Risk of suicide in patients who present to hospital after self-cutting according to site of injury: findings from the Multicentre Study of Self-harm in England.

BACKGROUND: We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab. METHOD: We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004-31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models. RESULTS: In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03-2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80-9.30, p = 0.001). CONCLUSIONS: Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

The characteristics, life problems and clinical management of older adults who self-harm: Findings from the multicentre study of self-harm in England.

BACKGROUND: Older adults have a high risk of suicide following self-harm. Contemporary information on self-harm in this population is needed to inform care provision. OBJECTIVES: To examine subgroup differences in the incidence of self-harm, sociodemographic and clinical characteristics, preceding life problems and outcomes in individuals aged 60 years and over presenting to hospital following self-harm. METHOD: Data on Emergency Department (ED) presentations for self-harm from 2003 to 2016 from three centres in the Multicentre Study of Self-Harm in England were analysed. Changes in self-harm rates were examined using Poisson regression. Univariable logistic regression was used to investigate factors associated with 12-month self-harm repetition. RESULTS: There were 3850 presentations for self-harm by 2684 individuals aged 60 years and over. Self-harm rates increased over time for 60-74-year-old men (Incident Rate Ratio = 1.04, 95% Confidence Interval 1.02-1.06, p < 0.0001). Problems most frequently reported to have preceded self-harm were mental health (40.5%) and physical health (38.3%) concerns. Problems with alcohol, finances, employment and relationship with partner were found more frequently in 60-74-year-olds compared with those aged over 74 years. Physical health problems were common with increasing age, as were problems with alcohol for men. One in ten (10.8%) individuals presented to hospital with self-harm within 12 months of their index presentation. CONCLUSIONS: Self-harm-related ED attendances in older men have increased, particularly for men aged 60-74 years. Prevention and clinical management should involve a comprehensive psychosocial assessment to target common precipitants for the wide range of problems preceding self-harm and may include support with physical and mental wellbeing and advice on safer alcohol use.

Self-harm in children 12 years and younger: characteristics and outcomes based on the Multicentre Study of Self-harm in England.

BACKGROUND: Very little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England. METHODS: We included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients' characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD). RESULTS: 387 children aged 5-12 years presented to the study hospitals in 2000-2016, 39% of whom were 5-11 years. Boys outnumbered girls 2:1 at 5-10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year. CONCLUSIONS: Gender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5-10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.

Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England.

BACKGROUND: Self-harm, a significant and increasing global problem in children and adolescents, is often repeated and is associated with risk of future suicide. To identify potential interventions, we need to understand the life problems faced by children and adolescents, and by sub-groups of younger people who self-harm. Our aims were to include the following: (a) investigate the type and frequency of life problems in a large sample of children and adolescents who self-harmed. (b) Examine whether problems differ between those who repeat self-harm and those who do not. METHODS: We analysed data for 2000 to 2013 (follow up until 2014) from the Multicentre Study of Self-harm in England on individuals aged 11 to 18 years who presented to one of the five study hospitals following self-harm and received a psychosocial assessment including questions about problems, which precipitated self-harm. RESULTS: In 5648 patients (12,261 self-harm episodes), (75.5% female, mean age 16.1 years) the most frequently reported problems at first episode of self-harm were family problems. Problems around study/employment/study and relationships with friends also featured prominently. The types of problems that precede self-harm differed between late childhood/early adolescence. Abuse, mental health problems and legal problems significantly predicted repeat self-harm for females. CONCLUSION: The most common problems reported by both genders were social/interpersonal in nature, indicating the need for relevant services embedded in the community (e.g. in schools/colleges). Self-harm assessment and treatment choices for children and adolescents must take age and gender into account. To prevent future self-harm, individualised supports and services are particularly needed for abuse, mental health and legal problems.

Low SARS-CoV-2 Transmission in Elementary Schools - Salt Lake County, Utah, December 3, 2020-January 31, 2021.

School closures affected more than 55 million students across the United States when implemented as a strategy to prevent the transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Reopening schools requires balancing the risks for SARS-CoV-2 infection to students and staff members against the benefits of in-person learning (2). During December 3, 2020-January 31, 2021, CDC investigated SARS-CoV-2 transmission in 20 elementary schools (kindergarten through grade 6) that had reopened in Salt Lake County, Utah. The 7-day cumulative number of new COVID-19 cases in Salt Lake County during this time ranged from 290 to 670 cases per 100,000 persons.† Susceptible§ school contacts¶ (students and staff members exposed to SARS-CoV-2 in school) of 51 index patients** (40 students and 11 staff members) were offered SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) testing. Among 1,041 susceptible school contacts, 735 (70.6%) were tested, and five of 12 cases identified were classified as school-associated; the secondary attack rate among tested susceptible school contacts was 0.7%. Mask use among students was high (86%), and the median distance between students' seats in classrooms was 3 ft. Despite high community incidence and an inability to maintain ≥6 ft of distance between students at all times, SARS-CoV-2 transmission was low in these elementary schools. The results from this investigation add to the increasing evidence that in-person learning can be achieved with minimal SARS-CoV-2 transmission risk when multiple measures to prevent transmission are implemented (3,4).

