Experiences of intensive home treatment for a mental health crisis during the perinatal period: A UK qualitative study

Some women with severe perinatal mental health difficulties in England are cared for by acute home treatment services, known as Crisis Resolution Teams (CRTs), which provide short-term home-based treatment for adults experiencing a mental health crisis. Intensive home treatment has been trialed in a number of countries, but it is not known how well suited it is to the needs of perinatal women. This qualitative study aimed to explore how women and practitioners experience the provision of intensive home treatment for perinatal mental health problems. Semi-structured interviews were conducted with women who had received intensive home treatment in the perinatal period (n = 15), and focus groups were held with practitioners working in CRTs or in specialist perinatal mental health services (3 groups, n = 25). Data were analysed thematically. Women commonly found intensive home treatment problematic, experiencing it as intrusive and heavily risk-focused, with poor staff continuity and little tailoring to the perinatal context. However, women valued emotional support when provided, particularly when it had a perinatal focus, sometimes based on practitioners sharing their own experiences. Some women also appreciated avoiding hospital admission, but choice was often limited. Practitioners reported a lack of perinatal training among CRT staff and described difficulties tailoring treatment to perinatal women's needs. Currently, intensive home treatment, as offered by CRTs, may not be well suited to women with perinatal mental health difficulties. Findings suggest a need to develop community crisis responses that are better tailored to the needs of this population

How do women's partners view perinatal mental health services? A qualitative meta-synthesis.

OBJECTIVES: Perinatal mental health difficulties are prevalent among women and can adversely affect their partners too. There is also increasing recognition that a woman's partner can play a vital role in relation to her perinatal mental health and should be supported and involved in decisions about her care. Yet it is unclear how services are experienced by the partners of women with perinatal mental health difficulties. This study aimed to synthesize qualitative evidence of partners' views of perinatal mental health care. METHODS: A systematic search of 5 electronic databases identified 20 studies that met the inclusion criteria. The findings of these studies were synthesized using an approach based on meta-ethnography. RESULTS: Six themes were identified, namely, the marginalization and neglect of women's partners, an unmet need for information, partners' ambivalence about involvement and support, practical barriers to involvement, views about support for women's partners, and the impact on partners of the care women received. CONCLUSIONS: Given the importance of women's partners in relation to perinatal mental health as well as to women's engagement with support and treatment outcomes, greater consideration should be given to their needs to ensure they feel well informed and involved in perinatal mental health care, rather than marginalized. However, professionals also need to challenge the barriers to involvement and support that women's partners face and consider the ways in which services may reinforce these barriers. KEY PRACTITIONER MESSAGE Partners of women with perinatal mental health difficulties play a vital role. However, they often feel uninformed and marginalized by services and professionals. They also face significant barriers to accessing support themselves or being more involved. Services and professionals may reinforce these barriers and need to challenge them. Further consideration must be given to the needs of women's partners

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses

PURPOSE: The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. METHODS: We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. RESULTS: We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. CONCLUSION: Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research

Urban Systems Between National and Global: Recent Reconfiguration Through Transnational Networks

Because the whole book’s issue assumes the uneven integrations of national/continental urban systems inside the global economy, this chapter evaluates the rates and qualitative modes of integration of the national urban systems by the economic networks that are dominated by multinational firms. The empirical study encompasses the largest 1250 cities of the world delineated in a comparative way according to common definitions of large urban regions (LURs). The position of LURs in multinational firms’ ownership networks in 2 years, 2010 and 2013, corresponds to the deepest period of the crisis and the following recovery, respectively. Thus, we checked that the fast reorganization of multinational firms facing this crisis between 2010 and 2013 did not fundamentally transform their strong urban organization but rather introduced some minor changes, particularly due to the simultaneous breakthrough of emergent countries’ companies (especially the Chinese ones). Synthetic network clustering methods partitioning cities of the world offer clear visions of the structure of the multipolar urban networks. They reveal “regions” of integration of cities for all kinds of multinational companies but also distinguishing companies according to their skill levels either in industry or in services. A special attention is given to some highly integrated cities appearing with properties of “city-states,” i.e., without a strong national urban system

A randomised controlled trial of a brief online mindfulness-based intervention in a non-clinical population: replication and extension

Building on previous research, this study compared the effects of two brief, online mindfulness-based interventions (MBIs; with and without formal meditation practice) and a no intervention control group in a non-clinical sample. One hundred and fifty-five university staff and students were randomly allocated to a 2-week, self-guided, online MBI with or without mindfulness meditation practice, or a wait list control. Measures of mindfulness, perceived stress, perseverative thinking and anxiety/depression symptoms within were administered before and after the intervention period. Intention to treat analysis identified significant differences between groups on change over time for all measured outcomes. Participation in the MBIs was associated with significant improvements in all measured domains (all ps < 0.05), with effect sizes in the small to medium range (0.25 to 0.37, 95% CIs 0.11 to 0.56). No significant changes on these measures were found for the control group. Change in perseverative thinking was found to mediate the relationship between condition and improvement on perceived stress and anxiety/ depression symptom outcomes. Contrary to our hypotheses, no differences between the intervention conditions were found. Limitations of the study included reliance on self-report data, a relatively high attrition rate and absence of a longer-term follow-up. This study provides evidence in support of the feasibility and effectiveness of brief, self-guided MBIs in a non-clinical population and suggests that reduced perseverative thinking may be a mechanism of change. Our findings provide preliminary evidence for the effectiveness of a mindfulness psychoeducation condition, without an invitation to formal mindfulness meditation practice. Further research is needed to confirm and better understand these results and to test the potential of such interventions

