According to many of its proponents, shared decision making (“SDM”) is the right way to interpret the clinician‐patient relationship because it respects patient autonomy in decision‐making contexts. ...In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy.
The High Court continues to exercise its inherent jurisdiction to make declarations about interventions into the lives of situationally vulnerable adults with mental capacity. In the light of the ...protective responses of health care providers and the courts to decision-making situations involving capacitous vulnerable adults, this article has two aims. The first is diagnostic. The second is normative. The first aim is to identify the harms to a capacitous vulnerable adult’s autonomy that arise based on the characterisation of situational vulnerability and autonomy as fundamentally opposed concepts or the failure to adequately acknowledge the conceptual relationship between them at common law. The second (normative) aim is to develop an account of self-authorised, intersubjective autonomy based on insights from analytic feminist philosophy. This approach not only attempts to capture the autonomy of capacitous vulnerable adults and account for the necessary harms to their autonomy that arise from standard common law responses to their situational vulnerability, it is also predicated on the distinctions between mental capacity, informed consent, and autonomy, meaning that it is better placed to fulfil the primary aim of the inherent jurisdiction—to facilitate the autonomy of vulnerable adults with capacity.
Dementia is the leading cause of death in elderly Western populations. Preventative interventions that could delay dementia onset even modestly would provide a major public health impact. There are ...no disease-modifying treatments currently available. Lithium has been proposed as a potential treatment. We assessed the association between lithium use and the incidence of dementia and its subtypes.
We conducted a retrospective cohort study comparing patients treated between January 1, 2005 and December 31, 2019, using data from electronic clinical records of secondary care mental health (MH) services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), United Kingdom (catchment area population approximately 0.86 million). Eligible patients were those aged 50 years or over at baseline and who had at least 1 year follow-up, excluding patients with a diagnosis of mild cognitive impairment (MCI) or dementia before, or less than 1 year after, their start date. The intervention was the use of lithium. The main outcomes were dementia and its subtypes, diagnosed and classified according to the International Classification of Diseases-10th Revision (ICD-10). In this cohort, 29,618 patients (of whom 548 were exposed to lithium) were included. Their mean age was 73.9 years. A total of 40.2% were male, 33.3% were married or in a civil partnership, and 71.0% were of white ethnicity. Lithium-exposed patients were more likely to be married, cohabiting or in a civil partnership, to be a current/former smoker, to have used antipsychotics, and to have comorbid depression, mania/bipolar affective disorder (BPAD), hypertension, central vascular disease, diabetes mellitus, or hyperlipidemias. No significant difference between the 2 groups was observed for other characteristics, including age, sex, and alcohol-related disorders. In the exposed cohort, 53 (9.7%) patients were diagnosed with dementia, including 36 (6.8%) with Alzheimer disease (AD) and 13 (2.6%) with vascular dementia (VD). In the unexposed cohort, corresponding numbers were the following: dementia 3,244 (11.2%), AD 2,276 (8.1%), and VD 698 (2.6%). After controlling for sociodemographic factors, smoking status, other medications, other mental comorbidities, and physical comorbidities, lithium use was associated with a lower risk of dementia (hazard ratio HR 0.56, 95% confidence interval CI 0.40 to 0.78), including AD (HR 0.55, 95% CI 0.37 to 0.82) and VD (HR 0.36, 95% CI 0.19 to 0.69). Lithium appeared protective in short-term (≤1-year exposure) and long-term lithium users (>5-year exposure); a lack of difference for intermediate durations was likely due to lack of power, but there was some evidence for additional benefit with longer exposure durations. The main limitation was the handling of BPAD, the most common reason for lithium prescription but also a risk factor for dementia. This potential confounder would most likely cause an increase in dementia in the exposed group, whereas we found the opposite, and the sensitivity analysis confirmed the primary results. However, the specific nature of the group of patients exposed to lithium means that caution is needed in extending these findings to the general population. Another limitation is that our sample size of patients using lithium was small, reflected in the wide CIs for results relating to some durations of lithium exposure, although again sensitivity analyses remained consistent with our primary findings.
We observed an association between lithium use and a decreased risk of developing dementia. This lends further support to the idea that lithium may be a disease-modifying treatment for dementia and that this is a promising treatment to take forwards to larger randomised controlled trials (RCTs) for this indication.
