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Previous research has shown an association between subjective wellbeing and incident diabetes. Less is known about the role of wellbeing for subclinical disease trajectories as captured via glycated hemoglobin (HbA1c). We aimed to explore the association between subjective wellbeing and future HbA1c levels, and the role of sociodemographic, behavioral and clinical factors in this association.
We used data from the English Longitudinal Study of Ageing for this study (N = 2161). Subjective wellbeing (CASP-19) was measured at wave 2 and HbA1c was measured 8 years later at wave 6. Participants were free from diabetes at baseline. We conducted a series of analyses to examine the extent to which the association was accounted for by a range of sociodemographic, behavioral and clinical factors in linear regression models.
Models showed that subjective wellbeing (CASP-19 total score) was inversely associated with HbA1c 8 years later after controlling for depressive symptoms, age, sex, and baseline HbA1c (B = −0.035, 95% CI −0.060 to –0.011, p = 0.005). Inclusion of sociodemographic variables and behavioral factors in models accounted for a large proportion (17.0% and 24.5%, respectively) of the relationship between wellbeing and later HbA1c; clinical risk factors explained a smaller proportion of the relationship (3.4%).
Poorer subjective wellbeing is associated with greater HbA1c over 8 years of follow-up and this relationship can in part be explained by sociodemographic, behavioral and clinical factors among older adults.
This study used a single case experimental design to investigate the use of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) among a sample of individuals with depression and anxiety who also presented with borderline personality disorder (BPD). Eight women received individual treatment with the UP over the course of 14–16 treatment sessions, and were assessed for anxiety and depression severity on a weekly basis over a 2–6 week baseline period and throughout treatment. Three of the eight participants demonstrated reliable pre- to post-treatment clinical improvements on depression and stress scales, and one participant demonstrated a reliable reduction on an anxiety scale. Two participants demonstrated a reliable improvement in overall anxiety. The results indicate that the UP applied to individuals diagnosed with primary BPD may lead to clinical improvement in depression, stress and anxiety for some individuals. However, the majority of individuals with BPD in our sample did not show strong improvement, and this suggests the need for additional sessions of UP or an intervention that focuses on the symptoms of BPD specifically for some women.
Key learning aims
(1)To describe the applicability of the Unified Protocol in the treatment of individuals with borderline personality and co-occurring anxiety or depression.
(2)To understand the value of utilizing a transdiagnostic approach as an alternative to diagnosis-specific approaches to treatment.
(3)To identify the four core modules of the Unified Protocol and describe the general format for individual treatment.
This chapter takes the case study of one couple in wartime to examine the intersections between private life and ideas about the Volksgemeinschaft. It argues that the couple’s performance of the rituals of intimacy, the cultivation by each of them of a particular individual persona, and their exchange of letters, photographs and goods were all embedded within the war’s larger material, emotional and political economies. In the process, the couple sought to aestheticise their experiences and to capture through photographs happy memories of moments during wartime for the post-war future they envisaged.
Ragged schools provided a free education to impoverished children in the mid-nineteenth century. Inspired by religious fervour and presided over by Lord Shaftesbury, that figurehead of evangelical Anglicans, the schools taught the most destitute to read and write, as well as about the God who loved them. By 1870 the London schools alone recorded an average attendance of 32,231 children. The missionary aspect of the classroom shaped the recommended character of the teacher. Teachers were to be benevolent, while corporal punishment was discouraged. Teaching advice demonstrates that the classroom could prove difficult terrain and suggests that the respect of scholars was hard-won and highly valued. With children attending freely, it was necessary that they desired to return. The children were consumers whom teachers sought to please; their responses determined the success or failure of lessons. This article responds to recent scholarship that interprets the teachers as imposed and powerful agents. By focusing on advice given to teachers, it highlights both how the children were perceived and the impact evangelical theology had upon ideas regarding the teacher's character. Largely overlooked by church historians, the ragged school movement embodies the profound impact of evangelical Christians on popular education in the nineteenth century.
