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To evaluate broad-spectrum intravenous antibiotic use before and after the implementation of a revised febrile neutropenia management algorithm in a population of adults with hematologic malignancies.
Setting and population:
Patients admitted between 2014 and 2018 to the Adult Malignant Hematology service of an acute-care hospital in the United States.
Aggregate data for adult malignant hematology service were obtained for population-level antibiotic use: days of therapy (DOT), C. difficile infections, bacterial bloodstream infections, intensive care unit (ICU) length of stay, and in-hospital mortality. All rates are reported per 1,000 patient days before the implementation of an febrile neutropenia management algorithm (July 2014–May 2016) and after the intervention (June 2016–December 2018). These data were compared using interrupted time series analysis.
In total, 2,014 patients comprised 6,788 encounters and 89,612 patient days during the study period. Broad-spectrum intravenous (IV) antibiotic use decreased by 5.7% with immediate reductions in meropenem and vancomycin use by 22 (P = .02) and 15 (P = .001) DOT per 1,000 patient days, respectively. Bacterial bloodstream infection rates significantly increased following algorithm implementation. No differences were observed in the use of other antibiotics or safety outcomes including C. difficile infection, ICU length of stay, and in-hospital mortality.
Reductions in vancomycin and meropenem were observed following the implementation of a more stringent febrile neutropenia management algorithm, without evidence of adverse outcomes. Successful implementation occurred through a collaborative effort and continues to be a core reinforcement strategy at our institution. Future studies evaluating patient-level data may identify further stewardship opportunities in this population.
Can delusions, in the context of psychosis, enhance a person’s sense of meaningfulness? The case described here suggests that, in some circumstances, they can. This prompts further questions into the complexities of delusion as a lived phenomenon, with important implications for the clinical encounter. While assumptions of meaninglessness are often associated with concepts of ‘disorder’, ‘harm’ and ‘dysfunction’, we suggest that meaning can nonetheless be found within what is commonly taken to be incomprehensible or even meaningless. A phenomenological and value-based approach appears indispensable for clinicians facing the seemingly paradoxical coexistence of harmfulness and meaningfulness.
Mild cognitive impairment (MCI) and Alzheimer’s Disease (AD) prevalence is expected to continue to increase, due to the population ageing. MCI and AD may impact patients’ decision-making capacities, which should be assessed through the disease course. These medical conditions can affect the various areas of decision-making capacity in different ways. Decision-making capacity in healthcare is particularly relevant among this population. Elders often suffer from multimorbidity and are frequently asked to make healthcare decisions, which can vary from consenting a routine diagnostic procedure to decide receiving highly risk treatments.
To assess this capacity in elders with MCI or AD, we developed the Healthcare Decision-Making Capacity Assessment Instrument (IACTD-CS - Instrumento de Avaliação da Capacidade de Tomada de Decisão em Cuidados de Saúde). This project is funded by Portuguese national funding agency for science, research and technology, FCT (SFRH/BD/139344/2018). IACTD-CS was developed based on Appelbaum and Grisso four abilities model, literature review and review of international assessment instruments. After IACTD-CS first version development, an exploratory study with focus groups was conducted. This study included focus groups with healthcare professionals and nursing homes’ professionals.
The focus groups main goals were: 1) understand the participants perception regarding healthcare decision-making capacity, 2) distinguish relevant aspects of decision-making, 3) discuss the abilities and items included in IACTD-CS and 4) identify new aspects or items to be added to IACTD-CS. A content analysis of the focus groups results, with resource to MAXQDA, was conducted afterwards. This exploratory study allowed to identify professionals’ perceptions on healthcare decision-making and its results were a significant contribute to IACTD-CS development. The proposed communication aims to describe the methodology used and present the results of content analysis.
To characterize associations between exposures within and outside the medical workplace with healthcare personnel (HCP) SARS-CoV-2 infection, including the effect of various forms of respiratory protection.
We collected data from international participants via an online survey.
