Search

Abstract: Objectives: to explore midwives'' intrapartum referral decisions in relation to their dispositional attitude towards risk. Design: a web-based correlation study examined the association between midwife''s personality (personal risk tendency), place of work (location), years of experience and the timing of their decisions to make referrals (referral score) in a series of fictitious case scenarios (vignettes). Participants: 102 midwives providing labour care in both consultant-led units (CLU) and community maternity units (CMU) from four Scottish health board areas. Analysis: a correlational analysis was carried out to test the association between total risk scores and midwives'' referral scores. Between-group comparisons were also conducted for experienced vs inexperienced midwives, midwives practising in CLU vs CMU settings and between the four health board areas. Findings: despite being presented with identical information in the vignettes, midwives made a wide range of referral decisions. There was no association between referral scores and measures of risk, personality or years of experience. No statistically significant difference between the referral scores of midwives working in CLUs or CMUs was observed. However, a statistically significant difference did emerge between the four health board areas, with midwives from one area making referrals at a significantly earlier stage. The maternity services in this area had experienced several high profile adverse events prior to this study; this may have influenced their referral behaviour (the availability heuristic), in terms of making more cautious decisions. Key conclusions: there was no evidence that variability in the range of referral decisions was due to personality factors, risk propensity, experience or whether the midwife worked in a CLU or CMU. Local factors such as recent adverse events may significantly influence subsequent referral behaviour. Further research is required to identify why the midwives showed so much unexplained variability in their responses to the vignettes. [ABSTRACT FROM AUTHOR]

Objectives: Social distancing restrictions in the COVID-19 pandemic may have had adverse effects on older adults' mental health. Whereby the impact on mood is well-described, less is known about psychotic symptoms. The aim of this study was to compare characteristics associated with psychotic symptoms during the first UK lockdown and a pre-pandemic comparison period., Methods: In this retrospective observational study we analysed anonymised records from patients referred to mental health services for older adults in South London in the 16-week period of the UK lockdown starting in March 2020, and in the comparable pre-pandemic period in 2019. We used logistic regression models to compare the associations of different patient characteristics with increased odds of presenting with any psychotic symptom (defined as hallucinations and/or delusion), hallucinations, or delusions, during lockdown and the corresponding pre-pandemic period., Results: 1991 referrals were identified. There were fewer referrals during lockdown but a higher proportion of presentations with any psychotic symptom (48.7% vs. 42.8%, p = 0.018), particularly hallucinations (41.0% vs. 27.8%, p < 0.001). Patients of non-White ethnicity (adjusted odds ratio (OR): 1.83; 95% confidence interval (CI): 1.13-2.99) and patients with dementia (adjusted OR: 3.09; 95% CI: 1.91-4.99) were more likely to be referred with psychotic symptoms during lockdown. While a weaker association between dementia and psychotic symptoms was found in the pre-COVID period (adjusted OR: 1.55; 95% CI: 1.19-2.03), interaction terms indicated higher odds of patients of non-White ethnicity or dementia to present with psychosis during the lockdown period., Conclusions: During lockdown, referrals to mental health services for adults decreased, but contained a higher proportion with psychotic symptoms. The stronger association with psychotic symptoms in non-White ethnic groups and patients with dementia during lockdown suggests that barriers in accessing care might have increased during the COVID-19 pandemic., (© 2022 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons Ltd.)

Objectives: Loneliness is associated with psychiatric morbidity. Restrictions placed on the population during the first COVID-19 lockdown may have disproportionately affected older adults, possibly through increasing loneliness. We sought to investigate this by examining loneliness in referrals to mental health of older adults (MHOA) services during the first UK COVID-19 lockdown., Methods: Referrals to MHOA services from a large South London catchment area were identified for the 16-week period of the UK lockdown starting in March 2020 and for the corresponding period in 2019. A natural language processing algorithm identified loneliness in the patients' records. We applied logistic regression models adjusted for age, gender, ethnicity and diagnosis, to examine associations of loneliness in the study population., Results: 1991 referrals were identified, 56.9% of whom were female, with a mean age of 77.9 years. Only 26.9% occurred during the 2020 lockdown, but with a higher prevalence of loneliness (22.0 vs. 17.7%, p = 0.028). In the whole sample, loneliness was associated with non-accidental self-injury (Odds ratio [OR]: 1.65), depressed mood (OR: 1.73), psychotic symptoms (OR: 1.65), relationship problems (OR: 1.49), problems with daytime activities (OR: 1.36), and antidepressant use (OR: 2.11). During lockdown, loneliness was associated with non-accidental self-injury (OR: 2.52), problem drinking or drug-taking (OR 2.33), and antidepressant use (OR 2.10)., Conclusions: Loneliness is associated with more severe symptoms of affective illness, worse functional problems and increased use of antidepressant medication in older adults. During lockdown, loneliness in referrals to MHOA services increased and was associated with increased risk-taking behaviour. Loneliness is a potential modifiable risk factor for mental illness, and efforts to minimise it in older adults should be prioritised as we emerge from the pandemic., (© 2021 John Wiley & Sons Ltd.)

