Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study

BACKGROUND

Evidence from high income countries (HICs) suggests that individuals who present to hospital after self-harm are an important target for suicide prevention, but evidence from low and middle-income countries (LMICs) is lacking. We aimed to investigate the risk of repeat self-harm and suicide, and factors associated with these outcomes, in a large cohort of patients presenting to hospital with self-harm in rural Sri Lanka.

METHODS

In this cohort study, hospital presentations for self-harm at 13 hospitals in a rural area of North Central Province (population 224 000), Sri Lanka, were followed up with a self-harm surveillance system, established as part of a community randomised trial, and based on data from all hospitals, coroners, and police stations in the study area. We estimated the risk of repeat non-fatal and fatal self-harm and risk factors for repetition with Kaplan-Meier methods and Cox proportional hazard models. Sociodemographic (age, sex, and socioeconomic position) and clinical (past self-harm and method of self-harm) characteristics investigated were drawn from a household survey in the study area and data recorded at the time of index hospital presentation. We included all individuals who had complete data for all variables in the study in our primary analysis.

OUTCOMES

Between July 29, 2011, and May 12, 2016, we detected 3073 episodes of self-harm (fatal and non-fatal) in our surveillance system, of which 2532 (82·3%) were linked back to an individual in the baseline survey. After exclusion of 145 ineligible episodes, we analysed 2259 index episodes of self-harm. By use of survival models, the estimated risk of repeat self-harm (12 months: 3· 1%, 95% CI 2·4-3·9; 24 months: 5·2%, 4·3-6·4) and suicide (12 months: 0·6%, 0·4-1·1; 24 months: 0·8%, 0·5-1·3) in our study was considerably lower than that in HICs. A higher risk of repeat self-harm was observed in men than in women (fatal and non-fatal; hazard ratio 2·0, 95% CI 1·3-3·2; p=0·0021), in individuals aged 56 years and older compared with those aged 10-25 years (fatal; 16·1, 4·3-59·9; p=0·0027), and those who used methods other than poisoning in their index presentation (fatal and non-fatal; 3·9, 2·0-7·6; p=0·00027). We found no evidence of increased risk of repeat self-harm or suicide in those with a history of self-harm before the index episode.

INTERPRETATION

Although people who self-harm are an important high-risk group, focusing suicide prevention efforts on those who self-harm might be somewhat less important in LMICs compared with HICs given the low risk of repeat self-harm and subsequent suicide death. Strategies that focus on other risk factors for suicide might be more effective in reducing suicide deaths in LMICs in south Asia. A better understanding of the low incidence of repeat self-harm is also needed, as this could contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death.

FUNDING

Wellcome Trust.

The effect of sex and body weight on lung volumes during sleep

Study Objectives

Low lung volumes are thought to contribute to obstructive sleep apnea (OSA). OSA is worse in the supine versus lateral body position, men versus women, obese versus normal-weight (NW) individuals and REM versus NREM sleep. All of these conditions may be associated with low lung volumes. The aim was to measure FRC during wake, NREM, and REM in NW and overweight (OW) men and women while in the supine and lateral body positions.

Methods

Eighty-one healthy adults were instrumented for polysomnography, but with nasal pressure replaced with a sealed, non-vented mask connected to an N2 washout system. During wakefulness and sleep, repeated measurements of FRC were made in both supine and right lateral positions.

Results

Two hundred eighty-five FRC measures were obtained during sleep in 29 NW (body mass index [BMI] = 22 ± 0.3 kg/m2) and 29 OW (BMI = 29 ± 0.7 kg/m2) individuals. During wakefulness, FRC differed between BMI groups and positions (supine: OW = 58 ± 3 and NW = 68 ± 3% predicted; lateral OW = 71 ± 3, NW = 81 ± 3% predicted). FRC fell from wake to NREM sleep in all participants and in both positions by a similar amount. As a result, during NREM sleep FRC was lower in OW than NW individuals (supine 46 ± 3 and 56 ± 3% predicted, respectively). FRC during REM was similar to NREM and no sex differences were observed in any position or sleep stage.