Inferring Networks of Interdependent Labor Skills to Illuminate Urban Economic Structure.

Cities are among the best examples of complex systems. The adaptive components of a city, such as its people, firms, institutions, and physical structures, form intricate and often non-intuitive interdependencies with one another. These interdependencies can be quantified and represented as links of a network that give visibility to otherwise cryptic structural elements of urban systems. Here, we use aspects of information theory to elucidate the interdependence network among labor skills, illuminating parts of the hidden economic structure of cities. Using pairwise interdependencies we compute an aggregate, skills-based measure of system "tightness" of a city's labor force, capturing the degree of integration or internal connectedness of a city's economy. We find that urban economies with higher tightness tend to be more productive in terms of higher GDP per capita. However, related work has shown that cities with higher system tightness are also more negatively affected by shocks. Thus, our skills-based metric may offer additional insights into a city's resilience. Finally, we demonstrate how viewing the web of interdependent skills as a weighted network can lead to additional insights about cities and their economies.

Self-harm in midlife: analysis using data from the Multicentre Study of Self-harm in England.

BACKGROUND: In England suicide rates are highest in midlife (defined as age 40-59). Despite a strong link with suicide there has been little focus on self-harm in this age group.AimTo describe characteristics and treatment needs of people in midlife who present to hospital following self-harm. METHOD: Data from the Multicentre Study of Self-harm in England were used to examine rates over time and characteristics of men and women who self-harm in midlife. Data (2000-2013) were collected via specialist assessments or hospital records. Trends were assessed by negative binomial regression models. Comparative analysis used logistic regression models for binary outcomes. Repetition and suicide mortality were assessed by Cox proportional hazards models. RESULTS: A quarter of self-harm presentations were made by people in midlife (n = 24 599, 26%). Incidence rates increased over time in men, especially after 2008 (incidence rate ratio [IRR] 1.07, 95% CI 1.02-1.12, P < 0.01), and were positively correlated with national suicide incidence rates (r = 0.52, P = 0.05). Rates in women remained relatively stable (IRR 1.00, 95% CI 1.00-1.02, P = 0.39) and were not correlated with suicide. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide. CONCLUSION: Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.Declaration of interestK.H. and N.K. are members of the Department of Health's National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group which developed the quality standards for self-harm services. N.K. also chairs the NICE guideline committee for the management of depression. All other authors declare no conflict of interest.

Success of a South-South collaboration on Human Resources Information Systems (HRIS) in health: a case of Kenya and Zambia HRIS collaboration.

BACKGROUND: Shortage of health workforce in most African countries is a major impediment to achieving health and development goals. Countries are encouraged to develop evidence-based strategies to scale up their health workforce in order to bridge the gap. South-South collaborations have gained popularity due to similarities in the challenges faced in the region. This strategy has been used in trade, education, and health sector among others. This paper is a road map of using a South-South collaboration to develop a Human Resources Information System (HRIS) to inform scale-up of the health workforce. CASE PRESENTATION: In the last decade, Kenya implemented one of the most comprehensive HRIS in Africa. The HRIS was funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) and implemented by Emory University. The Kenyan team collaborated with the Zambian team to establish a similar HRIS in Zambia. This case study describes the collaboration activities between Zambia and Kenya which included needs assessment, establishment of project office, stakeholders' sensitization, technical assistance and knowledge transfer, software reuse, documents and guidelines reuse, project structure and management, and project formative evaluation. Furthermore, it highlights the need for adopting effective communication strategies, collaborative planning, teamwork, willingness to learn, and having minimum technical skills from the recipient country as lessons learned from the collaboration. As a result of the collaboration, while Kenya took 5 years, Zambia was able to implement the project within 2 years which is less than half the time it took Kenya. CONCLUSIONS: This case presents a unique experience in the use of South-South collaboration in establishing a HRIS. It illustrates the steps and resources needed while identifying the successes and challenges in undertaking such collaboration.

eSIP-Saúde: Mozambique's novel approach for a sustainable human resources for health information system.