Purpose of the Study: To ascertain factors influencing referral to, and outcomes from medical tribunals for junior doctors with less than 7 years of postgraduate training., Study Design: A mixed methods analysis of 49 publicly available determinations from the UK Medical Practitioner Tribunal Service (MPTS) between 2014 and 2020 was undertaken. Data on demographics, training grade, type of case and outcomes from the tribunal were recorded. A qualitative thematic analysis of the determinations was also undertaken, with themes being identified based on frequency and pertinence to the process of determination., Results: The largest group of junior doctors referred to an MPTS tribunal (38%) was those on the foundation programme; in their first 2 years postgraduation. Fifty-three per cent of all junior doctors referred to a tribunal were erased from the medical register. Erasure from the register was significantly associated with male gender, less than 4 years postqualification, non-attendance at the tribunal hearing, lack of legal representation and lack of insight or remorse at the tribunal hearing. Several cases involved dishonesty in relation to academic achievements and workplace-based assessments., Conclusion: Consideration should be given as to how best to support the transition in professional identity from student to doctor. Teaching medical professionalism should be a priority in undergraduate and early postgraduate education, with lessons from fitness to practice tribunals shared for educational purposes., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Summary: Since the start of the COVID-19 pandemic the UK's National Health Service (NHS) has been transformed to meet the acute healthcare needs of infected patients. This has significantly affected medical education, both undergraduate and postgraduate, with potential long-term implications for psychiatric recruitment. This article discusses these ramifications, and the opportunities available to mitigate them as well as to enhance the profile of psychiatry.

Definitive haematopoiesis in the fetal liver supports self-renewal and differentiation of haematopoietic stem cells and multipotent progenitors (HSC/MPPs) but remains poorly defined in humans. Here, using single-cell transcriptome profiling of approximately 140,000 liver and 74,000 skin, kidney and yolk sac cells, we identify the repertoire of human blood and immune cells during development. We infer differentiation trajectories from HSC/MPPs and evaluate the influence of the tissue microenvironment on blood and immune cell development. We reveal physiological erythropoiesis in fetal skin and the presence of mast cells, natural killer and innate lymphoid cell precursors in the yolk sac. We demonstrate a shift in the haemopoietic composition of fetal liver during gestation away from being predominantly erythroid, accompanied by a parallel change in differentiation potential of HSC/MPPs, which we functionally validate. Our integrated map of fetal liver haematopoiesis provides a blueprint for the study of paediatric blood and immune disorders, and a reference for harnessing the therapeutic potential of HSC/MPPs.

Studies of DALT in pediatric recipients describe incidence and risk factors, but diagnostic criteria varied. This study reports characteristics and course of pediatric DALT by established diabetes criteria. Retrospective chart review of pediatric LT recipients evaluated for hyperglycemia (1/1/1997-12/30/2009) and matched, non-diabetic controls. DALT: random blood glucose >11.1 mm, ≥ 2 times, with insulin treatment. DALT diagnosed in 8.0% (24/300) included 7/24 (29.2%) with severe hyperglycemia (>27.7 mm), ketoacidosis in 2/24 (8.3%). At diagnosis, age was ≥ 11 yr old in 22/24 (91.7%); body mass was lean (BMIz -0.2 ± 1.5). Mean blood glucose was 24.6 mm with negative diabetes autoantibodies (19/19) and elevated C-peptide (2.3 nm). DALT onset median 5.0 months included 29.1% >12 months. Insulin duration median 4.6 months included 41.7% >6 months. DALT resolved in 83.3% over 4.9 (0.9-9.1) yr. DALT differed from controls by increased preceding rejections, prednisolone dose, tacrolimus level, and triple immunosuppression (all p < 0.01). In conclusion, pediatric DALT occurred in non-obese adolescents with insulin resistance, distinct from diabetes types 1 or 2. DALT was associated with preceding rejection and increased immunosuppression. Blood glucose monitoring, especially during increased immunosuppression following LT, could allow early diagnosis and reduce morbidity., (© 2012 John Wiley & Sons A/S.)

