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OBJECTIVES/SPECIFIC AIMS: The objective of this project is to determine whether HRV, collected peri-operatively, is predictive of cognitive decline among older adults who undergo elective surgery/anesthesia. METHODS/STUDY POPULATION: This project is a part of the ongoing INTUIT/PRIME study, which is collecting pre- and post-operative cognitive testing, fMRI imaging, CSF samples, and EEG recordings from 200 older adults (age ≥ 60) undergoing elective non-cardiac/non-neurologic surgery scheduled to last > 2 hours at Duke University Medical Center and Duke Regional Hospital. This project utilizes data from the first 60 INTUIT participants who contributed continuous heart rate data before and during surgery. Participants undergo cognitive testing prior to surgery (baseline) and at 6 weeks after surgery. Our primary dependent variable is the change in the composite score from baseline to 6-weeks. Delirium is assessed in the hospital with the twice daily 3D-CAM tool, so we will report the proportion of individuals with 6-week cognitive decline who exhibited delirium in the days following surgery. Participants’ echocardiogram (ECG) recordings are extracted pre- and intraoperatively from B650/B850 patient monitors with VSCapture software. HRV is defined as the variability between successive R-spikes or inter-beat-intervals on ECG. RESULTS/ANTICIPATED RESULTS: We anticipate that lower intraoperative HRV is associated with worse cognitive decline at 6 weeks after surgery. As secondary objectives, we will determine whether pre-operative HRV or change in HRV (from pre-operative to intra-operative measures) are predictive of cognitive decline after surgery. We expect that in-hospital delirium will be detected in a higher proportion of those with 6-week cognitive decline, compared to those with stable or improved cognition at 6 weeks. DISCUSSION/SIGNIFICANCE OF IMPACT: HRV may address the present need for pre- and intra-operative cognitive risk stratification in the elderly. Physiological indices like HRV have the potential to dramatically change our understanding of CI in older adults undergoing surgery, as they offer an accessible, cost-effective, and non-invasive means whereby clinicians, particularly those unfamiliar with the nuances of geriatric and CI/dementia-related care, can monitor patients and refer those at high-risk of CI after surgery for early intervention.
Studies of parliamentary systems contend that backbench legislators are increasingly marginalized, with power being centralized in the executive. However, such research typically focuses on national legislatures, ignoring subnational jurisdictions. We extend this literature by exploring the process of “executive creep” in Canada's provinces; namely the tendency of executives to erode legislative independence by appointing backbenchers to quasi-executive positions or cabinet committees. We examine executive creep in all provinces since 1968, finding a clear trend towards the increased incorporation of backbenchers into the work of the executive. Moreover, these changes serve to strengthen the power of first ministers relative to their cabinets.
The role that vitamin D plays in pulmonary function remains uncertain. Epidemiological studies reported mixed findings for serum 25-hydroxyvitamin D (25(OH)D)–pulmonary function association. We conducted the largest cross-sectional meta-analysis of the 25(OH)D–pulmonary function association to date, based on nine European ancestry (EA) cohorts (n 22 838) and five African ancestry (AA) cohorts (n 4290) in the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium. Data were analysed using linear models by cohort and ancestry. Effect modification by smoking status (current/former/never) was tested. Results were combined using fixed-effects meta-analysis. Mean serum 25(OH)D was 68 (sd 29) nmol/l for EA and 49 (sd 21) nmol/l for AA. For each 1 nmol/l higher 25(OH)D, forced expiratory volume in the 1st second (FEV1) was higher by 1·1 ml in EA (95 % CI 0·9, 1·3; P<0·0001) and 1·8 ml (95 % CI 1·1, 2·5; P<0·0001) in AA (Prace difference=0·06), and forced vital capacity (FVC) was higher by 1·3 ml in EA (95 % CI 1·0, 1·6; P<0·0001) and 1·5 ml (95 % CI 0·8, 2·3; P=0·0001) in AA (Prace difference=0·56). Among EA, the 25(OH)D–FVC association was stronger in smokers: per 1 nmol/l higher 25(OH)D, FVC was higher by 1·7 ml (95 % CI 1·1, 2·3) for current smokers and 1·7 ml (95 % CI 1·2, 2·1) for former smokers, compared with 0·8 ml (95 % CI 0·4, 1·2) for never smokers. In summary, the 25(OH)D associations with FEV1 and FVC were positive in both ancestries. In EA, a stronger association was observed for smokers compared with never smokers, which supports the importance of vitamin D in vulnerable populations.
