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Community and primary health care nursing is experiencing a rapid metamorphosis as our population ages and the prevalence of chronic and complex conditions increase. To meet these changing needs, our health workforce has evolved with a range of specialised disciplines now working in diverse health settings. Throughout these changes, nursing continues to be the largest global health workforce providing the most direct client care. Historically, nurses were the original transdisciplinary health care workers, providing basic physiotherapy, occupational therapy, nutritional advice and all other care as required. As more detailed knowledge developed in an area of practice, specialised areas of care evolved and a variety of allied health professions emerged. Nursing itself became more specialised due to developments in clinical practice, technological advances and clients requiring more complex care. This chapter examines how professional identity and culture influence interprofessional practice, describes the behaviour and skills that facilitate effective communication, and identifies the barriers and facilitators to multidisciplinary health professionals working well together.
Life course research embraces the complexity of health and disease development, tackling the extensive interactions between genetics and environment. This interdisciplinary blueprint, or theoretical framework, offers a structure for research ideas and specifies relationships between related factors. Traditionally, methodological approaches attempt to reduce the complexity of these dynamic interactions and decompose health into component parts, ignoring the complex reciprocal interaction of factors that shape health over time. New methods that match the epistemological foundation of the life course framework are needed to fully explore adaptive, multilevel, and reciprocal interactions between individuals and their environment. The focus of this article is to (1) delineate the differences between lifespan and life course research, (2) articulate the importance of complex systems science as a methodological framework in the life course research toolbox to guide our research questions, (3) raise key questions that can be asked within the clinical and translational science domain utilizing this framework, and (4) provide recommendations for life course research implementation, charting the way forward. Recent advances in computational analytics, computer science, and data collection could be used to approximate, measure, and analyze the intertwining and dynamic nature of genetic and environmental factors involved in health development.
OBJECTIVES/GOALS: To identify possible failures that could occur in the delivery of an evidence-based parenting program for mothers with substance use disorders (SUD) through existing home-visiting services, and to develop solutions to the most significant failures. METHODS/STUDY POPULATION: Using failure modes and effects analysis (FMEA) methodology, we conducted two 2-hour advisory panel discussions with 15 people from a variety of disciplines and life experiences related to SUDs. The intervention delivery process included five steps: (1) Recruitment, (2) Screening, (3) Matching, (4) Enrollment in person, and (5) Intervention delivery. Participants collectively determined possible failures, causes, and consequences. Participants then agreed on three scores (Likert Scale 0-10) for the likelihood of occurrence, detection, and severity of the failure, with 10 being the highest likelihood, difficulty detecting, or severity. A risk priority number (RPN) was calculated as the product of the 3 scores (maximum RPN = 1,000). The group then identified possible solutions for failures with higher RPNs. RESULTS/ANTICIPATED RESULTS: For each step in the process we identified the following number of failure nodes and RPN scores: (1) recruitment: 13 failures; RPN = 800, (2) screening: 102 failures; RPN = 10, (3) matching: 4 failures: RPN = 490, (4) enrollment: 6 failures; RPN = 80, (5) delivery: 11 failures; RPN = 80. The most critical failures related to recruitment and were perceived as being caused by potential development of mistrust in the community. Participants strongly encouraged the use of “strengths-based language,” clear referral plans for mothers that did not qualify, and inclusion of mothers that did not have custody of their children. These findings resulted in changes to the screening script, enrollment procedures, and inclusion criterial for the program. DISCUSSION/SIGNIFICANCE OF IMPACT: FMEA methodology was particularly effective in identifying possible failures for the integration of an evidence-based parenting program into existing home-visiting services as they related to the psychological safety of mothers with SUDs. The process resulted in direct changes to procedures for the anticipated program integration and study.