Purpose: Most obese youth screened for diabetes have normal fasting glucose levels. Identification of youth with increased risk for type 2 diabetes (T2D) is needed within this large population to guide further management., Methods: Retrospective chart review was performed for obese youth, 8-20 yr old, who met American Diabetes Association criteria for screening (OB) or had T2D (D). Measures included body mass index z-score (BMIz) and homeostasis model assessment of insulin resistance (HOMA-IR) by fasting plasma glucose (FPG) and insulin. Statistics compared OB with D and further examined OB by latent class analysis (LCA)., Results: Normal FPG was found in 91.5% of all obese youth (OBt n = 94) Comparison of OB with normal FPG (OBng; n = 86) and D (n = 44) was significant for family history of T2D (p = 0.008) without other associations. Evaluation of OBng by LCA showed three classes with increasing BMIz and HOMA-IR. Class 3 (32.5%; BMIz 2.66 ± 0.38; HOMA-IR 6.72 ± 2.29) differed from classes 1 and 2 (p < 0.05), and was associated with family history of T2D., Conclusion: Currently recommended screening of obese youth by FPG is normal in 91.5%, but lacks further information to detect increased risk for youth-onset T2D. Evaluation of obese youth by LCA identified one third (class 3) in whom the combination of higher levels of BMIz, HOMA-IR, and family history suggests the greatest risk for T2D and targets them for further evaluation and intensive preventative management., (© 2011 John Wiley & Sons A/S.)

Objectives: to develop appropriate tools to assess midwives' attitudes and behaviour in relation to decision making involving risk., Design: a questionnaire and series of vignettes were developed and testes to explore midwives' intrapartum decision making in relation to their attitudes towards risk. An innovative online computer package was developed specifically for use in the STORK Study which enabled the programme to be very tightly controlled with limited functions accessible to participants., Testing: a pilot study was conducted with over 50 midwives and nurses to ensure face and content validity of the vignettes and questionnaire. Initially designed to be a paper-based study, rigorous piloting highlighted the many difficulties in presenting it in that particular format. The solution to this problem was to develop the study as a secure online package., Findings: online data collection provided the researchers with a greater degree of control of the data collection process, not achievable using traditional paper survey methods. Another example of this control is the immediate entry of data from participants' responses to a background database which automatically stores and backs up data this means that no additional time is required for data entry. The cost of employing an information technology professional was easily offset by the financial savings made through the limited use of stationery and postage., Key Conclusions: although the development and testing of the research tools for the STORK Study was labour and time intensive, ultimately a questionnaire and vignette package was produced that had been rigorously tested by over 50 midwives and nurses. The researchers are confident in the reliability of the questionnaire and vignettes, as well as the validity of the data collected. The use of an online survey is clearly indicated when the population has readily available internet access, and where controlling the process of data collection is required, as such control cannot be achieved in traditional survey and questionnaire implementation., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: Guide policy-makers in prioritizing safe motherhood interventions., Methods: Three models (LOW, MED, HIGH) were constructed based on 34 sub-Saharan African countries to assess the relative cost-effectiveness of available safe motherhood interventions. Cost and effectiveness data were compiled and inserted into the WHO Mother Baby Package Costing Spreadsheet. For each model we assessed the percentage in maternal mortality reduction after implementing all interventions, and optimal combinations of interventions given restricted budgets of US$ 0.50, US$ 1.00, US$ 1.50 per capital maternal health expenditures respectively for LOW, MED, and HIGH models., Results: The most cost-effective interventions were family planning and safe abortion (fpsa), antenatal care including misoprostol distribution for postpartum hemorrhage prevention at home deliveries (anc-miso), followed by sepsis treatment (sepsis) and facility-based postpartum hemorrhage management (pph)., Conclusions: The combination of interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk. Those which save the most number of lives in each model are 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for LOW; 'fpsa, anc-miso' and 'fpsa, sepsis, safe delivery' for MED; and 'fpsa, anc-miso, sepsis, eclampsia treatment, safe delivery' for HIGH settings. Safe motherhood interventions save a significant number of newborn lives.

