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As refugees and asylum seekers are at high risk of developing mental disorders, we assessed the effectiveness of Self-Help Plus (SH + ), a psychological intervention developed by the World Health Organization, in reducing the risk of developing any mental disorders at 12-month follow-up in refugees and asylum seekers resettled in Western Europe.
Methods
Refugees and asylum seekers with psychological distress (General Health Questionnaire-12 ⩾ 3) but without a mental disorder according to the Mini International Neuropsychiatric Interview (M.I.N.I.) were randomised to either SH + or enhanced treatment as usual (ETAU). The frequency of mental disorders at 12 months was measured with the M.I.N.I., while secondary outcomes included self-identified problems, psychological symptoms and other outcomes.
Results
Of 459 participants randomly assigned to SH + or ETAU, 246 accepted to be interviewed at 12 months. No difference in the frequency of any mental disorders was found (relative risk [RR] = 0.841; 95% confidence interval [CI] 0.389–1.819; p-value = 0.659). In the per protocol (PP) population, that is in participants attending at least three group-based sessions, SH + almost halved the frequency of mental disorders at 12 months compared to ETAU, however so few participants and events contributed to this analysis that it yielded a non-significant result (RR = 0.528; 95% CI 0.180–1.544; p-value = 0.230). SH + was associated with improvements at 12 months in psychological distress (p-value = 0.004), depressive symptoms (p-value = 0.011) and wellbeing (p-value = 0.001).
Conclusions
The present study failed to show any long-term preventative effect of SH + in refugees and asylum seekers resettled in Western European countries. Analysis of the PP population and of secondary outcomes provided signals of a potential effect of SH + in the long-term, which would suggest the value of exploring the effects of booster sessions and strategies to increase SH + adherence.
We introduce shadow structures for singular knot theory. Precisely, we define two invariants of singular knots and links. First, we introduce a notion of action of a singquandle on a set to define a shadow counting invariant of singular links which generalize the classical shadow colorings of knots by quandles. We then define a shadow polynomial invariant for shadow structures. Lastly, we enhance the shadow counting invariant by combining both the shadow counting invariant and the shadow polynomial invariant. Explicit examples of computations are given.
An encoder–decoder neural network has been used to examine the possibility for acceleration of a partial integro-differential equation, the Fokker–Planck–Landau collision operator. This is part of the governing equation in the massively parallel particle-in-cell code XGC, which is used to study turbulence in fusion energy devices. The neural network emphasizes physics-inspired learning, where it is taught to respect physical conservation constraints of the collision operator by including them in the training loss, along with the $\ell _2$ loss. In particular, network architectures used for the computer vision task of semantic segmentation have been used for training. A penalization method is used to enforce the ‘soft’ constraints of the system and integrate error in the conservation properties into the loss function. During training, quantities representing the particle density, momentum and energy for all species of the system are calculated at each configuration vertex, mirroring the procedure in XGC. This simple training has produced a median relative loss, across configuration space, of the order of $10^{-4}$, which is low enough if the error is of random nature, but not if it is of drift nature in time steps. The run time for the current Picard iterative solver of the operator is $O(n^2)$, where $n$ is the number of plasma species. As the XGC1 code begins to attack problems including a larger number of species, the collision operator will become expensive computationally, making the neural network solver even more important, especially since its training only scales as $O(n)$. A wide enough range of collisionality has been considered in the training data to ensure the full domain of collision physics is captured. An advanced technique to decrease the losses further will be subject of a subsequent report. Eventual work will include expansion of the network to include multiple plasma species.
In the UK, Black and minority ethnic (BME) patients have been reported to be disproportionately detained under the Mental Health Act.
Aims:
Systematic review of all UK literature on ethnicity and detention with meta-analysis of detention rates for BME patients, to determine range of explanatory hypotheses and examine the evidence for these hypotheses
Methods:
Electronic data bases searched for all date-based studies (1984-2005). Meta-analyses performed where data available. Explanations offered for any excess categorised and evidence examined.
