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Understanding post-stroke spasticity (PSS) treatment in everyday clinical practice may guide improvements in patient care.
Methods:
This was a retrospective cohort study that used population-level administrative data. Adults (aged ≥18 years) who initiated PSS treatment (defined by the first PSS clinic visit, focal botulinum toxin injection, or anti-spasticity medication dispensation [baclofen, dantrolene and tizanidine] with none of these treatments occurring during the 2 years before the stroke) were identified between 2012 and 2019 in Alberta, Canada. Spasticity treatment use, time to treatment start and type of prescribing/treating physician were measured. Descriptive statistics were performed.
Results:
Within the cohort (n = 1,079), the most common PSS treatment was oral baclofen (initial treatment: 60.9%; received on/after the initial treatment date up to March 31, 2020: 69.0%), largely prescribed by primary care physicians (77.6%) and started a median of 348 (IQR 741) days after the stroke. Focal botulinum toxin (23.3%; 37.7%) was largely prescribed by physiatrists (72.2%) and started 311 (IQR 446) days after the stroke; spasticity clinic visits (18.6%; 23.8%) were also common.
Conclusions:
We found evidence of gaps in provision of spasticity management in persons with PSS including overuse of systemic oral baclofen (that has common adverse side effects and lacks evidence of effectiveness in PSS) and potential underuse of focal botulinum toxin injections. Further investigation and strategies should be pursued to improve alignment of PSS treatment with guideline recommendations that in turn will support better outcomes for those with PSS.
Limited evidence exists regarding care pathways for stroke survivors who do and do not receive poststroke spasticity (PSS) treatment.
Methods:
Administrative data was used to identify adults who experienced a stroke and sought acute care between 2012 and 2017 in Alberta, Canada. Pathways of stroke care within the health care system were determined among those who initiated PSS treatment (PSS treatment group: outpatient pharmacy dispensation of an anti-spastic medication, focal chemo-denervation injection, or a spasticity tertiary clinic visit) and those who did not (non-PSS treatment group). Time from the stroke event until spasticity treatment initiation, and setting where treatment was initiated were reported. Descriptive statistics were performed.
Results:
Health care settings within the pathways of stroke care that the PSS (n = 1,079) and non-PSS (n = 22,922) treatment groups encountered were the emergency department (86 and 84%), acute inpatient care (80 and 69%), inpatient rehabilitation (40 and 12%), and long-term care (19 and 13%), respectively. PSS treatment was initiated a median of 291 (interquartile range 625) days after the stroke event, and most often in the community when patients were residing at home (45%), followed by “other” settings (22%), inpatient rehabilitation (18%), long-term care (11%), and acute inpatient care (4%).
Conclusions:
To our knowledge, this is the first population based cohort study describing pathways of care among adults with stroke who subsequently did or did not initiate spasticity treatment. Areas for improvement in care may include strategies for earlier identification and treatment of PSS.
The aim of this study was to evaluate the association of bicuspid aortic valve on contemporary outcomes, including reoperation rates, after one-stage correction for interrupted aortic arch with ventricular septal defect or for aortic coarctation with hypoplastic aortic arch and ventricular septal defect.
Methods:
Seventy-four consecutive patients (35 boys, 47% and 39 girls, 53%) with interrupted aortic arch (n = 41, 55%) or aortic coarctation with hypoplastic aortic arch (n = 33, 45%) with ventricular septal defect underwent early one-stage correction. Twenty (27%) patients had bicuspid aortic valve, and the remaining 54 (73%) had a tricuspid aortic valve. The median aortic valve annulus diameter was 6.0 mm (IQR: 2.0). Patients’ median age was 7 ± 29 days (range, 2–150); median weight was 3.3 ± 0.7 kg (range, 1.5–6.0), with 21 (28%) patients <3.0 kg. Selective brain perfusion through the innominate artery and selective coronary perfusion through the aortic root during aortic arch reconstruction were used in all patients. Statistical analysis was performed using SPSS version 20.0 software (SPSS Inc., Chicago, IL, USA).
Results:
The early mortality was 1.3%. One premature neonate died in the hospital with extracorporeal membrane oxygenation after aortic coarctation plus ventricular septal defect repair. There was no further mortality. Median follow-up was 5.7 years (IQR: 10.48). Reinterventions occurred in 36 (49%) patients: balloon angioplasty in 18 (24%) patients, reoperations in 4 (5%) patients, and both in 14 (19%) patients. A total of 86 follow-up procedures were required in these 36 (49%) patients: aortic valve valvulopasty (n = 6, 8%), stent implantation (n = 8, 11%), balloon dilatation (n = 39, 53%), and reoperation (n = 33, 45%). The median time to reinterventions was 9.094 years (SE 0.890). A potential risk factor for reintervention after interrupted aortic arch and aortic coarctation with ventricular septal defect repair was bicuspid aortic valve (p = 0.019, Chi2 (1) = 5.457). In addition, a multivariate Cox analysis with backward selection and significance level <0.015 was applied to all variables that showed significant effects in univariable analyzes. This regression confirmed that bicuspid aortic valve (HR = 0.381, p = .016), and interrupted aortic arch (HR = 0.412, p = 0.043) were predictors of late reintervention. All patients had no obvious neurologic impairment in routine examinations at last follow-up.
