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Introduction: In 2018, Canadian postgraduate specialist Emergency Medicine (EM) programs began implementing a competency-based medical education (CBME) assessment system. To support improvement of this assessment program, we sought to evaluate its short-term educational outcomes nationally and within individual programs. Methods: Program-level data from the 2018 resident cohort were amalgamated and analyzed. The number of Entrustable Professional Activity (EPA) assessments (overall and for each EPA) and the timing of resident promotion through program stages was compared between programs and to the guidelines provided by the national EM specialty committee. Total EPA observations from each program were correlated with the number of EM and pediatric EM rotations. Results: Data from 15 of 17 (88.2%) EM programs containing 9,842 EPA observations from 68 of the 77 (88.3%) Canadian EM specialist residents in the 2018 cohort were analyzed. The average number of EPAs observed per resident in each program varied from 92.5 to 229.6 and correlated strongly with the number of blocks spent on EM and pediatric EM (r = 0.83, p < 0.001). Relative to the guidelines outlined by the specialty committee, residents were promoted later than expected and with fewer EPA observations than suggested. Conclusion: We present a new approach to the amalgamation of national and program-level assessment data. There was demonstrable variation in both EPA-based assessment numbers and promotion timelines between programs and with national guidelines. This evaluation data will inform the revision of local programs and national guidelines and serve as a starting point for further reaching outcome evaluation. This process could be replicated by other national assessment programs.
Altered neurocognitive function in schizophrenia could reflect both genetic and illness-specific effects.
To use functional magnetic resonance imaging to discriminate between the influences of the genetic risk for schizophrenia and environmental factors on the neural substrate of verbal fluency, a candidate schizophrenia endophenotype using a case control twin design.
We studied 23 monozygotic twin pairs: 13 pairs discordant for schizophrenia and 10 pairs of healthy volunteer twins. Groups were matched for age, gender, handedness, level of education, parental socio-economic status, and ethnicity. Behavioural performance and regional brain activation during a phonological verbal fluency task were assessed.
Relative to healthy control twins, both patients and their non-psychotic co-twins produced fewer correct responses and showed less activation in the medial temporal region and inferior frontal gyrus. Twins with schizophrenia showed greater activation than both their non-psychotic co-twins and controls in right lateral temporal cortex, reflecting reduced deactivation during word generation while their non-psychotic co-twins showed greater activation in the left temporal cortex.
Both genetic vulnerability to schizophrenia and schizophrenia were associated with impaired verbal fluency performance, reduced engagement of the medial temporal region and dorsal inferior frontal gyrus. Schizophrenia was specifically associated with an additional reduction in deactivation in the right temporal cortex.
To investigate associations between schizophrenia candidate gene polymorphisms and regional cortical thickness and volume in patients with schizophrenia and healthy control subjects.
Genotyping was performed using PCR and pyrosequencing techniques. Cortical morphology was analyzed by processing magnetic resonance brain images with the FreeSurfer software package. General linear model analysis was used to study associations between gene variants and cortical thickness in patients and controls, respectively. Regional cortical volumes were defined from automatic cortical parcellations. Our first studies from 96 patients with schizophrenia and 104 healthy control subjects demonstrate that polymorphisms in the brain derived neurotrophic factor (BDNF) gene may be associated with variation in frontal lobe morphology. Associations seem to be stronger in patients with schizophrenia than in healthy controls.
Abnormalities of orbitofrontal cortex (OFC) sulcogyral patterns have been reported in schizophrenia, but it is not known if these predate psychosis.
Hundred and forty-six subjects at high genetic risk of schizophrenia, 34 first episode of schizophrenia patients (SZ) and 36 healthy controls were scanned and clinically assessed. Utilising the classification system proposed by Chiavaras, we categorised OFC patterns and compared their distribution between the groups, as well as between those high risk subjects who did, and did not develop schizophrenia. The relationship between OFC pattern and schizotypy was explored in high risk subjects.
We refined Chiavaras’ classification system, with the identification of a previously unreported variant of OFC surface structure. There were significant differences in distribution of OFC patterns between high risk subjects who did or did not develop schizophrenia as well as between the first episode of schizophrenia group and healthy controls. Within the high risk group, possession of OFC Type III was associated with higher ratings on the Structured Inventory for Schizotypy (SIS) psychotic factor.
Our results suggest that OFC Type III is associated with psychotic features before the development of schizophrenia. Characterisation of OFC morphology may have a role in the identification of those at greatest risk of developing schizophrenia.