Conclusions

Reductions in FRC while supine and with increased body weight may contribute to worsened OSA in these conditions, but low lung volumes appear unlikely to explain the worsening of OSA in REM and in men versus women.

Capacity, control and responsibility in Parkinson's disease patients with impulse control disorders: Views of neurological and psychiatric experts

Dopamine replacement therapy can induce impulse control disorders (ICDs) (e.g., hypersexuality) in susceptible Parkinson's disease patients. ICDs can sometimes result in criminal offending. In a number of past Commonwealth cases, it appears offending ICD patients have been considered to be suffering from 'irresistible impulses' such that their decision-making capacity, behavioural control and responsibility were totally compromised. This contrasts with courts' general scepticism of drug-induced 'compulsion' in cases of addiction-related offending. In one case of explicit ICD-related offending, testimony was limited to three experts and not contested by the prosecution. We explored whether the testimony offered in this particular case, and another similar case, reflects the views of the neurological and psychiatric communities at large. Thematic analysis revealed that neurologists, geriatricians and psychiatrists (n = 11): (a) attributed ICDs to a variety of causes; (b) considered ICD patients' decision-making capacities and behavioural control to be partially, but not totally, compromised; (c) were divided or ambivalent about ICD patients' responsibility; and (d) astutely noted the difficulties inherent in assessing complex constructs such as 'control' and 'responsibility'. We suggest that there is sufficient divergence between our findings and expert testimony from past cases for prosecution teams to engage their own experts in future cases of ICD-related offending.

Two rare case reports of ingestion of ammonium hydroxide and novel study of gastrointestinal toxicity

OBJECTIVE

We report the only two adult cases of NH4OH ingestion described in literature at the Peradeniya Teaching Hospital in Sri Lanka. Both cases showed clinical evidence of gastrointestinal toxicity and using intestinal fatty acid binding protein (IFABP), a novel biomarker, we attempted to quantify the extent of enterocyte damage. Procalcitonin was also measured as a maker of bacterial sepsis to ascertain whether there was a link between enterocyte damage and infection secondary to bacterial translocation.

CASES

A 45-year-old, previously well man was brought in by family with a reduced level of consciousness after ingestion of an unknown quantity of industrial NH4OH (29% solution) with suicidal intent. Peak IFABP and procalcitonin levels were 1274 pg/mL and 2.0 ng/mL, respectively, 7.7 hours following presumed ingestion. A 23-year-old, previously well woman presented 24 hours after consuming 100 mL of NH4OH (5.4% solution) used as a cleaning product. She presented with ongoing vomiting and oropharyngeal pain. Her peak IFABP and procalcitonin levels were 865 pg/mL and 5.8 ng/mL, respectively, 27.2 hours following ingestion.

CONCLUSION

We report the only two adult cases of NH4OH ingestion and describe severe gastrointestinal damage both clinically and biochemically. IFABP, currently only a marker used in research settings, was elevated in both cases but only marginally below that of levels seen in mesenteric ischaemia (levels greater than 1300 pg/mL). The use of a marker for enterocyte damage especially in ingestion of caustic solutions can allow clinicians to monitor progress, predict complications and evaluate the need for further invasive procedures.

The hot patient: acute drug-induced hyperthermia

Drugs can cause dysregulation of the hypothalamic–pituitary–adrenal axis which can result in a rise in core temperature This type of hyperthermia is unresponsive to antipyretics and can be complicated by rhabdomyolysis multi-organ failure and disseminated intravascular coagulation

Organic causes of fever such as infection must be ruled out Syndromes associated with drug-induced fever include neuroleptic malignant syndrome and anticholinergic sympathomimetic and serotonin toxicity

The class of offending drugs as well as the temporal relationship to starting or stopping them assists in differentiating between neuroleptic malignant syndrome and serotonin toxicity

Immediate inpatient management is needed The mainstay of management is stopping the drug and supportive care often in the intensive care unit

Unmasking neurobiological commonalities between addictive disorders and impulse control disorders in Parkinson’s disease

