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To examine the costs and cost-effectiveness of mirtazapine compared to placebo over 12-week follow-up.
Economic evaluation in a double-blind randomized controlled trial of mirtazapine vs. placebo.
Community settings and care homes in 26 UK centers.
People with probable or possible Alzheimer’s disease and agitation.
Primary outcome included incremental cost of participants’ health and social care per 6-point difference in CMAI score at 12 weeks. Secondary cost-utility analyses examined participants’ and unpaid carers’ gain in quality-adjusted life years (derived from EQ-5D-5L, DEMQOL-Proxy-U, and DEMQOL-U) from the health and social care and societal perspectives.
One hundred and two participants were allocated to each group; 81 mirtazapine and 90 placebo participants completed a 12-week assessment (87 and 95, respectively, completed a 6-week assessment). Mirtazapine and placebo groups did not differ on mean CMAI scores or health and social care costs over the study period, before or after adjustment for center and living arrangement (independent living/care home). On the primary outcome, neither mirtazapine nor placebo could be considered a cost-effective strategy with a high level of confidence. Groups did not differ in terms of participant self- or proxy-rated or carer self-rated quality of life scores, health and social care or societal costs, before or after adjustment.
On cost-effectiveness grounds, the use of mirtazapine cannot be recommended for agitated behaviors in people living with dementia. Effective and cost-effective medications for agitation in dementia remain to be identified in cases where non-pharmacological strategies for managing agitation have been unsuccessful.
Barrett’s oesophagus (BE) is the precursor of oesophageal adenocarcinoma, which has become the most common type of oesophageal cancer in many Western populations. Existing evidence on diet and risk of BE predominantly comes from case–control studies, which are subject to recall bias in measurement of diet. We aimed to investigate the potential effect of diet, including macronutrients, carotenoids, food groups, specific food items, beverages and dietary scores, on risk of BE in over 20 000 participants of the Melbourne Collaborative Cohort Study. Diet at baseline (1990–1994) was measured using a food frequency questionnaire. The outcome was BE diagnosed between baseline and follow-up (2007–2010). Logistic regression models were used to estimate OR and 95 % CI for diet in relation to risk of BE. Intakes of leafy vegetables and fruit were inversely associated with risk of BE (highest v. lowest quartile: OR = 0·59; CI: 0·38, 0·94; P-trend = 0·02 and OR = 0·58; CI: 0·37, 0·93; P-trend = 0·02 respectively), as were dietary fibre and carotenoids. Stronger associations were observed for food than the nutrients found in them. Positive associations were observed for discretionary food (OR = 1·54; CI: 0·97, 2·44; P-trend = 0·04) and total fat intake (OR per 10 g/d = 1·11; CI: 1·00, 1·23), the association for fat was less robust in sensitivity analyses. No association was observed for meat, protein, dairy products or diet scores. Diet is a potential modifiable risk factor for BE. Public health and clinical guidelines that incorporate dietary recommendations could contribute to reduction in risk of BE and, thereby, oesophageal adenocarcinoma.
Nitrogen fixation from pasture legumes is a fundamental process that contributes to the profitability and sustainability of dryland agricultural systems. The aim of this research was to determine whether well-managed pastures, based on aerial-seeding pasture legumes, could partially or wholly meet the nitrogen (N) requirements of subsequent grain crops in an annual rotation. Fifteen experiments were conducted in Western Australia with wheat, barley or canola crops grown in a rotation that included the pasture legume species French serradella (Ornithopus sativus), biserrula (Biserrula pelecinus), bladder clover (Trifolium spumosum), annual medics (Medicago spp.) and the non-aerial seeded subterranean clover (Trifolium subterraneum). After the pasture phase, five rates of inorganic N fertilizer (Urea, applied at 0, 23, 46, 69 and 92 kg/ha) were applied to subsequent cereal and oil seed crops. The yields of wheat grown after serradella, biserrula and bladder clover, without the use of applied N fertilizer, were consistent with the target yields for growing conditions of the trials (2.3 to 5.4 t/ha). Crop yields after phases of these pasture legume species were similar or higher than those following subterranean clover or annual medics. The results of this study suggest a single season of a legume-dominant pasture may provide sufficient organic N in the soil to grow at least one crop, without the need for inorganic N fertilizer application. This has implications for reducing inorganic N requirements and the carbon footprint of cropping in dryland agricultural systems.
