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There is an urgent need to provide evidence-based well-being and mental health support for front-line clinical staff managing the COVID-19 pandemic who are at risk of moral injury and mental illness. We describe the evidence base for a tiered model of care, and practical steps on its implementation.
Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample.
This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans.
A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated.
The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD.
The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.
An improved understanding of diagnostic and treatment practices for patients with rare primary mitochondrial disorders can support benchmarking against guidelines and establish priorities for evaluative research. We aimed to describe physician care for patients with mitochondrial diseases in Canada, including variation in care.
We conducted a cross-sectional survey of Canadian physicians involved in the diagnosis and/or ongoing care of patients with mitochondrial diseases. We used snowball sampling to identify potentially eligible participants, who were contacted by mail up to five times and invited to complete a questionnaire by mail or internet. The questionnaire addressed: personal experience in providing care for mitochondrial disorders; diagnostic and treatment practices; challenges in accessing tests or treatments; and views regarding research priorities.
We received 58 survey responses (52% response rate). Most respondents (83%) reported spending 20% or less of their clinical practice time caring for patients with mitochondrial disorders. We identified important variation in diagnostic care, although assessments frequently reported as diagnostically helpful (e.g., brain magnetic resonance imaging, MRI/MR spectroscopy) were also recommended in published guidelines. Approximately half (49%) of participants would recommend “mitochondrial cocktails” for all or most patients, but we identified variation in responses regarding specific vitamins and cofactors. A majority of physicians recommended studies on the development of effective therapies as the top research priority.
While Canadian physicians’ views about diagnostic care and disease management are aligned with published recommendations, important variations in care reflect persistent areas of uncertainty and a need for empirical evidence to support and update standard protocols.
OBJECTIVES/SPECIFIC AIMS: Immigrants to North America receive more interventions at end of life.The reasons for this are not entirely clear but may potentially be due to knowledge gaps. The primary objective of this study was to measure and describe levels of perceived knowledge about palliative care among immigrants to the US compared to those born in the US. Our secondary objective was to identify trusted sources for seeking information about palliative care among immigrants and compare these trusted sources with those born in the US. We hypothesized that immigrants would have less knowledge of palliative care than those born in US and would trust different sources for information about palliative care. METHODS/STUDY POPULATION: We analyzed data from the nationally representative 2018 Health Information National Trends Survey (HINTS 5, cycle 2). Questionnaires were administered via mail between January and May 2018 to a population-based sample of adults. The primary outcome of interest was assessed using the item “How would you describe your level of knowledge about palliative care?” The secondary outcome of interest was determined using the item “Imagine you had a strong need to get information about palliative care, which of the following would you most trust as a source of information about palliative care?” All analyses were complete case analyses and conducted with survey commands using SAS 9.3 (SAS Institute Inc, Cary, NC, USA). Descriptive statistics were calculated, and bivariate analyses run between the outcomes of interest and sociodemographic characteristics (age, sex, education, race/ethnicity, nativity, English language proficiency). Multivariable logistic regressions were conducted to assess the role of nativity, controlling for statistically significant and relevant sociodemographic variables. Jackknife weighting was used to generate population-level estimates. RESULTS/ANTICIPATED RESULTS: The response rate was 33% (n=3384) and included 2846 (85.3% weighted) born in the US and 492 (14.7% weighted) not born in the USA. About 70% of those born in the US and 77% of immigrants (weighted) responded that they had “never heard of palliative care.” Trusted sources of palliative care were very similar between the groups (all p > 0.05). Both groups’ preferred trusted source of palliative care knowledge was “health care provider,” with over 80% of respondents in each group selecting this option. Printed materials and social media were the least popular trusted sources among both groups. After adjusting for relevant sociodemographic characteristics, we found no association between poor knowledge of palliative care and nativity (p=0.22). Female respondents had 2.5-fold increased odds of reporting low levels of perceived knowledge of palliative care (OR = 2.58, 95% CI = 1.76-3.78; p<0.001). Education was an important predictor of perceived knowledge of palliative care; as education level increased, so did perceived knowledge of palliative care (p < 0.001). DISCUSSION/SIGNIFICANCE OF IMPACT: Perceived knowledge of palliative care is poor generally, regardless of birthplace. Trusted sources for palliative care are similar between immigrants and those born in the US. Education is important and is a strong predictor of perceived knowledge of palliative care. Women perceive they have lower levels of knowledge of PC than men. Differences in end of life care between immigrants and non-immigrants cannot be explained by knowledge differences. Further research is needed to examine the potential factors including suboptimal communication between providers and immigrant patients to understand why these differences are noted. Future strategies for improving knowledge of palliative care should target health care providers as the key trusted source of information to help address deficits noted in this study.
