OBJECTIVES:To investigate whether high-lethality suicide attempters align to the demographic and clinical features observed in completed suicide in the national and international literature, and whether low-lethality attempters more closely align with the clinical profile of non-attempter ideators. METHODS:A retrospective chart review of adult suicide ideators and attempters presenting to an urban tertiary care hospital was performed. Suicide ideators (n = 50) and attempters (n = 50) were coded for variables including demographics and clinical characteristics (e.g. psychiatric diagnosis and previous suicide attempt). Method and lethality of suicide attempt were coded using the medical Lethality Rating Scale. RESULTS:High-lethality attempters were more likely to be younger in age than low-lethality attempters (p = 0.026) and ideators (p = 0.041). The lethality scores of suicide attempts were significantly inversely correlated with age (p = 0.017). CONCLUSIONS:Our study adds to the small but increasing body of literature investigating the characteristics of high-lethality suicide attempters and suggests younger adult age is a risk factor for a high-lethality attempt. Further understanding of this unique group would be aided by widespread agreement on the definition of a high-lethality suicide attempt and longitudinal studies of this cohort.

BACKGROUND:No investigation has analyzed the time from injury to operative intervention and its effect on complications and functional outcomes in distal radius fractures. This investigation aimed to establish whether the time to surgical intervention from injury was associated with the observed rate of complications in distal radius fractures.METHODS:A retrospective review of all orthopedic trauma patients who came to our center was conducted from 2008 through 2014. Patients who sustained closed distal radius fractures were included. A postoperative complication following distal radius fracture was defined as reoperation, superficial or deep infection, complex regional pain syndrome, new-onset carpal tunnel syndrome, tendon irritation, and symptomatic hardware.RESULTS:In all, 190 patients were included in the study with a mean age of 48 years (SD ±14.7). According to the AO-Müller/Orthopaedic Trauma Association classification, radiographs revealed 80 A fractures, 15 B fractures, and 95 C fractures. Thirty distal radii were fixed within 0 to 3 days after injury, 91 patients within 4 to 10 days, and 69 patients after 10 days. Overall, 28 complications (14.7%) were identified. There was no statistical difference in the rate of complications between the time interval groups (P = .17).CONCLUSIONS:Despite the increased popularity of surgical intervention for distal radius fractures, the optimal parameters to maximize patient outcomes have yet to be clearly defined. Time to intervention did not affect the rate of postoperative complication and range of motion.

Background Suicide is the second leading cause of death among young people worldwide and remains a major public health concern. Research indicates that negative social contexts involving familial and peer relationships, have far-reaching influences on levels of suicidal behaviours in later life. Previous systematic reviews have focused on evaluating associations between negative life events such as abuse and bullying in childhood and subsequent self-harm or suicidality. However, the association between adolescent experiences of humiliation and shame, and subsequent self-harm or suicidal behaviour among children and young adults has not been well examined. As such, this systematic review is conducted to examine the prevalence and association between humiliation and shame and self-harm, suicidal ideation, and death by suicide among adolescents and young adults. Methods A systematic literature search in extant electronic databases including; MEDLINE, Web of Science Core Collection, CINAHL, PsycINFO, and Embase will be conducted to identify potential studies. Google Scholar, and the reference list of the retrieved articles and/or previous systematic reviews in this area, will also be scanned to identify further potential studies. ProQuest will be searched to identify relevant studies available within grey literature. There are no restrictions on the date of publications. Based on our initial review, the following terms were identified: Population: Adolescent (MESH), young adult (MESH), teen, teenage. Exposure: Humiliation, degradation, shame (MESH) or embarrassment (MESH), harassment victimisation, abasement. Outcome: Self-injurious behaviour (MESH), suicide (MESH), suicide attempted (MESH), suicide completed (MESH), self-harm, intentional self-injury, deliberate self-harm, overdose, deliberate self-poisoning, non-suicidal self-injury, self-mutilation, suicidal thought, suicidal ideation, suicidal intent, suicide. At least one term from each category will be used for conducting the literature search. All original quantitative studies published in the English language which examined the prevalence or association between humiliation or shame and self-harm and/or suicidal ideation and/or completed suicide will be included. The studies will be assessed for methodological quality using the Joanna Briggs Institute critical appraisal tools. Narrative synthesis will be performed for all of the studies. If the studies are sufficiently homogenous, the results will be pooled for a meta-analysis. This systematic review protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) guidelines. The protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022289843]. Discussion This is the first review to synthesise evidence on the prevalence of, and associations between the experiences of humiliation and shame and subsequent self-harm and/or suicidal behaviours among adolescents and young adults. As there is growing evidence on increased self-harm among this age group, it is important to identify population-specific risk factors for self-harm and suicidality which will have significance in formulating tailored and effective treatment and therapeutic services for adolescents and young adults.

