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ObjectiveTo summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).MethodsA prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults 6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect.ResultsOf 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6–5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.InterpretationOverall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent.PROSPERO registration numberCRD42019141136.

Attention deficit hyperactivity disorder (ADHD) is an inheritable neurodevelopmental condition, often coexisting with other psychiatric conditions and learning difficulties. This exploratory qualitative investigation sought to explore and advance knowledge on mental health recovery–oriented principles and practices for young people and their families. We examined factors identified by parents as promoting and enabling young people living with ADHD to lead an engaged and meaningful life despite experiencing the challenges of their condition. The study was guided by grounded theory with purposeful sampling deployed to recruit 11 parents (8 mothers and 3 fathers) of children with ADHD. Two focus groups adopting a semi-structured interview format were convened to collect data. The interviews were audio recorded and transcribed verbatim. Thematic analysis was employed and focused on the identification and organization of common themes and patterns observed across the dataset. Nine primary themes were identified as captured by the acronym THRIVESSS (Time, Having a plan, Routine and structure, Identity, Valued social supports, Educating and collaborating, Self-awareness, Self-acceptance, and Symptom control) and explicated by 22 subthemes. Results showed that personal recovery for young people with ADHD is a specific and definable construct which offers a conceptual and applied alternative to the deficit-focused view of ADHD. Our findings provide support for the pressing need to develop a novel lexicon to represent a mental health personal recovery pathway specific for young people and their families predicated upon a strength-based foundation.

Background Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. Methods and analysis The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. Discussion This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. Systematic review registration PROSPERO CRD42017081030

Background\ud \ud The influence of patient demographics and mode of admission on the ‘weekend effect’ remains unclear. This study examins the relationship between day of admission, patient demographics, mode of presentation and survival.\ud \ud \ud Methods\ud \ud Hospital admissions over a three-year period were studied. Patients with an inpatient stay less than 24 h and those who were discharged from the emergency department were excluded. In-hospital mortality was correlated with day of admission, age, gender and mode of presentation in a binary logistical regression analysis.\ud \ud \ud Results\ud \ud There were 448,827 admissions, of which 350,648 (85.7%) occurred during a weekday. 256,777 (62.7%) were emergency presentations, which was closely related to a weekend admission (92.3% vs 57.8%, p < 0.001). There were 8099 deaths of which 6336 (78.2%) related to a weekday admission and 1736 (21.4%) related a weekend admission. Mortality for elective admissions was 78 (0.05%) compared to 8021 (3.12%), p < 0.001 in emergency admissions. Univariable regression analysis revealed a weekend admission (Odds Ratio (OR) 1.68 (95% confidence interval (CI) 1.60–1.78, p < 0.001) and emergency presentation (OR 63.02 (95%CI 50.42–78.77), p < 0.011) were associated with weekend mortality. On multivariable analysis the OR for weekend admission reduced to 1.07 (95%CI 1.01–1.13), p = 0.013 and the OR for emergency presentation increased to 76.68 (95%CI 61.40–96.00), p < 0.001.\ud \ud \ud Conclusion\ud \ud This study highlights that higher weekend mortality rates are a consequence of a lower proportion of elective admissions. Extending the working week to seven days might reduce weekend mortality without reducing the total number of deaths.

BackgroundSupport workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and that there are gaps in understanding support worker roles across different care settings. In the context of a population that is growing older, having a skilled and knowledgeable workforce is an imperative. Workforce development includes the support required to equip those providing care to older people with the right skills, knowledge and behaviours to deliver safe and high-quality services.ObjectiveThe review answered the question ‘how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services?’.DesignA realist synthesis was conducted. In realist synthesis, contingent relationships are expressed as context–mechanism–outcomes (CMOs), to show how particular contexts or conditions trigger mechanisms to generate outcomes. The review was conducted in four iterative stages over 18 months: (1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce, guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories and establish their practical relevance/potential for implementation; and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people.ParticipantsTwelve stakeholders were involved in workshops to inform programme theory development, and 10 managers, directors for training/development and experienced support workers were interviewed in phase 4 of the study to evaluate the findings and inform knowledge mobilisation.ResultsEight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points. These include personal factors about the support worker, the specific requirements of workforce development and the fit with broader organisational strategy and goals.Conclusions and recommendationsThe review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers in older people’s health and social care services. Implications for the practice of designing and delivering older person’s support workforce development interventions are directly related to the eight CMO configuration of the programme theory. Our recommendations for future research relate both to aspects of research methods and to a number of research questions to further evaluate and explicate our programme theory.LimitationsWe found that reports of studies evaluating workforce development interventions tended to lack detail about the interventions that were being evaluated. We found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated.Study registrationThis study is registered as PROSPRERO CRD42013006283.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Advances in newborn screening technology, coupled with recent advances in the diagnosis and treatment of rare but serious congenital conditions that affect newborn infants, provide increased opportunities for positively affecting the lives of children and their families. These advantages also pose new challenges to primary care pediatricians, both educationally and in response to the management of affected infants. Primary care pediatricians require immediate access to clinical and diagnostic information and guidance and have a proactive role to play in supporting the performance of the newborn screening system. Primary care pediatricians must develop office policies and procedures to ensure that newborn screening is conducted and that results are transmitted to them in a timely fashion; they must also develop strategies to use should these systems fail. In addition, collaboration with local, state, and national partners is essential for promoting actions and policies that will optimize the function of the newborn screening systems and ensure that families receive the full benefit of them.