Data from the in-school sample of the PROSPER preventive intervention dissemination trial were used to investigate associations between alcohol dehydrogenase genes and alcohol use across adolescence, and whether substance misuse interventions in the 6th and 7th grades (targeting parenting, family functioning, social norms, youth decision making, and peer group affiliations) modified associations between these genes and adolescent use. Primary analyses were run on a sample of 1,885 individuals and included three steps. First, we estimated unconditional growth curve models with separate slopes for alcohol use from 6th to 9th grade and from 9th to 12th grade, as well as the intercept at Grade 9. Second, we used intervention condition and three alcohol dehydrogenase genes, 1B (ADH1B), 1C (ADH1C), and 4 (ADH4) to predict variance in slopes and intercept. Third, we examined whether genetic influences on model slopes and intercepts were moderated by intervention condition. The results indicated that the increase in alcohol use was greater in early adolescence than in middle adolescence; two of the genes, ADH1B and ADH1C, significantly predicted early adolescent slope and Grade 9 intercept, and associations between ADH1C and both early adolescent slope and intercept were significantly different across control and intervention conditions.
The prospect of improving “noncognitive” skills through intervention increases the need to understand how to represent them in evaluations. Economic assessment of such efforts rarely incorporates these factors, especially when a benefit-cost approach is employed. Programs targeting such skills are more likely to be assessed through approaches that do not monetize noncognitive ability (e.g., using cost-effectiveness analysis). This could lead to ineffective policy formulations in situations where policy is swayed toward programs that can show monetized effects. Benefit-cost analyses (BCAs) that are employed for programs that target noncognitive competencies currently may underestimate the true economic impact if such skills are left out of the equation. The limitations in valuing these skills impede thorough economic assessment for important and effective programs that target noncognitive competencies. This is especially the case for programs for younger children where readily monetized outcomes are few. The targeted outcomes in programs for children are often noncognitive skills, skills that are perceived as vital to healthy human development and valued by parents, teachers, and educators.
In this paper, we review the state of valuation of key noncognitive skills that are often targeted in social policy intervention directed toward children in youth. We examine the state of valuation of noncognitive skills through a summary of the frameworks in research for characterizing noncognitive ability and by considering the measurement approaches for noncognitive skills in terms of origin (interpersonal versus intrapersonal) and measurement type (observed versus assessed). We review examples of recent BCAs that have employed shadow prices for certain noncognitive skills. Finally, we consider what research is necessary to facilitate valuation in BCA in the future. Shadow price methodology should be carried out in a rigorous manner that recognizes uncertainty in cost projections. Improved methodologies in this area will increase the potential for more comprehensive BCA in evaluations of programs for children and youth.