Reconstructing the provenance of siliciclastic marine sediment is important for understanding sediment pathways and constraining palaeoclimate and erosion records. However, physical fractionation of different size fractions can occur during sediment transport, potentially biasing records derived from bulk sediment. In this study, records of radiogenic Sr and Nd isotopic composition and K/Al ratio of the separated clay fraction, as well as bulk grain size, are presented, measured from deep-sea sediments recovered from International Ocean Discovery Program (IODP) Sites U1456 and U1457 in the Arabian Sea. These new records are compared with published bulk sediment records to investigate the influence of sediment transport on these proxies and to constrain provenance evolution and its relationship to climate variability since middle Miocene time. Correlations between grain size and the bulk sediment isotopic composition confirm that transport processes are influencing the bulk sediment record. This relationship, although present, is not as strong in the clay-fraction isotopic records. Heterogeneity of bulk sediment likely drives differences between bulk and clay records, thought to be largely controlled by sediment transport processes. The isotopic records reveal variations in provenance that correlate with climatic change at 8–7 Ma, as well as an increase in overall provenance variability beginning at c. 3.5 Ma, likely linked to monsoon strength and glacial–interglacial cycles. The clay-fraction records highlight the potential value of measuring proxy records from multiple size fractions to help constrain provenance records as well as investigate sediment transport and/or weathering and erosion processes recorded in deep-sea sediment archives.
This rejoinder begins with an expression of gratitude and broad agreement with the two commentaries by Kenneth Levy and Nicholas Salsman. The rejoinder considers three main issues: (1) the fact of the range of psychodynamic treatments that have been found to be effective in the treatment of personality disorder (PD); (2) the value of considering a dimensional approach to psychopathology in general and PD more specifically, particularly in the context of recent work on the general psychopathology factor; and (3), the issue of transference and different ways of approaching it across different psychodynamic treatments.
This chapter gives an account of the different psychoanalytic traditions and their approaches to PD: the Kleinian/Bionian model, the British object relations perspective, Kohut’s self psychology, the structural object relations model, the interpersonal-relational approach, and mentalizing theory. The chapter goes on to describe two contemporary psychodynamic treatments, along with their evidence base: transference-focused therapy and mentalization-based treatment. Recent developments in the authors’ thinking in relation to PD are then described, partly in the context of recent work in the area of a general psychopathology or “p” factor. In particular, the authors discuss personality disorder in relation to epistemic trust, and suggest that psychopathology might be understood as a form of disordered social cognition, perpetuated by the obstacles to communication that these social cognitive difficulties create. It is postulated that effective therapeutic interventions for PD possess the shared characteristic of stimulating epistemic trust and creating a virtuous circle of improved social communication.
While it is known that patients with schizophrenia recognize facial emotions, specifically negative emotions, less accurately, little is known about how they misattribute these emotions to other emotions and whether such misattribution biases are associated with symptoms, course of the disorder, or certain cognitive functions.
Outpatients with schizophrenia or schizoaffective disorder (n = 73) and healthy controls (n = 30) performed a computerised Facial Emotion Attribution Test and Wisconsin Card Sorting Test (WCST). Patients were also rated on the Positive and Negative Syndrome Scale (PANSS).
Patients were poor at recognizing fearful and angry emotions and attributed fear to angry and angry to neutral expressions. Fear-as-anger misattributions were predicted independently by a longer duration of illness and WCST perseverative errors.
The findings show a bias towards misattributing fearful and angry facial emotions. The propensity for fear-as-anger misattribution biases increases as the length of time that the disorder is experienced increases and a more rigid style of information processing is used. This, at least in part, may be perpetuated by subtle fearfulness expressed by others while interacting with people with schizophrenia.
For children with normal hearing (NH), early communication skills predict vocabulary, a precursor to grammar. Growth in early communication skills of infants with cochlear implants (CIs) was investigated using the Early Communication Indicator (ECI), a play-based observation measure. Multilevel linear growth modelling on data from six ECI sessions held at three-monthly intervals revealed significant growth overall, with a non-significant slower growth rate than that of children with NH (comparison age centred at 18 months). Analyses of gesture use and of nonword vocalisations revealed the CI group used significantly more of each, with more rapid growth. In contrast, the CI group used significantly fewer single words and multiword utterances, and with slower growth. Maternal education and time to achieve consistent CI use impacted significantly on growth for the CI sample. The results indicate that progression to vocabulary by young CI users can be supported by encouraging their use of prelinguistic communication.
Harbour (2016) argues for a parsimonious universal set of features for grammatical person distinctions, and suggests (ch. 7) that the same features may also form the basis for systems of deixis. We apply this proposal to an analysis of Heiltsuk, a Wakashan language with a particularly rich set of person-based deictic contrasts (Rath 1981). Heiltsuk demonstratives and third-person pronominal enclitics distinguish proximal-to-speaker, proximal-to-addressee, and distal (in addition to an orthogonal visibility contrast). There are no forms marking proximity to third persons (e.g., ‘near them’) or identifying the location of discourse participants (e.g., ‘you near me’ vs. ‘you over there’), nor does the deictic system make use of the clusivity contrast that appears in the pronoun paradigm (e.g., ‘this near you and me’ vs. ‘this near me and others’). We account for the pattern by implementing Harbour's spatial element χ as a function that yields proximity to its first- or second-person argument.
