bluuebunny/crossref_metadata_2025 huggingface dataset:
Neurological dementias
Authors: Graham Andrew
Published: February 2021

Dementia in old age is usually due to Alzheimer’s disease, cerebrovascular disease, or mixed pathology. Dementia due to other neurological disorders is uncommon, but important to recognize because management may be very different to that in primary or vascular dementia. This chapter surveys five neurological conditions that may present with dementia in later life: idiopathic normal pressure hydrocephalus (INPH); Huntington’s disease (HD); multiple sclerosis (MS); autoimmune limbic encephalitis (LE); and prion disease. For each disorder it reviews the epidemiology, clinical features, investigations, and treatment, with examples of the characteristic brain imaging changes. Accurate diagnosis of these conditions can be challenging even for physicians with a special interest in dementia, and often requires a neurological referral.
Delirium
Authors: Davis Daniel , Teale Elizabeth , Harwood Rowan H.
Published: February 2021

Delirium is an acute neuropsychiatric disturbance secondary to a pathophysiological insult, including illness, injury, or the effects or withdrawal of drugs. Features are variable, and fluctuate, with drowsiness or inattention, change in cognition, and often delusions, hallucinations, emotional, autonomic, and motor disturbance. It is commoner in those with prior dementia, and is seen in medical, surgical, intensive care, and palliative settings. Pathological mechanisms are uncertain. Nonpharmacological prevention strategies reduce incidence by up to 30%, including early mobilization, drug review, and sleep hygiene. Diagnosis is clinical, supported by various tools. Delirium is often underdiagnosed. Treatment comprises identifying and treating the (sometimes multiple) causes, avoiding complications, rehabilitation, and symptomatic relief of distress. Short-term, low-dose antipsychotic drugs may be used, but with limited supporting evidence. Prognosis is variable: some with delirium resolve within 24 hours, one-quarter persist for three months, and some never recover. Morality is up to 40% at six months.
Depression in older people
Authors: Thomas Alan
Published: February 2021

Depression remains common in older people. It is strongly associated with physical illnesses and with cognitive impairment and has a complex set of relationships with dementia. Its aetiology involves a complex interplay of physical and psychosocial risk and protective factors. Its neurobiology includes a strong relationship with vascular diseases, neuroendocrine abnormalities, an increase in MRI white matter hyperintense lesions, a reduction in volume of the hippocampus and frontal and subcortical structures, and neuronal abnormalities in such structures. Management involves physical (mainly drugs but also ECT) and psychological treatments. In the acute phase, remission is the aim, and following this, continuation and maintenance stages should continue with the same treatments indefinitely. Prognosis overall is not as good as in younger adults, but this is largely due to the presence of cognitive deficits and physical ill health.
Suicide and attempted suicide in older people
Authors: Chiu Helen F.K , Zhong Baoliang , Tsoh Joshua
Published: February 2021

Attempted and completed suicide among older adults are increasingly significant global public health challenges. This chapter presents epidemiological data on such behaviours, addressing the risk factors in the domains of mental health, personality, physical health and functioning, social factors (e.g. life events and social support), and neurobiological mechanisms, as derived from retrospective (mainly psychological autopsy [PA] studies) and prospective case-control studies. Suicide prevention initiatives in the elderly have progressed greatly in the past decade based on better understanding of the risk and protective factors. Given the multi-determined nature of suicidal behaviours, further improvements will require sustained collaborations across clinicians, researchers, health administrators, and politicians. Furthermore, given the disparity between male and female suicide rates, research on the gender differences of suicidal behaviours is urgently needed in order to understand the different psychopathological mechanisms, and to adequately address the healthcare needs of older men, the largest group of completed suicides across the world.
Anxiety disorders in older people
Authors: Byrne Gerard
Published: February 2021

Fear and anxiety are phylogenetically ancient emotions that confer survival advantage across species. They facilitate escape from present danger and prepare the individual to deal rapidly with future threats. In contemporary life, a moderate increase in anxiety is commonly associated with increased performance. However, anxiety that is excessive or prolonged is maladaptive and may represent a mental disorder. Individual differences and contextual factors influence the final form that an anxiety disorder takes. Like many complex behaviours, anxiety disorders result from interactions between genetic and environmental factors. In older people, anxiety often complicates physical frailty and cognitive decline. From a nosological perspective, anxiety can be conceptualized as both dimensional and categorical. Both psychological and pharmacological treatments are commonly applied to anxiety disorders in older people, with moderate efficacy. This chapter deals with classification, epidemiology, scientific underpinnings, phenomenology, and modern treatment approaches to anxiety disorders in later life.
Personal experience
Authors: Gosling Julie
Published: February 2021

In a personal narrative of maternal love and loss, trauma and strength, the author in her sixties makes an inward journey to touch the untold depths of love and pain that run through her as a constant stream.