The aim of this study was to identify the types of reflective writing produced by a cohort of medical students undertaking a clinical psychiatry module as part of their undergraduate medical programme at a University in the Republic of Ireland. A random sample of 80 reflective essays were selected for review. These assignments were evaluated using a comprehensive content analysis process with a pre-determined reflective writing coding instrument and coding protocol. Dialogic reflection was the most common type of reflective writing identified, with 56.3% (n = 45) of the summative assignments categorised as such. Twenty five percent (n = 20) of the assignments were classified as descriptive reflection, while 18.8% (n = 15) of the assignments demonstrated critical reflection. Overall, the findings of the study indicate that this innovative programme was successful in fostering and developing reflective writing in medical students to quite an advanced level. The paper concludes with specific recommendations for facilitating reflective writing in professional and higher education.

Background: Few “interventions” around suicide and stigma have reached into psychiatric institutions. Lived Lives is a science-arts approach to addressing suicide and stigma, informed by a psychobiographical and visual arts autopsy. The resulting artworks and mediated exhibition ( Lived Lives), has facilitated dialogue, response and public action around stigma-reduction, consistent with a community intervention. Recent evidence from Lived Lives moved us to consider how it may situate within a psychiatric hospital. Methods: Lived Lives manifested in St. Patrick’s University Hospital (Ireland’s oldest and largest psychiatric hospital) in November 2017. A mixed-methods approach was used to evaluate the exhibition as a potential intervention to address stigma around suicide, with quantitative and qualitative data collected via written questionnaire and oral data collected via video documentation. Bereavement support was available. A Clinician and an artist also provided independent evaluation. Results: 86 participants engaged with the exhibition, with 68 completing questionnaire data. Audiences included service users, policy makers, health professionals, senior hospital administrators and members of the public. 62% of participants who completed questionnaires were suicide-bereaved; 46% had experienced a mental health difficulty, and 35% had been suicidal in the past. 91% thought Lived Lives could be of benefit in the aftermath of a suicide death. Half of participants thought Lived Lives could help reduce suicidal feelings, whereas 88% thought it could benefit those with Mental Health difficulties. The emotional response was of a visceral nature, including fear, anger, sadness, disgust and anxiety. Conclusions: Lived Lives sits comfortably in discomfort, unafraid to call out the home-truths about stigma and its pervasive and pernicious impact, and with restoring identity at its core. Lived Lives can operate within a psychiatric hospital, as well as in community. The challenge is to move it forward for greater exposure and impacts in at-risk communities.

Background: Current treatment for volumetric muscle loss is limited to muscle transfer or acellular collagen scaffold (ACS) therapies that are associated with donor site morbidity and nonfunctional fibrosis, respectively. The aim of this study is to assess the utility of amniotic membrane scaffold (AMS) for volumetric muscle loss treatment. Methods: Murine quadriceps defects were created and randomized to three groups (n = 5/group): untreated controls, ACS, and AMS. In vivo muscle regeneration volume was quantified by MRI and microcomputed tomography. Muscle explants were analyzed using standard histology and whole-mount immunofluorescence at 8 weeks. Results: The cross-sectional muscle regeneration ratio was 0.64 ± 0.3 for AMS, 0.48 ± 0.07 for ACS, and 0.4 0 ± 0.03 for controls as assessed by MRI (P = 0.09) and 0.61 ± 0.28 for AMS, 0.50 ± 0.06 for ACS, and 0.43 ± 0.04 for controls as assessed by microcomputed tomography (P = 0.2). Histologically, AMS demonstrated significantly higher cellular density (900 ± 2 70 nuclei/high powered field) than ACS (210 ± 36) and control (130 ± 4) groups (P = 0.05). Immunofluorescence for laminin (AMS 623 ± 11 versus ACS 339 ± 3 versus control 115 ± 7; P < 0.01) and myosin heavy chain (AMS 509 ± 7 versus ACS 288 ± 5 versus control 84 ± 5; P = 0.03) indicated greater organized muscle fiber formation with AMS. Conclusion: AMS mediated muscle healing was characterized by increased cellular infiltration and organized muscle formation when compared with controls and ACS.