Extant research has established an empirical relationship between fatigue and safety-related outcomes. It is not clear if these findings are relevant to Canadian paramedicine. The purpose of this study was to determine if fatigue and shiftwork variables were related to safety outcomes in Canadian paramedics.
A survey was conducted with ten paramedic services in Ontario with a 40.5% response rate (n = 717). Respondents reported levels of fatigue, safety outcomes (injury, safety compromising behaviours, and medical errors/adverse events), work patterns (types of shifts, hours worked weekly) and demographic characteristics. Univariate and logistic regression analyses were used to assess for significant differences.
In this sample, 55% of paramedics reported being fatigued at work. Fatigued paramedics were over twice as likely to report injuries, three times as likely to report safety compromising behaviors, and 1.5 times more likely to report errors/adverse outcomes. When controlling for fatigue, shift length variables did not consistently influence safety outcomes.
These results create preliminary evidence of a relationship between fatigue and safety outcomes in Canadian paramedicine. While more research is needed, these findings point to the influence fatigue has on safety outcomes and provide an indication that fatigue mitigation efforts may be worthwhile.
The landscape of antimicrobial resistance (AMR) surveillance is changing rapidly. The primary objective of this study was to assess the benefit of linking population-based infection prevention and control surveillance data on methicillin-resistant Staphylococcus aureus (MRSA) to hospital discharge abstract data (DAD). We assessed the value of this novel data linkage for the characterization of hospital-acquired (HA) and community-acquired MRSA (CA-MRSA) cases.
Incident inpatient MRSA surveillance data for all adults (≥18 years) from 4 acute-care facilities in Calgary, Alberta, between April 1, 2011, and March 31, 2017, were linked to DAD. Personal health number (PHN) and gender were used to identify specific individuals, and specimen collection time-points were used to identify specific hospitalization records. A third common variable on admission date between these databases was used to validate the linkage process. Descriptive statistics were used to characterize HA-MRSA and CA-MRSA cases identified through the linkage process.
A total of 2,430 surveillance records (94.6%) were successfully linked to the correct hospitalization period. By linking surveillance and administrative data, we were able to identify key differences between patients with HA- and CA-MRSA. These differences are consistent with previously reported findings in the literature. Data linkage to DAD may be a novel tool to enhance and augment the details of base surveillance data.
Conclusion and recommendations:
This is the first Canadian study linking a frontline healthcare-associated infection AMR surveillance database to an administrative population database. This work represents an important methodological step toward complementing traditional AMR surveillance data practices. Data linkage to other data types, such as primary care, emergency, social, and biological data, may be the basis of achieving more precise data focused around AMR.
Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated.
147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion.
The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.
DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.
OBJECTIVES/SPECIFIC AIMS: The development of new anti-cancer agents for children requires an inherently longer timeline than in adults. The 3+3 study design for Phase 1 dose escalation trials is commonly used to estimate the maximum tolerated dose and assess safety. The Rolling 6 study design was developed to shorten the study conduct timeline. METHODS/STUDY POPULATION: This study compares twenty Phase 1 COG Pilot and Phase 1 Consortium trials that employed the Rolling 6 design with hypothetical results under the assumption that a 3+3 design had been executed. The number of evaluable patients required to complete the study, number of DLTs, number of inevaluable patients, overall study duration, time suspended to enrollment (i.e., waiting for DLT evaluation), and DLT risk are compared between study designs using Wilcoxon’s signed rank test. RESULTS/ANTICIPATED RESULTS: The Rolling 6 study design required less time to complete the studies compared with 3+3 design (median 273 vs. 297 days, P = 0.01). In general, the Rolling 6 study design required more patients, had more inevaluable patients, and there were more dose limiting toxicity (DLT) events. However, there was no significant difference in DLT risk (median 0.15 vs. 0.17, P = 0.72). DISCUSSION/SIGNIFICANCE OF IMPACT: The Rolling 6 study design effectively shortens the study conduct timeline compared with the traditional 3+3 design for Phase 1 COG Pilot and Phase 1 Consortium trials without increasing the risk of toxicity.