Results:
49 studies identified, 19 included in meta-analyses. Compared with White patients, Blacks were 3.83 times, BME patients 3.35 times and Asians 2.06 times more likely to be detained. Racial stereotyping and discrimination against BME patients was the most often cited explanation (53% studies); followed by alienation and mistrust of psychiatric services (28%); higher rates of psychosis (22%); delay in help seeking (18%); and misdiagnosis/ under recognition of illness (16%). There was no primary evidence provided by any study to confirm any of these explanations, while some papers presented data that contradicted these explanations.
Conclusions:
BME patients experience higher rates of detention under the MHA than White patients. Available explanations offered for this excess are largely unsupported. Explanations such as ‘institutional racism’ in psychiatry neither accurately account for the excess, nor help find ways of reducing detention rates.
UK studies have reported disproportionate detentions of Black and minority ethnic (BME) patients under the Mental Health Act 1983 (MHA). We conducted a systematic review to examine the evidence for greater detention of BME patients within psychiatric services in the UK and to examine evidence offered for these explanations, including racism in psychiatry.
Methods:
Bibliographic databases were searched, descriptive analyses used to summarise studies and meta-analyses performed to produce pooled odds ratios. Possible sources of heterogeneity were investigated.
Results:
Meta-analysis revealed that BME patients were over three times (3.35), Black patients were nearly four times (3.83), and Asian patients are twice as likely (2.06) to be detained as compared to White patients, even when other predictors of detention were controlled. There was a striking lack of primary evidence to support most explanations to account for this excess.
Conclusions:
While there is robust evidence that BME status is an independent predictor of psychiatric detention in UK, the causes of this remain unclear. Many potential explanations for greater detention such as length and severity of illness, pre-morbid personality, subjective experiences of receiving psychiatric care, lack of a social support system that can provide alternatives to detention and the relationship between local service structure and detention rates have not been studied. A simple ‘race-based’ explanation has possibly been detrimental to understanding the true reasons behind this excess and need to be explored in better designed studies using mixed qualitative and quantities methods.
The aim of this presentation is to summarize the results of the published systematic reviews / meta-analyses of the randomized controlled trials that have investigated the effectiveness of medications for the treatment of obsessive compulsive disorder (OCD) in children/adolescents and adults and to present preliminary results from a new review study using network meta-analytical techniques
Methods
Medline, Cochrane database, and the register of controlled trials maintained by the Cochrane Collaboration Depression, Anxiety & Neurosis Group (CCDAN) were searched for relevant trials, systematic reviews and/or meta-analyses.
Results
Regarding the new review study we were able to extract 103 pharmacological arms (preliminary results: 9 for Fluoxetine, 16 for Fluvoxamine, 11 for Paroxetine, 10 for Sertraline, 16 for Clomipramine, 7 for Citalopram / escitalopram, 2 for Venlafaxine, and 32 for Placebo) with a total number of 6572 patients randomized. The previous meta-analyses have confirmed the efficacy for all SSRIs and Clomipramine in all age groups while for other drugs further evidence is required. In the context of this presentation preliminary results of the relative efficacy of each drug, using network meta-analysis techniques will also be reported.
Conclusions
Several antidepressants have established their efficacy and acceptability for the management of non-resistant OCD. The major weakness of the literature so far is that head to head comparisons between antidepressants are few and therefore it is difficult to establish a clear hierarchy of the efficacy and acceptability of the various agents. This gap in the present literature will be filled by the present review.
Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standardised difference in mean change of −1.11 (95% credible interval −1.62 to −0.60) for face-to-face CBT, −1.06 (−2.05 to −0.08) for hybrid CBT, and −0.59 (−1.20 to 0.02) for multimedia CBT, whereas wait list control showed a detrimental effect of 0.72 (0.09 to 1.35). We found no evidence of specific effects of any content components or combinations of components. Technology is increasingly used in the context of CBT interventions for depression. Multimedia and hybrid CBT might be as effective as face-to-face CBT, although results need to be interpreted cautiously. The effectiveness of specific combinations of content components and delivery formats remain unclear. Wait list controls should be avoided if possible.