Accurate assessments of population sizes and trends are fundamental for effective species conservation, particularly for social and long-lived species in which low reproductive rates, aging demographic structure and Allee effects could interact to drive rapid population declines. In the parrots (Order Psittaciformes) these life history characteristics have combined with habitat loss and capture for the pet trade to lead to widespread endangerment, with over 40% of species classified under some level of threat. Here we report the results of a population survey of one such species, the Yellow-naped Amazon, Amazona auropalliata, that is classified as ‘Endangered’ on the IUCN Red List. We conducted a comprehensive survey in June and July of 2016 of 44 night roosts of the populations in contiguous Pacific lowlands of northern Costa Rica and southern Nicaragua and compared numbers in Costa Rica to those found in a similar survey conducted in June 2005. In 2016 we counted 990 birds across 25 sites surveyed in Costa Rica and 692 birds across 19 sites surveyed in Nicaragua for a total population estimate of only 1,682 birds. Comparisons of 13 sites surveyed in both 2005 and 2016 in Costa Rica showed a strong and statistically significant decline in population numbers over the 11-year period. Assessment of group sizes approaching or leaving roosts indicated that less than 25% of groups consisted of three or more birds; there was a significantly higher proportion of these putative family groups observed in Nicaragua than Costa Rica. Taken together, these results are cause for substantial concern for the health of this species in a region that has previously been considered its stronghold, and suggest that stronger conservation action should be undertaken to protect remaining populations from capture for the pet trade and loss of key habitat.
Following a cluster of serious pseudomonas skin infections linked to a body piercing and tattooing premises, a look-back exercise was carried out to offer clients a screen for blood-borne viruses. Of those attending for screening 72% (581/809) had a piercing procedure in the premises of interest: 94 (16%) were under 16 years of age at the time of screening. The most common site of piercing was ear (34%), followed by nose (27%), nipple (21%) and navel (21%). A small number (<5) tested positive for hepatitis B and C, with no evidence this was linked to the premises. However, 36% (211/581) of clients reported a skin infection associated with their piercing. Using data from client forms, 36% provided a false age. Those aged under 16 years (OR 4.5, 95% CI 2.7–7.7) and those receiving a piercing at an intimate site (OR 2.1, 95% CI 1.3–3.6) were more likely to provide a false age. The findings from this exercise were used to support the drafting of the Public Health (Wales) Bill which proposed better regulation of piercing premises and the need to provide proof of being 18 years of age or over before having a piercing of an intimate site.
To assess the benefits of the introduction of routine vitamin D serum sampling for all patients admitted to a secure in-patient hospital in the North of England providing medium security, low security and rehabilitation services for offenders with intellectual and developmental disability. The vitamin D levels of 100 patients were analysed at baseline. Those with insufficient or deficient levels were offered treatment and retested after 1 year. Vitamin D levels were analysed in the context of level of security, seasonality of test and co-prescription of psychotropic medications.
Eighty-three per cent of patients had suboptimal vitamin D levels at initial test (41% deficient and 42% insufficient). This was seen among established patients and new admissions. Regression analysis of baseline vitamin D levels revealed no differences for levels of security, seasonality, whether patients were taking antipsychotic or anticonvulsant medication, or length of stay. Patients with deficiency or insufficiency were all offered supplementation. Those who opted in had significantly higher vitamin D levels at follow-up, compared with those who declined treatment.