Experiential learning, such as simulation-based training, is widely used in health education. Dramatic self-expression adds another layer through enacted perspective taking, and embodied self-exploration of interaction with others, to foster situated learning. We describe the evaluation of an innovative drama-based experiential learning project involving collaboration between multidisciplinary mental healthcare staff and people with lived experience of mental illness. The programme was facilitated at East London NHS Foundation Trust by a theatre company experienced in delivering workshops with service users. A weekly group programme took place online over 8 weeks during the COVID-19 pandemic and included activities of improvisation, embodied enactments and debriefing. The programme led to co-production of a drama piece that was filmed and distributed online. It was hypothesised that the experiential learning might result in individual benefits for all participants, such as improved well-being and increased mutual understanding of each other's experience of mental health care. The project aimed to improve relationships between healthcare disciplines, and between staff and service users. Additionally, aims were to empower service users, and support staff to practice core interpersonal skills. Objectives of the evaluation were to study the impact of the experiential learning, understand participants’ experience, and explore challenges and benefits.
A mixed methods approach was taken to evaluate the programme. Following completion of the project, participants were invited to complete a questionnaire utilising a Likert scale rating of overall satisfaction with the project, perceived benefit and impact on specific domains such as working with others. One-to-one semi-structured interviews were conducted according to a topic-guide, and qualitative data were analysed using open & axial coding for thematic analysis.
11 participants, including Psychiatrists, Occupational Therapists and current service users, completed the experiential learning and filming. Questionnaire data suggested participants were highly satisfied with the learning and felt it would be valuable to others. Themes include the positive experience of creativity, dismantling of hierarchy, improved empathy, confidence and connection. Potential challenges were digital inequality and lack of dedicated time for professional development.
A drama-based experiential learning group programme for healthcare staff and service users is a highly beneficial learning experience. Participants describe changes on a personal level as well as improved understanding of others’ perspectives. This form of experiential learning features collaborative working that aligns with principles of co-production and supports the development of interpersonal skills; the findings suggest that drama-based experiential learning is a useful method in health education to complement knowledge acquisition.
The western Antarctic Peninsula is facing rapid environmental changes and many recent publications stress the need to gain new knowledge regarding ecosystems responses to these changes. In the framework of the Belgica 121 expedition, we tested the use of a nimble vessel with a moderate environmental footprint as an approach to tackle the urgent needs of the Southern Ocean research community in terms of knowledge regarding the levels of marine biodiversity in shallow areas and the potential impacts of retreating glaciers on this biodiversity in combination with increasing tourism pressure. We discuss the strengths and drawbacks of using a 75’ (23 m) sailboat in this research framework, as well as its sampling and environmental efficiency. We propose that the scientific community considers this approach to 1) fill specific knowledge gaps and 2) improve the general coherence of the research objectives of the Antarctic scientific community in terms of biodiversity conservation and the image that such conservation conveys to the general public.
