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Competing Interests: Declaration of interests PM reports grants from National Institute for Health and Care Research (NIHR), the Medical Research Council (MRC), Bristol & Weston Hospitals Charity, and The Cassell Hospital Charitable Trust; and salary support from the NIHR Applied Research Collaboration Southwest, the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation, and Avon and Wiltshire Mental Health Partnership NHS Trust. NK reports grants from NIHR, Health Quality Improvement Partnership, and the Department of Health and Social Care; has received salary support from the Greater Manchester NIHR Patient Safety Research Collaboration, Mersey Care NHS Foundation Trust, and the University of Manchester; has chaired and contributed to committees for the National Institute for Health and Clinical Excellence (NICE) guidelines, including those on the management of self-harm; and is a member of the National Suicide Prevention Strategy Advisory Group (England). RCO is a trustee and science council member of MQ Mental Health Research, president of the International Association for Suicide Prevention, co-chair of the academic advisory group to the Scottish Government's National Suicide Prevention Leadership Group, and a board member of the International Academy of Suicide Research; was a member of the NICE guideline group for the management of self-harm; and reports grants from Medical Research Foundation, the Mindstep Foundation, Chief Scientist Office, MRC, Public Health Scotland, Scottish Government, NIHR, Shout 85258, Scottish Association for Mental Health, Zoetis Foundation, Jonathan's Voice, ADHD UK, and Barfil Charitable Trust. HC reports grants from the National Health and Medical Research Council (NHMRC), the Medical Research Future Fund, Paul Ramsay Foundation, and the Australian Government; is Scientia Professor at the University of New South Wales, supported by an NHMRC Elizabeth Blackburn Research Fellowship, and chief investigator on the NHMRC Centre for Research Excellence in Suicide Prevention; sits on the Million Minds Committee; and is a director of the Black Dog Institute Board and the Ramsay Health Care Research Foundation. MS declares salary support through academic scholar awards from Sunnybrook Health Sciences Centre and the University of Toronto. OJK is currently supported by a Research Foundation Flanders Senior Postdoctoral Fellowship; reports grants from Research Foundation Flanders and the King Baudouin Foundation; is co-chair of the International Association for Suicide Prevention Early Career Group, for which she receives complimentary student membership; is a former member of the Samaritans research ethics board; and has previously received travel grants and waived registration to present at conferences of the International Academy of Suicide Research. JP reports grants from NHMRC, the Medical Research Future Fund, Department of Health of the Australian Government, New South Wales Health, and the National Suicide Prevention Office. LFC is the vice president of the International Association for Suicide Prevention and is a permanent member of the Malaysian technical working group for suicide prevention; reports grants from the Centre of Pesticide Suicide Prevention at the University of Edinburgh; has received honorarium from Johnson & Johnson as a consultant and speaker; and, through her institution, has received access to the industry-sponsored medication sampling programme (compassionate patient programme) for clinical use for medication samples of esketamine (Johnson & Johnson), brexpiprazole (Lundbeck), Abilify Maintena (Lundbeck), and Trinza (Johnson & Johnson). DK is funded through the Elizabeth Blackwell Institute for Health Research at the University of Bristol, which is supported by the Wellcome Trust; has received grants from the Centre for Pesticide Suicide Prevention and the American Foundation for Suicide Prevention; and is a steering group member of the UK's National Suicide Prevention Alliance, and the Migration Health and Development Research Initiative. VP has consulted with Google and Modern Health (unrelated to the scope of this project). AC reports grants from Wellcome Trust, Leverhulme Trust, Economic and Social Research Council; has received funded consultancy from the Scottish Government and Alcohol Change UK; and is a member of the academic advisory group to the Scottish Government's National Suicide Prevention Leadership Group. SPe reports a 2021–2024 Vanier Canada Graduate Scholarship from the Canadian Institutes of Health Research. NS is a lived experience advisor to the Wellcome Trust, consumer academic at the University of Melbourne, lived experience lead at the Royal Children's Hospital, member of the Lived Experience Air Academy for University of Wollongong's Project Air, lived experience director for the Australian BPD Foundation, and associate at yLab (a division of the Foundation for Young Australians); reports previous employment with Orygen, and previous roles with the Youth Affairs Council of Victoria, Victorian Department of Families, Fairness, and Housing, Victorian Department of Premier and Cabinet, and Moonee Valley City Council; funded travel through Black Dog Institute and International Association of Suicide Prevention; and a current research tie to Orygen. FSt reports a grant from the Burdett Trust for Nursing and support from Abertay University. PSFY is a member of the advisory committee on mental health for the government of the Hong Kong Special Administrative Region. All other authors declare no competing interests.