OBJECTIVES/SPECIFIC AIMS: This study aims to understand the factors influencing engagement with out-patient services from pregnancy to 1 year postpartum among women in recovery from opioid use disorders (OUD). METHODS/STUDY POPULATION: We conducted semi-structured qualitative interviews and a brief survey with 20 mothers in OUD recovery recruited from health care and community organizations in Western MA. Transcripts were coded by two independent coders and analyzed using a qualitative descriptive approach. RESULTS/ANTICIPATED RESULTS: The average duration of any addiction treatment among the 20 participants was 5.6 years with 80% receiving medication-assisted treatment during a pregnancy. Approximately two-thirds experienced relapse during pregnancy or the first year postpartum. We identified 3 themes elucidating women’s experiences around service engagement: “How I see myself” (personal development), “How services see me” (service delivery quality), and “Are you with me?” Personal development included response to past trauma, coping strategies and self-advocacy, and adjusting to parenthood. Service delivery quality was influenced by service design, efficacy of individual providers, and cultural norms (organizational and societal). In the final theme, intersection of individual and service-level factors influenced the degree and quality of the women’s experience engaging with services. DISCUSSION/SIGNIFICANCE OF IMPACT: Women describe successful engagement when they experience service providers as being emotionally supportive, delivering relevant services, and advocating on their behalf. To best support and engage families affected by OUD, relevant and timely services should be linked with compassionate delivery.
The short-term impact of prolonged grief disorder (PGD) following bereavement is well documented. The longer term sequelae of PGD however are poorly understood, possibly unrecognized, and may be incorrectly attributed to other mental health disorders and hence undertreated.
The aims of this study were to prospectively evaluate the prevalence of PGD three years post bereavement and to examine the predictors of long-term PGD in a population-based cohort of bereaved cancer caregivers.
A cohort of primary family caregivers of patients admitted to one of three palliative care services in Melbourne, Australia, participated in the study (n = 301). Sociodemographic, mental health, and bereavement-related data were collected from the caregiver upon the patient's admission to palliative care (T1). Further data addressing circumstances around the death and psychological health were collected at six (T2, n = 167), 13 (T3, n = 143), and 37 months (T4, n = 85) after bereavement.
At T4, 5% and 14% of bereaved caregivers met criteria for PGD and subthreshold PGD, respectively. Applying the total PGD score at T4, linear regression analysis found preloss anticipatory grief measured at T1 and self-reported coping measured at T2 were highly statistically significant predictors (both p < 0.0001) of PGD in the longer term.
For almost 20% of caregivers, the symptoms of PGD appear to persist at least three years post bereavement. These findings support the importance of screening caregivers upon the patient's admission to palliative care and at six months after bereavement to ascertain their current mental health. Ideally, caregivers at risk of developing PGD can be identified and treated before PGD becomes entrenched.
A 1108.6 m long core was recovered at Site U1457 located on the Indus Fan in the Laxmi Basin of the eastern Arabian Sea during IODP Expedition 355. Shipboard examinations defined five lithologic units (I to V) of the lower Paleocene to Holocene sedimentary sequence. In this study, δ13C values of sedimentary organic matter (SOM) confirm the differentiation of the lithologic units and further divide units III and IV into two subunits (1 and 2). Based on the underlying assumption that the SOM is decided primarily by a mixture of marine and terrestrial origins, δ13CSOM values at Site U1457 provide information on the terrestrial catchment conditions since late Miocene time. Low δ13CSOM values from late Miocene to late Pleistocene times are similar (c. −22.0 ‰) for the most part, reflecting a consistent contribution of terrestrial organic matter from the catchment areas characterized by dominant C3 land plants. Significantly lower δ13CSOM values (c. −24.0 ‰) in Unit III-2 (∼8 to ∼7 Ma) might be due to a greater input of C3 terrestrial organic matter. The increase in δ13CSOM values at ∼7 Ma and the appearance of high δ13CSOM values (c. −18.0 ‰) within Unit III-1 (∼7 to ∼2 Ma) indicate that C4 biomass overwhelmed the terrestrial catchment environment as a result of enhanced terrestrial aridity in the Himalayan foreland. The three-end-member simple mixing model, estimating the relative contributions of SOM from terrestrial C3 and C4 plants and marine phytoplankton, supports our interpretation of the distribution of C3 and C4 land plants in the terrestrial catchment environment.
