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Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.
Aims:
Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?
Method:
CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.
Results:
Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.
Conclusions:
This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.
In order to maximize the utility of future studies of trilobite ontogeny, we propose a set of standard practices that relate to the collection, nomenclature, description, depiction, and interpretation of ontogenetic series inferred from articulated specimens belonging to individual species. In some cases, these suggestions may also apply to ontogenetic studies of other fossilized taxa.
Background: Since 2015, the CDC has supported the development and implementation of healthcare-associated infection (HAI) surveillance in resource-limited settings through technical support of case definitions and methods that are feasible with existing surveillance capacity and integration with clinical care to maximize sustainability and data use for action. Methods: Surveillance initiatives included facility-level implementation programs in Kenya, Sierra Leone, Thailand, and Georgia; larger national or regional network-level projects in India and Vietnam were also supported. For assessment and planning, surveillance capacities were grouped into 3 domains: staff, informatics, and diagnostic capacities. Based on these capacities, simplified case definitions surveillance methodologies were devised to balance resources and effort with the anticipated value and use of findings. Results: There was broad understanding of the importance of HAI surveillance; however, the required resources and other challenges (eg, training, staffing, quality of available data) were underappreciated. Staff capacities were often influenced by a lack of dedicated surveillance staff and limited experience in systematic data collection and analysis. Informatics capacities were generally limited by the lack of digital data management, nonstandardized clinical data collection and storage, and the inability to assign and maintain unique patient identifiers. We found that capacity for diagnostics, a critical component of traditional HAI surveillance systems, was limited by its availability, frequency of use, and inconsistent rationale in clinical care. We found that successful surveillance strategies were generally simple, matched existing capacities, and targeted specific HAI priorities identified by clinical teams. For example, in Kenya and Sierra Leone, participating facilities established, with minimal external support, simplified SSI surveillance among post–caesarean-delivery patients. These initiatives improved integration of surveillance with clinical care through encouraging participation of the clinical team in surveillance and planning. Furthermore, these models directly linked surveillance activities to improved patient care (eg, combined clinical checklists with surveillance data collection forms). Discussion: In resource-limited settings, the local cost and effort required to establish and sustain the necessary infrastructure for HAI surveillance can be substantial. Establishing actionable and sustainable HAI surveillance can be achieved through simplifying HAI surveillance to match existing capacities and can result in valuable surveillance programs, even in very resource-limited settings.
Background: Estimating the burden of intestinal colonization with antibiotic-resistant gram-negative bacteria (AR-GNB) is critical to understanding their global epidemiology and spread. We aimed to determine the prevalence of, and risk factors for, intestinal colonization due to AR-GNB in population-based hospital and community settings in Chile. Methods: Between December 2018 and May 2019, we enrolled randomly selected hospitalized adults in 4 tertiary-care public hospitals (Antofagasta, Santiago, Curico and Puerto Montt), and adults residing in a community-based cohort in the rural town of Molina. Following informed consent, we collected rectal swabs and epidemiological information through a standardized questionnaire. Swabs were plated onto MacConkey agar with 2 µg/mL ciprofloxacin or ceftazidime. All recovered morphotypes were identified, and antibiotic susceptibility testing was performed via disk diffusion. The primary outcome was the prevalence of colonization with fluoroquinolone (FQ)- or third-generation cephalosporin (3GC)–resistant GNB. The secondary outcome was the prevalence of colonization with multidrug-resistant (MDR) GNB, defined as GNB resistant to ≥3 antibiotic classes. Categories were not mutually exclusive. Bivariate and multivariate analyses were performed to describe risk factors for colonization with these categories. Results: In total, 775 hospitalized adults and 357 community participants were enrolled, with a median age of 60 years (IQR, 42–72) and 55 years (IQR, 48–62) years, respectively. Among hospitalized participants, the prevalence of colonization with FQ- or 3GC-resistant GNB was 47% (95% CI, 43%–50%) and 41% (95% CI, 38%–45%), respectively, whereas the prevalence of MDR-GNB colonization was 27% (95% CI, 24%–31%). In the community setting, the prevalence of colonization with either FQ-, 3GC-resistant GNB, or MDR-GNB was 40% (95% CI, 34%–45%), 29% (95% CI, 24%– 34%), and 5% (95% CI, 3%–8%), respectively. Independent risk factors for hospital MDR-GNB colonization included the hospital of admission, unit of hospitalization (intensive care units carried the highest risk), in-hospital antimicrobial exposure, comorbidities (Charlson index), and length of stay. In the community setting, recent antibiotic exposure (<3 months) predicted colonization with either FQ- or 3GC-resistant GNB, and alcohol consumption was inversely associated with MDR GNB colonization. Conclusions: A high burden of colonization with AR-GNB was observed in this sample of hospitalized and community-dwelling adults in Chile. The high burden of colonization with GNB resistant to commonly used antibiotics such as FQ and 3GC found in community dwellers, suggests that the community may be a relevant source of antibiotic resistance. Efforts to understand relatedness between resistant strains circulating in the community and the hospital are needed.