A field experiment was conducted in 2019 and 2020 including a total of six site-years and four locations in Arkansas to determine the optimal sequence and timing of dicamba and glufosinate applications when applied alone, sequentially, or in combination to control Palmer amaranth by size: labeled (<10-cm height) and non-labeled (13- to 25-cm height). Single applications of dicamba, glufosinate, and dicamba plus glufosinate (not labeled) resulted in less than 80% Palmer amaranth control, regardless of weed size. The mixture of dicamba plus glufosinate was antagonistic for Palmer amaranth control and percent mortality. Sequential applications, averaged over all time intervals and herbicides, improved the percentage of Palmer amaranth control 11 to 17 percentage points over a single application, regardless of weed size at application 28 d after final application (DAFA). Palmer amaranth control with glufosinate followed by (fb) glufosinate and dicamba fb dicamba, pending weed size, were optimized at 7-, and 14- to 21-day intervals, respectively. Since single site of action (SOA) postemergence systems increase the likelihood of resistant biotypes and are not a best management practice (BMP) in that regard, sequential applications involving both dicamba and glufosinate were more effective. Further the sequence of application mattered with a preference for applying dicamba first. Dicamba fb glufosinate at a 14-day interval was profit-maximizing and the only herbicide treatment that resulted in 100% weed control when size was <10-cm. For larger weed sizes, economic analysis revealed dicamba fb dicamba to perform better than dicamba fb glufosinate when no penalty was assigned for using a single SOA. This resulted in greater yield loss risk and soil weed seed bank in comparison to timelier weed control with the smaller weed size. Hence timely weed control and two SOA to control Palmer amaranth are recommended as BMPs that reduce producer risk.
The first paleontological surveys of the Mullu basin in the Somali Region (Figure 20.1A,B) were conducted by Yohannes Haile-Selassie and colleagues in 1997. They collected several isolated hominin teeth, preliminarily attributed to Australopithecus anamensis, and a few other large mammal remains in the Galili area in the southern Afar depression of Ethiopia (Haile-Selassie and Asfaw, 2000). Subsequently, between 2000 and 2009, the International Paleoanthropological Research Team consisting of Ethiopian, Austrian, American, Italian, and German anthropologists, paleontologists, and geologists recovered and catalogued more than 2000 vertebrate fossils from Galili sites (Figure 20.1C) during annual field seasons. Besides a number of fish, reptile, bird, and small mammal remains, a great variety of large mammal species, including primates, carnivores, proboscideans, perissodactyls, and artiodactyls have been found (Kullmer et al.
Palmer amaranth is a common weed on levees in rice fields but has become increasingly problematic with the adoption of furrow-irrigated rice and lack of an established flood. Florpyrauxifen-benzyl previously has been found effective for controlling Palmer amaranth in rice, but the efficacy of low rates of florpyrauxifen-benzyl and the effect of Palmer amaranth size on controlling it is unknown. The objective of this research was to determine the level of Palmer amaranth control expected with single and sequential applications of florpyrauxifen-benzyl at varying weed heights. The first study was conducted near Marianna, AR, in 2019 and 2020, to determine the effect of florpyrauxifen-benzyl rate on control of <10 cm (labeled size) and 28- to 32-cm-tall (larger-than-labeled size) Palmer amaranth. The second experiment was conducted in 2020 at two locations in Arkansas to compare single applications of florpyrauxifen-benzyl at low rates to sequential applications at the same rates with a 14-d interval on 20- and 40-cm-tall Palmer amaranth. Results revealed that florpyrauxifen-benzyl at 15 g ae ha−1 was as effective as 30 g ae ha−1 in controlling <10-cm-tall Palmer amaranth (92% and 95% mortality in 2019). Sequential applications of florpyrauxifen-benzyl at 8 g ae ha−1 were as effective as single or sequential applications at 30 g ae ha−1. However, no rate of florpyrauxifen-benzyl applied to 20- or 40-cm-tall Palmer amaranth was sufficient to provide season-long control of the weed, with the escaping female plants producing as many as 6,120 seed per plant following a single application.
The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.
The ability of weed populations to evolve resistance to herbicides affects management strategies and the profitability of crop production. The objective of this research was to screen Palmer amaranth accessions from Arkansas for glufosinate resistance. Additional efforts focused on the effectiveness of various herbicides, across multiple sites of action (SOAs), on each putative-resistant accession. The three putative accessions were selected from 60 Palmer amaranth accessions collected in 2019 and 2020 and screened with to 0.5× and 1× rates of glufosinate. A dose-response experiment was conducted for glufosinate on accessions A2019, A2020, and B2020. The effectiveness of various preemergence- and postemergence-applied herbicides were evaluated on each accession. Resistance ratios of A2019, A2020, and B2020 to glufosinate ranged from 5.1 to 27.4 when comparing LD50 values to two susceptible accessions, thus all three accessions were resistant to glufosinate. All three accessions (A2019, A2020, and B2020) were found to have a reduction equal to or greater than 20 percentage points in mortality to at least one herbicide from five different SOAs equal to or greater than five sites of action. Herbicides from nine different SOAs controlled A2019 at least 20 percentage points less than the susceptible accessions, which points to a need for additional research to characterize the response of this accession.
