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The neurodevelopmental model of psychosis was established over 30 years ago; however, the developmental influence on psychotic symptom expression – how age affects clinical presentation in first-episode psychosis – has not been thoroughly investigated.
Using generalized additive modeling, which allows for linear and non-linear functional forms of age-related change, we leveraged symptom data from a large sample of antipsychotic-naïve individuals with first-episode psychosis (N = 340, 12–40 years, 1–12 visits), collected at the University of Pittsburgh from 1990 to 2017. We examined relationships between age and severity of perceptual and non-perceptual positive symptoms and negative symptoms. We tested for age-associated effects on change in positive or negative symptom severity following baseline assessment and explored the time-varying relationship between perceptual and non-perceptual positive symptoms across adolescent development.
Perceptual positive symptom severity significantly decreased with increasing age (F = 7.0, p = 0.0007; q = 0.003) while non-perceptual positive symptom severity increased with age (F = 4.1, p = 0.01, q = 0.02). Anhedonia severity increased with increasing age (F = 6.7, p = 0.00035; q = 0.0003), while flat affect decreased in severity with increased age (F = 9.8, p = 0.002; q = 0.006). Findings remained significant when parental SES, IQ, and illness duration were included as covariates. There were no developmental effects on change in positive or negative symptom severity (all p > 0.25). Beginning at age 18, there was a statistically significant association between severity of non-perceptual and perceptual symptoms. This relationship increased in strength throughout adulthood.
These findings suggest that as maturation proceeds, perceptual symptoms attenuate while non-perceptual symptoms are enhanced. Findings underscore how pathological brain–behavior relationships vary as a function of development.
Psychosis is more prevalent among people in prison compared with the community. Early detection is important to optimise health and justice outcomes; for some, this may be the first time they have been clinically assessed.
Determine factors associated with a first diagnosis of psychosis in prison and describe time to diagnosis from entry into prison.
This retrospective cohort study describes individuals identified for the first time with psychosis in New South Wales (NSW) prisons (2006–2012). Logistic regression was used to identify factors associated with a first diagnosis of psychosis. Cox regression was used to describe time to diagnosis from entry into prison.
Of the 38 489 diagnosed with psychosis for the first time, 1.7% (n = 659) occurred in prison. Factors associated with an increased likelihood of being diagnosed in prison (versus community) were: male gender (odds ratio (OR) = 2.27, 95% CI 1.79–2.89), Aboriginality (OR = 1.81, 95% CI 1.49–2.19), older age (OR = 1.70, 95% CI 1.37–2.11 for 25–34 years and OR = 1.63, 95% CI 1.29–2.06 for 35–44 years) and disadvantaged socioeconomic area (OR = 4.41, 95% CI 3.42–5.69). Eight out of ten were diagnosed within 3 months of reception.
Among those diagnosed with psychosis for the first time, only a small number were identified during incarceration with most identified in the first 3 months following imprisonment. This suggests good screening processes are in place in NSW prisons for detecting those with serious mental illness. It is important these individuals receive appropriate care in prison, have the opportunity to have matters reheard and possibly diverted into treatment, and are subsequently connected to community mental health services on release.