Introduction: Irish Travellers are an indigenous ethnic minority (IEM) with poor health outcomes. Whilst they constitute less than 1% of the Irish population, they account for 10% of national young adult male suicide statistics. Methods: A rapid review of scientific publications related to mental health and suicide in Irish Travellers was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches of PubMed, PsycINFO and Google Scholar were performed. Eligibility criteria included: (i) Irish Travellers/Gypsy Travellers; (ii) information on mental health/suicide/self-harm; (iii) psychosocial anthropological perspectives of mental health; (iv) publications in english. Data on studies including design, methods, participants and key findings were extracted using a spreadsheet template. Results: From 5160 scientific references over the past 20 years, 19 papers made reference to Traveller mental health, and only 5 papers made specific data-based reference to suicide in Travellers. It was only when we qualified Travellers as being 'Irish Travellers' in our scientific review did we detect meaningful references to their existence as an IEM, and their health and well-being. Due to sample sizes and heterogeneity in design, results were synthesised narratively. Discussion: This paper draws together strands from the disciplines of psycho/socio/anthropological perspectives to gain deeper insights into mental health and suicide in Irish Travellers. In a knowledge vacuum, it behoves the scientific community to explain the value of scientific research and rigour to both policymakers as well as Travellers, shifting the existing discourse towards new knowledge and understanding around mental health and suicide in Travellers.

Background: Elevated suicide rates have alarmed policy makers and communities. In these circumstances, the value of understanding more about communities and their potential role in suicide intervention is becoming more apparent. This study involved evaluating feedback from individuals with and without previous suicidal thinking who participated in an arts-science rural community-based intervention project around suicide in County Donegal, Ireland (Lived Lives at Fort Dunree). Methods: A combined quantitative and qualitative questionnaire was used to evaluate individual and community responses to the Lived Lives project. Results: Participants (n = 83), with and without a mental health history and previous suicidal ideation, reported they believed Lived Lives could have potential to help suicide-bereaved families, people with mental illness and people with suicidal thinking. Qualitative results suggested its’ suitability for specific groups affected by suicide. Discussion: The evaluation of the Lived Lives project indicated that supervised, “safe-space” community intervention projects around suicide have inherent value with positive impacts for bereaved individuals and communities, including those who have experienced suicidal feelings. Future research should explore the transferability of these findings to other communities, and at-risk groups.

Background: Elevated suicide rates have alarmed policy makers and communities. In these circumstances, the value of understanding more about communities and their potential role in suicide intervention is becoming more apparent. This study involved evaluating feedback from individuals with and without previous suicidal thinking who participated in an arts-science rural community-based intervention project around suicide in County Donegal, Ireland (Lived Lives at Fort Dunree). Methods: A combined quantitative and qualitative questionnaire was used to evaluate individual and community responses to the Lived Lives project. Results: Participants (n = 83), with and without a mental health history and previous suicidal ideation, reported they believed Lived Lives could have potential to help suicide-bereaved families, people with mental illness and people with suicidal thinking. Qualitative results suggested its’ suitability for specific groups affected by suicide. Discussion: The evaluation of the Lived Lives project indicated that supervised, “safe-space” community intervention projects around suicide have inherent value with positive impacts for bereaved individuals and communities, including those who have experienced suicidal feelings. Future research should explore the transferability of these findings to other communities, and at-risk groups.

Despite prevailing negative attitudes, Electroconvulsive Therapy (ECT) is an effective treatment for major depressive disorder. Few studies have taken an in-depth mixed methods approach to explore attitudes towards ECT, or the changes that occur through experience of treatment. The aim of this study was to compare attitudes of patients and their relatives before and after ECT using quantitative and qualitative methods.

