development revealed a Mesolithic site in a primary context. A central hearth was evident from a cluster of calcined flint and bone, the latter producing a modelled date for the start of occupation at 8220–7840 cal bc and ending at 7960–7530 cal bc (95% probability). The principal activity was the knapping of bladelets, the blanks for microlith production. Impact-damaged microliths indicated the re-tooling of hunting weaponry, while microwear analysis of other tools demonstrated hide working and butchery activity at the site. The lithics can be classified as a Honey Hill assemblage type on the basis of distinctive leaf-shaped microlithic points with inverse basal retouch.
Such assemblages have a known concentration in central England and are thought to be temporally intermediate between the conventional British Early and Late Mesolithic periods. The lithic assemblage is compared to other Honey Hill type and related Horsham type assemblages from south-eastern England. Both assemblage types are termed Middle Mesolithic and may be seen as part of wider developments in the late Preboreal and Boreal periods of north-west Europe. Rapid climatic warming at this time saw the northward expansion of deciduous woodland into north-west Europe. Emerging new ecosystems presented changes in resource patterns and the Middle Mesolithic lithic typo-technological developments reflect novel foraging strategies as adaptations to the new opportunities of Boreal forest conditions. While Honey Hill-type assemblages are seen as part of such wider processes their distinctive typological signature attests to autochthonous, regional developments of human groups infilling the landscape. Such cultural insularity may reflect changing social boundaries with reduction in mobility range and physical isolation caused by rising sea level and the creation of the British archipelago.
Glacier mass balance and hydrology are strongly influenced by the distribution of snow accumulation at the start of the melt season. Two successive end-of-winter snow-cover surveys at Finsterwalderbreen, Svalbard, are here used to investigate the interannual variability in the spatial distribution of accumulation, and its relationship with topography. 40–62% of the variance in snow depth was not determined by elevation (assessed by linear regression of snow depth on surface elevation), which could not therefore necessarily be used as a sole predictor of the spatial distribution of accumulation here. Principal components (PC) analysis of the topographic variables elevation, slope, north–south and east–west aspects shows that only two of six PCs, determined for 2years’ sampling locations, had maximum loadings on altitude; aspect was more important, with maximum loadings on four PCs. Hierarchical cluster analysis was then applied to these PCs: significant correlations with accumulation in each of two terrain clusters were given by (1) elevation and slope, (2) east–west aspect only (1999); (1) elevation only, (2) no significant correlations (2000). There is strong interannual variability not only in the magnitude of winter accumulation (0.41 mw.e. in 1999, 0.58 mw.e. in 2000), but also in its spatial distribution, and its relationship with topography.
Computerised cognitive–behavioural therapy (cCBT) for depression has the potential to be efficient therapy but engagement is poor in primary care trials.
We tested the benefits of adding telephone support to cCBT.
We compared telephone-facilitated cCBT (MoodGYM) (n = 187) to minimally supported cCBT (MoodGYM) (n = 182) in a pragmatic randomised trial (trial registration: ISRCTN55310481). Outcomes were depression severity (Patient Health Questionnaire (PHQ)-9), anxiety (Generalized Anxiety Disorder Questionnaire (GAD)-7) and somatoform complaints (PHQ-15) at 4 and 12 months.
Use of cCBT increased by a factor of between 1.5 and 2 with telephone facilitation. At 4 months PHQ-9 scores were 1.9 points lower (95% CI 0.5–3.3) for telephone-supported cCBT. At 12 months, the results were no longer statistically significant (0.9 PHQ-9 points, 95% CI −0.5 to 2.3). There was improvement in anxiety scores and for somatic complaints.
Telephone facilitation of cCBT improves engagement and expedites depression improvement. The effect was small to moderate and comparable with other low-intensity psychological interventions.
Anxiety disorders are common, and cognitive–behavioural therapy (CBT) is a first-line treatment. Candidate gene studies have suggested a genetic basis to treatment response, but findings have been inconsistent.
To perform the first genome-wide association study (GWAS) of psychological treatment response in children with anxiety disorders (n = 980).
Presence and severity of anxiety was assessed using semi-structured interview at baseline, on completion of treatment (post-treatment), and 3 to 12 months after treatment completion (follow-up). DNA was genotyped using the Illumina Human Core Exome-12v1.0 array. Linear mixed models were used to test associations between genetic variants and response (change in symptom severity) immediately post-treatment and at 6-month follow-up.
No variants passed a genome-wide significance threshold (P=5×10–8) in either analysis. Four variants met criteria for suggestive significance (P<5×10–6) in association with response post-treatment, and three variants in the 6-month follow-up analysis.
This is the first genome-wide therapygenetic study. It suggests no common variants of very high effect underlie response to CBT. Future investigations should maximise power to detect single-variant and polygenic effects by using larger, more homogeneous cohorts.