… I permit myself now to live in the house of the mothers and I call it mine. I think increasingly about all of our lives, about their deaths, about time passing and my own death ahead of me … I find myself both war correspondent and war casualty, and surely war criminal also … I do not fear death. It is legacy from my mothers, that death in itself brings only release. It is living that hurts …

With insight comes compassion and reconciliation for the author, the women and the wounds. The loving strength of mothers and daughters overcomes the pain they inflict on one another. Scars remain but they are intelligent and wise. Is healing rooted within this understanding?
Severe and enduring mental illness
Authors: Hatfield Catherine , Dening Tom
Published: February 2021

Severe and enduring mental illness refers mainly to the long-term experience of schizophrenia and psychosis but also to other chronic functional disorders. The prevalence of psychoses in older people is hard to measure but estimates are around 0.5% of the population. Historically many people with long term illness resided in psychiatric hospitals but now most are in the community, receiving variable amounts of support from mental health, primary care, and social services. The physical health of this population is often poor and they receive less treatment and support than other older people with comparable physical health needs. Problems with psychiatric comorbidity (e.g. depression and substance misuse), cognitive impairment and social exclusion are also common. Treatment includes the judicious use of medication, nonpharmacological approaches, and social support—especially appropriate accommodation. Positive outcomes can be achieved by a recovery approach that attends to all aspects of the person’s health.
Older people with intellectual disability
Authors: Hanney Maria Luisa , Tyrer Stephen , Moore Brian
Published: February 2021

Older people with intellectual disabilities (ID) have a higher rate of mental ill health than those without disability. Although the prevalence of anxiety and depression is greater in older people than in younger people with ID, the main reason for this increase is because of an increased rate of dementia, not all of which is confined to those with Down’s syndrome (DS). Assessment of dementia in this population requires both information from informants as well as direct assessment of the subject. Neuropathological changes in dementia are directly related to the presence of neurofibrillary tangles and are associated with reduction in brain size, which is determined by neuroimaging. In DS there is overproduction of ß-amyloid and increased cerebral amyloid angiopathy. Shorter telomere length in T lymphocytes has been reported. Treatment options in dementia, even with the new cholinesterase inhibitors, are limited.
The effects of ageing on personality
Authors: Woods Bob , Windle Gill
Published: February 2021

Ageing and personality interact. While experiences that may be associated with age, including changes in roles and social networks, losses and health challenges, may require adaptation of aspects of personality, personality across the lifespan fundamentally influences how ageing is experienced. There are indications that extraversion, conscientiousness, and openness show reduced levels in later life, but people’s rank order on personality traits remains stable. Development continues into later life, but builds on earlier experiences and ways of coping. Personality resources such as self-esteem, perceived control, self-efficacy, and resilience shape the person’s response to adversity in later life, enabling older people to maintain high levels of well-being, despite the challenges. Dementia, the ultimate challenge, is accompanied by personality change, with raised neuroticism and lowered conscientiousness both predicting its onset and accompanying its course. Pre-morbid personality does also appear to have some influence on behavioural problems experienced.
Paediatrics
Authors: Buckley Simon
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of paediatrics. It discusses emergencies such as life support, anaphylaxis, and cardiac arrest. It explores taking a history, physical examination, and how to deal with fever and common problems, including non-accidental injury. It discusses common viral infection and respiratory issues such as asthma and cystic fibrosis, as well as gastrointestinal and genitourinary issues such as abdominal pain and distension, diarrhoea, malnutrition, malformations, nephrotic syndrome, and renal disease. It explores neurology from epilepsy to headache, and cardiology from congenital heart disease to heart murmurs. It discusses haematology and immunology, endocrinology, and growth. It ends with a detailed discussion of neonatology, from examination to common illnesses, daily requirements to breastfeeding, jaundice to haemolytic disease, and respiratory distress to the neonatal intensive care unit, respiratory support, and sudden unexplained infant death.
Dermatology
Authors: Arianayagam Sanju
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of dermatology. It works up from the basics of dermatology through describing a lesion and patterns of skin disease to itch and signs of systemic disease. Cancer is reviewed, including common skin cancers and premalignant tumours and malignant melanoma. Psoriasis is explored, along with eczema, skin infections, acne vulgaris, rosacea, drug eruptions, photosensitivity, urticaria, ulcers, HIV, infestations, and psychodermatoses.
Psychiatry
Authors: Myers Gil
Published: February 2021

This chapter in the Oxford Handbook of Clinical Specialties explores the specialty of psychiatry. It discusses seeing patients, taking a psychiatric history, the mental state exam, risk assessment, confidentiality, physical examination, descriptive psychopathology, the classification of disorders (ICD-10/DSM-5), and community care. It explores schizophrenia, depression, bipolar affective disorder, anxiety, withdrawing psychotropics, suicide, self-harm, crisis intervention, urgent psychiatry situations, and managing violence. It describes dealing with delirium, dementia, depression, psychosis, and behavioural difficulties, as well as disorders of sleep, autism spectrum disorders, attention deficit hyperactivity disorder, intellectual disability, and personality, eating, psychosexual, and perinatal disorders. It examines therapies and psychotherapies including cognitive, behavioural, dynamic, systemic/family, counselling, and supportive, group, play, and art therapies. It discusses compulsory treatment and hospitalization, the Mental Health Act law and consent, and capacity.
Small bowel
Authors: Burch Jennie , Collins Brigitte
Published: February 2021