To understand why autistic people are misperceived in the way Jaswal & Akhtar suggest, we should embrace concepts like the “double empathy problem” and camouflaging and recognize the negative consequences these have for mental health in autism. Moreover, we need to value expertise from experience so that autistic people have a voice and indeed a stake in research into autism.
OBJECTIVES/SPECIFIC AIMS: To build a multisite de-identified database of female adolescents, aged 12–21 years (January 2011–December 2012), and their subsequent offspring through 24 months of age from electronic health records (EHRs) provided by participating Community Health. METHODS/STUDY POPULATION: We created a community-academic partnership that included New York City Community Health Centers (n=4) and Hospitals (n=4), The Rockefeller University, The Sackler Institute for Nutrition Science and Clinical Directors Network (CDN). We used the Community-Engaged Research Navigation model to establish a multisite de-identified database extracted from EHRs of female adolescents aged 12–21 years (January 2011–December 2012) and their offspring through 24 months of age. These patients received their primary care between 2011 and 2015. Clinical data were used to explore possible associations among specific measures. We focused on the preconception, prenatal, postnatal periods, including pediatric visits up to 24 months of age. RESULTS/ANTICIPATED RESULTS: The analysis included all female adolescents (n=122,556) and a subset of pregnant adolescents with offspring data available (n=2917). Patients were mostly from the Bronx; 43% of all adolescent females were overweight (22%) or obese (21%) and showed higher systolic and diastolic blood pressure, blood glucose levels, hemoglobin A1c, total cholesterol, and triglycerides levels compared with normal-weight adolescent females (p<0.05). This analysis was also performed looking at the nonpregnant females and the pregnant females separately. Overall, the pregnant females were older (mean age=18.3) compared with the nonpregnant females (mean age=16.5), there was a higher percentage of Hispanics among the pregnant females (58%) compared with the nonpregnant females (43.9%). There was a statistically significant association between the BMI status of mothers and infants’ birth weight, with underweight/normal-weight mothers having more low birth weight (LBW) babies and overweight/obese mothers having more large babies. The odds of having a LBW baby was 0.61 (95% CI: 0.41, 0.89) lower in obese compared with normal-weight adolescent mothers. The risk of having a preterm birth before 37 weeks was found to be neutral in obese compared with normal-weight adolescent mothers (OR=0.81, 95% CI: 0.53, 1.25). Preliminary associations are similar to those reported in the published literature. DISCUSSION/SIGNIFICANCE OF IMPACT: This EHR database uses available measures from routine clinical care as a “rapid assay” to explore potential associations, and may be more useful to detect the presence and direction of associations than the magnitude of effects. This partnership has engaged community clinicians, laboratory, and clinical investigators, and funders in study design and analysis, as demonstrated by the collaborative development and testing of hypotheses relevant to service delivery. Furthermore, this research and learning collaborative is examining strategies to enhance clinical workflow and data quality as well as underlying biological mechanisms. The feasibility of scaling-up these methods facilitates studying similar populations in different Health Systems, advancing point-of-care studies of natural history and comparative effectiveness research to identify service gaps, evaluate effective interventions, and enhance clinical and data quality improvement.
Collaborative care can support the treatment of depression in people with long-term conditions, but long-term benefits and costs are unknown.
To explore the long-term (24-month) effectiveness and cost-effectiveness of collaborative care in people with mental-physical multimorbidity.
A cluster randomised trial compared collaborative care (integrated physical and mental healthcare) with usual care for depression alongside diabetes and/or coronary heart disease. Depression symptoms were measured by the symptom checklist-depression scale (SCL-D13). The economic evaluation was from the perspective of the English National Health Service.
191 participants were allocated to collaborative care and 196 to usual care. At 24 months, the mean SCL-D13 score was 0.27 (95% CI, −0.48 to −0.06) lower in the collaborative care group alongside a gain of 0.14 (95% CI, 0.06-0.21) quality-adjusted life-years (QALYs). The cost per QALY gained was £13 069.
In the long term, collaborative care reduces depression and is potentially cost-effective at internationally accepted willingness-to-pay thresholds.