Preferential dissolution of the biogenic carbonate polymorph aragonite promotes preservational bias in shelly marine faunas. While field studies have documented the impact of preferential aragonite dissolution on fossil molluscan diversity, its impact on regional and global biodiversity metrics is debated. Epicontinental seas are especially prone to conditions that both promote and inhibit preferential dissolution, which may result in spatially extensive zones with variable preservation. Here we present a multifaceted evaluation of aragonite dissolution within the Late Cretaceous Western Interior Seaway of North America. Occurrence data of mollusks from two time intervals (Cenomanian/Turonian boundary, early Campanian) are plotted on new high-resolution paleogeographies to assess aragonite preservation within the seaway. Fossil occurrences, diversity estimates, and sampling probabilities for calcitic and aragonitic fauna were compared in zones defined by depth and distance from the seaway margins. Apparent range sizes, which could be influenced by differential preservation potential of aragonite between separate localities, were also compared. Our results are consistent with exacerbated aragonite dissolution within specific depth zones for both time slices, with aragonitic bivalves additionally showing a statistically significant decrease in range size compared with calcitic fauna within carbonate-dominated Cenomanian–Turonian strata. However, we are unable to conclusively show that aragonite dissolution impacted diversity estimates. Therefore, while aragonite dissolution is likely to have affected the preservation of fauna in specific localities, time averaging and instantaneous preservation events preserve regional biodiversity. Our results suggest that the spatial expression of taphonomic biases should be an important consideration for paleontologists working on paleobiogeographic problems.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Peter J. Dean, Senior Fellow in the Strategic and Defence Studies Centre at the Australian National University (ANU)'s Coral Bell School of Asia Pacific Affairs,
Greg Raymond, Research Fellow in the Strategic and Defence Studies Centre at the Australian National University (ANU)'s Coral Bell School of Asia Pacific Affairs, focusing on Southeast Asian security.
One of the most well-used quotes from Sun Tzu states that “if you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat.” Thucydides — who like Sun Tzu is a member of the “classical cannon” of strategic studies from the fifth century BCE — argued, in a not too dissimilar vein, that scrutinizing the political and cultural differences of the ancient Greek city states was critical in understanding their motivations and behaviour during the Peloponnesian War. For both writers, appreciating the strategic culture of the protagonists is essential to understanding war, and crucial in the formulation of strategy.
Shifting forward a mere 2,300 years to the 1960s in Southeast Asia, the concept of understanding thy enemy and knowing thyself had not changed. A lack of understanding of the region, and especially its culture and political make-up, was to prove fatal to the efforts of the United States to prop up successive South Vietnamese governments in the face of a communist led insurgency. Robert McNamara, U.S. Secretary of Defense in the Kennedy and Johnson administrations, noted that in accounting for the U.S. defeat in South Vietnam, one of the key reasons was that “we [the United States] viewed the people and leaders of South Vietnam in terms of our own experience … we totally misjudged the political forces within the country … our misjudgements of friend and foe alike reflected our profound ignorance of the history, culture, and politics of the people in the area, and the personalities and habits of their leaders” (McNamara 1995, p. 322). A decade later, Lawrence Sondhaus applied McNamara's analysis of the failings of U.S. policy in South Vietnam to the miscalculations and misjudgements evident in the U.S. invasion of Iraq: an observation that looks increasingly prophetic (Sondhaus 2006, p. 130).
What these insights from the ancient world and modern times reinforce is the continual failure of neorealist and traditional rationalistmaterialist approaches to explain strategic behaviour. As Rashed Uz Zaman has noted, the need for understanding ourselves, our potential adversaries, our allies, and the world we live in has not changed over time (Uz Zaman 2009, p. 84).
Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients. Methods: We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months. Results: A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS. Conclusions: Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.
Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.
Companies are increasingly requiring consumers to agree to arbitrate disputes they may have over the products or services they purchase. Pre-dispute arbitration agreements are controversial especially for consumer disputes, where, it is feared, consumers will not represent themselves and neither will lawyers come forward because of the small stakes involved in individual claims. Dean Rutledge addresses in this chapter whether consumer arbitration processes can be designed to provide greater access to justice for consumers.
Over a decade ago, Professor Samuel Estreicher laid plain the terms of the policy debate over arbitration of employment disputes. Invoking the provocative and memorable phrase “Saturns for Rickshaws,” Estreicher argued that the debate ultimately turned on one's view about the social goals of civil dispute resolution. Prohibiting arbitration clauses in employment disputes might guarantee a “Cadillac” system for the select few who had claims that could attract competent plaintiff's attorneys and plausible damages claims that a jury might buy. Yet for the rest (indeed the majority), civil litigation promised a “rickshaw” system – at best, little or no relief generally because their claims did not have the sticker value to attract competent counsel and, instead, languish on the dockets of understaffed and sometimes incompetent administrative agencies. By contrast, arbitration offered the prospect of “Saturns for all” – making those with “Cadillac” cases slightly worse off but those with “Rickshaw” cases comparatively better off.