OBJECTIVES/SPECIFIC AIMS: 1.Identify barriers to pursuing research for physician trainees 2.Develop a sustainable pipeline of physician-scientists at Duke 3.Coordinate physician-scientist development programs across the School of Medicine under one central Office 4.Provide infrastructure and resources for all physician-scientists 5.Increase the number of MDs and MD/PhDs who pursue, succeed, and are retained in research METHODS/STUDY POPULATION: To establish a baseline understanding of the needs and concerns of physician-scientist trainees at Duke, we conducted focus groups using a standardized interview guide and thematic analysis. Findings from these focus groups were used to develop a framework for support, leading to the creation of the Office of Physician-Scientist Development (OPSD) housed centrally within the Duke School of Medicine. The OPSD integrates programs and resources for multiple populations including medical students, residents, fellows, junior faculty, and faculty mentors. Pipeline programs will also be developed to enhance research engagement in targeted student populations prior to medical school. RESULTS/ANTICIPATED RESULTS: A total of 45 students and faculty participated in the focus groups and structured interviews (1st year medical student, n=11; 4th year medical students, n=11; residents/fellows, n=13; junior faculty, n=11). While participants raised a number of specific issues, one key message emerged: non-PhD MDs in basic research felt they lacked opportunities for directed training. Moreover, they felt the need to teach themselves many critical skills through trial and error. This has led to perceptions that they cannot compete effectively with PhDs and MD-PhD scientists for research funding and positions. Consensus recommendations included: better guidance in choosing mentors, labs, and projects; central resource for information relevant to physician scientists; training specifically tailored to physician scientists conducting laboratory-based research; improved infrastructure and well-defined training pathways; and assistance with grant preparation. To-date, over 90 students, residents, and fellows have been identified who identify as laboratory-based physician scientists. Additional efforts are underway to identify and characterize the broader range of physician-scientist students and trainees at Duke. DISCUSSION/SIGNIFICANCE OF IMPACT: Our planning study revealed specific steps forward toward developing a robust community of physician-scientists at Duke. As a first step, the Dean of the School of Medicine has appointed an Associate Dean of Physician-Scientist Development to oversee a new Office of Physician-Scientist Development (OPSD) being launched in December of 2018. The OPSD will offer four primary programs. 1) A concierge mentoring program will assist new trainees in identifying research areas of interest and mentors. Trainees will receive periodic contact to provide additional support as needed and promote success. 2) A physician-scientist training program is being created to provide training specific to laboratory research skills as well as career and professional development training to complement existing clinical and translational research programs. 3) Integrated training pathways will provide additional mentored research training for those pursuing research careers. Pathways will capitalize on existing resources from R38 programs, while pursuing additional R38 and R25 support. 4) An MD-Scientist funding program has been developed to provide additional research funding and protected time for students pursuing a second research year. Through the support and programming offered by the OPSD, we anticipate decreased perceptions of barriers to pursuing a physician-scientist career and increased satisfaction with training opportunities. Over time, we expect such support to increase the number of MD students pursuing research as a career and the number of residents, fellows, and MD junior faculty remaining in research careers.
In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.
To review the evidence on educational interventions on hospital care for older people with cognitive impairment.
A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool.
Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention.
The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.
Decision-makers are increasingly recognizing the usefulness of qualitative research to inform patient-centered policy decisions, and are accordingly increasingly demanding qualitative evidence as part of health technology assessment (HTA). In the context of tight HTA timelines, a new form of evidence synthesis has emerged—rapid qualitative reviews. The need for rapidity requires either an increase in resources or, more commonly, a compromise in rigor, yet guidance on appropriate compromises for qualitative reviews is lacking.
In order to inform de novo guidance, we conducted a systematic scoping review to identify existing guidance and published examples of rapid qualitative reviews. We searched Medline and CINAHL using medical subject headings and keywords related to “rapid reviews” and “qualitative” research, and screened the 1,771 resultant citations independently in duplicate. Additionally, we searched the grey literature and solicited examples from our contacts and other evidence-synthesis organizations. We summarized included guidance and reviews using the Search, AppraisaL, Synthesis, Analysis (SALSA) framework to identify abbreviations in the review process.