This article reviews the advancements and prospects of liquid cell transmission electron microscopy (TEM) imaging and analysis methods in understanding the nucleation, growth, etching, and assembly dynamics of nanocrystals. The bonding of atoms into nanoscale crystallites produces materials with nonadditive properties unique to their size and geometry. The recent application of in situ liquid cell TEM to nanocrystal development has initiated a paradigm shift, (1) from trial-and-error synthesis to a mechanistic understanding of the “synthetic reactions” responsible for the emergence of crystallites from a disordered soup of reactive species (e.g., ions, atoms, molecules) and shape-defined growth or etching; and (2) from post-processing characterization of the nanocrystals’ superlattice assemblies to in situ imaging and mapping of the fundamental interactions and energy landscape governing their collective phase behaviors. Imaging nanocrystal formation and assembly processes on the single-particle level in solution immediately impacts many existing fields, including materials science, nanochemistry, colloidal science, biology, environmental science, electrochemistry, mineralization, soft condensed-matter physics, and device fabrication.
Little is known about the impact of interpersonal betrayal experiences on mental health. Research suggests a link between betrayal and mental contamination (MC) within some forms of obsessive compulsive disorder (OCD). This study represents an initial exploration of that link in clinical samples.
Aims:
A measure for assessing perceptions of betrayal was developed and evaluated (Study 1) in order to assess the extent of specificity of any association between the impact of betrayal and MC, and to estimate the extent of the impact of betrayal across common psychological disorders (Study 2).
Method:
In Study 1, the Perception of Betrayal Scale (POBS) was completed by 217 community participants; an exploratory principal components analysis identified the dimensional structure of the POBS. Study 2 was based on a cross-sectional, between-groups design, with three clinical groups [OCD (n = 23), other anxiety disorders (n = 21) and depression (n = 18)] and a non-clinical control group (n = 21). Three clinical groups (OCD, other anxiety disorders, and depression) and a community group completed a selection of measures via questionnaire.
Results:
In Study 1, the POBS was found to have an internal consistency of α = .95, and four factors were identified: preoccupation with betrayal events, belief that betrayal had caused major life change, lack of trust due to betrayal and betrayal leading to traumatic responses. In Study 2, the OCD group scored more highly in terms of maladaptive perceptions of betrayal than the other groups. Regression analysis showed betrayal scores to be a moderate predictor of the experience of MC; the POBS subscales lack of trust due to betrayal and betrayal leading to traumatic responses were found to be significantly associated with MC. Although there was some overlap with bitterness, betrayal better predicted MC.
Conclusion:
Findings support the hypothesis of a specific relationship between the construct of betrayal and MC.
Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.
Methods
We conducted a retrospective cohort study comparing 3 clinicians’ determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.
Results
A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss’ Kappa of 0.30 (0.17–0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).