Objective: In this paper we describe the origins of suicide prevention contracting, identify the historical factors that led to the adoption of the intervention, and describe legal tensions that have emerged during its use. Conclusions: It would appear that one of the most frequently used clinical interventions for responding to suicidality has established a place in clinical practice without evidence attesting to its efficacy. We develop some propositions about how and why this clinical technique has been able to consolidate its place in mental health practice and, in so doing, suggest that the original technique was able to secure a clinical place without much apparent resistance because of the confluence of a number of emerging theories and community trends.

Primary objective: To investigate body image concerns and psycho-emotional health in females with acquired brain injury (ABI). Research design: Between subjects design. Methods and procedures: Thirteen females with ABI and thirteen matched controls were assessed on a number of variables relating to body image, self-esteem and affect. Main outcomes and results: Indicated that women with ABI had a different profile of body image dissatisfaction than controls and that in some areas it was significantly worse. The women with ABI had significantly lower self-esteem and higher levels of depression than controls and this related to body image. Conclusion: Significant changes in body image and self-concept are potentially damaging to quality of life post-injury and suggest a role for targeted therapeutic work with women with ABI.

Acquired traumatic brain injury (TBI) can leave the survivor with a complex range of psychological sequalae. This study aims to investigate the experience from the perspective of women with acquired TBI. Using a qualitative research method, six women with a TBI were interviewed about their experience, and the interviews were transcribed verbatim and analysed according to Interpretative Phenomenological Analysis (IPA). The major themes that emerged were: awareness of change; the emotional reaction; struggling to make sense; adaptation and acceptance. This article describes the process of adaptation, and the implications for rehabilitation are discussed. It is suggested that an intervention based on these themes might be an effective tool in rehabilitation.

Penile cancer, although statistically rare in Western countries (1:100 000 per year), results in considerable physical and psychological morbidity. The treatment of choice for penile cancer is either partial or total amputation of the penis. Metastatic spread into the surrounding lymphatic system may require additional surgery. To date, little is known of the lived experiences of men with penile cancer regarding the impact of the disease and its treatment on dimensions of masculinity.A small-scale qualitative study using Interpretative Phenomenological Analysis (IPA). IPA aims at exploring the experience of life events and the meaning and implications for the person living through them. A purposive sample of men with penile cancer who were within a minimum of 18 months post-surgery were recruited via a specialist urology clinic (n = 9). Participants were interviewed by a male researcher using a pre-agreed semi-structured interview schedule; interviews were audio recorded for transcription with detailed analyses of main and sub-themes conducted independently by three researchers. To maintain analytical rigour, constant comparisons of main and sub-themes were made between the individual transcripts and across the emergent themes within the research group.Central themes were (1) grappling with reality; (2) learning to cope and (3) changes to self.That men should have an altered sense of masculine identity following penile cancer surgery is not unexpected. However, the ways in which altered masculinity manifested itself were both subtle and insidious. The results have implications for clinical practice and demonstrated the need for further research.

The mean numbers of interphase fibrillar centers have been determined in triplicate experiments, using the argyrophil (AgNOR) method. Promonocytic U937 cells were incubated with each of three inducing agents, namely, interleukin-6, granulocyte-macrophage colony-stimulating factor, and the phorbol ester 12-O-tetradecanoylphorbol-13-acetate. The cells were examined at 24, 48, and 72 h during the induction periods and their doubling time and mean AgNOR score were calculated. After 72 h, the cells were maintained in culture for a further 24 h in the absence of an inducing agent and these parameters were determined again. It was found that whereas the unstimulated U937 cells had a mean value in the region of 50 AgNORs per nucleus, this diminished to about 20 after a 72 h incubation, but rose to 30 or more when the inducing agents had been withdrawn for 24 h. These observation confirm the results of previous studies using melanoma and HL60 cell lines: however, it has now been demonstrated that a variety of agents can modulate the numbers of fibrillar centers in a very similar way in a single cell line. Furthermore, we have shown that the “undifferentiated” U937 cell AgNOR score recovers when the agents no longer act upon the cells; this implies that fibrillar center numbers are intimately related to differentiation state in cell lines, as in the case in, for example, tumor specimens.

