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Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated.
147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion.
The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.
DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.
We present a new experimental platform for studying laboratory astrophysics that combines a high-intensity, high-repetition-rate laser with the Large Plasma Device at the University of California, Los Angeles. To demonstrate the utility of this platform, we show the first results of volumetric, highly repeatable magnetic field and electrostatic potential measurements, along with derived quantities of electric field, charge density and current density, of the interaction between a super-Alfvénic laser-produced plasma and an ambient, magnetized plasma.
We have previously shown that the minor alleles of vascular endothelial growth factor A (VEGFA) single-nucleotide polymorphism rs833069 and superoxide dismutase 2 (SOD2) single-nucleotide polymorphism rs2758331 are both associated with improved transplant-free survival after surgery for CHD in infants, but the underlying mechanisms are unknown. We hypothesised that one or both of these minor alleles are associated with better systemic ventricular function, resulting in improved survival.
This study is a follow-up analysis of 422 non-syndromic CHD patients who underwent neonatal cardiac surgery with cardiopulmonary bypass. Echocardiographic reports were reviewed. Systemic ventricular function was subjectively categorised as normal, or as mildly, moderately, or severely depressed. The change in function was calculated as the change from the preoperative study to the last available study. Stepwise linear regression, adjusting for covariates, was performed for the outcome of change in ventricular function. Model comparison was performed using Akaike’s information criterion. Only variables that improved the model prediction of change in systemic ventricular function were retained in the final model.
Genetic and echocardiographic data were available for 335/422 subjects (79%). Of them, 33 (9.9%) developed worse systemic ventricular function during a mean follow-up period of 13.5 years. After covariate adjustment, the presence of the VEGFA minor allele was associated with preserved ventricular function (p=0.011).
These data support the hypothesis that the mechanism by which the VEGFA single-nucleotide polymorphism rs833069 minor allele improves survival may be the preservation of ventricular function. Further studies are needed to validate this genotype–phenotype association and to determine whether this mechanism is related to increased vascular endothelial growth factor production.
The Megamaser Cosmology Project (MCP) measures the Hubble Constant by determining geometric distances to circumnuclear 22 GHz H2O megamasers in galaxies at low redshift (z < 0.05) but well into the Hubble flow. In combination with the recent, exquisite observations of the Cosmic Microwave Background by WMAP and Planck, these measurements provide a direct test of the standard cosmological model and constrain the equation of state of dark energy. The MCP is a multi-year project that has recently completed observations and is currently working on final analysis. Based on distance measurements to the first four published megamasers in the sample, the MCP currently determines H0 = 69.3 ± 4.2 km s−1 Mpc−1. The project is finalizing analysis for five additional galaxies. When complete, we expect to achieve a ~4% measurement. Given the tension between the Planck prediction of H0 in the context of the standard cosmological model and astrophysical measurements based on standard candles, the MCP provides a critical and independent geometric measurement that does not rely on external calibrations or a distance ladder.
Due to the limited availability of selective herbicides to control Sumatran fleabane after soybean emergence, it is essential to develop new options that provide effective control prior to planting. A new herbicide formulation containing diclosulam+halauxifen-methyl was evaluated for effectiveness at two Sumatran fleabane plant heights (5 to 10 cm, and 10 to 50 cm) and for soybean selectivity when applied at 7 or 3 d before planting. Combined results from the two sites showed that diclosulam+halauxifen, applied either alone or in a tank mixture with glyphosate, and the tank mixture of diclosulam+2,4-D amine+glyphosate are effective at all rates tested to control Sumatran fleabane in preplant applications. Crop response was observed with applications 7 days before planting at only one of the sites. A rate-dependent crop response was observed for pre-plant applications performed 3 days before soybean planting. However, crop yield was not significantly affected for either timing across all rates. All rates tested of diclosulam+halauxifen in this study were considered safe to soybean.
A 9-year-old boy who was born with bicuspid aortic stenosis underwent two unsuccessful aortic valvuloplasty interventions, and by 2 years of age he developed restrictive cardiomyopathy caused by left ventricular endocardial fibroelastosis and diastolic dysfunction. The attending cardiologist referred the patient to a high-volume, high-profile congenital cardiac surgical programme 1000 miles away that has a team with considerable experience with left ventricular endocardial fibroelastosis resection and a reputation of achieving good results. Owing to problems with insurance coverage, the parents sought other options for the care of their child in their home state. Dr George Miller is a well-respected local congenital and paediatric cardiac surgeon with considerable experience with the Ross operation as well as with right ventricular endocardial fibroelastosis resection. When talking with Dr Miller, he implied that there is little difference between right ventricular endocardial fibroelastosis and left ventricular endocardial fibroelastosis resection, and stated that he would perform the operation with low mortality based on his overall experience. Dr Miller stated that the local institution could provide an equivalent surgical procedure with comparable outcomes, without the patient and family having to travel out of state. A fundamental dilemma that often arises in clinical surgical practice concerns the conduct of assessing and performing new procedures, especially in rare cases, for which the collective global experience is scant. Although Dr Miller has performed right ventricular endocardial fibroelastosis resection, this procedure differs from left ventricular endocardial fibroelastosis resection, and he cannot be sure that he will indeed be able to perform the procedure better than the high-volume surgeon. This ethical situation is best understood in terms of the principles of respect for patient autonomy, beneficence, non-maleficence, and justice. The tension between the imperatives of beneficence and the obligation to respect the autonomy of the patient by acting only with the patient’s best interest in mind is discussed.