Conclusions
Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
Gac is a dioecious tropical and perennial climber. The fruit is a rich source of carotenoids and is used in traditional cuisine and medicine. Improving propagation methods using simple techniques would increase production and improve conservation in regional areas. This study evaluated temperature requirements for seed germination, the use of rooting hormones to strike female cuttings and the grafting of female scions onto seedling rootstock. Seed germination was optimised between 25 and 35 °C, with a maximum germination percentage of 91% at 30 °C. However, increasing storage time from 6 to 18 months under laboratory conditions (21 ± 1°C and 60% relative humidity) reduced germination and this was associated with seed weight loss, highlighting the need to develop storage guidelines, particularly for the higher temperature and humidity conditions where Gac is grown. Survival of softwood cuttings was improved from 53 to 77% with indole-3-butyric acid (IBA) (3–5 g/L) and semi-hardwood cuttings did not require IBA treatment. Both splice and wedge grafting techniques achieved a survival rate > 53% and with the youngest rootstock (4 and 8 weeks) this increased to > 85%. Further work could investigate the production potential of crops using cuttings and grafted plants.
Positive findings on early detection and early intervention services have been consistently reported from many different countries. The aim of this study, conducted within the European Brain Council project “The Value of Treatment”, was to estimate costs and the potential cost- savings associated with adopting these services within the context of the Czech mental health care reform.
Methods:
Czech epidemiological data, probabilities derived from meta-analyses, and data on costs of mental health services in the Czech Republic were used to populate a decision analytical model. From the health care and societal perspectives, costs associated with health care services and productivity lost were taken into account. One-way sensitivity analyses were conducted to explore the uncertainty around the key parameters.
Results:
It was estimated that annual costs associated with care as usual for people with the first episode of psychosis were as high as 46 million Euro in the Czech Republic 2016. These annual costs could be reduced by 25% if ED services were adopted, 33% if EI services were adopted, and 40% if both, ED and EI services, were adopted in the country. Cost-savings would be generated due to decreased hospitalisations and better employment outcomes in people with psychoses.
Conclusions:
Adopting early detection and early intervention services in mental health systems based on psychiatric hospitals and with limited access to acute and community care could generate considerable cost- savings. Although the results of this modelling study needs to be taken with caution, early detection and early intervention services are recommended for multi-centre pilot testing accompanied by full economic evaluation in the region of Central and Eastern Europe.
The stably stratified Taylor–Couette flow is investigated experimentally and numerically through linear stability analysis. In the experiments, the stability threshold and flow regimes have been mapped over the ranges of outer and inner Reynolds numbers:
$-2000<Re_{o}<2000$
and
$0<Re_{i}<3000$
, for the radius ratio
$r_{i}/r_{o}=0.9$
and the Brunt–Väisälä frequency
$N\approx 3.2~\text{rad}~\text{s}^{-1}$
. The corresponding Froude numbers
$F_{o}$
and
$F_{i}$
are always much smaller than unity. Depending on
$Re_{o}$
(or equivalently on the angular velocity ratio
$\unicode[STIX]{x1D707}=\unicode[STIX]{x1D6FA}_{o}/\unicode[STIX]{x1D6FA}_{i}$
), three different regimes have been identified above instability onset: a weakly non-axisymmetric mode with low azimuthal wavenumber
$m=O(1)$
is observed for
$Re_{o}<0$
(
$\unicode[STIX]{x1D707}<0$
), a highly non-axisymmetric mode with
$m\sim 12$
occurs for
$Re_{o}>840$
(
$\unicode[STIX]{x1D707}>0.57$
) while both modes are present simultaneously in the lower and upper parts of the flow for
$0\leqslant Re_{o}\leqslant 840$
(
$0\leqslant \unicode[STIX]{x1D707}\leqslant 0.57$
). The destabilization of these primary modes and the transition to turbulence as
$Re_{i}$
increases have been also studied. The linear stability analysis proves that the weakly non-axisymmetric mode is due to the centrifugal instability while the highly non-axisymmetric mode comes from the strato-rotational instability. These two instabilities can be clearly distinguished because of their distinct dominant azimuthal wavenumber and frequency, in agreement with the recent results of Park et al. (J. Fluid Mech., vol. 822, 2017, pp. 80–108). The stability threshold and the characteristics of the primary modes observed in the experiments are in very good agreement with the numerical predictions. Moreover, we show that the centrifugal and strato-rotational instabilities are observed simultaneously for
$0\leqslant Re_{o}\leqslant 840$
in the lower and upper parts of the flow, respectively, because of the variations of the local Reynolds numbers along the vertical due to the salinity gradient.