A paper delivered to a Medicolegal Seminar conducted by the Medical Record Association of Australia — WA Branch entitled “Medicolegal Countdown — Do Your Health Records Meet Ethical and Legal Requirements?” in Perth on 25 August 1989.

The Federal Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) has been involved with newborn screening and genetic testing and services since the 1960s. Although other branches of the federal government, such as the National Institutes of Health and the Centers for Disease Control and Prevention, have played key roles in newborn screening, this report focuses on the issues from the perspective of HRSA and its collaboration with the American Academy of Pediatrics (AAP). Genetic diseases gained recognition in public health with the … Address correspondence to Peter C. van Dyck, MD, MPH, FAAP, Associate Administrator, Maternal and Child Health Bureau, 5600 Fishers Lane, Room 18-05, Rockville, MD 20857. E-mail: pvandyck{at}hrsa.gov

For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully.This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning.

Objectives: The study sought to determine: (i) the prevalence rates of psychological distress and suicidal ideation among 15–24–year-old patients presenting to general practice; and (ii) the relationship between patients' presenting complaints and their levels of psychological distress and suicidal ideation. Method: This was a pilot study designed to sample patients aged 15–24 years presenting consecutively to general practitioners during a 4–week period. The study was set among five general practices in the western suburbs of Perth, Western Australia. Participants included five general practitioners and 69 patients aged 15–24 years. Main outcome measures were the General Health Questionnaire (GHQ-12), the Centre for Epidemiological Studies Depression Scale (CES-D) and the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS). Results: One-third of patients scored above the cut-off of the GHQ-12,31.9% above the cut-off of the CES-D and 20.3% above the cut-off of the DSI-SS. The majority of patients (87.5%) presented with medical complaints. Of these, 26.8%, 23.2% and 21.4% scored above the cut-offs of the GHQ-12, CES-D and DSI-SS, respectively. Patients presenting with psychological complaints (12.5%) were significantly more likely to score above the cut-off of the CES-D. Conclusions: In this pilot study, patients aged 15–24 presenting to five general practices had relatively high levels of psychological distress and suicidal ideation. Of most concern were those presenting with medical complaints and who also had high levels of unreported psychological distress.

An analysis of the bowling action of professional cricketers in the UK for four seasons between 1981 and 1991 shows there to be a significant association between handedness and bowling style (seam or spin bowling). Furthermore, there is a significantly higher number of left-handed spin bowlers than would be predicted from the general population, but not left-handed seam bowlers. As the technical differences between left- and right-handed orthodox spin bowlers are much greater than those between left- and right-handed seam bowlers, these data are consistent with the view that the over-representation of left-handed bowlers reported by Wood and Aggleton (1989) is due to strategic rather than neuropsychological factors.

Adult male rats were allowed to free-feed until their body weights had stabilised. They were next trained onto a 4 h per day feeding regimen, until further stabilisation occurred. All rats then received saline injections for 5 days, to establish baseline body weights. One group was then injected with 5.0 mg/kg 5-HT daily for 30 days while the other group continued with saline. Progressive and significant weight loss occurred in the drug-treated animals. After 30 days, the 5-HT-treated rats had lost 7.0% of their baseline body weights, whereas the control group had gained 1.3%. At this point, the 5-HT treated rats were switched back to saline injections to investigate rebound effects. Although the group that had received 5-HT treatment showed evidence of rebound weight gain, mean weights at the end of the 10 day rebound period were still 4.5% lower than baseline values. These data clearly indicate that chronic systemic administration of 5-HT can produce considerable weight loss in rats.

