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High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care ‘Improving Access to Psychological Therapies’ (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England.
This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the ‘Standardised Assessment of Personality – Abbreviated Scale’ (SAPAS) in receipt of primary care-based IAPT treatment.
A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach.
Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important.
For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.
Hispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy.
We evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients.
A retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients.
Of 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04).
Significance of results
Spanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.
OBJECTIVES/GOALS: The purpose of this secondary data analysis was to identify latent subgroups of seriously ill adults based on multiple chronic conditions and mortality risk using the CCI. This study was conducted by performing a secondary analysis of data from a randomized controlled trial of seriously ill patients receiving palliative care. METHODS/STUDY POPULATION: A cross-sectional analysis of baseline CCI data was conducted. 381 seriously ill adults receiving palliative care were in the original study. Latent subgroups were identified based on the CCI by conducting a latent class analysis in MPlus. The LCA was modeled on each of the 19 disease items as binary latent predictor variables, an additional binary variable representing presence of any disease not accounted for by the CCI, and a final categorical variable representing the total CCI score divided based on clinically significant cutoffs including zero, low (> = 1-<2), moderate (> = 2-<5), and high CCI (> = 5). RESULTS/ANTICIPATED RESULTS: Three distinct latent subgroups were identified based on the CCI. Latent subgroup 1 included those with a low-moderate CCI consisting of MCC and non-Metastatic Cancers (n = 178), with 45% of this group having chronic obstructive pulmonary disease. The second two subgroups included individuals with a high CCI or a score greater than or equal to 5. Latent subgroup 2 (n = 64) was comprised of individuals with MCC and non-metastatic cancer. Latent subgroup 3 (n = 139) included individuals with metastatic cancer. DISCUSSION/SIGNIFICANCE OF IMPACT: In a sample of seriously ill adults with MCC, latent subgroups were identified consisting of individuals with low, moderate, or high CCI. The low to moderate CCI group consists of individuals with chronic conditions including COPD, congestive heart failure, myocardial infarction, cardiovascular disease. There were two subgroups with high CCI scores and the differentiating factor between the two subgroups was the presence of metastatic cancer in latent subgroup 3. The identification of latent subgroups sets the groundwork for further analyses to compare differences in symptom burden, quality of life, and functional status between groups. The findings have the potential to inform future studies seeking to better characterize seriously adults with MCC based on their disease burden and mortality risk.
As the nature of work and the workplace continue to change, leaders need to become adept at changing how they lead. In this chapter, we describe four broad leader behavior categories (task-oriented, relations-oriented, change-oriented, and external behaviors), their specific component behaviors, and evidence for the importance of these behaviors. We also describe several major changes facing leaders in the coming years, including demographic changes in the workforce, technological changes, changes in occupations and work tasks, and global and strategic changes. Then we provide suggestions for how leaders should flexibly use the different types of behaviors to reflect these changes and the leadership situation. Finally, we offer some suggestions for future research that would make theoretical and methodological contributions to the leadership literature.
Methamphetamine has been consistently associated with positive psychotic symptoms, but little is known about whether the reverse also occurs.
This study determined whether the relationship between methamphetamine use and positive psychotic symptoms is bidirectional over 12 months. The impact of lifetime psychotic disorders and methamphetamine dependence on these relationships was also examined.
A total of 201 regular (at least monthly) primary methamphetamine users were recruited from free needle and syringe programmes in three Australian cities. Data on the frequency of methamphetamine and other drug use (from Timeline Followback inteviews) and the severity of positive psychotic symptoms (using the Brief Psychiatric Rating Scale) in the past 2 weeks were collected in 12 contiguous monthly face-to-face interviews (mean of 9.14/11 (s.d. = 3.16) follow-ups completed). Diagnoses were derived using the Psychiatric Research Interview for DSM-IV Substance and Mental Disorders.
The mean age of participants was 31.71 years (s.d. = 8.19) and 39% (n = 77) were women. At baseline 55% (n = 110) were dependent on methamphetamine and 51% (n = 102) had a lifetime psychotic disorder. Cross-lagged dynamic panel models found a significant bidirectional relationship between psychotic symptoms and methamphetamine use (Comparative Fit Index (CFI) = 0.94, standardised root mean square residual (SRMR) = 0.05, root mean square error of approximation (RMSEA) = 0.05, 95% CI 0.04–0.06). The magnitude of the relationship in each direction was similar, and the presence of methamphetamine dependence or a lifetime psychotic disorder did not have an impact on results.
A dynamic, bidirectional relationship between methamphetamine and psychotic symptoms of similar magnitude in each direction was found over 1 year. This suggests integrated treatments that target methamphetamine, psychotic symptoms and their interrelationship may be of most benefit.
We report on the successful demonstration of a 150 J nanosecond pulsed cryogenic gas cooled, diode-pumped multi-slab Yb:YAG laser operating at 1 Hz. To the best of our knowledge, this is the highest energy ever recorded for a diode-pumped laser system.