INTRODUCTION: Over the past decade, governments and international partners have responded to calls for health workforce data with ambitious investments in human resources information systems (HRIS). However, documentation of country experiences in the use of HRIS to improve strategic planning and management has been lacking. The purpose of this case presentation is to document for the first time Mozambique's novel approach to HRIS, sharing key success factors and contributing to the scant global knowledge base on HRIS. CASE PRESENTATION: Core components of the system are a Government of Mozambique (GOM) registry covering all workers in the GOM payroll and a "health extension" which adds health-sector-specific data to the GOM registry. Separate databases for pre-service and in-service training are integrated through a business intelligence tool. The first aim of the HRIS was to identify the following: who and where are Mozambique's health workers? As of July 2015, 95 % of countrywide health workforce deployment information was populated in the HRIS, allowing the identification of health professionals' physical working location and their pay point. HRIS data are also used to quantify chronic issues affecting the Ministry of Health (MOH) health workforce. Examples include the following: HRIS information was used to examine the deployment of nurses trained in antiretroviral therapy (ART) vis-à-vis the health facilities where ART is being provided. Such results help the MOH align specialized skill sets with service provision. Twenty-five percent of the MOH health workforce had passed the 2-year probation period but had not been updated in the MOH information systems. For future monitoring of employee status, the MOH established a system of alerts in semi-monthly reports. As of August 2014, 1046 health workers were receiving their full salary but no longer working at the facilities. The MOH is now analyzing this situation to improve the retirement process and coordination with Social Security. CONCLUSION: The Mozambican system is an important example of an HRIS built on a local platform with local staff. Notable models of strategic data use demonstrate that the system is empowering the MOH to improve health services delivery, health workforce allocation, and management. Combined with committed country leadership and ownership of the program, this suggests strong chances of sustainability and real impact on public health equity and quality.

Self-harm and life problems: findings from the Multicentre Study of Self-harm in England.

PURPOSE: Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm. METHODS: Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. RESULTS: Of 24,598 patients (36,431 assessed episodes), 57% were female and with a mean age of 33.1 years (SD 14.0 years), 92.6% were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (especially in those aged 35-54 years, and those who repeated self-harm). Those who repeated self-harm were more likely to report problems with housing, mental health and dealing with the consequences of abuse. CONCLUSIONS: Self-harm usually occurs in the context of multiple life problems. Clinical services for self-harm patients should have access to appropriate care for provision of help for relationship difficulties and problems concerning alcohol and mental health issues. Individualised clinical support (e.g. psychological therapy, interventions for alcohol problems and relationship counselling) for self-harm patients facing these life problems may play a crucial role in suicide prevention.

Variation by ethnic group in premature mortality risk following self-harm: a multicentre cohort study in England.

BACKGROUND: Incidence and risk factors for self-harm vary according to ethnicity. People who self-harm have been shown to have increased risk of premature death, but little is known about mortality following self-harm in ethnic minority groups. METHODS: A prospective cohort study of self-harm presentations to three English cities (Derby, Manchester, Oxford) between 2000 and 2010. We linked to a national mortality dataset to investigate premature death in South Asian and Black people in comparison with White people to the end of 2012. RESULTS: Ethnicity was known for 72% of the 28,512 study cohort members: 88% were White, 5% were South Asian, and 3% were Black. After adjusting for age, gender and area-level socioeconomic deprivation, the risk of all-cause mortality was lower in South Asian (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.42 - 0.62) and Black people (HR 0.46, 95% CI 0.39 - 0.55) versus White people. Suicide risk was significantly lower in Black people (HR 0.43, 95% CI 0.19 - 0.97) than in White people. Prevalence of risk factors for premature death, such as previous self-harm, psychiatric treatment or concurrent alcohol misuse, was lower in South Asian and Black people than in White people. CONCLUSIONS: The risk of death following self-harm is lower in South Asian and Black people than White people in the UK, and they also have lower prevalence of risk factors for premature death. Awareness of both protective and risk factors might help to inform clinical decisions following assessment.

Alcohol use and misuse, self-harm and subsequent mortality: an epidemiological and longitudinal study from the multicentre study of self-harm in England.

OBJECTIVES: Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death. METHODS: We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009. RESULTS: Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm and particularly with alcohol misuse. Risk of suicide was increased significantly in women misusing alcohol. CONCLUSIONS: Alcohol use and misuse in self-harm patients appears to have increased in recent years, particularly in women. The association of alcohol with greater risk of self-harm repetition and mortality highlights the need for clinicians to investigate alcohol use in self-harm patients. Ready availability of alcohol treatment staff in general hospitals could facilitate appropriate aftercare and the prevention of adverse outcomes.