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.
Methods
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.
Results
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.
Conclusions
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.
Health care reform has been stalled since the Clinton health care initiative, but the political difficulties internal to that initiative and the ethical problems that provoked it -- of cost, coverage, and overall fairness, for example -- have only gotten worse. This collection examines the moral principles that must underlie any new reform initiative and the processes of democratic decision-making essential to successful reform. This volume provides careful analyses that will allow the reader to short-circuit the mythmaking, polemics, and distortions that have too often characterized public discussion of health care reform. Its aim is to provide the moral foundations and institutional arrangements needed to drive any new health care initiative and so to stimulate a reasoned discussion before the next inevitable round of reform efforts.
Foreword by Thomas H. Murray. Contributors: Howard Brody, Norman Daniels, Theodore Marmor, Tobie H. Olsan, Uwe E. Reinhardt, Gerd Richter, Rory B. Weiner, Lawrence W. White
Wade L. Robison is the Ezra A. Hale Professor in Applied Ethics at the Rochester Institute of Technology and recipient of the Nelson A. Rockefeller Prize for Social Science and Public Policy for his book Decisions in Doubt: The Environment and Public Policy. Timothy H. Engström is Professor of Philosophy at the Rochester Institute of Technology and recipient of the Eisenhart Award for Outstanding Teaching.
African wild dogs (Lycaon pictus) occupy an ecological niche characterized by hypercarnivory and cursorial hunting. Previous interpretations drawn from a limited, mostly Eurasian fossil record suggest that the evolutionary shift to cursorial hunting preceded the emergence of hypercarnivory in the Lycaon lineage. Here we describe 1.9—1.0 ma fossils from two South African sites representing a putative ancestor of the wild dog. the holotype is a nearly complete maxilla from Coopers Cave, and another specimen tentatively assigned to the new taxon, from Gladysvale, is the most nearly complete mammalian skeleton ever described from the Sterkfontein Valley, Gauteng, South Africa. the canid represented by these fossils is larger and more robust than are any of the other fossil or extant sub-Saharan canids. Unlike other purported L. pictus ancestors, it has distinct accessory cusps on its premolars and anterior accessory cuspids on its lower premolars—a trait unique to Lycaon among living canids. However, another hallmark autapomorphy of L. pictus, the tetradactyl manus, is not found in the new species; the Gladysvale skeleton includes a large first metacarpal. Thus, the anatomy of this new early member of the Lycaon branch suggests that, contrary to previous hypotheses, dietary specialization appears to have preceded cursorial hunting in the evolution of the Lycaon lineage. We assign these specimens to the taxon Lycaon sekowei n. sp.
To evaluate the impact and burden of the new National Healthcare Safety Network surveillance definition, mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI), in hematology, oncology, and stem cell transplant populations.
Design
Retrospective cohort study.
Setting
Two hematology, oncology, and stem cell transplant units at a large academic medical center.
Methods
Central line–associated bloodstream infections (CLABSIs) identified during a 14-month period were reviewed and classified as MBI-LCBI or non-MBI-LCBI (MBI-LCBI criteria not met). During this period, interventions to improve central line maintenance were implemented. Characteristics of patients with MBI-LCBI and non-MBI-LCBI were compared. Total CLABSI, MBI-LCBI, and non-MBI-LCBI rates were compared between baseline and postintervention phases of the study period.