Introduction: Antiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts., Materials and Methods: Patients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 μg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition., Results: Among the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups., Conclusions: These findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Introduction: The disparity in mental health outcomes compared with non-Indigenous Australians means that there is an urgent need to develop an evidence base around how services can better support Aboriginal and Torres Strait Islander communities. A critical first step is to embed cultural safety into research methodologies., Objective: Here, we aim to establish the foundation of a research project through co-designing a qualitative interview with Aboriginal and Torres Strait Islander consumers and community members about experiences of cultural safety with mainstream mental health services., Design: Voices of Aboriginal and Torres Strait Islander peoples must be empowered across all stages of research. An Aboriginal-led research team conducted focus groups to understand clear, sensitive, and culturally appropriate ways of asking about experiences in mental health care, to co-design an interview on this topic. Participants were Aboriginal and Torres Strait Islander consumers of mental health services, carers, mental health workers, Elders and Cultural Healers, living in Metropolitan and Regional Western Australia., Findings: Results suggest that Indigenous governance, together with investing in ongoing, and meaningful cultural awareness and cultural safety training (cultural awareness being a first step towards safety) for non-Indigenous researchers, together with taking the time to build respectful partnerships with communities through ongoing consultation, were appropriate and comprehensive methods of co-designing an interview., Discussion: The process of working with Aboriginal and Torres Strait Islander peoples in research is as important as the outcome. Aboriginal and Torres Strait Islander leadership, self-determination, and relationship building with communities are essential., Conclusion: Empowering co-design methodologies are flexible, iterative, and ensure that the experiences and views of participants are valued, leading to more meaningful results., (© 2022 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Culturally safe and responsive interventions that acknowledge Aboriginal models of selfhood are needed. Such interventions empower Aboriginal peoples and communities by increasing self-determination over individual and community social and emotional wellbeing (SEWB). In response to this need, the National Empowerment Project developed the Cultural, Social, and Emotional Wellbeing Program (CSEWB). The CSEWB aims to strengthen SEWB and cultural identity and subsequently reduce psychological distress in Aboriginal peoples. An Aboriginal Participatory Action Research approach ensured community ownership and engagement. Seven research questions and a culturally modified adaption of the Most Significant Change technique informed a thematic analysis of the evaluation content. Aboriginal adults ( n = 49; 53% ≥50 years, 66% female, 34% male) from three Western Australian urban communities participated in the program evaluation workshops. Participants reported the benefits of enhanced SEWB and reduced psychological distress. This research reaffirms the need for culturally safe programs that acknowledge social determinants of health and are guided by the SEWB framework. Long-term commitment from the government is needed to support such programs.

The study aims to explore the role of mental health care in remote Aboriginal health services in the Kimberley region of Western Australia and provide a more nuanced understanding of the patients presenting for care, their needs, and the clinical response. Little is currently known about primary health care presentations for mental health, suicide, and self-harm for remote dwelling Aboriginal residents of the Kimberley region, despite high rates of psychological distress, self-harm, and suicide across the area. This study was progressed through a retrospective, cross-sectional audit of the electronic medical records system used by three remote clinics to explore the interactions recorded by the clinics about a patient's mental health. In addition, an in-depth file review was conducted on a stratified purposive sample of 30 patients identified through the audit. Mental ill-health and psychological distress were found to be prominent within clinical presentations. Psychosocial factors were frequently identified in relation to a patient's mental health presentation. Optimizing patients' recovery and wellness through service improvements, including an enhanced mental health model of care, is an important next step.

Objectives: In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure., Design: Prospective cohort study., Setting: Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital., Patients: Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded., Interventions: Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days., Measurements and Main Results: Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01)., Conclusions: Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth., Competing Interests: Dr. Beitler’s institution received funding from the National Institutes of Health (NIH); he received funding from Hamilton Medical and Sedana Medical; he received support for article research from the NIH. Drs. Dzierba, Khalil, Derry, and Madahar have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making., Objectives: To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions., Methods: A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses., Results: The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress., Conclusions: Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards., (©2021 American Association of Critical-Care Nurses.)

