Search

Background: Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this. Methods: Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000–04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence. Results: N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes. Conclusions: This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences. Trial registration: PROSPERO-CRD42022315252. [ABSTRACT FROM AUTHOR]

Objective: Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers. Methods: Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data. Results: Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting). Conclusion: Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk. [ABSTRACT FROM AUTHOR]

Surveys of microbial communities across transitions coupled with contextual measures of the environment provide a useful approach to dissect the factors determining distributions of microorganisms across ecological niches. Here, monthly time-series samples of surface seawater along a transect spanning the nearshore coastal environment within Kāneʻohe Bay on the island of Oʻahu, Hawaiʻi, and the adjacent offshore environment were collected to investigate the diversity and abundance of SAR11 marine bacteria (order Pelagibacterales) over a 2-year time period. Using 16S ribosomal RNA gene amplicon sequencing, the spatiotemporal distributions of major SAR11 subclades and exact amplicon sequence variants (ASVs) were evaluated. Seven of eight SAR11 subclades detected in this study showed distinct subclade distributions across the coastal to offshore environments. The SAR11 community was dominated by seven (of 106 total) SAR11 ASVs that made up an average of 77% of total SAR11. These seven ASVs spanned five different SAR11 subclades (Ia, Ib, IIa, IV, and Va), and were recovered from all samples collected from either the coastal environment, the offshore, or both. SAR11 ASVs were more often restricted spatially to coastal or offshore environments (64 of 106 ASVs) than they were shared among coastal, transition, and offshore environments (39 of 106 ASVs). Overall, offshore SAR11 communities contained a higher diversity of SAR11 ASVs than their nearshore counterparts, with the highest diversity within the little-studied subclade IIa. This study reveals ecological differentiation of SAR11 marine bacteria across a short physiochemical gradient, further increasing our understanding of how SAR11 genetic diversity partitions into distinct ecological units. [ABSTRACT FROM AUTHOR]

The climate change issue has attracted the attention of civil society organisations in the European Union but standard theories of groups as interest aggregators fail to offer a convincing explanation of their characteristics and contribution. However as the concept of representation has been transformed – from a static view pertaining mostly to legislatures, to a dynamic view of a creative act involving all political actors – it has opened up the possibility of a new explanatory framework for understanding how groups make environmental issues present. This is in direct contrast to the idea of representation and the role of groups outlined in the Lisbon Treaty. [ABSTRACT FROM PUBLISHER]

the European Citizens’ Initiative (ECI) is the latest in a line of institutional innovations that have sought to enhance the participatory nature of EU politics. The extent to which this results in a more democratic EU, however, is questionable because simply having opportunities for participation does not equate to participatory democracy. Participation in the EU has tended to favour the involvement of various ‘civil society’ organisations rather than individual citizens. Moreover it has been justified largely on the grounds that it results in more democratic and efficient institutions and decision-making processes. The notion of participation and its relationship with democracy found in the writings of theorists of participatory democracy is somewhat more radical. Not only does it address individuals in favouring measures that make democracy count in people's everyday lives, it also views participation as leading to human development by enhancing feelings of efficacy, reducing a sense of distance from political authority, stimulating concern for collective problems and solutions, and encouraging citizens to be active and knowledgeable about politics. This paper argues that the ECI sees the EU move a little closer to a more radical view. It finds evidence of this in an acknowledgement that the ECI is to be valued partly because of the ways in which it can benefit individual citizens (as opposed to the EU's decision-making structures) in the arguments for a ‘citizen-friendly’ and usable instrument. [ABSTRACT FROM PUBLISHER]

In this article we analyse the phenomenon of public debate on the future of Europe which has been become a preferred tool of EU policymakers over the last decade. We assess the potential legitimacy benefits of such a public debate process and examine in detail two case studies: the Convention on the Future of Europe and the Debate Europe website. We compare these two public debates with regard to their composition, objectives and working procedures. Our findings show that public debate is no panacea for the EU's ongoing legitimacy-related problems and they also point to general challenges for citizens' involvement in the ongoing European integration process. [ABSTRACT FROM AUTHOR]

Describes the role of the receptor for urokinase-type plasminogen activator in regulating fibronectin matrix assembly in human skin fibroblasts. Integrins; Extracellular matrix; Monoclonal antibodies.