Risk and risk management are essential elements of farming. We show that strategies to cope with risk often go beyond the level of the individual farm. Cooperation, learning and sharing of risks play a vital role in European agriculture. An enabling environment should support cooperative approaches, enable a diversity of risk management solutions and harness novel technological opportunities.
Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy.
In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures.
79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%).
Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.
Paediatric residents are often taught cardiac anatomy with two-dimensional images of heart specimens, or via imaging such as echocardiography or computed tomography. This study aimed to determine if the use of a structured, interactive, teaching session using heart specimens with CHD would be effective in teaching the concepts of cardiac anatomy.
The interest amongst paediatric residents of a cardiac anatomy session using heart specimens was assessed initially by circulating a survey. Next, four major cardiac lesions were identified to be of interest: atrial septal defect, ventricular septal defect, tetralogy of Fallot, and transposition. A list of key structures and anatomic concepts for these lesions was developed, and appropriate specimens demonstrating these features were identified by a cardiac morphologist. A structured, interactive, teaching session was then held with the paediatric residents using the cardiac specimens. The same 10-question assessment was administered at the beginning and end of the session.
The initial survey demonstrated that all the paediatric residents had an interest in a cardiac anatomy teaching session. A total of 24 participated in the 2-hour session. The median pre-test score was 45%, compared to a median post-test score of 90% (p < 0.01). All paediatric residents who completed a post-session survey indicated that the session was a good use of educational time and contributed to increasing their knowledge base. They expressed great interest in future sessions.
A 2-hour hands-on cardiac anatomy teaching session using cardiac specimens can successfully highlight key anatomic concepts for paediatric residents.
The importance of studying the radiocarbon content of dissolved inorganic carbon (DI14C) in the oceans has been recognized for decades. Starting with the GEOSECS program in the 1970s, 14C sampling has been a part of most global survey programs. Early results were used to study air-sea gas exchange while the more recent results are critical for helping calibrate ocean general circulation models used to study the effects of climate change. Here we summarize the major programs and discuss some of the important insights the results are starting to provide.
In March 2020, New York City (NYC) became the epicenter of the COVID-19 pandemic in the United States (US). As healthcare facilities were overwhelmed with patients, the Jacob K. Javits Convention Center was transformed into the nation’s largest alternate care site (ACS): Javits New York Medical Station (Javits). Protecting healthcare workers during a global shortage of personal protective equipment (PPE) in a non-traditional healthcare setting posed unique challenges. We describe components of the healthcare worker safety program implemented at Javits.
Javits, a large convention center transformed into a field hospital, with clinical staff from the US Public Health Service Commissioned Corps (USPHS) and the Department of Defense (DoD).
Healthcare Worker Safety Methods:
Key strategies included ensuring one-way flow of traffic on and off the patient floor; developing a matrix detailing PPE required for each work activity and location; PPE extended use and reuse protocols; personnel training; and monitoring adherence to PPE donning/doffing protocols when entering or exiting the patient floor. Javits staff who reported COVID-19 symptoms were immediately isolated, monitored, and offered a SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) test.
A well-designed and implemented healthcare worker safety plan can minimize the risk of SARS-CoV-2 infection for healthcare workers. The lessons learned from operating the nation’s largest COVID-19 ACS can be adapted to other environments during public health emergencies.
Optimizing needleless connector hub disinfection practice is a key strategy in central-line–associated bloodstream infection (CLABSI) prevention. In this mixed-methods evaluation, 3 products with varying scrub times were tested for experimental disinfection followed by a qualitative nursing assessment of each.