Neurocognitive and functional neuroimaging studies point to frontal lobe abnormalities in schizophrenia. Molecular and behavioural genetic studies suggest that the frontal lobe is under significant genetic influence. We carried out structural magnetic resonance imaging (MRI) of the frontal lobe in monozygotic (MZ) twins concordant or discordant for schizophrenia and healthy MZ control twins.
The sample comprised 21 concordant pairs, 17 discordant affected and 18 discordant unaffected twins from 19 discordant pairs, and 27 control pairs. Groups were matched on sociodemographic variables. Patient groups (concordant, discordant affected) did not differ on clinical variables. Volumes of superior, middle, inferior and orbital frontal gyri were calculated using the Cavalieri principle on the basis of manual tracing of anatomic boundaries. Group differences were investigated covarying for whole-brain volume, gender and age.
Results for superior frontal gyrus showed that twins with schizophrenia (i.e. concordant twins and discordant affected twins) had reduced volume compared to twins without schizophrenia (i.e. discordant unaffected and control twins), indicating an effect of illness. For middle and orbital frontal gyrus, concordant (but not discordant affected) twins differed from non-schizophrenic twins. There were no group differences in inferior frontal gyrus volume.
These findings suggest that volume reductions in the superior frontal gyrus are associated with a diagnosis of schizophrenia (in the presence or absence of a co-twin with schizophrenia). On the other hand, volume reductions in middle and orbital frontal gyri are seen only in concordant pairs, perhaps reflecting the increased genetic vulnerability in this group.
Recent findings support sex-specific effects of PDYN polymorphisms on association with opioid addiction (Clarke et al. 2012). We have demonstrated that PDYN haplotypes, which include rs2281285, are associated with alcohol dependence and propensity to drink in negative emotional situations (negative craving) (Karpyak et al 2012). The rs2281285 variant may contribute to regulation of alternative PDYN mRNA transcription specific to brain area or physiological condition.
To investigate sex-specific effects of the PDYN rs2281285 variant on risk for alcohol dependence.
To examine the association of the PDYN rs2281285 variant with alcohol dependence in male and female subjects.
rs2281285 was genotyped in the investigation cohort of 816 (554 males) alcohol dependent subjects (DSM-IV-TR) and 1248 (603 males) non-alcoholic controls and in the replication cohort of 467 (347 males) alcohol dependent subjects and 431 (224 males) non-alcoholic controls. Logistic regression models were used to test for sex-specific associations after controlling for age.
As previously reported, significant association of the PDYN rs2281285 variant with alcohol dependence was found in the investigation (p = 0.008, odds ratio = 1.299), but not the replication cohort (0.223, OR = 0.118). However, sex-specific analyses revealed stronger association in males (p = 0.002, OR = 1.493) but not females (p = 0.684, OR = 1.066) in the investigation cohort, and a trend for association in males (p = 0.086, OR = 1.352) but not females (p = 0.808, OR = 0.947) in the replication cohort.
Our findings support association of PDYN rs2281285 variant with alcohol dependence in male but not female subjects. Future studies should investigate functional mechanisms of this effect.
[Improvement in daily accessible risk assessments]
We show enhanced patient safety through a quality improvement methodology project in an intensive psychiatric care unit of a psychiatric hospital in southwest of Scotland. This is a project as part of the national patient safety programme in mental health. The Scottish Patient Safety Programme for Mental Health aims to systematically reduce harm experienced by people using mental health services in Scotland, by supporting frontline staff to test, gather real-time data and reliably implement interventions, before spreading across their catchment area.
Multidisciplinary staff worked together in improving recording of daily electronic and paper based risk assessments from a baseline of 20% to nearly 100% over a sixth month period. We expect better quality risk management by readily accessible risk assessments and safe practise through enhanced safety perception by the patients as well as staff. Patient and staff safety perception tools were designed to measure impact of improvement in risk management. We have seen drop in the number of critical incidents and challenging situations requiring restraint following coordinated approach to risk assessment and easy access to key information. We have been successful as the frontline staff became part of the process of change and this has enabled sustained improvement.
It is widely recognised that people with intellectual disabilities receive a poorer quality of healthcare than their non-disabled counterparts. Training for healthcare professionals in intellectual disability is often scant or non-existent. The purpose of this work is to explore the usefulness of employing actors with intellectual disabilities as simulated patients in the assessment of trainee psychiatrists.
The development of a structured clinical exam “station” designed to assess the ability of trainee psychiatrists to communicate with a simulated patient played by an actor with an intellectual disability is described. The paper also assesses the potential benefits of this kind of assessment and the experience of actors and examiners taking part in this process.
The station was found to perform well in discriminating between candidates of various abilities and was well received by actors, examiners and observers. The station is now routinely used in the formal assessment of trainee psychiatrists in the UK.