Objectives: This study aims to examine the proportions of patients referred to mental health, social and voluntary, community and social enterprise (VCSE) services and general practice and to assess care gaps among people presenting to the hospital following self-harm., Design: Population-based observational study. Data were extracted from hospital records., Setting: Three emergency departments (EDs) in Manchester, UK., Participants: 26 090 patients aged 15+ years who presented to participating EDs following self-harm and who received a psychosocial assessment by a mental health specialist., Primary and Secondary Outcome Measures: Primary outcome measures are as follows: care gaps, estimated from the proportion of patients with evidence of social and mental health needs with no new or active referral to mental health, social and VCSE services. Secondary outcome measures are as follows: proportions of referrals by groups of patients, estimated mental health and social needs of patients. Indicators of mental health and social need were developed with academic clinicians (psychiatrist, general practitioner and social worker) and expert lived experience contributors., Results: 96.2% (25 893/26 909) of individuals were estimated as having mental health needs. Among this group, 29.9% (6503/21 719) had no new or active referral to mental health services (indicating a care gap). Mental healthcare gaps were greater in men and those who were aged under 35 years, from a black, South Asian or Chinese ethnic group, living in the most deprived areas and had no mental health diagnosis, or alcohol, substance misuse, anxiety or trauma-related disorder. 52.8% (14 219/26 909) had social needs, with care gaps greater for men, individuals aged 45-64 and those who were unemployed or had a diagnosed mental disorder., Conclusions: Care gaps were higher among hospital-presenting groups known to have increased risks of suicide: men, those in middle age, unemployed individuals and those misusing substances. Improved access to mental health, social and VCSE services and general practice care is vital to reduce inequities in access to self-harm aftercare., Competing Interests: Competing interests: NK reports research grants and fees to related his research and implementation work in self-harm and suicide prevention from the Department of Health and Social Care, the National Institute for Health and Care Research, the Healthcare Quality Improvement Partnership and the National Institute for Health and Care Excellence (NICE). NK does not receive industry funding for research. NK is a member of England's National Suicide Prevention Strategy Advisory Group and is supported by Mersey Care NHS Foundation Trust. NK chaired the NICE guideline development group for the NICE depression in adults' guideline and was a topic expert member for the NICE suicide prevention guideline. NK chaired the guideline development group for the NICE guidelines on the longer-term management of self-harm and was a topic advisor on the 2022 NICE guideline on self-harm. FM was a member of the 2022 NICE guideline development committee. The other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Psychological therapies following an episode of self-harm should happen quickly to ensure patients receive the care they need and to reduce the likelihood of repetition., Aims: We sought to explore patients' subjective experience of accessing psychological therapies following self-harm and their views on improving practice., Method: Between March and November 2019, we recruited 128 patients and 23 carers aged 18 years or over from 16 English mental health trusts, from community organisations and via social media. Thematic analyses were used to interpret the data., Results: Participants reported long waiting times, multiple failed promises and rejection when trying to access psychological therapies following self-harm. Poor communication and information provision contributed to uncertainty, worsening mental health and further self-harm. Other barriers included: lack of tailored interventions, stigmatising responses, use of exclusionary thresholds to access services, and punitive approaches to treating these patients. Participant recommendations to improve access to psychological therapies included: (a) the importance of compassionate and informed staff; (b) having timely access to aftercare from well-funded and well-resourced teams; (c) continuity of care, improved communication, and support during waiting times and while navigating the referral process; (d) greater information on the availability and benefits of psychological therapies; and (e) greater choice and flexibility over interventions., Conclusion: Our findings identify long waiting times and inadequate service provision as barriers to high-quality and safe aftercare for patients who have self-harmed. Consistent with clinical guidelines, all patients should receive prompt aftercare and access to tailored psychological treatments following a self-harm episode.

Background: Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide., Aims: To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services., Method: A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis., Results: Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement., Conclusions: Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.

Background: Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate., Aims: To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners., Method: Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data., Results: Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services., Conclusions: Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

Objectives: We sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm., Design: Thematic analysis of free-text responses to an open-ended online survey., Setting: Between March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media., Results: Psychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a 'behavioural issue', inappropriate use of services and psychiatric diagnosis., Conclusion: Our findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency., Competing Interests: Competing interests: NK is a member of the Department of Health’s (England) National Suicide Prevention Advisory Group. He chaired the NICE guideline development group for the long-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). NK is currently chair of the updated NICE guideline for Depression and Topic Advisor to the new NICE self-harm guideline. He is also supported by the Greater Manchester Mental Health NHS Foundation Trust., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

While marine microorganisms are frequently studied in their natural environment, isolated strains are invaluable resources that can be used in controlled experiments to expand upon direct observations from natural systems. Here, we sought a means to enhance culture collections of SAR11 marine bacteria by testing the use of seawater cryopreserved with glycerol as an inoculum. Using a raw seawater sample collected from the tropical Pacific Ocean, a subsample was diluted in seawater growth medium to create 576 2-ml dilution cultures containing 5 cells each and incubated for a high-throughput culturing (HTC) experiment, while another portion was cryopreserved in 10% glycerol. After 10 months, a cryopreserved aliquot was thawed and used to create a second cultivation experiment of 480 2-ml cultures containing 5 cells each and 470 cultures containing 105 cells each. The raw seawater cultivation experiment resulted in the successful isolation of 54 monocultures and 29 mixed cultures, while cryopreserved seawater resulted in 59 monocultures and 29 mixed cultures. Combined, the cultures included 51 SAR11 isolates spanning 11 unique 16S rRNA gene amplicon sequence variants (ASVs) from the raw seawater inoculum and 74 SAR11 isolates spanning 13 unique ASVs from cryopreserved seawater. A vast majority (92%) of SAR11 isolates from the two HTC experiments were members of SAR11 subclade Ia, though subclades IIIa and Va were also recovered from cryopreserved seawater and subclade Ib was recovered from both. The four most abundant SAR11 subclade Ia ASVs found in the initial seawater environmental sample were isolated by both approaches. IMPORTANCE High-throughput dilution culture has proved to be a successful approach to bring some difficult-to-isolate planktonic microorganisms into culture, including the highly abundant SAR11 lineage of marine bacteria. While the long-term preservation of bacterial isolates by freezing them in the presence of cryoprotectants, such as glycerol, has been shown to be an effective method of storing viable cells over long time periods (i.e., years), to our knowledge it had not previously been tested for its efficacy in preserving raw seawater for later use as an inoculum for high-throughput cultivation experiments. We found that SAR11 and other abundant marine bacteria could be isolated from seawater that was previously cryopreserved for nearly 10 months at a rate of culturability similar to that of the same seawater used fresh, immediately after collection. Our findings (i) expand the potential of high-throughput cultivation experiments to include testing when immediate isolation experiments are impractical, (ii) allow for targeted isolation experiments from specific samples based on analyses such as microbial community structure, and (iii) enable cultivation experiments across a wide range of other conditions that would benefit from having source inocula available over extended periods of time., (Copyright © 2020 Monaghan et al.)