Effects of stricter legislation on coercive measures in child and adolescent psychiatric care: a qualitative interview study with staff.

BACKGROUND: Legislators often want to positively affect psychiatric inpatient care and reduce coercion by a stricter judicial regulation. However, staff experiences and comprehension of such legal changes are largely unknown, yet essential in obtaining the intended outcomes. We examined staff understanding and implementation of a July 1, 2020 legal change in Sweden regarding the use of coercive measures (e.g., restraint, seclusion, and forced medication) in child and adolescent psychiatric inpatient care. METHODS: During 2021, semi-structured interviews were conducted with nine child and adolescent psychiatric inpatient staff (nurses, senior consultants, and head of units). Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We used an implementation outcomes framework to relate data to a wider implementation science context. RESULTS: The legislative change was viewed as both positive and negative by participating staff. They reported mixed levels of preparedness for the legislative change, with substantial challenges during the immediate introduction, including insufficient preparations and lack of clear guidelines. A knowledge hierarchy was evident, affecting various professional roles differently. While the law was positively viewed for its child-centred approach, we found notable distrust in legislators' understanding of the clinical reality, leading to practical difficulties in implementation. Care practices after the legal change varied, with some participants reporting little change in the use of coercive measures, while others noted a shift towards more seclusion and sedative medication usage. The work environment for consultants was described as more challenging due to increased bureaucratic procedures and a heightened pressure for accuracy. CONCLUSIONS: The study highlights the complexities and challenges in implementing legislative changes in psychiatric care, where stricter legislation does not necessarily entail reduced use of coercion.

[Dropout from Specialty Training is determined by the perception of autonomy and treatment efficacy]. / 6 av 10 ST-läkare på BUP funderar på att hoppa av - Upplevelse av brist på effektiv psykologisk behandling och låg autonomi på arbetsplatsen främsta orsaker.

The Swedish Association for Child and Adolescent Psychiatry conducted a survey among their specialty trainees in 2018. Of the 48% response rate, around 48% admitted hesitancy to continue in their chosen specialty. A further 12% planned to depart from their field after completion of training. Factors associated with discontinuation in training were the perception of ineffective psychotherapeutic treatments and a lack of autonomy at work; which was strongly correlated to the doctor's role and team collaboration. Workload was generally perceived as excessive, with not enough time for after work recovery and the subsequent negative impact on private life. However, these factors were not found to significantly affect trainees' decision to leave. The doctor's role requires better clarification and medical leadership needs to be improved, so that evidence based treatments can be offered.

Can association between preterm birth and autism be explained by maternal or neonatal morbidity?

OBJECTIVE: We examined whether an association between preterm birth and risk of autistic disorders could be explained by pregnancy complications or neonatal morbidity. METHODS: This Swedish, population-based, case-control study included 1216 case subjects with autistic disorders who were born between 1987 and 2002 and 6080 control subjects who were matched with respect to gender, birth year, and birth hospital. We assessed associations between gestational age and autistic disorders and adjusted for maternal, birth, and neonatal characteristics. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Compared with infants born at term, the unadjusted ORs for autistic disorders among very and moderately preterm infants were 2.05 [95% CI: 1.26-3.34] and 1.55 [95% CI: 1.22-1.96], respectively. When we controlled for maternal, pregnancy, and birth characteristics, ORs were reduced to 1.48 [95% CI: 0.77-2.84] and 1.33 [95% CI: 0.98-1.81], respectively. When we also controlled for neonatal complications, ORs were 0.98 [95% CI: 0.45-2.16] and 1.25 [95% CI: 0.90-1.75], respectively. Reductions in risks of autistic disorders related to preterm birth were primarily attributable to preeclampsia, small-for-gestational age birth, congenital malformations, low Apgar scores at 5 minutes, and intracranial bleeding, cerebral edema, or seizures in the neonatal period. Neonatal hypoglycemia, respiratory distress, and neonatal jaundice were associated with increased risk of autistic disorders for term but not preterm infants. CONCLUSION: The increased risk of autistic disorders related to preterm birth is mediated primarily by prenatal and neonatal complications that occur more commonly among preterm infants.

Infection with Parvovirus B19 and Herpes viruses in early pregnancy and risk of second trimester miscarriage or very preterm birth.