The small bowel chapter explores the diseases and conditions of the small bowel. These conditions are listed and the possible presenting symptoms defined. The occurrence rates of the conditions within the small bowel are explored and the potential causes detailed. The investigations that are frequently used to diagnose these conditions are identified. Treatment options or preventative measures are explained with description of any potential complications. Diverse conditions and diseases can affect the small bowel; these include coeliac disease, lactose intolerance, and Meckel’s diverticulum. There is a more in-depth focus on intestinal failure. Intestinal failure is rare but can result in permanent, life-altering changes to the small bowel, potentially the result of treatment for Crohn’s disease or a small bowel infarct. Succinct descriptions of these conditions and diseases can assist the nurse in clinical care.
Bowel care
Authors: Burch Jennie , Collins Brigitte
Published: February 2021

The bowel care chapter explores two commonly encountered issues that are both explored in depth: these are constipation and incontinence. Both conditions are examined in respect of treatment options that include conservative treatment, treatment with diet, and medication. These conditions can be compared to how defaecation works in health. Additionally there is an in-depth discussion on neurogenic bowel dysfunction related to spinal cord injury, spina bifida, multiple sclerosis, cerebrovascular accident, and Parkinson’s disease. There are many therapies that can be used that have not been explored in other chapters and these will be encompassed within this chapter. Treatment can include manual evacuation for constipation or other therapies such as biofeedback to potentially treat constipation or evacuation disorders. Succinct explanation of gastrointestinal emergencies within this chapter can be used within clinical practice by the nurse.
Physical migration
Authors: Ayonrinde Oyedeji , Busuttil Nicolette
Published: February 2021

This chapter focuses on the migrant’s journey in between the point of departure from the country of residence to arrival in the country of destination, highlighting the ways in which movement is rendered possible across the international legislative framework. It explores the potential routes open to migrants and emphasizes the qualitative difference between those who can embark on safe and legal means of migration and those whose movement is restricted to unsafe journeys. In so doing, it elucidates the circumstances that can be encountered by those in transit, outlining their vulnerability to human rights’ violations arising from their status as migrants. This is further explored by reference to the implications that the physical migration journey carries for the individual migrant. Finally, it emphasizes the need for the mental healthcare professional to elicit the migrant’s narrative of the physical journey and suggests the means through which mental healthcare interventions can contextualize their lived experience.
The cross-cultural assessment of migrants
Authors: Aggarwal Neil Krishan
Published: February 2021

For close to 40 years, cultural psychiatrists have struggled to institutionalize cross-cultural assessments with the recognition that culture influences ideas about desired and undesired treatments, social norms of appropriate and inappropriate communication in healthcare settings, and the ways that clinicians interpret symptoms into diagnoses. This chapter first establishes a common definition for the terms ‘culture’ and ‘migrant’, which can be used in mental health settings. Next, it traces how the care of migrants formed a central concern as psychiatrists, psychologists, and anthropologists made cultural recommendations for DSM-IV and DSM-5. Finally, the chapter discusses the DSM-5 Cultural Formulation Interview Supplementary Module for Immigrants and Refugees as a clinical assessment tool that can help clinicians ask patients about their backgrounds; pre-migration-, and post-migration trajectories; resettlement life; and plans for the future. This supplementary module may help clinicians systematically and comprehensively develop diagnostic assessments and treatment plans for immigrants and refugees in a patient-centred way.
Separate services or integrated services
Authors: Carlsson Jessica , Kastrup Marianne C.
Published: February 2021

The chapter takes its position in the consequences of globalization and its disequalizing effects on equity in care. The chapter presents and discusses pros and cons related to separate versus integrated services in mental health care for migrants, including trauma-affected refugees. Throughout the chapter there is a special focus on trauma-affected refugees as a particularly vulnerable group. The chapter gives a brief overview of the historical development behind specialized services for trauma-affected refugees and other migrants, including their relation to documentation of human rights violations, and the variations among such services are described. With the overall aim of avoiding inequalities in mental health care, the chapter then compares specialized versus integrated services. The comparison is done with a focus on diagnostic assessment, access to mental health care, treatment outcomes, and treatment satisfaction. Finally, the role of specialized services is discussed.
Use of telepsychiatry for the management of mental health problems in migrants
Authors: Hariman Keith , Ventriglio Antonio , Bhugra Dinesh
Published: February 2021