In total, 1,130 HCP (244 cases with laboratory-confirmed COVID-19, and 886 controls healthy throughout the pandemic) from 67 countries not meeting prespecified exclusion (ie, healthy but not working, missing workplace exposure data, COVID symptoms without lab confirmation) were included in this study.
Respondents were queried regarding workplace exposures, respiratory protection, and extra-occupational activities. Odds ratios for HCP infection were calculated using multivariable logistic regression and sensitivity analyses controlling for confounders and known biases.
HCP infection was associated with non–aerosol-generating contact with COVID-19 patients (adjusted OR, 1.4; 95% CI, 1.04–1.9; P = .03) and extra-occupational exposures including gatherings of ≥10 people, patronizing restaurants or bars, and public transportation (adjusted OR range, 3.1–16.2). Respirator use during aerosol-generating procedures (AGPs) was associated with lower odds of HCP infection (adjusted OR, 0.4; 95% CI, 0.2–0.8, P = .005), as was exposure to intensive care and dedicated COVID units, negative pressure rooms, and personal protective equipment (PPE) observers (adjusted OR range, 0.4–0.7).
COVID-19 transmission to HCP was associated with medical exposures currently considered lower-risk and multiple extra-occupational exposures, and exposures associated with proper use of appropriate PPE were protective. Closer scrutiny of infection control measures surrounding healthcare activities and medical settings considered lower risk, and continued awareness of the risks of public congregation, may reduce the incidence of HCP infection.
Functional impairment is a defining feature of psychotic disorders. A range of factors has been shown to influence functioning, including negative symptoms, cognitive performance and cognitive reserve (CR). However, it is not clear how these variables may affect functioning in first-episode psychosis (FEP) patients. This 2-year follow-up study aimed to explore the possible mediating effects of CR on the relationship between cognitive performance or specific clinical symptoms and functional outcome.
A prospective study of non-affective FEP patients was performed (211 at baseline and 139 at follow-up). CR was entered in a path analysis model as potential mediators between cognitive domains or clinical symptoms and functioning.
At baseline, the relationship between clinical variables or cognitive performance and functioning was not mediated by CR. At follow-up, the effect of attention (p = 0.003) and negative symptoms (p = 0.012) assessed at baseline on functioning was partially mediated by CR (p = 0.032 and 0.016), whereas the relationship between verbal memory (p = 0.057) and functioning was mediated by CR (p = 0.014). Verbal memory and positive and total subscales of PANSS assessed at follow-up were partially mediated by CR and the effect of working memory on functioning was totally mediated by CR.
Our results showed the influence of CR in mediating the relationship between cognitive domains or clinical symptoms and functioning in FEP. In particular, CR partially mediated the relationship between some cognitive domains or clinical symptoms and functioning at follow-up. Therefore, CR could improve our understanding of the long-term functioning of patients with a non-affective FEP.
Aggressive behaviour is a highly prevalent and devastating condition in autism spectrum disorder resulting in impoverished quality of life. Gold-standard therapies are ineffective in about 30% of patients leading to greater suffering. We investigated cortical thickness in individuals with autism spectrum disorder with pharmacological-treatment-refractory aggressive behaviour compared with those with non-refractory aggressive behaviour and observed a brain-wide pattern of local increased thickness in key areas related to emotional control and overall decreased cortical thickness in those with refractory aggressive behaviour, suggesting refractoriness could be related to specific morphological patterns. Elucidating the neurobiology of refractory aggressive behaviour is crucial to provide insights and potential avenues for new interventions.
Mixed Bipolar patients are those who have co-existing depressive symptoms during mania. These patients are supposed to have a worse evolution.
The objective of this study was to compare the long-term outcomes of patients who had at least one mixed episode with those who experienced only pure manic episodes.
169 outpatients diagnosed of Bipolar I disorder and treated at least during two years were included. 120 patients (71%) complited the follow-up over 10 years. Baseline demographic and clinical variables were included.
