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No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment.
From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment.
Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043).
Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.
We describe the delivery of real-time feedback on hand hygiene compliance between healthcare personnel over a 3-year time period via a crowdsourcing web-based application. Feedback delivery as a metric can be used to examine and improve a culture of safety within a healthcare setting.
To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events
Retrospective chart review
A convenience sample of 8 acute-care hospitals in Pennsylvania
All patients hospitalized during 2011–2012
Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded.
We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented.
In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015.
It is recognized that people with dementia are likely to need to stop driving at some point following diagnosis. Driving cessation can lead to negative outcomes for people with dementia and their family caregivers (FC), who often experience family conflict and tension throughout the process. Family experiences surrounding driving cessation have begun to be explored but warrant further examination.
Using a descriptive phenomenological approach, semi-structured interviews were undertaken with key stakeholders, including 5 retired drivers with dementia, 12 FC, and 15 health professionals (HP). Data were analyzed inductively to explore the needs and experiences of people with dementia and FC.
The data revealed a range of possible interactions between people with dementia and FC. These were organized into a continuum of family dynamics according to levels of collaboration and conflict: in it together, behind the scenes, active negotiations, and at odds. At the in it together end of the continuum, people with dementia and FC demonstrated collaborative approaches and minimal conflict in managing driving cessation. At the at odds end, they experienced open conflict and significant tension in their interactions. Contextual factors influencing family dynamics were identified, along with the need for individualized approaches to support.
The continuum of family dynamics experienced during driving cessation may help clinicians better understand and respond to complex family needs. Interventions should be tailored to families’ distinctive needs with consideration of their unique contextual factors influencing dynamics, to provide sensitive and responsive support for families managing driving cessation.
This article is an executive summary of a report from the Centers for Disease Control and Prevention Ventilator-Associated Pneumonia Surveillance Definition Working Group, entitled “Developing a new, national approach to surveillance for ventilator-associated events” and published in Critical Care Medicine. The full report provides a comprehensive description of the Working Group process and outcome.
In September 2011, the Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group to organize a formal process for leaders and experts of key stakeholder organizations to discuss the challenges of VAP surveillance definitions and to propose new approaches to VAP surveillance in adult patients (Table 1).
The impact of dementia on safe driving is well recognized and is generally accepted that all people with dementia are likely to need to cease driving at some stage in the disease process. Both driving and driving cessation can have poor outcomes for people with dementia and their caregivers in terms of health, safety, community access, and well-being. Although approaches to facilitate better outcomes from driving cessation are being developed, the processes of driving cessation for people with dementia are still not fully understood.
Within a descriptive phenomenological framework, semi-structured interviews were undertaken with key stakeholders, including retired drivers with dementia, family members, and health professionals.
Findings from four retired drivers with dementia, 11 caregivers, and 15 health professionals characterized driving cessation for people with dementia as a process with three stages and associated challenges and needs. The early stage involved worried waiting, balancing safety with impending losses, and the challenge of knowing when to stop. The crisis stage involved risky driving or difficult transportation, acute adjustment to cessation and life without driving, and relationship conflict. The post-cessation stage was described as a long journey with ongoing battles and adjustments as well as decreased life space, and was affected by the disease progression and the exhaustion of caregiver.
The concept of stages of driving cessation for people with dementia could be used to develop new approaches or adapt existing approaches to driving cessation. Interventions would need to be individualized, optimally timed, and address grief, explore realistic alternative community access, and simultaneously maintain key relationships and provide caregiver support.
Wild potato contains about 100 species that are native to the Americas from the southwestern United States to central Chile and adjacent Argentina, Uruguay, Paraguay, and southern Brazil. We report the occurrence of naturalized populations of the wild potato Solanum chacoense in seven sites in southern Australia, eastern China, England, New Zealand, the eastern United States, central Peru, and east-central Argentina. Modeling similar climatic niches on the basis of the distribution of S. chacoense from South America shows that observations of naturalized S. chacoense overlap with predicted areas. A literature review reveals that although S. chacoense possesses traits typical of an invasive species, all populations presently appear to be contained near their site of introduction.
Alligator weed is a serious weed in many countries. In Australia, it is a “weed of national significance” because of its actual and potential impact. We surveyed all local governments in New South Wales in 2001 and 2007 to determine whether the weed is being contained. We found an increased number and extent of infestations, despite more resources and a better knowledge base. Most considered that further research is needed in tactics for control of the weed. On the basis of current containment in urban gardens, we recommend that governments better mobilize the community (e.g., bush restoration consultants, Landcare groups) to deal with alligator weed infestations.
We consider an M/G/1 queue in which an arriving customer does not enter the system whenever its virtual waiting time, i.e. the amount of work seen upon arrival, is larger than a certain random patience time. We determine the busy period distribution for various choices of the patience time distribution. The main cases under consideration are exponential patience and a discrete patience distribution.
Terry E. L. Langford, Centre for Environmental Sciences, School of Civil Engineering and Environment, University of Southampton, United Kingdom,
Peter. J. Shaw, Centre for Environmental Sciences, School of Civil Engineering and Environment, University of Southampton, United Kingdom,
Shelley R. Howard, Environment Agency, Bristol, United Kingdom,
Alastair J. D. Ferguson, Environment Agency, Bristol, United Kingdom,
David Ottewell, Environment Agency, Bristol, United Kingdom,
Rowland Eley, Environment Agency, Bristol, United Kingdom
In many industrialised regions particularly in Britain, rivers have been impounded for use by mills, polluted by multiple point sources and channelised to the very source over many centuries (e.g., Bracegirdle 1973; Lester 1975; Harkness 1982; Holland & Harding 1984; Haslam 1991). Since the 1960s, the ecological recovery of such historically polluted and disturbed rivers in Britain has been remarkable. Long reaches of once black, foetid, fishless watercourses, some almost completely devoid of macroscopic biota, have been transformed into clear streams and rivers with diverse floras and faunas and prolific fish populations. This transformation is perceived to have been the result of a number of factors, including law, public pressure, new technologies, new infrastructure and changes in the economy and industry. Even so, ecological recovery is still poorly advanced in some rivers and the reasons for this have not been explained in any detail. This short chapter uses sets of long-term chemical and biological data from three sites on a Midland river in a preliminary analysis of the possible reasons for the variable rates of ecological recovery and the relationship between the long-term chemical and biological changes in the river. It is part of a series of longer term studies of the problems associated with ecological recovery of polluted rivers (e.g., Langford et al. 2009).
This study builds on previous work that explored the lived experience of meaning in advanced cancer. The aims were to explore the associations of suffering (physical and existential distress) and coping (via social support) with psychological distress and global meaning using a battery of instruments among adults attending an Australian metropolitan cancer service (n = 100).
The contribution of suffering and coping via social support to psychological distress and meaning were examined using a variety of statistical methods. Multiple regression analyses were conducted to further examine relative contributions to both psychological distress and global meaning.
Physical and existential distress were found to be positively associated with psychological distress whereas high social support and personal meaning are related to lower levels of psychological distress. Social support was the strongest correlate of global meaning whereas high levels of existential distress were related to lower levels of global meaning. On the basis of this study, it is concluded that the factors related to suffering clearly promote psychological distress, and the reverse is true for global meaning for those living with cancer.
Significance of results:
This study speaks to the clinical complexity of the dynamic experience of suffering and meaning in cancer. We need to better understand the impact of physical suffering and meaning in the lives of this population and to actively work toward the enhancement of social support and connection with others for this group. Optimal palliative and family-centered care blended with therapies that promote a sense of meaning of life lived appear crucial to ameliorate suffering.