OBJECTIVES:Irish Travellers are an indigenous ethnic minority population in Ireland, with poor life expectancy. This study aims to identify factors associated with reported discrimination and how this affects their experiences of accessing and quality of health services, including mental health.METHODS:The All Ireland Traveller Health Study was a cross-sectional census study in 2010. All Traveller families completed a survey questionnaire (n = 6540), and at random an adult selected from the family completed either a health status (health status study = 1547) or health services utilisation survey (HSU = 1576). Experience of discrimination (EOD) from the census was analysed in relation to HSU data on services used in the previous 12 months and reported experiences of access and quality of that health service. Census variables were analysed in relation to EOD and perceived discrimination (PD).RESULTS:In the final models, EOD and PD were significantly associated with socio-demographic, socio-cultural and living conditions. The multivariate odds of reporting EOD ranged from OR 1.84 to 2.13 and were significant for those reporting worse opportunities in accessing health services, mental health (p = 0.001), hospitals (p < 0.001) and public health nurses (p < 0.001). The multivariate odds of reporting EOD ranged from OR 1.95 to 2.71 and remained significant for those who reported they had poorer experiences than others when using health services, quality of experience (OR 2.18, p =< 0.001), trust in providers (OR 1.95, p =< 0.001) and appropriate information (OR 2.71, p =< 0.001).CONCLUSIONS:Travellers experience high levels of discrimination which negatively affects their engagement with health services. Culturally competent services need to be developed.

Objective Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder, but some aspects remain controversial. Few studies have taken an in-depth mixed methods approach toward the study of attitudes, and there are no significant studies that explore the change of attitudes before and after treatment. The aim was to compare attitudes of patients and their relatives before and after ECT using quantitative and qualitative methods. Methods One hundred twenty-three participants were recruited. Forty-one patient/relative participants were recruited from 2 accredited ECT centers along with 82 age- and sex-matched general population controls. A validated 22-item survey about attitudes toward ECT was administered. Patient/relative participants completed the survey before treatment with ECT and engaged in a repeat survey and a semistructured interview 1 month after completion of ECT. Control participants completed the survey on a single occasion. Results Control versus pre-ECT surveys and pre-ECT versus post-ECT surveys both demonstrated statistically and clinically significant positive attitudinal differences (Cohen d = 1.37, P < 0.001; Cohen d = 1.2, P < 0.001). These differences were maintained for both the patient and relative pre/post subgroups (Cohen d = 1.15, P < 0.001; Cohen d = 1.33, P < 0.001). Qualitative analysis identified 13 attitudinal transitions in cognition, emotion, and imagery domains. Conclusions This is the first study to examine a change in attitudes toward ECT of patients, their relatives, and with controls using mixed methods. The findings suggest a 2-phase positive attitudinal change, in which accurate information (phase 1) and experiential learning (phase 2) are both key components. These findings address stigma through accurate knowledge and experiential learning, with a positive outcome through changed attitudes.

Objective Although there is much focus on burnout and psychological distress among doctors, studies about stress and well-being in medical students are limited but could inform early intervention and prevention strategies. Design The primary aim of this mixed-method, cross-sectional survey was to compare objective and subjective levels of stress in final-year medical students (2017) and to explore their perspectives on the factors they considered relevant to their well-being. Setting University College Dublin, the largest university in Ireland. Participants 161 of 235 medical students participated in this study (response rate 69%). Results 65.2% of students scored over accepted norms for the Perceived Stress Scale (34.8% low, 55.9% moderate and 9.3% high). 35% scored low, 28.7% moderate and 36.3% high on the Subjective Stress Scale. Thematic analysis identified worry about exams, relationships, concern about the future, work–life balance and finance; one in three students reported worry, irritability and hostility; many felt worn out. Cognitive impacts included overthinking, poor concentration, sense of failure, hopelessness and procrastination. Almost a third reported sleep and appetite disturbance, fatigue and weariness. A quarter reported a ‘positive reaction’ to stress. Positive strategies to manage stress included connection and talking, exercise, non-study activity and meditation. Unhelpful strategies included isolation and substance use. No student reported using the college support services or sought professional help. Conclusion Medical students experience high levels of psychological distress, similar to their more senior doctor colleagues. They are disinclined to avail of traditional college help services. Toxic effects of stress may impact their cognition, learning, engagement and empathy and may increase patient risk and adverse outcomes. The focus of well-being in doctors should be extended upstream and embedded in the curriculum where it could prevent future burnout, improve retention to the profession and deliver better outcomes for patients.