Purpose: To characterize the impact of add-on dexmedetomidine therapy on baseline continuous infusion sedative use., Methods: A retrospective, single-center, chart review-based study was conducted to assess outcomes of and potential predictors of response to add-on dexmedetomidine therapy in mechanically ventilated intensive care unit (ICU) patients who were already receiving continuous infusions of sedatives. Patients were defined as complete, partial, or nonresponders to add-on dexmedetomidine therapy if initial sedative infusion rates were reduced by 100%, by 50% to 99%, and by less than 50%, respectively, at 6 and 24 hours after initiation of dexmedetomidine., Results: Among the 100 patients included in the study sample, there were 54 complete responders, 21 partial responders, and 25 nonresponders to dexmedetomidine add-on therapy at 6 hours after dexmedetomidine initiation; at 24 hours, there were 65 complete and 12 partial responders and 23 nonresponders. Of the variables tested (ie, baseline characteristics, opioid and antipsychotic use, hemodynamic parameters), none differentiated between complete or partial responders and nonresponders. Ventilator time, ICU length of stay (LOS), and hospital LOS after add-on dexmedetomidine therapy initiation were shorter among both partial responders and complete responders vs nonresponders (median, 1.1 days vs 4.1 days [P = 0.01], 7.0 days vs 14.1 days [P = 0.20], and 11.0 vs 17.0 days [P = 0.58], respectively), with only ventilator time being significantly different., Conclusion: Add-on dexmedetomidine therapy can obviate or reduce the need for alternate sedation in as many as 75% of mechanically ventilated ICU patients. However, the addition of dexmedetomidine does not allow the reduction of alternate sedation in a substantial minority of patients, and failure to respond to dexmedetomidine can be identified as early at 6 hours after add-on therapy initiation. In the absence of clear predictors of response to dexmedetomidine, these data suggest empiric trials of dexmedetomidine can be considered but should be time-limited., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The distinction between grandiose and vulnerable narcissism is new to the child literature, but initial findings suggest that it may have important implications for understanding adjustment. This study examined how expressions of narcissism in children influence their reactions to a mild egothreats experience. Children (N = 124; aged 8-12 years) completed self-ratings before and after doing a brief but challenging task. Negative emotions, self-conscious emotions, and performance estimates were measured. Regression analyses showed that, even after controlling the effects of self-esteem and temperament, vulnerable narcissism was related to increased hostility, anger, and shame, whereas grandiose narcissism was related to inflated performance estimates following the task. These results demonstrate the unique roles of grandiose and vulnerable narcissism in children., (© 2019 Society for Research in Child Development, Inc.)

Background: Delirium in the hospitals leads to worse outcomes for patients. There were no previous studies that characterize patients with delirium from multiple hospital locations., Objective: To describe patient characteristics screening positive for delirium and identify any correlations with hospital location and medication use., Design, Settings, Patients: Retrospective chart review of 227 hospitalized patients from a large, academic, tertiary referral, 2-campus health system. Patients were ≥18 years old and had delirium for at least ≥24 hours. Validated delirium screening tools were utilized., Measurements: Patients' demographics, inpatient stay information, delirium episodes characteristics, drugs, and palliative and psychiatry teams' involvement., Results: Most patients were older with a mean age of 64.1 years. The most common primary diagnoses were infection, cardiac, and pulmonary. Average length of delirium was 7.2 days (standard deviation [SD] = 8.2), and average length of stay (LOS) was 18.7 days (median = 10.5, SD = 35.1, 95% confidence interval = 14.1-23). Thirty-day readmission rate was 24.8% (65/262 hospitalizations); 12.8% of patients died in the hospital (29/227). Around one-third of hospitalizations had involvement of palliative care, palliative psychiatry, or general psychiatry team. There was a decrease in the number of medications administered 24 hours after the first recording of delirium compared to the immediate preceding 48 hours. Those hospitalizations where delirium first occurred in the intensive care unit (ICU) did have a longer LOS (average = 22.9, SD = 45.7) than those where delirium first occurred outside the ICU (average = 14.8, SD = 20.5). Patients were likely to have received an opioid within 48 hours in 51% of hospitalizations and to have received benzodiazepines in 16% of hospitalizations., Conclusion: In our study, we found that delirium significantly impacted length of delirium episode, number of episodes of delirium, length of hospital admission, and mortality. The population most sensitive to the impacts of delirium were elderly patients.

Clinical and empirical research have consistently distinguished two dimensions of narcissism: grandiose narcissism and vulnerable narcissism. However, to date there is no psychometrically validated measure of grandiose and vulnerable narcissism for children. A measure that assesses both expressions of narcissism in children and adolescents is necessary to understand the causes and consequences of narcissistic self-views prior to adulthood. In this article, four studies are presented documenting the construction and psychometric properties of a 15-item Narcissism Scale for Children, adapted from the (adult) Narcissism Scale. Partial confirmatory factor analysis supported two dimensions of narcissism in children (Study 1) and adolescents (Study 4), with evidence for good validity and reliability (Studies 1-4). As in adults, trait narcissism in children and adolescents consists of both grandiose and vulnerable dimensions. Enabling the measurement of multidimensional narcissism prior to adulthood has important implications for narcissism theory and future research.