We found no guidance documents specific to rapid qualitative reviews. We found one published peer-reviewed rapid qualitative review, and several more (>10; grey literature search in process) through our organizational contacts. While methods to abbreviate the process are poorly reported, an abbreviated literature search (years and databases searched) and the use of a single reviewer appear common.
A number of agencies are producing rapid qualitative reviews, however our review identifies the urgent need to develop and explore methods for the synthesis of qualitative research that balance rapidity and rigor.
Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples.
Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.
Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.
Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms of C. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.
Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.
Understanding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis (FEP) is an important area of practice.
A systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment with total discontinuation or medication discontinuation strategies following remission in FEP.
Seven studies were included. Relapse rates were higher in the discontinuation group (53%; 95% CIs: 39%, 68%; N = 290) compared with maintenance treatment group (19%; 95% CIs: 0.05%, 37%; N = 230). In subgroup analyses, risk difference of relapse was lower in studies with a longer follow-up period, a targeted discontinuation strategy, a higher relapse threshold, a larger sample size, and samples with patients excluded for drug or alcohol dependency. Insufficient studies included psychosocial functioning outcomes for a meta-analysis.
There is a higher risk of relapse for those who undergo total or targeted discontinuation strategies compared with maintenance antipsychotics in FEP samples. The effect size is moderate and the risk difference is lower in trials of targeted discontinuation strategies.
Declaration of interest
A.T. has received honoraria and support from Janssen-Cilag and Otsuka Pharmaceuticals for meetings and has been has been an investigator on unrestricted investigator-initiated trials funded by AstraZeneca and Janssen-Cilag. He has also previously held a Pfizer Neurosciences Research Grant. S.M. has received sponsorship from Otsuka and Lundbeck to attend an academic congress and owns shares in GlaxoSmithKline and AstraZeneca. J.H. has attended meetings supported by Sunovion Pharmaceuticals.
Underwater photo-elicitation is a novel experiential marine education technique that combines direct experience in the marine environment with the use of digital underwater cameras. A program called Show Us Your Ocean! (SUYO!) was created, utilising a mixed methodology (qualitative and quantitative methods) to test the efficacy of this technique. Participants (adults and high school students) snorkelled, explored the ocean, and captured images both in and out of the water. Underwater photo-elicitation was proven effective at increasing awareness, eliciting emotional reactions, and fostering a sense of connection to the ocean. However, it was not necessarily effective for raising awareness of environmental issues nor for motivating pro-environmental behaviour. Interestingly, while some attitudes about and behaviours toward the ocean did become more environmentally sensitive, others appeared to shift unexpectedly away from environmental concern. This result was perhaps due to the lack in the program of an ecological knowledge-based component. Participants enjoying the beauty of the ocean did not realise the threats facing it or what to do about these. If the goal is to achieve significant attitude change and cultivate pro-environmental behaviour, this new approach should be supplemented with critical thinking/action competence and ecological/ocean literacy.
Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.
BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The Ethics of Real-Time EMS Direction: Suggested Curricular Content. Prehosp Disaster Med. 2018;33(2):201–212.
Excavations at the Latin city of Gabii in 2012–15 conducted by the Gabii Project have uncovered a monumental building complex, hitherto known only very partially from previous excavations in the 1990s. Organized on a series of three artificial terraces that regularized the slope of the volcanic terrain, it measures some 60 m by 35 m, occupying an entire city-block. It is prominently situated at one of the most central locations within the city, on the main urban thoroughfare at the important intersection of the roads from Tibur, Praeneste and Rome. Stratigraphic evidence and construction techniques date the original phase of the building to the mid-third century BC. This report focuses on a contextualization and description of this first, mid-Republican phase and offers a preliminary interpretation of this complex as a public building, with spaces designed for a variety of functions: bathing, public feasting, and ritual activity. If this is correct, it now represents one of the very few examples of public buildings other than temples and fortifications known from the mid-Republican period, and sheds important light on the development of Roman architecture and of the Latin cities in a crucial and obscure period.
