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STUDY OBJECTIVE: Vasopressin may be administered to treat vasospasm follow aneurysmal subarachnoid hemorrhage (aSAH). Few data support this practice, and it has recently been associated with clinically significant hyponatremia. The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature on this adverse effect. DESIGN: Single-center, observational case series of intensive care unit (ICU) patients SETTINGS: Ten-bed neurological intensive care unit at Maine Medical Center in Portland, Maine PATIENTS: Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically-confirmed vasospasm MEASUREMENTS AND MAIN RESULTS: A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were female. The median Glasgow coma scale score was 15 (11, 15) on admission and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically-confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of 0.03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of −16 (−10, −16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. CONCLUSIONS: Vasopressin administration to treat vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the vasopressin infusion. Additional study in a larger sample size is needed to determine if a causal relationship exists.

Background Patient safety is a worldwide problem, and the patient contribution to mitigate the risk of patient harm is now recognized as a cornerstone to its solution. In order to understand the nature of integrating patients into patient safety and healthcare organizations and to monitor their integration, a Canadian survey tool has been co-constructed by patients, researchers and the Canadian Patient Safety Institute (CPSI). This questionnaire has been adapted from the French version of the patient engagement (PE) in patient safety (PS) questionnaire created for the province of Quebec, Canada. Methodology The pan-Canadian PE in PS survey tool was developed in a five-step process: (1) a literature review and revision of the initial tool developed in the province of Quebec; (2) translation of the French questionnaire into an English version tool; (3) creation of a Canadian expert advisory group; (4) adaptation of the English version tool based on feedback from the expert advisory group (assessment and development of the construct’s dimensions, wording assessment and adaptation for pan-Canadian use, technical testing of the online platform for the survey); and (5) pilot testing and pre-validation of the tool before pan-Canadian use. Results and conclusion Eight pan-Canadian PE in PS surveys were completed from five Canadian provinces by the expert advisory group and six surveys were completed during the pilot project by participants from different provinces in Canada. This survey tool comprises 5 sections: (1) demographic identification of the participants (Q1 to Q5); (2) general questions (Q6 to Q17); (3) the patient engagement process (experience level of participants and organizational incentives for PE in general) (Q18 to Q33); (4) PE in PS processes, such as current activities, strategies, structures, resources and factors (Q34 to Q67); and (5) the context and impact of PE in PS initiatives in Canadian healthcare organizations (CHOs) (Q68 to Q75), including outcome identification, improvement mechanisms and strategies, evaluation mechanisms, and indicators.

This article examines the ways in which changes in Marian theology and the defaming and execution of two of Henry viii’s queens affected early modern literary representations of female power. It argues that, through the translations of Thomas Wyatt, Petrarchan poetry entered into a world of state-sponsored iconoclasm, a world where images of the sacred feminine, once revered, could be destroyed, and queens, once exalted as beloveds, could quickly be reduced to “whores” and executed. The first part of the article considers Wyatt’s “Whoso list to hunt,” a translation of Petrarch’s “Rime 190,” as a lens for examining the female body as both object of desire and site of violent destruction. The second part of the article considers English Petrarchism late in the reign of Elizabeth i, examining how John Donne’s “Love’s Progress” and Edmund Spenser’s The Faerie Queene (Book ii) construct violent fantasies of male control over the powerful female.

Background ADHD affects some individuals throughout their lifespan, yet service provision for adults in the United Kingdom (UK) is patchy. Current methods for mapping health service provision are resource intensive, do not map specialist ADHD teams separately from generic mental health services, and often fail to triangulate government data with accounts from service users and clinicians. Without a national audit that maps adult ADHD provision, it is difficult to quantify current gaps in provision and make the case for change. This paper describes the development of a seven step approach to map adult ADHD service provision in the UK. Methods A mapping method was piloted in 2016 and run definitively in 2018. A seven step method was developed: 1. Defining the target service 2. Identifying key informants 3. Designing the survey 4. Data collection 5. Data analysis 6. Communicating findings 7. Hosting/updating the service map. Patients and members of the public (including clinicians and commissioners) were involved with design, data collection and dissemination of findings. Results Using a broad definition of adult ADHD services resulted in an inclusive list of identified services, and allowed the definition to be narrowed to National Health Service (NHS) funded specialist ADHD services at data analysis, with confidence that few relevant services would be missed. Key informants included patients, carers, a range of health workers, and commissioners. A brief online survey, written using lay terms, appeared acceptable to informants. Emails sent using national organisations’ mailing lists were the most effective way to access informants on a large scale. Adaptations to the methodology in 2018 were associated with 64% more responses (2371 vs 1446) collected in 83% less time (5 vs 30 weeks) than the pilot. The 2016 map of adult ADHD services was viewed 13,688 times in 17 weeks, indicating effective communication of findings. Conclusion This seven step pragmatic method was effective for collating and communicating national service data about UK adult ADHD service provision. Patient and public involvement and engagement from partner organisations was crucial throughout. Lessons learned may be transferable to mapping service provision for other health conditions and in other locations. Electronic supplementary material The online version of this article (10.1186/s12913-019-4287-7) contains supplementary material, which is available to authorized users.