A 4-factor prothrombin complex concentrate (4F-PCC, Kcentra®) was recently approved in the United States for the reversal of vitamin K antagonist-associated major bleeding, but it is often used to reverse coagulopathy in patients with liver disease (LD). This single-center, retrospective study analyzed the efficacy and safety of 4F-PCC administered in patients with and without LD. Prothrombin time/International Normalized Ratio (PT/INR) reversal with 4F-PCC was attempted in 85 patients; LD was documented in 31 patients. Coagulopathy reversal and hemostasis with 4F-PCC were inferior in patients with LD compared to patients without LD. Coagulopathy reversal, defined as INR = 1.5 after 4F-PCC administration, was achieved in 6 (19.4%) LD patients, compared to 44 (81.5%) non-LD patients ( p < 0.01). Hemostasis was achieved in 6 LD patients (19.4%) compared to 23 non-LD patients (42.6%) ( p = 0.03). Thromboembolic events occurred in 1 LD patient (3.2%) and 8 non-LD patients (14.8%) ( p = 0.15). Mortality was 51.6% in LD patients and 18.5% in non-LD patients ( p < 0.01). These observations suggest that the efficacy of 4F-PCC is suboptimal to correct coagulopathy and hemostasis in patients with LD, who have high rates of in-hospital mortality due to sequelae of LD. The incidence of thromboembolic events appeared comparable, suggesting that 4F-PCC does not cause undue thromboembolism in LD patients. In conclusion, 4F-PCC appears to be safe in LD patients when administered judiciously; however, further studies are necessary to optimize its use and elucidate its hemostatic potential in this patient population.

Introduction: Electromyography is useful in the diagnosis of myopathies, but its utility in determining disease severity requires further investigation. In this study we aimed to determine whether decomposition-based quantitative electromyography (DQEMG) could indicate the severity of involvement in a cohort of patients with muscular dystrophies (MDs)., Methods: Fifteen patients with facioscapulohumeral (FSHD), limb-girdle (LGMD), and Becker (BMD) muscular dystrophy, and 7 healthy controls, participated in this investigation. Knee extensor isometric strength differentiated the "more severe" and "less severe" MD groups. The vastus lateralis (VL), biceps brachii (BB), and tibialis anterior (TA) muscle groups were investigated using DQEMG., Results: All muscles from the MD group showed changes in mean MUP (motor unit potential) AAR (area-to-amplitude ratio), and turns, compared with controls (P < 0.05). More severely affected muscles (VL and BB) also had shortened mean MUP durations compared with controls (P < 0.01)., Conclusions: DQEMG was capable of indicating the severity of MD involvement, as changes in MUP morphology reflected the progressive nature of the disease., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: In the present study we review our experience with 900 consecutive percutaneous muscle biopsies over the period 1993 to 2007. We examined the advantages and limitations of the procedure, biopsy site preferences, diagnostic range, frequency of diagnoses and quality of histopathology. Demographics, referral patterns and patients' perceptions of the procedure were also assessed., Methods: Cases were identified through the London Health Sciences Centre Department of Pathology database. Standard biopsy procedures were followed using a manual trocar style instrument. With a neuropathology technologist in attendance at all biopsies, biopsies were oriented in the fresh state and snap frozen., Results: Most referrals for muscle biopsy were from neuromuscular neurologists. The procedure was found to be efficient, well-tolerated and produced high quality specimens in all diagnostic categories. No major complications occurred. Failure to obtain an adequate tissue sample, although uncommon (< 2%), was usually due to marked obesity, edema or muscle wasting. Bleeding at the site was rarely problematic and no wound infections were reported., Conclusions: Needle muscle biopsies represent an efficient alternative to open biopsies when peripheral nerve sampling is not required and when large tissue samples are not needed for extensive biochemical analyses.

Proliferating cell nuclear antigen (PCNA) plays an essential role in eukaryotic DNA replication, and numerous DNA replication proteins have been found to interact with PCNA through a conserved eight-amino acid motif called the PIP-box. We have searched the genome of the yeast Saccharomyces cerevisiae for open reading frames that encode proteins with putative PIP-boxes and initiated testing of 135 novel candidates for their ability to interact with PCNA-conjugated agarose beads. The first new PCNA-binding protein identified in this manner is the 5' to 3' DNA helicase RRM3. Yeast two-hybrid tests show that N-terminal deletions of RRM3, which remove the PIP-box but leave the helicase motifs intact, abolish the interaction with PCNA. In addition, mutating the two phenylalanine residues in the PIP-box to alanine or aspartic acid reduces binding to PCNA, confirming that the PIP-box in RRM3 is responsible for interaction with PCNA. The results presented here suggest that the RRM3 helicase functions at the replication fork.

The amyloid precursor protein is contained in platelet alpha granules and released with degranulation. Methods are described to control for amyloid precursor protein release from platelets during blood collection and processing. In normal subjects (n = 97; age range, 44-84 years), the average plasma level of amyloid precursor protein was 6.5 +/- 1.8 ng/ml.