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Several in-person and remote delivery formats of cognitive-behavioural therapy (CBT) for panic disorder are available, but up-to-date and comprehensive evidence on their comparative efficacy and acceptability is lacking. Our aim was to evaluate the comparative efficacy and acceptability of all CBT delivery formats to treat panic disorder. To answer our question we performed a systematic review and network meta-analysis of randomised controlled trials. We searched MEDLINE, Embase, PsycINFO, and CENTRAL, from inception to 1st January 2022. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO. We found a total of 74 trials with 6699 participants. Evidence suggests that face-to-face group [standardised mean differences (s.m.d.) −0.47, 95% confidence interval (CI) −0.87 to −0.07; CINeMA = moderate], face-to-face individual (s.m.d. −0.43, 95% CI −0.70 to −0.15; CINeMA = Moderate), and guided self-help (SMD −0.42, 95% CI −0.77 to −0.07; CINeMA = low), are superior to treatment as usual in terms of efficacy, whilst unguided self-help is not (SMD −0.21, 95% CI −0.58 to −0.16; CINeMA = low). In terms of acceptability (i.e. all-cause discontinuation from the trial) CBT delivery formats did not differ significantly from each other. Our findings are clear in that there are no efficacy differences between CBT delivered as guided self-help, or in the face-to-face individual or group format in the treatment of panic disorder. No CBT delivery format provided high confidence in the evidence at the CINeMA evaluation.
Atrial fibrillation (AF) is the most important cause of embolic stroke of undetermined source (ESUS). Implantable loop recorder (ILR) demonstrated the highest sensitivity for detecting it. This register was created to confirm the high prevalence of AF in patients after ESUS and to verify possible benefits on clinical outcomes such as TIA (Transient Ischaemic Attack)/stroke recurrence and death using ILR.
A total of 278 patients admitted to “Molinette” Hospital in Stroke Unit department between 2011 and 2016, diagnosed with ESUS, underwent ILR implantation if they had at least one risk factor for AF. A total of 165 patients admitted to other departments in the same center for the same pathology, without ILR, represent the control group. We used propensity score to select 132 patients from each group (matching age, sex, CHADS-VASC, and HAS-BLEED baseline characteristics).
The detection rate of AF episodes was significantly higher in the ILR group (p < 0.001). No significant protective role of ILR for clinical endpoints was found on univariate analysis, although a trend towards significance has been pointed for the composite outcome of death and ischemic events recurrence (OR 0.52, CI 0.26–1.04, p = 0.06). A protective role of ILR was found for deaths (OR 0.4, CI 0.17–0.94, p 0.03) and for the composite outcome (OR 0.41, CI 0.19–0.87, p 0.02) on multivariate analysis in the best subsets.
With our statistical models, we identified a significant clinical benefit from ILR monitoring, evidenced by a trend of less death and TIA/stroke recurrence and relevant ILR protection for prediction of TIA/stroke recurrence.
Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.
The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected.
A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.
A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated.
Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags.
Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.
Refreezing of meltwater in firn is a major component of Greenland ice-sheet's mass budget, but in situ observations are rare. Here, we compare the firn density and total ice layer thickness in the upper 15 m of 19 new and 27 previously published firn cores drilled at 15 locations in southwest Greenland (1850–2360 m a.s.l.) between 1989 and 2019. At all sites, ice layer thickness covaries with density over time and space. At the two sites with the earliest observations (1989 and 1998), bulk density increased by 15–18%, in the top 15 m over 28 and 21 years, respectively. However, following the extreme melt in 2012, elevation-detrended density using 30 cores from all sites decreased by 15 kg m−3 a−1 in the top 3.75 m between 2013 and 2019. In contrast, the lowest elevation site's density shows no trend. Thus, temporary build-up in firn pore space and meltwater infiltration capacity is possible despite the long-term increase in Greenland ice-sheet melting.
Psychotherapies are the treatment of choice for panic disorder, but which should be considered as first-line treatment is yet to be substantiated by evidence.