Changes in reward circuitry have been studied extensively in substance and behavioural addictions. However, comparatively little is known about the neurobiology underlying impulse control disorders (ICDs) in Parkinson's disease, which show roughly similar risk factors and behavioural presentations to both stimulant and behavioural addictions. ICDs occur in a subset of susceptible patients with Parkinson's disease (PD) following intake of dopamine replacement therapy (DRT). These behavioural disorders often have debilitating effects on a patient's quality of life and increase caregiver burden. This comprehensive review examined findings of 40 neuroimaging studies of ICDs in PD to determine (a) whether there are putative neurobiological commonalities between traditional substance and behavioural addictions and DRT-induced ICD in PD and (b) opportunities for future studies to advance current neurobiological understanding of the phenomenon. Results revealed that strikingly similar (a) deficits in dopaminergic receptor expression, (b) connectivity changes in corticostriatal circuitry and (c) neural responses to cue exposure are observed in both ICDs in PD and addictive disorders. These findings point to the value of adopting a transdiagnostic approach when studying addicted populations and pave the way for demystifying this peculiar, often-devastating phenomenon in PD that has so far proven extremely difficult to treat and predict with any precision.

Analysing truck harsh braking incidents to study roundabout accident risk

In order to reduce accident risk, highway authorities prioritise maintenance budgets partly based upon previous accident history. However, as accident rates have continued to fall, this approach has become problematic as accident 'black spots' have been treated and the number of accidents at any individual site has fallen, making previous accident history a less reliable indicator of future accident risk. Another way of identifying sites of higher accident risk might be to identify near-miss accidents (where an accident nearly happened but was avoided). The principal aim of this paper is to analyze potentially unsafe truck driving conditions from counts of Harsh Braking Incidents (HBIs) at roundabouts and compare the results to similar, previous studies of accident numbers at the same sites, to explore if HBIs can be studied as a surrogate for accidents. This is achieved by processing truck telematics data with geo-referenced incidents of harsh braking. Models are then developed to characterise the relationships between truck HBIs and geometric and traffic variables. These HBIs are likely to occur more often than accidents and may, therefore, be useful in identifying sites with high accident risk. Based on the results of this study, it can be concluded that HBIs are influenced by traffic and geometric variables in a similar way to accidents; therefore they may be useful in considering accident risk at roundabouts. They are a source of higher volumes of data than accidents, which is important in considering changes or trends in accident risk over time. The results showed that random-parameters count data models provide better goodness of fit compared to fixed-parameters models and more variables were found to be significant, giving a better prediction of events.

Ageing and Dying Radically

This biographical and, in part, phenomenological anthropology of older people in post-industrial England illuminates a local and generationally specific communitarian critique of and form of resistance against the process of individualisation. Rather than presenting communitarianism conventionally as an abstract political ideology or set of ideas about locality, it is conceptualised as emerging from and being reinforced by experiences of ageing, especially bodily ageing. It these respects, the article responds positively to Tatjana Thelen and Cati Coe’s call to take the anthropology of ageing out of its current condition of relative intellectual marginality, by recognising ageing and its related care arrangements as key structuring features within societies and political organisation and by treating them as a window onto understanding broad-scale social and political processes.

Evaluating temporal patterns of snakebite in Sri Lanka: the potential for higher snakebite burdens with climate change

Background

Snakebite is a neglected tropical disease that has been overlooked by healthcare decision makers in many countries. Previous studies have reported seasonal variation in hospital admission rates due to snakebites in endemic countries including Sri Lanka, but seasonal patterns have not been investigated in detail.

Methods

A national community-based survey was conducted during the period of August 2012 to June 2013. The survey used a multistage cluster design, sampled 165 665 individuals living in 44 136 households and recorded all recalled snakebite events that had occurred during the preceding year. Log-linear models were fitted to describe the expected number of snakebites occurring in each month, taking into account seasonal trends and weather conditions, and addressing the effects of variation in survey effort during the study and of recall bias amongst survey respondents.