The inland advance of supraglacial lakes (SGLs) towards the interior regions of the Greenland ice sheet (GrIS) may have implications for the water volumes reaching the subglacial drainage system, and could consequently affect long-term ice-sheet dynamics. Here, we investigate changes to the areas, volumes and elevation distributions of over 8000 manually delineated SGLs using 44 Landsat images of a 6200 km2 sector of north-west Greenland over three decades (1985–2016). Our results show that SGLs have advanced to higher maximum (+418 m) and mean (+299 m) elevations, and that there has been a near-doubling of total regional SGL areas and volumes over the study period, accelerating after 2000. These changes were primarily caused by an increased SGL area and volume at high (≥1200 m a.s.l.) elevations, where SGL coverage increased by over 2750% during the study period. Many of the observed changes, particularly the post-2000 accelerations, were driven by changes to regional surface-temperature anomalies. This study demonstrates the past and accelerating response of the GrIS's hydrological system due to climatic warming, indicating an urgent need to understand whether the increasingly inland SGLs will be capable of hydrofracture in the future, thus determining their potential implications for ice-sheet dynamics.
OBJECTIVES/SPECIFIC AIMS: The purpose of this study is to use the baboon as a novel animal model for breath research and to identify and characterize baboon breath metabolites that reflect cardiometabolic function to inform us in the development of a noninvasive, cost-effective, and repeatable point-of-care diagnostic breath test. METHODS/STUDY POPULATION: Blood and urine was collected from control and IUGR at the approximate age of 3.5 years. Both groups were then placed on a high fat, high sugar, high salt diet for 7 weeks, after which blood, urine, and breath were collected. The breath samples were then subjected to comprehensive, 2-dimensional gas chromatography coupled with time-of-flight mass spectrometry. Using ChromaTOF software, breath VOCs were identified with at least an 80% spectral match against the National Institute of Standards and Technology (NIST) chemical reference library. The raw data were then statistically analyzed using MetaboAnalyst. We then interrogated multiple online databases to characterize and identify the role of VOCs that were present in both control and IUGR groups. RESULTS/ANTICIPATED RESULTS: Preliminary analyses of the breath VOCs indicate differences in expression between sexes and in control Versus IUGR groups. These results indicate unique “breath signatures.” Further analysis of the breath VOCs reveals the presence of metabolites that are involved in β-oxidation and oxidative stress pathways. DISCUSSION/SIGNIFICANCE OF IMPACT: This breath study, a first of its kind, will develop the baboon as a superior animal model for breath biomarker research. Our observed unique “breath signatures” indicate changes in lipid metabolism and oxidative stress pathways, which we hypothesize are the early metabolic changes at the cellular level that are not yet reflected in clinical lab measures. Future directions include analyzing breath VOCs that did not meet 80% spectral match, validation using SPME technology and commercial standards, and initiating a human pilot study in clinically obese, at-risk children in collaboration with physicians at the Children’s Hospital of San Antonio to develop a noninvasive, cost-effective, rapid, and repeatable point-of-care diagnostic breath test.
Intensive archaeobotanical investigations at Çatalhöyük have created a unique opportunity to explore change and continuity in plant use through the ca 1,500-year Neolithic to early Chalcolithic sequence of an early established farming community. The combination of crops and herd animals in the earliest (Aceramic) part of the sequence reflects a distinct and diverse central Anatolian ‘package’ at the end of the eighth millennium cal. BC. Here we report evidence for near continual adjustment of cropping regimes through time at Çatalhöyük, featuring recruitment of minor crops or crop contaminants to become major staples. We use panarchy theory to frame an understanding of Çatalhöyük's long-term sustainability, arguing that its resilience was a function of three key factors: its diverse initial crop spectrum, which acted as an archive for later innovations; its modular social structure, enabling small-scale experimentation and innovation in cropping at the household level; and its agglomerated social morphology, allowing successful developments to be scaled up across the wider community. This case study in long-term sustainability through flexible, changeable cropping strategies is significant not only for understanding so-called boom and bust cycles elsewhere but also for informing wider agro-ecological understanding of sustainable development in central Anatolia and beyond.