Betavoltaics (BV) cells (or nuclear batteries) have long-lasting power and high volumetric energy densities that open a broad range of applications that are not currently available, especially in low-power electronics for the internet-of-things, internal medical devices, and harsh environments. The introduction of very low-power electronics has opened up a market for the wide and accepted use of BV cells. As BVs have potentially decades-long useful lifetimes and are anticipated to be used in harsh environments, a method to describe accelerated contact aging has been developed. Monte Carlo radiation simulations show that energy can be deposited in the interface 10-50 times faster than real-world applications. The models can be used to design contact aging experiments for BV cell deployments.
Poor physical health in severe mental illness (SMI) remains a major issue for clinical practice.
To use electronic health records of routinely collected clinical data to determine levels of screening for cardiometabolic disease and adverse health outcomes in a large sample (n = 7718) of patients with SMI, predominantly schizophrenia and bipolar disorder.
We linked data from the Glasgow Psychosis Clinical Information System (PsyCIS) to morbidity records, routine blood results and prescribing data.
There was no record of routine blood monitoring during the preceding 2 years for 16.9% of the cohort. However, monitoring was poorer for male patients, younger patients aged 16–44, those with schizophrenia, and for tests of cholesterol, triglyceride and glycosylated haemoglobin. We estimated that 8.0% of participants had diabetes and that lipids levels, and use of lipid-lowering medication, was generally high.
Electronic record linkage identified poor health screening and adverse health outcomes in this vulnerable patient group. This approach can inform the design of future interventions and health policy.
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.
On January 13, 2018, a false ballistic missile alert that lasted 38 minutes was issued across Oahu, Hawaii, United States. As a result of a system failure, an erroneous text message was sent that stated, “Ballistic missile threat inbound to Hawaii. Seek immediate shelter.”
The research team wanted to know the degree of reported anxiety triggered by the event and if knowledge, attitudes, or behaviors for individual/family emergency preparedness (EP) changed post-event.
A 50-question survey that asked about individual and family EP pre- and post-event, and the level of anxiety triggered by the event, was administered to a convenience sample of full-time adult residents of Oahu. The study was conducted over a 6-8 week period post-event. Statistical analysis was used to identify factors associated with an increasing level of EP post-event and reported event-triggered anxiety.
209 participants completed the survey (29% male, 71% female) with about one half living with children. One third were essential workers. Key factors that correlate with increasing various areas of EP post-event include higher educational, receipt of electronic emergency alerts, prior emergency training, and higher reported connectedness to community. Those with higher event anxiety were more likely to develop and practice an EP plan post-event, encourage EP with friends, and report a higher level of community connectedness. The elderly were more likely to have higher levels of EP before and after the event but were less likely to receive emergency alert notifications or have EP training.
While the event was very unfortunate, it did seem to stimulate citizen disaster EP among some groups. Additional research should explore the utility of increasing EP education for communities immediately after disasters, tailoring this education for groups, and targeting the elderly for participation in the emergency alert system.
Foundations of the Global Value Chain Framework
Gary Gereffi, Professor of Sociology and Director of the Global Value Chains Center at Duke University, Durham, USA.,
John Humphrey, Honorary Professor at the Department of Business and Management at Sussex University.,
Timothy J. Sturgeon, Senior Researcher at the Industrial Performance Center at Massachusetts Institute of Technology
The world economy has changed in significant ways during the past several decades, especially in the areas of international trade and industrial organization. Two of the most important new features of the contemporary economy are the globalization of production and trade, which have fueled the growth of industrial capabilities in a wide range of developing countries, and the vertical disintegration of transnational corporations, which are redefining their core competencies to focus on innovation and product strategy, marketing, and the highest value-added segments of manufacturing and services, while reducing their direct ownership over ‘non-core’ functions such as generic services and volume production. Together, these two shifts have laid the groundwork for a variety of network forms of governance situated between arm's length markets, on the one hand, and large vertically integrated corporations, on the other. The purpose of this chapter is to generate a theoretical framework for better understanding the shifting governance structures in sectors producing for global markets, structures we refer to as ‘global value chains’. Our intent is to bring some order to the variety of network forms that have been observed in the field.
The evolution of global-scale industrial organization affects not only the fortunes of firms and the structure of industries, but also how and why countries advance—or fail to advance—in the global economy. Global value chain research and policy work examine the different ways in which global production and distribution systems are integrated, and the possibilities for firms in developing countries to enhance their position in global markets. We hope that the theory of global value chain governance that we develop here will be useful for the crafting of effective policy tools related to industrial upgrading, economic development, employment creation, and poverty alleviation.
Fragmentation, Coordination, and Networks in the Global Economy
For us, the starting point for understanding the changing nature of international trade and industrial organization is contained in the notion of a value-added chain, as developed by international business scholars who have focused on the strategies of both firms and countries in the global economy. In its most basic form, a value-added chain is ‘the process by which technology is combined with material and labor inputs, and then processed inputs are assembled, marketed, and distributed.
