The influence of personal communities in understanding avoidable emergency department attendance: qualitative study

Background: Use of emergency department (ED) care globally seems to be increasing at a faster rate than population growth (Baker, House of Commons Library. Accident and Emergency Statistics, Demand, Performance, 2017). In the UK there has been a reported 16% rise in emergency admissions over the past 5 years. Estimates that between 11 and 40% of ED attendances are non-urgent, with 11% of patients being discharged from the ED without treatment (NHS Digital 2017), and a further 44% require no follow-up treatment (NHS Digital, Hospital Accident and Emergency Activity 2016-17, 2019) is cited as evidence that these patients did not require this level of care. The solution to not using the most appropriate point in the system has traditionally been seen as a knowledge problem, requiring, improved sign-posting and information to enable people to self-manage or use health care management for minor ailments. However research about help-seeking behaviour suggests that the problem may not be an informational one. A considerable literature points to help seeking as a social process influenced by a range of contingencies and contextual factors including the way in which lay people influence health care utilisation (Giebel et al. BMJ Open 9:1, 2019). Personal communities comprise a variety of active and significant social ties which have potential to influence individual capacity to seek help. Here we extend and unpack further influencing decisions about seeking formal health care with reference to how they are shaped and informed by and within personal social networks. Methods: We undertook a personal network mapping and qualitative interview-based study to look at, problematize and understand attendance for non-urgent problems. We used network analysis and methods to map and characterise the personal communities of people seeking help from ED for minor ailments and semi-structured interviews with 40 people attending a single ED and associated GP hub providing equivalent care. Interviews were built around an ego network mapping activity and a topic guide structured to explore attender's narratives about why they had visited the ED. This ego network activity uses a diagram consisting of three concentric circles (Fiori et al. J Gerontol B-Psychol 62: 322-30, 2007), representing closest social network members (in the centre) and those at further distance. Participants were initially presented with one of these diagrams and asked to write names of people or resources that had played a role in their attendance and the interviewer probed the interviewee to discuss the actions, input and value of the people and services that supported the visit to the ED. Results: We analysed number and type of network connections and undertook a thematic analysis to identify how imagined and actual network members and influences were implicated in ED attendance. The network maps created during the interviews were examined and a typology of networks was developed and used to distinguish different types of networks informed by our reading of the data, and a Network Typology Scoring Tool, a measure of frequency of contact and relationship type in networks. Conclusions: Our study suggests that faced with acute minor illness or injury people's networks narrow: they do not (and perhaps cannot) mobilise their imagined care network because the resources or connections may not be there or are difficult to engage. In addition we identified important system drivers of behaviour, notably that these patients are often directed to the ED by 'professional influencers' including health services staff.</p

Oculomotor and linguistic processing effects in reading dynamic horizontally scrolling text.

Two experiments are reported investigating oculomotor behavior and linguistic processing when reading dynamic horizontally scrolling text (compared to reading normal static text). Three factors known to modulate processing time in normal reading were investigated: Word length and word frequency were examined in Experiment 1, and target word predictability in Experiment 2. An analysis of global oculomotor behavior across the 2 experiments showed that participants made fewer and longer fixations when reading scrolling text, with shorter progressive and regressive saccades between these fixations. Comparisons of the linguistic manipulations showed evidence of a dissociation between word-level and sentence-level processing. Word-level processing (Experiment 1) was preserved for the dynamic scrolling text condition with no difference in length and frequency effects between scrolling and static text formats. However, sentence-level integration (Experiment 2) was reduced for scrolling compared to static text in that we obtained no early facilitation effect for predictable words under scrolling text conditions

Trace Element Partitioning between CAI-Type Melts and Grossite, Melilite, Hibonite, and Olivine

We determined the mineral-melt partition coefficients (Di's) and the compositional and/or temperature dependency between grossite, melilite, hibonite, olivine and Ca-, Al-inclusion (CAI)-type liquids for a number of light (LE), high field strength (HFSE), large ion lithophile (LILE), and rare earth (REE) elements including Li, Be, B, Sr, Zr, Nb, Ba, La, Ce, Eu, Dy, Ho, Yb, Hf, Ta, Th. A series of isothermal crystallization experiments was conducted at 5 kbar pressure and IW+1 in graphite capsules. The starting compositions were selected based on the calculated and experimentally confirmed phase relations during condensation in CI dust-enriched systems (Ebel and Grossman, 2000; Ebel, 2006; Ustunisik et al., 2014). Partition coefficients between melt and gehlenite, hibonite, and grossite show that the trace element budget of igneous CAIs is controlled by these three major Al-bearing phases in addition to pyroxene. In general, LE, LILE, REE, and HFSE partition coefficients (by mass) decrease in the order of Di(Gehlenite-Melt) > Di(Hibonite-Melt) > Di(Grossite-Melt). Results suggest that Di(Gehlenite-Melt) vary by a factor of 2-3 in different melt compositions at the same T (~1500 C). Increased melt Al and Ca, relative to earlier work, increases the compatibility of Di(Gehlenite-Melt), and also the compatibility of Di(Hibonite-Melt), especially for La and Ce. Olivine partitioning experiments confirm that olivine contribution to the trace element budget of CAIs is small due to the low Di(Olivine-Melt) at a range of temperatures while D-Eu, Yb(Olivine-Melt) are sensitive to changes in T and oxygen fugacity. The development of a predictive model for partitioning in CAI-type systems would require more experimental data and the use of analytical instruments capable of obtaining single phase analyses for crystals < 5 micron.Comment: 23 pages, 15 figures, 5 table

Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

Background: Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need. Objective: This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory. Methods: The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool. Results: We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, “getting worse” or “getting better”; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code. Conclusions: Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively

Assessment tools of immediate risk of self-harm and suicide in children and young people: a scoping review

There are increasing numbers of children presenting to paediatric hospital settings in mental health crisis. Typically, non-mental health professionals are responsible for the initial assessment of these children and are required to identify immediate physical and emotional health needs. To ensure the safety of these children, immediate risk of suicide and self-harm should be assessed. However, no standardized assessment tool is used in clinical practice, and for those tools that are used, their validity and reliability is unclear. A scoping review was conducted to identify the existing assessment tools of immediate self-harm and suicide risk. Searches of electronic databases and relevant reference lists were undertaken. Twenty-two tools were identified and most assessed acute risk of suicide with only four tools incorporating a self-harm assessment. The tools varied in number of items (4?146), subscales (0?11) and total scores (16?192). Half incorporated Likert-type scales, and most were completed via self-report. Many tools were subject to limited psychometric testing, and no single tool was valid or reliable for use with children presenting in mental health crisis to non-mental health settings. As such, a clinically appropriate, valid and reliable tool that assesses immediate risk of self-harm and suicide in paediatric settings should be developed

The role of violent thinking in violent behaviour; it’s more about thinking than drinking

This article aims to explore and report on violent thinking and alcohol misuse; how these factors may predict self-reported violence. The role of violent thinking in violent behavior is both well established in theoretical models, yet there are few measures that explain this role. One measure that has been identified is the Maudsley Violence Questionnaire (MVQ). This is the first study to explore the use of the MVQ with a general (nonoffender) adult sample, having already been shown to be valid with young people (under 18 years old), adult male offenders, and mentally disordered offenders. This study involved 808 adult participants—569 female and 239 male participants. As figures demonstrate that around half of all violent crime in the United Kingdom is alcohol related, we also explored the role of alcohol misuse. Regression was used to explore how these factors predicted violence. The results demonstrate the important role of violent thinking in violent behavior. The MVQ factor of “Machismo” was the primary factor in regression models for both male and female self-reported violence. The role of alcohol in the regression models differed slightly between the male and female participants, with alcohol misuse involved in male violence. The study supports theoretical models including the role of violent thinking and encourages those hoping to address violence, to consider “Machismo” as a treatment target. The study also provides further validation of the MVQ as a helpful tool for clinicians or researchers who may be interested in “measuring” violent thinking

Assessing risk of self-harm in acute paediatric settings: a multicentre exploratory evaluation of the CYP-MH SAPhE instrument

Objective To psychometrically assess the Children and Young People-Mental Health Self-harm Assessment in Paediatric healthcare Environments (CYP-MH SAPhE) instrument for the identification of immediate risk of self-harm in CYP, aged 10–19 years, in acute paediatric wards or emergency departments.Design The CYP-MH SAPhE Instrument was developed through a robust scoping review and Delphi consensus with 30 clinicians/topic experts. To evaluate the psychometric properties, a multicentre exploratory study was conducted.Setting Three acute hospitals in the UK.Participants 163 CYP presenting at acute hospital settings with primary mental health (cases) or physical health (non-cases) conditions.Primary and secondary outcome measures Psychometric properties of the CYP-MH SAPhE instrument were evaluated through Principle Axis Factoring (PAF) with Oblimin (Kaiser normalisation) alongside measures of internal consistency (Cronbach’s α), convergent, discriminant and face validity.Results PAF of the dichotomous items (n=9) loaded onto three factors (1) behaviours and intentions; (2) suicidality and (3) self-harm. Factors 1 (Cronbach’s α=0.960) and 3 (Cronbach’s α=1) had high internal consistency. There was: good level of agreement between raters (kappa=0.65); a moderately positive correlation between the CYP-MH SAPhE instrument and the Columbia-Suicide Severity Rating Scale; and discrimination between cases and non-cases across the three factors (factor 1: m=88 vs 70; factor 2: m=102 vs 70; factor 3: m=104 vs 68). Assessment of face validity resulted in six items being removed, culminating in an eight question, rapid assessment instrument.Conclusions The results support the CYP-MH SAPhE Tool as a potentially reliable and valid instrument to identify immediate risk of self-harm in CYP presenting to acute paediatric healthcare environments, which is a burgeoning and significant global health issue

The quorum sensing transcription factor AphA directly regulates natural competence in Vibrio cholerae

Many bacteria use population density to control gene expression via quorum sensing. In Vibrio cholerae, quorum sensing coordinates virulence, biofilm formation, and DNA uptake by natural competence. The transcription factors AphA and HapR, expressed at low and high cell density respectively, play a key role. In particular, AphA triggers the entire virulence cascade upon host colonisation. In this work we have mapped genome-wide DNA binding by AphA. We show that AphA is versatile, exhibiting distinct modes of DNA binding and promoter regulation. Unexpectedly, whilst HapR is known to induce natural competence, we demonstrate that AphA also intervenes. Most notably, AphA is a direct repressor of tfoX, the master activator of competence. Hence, production of AphA markedly suppressed DNA uptake; an effect largely circumvented by ectopic expression of tfoX. Our observations suggest dual regulation of competence. At low cell density AphA is a master repressor whilst HapR activates the process at high cell density. Thus, we provide deep mechanistic insight into the role of AphA and highlight how V. cholerae utilises this regulator for diverse purposes