Publisher's version (útgefin grein), Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help. Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters. Young et al. Failure of ADHD Healthcare Provision Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD. Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue., The meeting was jointly funded by the ADHD Foundation, the UK Adult ADHD Network (UKAAN), and the UK ADHD Partnership (UKAP). Other than reimbursement of travel expenses to attend the meeting, none of the authors received any financial compensation for attending the meeting or writing the manuscript, aside from CS who was remunerated for her time. PA was supported by NIHR Biomedical Research Center for Mental Health, NIHR/MRC (14/23/17) and NIHR senior investigator award (NF-SI-0616-10040). TN-D was funded by an NIHR Advanced Fellowship (NIHR300056). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care., Peer Reviewed (ritrýnd grein)

Background Recent evidence shows that patient engagement is an important strategy in achieving a high performing healthcare system. While there is considerable evidence of implementation initiatives in direct care context, there is limited investigation of implementation initiatives in decision-making context as it relates to program planning, service delivery and developing policies. Research has also shown a gap in consistent application of system-level strategies that can effectively translate organizational policies around patient and family engagement into practice. Methods The broad objective of this initiative was to develop a system-level implementation strategy to include patient and family advisors (PFAs) at decision-making points in primary healthcare (PHC) based on wellestablished evidence and literature. In this opportunity sponsored by the Canadian Foundation for Healthcare Improvement (CFHI) a co-design methodology, also well-established was applied in identifying and developing a suitable implementation strategy to engage PFAs as members of quality teams in PHC. Diabetes management centres (DMCs) was selected as the pilot site to develop the strategy. Key steps in the process included review of evidence, review of the current state in PHC through engagement of key stakeholders and a co-design approach. Results The project team included a diverse representation of members from the PHC system including patient advisors, DMC team members, system leads, providers, Public Engagement team members and CFHI improvement coaches. Key outcomes of this 18-month long initiative included development of a working definition of patient and family engagement, development of a Patient and Family Engagement Resource Guide and evaluation of the resource guide. Conclusion This novel initiative provided us an opportunity to develop a supportive system-wide implementation plan and a strategy to include PFAs in decision-making processes in PHC. The well-established co-design methodology further allowed us to include value-based (customer driven quality and experience of care) perspectives of several important stakeholders including patient advisors. The next step will be to implement the strategy within DMCs, spread the strategy PHC, both locally and provincially with a focus on sustainability.

Background Whether patients receive low-value hospital care (care that is not expected to provide a net benefit) may be influenced by unmeasured factors at the hospital they attend or the hospital’s Local Health District (LHD), or the patients’ areas of residence. Multilevel modelling presents a method to examine the effects of these different levels simultaneously and assess their relative importance to the outcome. Knowing which of these levels has the greatest contextual effects can help target further investigation or initiatives to reduce low-value care. Methods We conducted multilevel logistic regression modelling for nine low-value hospital procedures. We fit a series of six models for each procedure. The baseline model included only episode-level variables with no multilevel structure. We then added each level (hospital, LHD, Statistical Local Area [SLA] of residence) separately and used the change in the c statistic from the baseline model as a measure of the contribution of the level to the outcome. We then examined the variance partition coefficients (VPCs) and median odds ratios for a model including all three levels. Finally, we added level-specific covariates to examine if they were associated with the outcome. Results Analysis of the c statistics showed that hospital was more important than LHD or SLA in explaining whether patients receive low-value care. The greatest increases were 0.16 for endoscopy for dyspepsia, 0.13 for colonoscopy for constipation, and 0.14 for sentinel lymph node biopsy for early melanoma. SLA gave a small increase in c compared with the baseline model, but no increase over the model with hospital. The VPCs indicated that hospital accounted for most of the variation not explained by the episode-level variables, reaching 36.8% (95% CI, 31.9–39.0) for knee arthroscopy. ERCP (8.5%; 95% CI, 3.9–14.7) and EVAR (7.8%; 95% CI, 2.9–15.8) had the lowest residual variation at the hospital level. The variables at the hospital, LHD and SLA levels that were available for this study generally showed no significant effect. Conclusions Investigations into the causes of low-value care and initiatives to reduce low-value care might best be targeted at the hospital level, as the high variation at this level suggests the greatest potential to reduce low-value care. Electronic supplementary material The online version of this article (10.1186/s12913-019-4159-1) contains supplementary material, which is available to authorized users.

Importance Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system. Objective To measure immediate in-hospital harm associated with 7 low-value procedures. Design, Setting, and Participants A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care. Main Outcomes and Measures For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated. Results Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care–associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care–associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC. Conclusions and Relevance These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.