Results

Snakebite events showed a clear seasonal variation. Typically, snakebite incidence is highest during November-December followed by March-May and August, but this can vary between years due to variations in relative humidity, which is also a risk factor. Low relative-humidity levels are associated with high snakebite incidence. If current climate-change projections are correct, this could lead to an increase in the annual snakebite burden of 31.3% (95% confidence interval: 10.7-55.7) during the next 25-50 years.

Conclusions

Snakebite in Sri Lanka shows seasonal variation. Additionally, more snakebites can be expected during periods of lower-than-expected humidity. Global climate change is likely to increase the incidence of snakebite in Sri Lanka.

Forcing Single-Column Models Using High-Resolution Model Simulations

To use single-column models (SCMs) as a research tool for parameterization development and process studies, the SCM must be supplied with realistic initial profiles, forcing fields, and boundary conditions. We propose a new technique for deriving these required profiles, motivated by the increase in number and scale of high-resolution convection-permitting simulations. We suggest that these high-resolution simulations be coarse grained to the required resolution of an SCM, and thereby be used as a proxy for the true atmosphere. This paper describes the implementation of such a technique. We test the proposed methodology using high-resolution data from the UK Met Office's Unified Model, with a resolution of 4 km, covering a large tropical domain. These data are coarse grained and used to drive the European Centre for Medium-Range Weather Forecast's Integrated Forecasting System (IFS) SCM. The proposed method is evaluated by deriving IFS SCM forcing profiles from a consistent T639 IFS simulation. The SCM simulations track the global model, indicating a consistency between the estimated forcing fields and the true dynamical forcing in the global model. We demonstrate the benefits of selecting SCM forcing profiles from across a large domain, namely, robust statistics, and the ability to test the SCM over a range of boundary conditions. We also compare driving the SCM with the coarse-grained data set to driving it using the European Centre for Medium-Range Weather Forecast operational analysis. We conclude by highlighting the importance of understanding biases in the high-resolution data set and suggest that our approach be used in combination with observationally derived forcing data sets.

The Australian high performance and sport science workforce: A national profile

OBJECTIVES

The purpose of this study was to provide a profile of the demographics and employment characteristics of the Australian high performance and sport science workforce.

DESIGN

This study used a cross-sectional, quantitative survey methodology to collect data about the Australian high performance and sport science workforce.

METHOD

175 Australian high performance and sport science employees completed an online survey which captured demographic information and work-related characteristics such as role, industry sector, income, permanence of employment and hours worked. Descriptive statistics were used to summarise information and some comparisons were made between position titles, industry sectors and sexes.

RESULTS

The Australian high performance and sport science workforce is predominantly male (76.0%), ≤35 years of age (50.3%), located on the eastern seaboard of Australia (69%) and have been in their current position for 2-5 years (37.4%). They are mostly employed on a fixed term contract of 2.4 years, by an institute of sport. Income varied, with those working in professional sporting clubs and/or employed as high performance managers earning the highest wage. On average, participants worked well over their contracted hours, with a considerable proportion of these hours outside the standard 9-5 working week.

CONCLUSIONS

Employees in the high performance and sport science workforce in Australia face significant professional issues that relate to long and unusual work hours, job insecurity and income disparity. Policy makers and the managers of this workforce should consider the impact of these issues on work-life balance, staff retention rates and the risk of burnout.

Muscle Mass, Muscle Morphology and Bone Health Among Community-Dwelling Older Men: Findings from the Hertfordshire Sarcopenia Study (HSS)