INTRODUCTION:Electroconvulsive therapy (ECT) is an established treatment for major depressive disorder, yet it remains controversial. Attitudes toward ECT have been studied in members of the public and service users, with diverse findings. There is no systematically validated scale to quantify attitudes.OBJECTIVES:The aim of this study was to validate a scale measuring attitudes toward ECT using a systematic analysis.METHODS:Validation consisted of 3 stages: item generation, theoretical analysis, and psychometric analysis. A total of 196 members of the public were surveyed, and the findings were used to perform principal component analysis, Cronbach alpha (CA), and interitem correlation.RESULTS:The Modified ECT Attitudes Questionnaire (EAQ) is a 22-item participant-rated questionnaire (0-44) consisting of 2 principal components: "moral and ethical perceptions of ECT" and "ECT as a last resort treatment." There was adequate reliability for the total EAQ (CA, 0.873) and each of the components (component 1 CA, 0.907; component 2 interitem correlation, 0.389). Among the 196 members of the public, the mean score was 20.4 (SD, 8.4), which equates to 46% positive responses. Component 1 elicited 39% positive responses; component 2 elicited 52% positive responses. The emotion components of attitudes elicited particularly negative responses.CONCLUSIONS:The EAQ is a validated and reliable scale for the measurement of attitudes toward ECT. Application of this scale to 196 members of the public indicates that negative attitudes are rooted in individuals' moral and ethical objections to ECT, particularly the emotion components of such attitudes. This scale can be applied to other groups, including service users, to further characterize attitudes that underlie the stigma toward ECT.

The Wrist and Radius Injury Surgical Trial (WRIST) collaboration is the largest clinical trial ever conducted in hand surgery. We applied data from this study to examine the relationship between functional outcomes and patient satisfaction after treatment of distal radial fractures. Patients aged 60 years and older with isolated distal radial fractures were enrolled at 24 health systems. Grip strength and the arc of wrist motion were measured after treatment. The Michigan Hand Outcomes Questionnaire was used to measure patient satisfaction. Receiver operating characteristic curves were created using patient satisfaction as the reference standard and each functional measure as a predictor. At 12 months after treatment, mean grip strength was 82% of normal and mean arc of motion was 88% of normal. The optimal cut-off points to distinguish satisfaction from dissatisfaction occurred when patients recovered 59% of hand strength and 79% of wrist motion. Continuing therapy to increase functional gains beyond this point unnecessarily utilizes healthcare resources without additional patient-reported gains. Level of evidence: IV

Objectives Restricting access to lethal means is an effective suicide prevention strategy. However, there is little discussion in the literature about the potential contribution of prescribing practices on discharge from inpatient psychiatric care (which has been established as a high-risk period for suicide) to suicide deaths by overdose of prescribed medication. This study aimed to assess the quantity, toxicity and potential lethality of psychotropic medication being prescribed on discharge from psychiatric care to those with and without indices of suicidality. Methods Patient demographic, clinical and prescription data were collected from 50 randomly selected charts following discharge from inpatient psychiatric care. Psychotropic medications (dose × duration) on discharge were converted to their equivalent doses of neuroleptics, antidepressants and anxiolytics to rate toxicity and potential lethality, using the Maudsley Prescribing Guidelines. Mood stabilizing medications were also documented. Results 39% of prescriptions analysed contained toxic and potentially fatal doses of either neuroleptic or antidepressant equivalent medication. Conclusions Patient discharge from inpatient psychiatric care presents a golden opportunity to moderate access to potentially fatal psychotropic medication. Iatrogenic provision of lethal means for suicide during a period of increased risk and in a group at increased suicide risk may impact suicide prevention efforts and requires further in-depth research. Current prescribing practices may be a missed opportunity to intervene in this regard.

IMPORTANCE Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. OBJECTIVES To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. DESIGN, SETTING, AND PARTICIPANTS The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. INTERVENTIONS Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. MAIN OUTCOMES AND MEASURES Complication rate. RESULTS The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). CONCLUSIONS AND RELEVANCE The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01589692

Purpose Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes. Methods The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common. Results Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes. Conclusions These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.