The fragile light elements lithium, beryllium, and boron (Li, Be, B) are easily destroyed in stellar interiors, and are thus superb probes of physical processes occuring in the outer stellar layers. The light elements are also excellent tracers of the chemical evolution of the Galaxy, and can test big bang nucleosynthesis (BBN). These inter-related topics are reviewed with an emphasis on stellar physics.
In Part I (presented by CPD), an overview is given of the physical processes which can modify the surface abundances of the light elements, with emphasis on Population I dwarfs - convection; gravitational settling, thermal diffusion, and radiative levitation; slow mixing induced by gravity waves or rotation. We will discuss the increasingly large body of data which begin to enable us to discern the relative importance of these mechanisms in Population I main sequence stars. In Part II (presented by MHP), discussion is extended to the issue of whether or not the halo Li plateau is depleted, and includes the following topics: Li dispersion in field and globular cluster stars, Li production vs. destruction in Li-rich halo stars, and constraints from 6Li. Also discussed are trends with metal abundance and Teff and implications for chemical evolution and BBN. In Part III (presented by CC), evidence is reviewed that suggests that in situ mixing occurs in evolved low mass Population I and Population II stars. Theoretical mechanisms that can create such mixing are discussed, as well as their implications in stellar yields.
See the abstract given in Part I (Deliyannis, Pinsonneault, Charbonnel, hereafter DPC, this volume). In Part III, we first discuss the LiBeB observations in subgiant stars and the constraints they bring on the transport processes occuring on the main sequence. Evidence is then reviewed that suggests that in situ mixing occurs in evolved low mass Population I and Population II stars. Theoretical mechanisms that can create such mixing are discussed, as well as their implications for the evolution of the LiBeB and 3He.
See the abstract given in Part I (Deliyannis, Pinsonneault, Charbonnel, hereafter DPC, in these proceedings). In Part II we discuss the lithium data for metal-poor stars and the constraints it places on stellar depletion. There are a variety of indicators that place interesting bounds on the degree of stellar depletion, and in contrast to the other two sections the data for Population II stars provides weaker evidence for stellar lithium depletion. We review both the theoretical studies and the observational data, and critically evaluate the degree of stellar depletion consistent with the data.
Standard stellar evolution predicts that F stars should retain their initial surface lithium (Li) abundance because their convection zones are too shallow to destroy it at their base. Yet, observations reveal a severe Li depletion (the “Boesgaard Gap”), perhaps by as much as about two orders of magnitude, in a narrow Teff range. Several physical mechanisms, not usually included in stellar evolution calculations, have been proposed to account for this Li deficiency. These include diffusion, mass loss, meridional circulation, and rotationally-induced mixing driven by angular momentum loss. Identifying which of these (if any) might really be at work is not only of vital interest to stellar evolution, but may also have serious implications elsewhere (e.g. cosmology, Deliyannis et al. 1991). We bring attention to beryllium (Be) observations in F stars, which are crucial for discriminating between scenarios. Particularly important is the star 110 Her, which is depleted in Be by about a factor of 5 -10, but still has a detectable Li abundance (depleted by a factor of 100 - 200). Depleting surface Be without having depleted nearly all of the surface Li requires specific circumstances; we discuss how this depletion property severely constrains or eliminates most of the proposed mechanisms. One mechanism, rotationally-induced mixing, predicts relative depletions for these elements that agree well with what is observed.
Since its introduction in the late 19th century, symmetry breaking has been found to play a crucial role in physics. In particular, it appears as one key phenomenon controlling hydrodynamic and acoustic instabilities in problems with rotational symmetries. A previous paper investigated its desired potential application to the control of circumferential thermoacoustic modes in one annular cavity coupled with multiple flames (Bauerheim et al., J. Fluid Mech., vol. 760, 2014, pp. 431–465). The present paper focuses on a similar problem when symmetry breaking appears unintentionally, for example when uncertainties due to tolerances are taken into account. It yields a large uncertainty quantification (UQ) problem containing numerous uncertain parameters. To tackle this well-known ‘curse of dimensionality’, a novel UQ methodology is used. It relies on the active subspace approach to construct a reduced set of input variables. This strategy is applied on two annular cavities coupled by 19 flames to determine its modal risk factor, i.e. the probability of an azimuthal acoustic mode being unstable. Since each flame is modelled by two uncertain parameters, it leads to a large UQ problem involving 38 parameters. An acoustic network model is then derived, which yields a nonlinear dispersion relation for azimuthal modes. This nonlinear problem, subject to bifurcations, is solved quasi-analytically. Results show that the dimension of the probabilistic problem can be drastically reduced, from 38 uncertain parameters to only 3. Moreover, it is found that the three active variables are related to physical quantities, which unveils underlying phenomena controlling the stability of the two coupled cavities. The first active variable is associated with a coupling strength controlling the bifurcation of the system, while the two others correspond to a symmetry-breaking effect induced by the uncertainties. Thus, an additional destabilization effect appear caused by the non-uniform pattern of the uncertainty distribution, which breaks the initial rotating symmetry of the annular cavities. Finally, the active subspace is exploited by fitting the response surface with polynomials (linear, quadratic and cubic). By comparing accuracy and cost, results prove that 5 % error can be achieved with only 30 simulations on the reduced space, whereas 2000 are required on the complete initial space. It exemplifies that this novel UQ technique can accurately predict the risk factor of an annular configuration at low cost as well as unveil key parameters controlling the stability.