Premature death after self-harm: a multicentre cohort study.

BACKGROUND: People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation. METHODS: We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation. FINDINGS: 30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease. INTERPRETATION: Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs. FUNDING: Department of Health Policy Research Programme.

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England.

BACKGROUND: Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group. AIMS: To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm. METHODS: Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated. RESULTS: The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students. CONCLUSIONS: Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

Risk factors for repetition and suicide following self-harm in older adults: multicentre cohort study.

BACKGROUND: Older adults have elevated suicide rates. Self-harm is the most important risk factor for suicide. There are few population-based studies of self-harm in older adults. AIMS: To calculate self-harm rates, risk factors for repetition and rates of suicide following self-harm in adults aged 60 years and over. METHOD: We studied a prospective, population-based self-harm cohort presenting to six general hospitals in three cities in England during 2000 to 2007. RESULTS: In total 1177 older adults presented with self-harm and 12.8% repeated self-harm within 12 months. Independent risk factors for repetition were previous self-harm, previous psychiatric treatment and age 60-74 years. Following self-harm, 1.5% died by suicide within 12 months. The risk of suicide was 67 times that of older adults in the general population. Men aged 75 years and above had the highest suicide rates. CONCLUSIONS: Older adults presenting to hospital with self-harm are a high-risk group for subsequent suicide, particularly older men.

Repetition of self-harm and suicide following self-harm in children and adolescents: findings from the Multicentre Study of Self-harm in England.

BACKGROUND: Self-harm (intentional self-poisoning and self-injury) in children and adolescents is often repeated and is associated with increased risk of future suicide. We have investigated factors associated with these outcomes. METHOD: We used data collected in the Multicentre Study of Self-harm in England on all self-harm hospital presentations by individuals aged 10-18 years between 2000 and 2007, and national death information on these individuals to the end of 2010. Cox hazard proportional models were used to identify independent and multivariable predictors of repetition of self-harm and of suicide. RESULTS: Repetition of self-harm occurred in 27.3% of individuals (N = 3920) who presented between 2000 and 2005 and were followed up until 2007. Multivariate analysis showed that repetition was associated with age, self-cutting, and previous self-harm and psychiatric treatment. Of 51 deaths in individuals who presented between 2000 and 2007 and were followed up to 2010 (N = 5133) half (49.0%) were suicides. The method used was usually different to that used for self-harm. Multivariate analysis showed that suicide was associated with male gender [Hazard ratio (HR) = 2.4, 95% CI 1.2-4.8], self-cutting (HR = 2.1, 95% CI 1.1-3.7) and prior psychiatric treatment at initial presentation (HR = 4.2, 95% CI 1.7-10.5). It was also associated with self-cutting and history of psychiatric treatment at the last episode before death, and history of previous self harm. CONCLUSIONS: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of suicide (and repetition) than self-poisoning although different methods are usually used for suicide. The findings underline the need for psychosocial assessment in all cases.

Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England.

We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5,205 individuals (7,150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0 and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres. In females they averaged 302 per 100,000 (95 % CI 269-335) in 10-14 year-olds and 1,423 (95 % CI 1,346-1,501) in 15-18 year-olds, and were 67 (95 % CI 52-82) and 466 (95 % CI 422-510), respectively, in males. Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a year). Relationship problems were the predominant difficulties associated with self-harm. Specialist assessment occurred in 57 % of episodes. Self-harm in children and adolescents in England is common, especially in older adolescents, and paracetamol overdose is the predominant method. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.

Skills-approximate occupations: using networks to guide jobs retraining.

An issue often confronting economic development agencies is how to minimize unemployment due to disruptions like technological change, trade wars, recessions, or other economic shocks. Decision makers are left to craft policies that can absorb surplus labor with as little pain to workers as possible. The questions they face include how to re-employ displaced workers and how to fill labor shortages. To address such questions, we quantify the proximity of any two occupations based on the skills inherent in each. Taking labor skills as nodes, we model US labor as a weighted network of interdependent skills, deriving link values from geographical patterns of skill co-occurrence. We use this network to locate occupations, measure their proximity to each other, and identify which missing skills may inhibit workers from easily transitioning from one occupation to another. Thus, given that an occupation is a bundle of skills, we use our skills network to help policy makers identify which other occupations are most proximate a worker's current occupation. Finally, we apply our method to assess various worker retraining pathways for metropolitan Washington, DC, USA, whose economy was simultaneously disrupted by both the COVID-19 pandemic and the arrival of a second headquarters for Amazon. Supplementary Information: The online version contains supplementary material available at 10.1007/s41109-022-00487-7.