Results
Among 66 total CLABSI cases, 47 (71%) met MBI-LCBI criteria. Patients with MBI-LCBI and non-MBI-LCBI were similar in regard to most clinical and demographic characteristics. Between the baseline and postintervention study periods, the overall CLABSI rate decreased from 3.37 to 3.21 infections per 1,000 line-days (incidence rate ratio, 0.95; 4.7% reduction, P=.84), the MBI-LCBI rate increased from 2.08 to 2.61 infections per 1,000 line-days (incidence rate ratio, 1.25; 25.3% increase, P=.44), and the non-MBI-LCBI rate decreased from 1.29 to 0.60 infections per 1,000 line-days (incidence rate ratio, 0.47; 53.3% reduction, P=.12).
Conclusions
Most CLABSIs identified among hematology, oncology, and stem cell transplant patients met MBI-LCBI criteria, and CLABSI prevention efforts did not reduce these infections. Further review of the MBI-LCBI definition and impact is necessary to direct future definition changes and reporting mandates.
Oxidative stress and neurotrophic factors have been implicated in the pathophysiology of bipolar disorder. Our objective was to determine whether plasma glutathione or brain-derived neurotrophic factor (BDNF) levels were abnormal in bipolar disorder and therefore useful as possible biomarkers.
Method
Blood samples were collected from subsyndromal, medicated bipolar I patients (n = 50), recruited from OXTEXT, University of Oxford, and from 50 matched healthy controls. Total and oxidized glutathione levels were measured using an enzymatic recycling method and used to calculate reduced, percentage oxidized, ratio of reduced:oxidized and redox state. BDNF was measured using an enzyme-linked immunoassay. Self-monitored mood scores for the bipolar group were available (Quick Inventory of Depressive Symptomatology and the Altman Self-Rating Mania Scale) over an 8-week period.
Results
Compared with controls, bipolar patients had significantly lower levels of total glutathione and it was more oxidized. BDNF levels were not different. Age of illness onset but not current mood state correlated with total glutathione levels and its oxidation status, so that lower levels of total and reduced glutathione were associated with later onset of disease, not length of illness.
Conclusions
Plasma glutathione levels and redox state detect oxidative stress even in subsyndromal patients with normal BDNF. It may relate to the onset and development of bipolar disorder. Plasma glutathione appears to be a suitable biomarker for detecting underlying oxidative stress and for evaluating the efficacy of antioxidant intervention studies.
It is generally accepted that archaic humans of the African later Early and early Middle Pleistocene constituted the source population for anatomically modern humans. Due to limited fossil and archaeological records, however, relatively little is known about the morphology, behaviour and ecology of these presumed ancestors of modern humans. Fragmentary fossils (variously attributed to Homo heidelbergensis, H. rhodesiensis and H. helmei) from across Africa suggest that these archaic humans were both taller and more massive than their extant modern human descendants in this region, and perhaps had a body shape that was stockier and less ‘nilotic’ than seen among extant sub-Saharan Africans. Fragmentary fossils attributed to Homo sapiens, on the other hand, appear to represent individuals closer in body size to the means of recent sub-Saharan Africans. Since body size and shape are critical to the ecology, energetics and thermoregulatory adaptations of early humans, these differences in morphology may signal important adaptive changes at the time of the origins of modern humans. Comparative analyses of femoral and orbital dimensions support the claim that Middle Pleistocene Africans were of greater body size (both stature and mass) and had greater mass/stature ratios than modern Africans, and support the claim that early African H. sapiens were of smaller body size than their Middle Pleistocene ancestors.
Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome.
Method
Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard.
Results
Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85–0.88 v. 0.54–0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001).
Conclusions
The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.
We use spectral sequence techniques to compute centralizers of elements within graded Lie algebras, and the methods are then applied to the calculation of unique normal forms of elements within one-parameter matrix Liealgebras. A finiteness criterion for unique normal forms is presented.
Samples of yellow-fever vaccine prepared from homogenized chick embryos, and of an experimental measles vaccine prepared from chick embryo cells, have each been shown to contain a contaminant virus similar in properties to an avian leukosis virus. Young adult males injected with the yellow-fever vaccine did not develop neutralizing antibodies for Rous sarcoma virus.