Most college students work for pay while enrolled, however theoretical and methodological concerns with the extant literature make it nearly impossible to understand how employment affects students. ...Responding to those shortcomings, I designed a validation study with robust statistical methods to examine relationships between student employment and leadership in a sample of nearly 36,000 students across 87 colleges and universities, recognizing that paid work provides an equitable, skills-focused environment in which students may refine and practice their own leadership skills. Findings suggest that working while enrolled is associated with lower self-reported capacity for socially responsible leadership and that this association varies across on-campus workplace locations and institutional characteristics. Recommendations are offered for supervisors to effectively incorporate socially responsible leadership into student employment structures and tasks.
Geoscience is plagued with structural and systemic barriers that prevent people of historically excluded groups from fully participating in, contributing to, and accruing the benefits of geosciences. ...A change in the culture of our learning and working environments is required to dismantle barriers and promote belonging, accessibility, justice, equity, diversity, and inclusion in our field. Inspired by a session organized at the 2020 Ocean Sciences Meeting, the goal of this paper is to provide a consolidated summary of a few innovative, broadening participation initiatives that are being led by various stakeholders in academia and research sectors (e.g., students, faculty, administrative leaders) at different institutional levels (e.g., universities, professional societies). The authors hope that the strategies outlined in this paper will inspire the coastal, ocean, and marine science community to take individual and collective actions that lead to a positive culture change.
This book analyses representations of the Algerian War of Independence (1954-62) in the literary output of French authors of Algerian origin, problematising the extent to which these literary 'sites ...of memory' provide appropriate spaces of consensus for hitherto competing memories of the war.
Feldspar in ordinary chondrites (OCs) is often associated with thermal metamorphism, as a secondary mineral that forms from the crystallization of matrix and chondrule mesostasis. However, studies of ...feldspar in equilibrated OCs show that there is a range of plagioclase compositions within chondrules, some of which may be primary products of chondrule crystallization. It is important to recognize primary feldspar within chondrules because it can be used to help understand the secondary effects of thermal metamorphism and aqueous alteration. The presence of primary feldspar also provides important petrologic constraints on chondrule formation time scales. We undertook a careful study of Semarkona (LL3.00) and observed feldspar in 18% of chondrules. The feldspar is plagioclase covering a wide range of compositions (An2–An99) with little K‐feldspar component (<Or3). We show that plagioclase is a primary igneous phase, based on grain morphology and compositions consistent with growth from a melt having the bulk compositions of the host chondrules. Based on experimental studies, the presence of plagioclase suggests chondrules cooled slowly at temperatures close to the solidus. We also observed several secondary features consistent with the aqueous alteration. These features include zoning of Na and Ca in plagioclase, heterogeneity in plagioclase compositions in altered chondrules, development of porosity from the dissolution of chondrule glass, and alteration of glass to phyllosilicates. Alteration of major Al‐bearing phases, like plagioclase and glass, has important implications for interpretations of ages derived from Al‐Mg dating of chondrules, if they have been affected by secondary processes.
COVID-19 has affected social interaction and healthcare worldwide.
We examined changes in presentations and referrals to the primary provider of mental health and community health services in ...Cambridgeshire and Peterborough, UK (population ~0·86 million), plus service activity and deaths. We conducted interrupted time series analyses with respect to the time of UK “lockdown”, which was shortly before the peak of COVID-19 infections in this area. We examined changes in standardized mortality ratio for those with and without severe mental illness (SMI).
Referrals and presentations to nearly all mental and physical health services dropped at lockdown, with evidence for changes in both supply (service provision) and demand (help-seeking). This was followed by an increase in demand for some services. This pattern was seen for all major forms of presentation to liaison psychiatry services, except for eating disorders, for which there was no evidence of change. Inpatient numbers fell, but new detentions under the Mental Health Act were unchanged. Many services shifted from face-to-face to remote contacts. Excess mortality was primarily in the over-70s. There was a much greater increase in mortality for patients with SMI, which was not explained by ethnicity.
COVID-19 has been associated with a system-wide drop in the use of mental health services, with some subsequent return in activity. “Supply” changes may have reduced access to mental health services for some. “Demand” changes may reflect a genuine reduction of need or a lack of help-seeking with pent-up demand. There has been a disproportionate increase in death among those with SMI during the pandemic.
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