The patients with mixed episodes (37%) had a significantly younger mean age at onset comparing with those with manic episodes (25.3 years vs. 30.8 years; p=0.025) they also had more previous mood- incongruent psychotic symptoms χ2= 6.77, p=0.034), more number of hospitalizations (OR= 1.36, 95% CI = 1.14; -1.63; p< 0.001), and more number of episodes (OR= 1.21, 95% CI = 1.10-1.31; p< 0.001). There were no significant differences relating to depressive episodes, alcohol use, drug abuse, suicidal behaviour and suicide attempts.
Age at onset differed significantly between the mixed episode and pure mania groups, with mixed episode patients having a younger age of onset. This is interesting as one of the major results of the study we have found that age at onset mediates some of the factors classically related to outcome in mixed episodes like alcohol abuse and suicide attempts. However, independently of age at onset, these patients represent a especially severe type of bipolar disorder.
The impact of Idiopathic Parkinson Disease (IPD) in patient’s sexual health is still a matter of debate. Clinicians should have a concern about the sexual function of their patients with IPD.
To evaluate sexual health of patients with IPD.
We randomly select a group of IPD patients and a group of healthy controls. We used the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) to assess sexual function. To evaluate depression and anxiety we used Brief Symptom Inventory (BSI) and Beck Depression Index (BDI).
We had 83 IPD patients, and 69 controls. Male patients had lower total IIEF scores than controls (p< 0,001). The analysis of linear regression shows a relationship between the IIFE and the duration of the disease, the patient age and the BDI score (R=0,72; Adjusted R square=0,49, p< 0,001) when adjusted to the variables: realization of deep brain cirurgy of subthalamic nucleus (DBS-STN) stage of the disease, BSI score, dopaminergic treatment, treatment with antidepressives and antipsychotics. The IFSF didn’t show differences between the cases and the controls. Patients had higher BSI and BDI scores than controls (p< 0,001).
Male IPD patients had an impairment of sexual function predicted by disease duration, patient age and BDI scores. Sexual function should be assessed in these patients
Recent studies have shown that N-acetyl-cysteine added to neuroleptics might ameliorate negative and positive symptoms in schizophrenia. This could be related to the ability to interact with the cysteine/glutammate antiporter and to restore the intraneuronal rate of reduced gluthatione. This could also lead to an improvement of cognitive-executive functions.
The aim of our study is the evaluation of co-administration of N-acetyl-cysteine (NAC) in cognitive functions in a sample of patients affected by schizophrenia diagnosed according to DSM IV-TR criteria, and treated with stable atypical antipsychotic therapy.
Materials & methods
We administered NAC (1800 mg/die) to 12 male patients, tested each patient at baseline and re-tested after 90 days using a battery of neurocognitive tests (Wisconsin Card Sorting Test, Verbal Fluency Test, Stroop Test) and PANSS scale for severity symptomatology evaluation. The results obtained in each test at baseline were compared with those at the end of the study.
A significant improvement for WCST error numbers (sig. 0.049), VFT fonemic (sig. 0.049), PANSS positive (sig. 0.028), negative (sig. 0.002) and total (sig. 0.024) was observed.
WCST error nr
ΔT Stroop Test
Statistical correlations day 0-day 90 (sig. ≤ 0.05)
Our results show that co-administration of N-acetyl-cysteine added to atypical antipsychotic therapy improves the cognitive-executive functions. The effectiveness on reducing positive and negative symptoms was confirmed.
Apathy could be considered as the reduction or loss of capacity to plan, organize and make emotionally motivated behaviours. It is related to an altered functioning of prefrontal cortex; and it can be found in many both psychiatric and neurological disorders, although temperamental traits of apathy could be identified also in healthy subjects.
The aim of our study is to assess the degree of apathetic dimension in healthy subjects and its correlation with the cognitive-executive functioning.
Materials and methods
Healthy subjects of both sex (n=50) were evaluated with Wisconsin Card SortingTest (WCST), Stroop Color/Word InterferenceTest and AB-AC Test for the neurocognitive assessment; the Apathy Evaluation Scale (AES) was used to quantify the degree of apathy.
Positive correlation between the degree of apathy and the number of WCST perseverations were observed (ρ=0.022), no correlations between the Stroop Test (ρ=0.702) and the AB-AC Test (ρ=0.448) with Apathy Evaluation Scale were observed.