Needleless connectors were inoculated with varying concentrations of Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus followed by disinfection with a 70% isopropyl alcohol (IPA) wipe (a 15-second scrub time and a 15-second dry time), a 70% IPA cap (a 10-second scrub time and a 5-second dry time), or a 3.15% chlorhexidine gluconate with 70% IPA (CHG/IPA) wipe (a 5-second scrub time and a 5-second dry time). Cultures of needleless connectors were obtained after disinfection to quantify bacterial reduction. This was followed by surveying a convenience sample of nursing staff with intensive care unit assignments at an academic tertiary hospital on use of each product.
All products reduced overall bacterial burden when compared to sterile water controls, however the IPA and CHG/IPA wipes were superior to the IPA caps when product efficacy was compared. Nursing staff noted improved compliance with CHG/IPA wipes compared with the IPA wipes and the IPA caps, with many preferring the lesser scrub and dry times required for disinfection.
Achieving adequate bacterial disinfection of needleless connectors while maximizing healthcare staff compliance with scrub and dry times may be best achieved with a combination CHG/IPA wipe.
Exposure to infected healthcare workers (HCWs) is a source of hospital-acquired (HA) influenza. We estimated the risk of HA influenza for hospitalized patients by rate of influenza vaccine coverage (IVC) of HCWs.
A case–case negative control study nested in a prospective cohort was conducted in 2 French university hospitals during 2 influenza seasons. Each inpatient with influenza-like illness (ILI) provided a nasal swab sample that was systematically analyzed for influenza virus by polymerase chain reaction (PCR) testing. An HA influenza case was a patient with a virological confirmation of influenza with onset of symptoms ≥72 hours after admission to the ward. The IVC rate of HCWs in each participating ward was calculated from the data provided by the occupational health departments. A mixed-effect logistic regression was performed with adjustments on patient sex, age, the presence of a potential source of influenza on the ward in the 5 days prior to the start of the ILI, type of ward and influenza season.
The overall HA influenza attack rate was 1.9 per 1,000 hospitalized patients. In total, 24 confirmed HA influenza cases and 141 controls were included. The crude odds ratio (OR) of HA influenza decreased from 0.52 (95% confidence interval [CI], 0.21–1.29) to 0.14 (95% CI, 0.03–0.63) when the IVC of HCWs increased from 20% to 40%. After adjustment, IVC ≥40% was associated with a risk reduction of HA influenza (aOR, 0.07; 95% CI, 0.01–0.78).
Considering a limited sample size, influenza vaccination of HCWs is highly suggestive of HA flu prevention among hospitalized patients.
OBJECTIVES/GOALS: Heart failure (HF) is a clinical condition that notably affects the lives of patients in rural areas. The partnering of a rural satellite hospital with an urban academic medical center may provide geographically underrepresented populations with HF an opportunity to access controlled clinical trials (CCTs). METHODS/STUDY POPULATION: We report our experience in screening, consenting and enrolling subjects at the VCU Health Community Memorial Hospital (VCU-CMH) in rural South Hill, Virginia, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospitals (VCU-MCV), Richmond, VA. Subjects were enrolled in a clinical trial sponsored by the National Institutes of Health (ClinicalTrials.gov: NCT03797001) and assigned to treatment with an anti-inflammatory drug for HF or placebo. We used the electronic health record and remote guidance and oversight from the VCU-MCV resources using a closed-loop communication network to work with local resources at the facility to perform screening, consenting and enrollment. RESULTS/ANTICIPATED RESULTS: One hundred subjects with recently decompensated HF were screened between January 2019 and August 2021, of these 61 are enrolled to date: 52 (85 %) at VCU-MCV and 9 (15%) at VCU-CMH. Of the subjects enrolled at VCU-CMH, 33% were female, 77% Black, with a mean age of 52ï‚±10 years. DISCUSSION/SIGNIFICANCE: The use of a combination of virtual/remote monitoring and guidance of local resources in this trial provides an opportunity for decentralization and access of CCTs for potential novel treatment of HF to underrepresented individuals from rural areas.