The treatment of rare and expensive medical conditions is one of the defining qualities of paediatric cardiology and congenital heart surgery. Increasing concerns over healthcare resource allocation are challenging the merits of treating more expensive forms of congenital heart disease, and this trend will almost certainly continue. In this manuscript, the problems of resource allocation for rare and expensive medical conditions are described from philosophical and economic perspectives. The argument is made that current economic models are limited in the ability to assess the value of treating expensive and rare forms of congenital heart disease. Further, multi-disciplinary approaches are necessary to best determine the merits of treating a patient population such as those with significant congenital heart disease that sometimes requires enormous healthcare resources.
Respect for patient autonomy is an important and indispensable principle in the ethical practice of clinical medicine. Legal tenets recognise the centrality of this principle and the inherent right of patients of sound mind – properly informed – to make their own personal medical decisions. In the course of everyday medical practice, however, challenging cases may result in ethical dilemmas for the patient, the physician, and society. Resolution of these dilemmas requires a thorough understanding of the underlying principles that allow the clinician to make informed decisions and to offer considered therapeutic options to the patient. We argue in this paper that there is also need for a transition of moral competency from understanding principles to attaining virtue in the classic Aristotelian tradition. Achieving moral virtue is based on a lifetime of learning, practising, and watching how others, who have achieved virtue, act and perform their duties. We further claim that learning moral virtue in medical practice is best realised by incorporating the lessons learnt during daily rounds where frank discussions and considered resolutions can occur under the leadership of senior practitioners who have achieved a semblance of moral excellence.
Anomalous aortic origins of the coronary arteries comprise approximately one-third of all coronary artery anomalies and are characterised by coronary arteries with anomalies of aortic origin involving abnormal courses, stenoses, and compression that can lead to myocardial ischaemia and sudden death. Operative techniques to treat these anomalies have not been standardised yet. Moreover, the management of potential complications has not been addressed. Common and rare forms of anomalous aortic origins of the coronary arteries are reviewed and understood standard techniques for an uncomplicated unroofing procedure are illustrated. Also noted are techniques that can be applied to unexpected anatomical findings and unwanted complications that could prove to be life-threatening. Several technical recommendations are offered.
Placebo responses raise significant challenges for the design of clinical trials. We report changes in agitation outcomes in the placebo arm of a recent trial of citalopram for agitation in Alzheimer's disease (CitAD).
In the CitAD study, all participants and caregivers received a psychosocial intervention and 92 were assigned to placebo for nine weeks. Outcomes included Neurobehavioral Rating Scale agitation subscale (NBRS-A), modified AD Cooperative Study-Clinical Global Impression of Change (CGIC), Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (NPI A/A) and Total (NPI-Total) and ADLs. Continuous outcomes were analyzed with mixed-effects modeling and dichotomous outcomes with logistic regression.
Agitation outcomes improved over nine weeks: NBRS-A mean (SD) decreased from 7.8 (3.0) at baseline to 5.4 (3.2), CMAI from 28.7 (6.7) to 26.7 (7.4), NPI A/A from 8.0 (2.4) to 4.9 (3.8), and NPI-Total from 37.3 (17.7) to 28.4 (22.1). The proportion of CGI-C agitation responders ranged from 21 to 29% and was significantly different from zero. MMSE improved from 14.4 (6.9) to 15.7 (7.2) and ADLs similarly improved. Most of the improvement was observed by three weeks and was sustained through nine weeks. The major predictor of improvement in each agitation measure was a higher baseline score in that measure.
We observed significant placebo response which may be due to regression to the mean, response to a psychosocial intervention, natural course of symptoms, or nonspecific benefits of participation in a trial.
We report on the composition of turn-off stars in the intriguing open cluster, NGC 6791, which is old, but super-metal-rich using Keck/HIRES spectra. We find [Fe/H] = +0.30 ±0.02[O/Fe]n −0.06 ±0.02,[Mg/Fe], [Si/Fe], [Ca/Fe], and [Ti/Fe] near solar and the two Fe-peak elements, Cr and Ni, are consistent with Fe.