To examine the most effective and accepted psychotherapy for the acute phase of panic disorder with or without agoraphobia via a network meta-analysis.
We conducted a systematic review and network meta-analysis of randomised controlled trials (RCTs) to examine the most effective and accepted psychotherapy for the acute phase of panic disorder. We searched MEDLINE, Embase, PsycInfo and CENTRAL, from inception to 1 Jan 2021 for RCTs. Cochrane and PRISMA guidelines were used. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO (CRD42020206258).
We included 136 RCTs in the systematic review. Taking into consideration efficacy (7352 participants), acceptability (6862 participants) and the CINeMA confidence in evidence appraisal, the best interventions in comparison with treatment as usual (TAU) were cognitive–behavioural therapy (CBT) (for efficacy: standardised mean differences s.m.d. = −0.67, 95% CI −0.95 to −0.39; CINeMA: moderate; for acceptability: relative risk RR = 1.21, 95% CI −0.94 to 1.56; CINeMA: moderate) and short-term psychodynamic therapy (for efficacy: s.m.d. = −0.61, 95% CI −1.15 to −0.07; CINeMA: low; for acceptability: RR = 0.92, 95% CI 0.54–1.54; CINeMA: moderate). After removing RCTs at high risk of bias only CBT remained more efficacious than TAU.
CBT and short-term psychodynamic therapy are reasonable first-line choices. Studies with high risk of bias tend to inflate the overall efficacy of treatments. Results from this systematic review and network meta-analysis should inform clinicians and guidelines.
This chapter reviews dramatic changes in the European economy between 1700 and 1870. The period saw a rapid population increase, slow structural transformation away from agriculture, and a gradual spread of modern economic growth across the continent. We discuss the proximate causes of these phenomena – namely, technical progress and the adaptation of English technology, growing integration of markets and upsurge of trade, and institutional modernization and the birth of the modern state.
The dispatch of Advanced Life Support (ALS) teams in Emergency Medical Services (EMS) is still a hardly studied aspect of prehospital emergency logistics. In 2015, the dispatch algorithm of Emilia Est Emergency Operation Centre (EE-EOC) was implemented and the dispatch of ALS teams was changed from primary to secondary based on triage of dispatched vehicles for high-priority interventions when teams with Immediate Life Support (ILS) skills were dispatched.
This study aimed to evaluate the effects on the appropriateness of ALS teams’ intervention and their employment time, and to compare sensitivity and specificity of the algorithm implementation.
This was a retrospective before-after observational study.
Settings and Participants:
Primary dispatches managed by EE-EOC involving ambulances and/or ALS teams were included. Two groups were created on the basis of the years of intervention (2013-2014 versus 2017-2018).
A switch from primary to secondary dispatch of ALS teams in case of high-priority dispatches managed by ILS teams was implemented.
Appropriateness of ALS team intervention, total task time of ALS vehicles, and sensitivity and specificity of the algorithm were reviewed.
The study included 242,501 emergency calls that generated 56,567 red code dispatches. The new algorithm significantly increased global sensitivity and specificity of the system in terms of recognition of potential need of ALS intervention and the specificity of primary ALS dispatch. The appropriateness of ALS intervention was significantly increased; total tasking time per day for ALS and the number of critical dispatches without ALS available were reduced.
The revision of the dispatch criteria and the extension of the two-tiered dispatch for ALS teams significantly increased the appropriateness of ALS intervention and reduced both the global tasking time and the number of high-priority dispatches without ALS teams available.
This paper examines price convergence and changes in the efficiency of wheat markets, covering the period from the mid-fourteenth to the early twentieth century and most of Europe. The analysis is based on a new data set of prices from almost 600 markets. Unlike previous research, we find that convergence was a predominantly pre-modern phenomenon. It started in the late fifteenth century, advanced rapidly until the beginning of the seventeenth century when it temporarily stalled, resumed after the Thirty Years’ War, and accelerated after the Napoleonic Wars in response to trade liberalization. From the late 1840s, convergence petered out and turned into divergence after 1875 as policy decisions dominated technological change. Our results point to the ‘Little Divergence’ between North-Western Europe and the rest of the continent as starting about 1600. Long-term improvements in market efficiency began in the early sixteenth century, with advances over time being as uneven as in price convergence. We trace this to differential institutional change and the non-synchronous spread of modern media and systems of information transmission that affected the ability of merchants to react to news.
Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.
Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services.
To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3.
Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach.
A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62–0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60–0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46–0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.
Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.
An unprecedented wave of patients with acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) hit emergency departments (EDs) in Lombardy, starting in the second half of February 2020. This study describes the direct and indirect impacts of the SARS-CoV-2 outbreak on an urban major-hospital ED.
Data regarding all patients diagnosed with COVID-19 presenting from February 1 to March 31, 2020, were prospectively collected, while data regarding non-COVID patients presenting within the same period in 2019 were retrospectively retrieved.
ED attendance dropped by 37% in 2020. Two-thirds of this reduction occurred early after the identification of the first autochthonous COVID-19 case in Lombardy, before lockdown measures were enforced. Hospital admissions of non-COVID patients fell by 26%. During the peak of COVID-19 attendance, the ED faced an extraordinary increase in: patients needing oxygen (+239%) or noninvasive ventilation (+725%), transfers to the intensive care unit (+57%), and in-hospital mortality (+309%), compared with the same period in 2019.
The COVID-19 outbreak determined an unprecedented upsurge in respiratory failure cases and mortality. Fear of contagion triggered a spontaneous, marked reduction of ED attendance, and, presumably, some as yet unknown quantity of missed or delayed diagnoses for conditions other than COVID-19.
For many years, dementia care has been dominated by the standard medical approach, in which dementia is treated mainly with drugs, such as anti-anxiety, antidepressant and anti-psychotic medications. With the aim of seeking effective treatments for patients with dementia, over the last years, several contributions have criticised the pervasive use of drugs for the management of behavioural and physiological symptoms related to dementia, proposing personalised interventions aimed at supporting patients and their relatives from diagnosis until death. With particular reference to long-term settings, in this work, we aim at understanding the organisational implications of three types of interventions (labelled supportive care interventions – SCIs) that have characterised this shift in dementia care: person-centred, palliative and multi-disciplinary care. Conducted by following the integrative review method, our review underlines how SCIs have controversial consequences on the quality of care, the care-givers’ quality of life and cultural backgrounds. After an in-depth analysis of selected papers, we offer some considerations about the implications of SCIs for long-term care organisations and future research directions.
This paper proposes novel inference procedures for instrumental variable models in the presence of many, potentially weak instruments that are robust to the presence of heteroskedasticity. First, we provide an Anderson–Rubin-type test for the entire parameter vector that is valid under assumptions weaker than previously proposed Anderson–Rubin-type tests. Second, we consider the case of testing a subset of parameters under the assumption that a consistent estimator for the parameters not under test exists. We show that under the null, the proposed statistics have Gaussian limiting distributions and derive alternative chi-square approximations. An extensive simulation study shows the competitive finite sample properties in terms of size and power of our procedures. Finally, we provide an empirical application using college proximity instruments to estimate the returns to education.
Despite the great number of resting state functional connectivity studies on Eating Disorders (ED), no biomarkers could be detected yet. Therefore, we here focus on a different measure of resting state activity that is neuronal variability. The objective of this study was to investigate neuronal variability in the resting state of women with ED and to correlate possible differences with clinical and psychopathological indices.
58 women respectively 25 with Anorexia Nervosa (AN), 16 with Bulimia Nervosa (BN) and 17 matched healthy controls (CN) were enrolled for the study. All participants were tested with a battery of psychometric tests and underwent a functional Magnetic Resonance Imaging (fMRI) resting state scanning. We investigated topographical patterns of variability measured by the Standard Deviation (SD) of the Blood-Oxygen-Level-Dependent (BOLD) signal (as a measure of neuronal variability) in the resting-state and their relationship to clinical and psychopathological indices.
