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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.

The absence of funding for legal representation is a major barrier to justice for victims seeking to hold corporations to account for human rights abuses. Litigation funders, which primarily invest in commercial litigation, are increasingly interested in funding large-scale multinational litigation. However, the level of their interest is a function of the magnitude of the potential return on the funder’s investment, the prospects of success and recoverability of damages, the legitimacy of the funding arrangements, and the funder’s confidence in the legal system of the country in question, as well as the magnitude of any adverse costs liability for which the funder might be liable. Susan Dunn and Felix Curtis outline the basic principles of litigation funding (where permitted); how it works; the considerations a funder will make to evaluate the viability of an investment in a multinational human rights or environmental case; and important variations in litigation funding rules in different countries.

Background UK clinical guidelines recommend treatment of attention-deficit hyperactivity disorder (ADHD) in adults by suitably qualified clinical teams. However, young people with ADHD attempting the transition from children's to adults’ services experience considerable difficulties in accessing care. Aims To map the mental health services in the UK for adults who have ADHD and compare the reports of key stakeholders (people with ADHD and their carers, health workers, service commissioners). Method A survey about the existence and extent of service provision for adults with ADHD was distributed online and via national organisations (e.g. Royal College of Psychiatrists, the ADHD Foundation). Freedom of information requests were sent to commissioners. Descriptive analysis was used to compare reports from the different stakeholders. Results A total of 294 unique services were identified by 2686 respondents. Of these, 44 (15%) were dedicated adult ADHD services and 99 (34%) were generic adult mental health services. Only 12 dedicated services (27%) provided the full range of treatments recommended by the National Institute for Health and Care Excellence. Only half of the dedicated services (55%) and a minority of other services (7%) were reported by all stakeholder groups (P < 0.001, Fisher's exact test). Conclusions There is geographical variation in the provision of NHS services for adults with ADHD across the UK, as well as limited availability of treatments in the available services. Differences between stakeholder reports raise questions about equitable access. With increasing numbers of young people with ADHD graduating from children's services, developing evidence-based accessible models of care for adults with ADHD remains an urgent policy and commissioning priority.

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 begins with a discussion of images of female power in Tempe Restored. It continues with an examination of Walter Montagu’s The Shepherd’s Paradise and the 1634 revival of John Fletcher’s Faithful Shepherdess. Read together, these two plays present a powerful image of Catholic community, female empowerment and options for rethinking the sacred space. For Catholics, this entertainment would have presented an image of Catholic utopia. For the Protestants, the plays represented Henrietta Maria’s extravagance and her immorality. The final portion of this chapter draws connections between Tempe Restored and John Milton’s Masque at Ludlow Castle to suggest the influence of the queen’s entertainments as well as the Protestant response to them.

This chapter examines Salmacida Spolia, the last masque performed by Charles I and Henrietta Maria in the context of coming civil war and the last gasps of a monarchy. The final Caroline masque provides a lens through which to view Henrietta Maria’s relationship to the English people. Although William Davenant presents the royal couple in opposition to the forces of disorder, this juxtaposition of the queen and female representations of disorder threatens to collapse. The chapter will show that in the rhetoric leading up to civil war and continuing into the Restoration, Henrietta Maria herself increasingly becomes connected to the iconography of Discord and disorder, a position that would persist in modern scholarship.

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 explores what Anna of Denmark and Henrietta Maria’s confessional identities meant politically and artistically, and how their identities fit into a larger framework of representations of Catholicism, female power and queenship. It explores not only the historical facts of the Reformation, but also the myths that informed people’s fears of Catholic plots against the English church. This chapter also considers how the queens used Catholicism and the images of the sacred feminine in the court entertainments they commissioned. Finally, the chapter concludes with a consideration of Catholic models of female autonomy, early modern stereotypes of Catholicism as a religion, and the ways in which fears of Catholicism and the Catholic woman influence attitudes toward the early Stuart queens.

This chapter uses Henrietta Maria’s court masques to trace the queen’s transformation from a young French princess in a foreign land to a powerful queen consort who pushed her agendas in a variety of personal, political and theatrical ways. The chapter examines the ways in which Henrietta Maria sought to carve out a space for Catholic worship in her new Protestant home. In particular, the chapter will consider Henrietta Maria’s religious and political interests and alliances as presented in three of her well-known masques Chloridia, The Temple of Love and Luminalia. In these masques, feminine beauty and chastity act in ways that foreground the female sacred as a source of authority and support the queen’s desire to restore Catholicism to England.

Anna’s masques, which at times weave Catholicism into their symbolic economy even as they deploy subversive representations of female power, played into societal fears at a particularly unstable and potentially dangerous time in terms of Jacobean religious politics. This chapter examines five of Anna’s significant early masques (A Vision of Twelve Goddesses, The Masque of Blackness, The Masque of Beauty, The Masque of Queens, and Tethys’ Festival), considering the ways in which these masques depict female power, the female body and, ultimately, the queen herself. In addition, the chapter considers how the combined threat of the powerful female and the Catholic sovereign elide in Anna’s court entertainments.

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.

To assess the potential effects of exposure to bleached sulfite mill effluent, long-term fathead minnow (Pimephales promelas) exposures were carried out on-site at the pulp mill secondary treatment lagoons. Exposure concentrations included 0, 1, 3, 10, 30, 50, or 100% final effluent, with the synthetic estrogen ethinylestradiol (10 ng/L) as a positive control compound. Fertilized minnow eggs were hatched in effluent and monitored through 140 d posthatch. The effluent produced a significant increase in the growth (length, weight, condition factor) of female fish (but not male fish). Exposure to high effluent concentrations resulted in a majority of fish with female secondary sex characteristics. Male fish with female characteristics and female fish with male sex characteristics were present at effluent concentrations of > or = 30%, but not in fish exposed to control water from the Saint John River. Effluent exposures (> or = 30%) also produced a reduction in the number of fish with testes, and most fish had ovaries when examined internally. A sensitive and meaningful endpoint was a decrease in reproduction. Fish exposed to 1 - 3% effluent produced a similar number of eggs to control fish; however, exposure to 10% effluent reduced egg production by over 80%. Fish exposed for an entire life cycle to > or = 30% effluent failed to produce eggs. The research demonstrates the feasibility and potential usefulness of on-site flow-through fish life-cycle exposures for the assessment of pulp mill final effluents.

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

In the summer of 1567, a rebellion forced Mary Stuart off the throne of Scotland. Mary’s political failure resulted, in part, from her unwise personal choices: her preference for her court favorites, particularly David Rizzio; her inability to extricate herself from the suspicion surrounding the murder of her husband, Lord Darnley; and her hasty marriage to James Hepburn, Earl of Bothwell, who was also suspected of taking part in Darnley’s murder. By 1567, the queen, whose “grace and good humour [had] made her appeal to the general populace” earlier in her reign, could no longer command the loyalty and respect of the nobility or the people.1 As Mary was taken to Edinburgh as a prisoner, the crowds revealed their contempt for their queen, crying out “burn the whore!… burn her, burn her, she is not worthy to live, kill her, drown her.”2 Their response to the fallen monarch, presented in unambiguously gendered terms, reveals a preoccupation with Mary’s physical body and her alleged sexual transgressions. In the eyes of her people, Mary was not only a murderess, she was a whore, and her sexual “taintedness” proved as deplorable as her other “crime.” Because of her position as queen, Mary’s physical body possessed political significance, and the crowd’s condemnation of Mary suggests anger at a woman who had sullied not only herself but also, by extension, Scotland.