Sarcopenia and osteoporosis are associated with poor health outcomes in older people. Relationships between muscle and bone have typically been reported at a functional or macroscopic level. The aims of this study were to describe the relationships between muscle morphology and bone health among participants of the Hertfordshire Sarcopenia Study (HSS). 105 older men, mean age 72.5 (SD 2.5) years, were recruited into the HSS. Whole body lean mass as well as appendicular lean mass, lumbar spine and femoral neck bone mineral content (BMC) and bone mineral density (BMD) were obtained through dual-energy X-ray absorptiometry scanning. Percutaneous biopsy of the vastus lateralis was performed successfully in 99 participants. Image analysis was used to determine the muscle morphology variables of slow-twitch (type I) and fast-twitch (type II) myofibre area, myofibre density, capillary and satellite cell (SC) density. There were strong relationships between whole and appendicular lean body mass in relation to femoral neck BMC and BMD (r ≥ 0.43, p < 0.001). Type II fibre area was associated with both femoral neck BMC (r = 0.27, p = 0.01) and BMD (r = 0.26, p = 0.01) with relationships robust to adjustment for age and height. In unadjusted analysis, SC density was associated with whole body area (r = 0.30, p = 0.011) and both BMC (r = 0.26, p = 0.031) and area (r = 0.29, p = 0.017) of the femoral neck. We have demonstrated associations between BMC and changes in muscle at a cellular level predominantly involving type II myofibres. Interventions targeted at improving muscle mass, function and quality may improve overall musculoskeletal health. Larger studies that include women are needed to explore these relationships further.

Photon Doppler velocimetry measurements of transverse surface velocities

The goal of this work was to develop a technique for making transverse surface velocity measures utilizing Photon Doppler Velocimetry (PDV). Such a task is achieved by transmitting light and collecting Doppler-shifted light at an angle relative to the normal axis, where measured velocities are representative of a component of the transverse velocity. Because surface characteristics have an intrinsic effect on light scatter, different surface preparations were explored to direct reflectivity, including diffusion by means of sandpapering, or increasing retroreflectivity by coating with microspheres, milling v-cuts, and electrochemically etching grooves. Testing of these surface preparations was performed using an experiment featuring a 30 mm diameter aluminum disk rotating at 6000 or 6600 RPM. A single PDV collimator was positioned along the rotational axis of the disk at various angles, resolving the apparent transverse velocity. To characterize surface preparations, light return and velocities were recorded as a function of probe angle ranging from 0° to 51° from the surface normal for each preparation. Polished and electrochemically etched surfaces did not provide enough reflected light to resolve a beat frequency; however, sandpapered surfaces, retroreflective microspheres, and milled v-cuts provided adequate reflected light for incidence angles up to 51°. Applications of the surface preparations were then studied in gas gun experiments. Retroreflective microspheres were studied in a planar impact experiment, and milled v-cuts were studied in an oblique impact experiment. A normal and transverse profile of particle velocity was resolved in the oblique impact experiment.

Life's end: Ethnographic perspectives

In this introduction to the special issue, Life's End: Ethnographic Perspectives, we review the field of anthropological studies of death and dying. We make the argument that, largely because of its sub-disciplining into the larger field of the anthropology of religion, ritual and symbolism, the focus of anthropological research on death has been predominantly on post- rather than pre-death events, on death's beginnings rather than life's ends. Additionally, we argue that an anthropological aversion to the study of dying may also lie in the intimacy of the discipline's principal method, ethnography. Contrastingly, we argue that this very methodological intimacy can be a source of insight, and we offer this as a rationale for the special issue as a whole, which comprises eight ethnographic studies of dying and social relations at life's end from across Africa, Australia, Europe, and North America. Each of these studies is then summarized, and a rationale for their presentation around the themes of "structures of dying," "care for the dying," "hope in dying," and "ending life" is presented.

Neurocognitive correlates of medication-induced addictive behaviours in Parkinson's disease: A systematic review

Dopaminergic medication can induce severe addictive behaviours (e.g., pathological gambling) in susceptible Parkinson's disease (PD) patients. It is still unknown which particular neurocognitive processes become exacerbated or dysfunctional in PD patients with addictive behaviours. We sought to systematically review the relevant literature to identity potential neurocognitive correlates of medication-induced addictive behaviours in PD. We framed our review around neurocognitive processes central to four dominant accounts of substance addiction: 'aberrant learning', 'incentive sensitization', 'impulsivity to compulsivity' and 'impaired response inhibition and salience attribution'. Searches of the PubMed and Scopus databases were completed on June 23, 2017. To be included, studies were required to involve: (a) medicated PD patients, without a history of deep brain stimulation, with and without addictive behaviours; (b) a reward-related or decision-making task; and (c) statistical comparison of addictive and non-addictive groups' 'on' medication performance on the task(s). Studies were summarised qualitatively with statistically significant (p<.05) group differences and effect sizes (Cohen's d) highlighted. 35 studies were included. Findings showed that the extant literature is highly heterogeneous. The domains of reward and punishment learning, reflection impulsivity and disadvantageous decision-making exemplify this. More homogeneity exists in domains in which (a) neurocognitive dysfunction is not apparent (motor control, cognitive/attentional flexibility and cognitive control) or (b) typical neurocognitive processes appear exacerbated by medication (reward motivation and choice impulsivity). Future large-scale neurocognitive studies are still required to develop our scientific understanding of addictive behaviours in PD and aid their clinical treatment and prediction.