The effectiveness of mindfulness-based interventions in the perinatal period: a systematic review and meta-analysis

Perinatal mental health difficulties are associated with adverse consequences for parents and infants. However, the potential risks associated with the use of psychotropic medication for pregnant and breastfeeding women and the preferences expressed by women for non-pharmacological interventions mean it is important to ensure that effective psychological interventions are available. It has been argued that mindfulness-based interventions may offer a novel approach to treating perinatal mental health difficulties, but relatively little is known about their effectiveness with perinatal populations. This paper therefore presents a systematic review and meta-analysis of the effectiveness of mindfulness-based interventions for reducing depression, anxiety and stress and improving mindfulness skills in the perinatal period. A systematic review identified seventeen studies of mindfulness-based interventions in the perinatal period, including both controlled trials (n = 9) and pre-post uncontrolled studies (n = 8). Eight of these studies also included qualitative data. Hedge’s g was used to assess uncontrolled and controlled effect sizes in separate meta-analyses, and a narrative synthesis of qualitative data was produced. Pre- to post-analyses showed significant reductions in depression, anxiety and stress and significant increases in mindfulness skills post intervention, each with small to medium effect sizes. Completion of the mindfulness-based interventions was reasonable with around three quarters of participants meeting study-defined criteria for engagement or completion where this was recorded. Qualitative data suggested that participants viewed mindfulness interventions positively. However, between-group analyses failed to find any significant post-intervention benefits for depression, anxiety or stress of mindfulness-based interventions in comparison to control conditions: effect sizes were negligible and it was conspicuous that intervention group participants did not appear to improve significantly more than controls in their mindfulness skills. The interventions offered often deviated from traditional mindfulness-based cognitive therapy or mindfulness-based stress reduction programmes, and there was also a tendency for studies to focus on healthy rather than clinical populations, and on antenatal rather than postnatal populations. It is argued that these and other limitations with the included studies and their interventions may have been partly responsible for the lack of significant between-group effects. The implications of the findings and recommendations for future research are discussed

Pemphigus autoimmunity: Hypotheses and realities

The goal of contemporary research in pemphigus vulgaris and pemphigus foliaceus is to achieve and maintain clinical remission without corticosteroids. Recent advances of knowledge on pemphigus autoimmunity scrutinize old dogmas, resolve controversies, and open novel perspectives for treatment. Elucidation of intimate mechanisms of keratinocyte detachment and death in pemphigus has challenged the monopathogenic explanation of disease immunopathology. Over 50 organ-specific and non-organ-specific antigens can be targeted by pemphigus autoimmunity, including desmosomal cadherins and other adhesion molecules, PERP cholinergic and other cell membrane (CM) receptors, and mitochondrial proteins. The initial insult is sustained by the autoantibodies to the cell membrane receptor antigens triggering the intracellular signaling by Src, epidermal growth factor receptor kinase, protein kinases A and C, phospholipase C, mTOR, p38 MAPK, JNK, other tyrosine kinases, and calmodulin that cause basal cell shrinkage and ripping desmosomes off the CM. Autoantibodies synergize with effectors of apoptotic and oncotic pathways, serine proteases, and inflammatory cytokines to overcome the natural resistance and activate the cell death program in keratinocytes. The process of keratinocyte shrinkage/detachment and death via apoptosis/oncosis has been termed apoptolysis to emphasize that it is triggered by the same signal effectors and mediated by the same cell death enzymes. The natural course of pemphigus has improved due to a substantial progress in developing of the steroid-sparing therapies combining the immunosuppressive and direct anti-acantholytic effects. Further elucidation of the molecular mechanisms mediating immune dysregulation and apoptolysis in pemphigus should improve our understanding of disease pathogenesis and facilitate development of steroid-free treatment of patients

Malandragem and Ginga: Socio-cultural constraints on the development of expertise and skills in Brazilian football

In an ecological dynamics rationale, the development of expertise in sports is shaped by interactions of personal, task and environmental constraints. A notable outcome of this process is the distinctive performance styles of athletes shaped by socio-cultural-historical constraints. To understand this process, we examined the role of socio-cultural constraints shaping the development of skill in Brazilian football players at the macrosystem level. A range of data sources were inductively generated and analysed through the qualitative interpretative paradigm, including historical contextual analysis, participant observation, and unstructured interviews. Malandragem (i.e., cunning) emerged as a major focus and our findings suggested that behavioural characteristics, such as mischief and deception, are common attributes valued by many elite Brazilian footballers. Our analysis suggests how the value system of Malandragem is a product of the socio-cultural constraints primarily influenced by the Mulattos’ cultural traditions, historically interacting with particular socio-economic conditions. In Brazil, Malandragem can manifest itself through the Ginga (i.e., body sway) playing style in which footballers move deceptively to gain competitive advantages over opponents. Whilst the theatrical antics of contemporary Malandros (i.e., tricksters and/or streetwise persons), such as Neymar Junior, are frowned upon by many football critics, we argue that some aspects of being Malandro may be contributing to the development of a high level of perceptual-motor and cognitive functioning that has underpinned the Ginga playing style in Brazilian football for many decades

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present — ‘D’, either elevated blood glucose levels or a family history of diabetes mellitus; ‘K’, the presence of high urinary or blood ketoacids; and ‘A’, a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children