Psychiatric manifestations ofoitamin B-12 deficiency are reuieuiedfrom 1986 to thepresent. Specific clinical entities reviewed include depression, organic psychosis , obsessive-compulsive disorder, childhood manifestations and dementia. We recommend that consideration be given to B-12 deficiency as an etiological fa ctor in some cases qf depression, organic psychosis, certain childhood disorders and dementia. Routinescreening ofpeople overage65 is addressed. Vita min B-12 (Co ba la m in) deficien cy may be as high as 5% in populat ions over age 50 a nd up to 10% in patients over age 65 ( I). The deficiency can result from inad equate intak e (e .g., chro nic unbalan ced diet , breast -fed ba bies of vegan mothers), impaired abso rpt ion (e.g., gas t r ic lesions, pernicious anemia, gast rectomy, small bowel disease), vit amin B-12 degr ad at ion (e .g., nit ro us oxide anesthesia) , increased re quire me nt (e .g., pan cr eatic insu fficien cy, hype rthyroidism), or can be multifactoria l (e .g., chro nic a lcoho lism) ( 1-3) . Since the firs t rep ort of psychiatric sequelae by Addison in 1868 (4), a number of th e manifesta tion s of this deficiency hav e been recorded. H ect or a nd Burton reviewed th e lit erature up to 1986 (5) and cited the following diagn oses, or sympto ms, with a n et iology of B-12 deficiency: 20 pat ient s presen ted with delirium; 24 with depression ; 14 with psych osis; 65 with slow cerebration, confus ion, or mem ory loss; 4 with irritability or person ality cha nge; 15 with hallucinations or delusions; 4 with schizophre nia or paraphreni a ; 3 with mania; a nd 3 wit h dem entia. Recently, Lindenbaum e t al (6) found a number of psychi atric man ifestations of cobala min deficiency in th e 40 pati ents whom th ey stud ied. They found 15 patients who exhibite d combinations of th e followin g sympto ms : 13 wit h memory loss; 3 with disorientation; I with obtundation; 2 with depression ; I with irrit ability; 2 with hallucinations; I with agitation; 2 with marked personality cha nge ; and I with

To the Editor. —The North Carolina Pediatric Society has worked for years to improve access to health care for children. We encouraged pediatricians to participate in the survey reported in "Factors Associated With Pediatricians' Participation in Medicaid in North Carolina." 1 Some of the study results, however, seem inconsistent with our experience of the access problem for Medicaid children. For years we have felt that a majority of the primary care physicians restricted open access to children covered by Medicaid. Therefore, we were puzzled when the results of this survey indicated only 29% of pediatricians restricted access. If that were true, then there should be enough providers available for this population. Since we are convinced that more providers are needed, we have made efforts to determine the significant factors necessary to attract them. Our impression is that reimbursement rates are a major factor. This current study indicated that improving reimbursement

The data in this paper show that when the inhibition of growth is measured, xeroderma pigmentosum (XP) complementation groups A, G and D are very sensitive to 4-nitroquinoline-1-oxide (4NQO), whereas only XP groups G and D are very sensitive to 3-methyl-4NQO (3me4NQO). Cells belonging to XP-C group are not particularly sensitive to either agent. Thus there are different epistasis groups for the excision repair of DNA adducts induced by these agents as opposed to the repair of u.v. damage. DNA polymerase alpha is involved in the repair of 4NQO-induced lesions because aphidicolin blocks their repair. XP cells from all the above groups are defective to some extent in this repair. The degree of repair defectiveness follows that seen after u.v., with even the XP-C cell line used having reduced repair (despite the fact that the inhibition of growth by 4NQO in this cell line was not markedly different from normal). Aphidicolin did not induce breaks in the normal or XP cell lines exposed to 3me4NQO, thus the repair of lesions induced by 3me4NQO does not involve DNA polymerase alpha in any of the cell lines. Finally, catalase reduces the alkaline labile lesions induced by 4NQO, but not 3me4NQO, suggesting the latter agent does not induce substantial amounts of DNA damage by the generation of radicals.

4-Nitroquinoline-1-oxide (4NQO) reacts with DNA primarily at the N2 and C8 of guanosine, with a small percent of reaction at the N6 of adenosine. In human cells it has been unclear whether or not all 4NQO-induced adducts are removed by a nucleotide excision repair mechanism. In this paper we demonstrate that the inhibitor of DNA polymerases alpha and delta, aphidicolin, blocks the repair of all 4NQO adducts. Hence excision repair must operate on all of these lesions. After 4NQO the residual excision repair seen in a xeroderma pigmentosum group A cell line virtually totally defective in UV repair was 40-60% of that in normal cells. Therefore there must be some differences between the excision repair operating on UV as opposed to 4NQO-induced DNA damage.

The experiments reported here have investigated the induction of ethylations to DNA in yeast cells exposed to the chemical mutagen ethylnitrosourea. A similar level of alkylation was seen at the N7 and O6 of guanine and at the N3 of adenine in either log phase cells or in temperature-sensitive cdc4 and cdc7 cells growth arrested at their specific G1 positions. Hence the changes in chromosome structure associated with the above cdc phenotypes do not modify the amount of DNA damage induced by ethylnitrosourea.

Auto racing is a diverse sport in terms of car design and sophistication, topography of race courses, speeds achieved, and driver experience. These factors relate directly to potential hazards of auto races and the approaches to safety utilized by the groups conducting these events. The evolution in recent years of technologically advanced racing machines capable of speeds exceeding 200 mph has mandated commensurate sophistication in acute medical care programs serving professional racing teams. A comprehensive team approach to the on-track evaluation and treatment of speed-sport-related trauma is described.