We investigated whether infections with Parvovirus B19 and Herpes viruses in early pregnancy increase risks of second trimester miscarriage or delivery before 32 gestational weeks. Blood samples taken in early pregnancy were analyzed for Parvovirus B19 or Herpes viruses. Viremia was found in blood samples of 11 (4.7%) women with second trimester miscarriage and 10 (3.7%) women with very preterm birth, compared to 5 (1.7%) women who delivered at term, corresponding to adjusted odds ratios [95% CI] of 3.32 [0.93, 11.8] and 2.21 [0.71, 6.84], respectively. In stratified analyses, Parvovirus B19 viremia was associated with adjusted odds ratios of 3.76 [0.77, 18.3] for second trimester miscarriage and 2.66 [0.64, 11.1] for very preterm birth. Corresponding odds ratios for Human Herpes virus 6 viremia was 2.52 [0.33, 19.5] and 1.08 [0.14, 8.08], respectively. In conclusion, this study lends some support to the hypothesis that women with viremia in early pregnancy may face an increased risk of second trimester miscarriage or very preterm birth. Studies with larger sample sizes are needed.

Previous pregnancy loss: risks related to severity of preterm delivery.

OBJECTIVES: The purpose of this study was to examine the association between previous pregnancy losses and subsequent risk of preterm delivery. STUDY DESIGN: A population-based Swedish study including information on all births and women's hospital admissions for pregnancy loss (n = 601,883) in Sweden between 1987 and 2000 was performed. The risk of preterm delivery after a previous pregnancy loss was estimated using logistic regression models. The risk of preterm premature ruptures of the membranes (PROM), preterm labor, and other reasons for preterm delivery was also assessed. RESULTS: Previous spontaneous abortions and missed abortions were associated with increased risks of preterm delivery, and the risks increased with severity of preterm delivery. Previous pregnancy loss increased the risk of preterm PROM and preterm labor foremost in deliveries before 32 weeks, but was not associated with other reasons of very preterm delivery. CONCLUSION: Our results support the hypothesis that pregnancy loss and early preterm delivery may share etiologic causes.

Signs of infection in Pap smears and risk of adverse pregnancy outcome.

Previous studies on whether signs of infection in Pap smears imply a risk factor for preterm delivery are conflicting. In a large population-based study, we combined information from the Swedish Medical Birth Register and the Swedish Pap Smear Screening Register to investigate whether signs of infection in Pap smears increase the risks of adverse pregnancy outcomes. Logistic regression analyses were used to estimate odds ratios (OR) for antepartum death, preterm or small-for-gestational-age delivery. The presence of Coccobacilli or Trichomonas vaginalis in Pap smears increased the risk of small-for-gestational-age delivery (OR 1.3 and 1.4, respectively). Signs of infection in Pap smears were generally not associated with an increased risk of antepartum death or preterm birth. However, the presence of Coccobacilli in Pap smears within 4 weeks before delivery was associated with a more than fourfold increase in risk of very preterm delivery (< or =31 weeks, OR 4.7). This indicates that if Coccobacilli are detected in Pap smears during the second trimester, antibacterial treatment may lower the risk of very preterm delivery.

The East African decapod crab Neosarmatium meinerti (de Man) sweeps mangrove floors clean of leaf litter.

Leaf litter removal by the abundant mangrove decapod crab Neosarmatium meinerti was studied in series of field and laboratory experiments in East Africa. In the high intertidal Avicennia marina zone crabs buried all leaves placed on the forest floor and consumed on average 67% of them within 2 hrs. High shore crabs in Kenya buried 4 g m(-2) leaf-litter in 1 hr, i.e. approx. twice the daily litter fall. In contrast, in the low shore Sonneratia alba zone, where typical leaf-eating crabs were absent, none of the offered leaves showed signs of herbivory. Leaf choice experiments in the laboratory showed that N. meinerti preferred some species to others. Leaf consumption per gram crab was higher in females than males. The laboratory studies also indicated that crabs could consume substantially more than the average daily litter fall. Video recordings documented frequent fights to gain or retain fallen leaves, suggesting strong competition for leaf litter. Earlier studies indicating that N. meinerti may sweep mangrove forest floors clean of leaf litter are confirmed. In high shore mangroves of East and South Africa where N. meinerti is common, energy flow appears unique: virtually all litter production is retained.