The use of people with intellectual disabilities in training and assessment appears to be advantageous in terms of improving knowledge, attitudes and skills amongst healthcare professionals and gives increased opportunities for people with intellectual disabilities to undertake valued social roles.
Few institutions currently employ actors with intellectual disabilities as simulated patients as part of their training programmes and as a result there is little in the way of literature on this subject. This paper describes an alternative approach to teaching and assessment which falls in line with recommendations from the UK Department of Health to involve service users in the training of healthcare professionals.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Self-reported activity restriction is an established correlate of depression in dementia caregivers (dCGs). It is plausible that the daily distribution of objectively measured activity is also altered in dCGs with depression symptoms; if so, such activity characteristics could provide a passively measurable marker of depression or specific times to target preventive interventions. We therefore investigated how levels of activity throughout the day differed in dCGs with and without depression symptoms, then tested whether any such differences predicted changes in symptoms 6 months later.
Design, setting, participants, and measurements:
We examined 56 dCGs (mean age = 71, standard deviation (SD) = 6.7; 68% female) and used clustering to identify subgroups which had distinct depression symptom levels, leveraging baseline Center for Epidemiologic Studies of Depression Scale–Revised Edition and Patient Health Questionnaire-9 (PHQ-9) measures, as well as a PHQ-9 score from 6 months later. Using wrist activity (mean recording length = 12.9 days, minimum = 6 days), we calculated average hourly activity levels and then assessed when activity levels relate to depression symptoms and changes in symptoms 6 months later.
Clustering identified subgroups characterized by: (1) no/minimal symptoms (36%) and (2) depression symptoms (64%). After multiple comparison correction, the group of dCGs with depression symptoms was less active from 8 to 10 AM (Cohen’s d ≤ −0.9). These morning activity levels predicted the degree of symptom change on the PHQ-9 6 months later (per SD unit β = −0.8, 95% confidence interval: −1.6, −0.1, p = 0.03) independent of self-reported activity restriction and other key factors.
These novel findings suggest that morning activity may protect dCGs from depression symptoms. Future studies should test whether helping dCGs get active in the morning influences the other features of depression in this population (i.e. insomnia, intrusive thoughts, and perceived activity restriction).
Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.
We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).
This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.
Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.
Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
Plasticity of skeletal cells, tissues and organs is a general vertebrate character and rampant among teleost fishes. Plasticity is not restricted to early ontogeny but is evident throughout the entire life history. Epigenetic factors during development influence skeletal anatomy, mechanical properties of skeletal tissues and numbers of meristic characters such as vertebrae. Adult teleost skeletons demonstrate plasticity in functional adaptation, especially to mechanical forces and mechanical loading and to physiological factors such as temperature or the availability of minerals. Plasticity influences the character of skeletal tissues that can range from cartilage to acellular bone, as well as numbers of serial elements such as vertebrae, scales or fin rays. Variable numbers of vertebrae and the existence of vestiges, rudiments, atavisms and hyperostotic bones are discussed as examples of skeletal variation. Plasticity at the cellular level is best understood by recognising features of fish skeletal cells not seen in mammals, two of which are the absence of osteocytes in the acellular bone of most species of teleosts and the resorption of bone by mononucleated rather than multinucleated osteoclasts. A third is that mineral resorption in teleosts is phosphorous rather than calcium-based. The fourth is the variety of skeletal tissues that share features of bone and cartilage (chondroid bone, secondary cartilage) or between cartilage and notochord (chondroid) or of bone and dentine. Phenotypic plasticity of skeletal tissues is affected at the cellular level by modulation, transdifferentiation, metaplasia and remodelling. Plasticity of skeletal cells, tissues and organs has important consequences for skeletal development and evolution.
High-rate lithium ion batteries with long cycling lives can provide electricity grid stabilization services in the presence of large fractions of intermittent generators, such as photovoltaics. Engineering for high rate and long cycle life requires an appropriate selection of materials for both electrode and electrolyte and an understanding of how these materials degrade with use. High-rate lithium ion batteries can also facilitate faster charging of electric vehicles and provide higher energy density alternatives to supercapacitors in mass transport applications.
High-rate lithium ion batteries can play a critical role in decarbonizing our energy systems both through their underpinning of the transition to use renewable energy resources, such as photovoltaics, and electrification of transport. Their ability to be rapidly and frequently charged and discharged can enable this energy storage technology to play a key role in stabilizing future low-carbon electricity networks which integrate large fractions of intermittent renewable energy generators. This decarbonizing transition will require lithium ion technology to provide increased power and longer cycle lives at reduced cost. Rate performance and cycle life are ultimately limited by the materials used and the kinetics associated with the charge transfer reactions and ionic and electronic conduction. We review material strategies for electrode materials and electrolytes that can facilitate high rates and long cycle lives and discuss the important issues of cost, resource availability and recycling.
