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Despite the lack of guidance available for practitioners, extensive polypharmacy has become the primary method of treating patients with severe and chronic mood, anxiety, psychotic or behavioral disorders. This ground-breaking new book provides an overview of psychopharmacology knowledge and decision-making strategies, integrating findings from evidence-based trials with real-world clinical presentations. It adopts the approach and mind-set of a clinical investigator and reveals how prescribers can practice 'bespoke psychopharmacology', tailoring care to the individualized needs of patients. Practitioners at all levels of expertise will enhance their ability to devise rationale-based treatments, targeting manifestations of dysfunctional neural circuitry and dimensions of psychopathology that cut across conventional psychiatric diagnoses. Presented in a user-friendly, practical, full-colour layout and incorporating summary tables, bullet points, and illustrative case vignettes, it is an invaluable guide for all healthcare professionals prescribing psychotropic medications, including psychiatry specialists, primary care physicians, and advanced practice registered nurses.
Prior to bacteriology, miasma theory advanced a climatic theory of health: vapors carrying disease were understood to be exacerbated by heat and humidity, and their dispersal changed depending on weather patterns. The story goes that germ theory corrected miasma’s mistakes, shifting attention away from humid, malodorous air and toward a new comprehension of the role played by microorganisms. But, in fact, a number of American writers resisted this paradigm shift. As these writers saw it, the dénouement of miasmatic depictions of disease heralded an evisceration of a familiar grammar of climatic reflexivity, which they felt compelled to retain and recuperate.
Bashir Bashir, Amos Goldberg, and seventeen contributors have produced a powerful and incisive book that deserves the attention of everyone interested in central European history. Bashir and Goldberg's volume engages readers methodologically as well as intellectually, politically, ethically, and personally. It challenges us to think, write, and do things differently, to take risks, and to welcome the invigorating and disruptive presence of people in every aspect of our work.
The extent and profiles of heterogeneity in cognitive functioning among participants in clinical trials of antidementia medication are unknown. We aimed to quantify and identify profiles of heterogeneity of cognition in Alzheimer’s disease.
Individual-level participant data were analyzed from five pivotal clinical trials of donepezil for Alzheimer’s disease (N = 2,919). Based on Alzheimer’s Disease Assessment Scale–Cognitive Subscale total scores from baseline up to week 12, a latent class model was used to identify heterogeneous groups. A logistic regression model was used to examine factors associated with group membership. Sensitivity analysis was conducted, restricted to the donepezil, and then the placebo arm.
The latent class model identified three classes labeled as low scorers (i.e., least cognitive impairment; N = 1,666, 76.04%), improvers (N = 27, 1.23%), and high scorers (N = 498, 22.73%). Logistic modeling showed that donepezil compared to placebo was significantly (p < 0.05) positively associated with membership in the improvers class (OR = 6.88, 95% CI = 2.03, 42.95), and negatively with high scorers (OR = 0.79, 95% CI = 0.64, 0.98). Sensitivity analysis restricted to the placebo, then donepezil arms replicated similar heterogeneity patterns.
Our results inform clinicians regarding the extent of heterogeneity in cognitive functioning during treatment and contribute to trial design considerations.
Hurricane Harvey (2017) forced the closure of hemodialysis centers across Harris County, Texas (USA) disrupting the provision of dialysis services. This study aims to estimate the percentage of hemodialysis clinics flooded after Harvey, to identify the proportion of such clinics located in high-risk flood zones, and to assess the sensitivity of the Federal Emergency Management Agency (FEMA) Flood Insurance Rate Maps (FIRMs) for estimation of flood risk.
Data on 124 hemodialysis clinics in Harris County were extracted from Medicare.gov and geocoded using ArcGIS Online. The FIRMs were overlaid to identify the flood zone designation of each hemodialysis clinic.
Twenty-one percent (26 of 124) of hemodialysis clinics in Harris County flooded after Harvey. Of the flooded clinics, 57.7% were in a high-risk flood zone, 30.8% were within 1km of a high-risk flood zone, and 11.5% were not in or near a high-risk flood zone. The FIRMs had a sensitivity of 58%, misidentifying 42% (11 of 26) of the clinics flooded.
Hurricanes are associated with severe disruptions of medical services, including hemodialysis. With one-quarter of Harris County in the 100-year floodplain, projected increases in the frequency and severity of disasters, and inadequate updates of flood zone designation maps, the implementation of new regulations that address the development of hemodialysis facilities in high-risk flood areas should be considered.
To examine the use of early intervention services in infants with CHD after open-heart surgery and identify factors associated with receipt of services.