Neuronal variability was increased in both anorectic and bulimic subjects specifically in the Ventral Attention Network (VAN) compared to healthy controls. No significant differences were found in the other networks. Significant correlations were found between neuronal variability of VAN and various clinical and psychopathological indices.
We here show increased neuronal variability of VAN in ED patients. As the VAN is relevant for switching between endogenous and exogenous stimuli, our results showing increased neuronal variability suggest unstable balance between body attention and attention to external world. These results offer new perspective on the neurobiological basis of ED. Clinical and therapeutic implication will be discussed.
The origins of the Italian North-South divide have always been controversial. We fill this gap by estimating a new dataset of real wages (Allen 2001; Allen et al. 2011) from Unification (1861) to WWI. Italy was very poor throughout the period, with a modest improvement since the late nineteenth century. This improvement started in the Northwest industrializing regions, while real wages in other macro-areas remained stagnant. The gap Northwest/South widened until the end of the period. Focusing on the drivers of regional trends, we find that human capital formation exerted strong positive effect on the growth of real wages.
This paper outlines the development of world trade from 1800 to 1938. It relies on a newly compiled database, which, unlike previous works (e.g. Lewis 1981), reports series of imports and exports at current and constant prices and at current and constant (1913) borders for almost all existing polities. In the first sections, we outline the estimation methodology and assess the reliability of the series (now available at http://www.uc3m.es/tradehist_db). World trade grew very fast throughout the «long» 19th century, but growth rates were higher before 1870. We measure the effects of war and the Great Depression on total trade and trade by continent and polity. Within this general upward trend, the performance of polities differed by geographical location, level of development, political status and factor endowment. Finally, we estimate trends in the share of primary products, which declined until World War One, with an acceleration in the second half of the 19th century.
Late-life depression is often associated with cognitive impairments and disability, which may persist even after adequate antidepressant drug treatment. Physical exercise is increasingly recognized as an effective antidepressant agent, and may exert positive effects on these features too. However, few studies examined this issue, especially by comparing different types of exercises.
We performed secondary analyses on data from the Safety and Efficacy of Exercise for Depression in Seniors study, a trial comparing the antidepressant effectiveness of sertraline (S), sertraline plus thrice-weekly non-progressive exercise (S+NPE), and sertraline plus thrice-weekly progressive aerobic exercise (S+PAE). Exercise was conducted in small groups and monitored by heart rate meters. Patients with late-life depression without severe cognitive impairment were recruited from primary care and assessed at baseline and 24 weeks, using the Montreal Cognitive Assessment (MOCA, total and subdomain scores) and Brief Disability Questionnaire. Analyses were based on Generalized Linear Models.
In total, 121 patients (mean age 75, 71% females) were randomized to the study interventions. Compared with the S group, patients in the S+PAE group displayed greater improvements of MOCA total scores (p=0.006, effect size=0.37), visuospatial/executive functions (p=0.001, effect size=0.13), and disability (p=0.02, effect size=−0.31). Participants in the S+NPE group did not display significant differences with the control group.
Adding aerobic, progressive exercise to antidepressant drug treatment may offer significant advantages over standard treatment for cognitive abilities and disability. These findings suggest that even among older patients exercise may constitute a valid therapeutic measure to improve patients’ outcomes.
The impact of protection on economic growth has enjoyed a revival in recent times, with the publication of a number of comparative quantitative papers. They all share a common weakness: they measure protection as the ratio of custom revenues to import value, which biases results if demand for imports is not perfectly inelastic. In this article, we show that the measure of protection matters. We estimate the James Anderson and Peter Neary (2005) Trade Restrictiveness Index for Italy from unification to the Great Depression. We suggest a different interpretation of some key moments of Italian trade policy and we show that the aggregate welfare losses were small in the long run and mostly related to protection on sugar in the 1880s and 1890s. We document that using different measures of protection affects results of the causal relation between trade policy on economic growth in Italy and in the United States. Accordingly, we argue that a systematic re-estimating of protection in the economic history of trade policy is needed.