A fine-grained, up to 3-m-thick tephra bed in southwestern Saskatchewan, herein named Duncairn tephra (Dt), is derived from an early Pleistocene eruption in the Jemez Mountains volcanic field of New Mexico, requiring a trajectory of northward tephra dispersal of ~1500 km. An unusually low CaO content in its glass shards denies a source in the closer Yellowstone and Heise volcanic fields, whereas a Pleistocene tephra bed (LSMt) in the La Sal Mountains of Utah has a very similar glass chemistry to that of the Dt, supporting a more southerly source. Comprehensive characterization of these two distal tephra beds along with samples collected near the Valles caldera in New Mexico, including grain size, mineral assemblage, major- and trace-element composition of glass and minerals, paleomagnetism, and fission-track dating, justify this correlation. Two glass populations each exist in the Dt and LSMt. The proximal correlative of Dt1 is the plinian Tsankawi Pumice and co-ignimbritic ash of the first ignimbrite (Qbt1g) of the 1.24 Ma Tshirege Member of the Bandelier Tuff. The correlative of Dt2 and LSMt is the co-ignimbritic ash of Qbt2. Mixing of Dt1 and Dt2 probably occurred during northward transport in a jet stream.
The US Navy utilizes numerous resources to encourage smoking cessation. Despite these efforts, cigarette smoking among service members remains high. Electronic cigarettes (EC) have provided an additional cessation resource. Little is known regarding the utilization efficacy of these cessation resources in the US Navy.
This study sought to explore the utilization and efficacy of ECs and other smoking cessation resources.
An anonymous cross-sectional survey was conducted at a military clinic from 2015 to 2016. Participants were active duty in the US Navy and reported demographics, smoking behaviors, and utilization of cessation resources.
Of the 977 participants in the study, 14.9% were current and 39.4% were former smokers. Most current smokers (83.6%) previously attempted cessation, smoked an average of 2–5 cigarettes per day (34.7%), and smoked every day of the month (26.4%). The number of daily cigarettes smoked and number of days cigarettes were smoked per month was not significantly different between cigarette-only smokers and EC dual users (p = 0.92, p = 0.75, respectively). Resources used by current and former smokers include: ‘cold turkey’ (44.6%, 57.1%, respectively), ECs (22.3%, 24.7%), nicotine patch (8.3%, 1.3%), medicine (6.6%, 3.9%), nicotine gum (5.8%, 10.4%), and quit programs (2.5%, 2.6).
Current and former cigarette smokers utilized similar resources to quit smoking. Electronic cigarettes are being used for cessation but do not significantly reduce the number of cigarettes smoked on a daily or monthly basis. Future studies may benefit from exploring the use of cessation resources and ECs within the military as a whole.
Adherence to dietary guidelines (DG) may result in higher intake of polyphenols via increased consumption of fruits, vegetables and whole grains. We compared polyphenol dietary intake and urinary excretion between two intervention groups in the Cardiovascular risk REduction Study: Supported by an Integrated Dietary Approach study: a 12-week parallel-arm, randomised controlled trial (n 161; sixty-four males, ninety-seven females; aged 40–70 years). One group adhered to UK DG, whereas the other group consumed a representative UK diet (control). We estimated polyphenol dietary intake, using a 4-d food diary (4-DFD) and FFQ, and analysed 24-h polyphenol urinary excretion by liquid chromatography-tandem MS on a subset of participants (n 46 control; n 45 DG). A polyphenol food composition database for 4-DFD analysis was generated using Phenol-Explorer and USDA databases. Total polyphenol intake by 4-DFD at endpoint (geometric means with 95 % CI, adjusted for baseline and sex) was significantly higher in the DG group (1279 mg/d per 10 MJ; 1158, 1412) compared with the control group (1084 mg/d per 10 MJ; 980, 1197). The greater total polyphenol intake in the DG group was attributed to higher intake of anthocyanins, proanthocyanidins and hydroxycinnamic acids, with the primary food sources being fruits, cereal products, nuts and seeds. FFQ estimates of flavonoid intake also detected greater intake in DG compared with the control group. 24-h urinary excretion showed consistency with 4-DFD in their ability to discriminate between dietary intervention groups for six out of ten selected, individual polyphenols. In conclusion, following UK DG increased total polyphenol intake by approximately 20 %, but not all polyphenol subclasses corresponded with this finding.