We examined norovirus contamination on hands of ill patients during 12 norovirus outbreaks in 12 long-term care facilities (LTCFs). The higher frequency and norovirus titers on hands of residents compared to hands of heathcare workers highlights the importance of adhering to appropriate hand hygiene practices during norovirus outbreaks in LTCFs.
Haemodynamically unstable patients can experience potentially hazardous changes in vital signs related to the exchange of depleted syringes of epinephrine to full syringes. The purpose was to determine the measured effects of epinephrine syringe exchanges on the magnitude, duration, and frequency of haemodynamic disturbances in the hour after an exchange event (study) relative to the hours before (control).
Materials and methods
Beat-to-beat vital signs recorded every 2 seconds from bedside monitors for patients admitted to the paediatric cardiovascular ICU of Texas Children’s Hospital were collected between 1 January, 2013 and 30 June, 2015. Epinephrine syringe exchanges without dose/flow change were obtained from electronic records. Time, magnitude, and duration of changes in systolic blood pressure and heart rate were characterised using Matlab. Significant haemodynamic events were identified and compared with control data.
Results
In all, 1042 syringe exchange events were found and 850 (81.6%) had uncorrupted data for analysis. A total of 744 (87.5%) exchanges had at least 1 associated haemodynamic perturbation including 2958 systolic blood pressure and 1747 heart-rate changes. Heart-rate perturbations occurred 37% before exchange and 63% after exchange, and 37% of systolic blood pressure perturbations happened before syringe exchange, whereas 63% occurred after syringe exchange with significant differences found in systolic blood pressure frequency (p<0.001), duration (p<0.001), and amplitude (p<0.001) compared with control data.
Conclusions
This novel data collection and signal processing analysis showed a significant increase in frequency, duration, and magnitude of systolic blood pressure perturbations surrounding epinephrine syringe exchange events.
Since the AD 775 and AD 994 Δ14C peak (henceforth M12) was first measured by Miyake et al. (2012, 2013), several possible production mechanisms for these spike have been suggested, but the work of Mekhaldi et al. (2015) shows that a very soft energy spectrum was involved, implying that a strong solar energetic particle (SEP) event (or series of events) was responsible. Here we present Δ14C values from AD 721–820 Sequoiadendron giganteum annual tree-ring samples from Sequoia National Park in California, USA, together with Δ14C in German oak from 650–670 BC. The AD 721–820 measurements confirm that a sharp Δ14C peak exists at AD 775, with a peak height of approximately 15‰ and show that this spike was preceded by several decades of rapidly decreasing Δ14C. A sharp peak is also present at 660 BC, with a peak height of about 10‰, and published data (Reimer et al. 2013) indicate that it too was preceded by a multi-decadal Δ14C decrease, suggesting that solar activity was very strong just prior to both Δ14C peaks and may be causally related. During periods of strong solar activity there is increased probability for coronal mass ejection (CME) events that can subject the Earth’s atmosphere to high fluencies of solar energetic particles (SEPs). Periods of high solar activity (such as one in October–November 2003) can also often include many large, fast CMEs increasing the probability of geomagnetic storms. In this paper we suggest that the combination of large SEP events and elevated geomagnetic activity can lead to enhanced production of 14C and other cosmogenic isotopes by increasing the area of the atmosphere that is irradiated by high solar energetic particles.
