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Veterans are at high risk for suicide; emotion dysregulation may confer additional risk. Dialectical behaviour therapy (DBT) is a well-supported intervention for suicide attempt reduction in individuals with emotion dysregulation, but is complex and multi-component. The skills group component of DBT (DBT-SG) has been associated with reduced suicidal ideation and emotion dysregulation. DBT-SG for Veterans at risk for suicide has not been studied.
This study sought to evaluate the feasibility and acceptability of DBT-SG in Veterans and to gather preliminary evidence for its efficacy in reducing suicidal ideation and emotion dysregulation and increasing coping skills.
Veterans with suicidal ideation and emotion dysregulation (N = 17) enrolled in an uncontrolled pilot study of a 26-week DBT-SG as an adjunct to mental health care-as-usual.
Veterans attended an average 66% of DBT-SG sessions. Both Veterans and their primary mental health providers believed DBT-SG promoted Veterans’ use of coping skills to reduce suicide risk, and they were satisfied with the treatment. Paired sample t-tests comparing baseline scores with later scores indicated suicidal ideation and emotion dysregulation decreased at post-treatment (d = 1.88, 2.75, respectively) and stayed reduced at 3-month follow-up (d = 2.08, 2.59, respectively). Likewise, skillful coping increased at post-treatment (d = 0.85) and was maintained at follow-up (d = 0.91).
An uncontrolled pilot study indicated DBT-SG was feasible, acceptable, and demonstrated potential efficacy in reducing suicidal ideation and emotion dysregulation among Veterans. A randomized controlled study of DBT-SG with Veterans at risk for suicide is warranted.
In the UK, 11.8% of expectant mothers undergo an elective caesarean section (ELCS) representing 92 000 births per annum. It is not known to what extent this procedure has an impact on mental well-being in the longer term.
To determine the prevalence and postpartum progression of anxiety and depression symptoms in women undergoing ELCS in Wales.
Prevalence of depression and anxiety were determined in women at University Hospital Wales (2015–16; n = 308) through completion of the Edinburgh Postnatal Depression Scale (EPDS; ≥13) and State-Trait Anxiety Inventory (STAI; ≥40) questionnaires 1 day prior to ELCS, and three postpartum time points for 1 year. Maternal characteristics were determined from questionnaires and, where possible, confirmed from National Health Service maternity records.
Using these criteria the prevalence of reported depression symptoms was 14.3% (95% CI 10.9–18.3) 1 day prior to ELCS, 8.0% (95% CI 4.2–12.5) within 1 week, 8.7% (95% CI 4.2–13.8) at 10 weeks and 12.4% (95% CI 6.4–18.4) 1 year postpartum. Prevalence of reported anxiety symptoms was 27.3% (95% CI 22.5–32.4), 21.7% (95% CI 15.8–28.0), 25.3% (95% CI 18.5–32.7) and 35.1% (95% CI 26.3–44.2) at these same stages. Prenatal anxiety was not resolved after ELCS more than 1 year after delivery.
Women undergoing ELCS experience prolonged anxiety postpartum that merits focused clinical attention.
Weed-suppressive rice cultivars have the potential to reduce heavy reliance on synthetic herbicides in rice production. However, the economics of using weed-suppressive rice cultivars in conventional rice systems have not been fully evaluated. This study uses simulation and stochastic efficiency with respect to a function to rank weed-suppressive and weed-nonsuppressive rice cultivars under alternative herbicide intensity levels based on their certainty equivalents mapped across increasing levels of absolute risk aversion. The results indicate risk-averse rice producers would prefer to grow weed-suppressive cultivars using less herbicide inputs than what would be used to grow weed-nonsuppressive rice cultivars.
Social support has been shown to be an important factor in improving depression symptom outcomes, yet less is known regarding its impact on antidepressant medication adherence. This study sought to evaluate the role of perceived social support on adherence to new antidepressant medication prescriptions in later-life depression.