Data drawn from the in-home subsample of the PROSPER intervention dissemination trial were used to investigate the moderation of intervention effects on underage alcohol use by maternal involvement and candidate genes. The primary gene examined was dopamine receptor D4 (DRD4). Variation in this gene and maternal involvement were hypothesized to moderate the influence of intervention status on alcohol use. The PROSPER data used were drawn from 28 communities randomly assigned to intervention or comparison conditions. Participating youth were assessed in five in-home interviews from sixth to ninth grades. A main effect of sixth-grade pretest maternal involvement on ninth-grade alcohol use was found. Neither intervention status nor DRD4 variation was unconditionally linked to ninth-grade drinking. However, moderation analyses revealed a significant three-way interaction among DRD4 status, maternal involvement, and intervention condition. Follow-up analyses revealed that prevention reduced drinking risk, but only for youth with at least one DRD4 seven-repeat allele who reported average or greater pretest levels of maternal involvement. To determine if this conditional pattern was limited to the DRD4 gene, we repeated analyses using the serotonin transporter linked polymorphic region site near the serotonin transporter gene. The results for this supplemental analysis revealed a significant three-way interaction similar but not identical to that found for DRD4.
Most studies of the mental health of UK armed forces focus on
retrospective accounts of deployment and few sample personnel while they
This study reports the results of a survey of deployed personnel,
examining the perceived impact of events at home and military support for
the family on current mental health during the deployment.
Surveys were conducted with 2042 British forces personnel serving in Iraq
and Afghanistan. Prevalence of common mental disorders was assessed with
the 12-item General Health Questionnaire (GHQ-12) and post-traumatic
stress disorder (PTSD) was assessed with the PTSD Checklist – Civilian
The prevalence of common mental disorders was 17.8% and of probable PTSD
was 2.8%. Perceived home difficulties significantly influenced the mental
health of deployed personnel; the greater the perception of negative
events in the home environment, the greater the reporting of adverse
mental health effects. This finding was independent of combat exposure
and was only partially mitigated by being well led and reporting
subjectively good unit cohesion; however, the effect of the totality of
home-front events was not improved by the latter. Poor perceived military
support for the family had a detrimental impact on deployment mental
The armed forces offer many support services to the partners and families
of deployed personnel and ensuring that the efforts being made on their
behalf are well communicated might improve the mental health of deployed
This chapter explores the potential of implementation science to support the development of school psychology. Implementation science perspectives and evidence base provide essential information for effective school psychology service delivery. In Scotland in particular, systems and frameworks exist in school psychology that provide a substrate for the effective incorporation of evidence-based implementations. Over the last forty years, school psychology practitioners have anticipated much of the evidence now emerging from implementation science. They have highlighted contextual barriers to change experienced in schools but arguably have lacked sufficient scientific influence and the large-scale evidential basis required to create scientific impact. Diversity in origins and scope is clearly influential in the context of the development of the role of educational psychology day to day. For school psychology, the development of realist epistemology has proved central to understanding, defining, focusing and measuring the processes which govern change in real-world contexts.
Early onset aggression precipitates a cascade of risk factors, increasing the probability of a range of externalizing and internalizing psychopathological outcomes. Unfortunately, decades of research on the etiological contributions to the manifestation of aggression have failed to yield identification of any risk factors determined to be either necessary or sufficient, likely attributable to etiological heterogeneity within the construct of aggression. Differential pathways of etiological risk are not easily discerned at the behavioral or self-report level, particularly in young children, requiring multilevel analysis of risk pathways. This study focuses on three domains of risk to examine the heterogeneity in 207 urban kindergarten children with high levels of aggression: cognitive processing, socioemotional competence and emotion processing, and family context. The results indicate that 90% of children in the high aggression group could be characterized as either low in verbal ability or high in physiological arousal (resting skin conductance). Children characterized as low verbal, high arousal, or both differed in social and emotional competence, physiological reactivity to emotion, and aspects of family-based contextual risk. The implications of this etiologic heterogeneity of aggression are discussed in terms of assessment and treatment.
Most research on the mental health of UK armed forces personnel has been conducted either before or after deployment; there is scant evidence concerning personnel while they are on deployment.
To assess the mental health of UK armed forces personnel deployed in Iraq and identify gaps in the provision of support on operations.
Personnel completed a questionnaire about their deployment experiences and health status. Primary outcomes were psychological distress (General Health Questionnaire–12, GHQ–12), symptoms of post-traumatic stress disorder (PTSD) and self-rating of overall health.
