William Alanson White,M. D. 1870-1937

Objective: Although the U.S. Army suicide rate is known to have risen sharply over the past decade, information about medically documented, nonfatal suicidal behaviors is far more limited. Here we examine trends and sociodemographic correlates of suicide attempts, suspicious injuries, and suicide ideation among regular Army soldiers. Methods: Data come from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) Historical Administrative Data Study (HADS), which integrates administrative records for all soldiers on active duty during the years 2004 through 2009 (n = 1.66 million). Results: We identified 21,740 unique regular Army soldiers with a nonfatal suicidal event documented at some point during the HADS study period. There were substantial increases in the annual incidence rates of suicide attempts (179–400/100,000 person-years) and suicide ideation (557–830/100,000 person-years), but not suspicious injuries. Using hierarchical classification rules to identify the first instance of each soldier’s most severe behavior, we found increased risk of all outcomes among those who were female, non-Hispanic White, never married, lower-ranking enlisted, less educated, and of younger age when entering Army service. These sociodemographic associations significantly differed across outcomes, despite some patterns that appear similar. Conclusion: Results provide a broad overview of nonfatal suicidal trends in the U.S. Army during 2004 through 2009 and demonstrate that integration of multiple administrative data systems enriches analysis of the predictors of such events.     

Consent in obstetric anaesthesia

Consent to medical treatment is a vital process that should occur prior to any procedure or intervention in a competent adult. There are ethical and legal reasons for doctors to ensure that valid, adequate consent has been obtained from a patient. It is generally accepted that written consent is acceptable, however, discussions regarding consent should be clearly documented, including specific risks discussed. Labouring women may have to consent for procedures when in severe pain, under the influence of strong analgesics, or in a time-pressured situation. However, the parturient is presumed to be competent. A competent pregnant woman may decline treatment for any reason, even if it puts her or her unborn child at risk of harm or death.     

Efficient national surveillance for health-care-associated infections

BackgroundThe detection of novel health-care-associated infections as early as possible is an important public health priority. However, no evidence base exists to guide the design of efficient and reliable surveillance systems. Here we address this issue in the context of a novel pathogen spreading primarily between hospitals through the movement of patients.MethodsUsing hospital admission data from the year 2007, we modelled the spread of a pathogen among a network of hospitals connected by patient movements using a hospital-based susceptible-infectious model. We compared the existing surveillance system in Scotland with a gold standard (a putative optimal selection algorithm) to determine its efficiency and to see whether it is beneficial to alter the number and choice of hospitals in which to concentrate surveillance effort.FindingsWe validated our model by demonstrating that it accurately predicted the risk of meticillin-resistant cases of Staphylococcus aureus bacteraemia in hospitals in Scotland in 2007. Furthermore, the model predicted that relying solely on the 29 (out of 182) sentinel hospitals that currently contribute most of the national surveillance effort results in an average detection time (time until first appearance of the pathogen in a hospital) of 117 days. This detection time could be reduced to 87 days by optimal selection of the same number of hospitals. Alternatively, the same detection time (117 days) can be achieved with just 22 optimally selected hospitals. Increasing the number of sentinel hospitals to 38 (teaching and general hospitals) reduced detection time by 43 days; a decrease to seven sentinel hospitals (all teaching hospitals) increased detection time substantially to 268 days.InterpretationOur results show that the present surveillance system used in Scotland is not optimal in detecting novel pathogens compared with a gold standard. However, efficiency gains are possible by better choice of sentinel hospitals, or by increasing the number of hospitals involved in surveillance. Similar studies could be used elsewhere to inform the design and implementation of efficient national, hospital-based surveillance systems that achieve rapid detection of novel health-care-associated infections for minimum effort.FundingThis research received funding from the European Union Seventh Framework Programme (FP7-HEALTH-2011-single-stage): Evolution and Transfer of Antibiotic Resistance (EvoTAR).