An estimated 3.3% of the global population lives outside their place of birth. This heterogenous group includes not only high-skilled labour and expats, but also refugees and asylum seekers. Research has shown that the prevalence of certain mental illnesses, such as post-traumatic stress disorder and depression, may be higher in migrants than in the general population. However, some migrants might not be able to receive the relevant mental health treatment owing to various social, cultural, and physical barriers. One possible solution is the use of telepsychiatry, defined as the delivery of psychiatric intervention from a distance. This includes real-time videoconferencing, pre-recorded videos, or even decision support systems. This technology has the ability to connect migrants with a clinician who understands their language and culture, thereby improving the patient satisfaction and outcome. The benefits of telepsychiatry, along with the challenges in its implementation, will be discussed in this chapter, as will potential problems related to ethics, regulation, and confidentiality.
Carbon dioxide output
Authors: Kinnear William J.M. , Hull James H.
Published: February 2021

This chapter describes how carbon dioxide is produced from metabolism and also from buffering of lactic acid. The volume of carbon dioxide exhaled (VCO2) is calculated from the concentration in exhaled gas and minute ventilation. If the lungs are less efficient than normal, with a high dead space, the amount of ventilation needed to achieve any given VCO2 is much higher. This index, known as the ventilatory equivalent for carbon dioxide, is an important prognostic marker. Early on in a cardiopulmonary exercise test (CPET), VCO2 is slightly less than the oxygen uptake (VO2). As exercise reaches its maximum, VCO2 increases more quickly when acidaemia starts to stimulate ventilation.
Suicide during war and genocides
Authors: Lester David
Published: February 2021

Research indicates that suicide rates decline during wartime. The most likely explanation for this decline is the greater social cohesion of societies during wartime, but changes in the economy during wartime, such as reduced rates of unemployment, may also play a role. The impact of civil wars on suicide rates is unclear since the data in the different reports are inconsistent. Prisoners of war who are treated harshly have higher suicide rates after release. The suicide rate of Jews was high during all phases of the Holocaust in the 1930s and 1940s. Whether suicide terrorists resemble typical suicides remains a subject for debate.
Suicide in military settings
Authors: Rozanov Vsevolod
Published: February 2021

Risk factors in the military include firearms, traumatic stress, insufficient social support, and lifestyle. Processes influencing suicide rates within the Armed Forces can be different to that of civilian life, especially when under reformation and economic pressure. Growth of suicides rates in active duty personnel may be noticed in many armies which seems to not only be associated with combat exposure; shifting focus to mental health of recruits. There are two main periods of higher risk—during the first year after recruitment and after leaving the military. Screening of recruits together with resilience training, leadership interventions, gatekeeper training, and firearm regulations are preventive methods. War veterans are also at risk; treatments for post-traumatic stress, depression, and substance abuse, together with social support are suggested. Post-modernity, which implies the role of wider factors associated with changes in the social environment and evolution of meanings and values in the world, is also discussed.
Mood and anxiety disorders in suicide and suicide attempters
Authors: Lönnqvist Jouko
Published: February 2021

Suicidal behaviour is closely connected with mood disorders. Virtually all mood, anxiety, obsessive-compulsive, and trauma-related disorders carry an increased risk of suicidal ideation, suicide attempt, and suicide. Psychiatric disorder may be an almost necessary, yet insufficient, risk factor for suicide. More than a half of individuals who attempt or commit suicide meet diagnostic criteria for a mood disorder, most often comorbid with anxiety symptoms, substance use disorders, personality disorders, or in severe cases psychotic symptoms. The risk of suicidal behaviour in anxiety disorders, obsessive-compulsive-disorders is often underestimated. Undertreatment, comorbidity, treatment non-compliance, and poor adherence, as well as a high frequency of non-responders are common problems and challenges in the treatment of suicidal persons. There is growing evidence of lower risk of suicidal behaviour during closely monitored long-term treatment of suicidal patients having mood disorder, especially bipolar illness, indicating that treatment adherence is an important factor in medical diagnostic-specific suicide prevention.
Post-traumatic stress disorder and risk for suicide in combat veterans
Authors: Hendin Herbert
Published: February 2021

Post-traumatic stress disorder (PTSD) is a condition associated with suicide in both military personnel and combat veterans. Most veterans with PTSD, however, are not at risk of suicide. The major factor distinguishing those who attempted or were preoccupied with suicide is persistent severe guilt over behaviour in combat while emotionally out of control. A 12-session short-term, psychodynamic psychotherapy, presented here in this chapter, showed promise of success in dissipating the guilt from combat-related actions in veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates it may be equally successful in treating them.
Crisis hotlines
Authors: Halford Emily , Lake Alison M. , Gould Madelyn S.
Published: February 2021

A rationale for the role of crisis hotlines in suicide prevention is that suicidal behaviour is often associated with a crisis. The psychological autopsy research generally supports the association of stressful life events, such as interpersonal losses and legal or disciplinary problems, with suicide. Hotlines are a ubiquitous source of help internationally and the evidence for their effectiveness has grown substantially over the last decade. Recent research provides strong support for crisis hotlines’ role in reducing callers’ crisis and suicidal states. In response to concerns about the extent and quality of suicide risk assessments and crisis interventions by hotline staff, new practice recommendations and training and outreach strategies in telephone crisis centres have been implemented and evaluated.
The link between physical disorders and suicidality in children and adolescents
Authors: Zalsman Gil , Madjar Nir , Shoval Gal
Published: February 2021