In this chapter, I consider Henrietta Maria as she appears in academic studies, as well as in two works of historical fiction: Myself, My Enemy by Jean Plaidy, and Cavalier Queen by Fiona Mountain. These novels present the queen’s transgressive behavior—advocating for her Catholic faith, advising her husband, and leading the Royalist army into battle—in ways that contain the threat of the powerful woman. In addition, the reductive way these texts represent Henrietta Maria raises the question of how much license fiction writers should take with history, particularly in the case of historical figures such as queens consort whose life stories may be unknown to the majority of readers.

ObjectiveTo examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals.DesignAnalysis of admitted patient data for financial years 2010–2011 to 2016–2017.Main outcome measuresNumber and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017.ResultsFor 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to $A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends.ConclusionsLow-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.

This chapter presents Anna’s transformation from Danish princess to Scottish queen. Using the juxtaposition of the royal marriage and witchcraft persecutions, the chapter considers societal concerns about women, sexuality and danger. This chapter examines the representational dichotomy that pits deviant female sexuality against appropriate female sexuality. As is often the case with such dichotomies, Anna could not fully remain on the side of appropriate feminine performance. In her plotting, her temper and her Catholicism, she moved dangerously close to the very image of disruptive female power that spurred on the witch trials and continued to haunt the nation. As such, Anna and the witches were part of a representational dichotomy that frequently collapsed, leaving Anna to take the role of the disruptive, subversive woman.

This chapter examines Anna’s influence on the arts both through her patronage of Jacobean artists and through oblique representations of her in the works of artists such as Shakespeare. In particular, it examines representations of Anna as a fecund queen, bringing life and progeny to a throne that had but recently been occupied by a powerful virgin queen. Her fecundity brings hope for the future, but it also brings the unruly aspects of female sexual desire to the foreground. As the chapter comes to an end, it will return to the discussion of early modern witchcraft, teasing out parallels between Anna and Frances Howard, whose connection to adultery, murder and the occult make her the very embodiment of the dangers of female sexuality and power.

Transplant candidate caregivers (TCCs) are an under-utilized but potentially devoted pool of advocates who themselves may be recruited to register for deceased organ donation.The purpose of this study was to assess and compare recruitment barriers to deceased donor registration efforts in TCCs and health fair attendees (HFAs).A 42-item questionnaire assessing willingness to register as an organ donor and perceptions and knowledge about organ donation was administered to 452 participants (174 in Denver, 278 in San Francisco). Logistic regression, stratified by study site, was used to assess associations between explanatory variables and willingness to register as an organ donor.In Denver, 83 % of TCCs versus 68 % of HFAs indicated a willingness to register (p = 0.03). Controlling for study group (TCC vs HFA), predictors of willingness to register were female gender [odds ratio (OR) 2.4], Caucasian race (OR 2.3), college graduate (OR 11.1), married (OR 2.4) and higher positive perception of organ donation (OR 1.2), each p0.05. In San Francisco, 58 % of TCCs versus 70 % of HFAs indicated a willingness to register (p = 0.03). Controlling for study group (TCC vs HFA), predictors of willingness to register were Caucasian race (OR 3.5), college graduate (OR 2.2), married (OR 1.9), higher knowledge (OR 1.6) and higher positive perception of organ donation (OR 1.2), each p0.05. In both locales, Caucasians were more likely to have positive perceptions about organ donation and were more willing to register.Demographic characteristics, not personal connection to a transplant candidate, explain willingness to register as an organ donor.

Yellow perch captured downstream of a bleached sulfite mill had reduced gonad size and fecundity, and circulating steroid levels declined in goldfish exposed to final effluent for 21 d. To assess bleached sulfite mill (BSM) effluent, long-term fathead minnow (Pimephales promelas) growth and reproduction tests were carried out in a flow-through bioassay trailer at the mill secondary treatment lagoons. Fertilized P. promelas eggs were hatched in effluent (0, 1, 3.2, 10, 32, 50, and 100% final effluent with 10 ng/L ethinylestradiol as a positive control compound) and monitored through to 30, 60, and 125 d posthatch. The effluent caused a significant increase in the growth of fish; this effect was evident within 30 d. Fish had changes in secondary sex characteristics at maturity: Male fish had ovipositors in effluent concentrations as low as 3.2%. Higher effluent concentrations (32-100%) resulted in a majority of fish that looked externally like females. Changes in external sex characteristics were the most sensitive endocrine disruption-specific endpoints and required four months of exposure. Exposure to low BSM effluent concentrations (3.2%) resulted in female fish that had male sex characteristics (tubercles and dorsal fin dots). This masculinization of female fish was statistically significant at 10% effluent and was not seen in control fish. Concentrations of final effluent in the Saint John River (Canada) range from less than 1% to 15%, depending on the season and river flow. The research assesses some of the changes seen in fathead minnows exposed to this complex effluent, and demonstrates a threshold of

How does the effort we put into helping clients build links with their immediate neighbours compare with the time spent getting them out of their immediate street and into the local community? This article is aimed at purchasers and providers and examines the problems associated with establishing good relationships between clients and their neighbours. It also discusses the importance of finding the right property for clients’ needs.