High maternal morbidity and mortality in many developing countries are highly associated with poor access to and quality of health care. Here we review the economic feasibility of the WHO's mother-baby package as a means of reducing maternal and neonatal mortality and morbidity in Tanzania. This paper examines the costs of maternal health care in Tanzania, and how much can we expect households to contribute to these expenses, if the MBP were implemented. Using data from the Tanzanian 1993 Living Standard Measurement Survey (LSMS), we analyze responses from 757 women of reproductive age who have had a birth in the 12 months preceding the survey. We estimate current spending on maternal health care by different socio-economic groups and its share in relation to total household expenditures. Using logistic regression analyses, we examine the effect of the prices paid for maternal health care on the likelihood of using antenatal and safe delivery services, controlling for relevant socio-economic and demographic factors. Results show that if the MBP recovered 100% of its costs, most of the households would have to allocate more than half of their annual consumption on maternal health care. Poor socio-economic groups would experience the greatest increase in service utilization if MBP care were subsidized. In the face of scarce resources, subsidies should be targeted according to socio-economic group, in order to attain equitable and sustainable maternal health services.

Cathepsin K, a lysosomal cysteine protease critical for bone remodeling by osteoclasts, was recently identified as the deficient enzyme causing pycnodysostosis, an autosomal recessive osteosclerotic skeletal dysplasia. To investigate the nature of molecular lesions causing this disease, mutations in the cathepsin K gene from eight families were determined, identifying seven novel mutations (K52X, G79E, Q190X, Y212C, A277E, A277V, and R312G). Expression of the first pro region missense mutation in a cysteine protease, G79E, in Pichia pastoris resulted in an unstable precursor protein, consistent with misfolding of the proenzyme. Expression of five mature region missense defects revealed that G146R, A277E, A277V, and R312G precursors were unstable, and no mature proteins or protease activity were detected. The Y212C precursor was activated to its mature form in a manner similar to that of the wild-type cathepsin K. The mature Y212C enzyme retained its dipeptide substrate specificity and gelatinolytic activity, but it had markedly decreased activity toward type I collagen and a cathepsin K-specific tripeptide substrate, indicating that it was unable to bind collagen triple helix. These studies demonstrated the molecular heterogeneity of mutations causing pycnodysostosis, indicated that pro region conformation directs proper folding of the proenzyme, and suggested that the cathepsin K active site contains a critical collagen-binding domain.

Transient congenital hypoparathyroidism (TCHP), with spontaneous resolution in infancy and subsequent recurrence in childhood, has not been associated with a specific cause. We report three patients with TCHP, initially with severe but transient neonatal hypocalcemia. During childhood, recurrence of hypoparathyroidism and recognition of phenotypic features suggested a diagnosis of velocardiofacial syndrome (VCFS). Features specific for the DiGeorge syndrome, with known clinical and genetic overlap with VCFS, were not present except for hypoparathyroidism. Genetic analysis confirmed chromosome 22q11 deletion in each patient. TCHP may be the earliest specific finding in 22q11 deletion/VCFS subgroup, with other diagnostic features emerging in later childhood. Infants with resolved TCHP need continued observation of parathyroid sufficiency, genetic analysis, and examination for anomalies associated with chromosome 22q11 deletion.

Male rats given 250 mug oestradiol benzoate by subcutaneous injection on Day 4 of postnatal life showed a marked delay in the onset of the pubertal increase in the weight of the testes and seminal vesicles and in spermatogenesis but not a complete failure of sexual development. The increase in plasma testosterone concentration at puberty was also delayed in oestrogen-treated males but the eventual increase in seminal vesicle weight was closely related in time to the delayed increase in plasma testosterone concentration. Both plasma LH and FSH concentrations were reduced for about 10 days after oestrogen administration as compared to control values. After 22 days of age, plasma LH concentration did not differ significantly from the control values. The plasma FSH concentration of the oestrogen-treated males showed a delayed rise to values equal to or higher than those of controls of the same age. The delayed rise in plasma FSH concentration in the oestrogen treated males preceded the delayed rise in plasma testosterone in these animals. The decrease in plasma FSH concentration from the high prepubertal values to the lower values in adults occurred at different ages in the control and in oestrogen-treated rats but in both groups the decrease occurred as plasma testosterone levels were increasing and the first wave of spermatogenesis was reaching completion. The increase in plasma FSH concentration after castration was reduced in oestrogen-treated males during the period throughout which FSH levels in the intact animals were subnormal but the levels in oestrogen-treated males castrated after the delayed rise in FSH had occurred did not differ from control values. It is suggested that the delayed sexual maturation of male rats treated with high doses of oestrogen in the neonatal period is related principally to abnormalities in the secretion of FSH.