The existence of physical disorders and disabilities has been associated with suicidal behaviour among adults. Though relatively less often studied in children and adolescents, a growing body of evidence supports a similar link in this population as well. This text describes recent studies on suicidality among young patients with diabetes mellitus, bronchial asthma, human immunodeficiency virus (HIV), epilepsy, multiple sclerosis, traumatic brain injuries, and physical injuries. Suggested models addressing biological, psychological, and social aspects relevant to the possible pathophysiological mechanisms linking physical disorders and disabilities to suicidal behaviour in the paediatric age group are also discussed.
Effective treatments for suicidal youth
Authors: Brent David A.
Published: February 2021

This chapter reviews the efficacy of interventions designed to prevent the onset or recurrence of suicidal ideation or behaviour in adolescents and young adults. First, community-based universal interventions designed to decrease the incidence of suicidal ideation and behaviour in youth are reviewed. Second, interventions designed to reduce suicidal risk in those already identified as at increased risk for suicidal behaviour are discussed. Third, the role of the pharmacological treatment of psychiatric disorder, such as the treatment of depression, in the reduction of suicidal risk in adolescents is delineated. Finally, on the basis of this review, recommendations for best practice in the prevention and treatment of suicidal behaviour in youth are offered.
Multilevel approaches in adult suicide prevention
Authors: Hegerl Ulrich , Heinz Ines , Hug Juliane
Published: February 2021

The next steps forward in suicide prevention are to learn (i) how to best combine single measures into a multilevel intervention in order to create additive and synergistic effects and (ii) how to implement them in the communities in different cultures and healthcare systems. A narrative review based on findings and experiences from existing community-based multilevel interventions which have provided some evidence for preventive effects on suicidal behaviour is presented. Most multilevel interventions combine training for primary care providers and gatekeepers, public awareness activities, restricting access to lethal means, engaging with the media, and support for high risk groups. However, effects on completed suicides and/or suicide attempts have only been reported for a few interventions. The best evaluated community-based intervention is the four-level programme offered by the European Alliance Against Depression (EAAD; implemented in over 115 regions in 15 countries by 2019).
Gun availability and gun control in suicide prevention
Authors: Reisch Thomas
Published: February 2021

Suicide by firearm is the most lethal method of suicide and is executed much more frequently by men than by women. In comparison with other suicide methods, pre-existing psychiatric conditions are found less often and medical comorbidities more often. Suicide by firearm is carried out impulsively, frequently following a relationship crisis. Firearm suicide is mainly found in high- and middle-income countries. There is a close correlation between the frequency of firearm ownership and the frequency of this suicide method. People living in households with a gun generally seem to be at a higher risk of suicide. Several changes of legislation that lead to a decreased availability of guns have proven to be effective. However, legislation changes regarding firearms often lead to resistance by gun lobbies. Which intervention can be successfully implemented, mostly depends on country-specific circumstances.
Describing equity impacts and trade-offs
Authors: Cookson Richard , Griffin Susan , Norheim Ole F. , Culyer Anthony J.
Published: February 2021

This chapter introduces the basic measurement concepts needed to understand and critically appraise distributional cost-effective analysis (DCEA) findings about equity impacts and trade-offs. It starts by introducing the key questions that research users need to ask about DCEA findings, drawing on basic concepts from the literature on measuring inequality and social welfare. It then introduces two diagrams for summarizing trade-offs between equity and efficiency impacts. Close attention is paid to the value judgments underpinning different equity impact metrics, with a view to helping research users engage in well-informed conversations about those value judgments.
Health by social variables
Authors: Love-Koh James , Mirelman Andrew
Published: February 2021

This chapter explains how to estimate baseline distributions of lifetime health by social group that can be used in equity-informative economic evaluation. It shows how social inequalities in health at baseline can have an influence on the relative inequality impact funding new health programmes and how the relevant distribution of health is defined by social value judgments about what constitutes unfair health inequality. A step-by-step guide to estimating distributions of health-adjusted life expectancy is provided, covering common analytical methods and measures of health-related quality of life. It also discusses appropriate sources of data and includes several practical examples demonstrating how baseline distributions have been produced in different settings.
Health opportunity costs
Authors: Love-Koh James
Published: February 2021

The net benefit of a health programme is defined as the benefits it generates minus its opportunity costs. Accounting for opportunity costs—the value of resources in their most highly valued alternative use—is an essential part of economic evaluation. This chapter discusses the role of health opportunity costs in equity-informative economic evaluation and describes some approaches to quantifying both total health opportunity costs and their distribution. Alternative methods are proposed where data availability is limited, emphasizing careful consideration of the funding context along with scenario analyses to examine the implications of alternative levels and patterns of health opportunity cost.
Financial protection
Authors: Mirelman Andrew , Cookson Richard
Published: February 2021