Established and newly admitted patients in our secure mental health services had substantial levels of vitamin D insufficiency. In the light of the morbidities that are associated with deficient vitamin D levels, routine screening and the offer of supplementation is advisable.
Cryoconite holes are water-filled holes in the surface of a glacier caused by enhanced ice melt around trapped sediment. Measurements on the ablation zones of four glaciers in Taylor Valley, Antarctica, show that cryoconite holes cover about 4–6% of the ice surface. They typically vary in diameter from 5 to 145 cm, with depths ranging from 4 to 56 cm. In some cases, huge holes form with 5 m depths and 30 m diameters. Unlike cryoconite holes elsewhere, these have ice lids up to 36 cm thick and melt from within each spring. About one-half of the holes are connected to the near-surface hydrologic system and the remainder are isolated. The duration of isolation, estimated from the chloride accumulation in hole waters, commonly shows ages of several years, with one hole of 10 years. The cryoconite holes in the McMurdo Dry Valleys create a near-surface hydrologic system tens of cm below the ice surface. The glacier surface itself is generally frozen and dry. Comparison of water levels between holes a few meters apart shows independent cycles of water storage and release. Most likely, local freeze–thaw effects control water passage and therefore temporary storage. Rough calculations indicate that the holes generate at least 13% of the observed runoff on the one glacier measured. This hydrologic system represents the transition between a melting ice cover with supraglacial streams and one entirely frozen and absent of water.
Epidemiology is the study of factors affecting the health and illness of populations, of how often diseases occur in different groups of people and why. The uses of epidemiology (Morris, 1957) are therefore quite varied. They range from studies about what might cause a disease to a purely descriptive account of how many people have or develop a condition. From the perspective of primary care, both these aspects could be important. Primary care, at least as provided in countries such as the UK, where almost everyone is registered with a general practitioner (GP), is population-based medicine. Primary care physicians often provide advice about prevention as well as treating people with existing conditions. They are also faced with the whole range of morbidity, and so data from household samples are often of value in helping to understand the population served by primary care. The gradations between normality and abnormality or between health and disease are as obvious to the primary care physician as to the epidemiologist. In this chapter, we restrict our discussion to descriptive aspects of epidemiology and their relevance to mental health in primary care.
‘Mental illness’ and ‘psychiatric disorder’ are terms that refer collectively to all of the diagnosable mental disorders (see Chapter 7 for further discussion). ‘Mental disorders’ are characterised by abnormalities in cognition, emotion or mood or by behavioural impairment in social interactions. A substantial range of conditions is therefore covered by this term, reflected in Chapter 5 of ICD–10 (World Health Organization, 1992). The commonest psychiatric disorders are depression and anxiety and, as a result, much of the research in primary care has focused on them. However, it is important to remember that other conditions, such as schizophrenia, bipolar affective disorder and dementia, also present to primary care physicians and require treatment in primary care. The preoccupation with depression and anxiety reflects the fact that most people with those conditions are treated within primary care, whereas secondary care, at least in the UK, tends to take the lead for psychotic conditions such as schizophrenia and for dementia.
In describing the epidemiology of mental illness in primary care, we have to consider the different organisational and reimbursement arrangements that occur around the world (see Chapter 1).
Background: Cognitive Behavioural Therapy (CBT) aims to teach people skills to help them self-manage their depression. Trial evidence shows that CBT is an effective treatment for depression and individuals may experience benefits long-term. However, there is little research about individuals’ continued use of CBT skills once treatment has finished. Aims: To explore whether individuals who had attended at least 12 sessions of CBT continued to use and value the CBT skills they had learnt during therapy. Method: Semi-structured interviews were held with participants from the CoBalT trial who had received CBT, approximately 4 years earlier. Interviews were audio-recorded, transcribed and analysed thematically. Results: 20 participants were interviewed. Analysis of the interviews suggested that individuals who viewed CBT as a learning process, at the time of treatment, recalled and used specific skills to manage their depression once treatment had finished. In contrast, individuals who viewed CBT only as an opportunity to talk about their problems did not appear to utilize any of the CBT skills they had been taught and reported struggling to manage their depression once treatment had ended. Conclusions: Our findings suggest individuals may value and use CBT skills if they engage with CBT as a learning opportunity at the time of treatment. Our findings underline the importance of the educational model in CBT and the need to emphasize this to individuals receiving treatment.
Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.
Pollen extracted from ocean and wetland sediments cored from the eastern Canadian Margin, James Bay region, and Atlantic provinces of Canada have been radiocarbon dated and results are reported here. Pollen dates from ocean sediments were compared with marine carbonate (mollusk shells or foraminifera) dates from the same core levels, dates for which validity was assessed via correlations with other cores, and for which reworking has been excluded. Pollen samples from 3 tidal wetlands were taken from levels dated with 137Cs and 210Pb profiles. Pollen dates from 2 additional wetlands were compared with 14C dates of botanical macrofossils. Most pollen dates disagree with 14C dates based on macrofossils or carbonates, with age differences typically exceeding 250 yr and reaching 4000 yr in one instance. In some cores, pollen dates show age reversals. Significant proportions of reworked pollen grains in ocean and wetland samples are associated with pollen dates that are too old. Prolonged core storage could result in pollen 14C ages that are too young, possibly because of growth of fungi or other microbes, but more work is needed to verify this hypothesis. Despite the problems we encountered, some pollen dates are consistent with other 14C dates from the same core levels, suggesting this dating method can work, but at present, more work is needed to understand the conflicting results obtained.
The Beck Depression Inventory, 2nd edition (BDI-II) is widely used in research on depression. However, the minimal clinically important difference (MCID) is unknown. MCID can be estimated in several ways. Here we take a patient-centred approach, anchoring the change on the BDI-II to the patient's global report of improvement.
We used data collected (n = 1039) from three randomized controlled trials for the management of depression. Improvement on a ‘global rating of change’ question was compared with changes in BDI-II scores using general linear modelling to explore baseline dependency, assessing whether MCID is best measured in absolute terms (i.e. difference) or as percent reduction in scores from baseline (i.e. ratio), and receiver operator characteristics (ROC) to estimate MCID according to the optimal threshold above which individuals report feeling ‘better’.
Improvement in BDI-II scores associated with reporting feeling ‘better’ depended on initial depression severity, and statistical modelling indicated that MCID is best measured on a ratio scale as a percentage reduction of score. We estimated a MCID of a 17.5% reduction in scores from baseline from ROC analyses. The corresponding estimate for individuals with longer duration depression who had not responded to antidepressants was higher at 32%.
MCID on the BDI-II is dependent on baseline severity, is best measured on a ratio scale, and the MCID for treatment-resistant depression is larger than that for more typical depression. This has important implications for clinical trials and practice.
Habitat fragmentation may lead to spatial genetic structuring of plant populations, but the magnitude of this effect differs among species. In this study, the effects of fragmentation on spatial genetic structure of Manilkara maxima, an ecologically important tree species endemic to the Atlantic forest of southern Bahia, Brazil, were examined. To address this issue, 222 individuals were sampled across two large-forest sites (200 and 400 ha) and one site comprising eight small fragments (5, 10 and 25 ha) roughly 35 y old. Five microsatellite loci were used. In general, M. maxima exhibited limited genetic structuring within and across the sites examined. At the landscape scale, genetic structure was not shaped by isolation by distance. Within individual sites, weak to moderate genetic structure was observed for both adults and saplings, which represented pre- and post-fragmentation, respectively. Sapling genetic structure did not clearly vary among the study sites, suggesting fragmentation has not affected spatial genetic structure. High levels of migration were observed, which would help maintain genetic connectivity. Taken together, these results suggest M. maxima, a long-lived tree that naturally occurs in low densities, may have limited spatial genetic structuring both within and across forest patches.