OBJECTIVES/SPECIFIC AIMS: Bladder cancer patients being considered for immune checkpoint blockade are often judged on immunohistochemical staining for the checkpoint target protein PD-L1 in the original surgery or biopsy sample. However, sampling error or the clinical evolution of most patients’ cancer can render the original PD-L1 assessment no longer accurate. In contrast, circulating tumor cells (CTCs) allow serial noninvasive sampling of the current tumor status throughout a patient’s clinical course including those with the highest metastatic potential. We therefore sought to develop a method for quantifying PD-L1 expression in CTCs towards addressing inherent limitations of current UC management. METHODS/STUDY POPULATION: This work utilizes both cancer cell lines as well as patient samples. Positive and negative control cancer cell lines were assessed via “industry standard” antibodies for PD-L1 expression via Western blots and immunofluorescence, and a threshold-based method was developed for reliable quantification. PDL-1 expression was additionally verified via interferon-mediated up-regulation. CTCs isolated from bladder cancer patient samples via a density centrifugation method were then assessed for PD-L1 via the same antibodies. RESULTS/ANTICIPATED RESULTS: We will show preliminary preclinical and clinical data that validates the sensitivity and specificity of our assay. A case study will be presented that illustrate the potential useful of the novel approach we describe and which should be complementary to current clinical practices. In a patient with metastatic bladder cancer, this method effectively detected the PD-L1 expression in CTCs taken at a time coincident to when the patient derived an excellent response to the PD-L1 checkpoint inhibitor Pembrolizumab. DISCUSSION/SIGNIFICANCE OF IMPACT: This work highlights the potential utility of CTCs in the management of bladder cancer. It may be the case that this assay in conjunction with current methods of patient selection for immunotherapy may allow for better response prediction than either method alone.
Educational tools for application of team science competencies in clinical research are needed. Our interdisciplinary group developed and evaluated acceptability of a virtual world game-based learning tool simulating a multisite clinical trial; performance hinges on effective intrateam communication. Initial implementation with clinical research trainees (n=40) indicates high satisfaction and perceived relevance to team science and research career goals. Game-based learning may play an important role in team science training.
To determine whether probiotic prophylaxes reduce the odds of Clostridium difficile infection (CDI) in adults and children.
Individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs), adjusting for risk factors.
We searched 6 databases and 11 grey literature sources from inception to April 2016. We identified 32 RCTs (n=8,713); among them, 18 RCTs provided IPD (n=6,851 participants) comparing probiotic prophylaxis to placebo or no treatment (standard care). One reviewer prepared the IPD, and 2 reviewers extracted data, rated study quality, and graded evidence quality.
Probiotics reduced CDI odds in the unadjusted model (n=6,645; odds ratio [OR] 0.37; 95% confidence interval [CI], 0.25–0.55) and the adjusted model (n=5,074; OR, 0.35; 95% CI, 0.23–0.55). Using 2 or more antibiotics increased the odds of CDI (OR, 2.20; 95% CI, 1.11–4.37), whereas age, sex, hospitalization status, and high-risk antibiotic exposure did not. Adjusted subgroup analyses suggested that, compared to no probiotics, multispecies probiotics were more beneficial than single-species probiotics, as was using probiotics in clinical settings where the CDI risk is ≥5%. Of 18 studies, 14 reported adverse events. In 11 of these 14 studies, the adverse events were retained in the adjusted model. Odds for serious adverse events were similar for both groups in the unadjusted analyses (n=4,990; OR, 1.06; 95% CI, 0.89–1.26) and adjusted analyses (n=4,718; OR, 1.06; 95% CI, 0.89–1.28). Missing outcome data for CDI ranged from 0% to 25.8%. Our analyses were robust to a sensitivity analysis for missingness.
Moderate quality (ie, certainty) evidence suggests that probiotic prophylaxis may be a useful and safe CDI prevention strategy, particularly among participants taking 2 or more antibiotics and in hospital settings where the risk of CDI is ≥5%.
To quantifying the interdependency within the regulatory environment governing human subject research, including Institutional Review Boards (IRBs), federally mandated Medicare coverage analysis and contract negotiations.
Over 8000 IRB, coverage analysis and contract applications initiated between 2013 and 2016 were analyzed using traditional and machine learning analytics for a quality improvement effort to improve the time required to authorize the start of human research studies.
Staffing ratios, study characteristics such as the number of arms, source of funding and number and type of ancillary reviews significantly influenced the timelines. Using key variables, a predictive algorithm identified outliers for a workflow distinct from the standard process. Improved communication between regulatory units, integration of common functions, and education outreach improved the regulatory approval process.
Understanding and improving the interdependencies between IRB, coverage analysis and contract negotiation offices requires a systems approach and might benefit from predictive analytics.
The Western tradition has always cherished the family as an essential foundation of a just and orderly society, and thus accorded it special legal and religious protection. Christianity embraced this teaching from the start, and many of the basics of Western family law were shaped by the Christian theologies of nature, sacrament, and covenant. This volume introduces readers to the enduring and evolving Christian norms and teachings on betrothals and weddings; marriage and divorce; women's and children's rights; marital property and inheritance; and human sexuality and intimate relationships. The chapters are authoritatively written but accessible to college and graduate students and scholars, as well as clergy and laity. While alert to the hot button issues of sexual liberty today, the contributing authors let the historical figures speak for themselves about what Christianity has and can contribute to the protection and guidance of our most intimate association.