This chapter shows how to analyse the impacts of healthcare and public health decisions on equity in the distribution of financial protection from out-of-pocket (OOP) healthcare costs. The basic analytical steps for analysing impacts on equity in financial protection are similar to those used for analysing impacts on equity in health—that is, one needs to analyse the baseline distribution of financial protection (pre-decision), the effects, the opportunity costs, and the final distribution (post-decision). However, different data and methods are required because at each step one is measuring distributions of financial protection rather than distributions of health. This chapter describes two main measures of financial protection—‘catastrophic’ and ‘impoverishing’ healthcare expenditure—and explains how the relevant distributions can be analysed. Accompanying the text is a step-by-step spreadsheet training exercise based on a previously published extended cost-effectiveness analysis study of a tobacco tax increase in Lebanon.
Dominance analysis
Authors: O’Donnell Owen , Ourti Tom Van
Published: February 2021

This chapter shows how to evaluate the distributional consequences of alternative health programmes using dominance analysis. It explains how to evaluate whether one distribution of health dominates another, in the sense that it is unambiguously preferred according to general ethical principles that value both efficiency and equity. The approach seeks to identify the least restrictive set of normative assumptions required to find dominance. When there is no dominance at a lower level, more restrictive, but still explicit, principles can provide the normative justification for using a higher order of dominance to rank distributions. The approach can be used both when the decision maker is averse to all health inequality and when aversion is restricted to health inequality in relation to some equity-relevant variable, such as socioeconomic status.
Direct equity weights
Authors: Paulden Mike , O’Mahony James , Round Jeff
Published: February 2021

Direct equity weights are indicators of relative importance applied to effects and opportunity costs for specific subgroups of the population—such as people with or without a severe or rare or terminal illness—giving higher priority to some and lower priority to others. This chapter shows how two different forms of direct equity weighting can be used: ‘health weighting’, in which weights are applied to the health effects and opportunity costs; and ‘threshold weighting’, in which an adjustment is instead made to the cost-effectiveness threshold. The two approaches are only equivalent in limited circumstances and threshold weighting can be misleading because it fails to account for equity concerns about the distribution of health opportunity costs. The chapter then shows how net equity impact can be plotted on the equity-efficiency impact plane using direct equity weights. The chapter concludes by examining the circumstances under which threshold weighting can be misleading, with the aid of simple hypothetical examples that illustrate the importance of paying explicit attention to the distribution of health opportunity costs.
Psychiatry and the pharmaceutical industry
Authors: Green Stephen A.
Published: February 2021

Conflicts of interest pervade the relationship between the psychiatric profession and pharmaceutical industry, threatening ethical standards of psychiatric care. They influence the quality and cost of treatment, the objectivity of research and educational activities, and the integrity of individual psychiatrists, as well as the profession in general. Various groups, apart from drug companies, bear responsibility for the prevalence of conflicts of interest, including individual practitioners and researchers, medical academe, professional organizations both within and external to psychiatry, and branches of the government. Reforming practices and policies that encourage such conflicts can only be contained by efforts aimed at educating the profession and public as to the relevant issues, as well as enlisting governmental action, in order to hold industry and the profession more accountable for potentially unethical collaborative activities.
Psychiatric research
Authors: Dunn Laura B. , Roberts Laura Weiss
Published: February 2021

The ethical engagement of human volunteers is critical to advancing research on mental disorders. The symptoms and impairments commonly associated with psychiatric disorders nevertheless raise numerous issues about the ethical dimensions of research involving people at risk for, living with, and suffering from these disorders. A substantial body of literature now exists addressing both conceptual and empirical issues related to ethical dimensions of psychiatric research. While much of the discussion of ethical issues in research has focused on informed consent and decision-making capacity, additional relevant issues also warrant consideration. These include influences on participants’ decisions about enrolling in research, potential sources of vulnerability, and investigator integrity. This chapter provides an overview of these topics, describes two frameworks for analysing the ethical dimensions of research, and utilizes case illustrations to highlight some of these issues.
Chandra grating spectroscopy of embedded wind shock X-ray emission from O stars shows low plasma temperatures and significant wind absorption
Authors: Cohen David H , Parts Winter , Doskoch Graham M , Wang Jiaming , Petit Véronique , Leutenegger Maurice A , Gagné Marc
Published: February 2021