While Saturns have disappeared from the new automobile market, Estreicher's metaphor retains its essential relevance to the study of arbitration. Though developed in the context of employment arbitration, it helps to frame the debate over consumer arbitration. One positive question is whether, in the consumer context, arbitration entails the same tradeoff – making a subset of consumers worse off even while making the majority of consumers better off. A related, normative question is whether that particular distribution of benefits is more socially desirable than the distribution of benefits offered by the civil litigation system.
Opinions differ sharply over the answers. To some, arbitration can help solve problems of access to justice by reducing aggregate process costs and expediting the delivery of relief to consumers with meritorious claims.
The years 1944 and 1945 were pivotal in the development of Australia's approach to strategy during the Second World War and beyond. While the main battlefront of the Pacific War had moved further north, Australian air, land and sea forces continued to make a significant contribution to the Allied campaign and towards achieving Australia's strategic interests and objectives. In New Guinea, Australian operations secured territories and released men from service, while in Borneo a highly successful campaign was clouded by uncertain motives and questionable strategy. Australia 1944–45: Victory in the Pacific examines this complex and fascinating period, which has been largely under-represented in Australian military history. Peter Dean leads a team of highly regarded military historians in assessing Australian, Allied and Japanese strategies, the conduct of the campaigns in the Southwest Pacific Area and Australia's significant role in achieving victory.
On Thursday 7 October 1943 two senior officers, one Australian and one American, held meetings in their respective headquarters. Even though some 2000 kilometres of the Coral Sea separated them, they were linked by a common cause and a common role. They were both senior operations officers of their respective headquarters in the Southwest Pacific Area (SWPA). US Brigadier-General Stephen Chamberlin was the senior operations officer for General Douglas MacArthur, the theatre Commander-in-Chief (C-in-C). The Australian Major-General Frank Berryman was the Deputy Chief of the General Staff responsible to the C-in-C General Sir Thomas Blamey, while concurrently also holding down the position of senior staff officer of New Guinea Force (NGF), the Australian Army formation fighting the Japanese in New Guinea.
On the morning of 7 October, Berryman sat in a tropical bungalow in Port Moresby, Papua, that served as the headquarters of NGF. Across from him sat Lieutenant-General Iven Mackay, or ‘Mister Chips’, as he was known, whom Blamey had installed as the General Officer-in-Command (GOC-in-C) New Guinea Force six weeks earlier. With them was Lieutenant-General Leslie Morshead, the ‘hero of Tobruk and El Alamein’ and commander of II Australian Corps.
Despite the fact that the three men had served together in the Australian Army for decades, had a close rapport and a high degree of mutual respect for one another, the atmosphere was tense. Morshead was about to fly out to relieve Lieutenant-General Edmund Herring of his command. Herring was the commander of I Corps, whose troops were in the frontline in the Markham Valley and Huon Peninsula fighting the Japanese. Berryman had held reservations over Herring's suitability for his command for some months and in September, after Herring had mishandled relations with the Americans, lost ‘grip’ of his operations and openly criticised Mackay, Berryman advised Blamey that he lad lost all confidence in him. He told Blamey that he did not think that Herring was ‘tough enough mentally’ for the job. Major-General Vasey, General Officer Commanding (GOC) of the 7th Australian Division in Herring's Corps was even more frank. He recorded that Herring's ‘trouble is a lack of decision occasioned by a lack of knowledge and combined with wishful thinking and optimism’. He is ‘incapable of training a staff … [and] good deal of our recent problems are his doing … Ned is a nice man but the army is not the place for those people’.