Safety and feasibility audit of a home-based drug-transitioning approach for patients with pulmonary arterial hypertension: an observational study

BACKGROUND

Newer endothelin receptor antagonists (ERAs) used to treat patients with pulmonary arterial hypertension (PAH) are associated with fewer drug-drug interactions than bosentan and require less monitoring. This, combined with a pharmacokinetic basis for improved efficacy, means there may be a clinical rationale for changing therapies. However, this can be challenging and few data on its safety in patients with PAH are available.

AIMS

At the Royal Free Hospital in London, UK, home-based medication transitioning has been standard practice since 2009 to avoid unnecessary hospital visits for patients, unless there is a clinical imperative. In this audit of standard practice we evaluated the consequences of adopting such a strategy when transitioning PAH patients between ERA therapies.

METHODS AND RESULTS

Using a Clinical Nurse Specialist-led, home-based transitioning strategy, 92 patients with PAH were transitioned from bosentan to macitentan or ambrisentan. Observational data were analysed retrospectively. The majority of patients were female with PAH associated with connective tissue disease and their ERA was changed in the hope of improving efficacy. The process was well tolerated with no adverse events associated with the process. Seventeen patients died during the study (macitentan, n = 5; ambrisentan, n = 12). None of the deaths was considered related to ERA treatment. The majority of patients remained clinically stable, based on WHO functional class and exercise capacity.

CONCLUSION

An established home-based transitioning strategy can be adopted safely for patients with PAH changing ERA therapies. Most patients remained stable and the therapy change was well tolerated.

Migration: a core public health ethics issue

OBJECTIVES

In this article, we outline the link between migration, public health and ethics.

STUDY DESIGN

Discussing relevant arguments about migration from the perspective of public health and public health ethics.

METHODS

Critical review of theories and frameworks, case-based analysis and systematic identification and discussion of challenges.

RESULTS

Migration is a core issue of public health ethics and must take a case-based approach: seeking to identify the specific ethical dimensions and vulnerabilities in each particular context. Public health as a practice, built upon the core value of justice, requires the protection and promotion of migrants' well-being (even if this produces tension with immigration services). Ethical analysis should take all phases of migration into account: before, during and after transit. We argue that migration policies, at least as they relate to migrants' well-being, should be founded upon a shared humanity, respect for human rights and on the idea that effective public health cannot and should not be confined within the borders and to the citizens of any host country.

CONCLUSIONS

We make the case for migration to be seen as a core issue of public health ethics.

Erratum: "A microfluidic chip based model for the study of full thickness human intestinal tissue using dual flow" [Biomicrofluidics , 064101 (2016)]

[This corrects the article DOI: 10.1063/1.4964813.].

Post-Fordist death: A comparative ethnographic analysis of milling and mining in northern England

Building on work on post-Fordist affect, we argue that the group-based and person-centred forms of production in mining and milling respectively produce contingent conceptualisations of culture, identity and personhood and, in turn, of dying and death. The 'communal solidarism' characteristic of post-mining milieu engenders senses of dying and death entailing a communal merging of erstwhile individual selfhoods. In post-milling milieu dying and death are conceptualised as individuated, but subject to social evaluation. The evaluative criterion in this regard is ability to 'perform' dying and death in ways that reflect the valorised essence of local culture, identity and personhood, 'resilient autonomy'.