Our study demonstrated that apathy is related to widespread prefrontal cortex functioning in healthy subjects, but not with specific areas of prefrontal cortex.
About 20-25% of children diagnosed as affected by ADHD show in adulthood residual symptoms such as hyperactivity, impulsive behaviours and disattention with a variable degree of cognitive impairment, and are diagnosed as affected by a cluster B personality disorder (mostly antisocial or borderline).
The aim of our study is the evaluation of the presence of ADHD and cognitive-executive functions in patients with Borderline Personality Disorder (BPD).
Materials & methods
We enrolled 54 adult male patients with BPD diagnosis (mean age 40,6 years). The Wender Utah Rating Scale 25-items (WURS) was used to assess the presence of ADHD in childhood. The neurocognitive assessment included the following tests: Wisconsin Card Sorting Test (WCST), Stroop Color/Word Interference Test, Verbal Fluency Test (VFT), AB-AC Test.
From scores obtained at WURS 25-items (cut-off score ≥ 46) the observed frequency of subjects with childhood ADHD was 27.8% (15/54). Therefore the subjects were divided into two groups: BPD without ADHD and borderline ADHD. Scores obtained were compared and statistical significance was observed in regard to WCST (p=0.006), VFT fonemic (p=0.04), VFT semantic (p= 0.05), AB-AC test (p=0.05).
Our study shows that borderline subjects with childhood ADHD have worse cognitive performances than borderline subjects without childhood ADHD.
Both oxidative stress and the inflammatory chemokine MCP-1 have been linked to the pathophysiology of certain mental illnesses such as psychosis. There are previous studies in rats and dogs suggesting that oxidative stress can cause cognitive impairment.
To correlate oxidative stress and the chemokine MCP-1 levels with cognitive impairment in first episode psychosis.
28 patients with first episode psychosis and 28 healthy controls matched by sex and age were included in the study, who were given a battery of neurocognitive tests and we determined their blood levels of lipid peroxidation (TBARS), nitric oxide, total antioxidant status (TAS), glutathione, activity of enzymes catalase (CAT), glutathione peroxidase (cGPx) and superoxide dismutase (SOD) and the inflammatory chemokine MCP-1.
Healthy controls had better TAS than patients and increased activity of enzymes cGPx and CAT.
We found a statistically significant negative relationship between levels of MCP-1 and working memory, attention and verbal memory. At higher levels of chemokines, worse cognitive functioning in these areas.
Verbal memory was also negatively related, in a meaningful way, with nitric oxide levels in blood.
Likewise, we found that higher levels of glutathione correlated with better scores on the 3 tests performed of verbal fluency.
In patients with a PEP, levels of certain markers of oxidative stress and inflammation are associated with poorer cognitive functioning.
The changes in sexual health of patients with Parkinson's disease must be a concern to the clinicians. The effects in sexual health of patients submitted to functional cirurgy is still a matter of debate.
To describe and evaluate the sexual health of patients with Parkinson's disease following deep brain stimulation (DBS) of the subthalamic nucleus (STN).
Patients with Parkinson's disease bilaterally implanted for DBS of STN and those only pharmacologically treated, will be evaluated. Sexual functioning will be assessed using the international erectile function indices (IEFI) and the female sexual function indices (FSFI). Depression and anxiety will be evaluated using the Beck depression inventory and the brief symptom indices. Relations between sexual functioning and modifications in the severity of disease (Hoehn and Yahr stage), reduction in levodopa equivalent daily dosage (LEDD), age, and duration of disease will be analyzed.
Results and conlusions:
We expect to find positive changes in the sexual health of these patients, given the fact of the procedure improve the overall burden of the disease by reduction of medication and motor symptoms.
A connection between balance system dysfunction and Agoraphobia (AG) in Panic Disorder (PD) has been found. Balance control of many patients with PD and AG rely mainly on visual cues (visual dependence) and moving visual stimuli in their peripheral visual field induce postural instability and anxiety. These features may maintain agoraphobic symptoms after standard treatments.