The stability of the Taylor–Couette flow is analysed when there is a stable density stratification along the axial direction and when the flow is centrifugally unstable, i.e. in the Rayleigh-unstable regime. It is shown that not only the centrifugal instability but also the strato-rotational instability can occur. These two instabilities can be explained and well described by means of a Wentzel–Kramers–Brillouin–Jeffreys asymptotic analysis for large axial wavenumbers in inviscid and non-diffusive limits. In the presence of viscosity and diffusion, numerical results reveal that the strato-rotational instability becomes dominant over the centrifugal instability at the onset of instability when the axial density stratification is sufficiently strong. Linear transient energy growth is next investigated for counter-rotating cylinders in the stable regime of the Froude number–Reynolds number parameter space. We show that there exist two types of transient growth mechanism analogous to the lift up and the Orr mechanisms in homogeneous fluids but with the additional effect of density perturbations. The dominant mechanism depends on the stratification: when the stratification is strong, non-axisymmetric three-dimensional perturbations achieve the optimal energy growth through the Orr mechanism while for moderate stratification, axisymmetric perturbations lead to the optimal transient growth by a lift-up mechanism involving internal waves.
Cantors made unparalleled contributions to the way time was understood and history was remembered in the medieval Latin West. The men and women who held this office in cathedrals and monasteries wereresponsible for calculating the date of Easter and the feasts dependent on it, for formulating liturgical celebrations season by season, managing the library and preparing manuscripts and other sources necessary to sustain the liturgical framework of time, and promoting the cults of saints. Crucially, their duties also often included committing the past to writing, from simple annals and chronicles to more fulsome histories, necrologies, and cartularies, thereby ensuring that towns, churches, families, and individuals could be commemorated for generations to come. The contributions hereseek to address the fundamental question of how the range of cantors' activities can help us to understand the many different ways in which the past was written and, in the liturgy, celebrated acrossthe middle ages. Cantors, as this volume makes clear, shaped the communal experience of the past in the Middle Ages; the essays are studies of constructions, both of the building blocks of time and ofthe people who made and performed them, in acts of ritual remembrance and in written records.
Contributors: Cara Aspesi, Alison I. Beach, Katie Ann-Marie Bugyis, Margot E. Fassler, David Ganz, James Grier, Paul Antony Hayward, A.B. Kraebel, Lori Kruckenberg, Rosamond McKitterick, Henry Parkes, Susan Rankin, C.C. Rozier, Sigbjoryn Olsen Sonnesyn, Teresa Webber, Lauren Whitnah,
‘History’, as it was understood by medieval Christians, was a broad concept with many meanings. It could be defined as a written record, compiled through processes inherited from classical Greek and Roman authors. But even when it proclaimed itself to be ‘factual’, the work of those who shaped the past in the Latin Middle Ages was different from that of their pagan ancestors. Although they often made claims about veracity, even when dealing with the miraculous, they did not ‘absolutize’ history (as de Lubac put it). Although they had a sense of universal history, time instead related to and unfolded within a framework conditioned by the Incarnation of the Word, and by the moral sense that this history-transforming event could impart to listeners and readers. The biblical orientation of history gave time a clear beginning and also predicted an apocalyptic end. But even as time moved relentlessly forward in this cosmic sense, the liturgy made it constantly spiral backward, rendering past sacred events present through ritual commemoration. Such liturgical celebration of time had many layers, mingled and arranged according to the calendar, with its varying and its fixed cycles of feasts, voiced through psalmody, readings from the Old and New Testaments and the lives of the saints.
How the past was known, both by individuals and within communities, varied from one specific local community to another, for the liturgy was ever changing, especially as new feasts, and feasts of new saints, were added to suit particular needs. Some knew about certain past events from what they read, as had long been the case, but in the Middle Ages many more knew about the past from various reenactments: ritual actions, dramatic productions, sermons and tales they heard about biblical characters and saints, encounters with art and architecture and from contact with shrines and relics.
Much of medieval history-making was thus memorial in nature, bringing the past forward, again and again, to recall its individual or communal significance. At the heart of the medieval Christian understanding of the past was a simple, foundational command from Christ: ‘Hoc facite in meam commemorationem’ [‘Do this in remembrance of me’] (Luke 22. 19).