Data from two prospective observational studies of participants ≥60 years old, diagnosed with depression, and recently prescribed a new antidepressant (N = 452). Perceived social support was measured using a subscale of the Duke Social Support Index and medication adherence was assessed using a validated self-report measure.
At four-month follow up, 68% of patients reported that they were adherent to antidepressant medication. Examining the overall sample, logistic regression analysis demonstrated no significant relationship between perceived social support and medication adherence. However, when stratifying the sample by social support, race, and gender, adherence significantly differed by race and gender in those with inadequate social support: Among those with low social support, African-American females were significantly less likely to adhere to depression treatment than white females (OR = 4.82, 95% CI = 1.14–20.28, p = 0.032) and white males (OR = 3.50, 95% CI = 1.03–11.92, p = 0.045).
There is a significant difference in antidepressant medication adherence by race and gender in those with inadequate social support. Tailored treatment interventions for low social support should be sensitive to racial and gender differences.
To determine the impact of an environmental disinfection intervention on the incidence of healthcare-associated Clostridium difficile infection (CDI).
A multicenter randomized trial.
In total,16 acute-care hospitals in northeastern Ohio participated in the study.
We conducted a 12-month randomized trial to compare standard cleaning to enhanced cleaning that included monitoring of environmental services (EVS) personnel performance with feedback to EVS and infection control staff. We assessed the thoroughness of cleaning based on fluorescent marker removal from high-touch surfaces and the effectiveness of disinfection based on environmental cultures for C. difficile. A linear mixed model was used to compare CDI rates in the intervention and postintervention periods for control and intervention hospitals. The primary outcome was the incidence of healthcare-associated CDI.
Overall, 7 intervention hospitals and 8 control hospitals completed the study. The intervention resulted in significantly increased fluorescent marker removal in CDI and non-CDI rooms and decreased recovery of C. difficile from high-touch surfaces in CDI rooms. However, no reduction was observed in the incidence of healthcare-associated CDI in the intervention hospitals during the intervention and postintervention periods. Moreover, there was no correlation between the percentage of positive cultures after cleaning of CDI or non-CDI rooms and the incidence of healthcare-associated CDI.
An environmental disinfection intervention improved the thoroughness and effectiveness of cleaning but did not reduce the incidence of healthcare-associated CDI. Thus, interventions that focus only on improving cleaning may not be sufficient to control healthcare-associated CDI.
To define the scope of an outbreak of Legionnaires’ disease (LD), to identify the source, and to stop transmission.
DESIGN AND SETTING
Epidemiologic investigation of an LD outbreak among patients and a visitor exposed to a newly constructed hematology-oncology unit.
An LD case was defined as radiographically confirmed pneumonia in a person with positive urinary antigen testing and/or respiratory culture for Legionella and exposure to the hematology-oncology unit after February 20, 2014. Cases were classified as definitely or probably healthcare-associated based on whether they were exposed to the unit for all or part of the incubation period (2–10 days). We conducted an environmental assessment and collected water samples for culture. Clinical and environmental isolates were compared by monoclonal antibody (MAb) and sequence-based typing.
Over a 12-week period, 10 cases were identified, including 6 definite and 4 probable cases. Environmental sampling revealed Legionella pneumophila serogroup 1 (Lp1) in the potable water at 9 of 10 unit sites (90%), including all patient rooms tested. The 3 clinical isolates were identical to environmental isolates from the unit (MAb2-positive, sequence type ST36). No cases occurred with exposure after the implementation of water restrictions followed by point-of-use filters.
Contamination of the unit’s potable water system with Lp1 strain ST36 was the likely source of this outbreak. Healthcare providers should routinely test patients who develop pneumonia at least 2 days after hospital admission for LD. A single case of LD that is definitely healthcare associated should prompt a full investigation.