To study whether balance rehabilitation with moving peripheral visual stimuli would benefit patients with PD and AG not fully responders to standard treatments.
Six patients with PD and AG were included. Inclusion criteria: 1) panic-phobic symptoms despite adequate treatments (SSRIs for at least 3 months; cognitive behavioral therapy) and 2) balance dysfunction with instability during peripheral visual stimuli (posturography with and without peripheral visual stimulation).
The patients went through 10 sessions (3 sessions/week) of balance rehabilitation: static and dynamic exercises, with movements of eyes and head, during projection of peripheral visual stimuli (video-films, 32 times-accelerated, on large lateral screens). Descriptive and non-parametric analyses were applied.
After rehabilitation, the patients showed significant improvement both in panic-phobic symptoms (specific psychometric scale scores) (p < 0.05) and in balance performance (post-rehabilitation posturography with and without peripheral visual stimulation) (p < 0.05).
Balance rehabilitation with peripheral visual stimuli may increase the efficacy of standard treatments in patients with PD and AG and visual-balance dysfunction. Mechanisms of physical and emotional habituation to environmental destabilizing stimuli may be involved. Further larger and controlled studies are warranted.
Evidence has suggested that immune imbalance is involved with bipolar disorder (BD); however, its precise mechanism is poorly understood.
This study investigated whether biochemical changes in the serum from BD patients could modulate the phenotype of macrophages.
Eighteen subjects with BD and healthy individuals (n = 5) were included in this study. The human monocyte cell line U-937 was activated with PMA (phorbol 12-myristate 13-acetate) and polarization was induced with RPMI-1640 media supplemented with 10% serum from each patient for 24 h. Gene expression of selected M1 and M2 markers was assessed by qPCR.
Macrophages exposed to serum of manic and depressive BD patients displayed an increase of IL-1β (6.40 ± 3.47 and 9.04 ± 5.84 versus 0.23 ± 0.11; P < 0.05) and TNF-α (2.23 ± 0.91 and 2.03 ± 0.45 versus 0.62 ± 0.24; P = 0.002 and P = 0.004, respectively) compared to remitted group. In parallel, U-937 macrophages treated with serum of patients in acute episode displayed a down-regulation of CXCL9 (0.29 ± 0.20 versus 1.86 ± 1.61; P = 0.006) and CXCL10 expression (0.36 ± 0.15 and 0.86 ± 0.24 versus 1.83 ± 0.88; P < 0.000 and P = 0.04) compared to remitters.
Our results are consistent with previous studies showing that changes in peripheral blood markers could modulate M1/M2 polarization in BD. The evidence of macrophages as source of inflammatory cytokines might be helpful to unravel how the mononuclear phagocyte system can be involved in the etiology of BD.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Economic crises have consequences on labor market, with impacts on mental health (MH) and psychological well-being (PWB). We describe the effectiveness of an intervention among unemployed, performed within EEA Grants Healthy Employment project.
Evaluate the effectiveness of an intervention for MH literacy, PWB and resilience among unemployed.
MH and PWB promotion, common mental disorders prevention and inequalities reduction linked to unemployment.
A five modules intervention (life-work balance; impact of unemployment on PWB and MH; stigma; depression and anxiety; health promotion) distributed by 20 hours was developed based on literature reviews and a Delphi panel. It was delivered to unemployees from two public employment centers (PECs). Inclusion criteria: 18–65 years old; registration in PEC for less than a year; minimum of nine years of formal education. Control groups from the same PECs received the care-as-usual. Measures of psychological WB, MH self-reported symptoms, life satisfaction, resilience and mental health literacy were collected through an online survey before and one week after intervention.
Overall, 87 unemployed participated, 48% allocated to the intervention group (IG); 56% women (21–64 years old), average education was 15 years. Mixed measures ANOVA showed that the interaction between time and group was significant for PWB and MH literacy measures. The IG showed better self-reported PWB and improved MH literacy after intervention, compared to controls. No significant interactions were found for MH symptoms, life satisfaction and resilience.
This study shows the contribution of short-term community-based interventions in increasing MH literacy and PWB among unemployed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.