We present a uniform analysis of six examples of embedded wind shock (EWS) O star X-ray sources observed at high resolution with the Chandra grating spectrometers. By modelling both the hot plasma emission and the continuum absorption of the soft X-rays by the cool, partially ionized bulk of the wind we derive the temperature distribution of the shock-heated plasma and the wind mass-loss rate of each star. We find a similar temperature distribution for each star’s hot wind plasma, consistent with a power-law differential emission measure, $\frac{{\rm d}\log EM}{{\rm d}\log T}$, with a slope a little steeper than −2, up to temperatures of only about 107 K. The wind mass-loss rates, which are derived from the broadband X-ray absorption signatures in the spectra, are consistent with those found from other diagnostics. The most notable conclusion of this study is that wind absorption is a very important effect, especially at longer wavelengths. More than 90 per cent of the X-rays between 18 and 25 Å produced by shocks in the wind of ζ Pup are absorbed, for example. It appears that the empirical trend of X-ray hardness with spectral subtype among O stars is primarily an absorption effect.
Guidelines for surfactant replacement therapy in neonates
Authors: Ng Eugene H , Shah Vibhuti
Published: February 2021

Surfactant replacement therapy (SRT) plays a pivotal role in the management of neonates with respiratory distress syndrome (RDS) because it improves survival and reduces respiratory morbidities. With the increasing use of noninvasive ventilation as the primary mode of respiratory support for preterm infants at delivery, prophylactic surfactant is no longer beneficial. For infants with worsening RDS, early rescue surfactant should be provided. While the strategy to intubate, give surfactant, and extubate (INSURE) has been widely accepted in clinical practice, newer methods of noninvasive surfactant administration, using thin catheter, laryngeal mask airway, or nebulization, are being adopted or investigated. Use of SRT as an adjunct for conditions other than RDS, such as meconium aspiration syndrome, may be effective based on limited evidence.
Emergency management of the paediatric patient with convulsive status epilepticus
Authors: McKenzie Kyle C , Hahn Cecil D , Friedman Jeremy N
Published: February 2021

This guideline addresses the emergency management of convulsive status epilepticus (CSE) in children and infants older than 1 month of age. It replaces a previous position statement from 2011, and includes a new treatment algorithm and table of recommended medications based on new evidence and reflecting the evolution of clinical practice over the past several years. This statement emphasizes the importance of timely pharmacological management of CSE, and includes some guidance for diagnostic approach and supportive care.
Development of a Sequential Sampling Plan using Spatial Attributes of Cercospora Leaf Spot Epidemics of Table Beet in New York
Authors: Heck Daniel W. , Kikkert Julie R. , Hanson Linda E. , Pethybridge Sarah J.
Published: February 2021

Sampling strategies that effectively assess disease intensity in the field are important to underpin management decisions. To develop a sequential sampling plan for the incidence of Cercospora leaf spot (CLS), caused by Cercospora beticola, 31 table beet fields were assessed in the state of New York. Assessments of CLS incidence were performed in six leaves arbitrarily selected in 51 sampling locations along each of three to six linear transects per field. Spatial pattern analyses were performed, and results were used to develop sequential sampling estimation and classification models. CLS incidence (p) ranged from 0.13 to 0.92 with a median of 0.31, and beta-binomial distribution, which is reflective of aggregation, best described the spatial patterns observed. Aggregation was commonly detected (>95%) by methods using the point-process approach, runs analyses, and autocorrelation up to the fourth spatial lag. For Spatial Analysis by Distance Indices, or SADIE, 45% of the datasets were classified as a random pattern. In the sequential sampling estimation and classification models, disease units are sampled until a prespecified target is achieved. For estimation, the goal was sampling CLS incidence with a preselected coefficient of variation (C). Achieving the C = 0.1 was challenging with <51 sampling units, and only observed on datasets with incidence >0.3. Reducing the level of precision, i.e., increasing C to 0.2, allowed the preselected C to be achieved with a lower number of sampling units and with an estimated incidence ([Formula: see text]) close to the true value of p. For classification, the goal was to classify the datasets above or below prespecified thresholds (pt) used for CLS management. The average sample number, or ASN, was determined by Monte Carlo simulations, and was between 20 and 45 at disease incidence values close to pt, and approximately 11 when far from pt. Correct decisions occurred in >76% of the validation datasets. Results indicated these sequential sampling plans can be used to effectively assess CLS incidence in table beet fields.
Co-infections of two carbapenemase-producing Enterobacter hormaechei clinical strains isolated from the same diabetes individual in China
Authors: Ding Manlin , Shi Jiao , Ud Din Ahmad , Liu Yao , Zhang Feiyang , Yan Xiangjin , Li Qin , Bai JiaWei , Chen Wenbi , Zhou Yingshun
Published: February 2021

Introduction. Since mcr-1 was first reported in China, there have been ten variants of MCR appearing nationwide so far. Multidrug-resistant

Enterobacteriaceae

bacteria carrying both NDM and MCR have become a serious threat to global public health.

Hypothesis/Gap Statement. The genetic structure of mcr-9 needs to be better understood in order to better prevent and control the transmission of drug-resistant genes.

Aims. The aim of this study was to characterize the presence of two

Enterobacter hormaechei

isolates, which carries bla
NDM-5 CME2 and the coexistence of mcr-9 and bla
NDM-1 strain CMD2, which were isolated from a patient with diabetes in Sichuan, China.