N- and p-type filled-skutterudite materials prepared for thermoelectric power generation modules were analyzed by neutron diffraction at the POWGEN beam line of the Spallation Neutron Source (SNS) and X-ray diffraction (XRD). The skutterudite powders were processed by melt spinning, followed by ball milling and annealing. The n-type material consists of Ba–Yb–Co–Sb and the p-type material consists of Di–Fe–Ni–Sb or Di–Fe–Co–Sb (Di = didymium, an alloy of Pr and Nd). Powders for prototype module fabrication from General Motors and Marlow Industries were analyzed in this study. XRD and neutron diffraction studies confirm that both the n- and p-type materials have cubic symmetry. Structural Rietveld refinements determined the lattice parameters and atomic parameters of the framework and filler atoms. The cage filling fraction was found to depend linearly on the lattice parameter, which in turn depends on the average framework atom size. This knowledge may allow the filling fraction of these skutterudite materials to be purposefully adjusted, thereby tuning the thermoelectric properties.
Various transmission routes contribute to spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospitalized patients. Patients with readmissions during which CRKP is again isolated (“CRKP readmission”) potentially contribute to transmission of CRKP.
To evaluate CRKP readmissions in the Consortium on Resistance against Carbapenems in K. pneumoniae (CRaCKLe).
Cohort study from December 24, 2011, through July 1, 2013.
Multicenter consortium of acute care hospitals in the Great Lakes region.
All patients who were discharged alive during the study period were included. Each patient was included only once at the time of the first CRKP-positive culture.
All readmissions within 90 days of discharge from the index hospitalization during which CRKP was again found were analyzed. Risk factors for CRKP readmission were evaluated in multivariable models.
Fifty-six (20%) of 287 patients who were discharged alive had a CRKP readmission. History of malignancy was associated with CRKP readmission (adjusted odds ratio [adjusted OR], 3.00 [95% CI, 1.32–6.65], P<.01). During the index hospitalization, 160 patients (56%) received antibiotic treatment against CRKP; the choice of regimen was associated with CRKP readmission (P=.02). Receipt of tigecycline-based therapy (adjusted OR, 5.13 [95% CI, 1.72–17.44], using aminoglycoside-based therapy as a reference in those treated with anti-CRKP antibiotics) was associated with CRKP readmission.
Hospitalized patients with CRKP—specifically those with a history of malignancy—are at high risk of readmission with recurrent CRKP infection or colonization. Treatment during the index hospitalization with a tigecycline-based regimen increases this risk.
Infect. Control Hosp. Epidemiol. 2016;37(3):281–288
This step-by-step guide to medical technology innovation, now in full color, has been rewritten to reflect recent trends of industry globalization and value-conscious healthcare. Written by a team of medical, engineering, and business experts, the authors provide a comprehensive resource that leads students, researchers, and entrepreneurs through a proven process for the identification, invention, and implementation of new solutions. Case studies on innovative products from around the world, successes and failures, practical advice, and end-of-chapter 'Getting Started' sections encourage readers to learn from real projects and apply important lessons to their own work. A wealth of additional material supports the book, including a collection of nearly one hundred videos created for the second edition, active links to external websites, supplementary appendices, and timely updates on the companion website at ebiodesign.org. Readers can access this material quickly, easily, and at the most relevant point in the text from within the ebook.
Africa is on the rise. The twenty-first century has been called the “African Century” due to the continent's potential for increased economic development in the coming decades. From 2000–2012, economic growth averaged more than 5 percent per year, driven by the recovery of commodity prices, government economic and policy reforms, and restoration of international donor confidence and aid. Africa's collective gross domestic product (GDP) topped US$1.7 trillion in 2012 (making it nearly comparable to Russia or Brazil), and its middle class expanded to more than 34 percent of the continent's 1 billion people.
Poverty is declining, yet Africa still has the highest poverty rate in the world with 47.5 percent of the population living on less than US$1.25 a day. The continent also accounts for 25 percent of the global disease burden. Maternal health, child health, HIV, tuberculosis, and malaria continue to be the continent's greatest health challenges. What may be surprising is that over the next 10 years, Africa will experience the largest increase in deaths from cardiovascular disease, cancer, respiratory disease, and diabetes of any continent in the world. For instance, the World Health Organization estimated that in 2008 the prevalence of hypertension was highest in its Africa region, with nearly half of the population affected, and this figure is on the rise.