Of 611 participants, 20.5% scored above the cut-off on the GHQ–12 and 3.4% scored as having probable PTSD. Higher risk of psychological distress was associated with younger age, female gender, weaker unit cohesion, poorer perceived leadership and non-receipt of a pre-deployment stress brief. Perceived threat to life, poorer perceived leadership and non-receipt of a stress brief were risk factors for symptoms of PTSD. Better self-rated overall health was associated with being a commissioned officer, stronger unit cohesion and having taken a period of rest and recuperation. Personnel who reported sick for any reason during deployment were more likely to report psychological symptoms. Around 11% reported currently being interested in receiving help for a psychological problem.
In an established operational theatre the prevalence of common psychopathology was similar to rates found in non-deployed military samples. However, there remains scope for further improving in-theatre support mechanisms, raising awareness of the link between reporting sick and mental health and ensuring implementation of current policy to deliver pre-deployment stress briefs.
To perform surgical closure of a clinically significant arterial duct on children in a third world country.
An arterial duct is one of the most common congenital cardiac defects. Large arterial ducts can cause significant pulmonary overcirculation, causing symptoms of congestive cardiac failure, ultimately resulting in premature death. Closure of an arterial duct is usually curative, allowing for a normal quality of life and expectancy. In western countries, arterial duct closure in children is usually performed by deployment of a device through a catheter-based approach, replacing previous surgical approaches. In third world countries, there is limited access to the necessary resources for performing catheter-based closure of an arterial duct. Consequently, children with an arterial duct in a third world country may only receive palliative care, can be markedly symptomatic, and often do not survive to adulthood.
We assembled a team of 11 healthcare workers with extensive experience in the medical and surgical management of children with congenital cardiac disease. In all, 21 patients with a history of an arterial duct were screened by performing a comprehensive history, physical, and echocardiogram at the Angkor Hospital for Children in Siem Reap, Cambodia.
A total of 18 children (eight male and ten female), ranging in age from 10 months to 14 years, were deemed suitable to undergo surgery. All patients were symptomatic, and the arterial ducts ranged in size from 4 to 15 millimetres. Surgical closure was performed using two clips, and in four cases with the largest arterial duct, sutures were also placed. All patients had successful closure without any significant complications, and were able to be discharged home within 2 days of surgery. Of note, four children with arterial ducts died in the 5 months before our arrival.
Surgical closure of an arterial duct can be performed safely and effectively by an experienced paediatric cardiothoracic surgical team on children in a third world country. We hope that our experience will inspire others to perform similar missions throughout the world.
This study identified profiles of 13 risk factors across child, family, school, and neighborhood domains in a diverse sample of children in kindergarten from four US locations (n = 750; 45% minority). It then examined the relation of those early risk profiles to externalizing problems, school failure, and low academic achievement in Grade 5. A person-centered approach, latent class analysis, revealed four unique risk profiles, which varied considerably across urban African American, urban White, and rural White children. Profiles characterized by several risks that cut across multiple domains conferred the highest risk for negative outcomes. Compared to a variable-centered approach, such as a cumulative risk index, these findings provide a more nuanced understanding of the early precursors to negative outcomes. For example, results suggested that urban children in single-parent homes that have few other risk factors (i.e., show at least average parenting warmth and consistency and report relatively low stress and high social support) are at quite low risk for externalizing problems, but at relatively high risk for poor grades and low academic achievement. These findings provide important information for refining and targeting preventive interventions to groups of children who share particular constellations of risk factors.
‘Gulf War syndrome’ was a phrase coined after the 1991 Gulf War. This article looks at the variety of hypotheses that have been put forward about the origins of the concept and the studies attempting to characterise the health manifestations of Gulf service and the lasting effects on veterans. It also serves to bring readers up to date with research on the present deployment in Iraq. Finally, consideration is given to how Gulf War syndrome compares with the rich historical literature of post-conflict medical syndromes and how sociological factors may interact with symptom attribution in veterans.