Short-term glacier velocity variations typically occur when a water input is accommodated by an increase in the subglacial water pressure. Although these velocity variations have been well documented on many glaciers, few studies have considered them on glaciers where heavy rain and glacier melt occur year-round. This study investigates the relationship between water inputs and glacier velocity on Franz Josef Glacier, New Zealand. We installed six GNSS stations across the lower glacier during austral summer 2010/11 and one station during summer 2012/13. Glacier velocity remained elevated at all stations for ∼7 days following large rain events. During diurnal melt events, we find velocity variations in the early afternoon (12:00–16:00) at 600 m a.s.l. and in the late evening (20:00–01:00) at 400 m a.s.l. We hypothesize that the late-evening velocity variations occurred as an upstream region of high subglacial water pressures and accelerated ice motion propagated downstream. This mechanism may also explain the increased longitudinal compression and transverse extension across the lower glacier during speed-up events. Our results indicate that the subglacial drainage system likely decreases in efficiency upstream and that the water input variability can still cause short-term velocity variations despite the large year-round water inputs.
Objectives: Coverage decisions are decisions by third party payers about whether and how much to pay for technologies or services, and under what conditions. Given their complexity, a systematic and transparent approach is needed. The DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) Project, a GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group initiative funded by the European Union, has developed GRADE Evidence to Decision (EtD) framework for different types of decisions, including coverage ones.
Methods: We used an iterative approach, including brainstorming to generate ideas, consultation with stakeholders, user testing, and pilot testing of the framework.
Results: The general structure of the EtD includes formulation of the question, an assessment using twelve criteria, and conclusions. Criteria that are relevant for coverage decisions are similar to those for clinical recommendations from a population perspective. Important differences between the two include the decision-making processes, accountability, and the nature of the judgments that need to be made for some criteria. Although cost-effectiveness is a key consideration when making coverage decisions, it may not be the determining factor. Strength of recommendation is not directly linked to the type of coverage decisions, but when there are important uncertainties, it may be possible to cover an intervention for a subgroup, in the context of research, with price negotiation, or with restrictions.
Conclusions: The EtD provides a systematic and transparent approach for making coverage decisions. It helps ensure consideration of key criteria that determine whether a technology or service should be covered and that judgments are informed by the best available evidence.
Approximately half of the variation in wellbeing measures overlaps with variation in personality traits. Studies of non-human primate pedigrees and human twins suggest that this is due to common genetic influences. We tested whether personality polygenic scores for the NEO Five-Factor Inventory (NEO-FFI) domains and for item response theory (IRT) derived extraversion and neuroticism scores predict variance in wellbeing measures. Polygenic scores were based on published genome-wide association (GWA) results in over 17,000 individuals for the NEO-FFI and in over 63,000 for the IRT extraversion and neuroticism traits. The NEO-FFI polygenic scores were used to predict life satisfaction in 7 cohorts, positive affect in 12 cohorts, and general wellbeing in 1 cohort (maximal N = 46,508). Meta-analysis of these results showed no significant association between NEO-FFI personality polygenic scores and the wellbeing measures. IRT extraversion and neuroticism polygenic scores were used to predict life satisfaction and positive affect in almost 37,000 individuals from UK Biobank. Significant positive associations (effect sizes <0.05%) were observed between the extraversion polygenic score and wellbeing measures, and a negative association was observed between the polygenic neuroticism score and life satisfaction. Furthermore, using GWA data, genetic correlations of -0.49 and -0.55 were estimated between neuroticism with life satisfaction and positive affect, respectively. The moderate genetic correlation between neuroticism and wellbeing is in line with twin research showing that genetic influences on wellbeing are also shared with other independent personality domains.