Surveys were administered to caregivers of infants who underwent open-heart surgery before 1 year of age at a single institution between July, 2017 and July, 2018. Information regarding the infant’s use of early intervention services and the caregiver’s experience with the programme was obtained. Clinical data were retrieved from the medical record review. Logistic regression identified factors associated with receipt of services.
The study included 158 eligible infants. Ninety-eight caregivers (62%) completed the surveys. Of those surveyed, 53.1% of infants were currently or previously enrolled in early intervention services. Infants most frequently received physical therapy (76.9%). The majority of caregivers found services to be moderately/very helpful (92.3%) and sufficient for their child (76.9%). In the univariate analysis, single-ventricle disease, known syndrome/genetic abnormality, extracardiac anomaly, and longer intensive care and hospital length of stay were associated with receipt of services. Single-ventricle disease (p = 0.004) and known syndrome/genetic abnormality (p < 0.0001) remained independently associated with receipt of services in the multivariable analysis.
Amongst infants at risk for neurodevelopmental deficits, approximately half received services after open-heart surgery. Caregivers expressed satisfaction with the programme. While infants with single-ventricle disease and a known syndrome/genetic abnormality were more likely to receive early intervention services, many at-risk infants with CHD failed to receive services. Further research is needed to identify barriers to early intervention services and promote developmental outcomes.
Our qualitative descriptive study compared how older patients and their informal caregivers experienced the care transition from acute care or rehabilitation to home. We recruited patients 65 years of age or older, or their informal caregivers, from in-patient units within acute care hospitals and rehabilitation facilities to participate in semi-structured interviews. We identified emergent themes via thematic analysis. In all, 16 patients and four patient caregivers participated. Across all care settings, caregivers were integral in facilitating the transition as well as experiencing variable discharge preparation, health care providers’ optimizing transitions, and missed care and medication discrepancies at transition points. Orthopedic and rehabilitation patients more commonly voiced prior transition experiences in discharge preparation, including having to unexpectedly coordinate and wait for outpatient services. Differing responses between acute care and orthopedic settings suggest that transitional care practices and policies favor an individualized approach that considers patients’ previous experiences, needs, and care expectations.
Scientific interest in the therapeutic effects of classical psychedelics has increased in the past two decades. The psychological effects of these substances outside the period of acute intoxication have not been fully characterized. This study aimed to: (1) quantify the effects of psilocybin, ayahuasca, and lysergic acid diethylamide (LSD) on psychological outcomes in the post-acute period; (2) test moderators of these effects; and (3) evaluate adverse effects and risk of bias.
We conducted a systematic review and meta-analysis of experimental studies (single-group pre-post or randomized controlled trials) that involved administration of psilocybin, ayahuasca, or LSD to clinical or non-clinical samples and assessed psychological outcomes ⩾24 h post-administration. Effects were summarized by study design, timepoint, and outcome domain.
A total of 34 studies (24 unique samples, n = 549, mean longest follow-up = 55.34 weeks) were included. Classical psychedelics showed significant within-group pre-post and between-group placebo-controlled effects on a range of outcomes including targeted symptoms within psychiatric samples, negative and positive affect-related measures, social outcomes, and existential/spiritual outcomes, with large between-group effect in these domains (Hedges' gs = 0.84 to 1.08). Moderator tests suggest some effects may be larger in clinical samples. Evidence of effects on big five personality traits and mindfulness was weak. There was no evidence of post-acute adverse effects.
High risk of bias in several domains, heterogeneity across studies, and indications of publication bias for some models highlight the need for careful, large-scale, placebo-controlled randomized trials.
Compared to the general population, individuals with complex congenital heart disease are at increased risk for deficits in cognitive, neurodevelopmental, psychosocial, and physical functioning, resulting in a diminished health-related quality of life. These deficits have been well described over the past 25 years, but significant gaps remain in our understanding of the best practices to improve neurodevelopmental and psychosocial outcomes and health-related quality of life for individuals with paediatric and congenital heart disease. Innovative clinical, quality improvement, and research opportunities with collaboration across multiple disciplines and institutions were needed to address these gaps. The Cardiac Neurodevelopmental Outcome Collaborative was founded in 2016 with a described mission to determine and implement best practices of neurodevelopmental and psychosocial services for individuals and their families with paediatric and congenital heart disease through clinical, quality improvement, and research initiatives. The vision is to be a multi-centre, multi-national, multi-disciplinary group of healthcare professionals committed to working together and partnering with families to optimise neurodevelopmental outcomes for individuals with paediatric and congenital heart disease through clinical, quality, and research initiatives, intending to maximise quality of life for every individual across the lifespan. This manuscript describes the development and organisation of the Cardiac Neurodevelopmental Outcome Collaborative.