Studies on the role of diet in the development of chronic diseases often rely on self-report surveys of dietary intake. Unfortunately, many validity studies have demonstrated that self-reported dietary intake is subject to systematic under-reporting, although the vast majority of such studies have been conducted in industrialised countries. The aim of the present study was to investigate whether or not systematic reporting error exists among the individuals of African ancestry (n 324) in five countries distributed across the Human Development Index (HDI) scale, a UN statistic devised to rank countries on non-income factors plus economic indicators. Using two 24 h dietary recalls to assess energy intake and the doubly labelled water method to assess total energy expenditure, we calculated the difference between these two values ((self-report − expenditure/expenditure) × 100) to identify under-reporting of habitual energy intake in selected communities in Ghana, South Africa, Seychelles, Jamaica and the USA. Under-reporting of habitual energy intake was observed in all the five countries. The South African cohort exhibited the highest mean under-reporting ( − 52·1 % of energy) compared with the cohorts of Ghana ( − 22·5 %), Jamaica ( − 17·9 %), Seychelles ( − 25·0 %) and the USA ( − 18·5 %). BMI was the most consistent predictor of under-reporting compared with other predictors. In conclusion, there is substantial under-reporting of dietary energy intake in populations across the whole range of the HDI, and this systematic reporting error increases according to the BMI of an individual.
Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.
Dual-Polarization Radar and Twitter were analyzed to determine the impact on injuries sustained by the Hattiesburg EF-4 tornado.
Tracking data provided from the Dual-Pol radar systems in National Weather Service Jackson were reviewed. Twitter data from four local Twitter handles were obtained. The change in tweets and followers for the day of the storm were compared to historical averages. A Student t-test was utilized in determining statistical significance (p<0.05). Medical records from two local emergency departments were reviewed for patients treated up to 24 hours after the tornado. An Injury Severity Score (ISS) was calculated for trauma records related to the tornado.
Radar detection of the tornado gave approximately 30 minutes of advanced warning time. Statistical significance in follower growth was seen in all four Twitter handles. Out of 50 patients, the average ISS was 3.9 with a range of 1 to 29. There were zero fatalities.
An ISS average of 3.9 was significantly less than two previous tornadoes of similar strength that occurred prior to increased usage of Dual-pol radar and Twitter as a means for communicating severe weather information. Early detection from Dual-pol radar improved warning time. Tweets informed citizens to seek appropriate shelter. (Disaster Med Public Health Preparedness. 2013;7:585-592)
Several factors threaten populations of albatrosses and giant petrels, including the impact of fisheries bycatch and, at some colonies, predation from introduced mammals. We undertook population monitoring on Gough Island of three albatross species (Tristan albatross Diomedea dabbenena L., sooty albatross Phoebetria fusca Hilsenberg, Atlantic yellow-nosed albatross Thalassarche chlororhynchos Gmelin) and southern giant petrels Macronectes giganteus (Gmelin). Over the study period, numbers of the Critically Endangered Tristan albatross decreased at 3.0% a year. Breeding success for this species was low (23%), and in eight count areas was correlated (r2 = 0.808) with rates of population decline, demonstrating chick predation by house mice Mus musculus L. is driving site-specific trends and an overall decline. Numbers of southern giant petrels were stable, contrasting with large increases in this small population since 1979. Significant population declines were not detected for either the Atlantic yellow-nosed or sooty albatross, however, caution should be applied to these results due to the small proportion of the population monitored (sooty albatross) and significant interannual variation in numbers. These trends confirm the Critically Endangered status of the Tristan albatross but further information, including a more accurate estimate of sooty albatross population size, is required before determining island wide and global population trends of the remaining species.
Studies of therapeutic contact following self-harm have had mixed results. We carried out a pilot randomised controlled trial comparing an intervention (information leaflet listing sources of help, two telephone calls soon after presentation and a series of letters over 12 months) to usual treatment alone in 66 adults presenting with self-harm to two hospitals. We found that our methodology was feasible, recruitment was challenging and repeat self-harm was more common in those who received the intervention (12-month repetition rate 34.4% v. 12.5%).
A series of very wide (up to 15 km) raised shore platforms in the Scottish Hebrides are identified and described for the first time and are considered part of a high rock platform shoreline in the western isles of Scotland described by W. B. Wright in his classic Geological Magazine paper a century ago as a ‘preglacial’ feature. Subsequent interpretations suggesting that the platforms were produced during the Pleistocene are rejected here in favour of a speculative hypothesis that the features are part of the well-known strandflat that is extensively developed across large areas of the northern hemisphere. It is argued that the Scottish strandflat developed during the Pliocene and was later subjected to extensive Pleistocene glacial erosion such that only a few areas of platform have survived in the Scottish Inner Hebrides (ice-proximal) while they are well-preserved in the Outer Hebrides (ice-distal). Support for a Pliocene hypothesis is provided by the marine oxygen isotope record for this time interval which points to prolonged periods of relative sea level stability as would be required for the production of such wide features. This hypothesis for the formation of a Scottish strandflat not only provides an elegant explanation for the origin and age of the raised rock platform fragments that occur throughout the western isles of Scotland, but it may also have relevance for other coastal areas of the northern hemisphere (e.g. Norway, Greenland, Alaska) where the strandflat is a well-developed feature.