Generalities are difficult to apply across this diverse continent. It is a massive, highly fragmented mosaic of more than 50 countries, with an estimated 2,000 languages spoken and thousands of distinct ethnic groups. The continent's diverse population is expected to double by 2050, from 1 billion to more than 2 billion. Africa is endowed with more than 30 million square miles of varied geography and could fit China, India, the United States, and most of Europe within its physical boundaries. Across this great expanse, the continent's health-care infrastructure is evolving. African governments are working to expand healthcare delivery systems through public and private investment, but in the meantime, millions of people must travel vast distances to receive basic medical care.
What do we mean by “value” and why is it so important?
The escalation of healthcare costs is one of the major economic and political issues of our time. The problem is most apparent in the United States, where healthcare as a share of the economy has more than doubled over the past 35 years. Spending on health accounted for 7.2 percent of the nation's gross domestic product (GDP) in 1970, expanded to 16 percent in 2005, and is projected to be as high as 20 percent of GDP by 2015.
Simply put, the US economy cannot sustain this spending trajectory, which has outpaced GDP growth for years (see Figure V1). The problem is not just straining the federal budget: state and local governments have been forced to reduce support for education, infrastructure, and other critical expenditures as they struggle to fund Medicaid and other health programs. In the private sector, the cost of employment-based health insurance is one of the main reasons workers have seen their wages stagnate.
Despite the fact that the US spends two-and-a-half times more per capita on health than most developed countries, it does not necessarily provide the best care to its citizens. In 2000, when the World Health Organization ranked the health systems of its 191 member states for the first time ever, the US found itself in 37th position. In a more recent study that compared the US to Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom on measures of quality, efficiency, access to care, equity, and the ability of citizens to lead long, healthy lives, America occupied last place. As the report pointed out, “While there is room for improvement in every country, the US stands out for not getting good value for its healthcare dollars.”
Against this backdrop, economists, researchers, and policy makers alike have pointed to medical technology as a dominant factor driving increased health expenditures in the US.
China is perhaps the most impressive economic development story in modern history. Sustaining annual growth rates upwards of 9 percent for more than two decades, the country's gross domestic product (GDP) reached US$8 trillion in 2012 (second only to the United States at US$16 trillion). This remarkable expansion has lifted hundreds of millions of Chinese out of poverty and created a new middle class that is larger than the entire US population.
With more than 1.35 billion people, China has the largest citizenry in the world. In 2011, the country's urban population surpassed its rural population for the first time, with close to 700 million people living in China's cities. Population growth in China has decreased steadily over the last 20 years due to the controversial one-child policy (from approximately 1.2 percent to less than half of one percent) and is expected to continue to decline. The country's median age is just 35 years, compared to nearly 40 years in more developed countries. However, as a whole, the population is aging rapidly; senior citizens will account for as much as 35 percent of the Chinese people by 2053.
One of the most important challenges facing China in the twenty-first century is how to allocate healthcare resources for its massive population. Despite progress in the country's economic transformation, China significantly lags the developed world in its ability to provide even basic health services to the vast majority of its people. The Chinese government spent approximately 5 percent of GDP on healthcare in 2011, compared to roughly 18 percent spent in the US and 9 percent on average in the OECD countries. Per capita spending on medical technologies is just US$ in China versus US$399 in the US.
China's centrally planned economy provides health insurance coverage to approximately 90 percent of the population under three primary programs (an employer-based system, one for urban residents, and another covering the rural population). These insurance schemes are largely inadequate to cover basic care but rather focus on protecting patients from catastrophic health events. As a result, the Chinese typically pay for basic health services out-of-pocket, causing many individuals to delay diagnosis and treatment until they are critically ill.