Methodology. The microbroth dilution method was used for antibiotic susceptibility. Conjugation experiment was used to investigate the transferability of bla
NDM-1, bla
NDM-5 and mcr-9. Whole-genome sequencing was performed on Illumina HiSeq platform. The ability of biofilm formation was detected by crystal-violet staining, the virulence of the bacteria was measured by Galleria mellonella killing assay.

Results.
bla
NDM-5 carrier CME2 and CMD2 with bla
NDM-1 and mcr-9 were resistant to carbapenems, β-lactam, aminoglycoside, quinolone and tetracycline, while CMD2 was also resistant to colistin. Conjugation assay and plasmid replicon typing further demonstrated that both bla
NDM-1 and bla
NDM-5 were respectively present on the self-transferrable IncX3 plasmid, mcr-9 was located on the self-transferrable IncHI2 plasmid. Through the analysis of mcr-9 gene context, the structure was DUF4942-rcnR-rcnA-copS-IS903-mcr-9-wbuC-qseC-qseB-IS1R-ΔsilR-IS903, bla
NDM-1 context was IS3000-ΔISAba125-IS5-bla
NDM-1-ble-trpF-groS-groL-insE-ΔIS26 structure, bla
NDM-5 structure was IS3000-bla
NDM-5-ble-trpF-dsbC-ΔIS26-umuD-ISKox3-tnpR-parA. Biofilm formation of CME2 was stronger than CMD2. There was no significant difference in virulence between the two strains.

Conclusion. This study reveals two multiple drug-resistant

E. hormaechei

isolates from diabetes patient samples.

E. hormaechei

carrying two NDM-resistant genes is already a serious threat, where MCR is an important cause of treatment failure in bacterial infections. This study is a reminder not only to prevent infection in patients with diabetes, but also to constantly monitor the epidemic and spread of the drug-resistant gene.
Emergence of universality in the transmission dynamics of COVID-19
Authors: Paul Ayan , Bhattacharjee Jayanta Kumar , Pal Akshay , Chakraborty Sagar
Published: February 2021

The complexities involved in modeling the transmission dynamics of COVID-19 has been a major roadblock in achieving predictability in the spread and containment of the disease. In addition to understanding the modes of transmission, the effectiveness of the mitigation methods also needs to be built into any effective model for making such predictions. We show that such complexities can be circumvented by appealing to scaling principles which lead to the emergence of universality in the transmission dynamics of the disease. The ensuing data collapse renders the transmission dynamics largely independent of geopolitical variations, the effectiveness of various mitigation strategies, population demographics, etc. We propose a simple two-parameter model—the Blue Sky model—and show that one class of transmission dynamics can be explained by a solution that lives at the edge of a blue sky bifurcation. In addition, the data collapse leads to an enhanced degree of predictability in the disease spread for several geographical scales which can also be realized in a model-independent manner as we show using a deep neural network. The methodology adopted in this work can potentially be applied to the transmission of other infectious diseases and new universality classes may be found. The predictability in transmission dynamics and the simplicity of our methodology can help in building policies for exit strategies and mitigation methods during a pandemic.
Impact of personalized-dose vaccination in Covid-19 with a limited vaccine supply in a 100 day period in the U.S.A.
Authors: Hunziker Patrick
Published: February 2021

Background

We aimed at minimizing loss of lives in the Covid-19 pandemic in the USA by identifying optimal vaccination strategies during a 100-day period with limited vaccine supplies. While lethality is highest in the elderly, transmission and case numbers are highest in the younger. A strategy of first vaccinating the elderly is widely used, thought to protect the vulnerable, elderly best. Despite lower immunogenicity in the elderly, mRNA vaccines retain high efficacy, implying that in the younger, reduced vaccine doses might suffice, thereby increasing vaccination counts with a given vaccine supply.

Methods

Using published immunogenicity data of the Moderna mRNA-1273 vaccine, we examined the value of personalized-dose vaccination strategies, using a modeling approach incorporating age-related vaccine immunogenicity, social contact patterns, population structure, Covid-19 case and death rates in the USA in late January 2021. An increase if the number of persons that can be vaccinated and a potential reduction of the individual protective efficacy was accounted for.

Results

Age-personalized dosing strategies reduced cases faster, shortening the pandemic, reducing the delay to reaching <100’000 cases/day from 64 to 30 days and avoiding 25’000 deaths within 100 days in the USA. In an “elderly first” vaccination strategy, mortality is higher even in the elderly. Findings were robust with transmission blocking efficacies of reduced dose vaccination between 30% to 90%, and with a vaccine supply from 1 to 3 million full dose vaccinations per day.

Conclusion

Rapid reduction of Covid-19 case and death rate in the USA in 100 days with a limited vaccine supply is best achieved when personalized, age-tailored dosing for highly effective vaccines is used, according to this vaccination strategy model parameterized to U.S. demographics, Covid-19 transmission and vaccine characteristics. Protecting the vulnerable is most effectively achieved by personalized-dose vaccination of all population segments, while an “elderly first” approach costs more lives, even in the elderly.