Conclusion:
Bicuspid aortic valve was a significant risk factor for valve-related reintervention after one-stage repair for aortic arch obstruction with ventricular septal defect due to later development of stenosis associated with higher late morbidity and mortality. Particularly neonates with bicuspid aortic valve will possibly require reintervention in the future. Regular lifelong cardiac follow-up is recommended.
This was a multi-site evaluation of psycho-educational transdiagnostic seminars (TDS) as a pre-treatment intervention to enhance the effectiveness and utilisation of high-intensity cognitive behavioural therapy (CBT).
Aims:
To evaluate the effectiveness of TDS combined with high-intensity CBT (TDS+CBT) versus a matched sample receiving CBT only. Second, to determine the consistency of results across participating services which employed CBT+TDS. Finally, to determine the acceptability of TDS across patients with different psychological disorders.
Method:
106 patients across three services voluntarily attended TDS while on a waiting list for CBT (TDS+CBT). Individual and pooled service pre–post treatment effect sizes were calculated using measures of depression, anxiety and functional impairment. Effectiveness and completion rates for TDS+CBT were compared with a propensity score matched sample from an archival dataset of cases who received high-intensity CBT only.
Results:
Pre–post treatment effect sizes for TDS+CBT were comparable to the matched sample. Recovery rates were greater for the group receiving TDS; however, this was not statistically significant. Greater improvements were observed during the waiting-list period for patients who had received TDS for depression (d = 0.49 compared with d = 0.07) and anxiety (d = 0.36 compared with d = 0.04).
Conclusions:
Overall, this new evidence found a trend for TDS improving symptoms while awaiting CBT across three separate IAPT services. The effectiveness of TDS now warrants further exploration through an appropriately sized randomised control trial.
Disturbed eating behaviors are a significant health concern among child and adolescents with type 1 diabetes mellitus (DM1) and are generally related to poor glycemic control, ketoacidosis, hospitalization and microvascular complications. Rates of eating problems among youths with DM1 have been reported to be as high as 38%.
Aims
To review clinical characteristics, demographic profiles and risk factors for the development of eating disturbances among child and adolescents with DM1.
Methods
We performed a literature research of articles from 1980 until present, in which a Disturbed Eating Behavior appeared comorbid with DM1 in children and adolescents, using Medline database.
Results
Almost all studies selected report a high prevalence of eating disturbances of child and adolescents with DM1 when compared with healthy pairs. This population trend to develop body image discontent and lower self-esteem. They are more likely to diet, skip meals, and omit insulin. All these practices have been associated with worsening diabetic medical complications and poorer psychological outcome.
Conclusions
Due to the high prevalence and severe medical and psychological complications associated with disturbed eating behaviors among pediatric population with DM1, clinicians and school professionals may benefit from specialized training to identify the range of unhealthy weight control behaviors used by youths with DM1. Preventive programs that address disturbed eating behaviors should be provided for adolescents with DM1 in order to reduce the psychological and medical impact of this comorbid situation.
New routes in additive devices fabrication techniques and advances in printable materials are required to meet the ever increasing demands for low-cost and large-area flexible electronics. In particular, perovskite-based materials have gained an appeal due to their unique optoelectronics and ferroelectrics properties, which may replace p-n junction in semiconductor devices. Metal-organic methylammonium lead trihalide perovskite formulations have been extensively studied in the last few years as promising materials for use in printed electronics, which do not require high temperatures or vacuum environment, contrary to conventional semiconductor fabrication techniques. In this work, digital inkjet-printing in ambient atmosphere is proposed as a deposition pathway for the fabrication of perovskite active layers in photodetector and thin-film photovoltaic device architectures. The device architecture containing a printed perovskite active layer sandwiched between TiO2 and Spiro-OMeTAD as electron and hole transport layers, respectively, as well as layer-on-layer fabrication and responsivity spectra of the perovskite-based device are presented.
Background: The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps.
Methods: The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps.
Results: The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities.
Conclusions: The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the “-omics” approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.
Despite the higher proportion of foreclosures and home evictions executed in Spain, compared to other countries, and the known link between social exclusion and mental health problems, studies exploring this association in Spain remain scarce. This study investigated the link between the process of home eviction and the appearance of symptomatology of post-traumatic stress disorder (PTSD), anxiety, depression, and perceived stress. Two hundred and five people affected by the process of home eviction were assessed using a structured interview that included three validated assessment instruments for PTSD, perceived stress, anxiety and depression. Analysis involved comparison with the normative groups that formed the validation studies together with regression analysis to determine the major psychological and socio-demographic predictors of perceived stress. Of the participants, 95.1% reported that they were experiencing the process of home eviction with fear, helplessness, or horror. In PTSD symptomatology, they scored higher than the normative PTSD group in symptoms of avoidance (t = 5.01; p < .05), activation (t = 5.48; p < .01), and total score (t = 4.15; p < .05). Of this subgroup, 72.5% fulfilled the DSM-IV symptom criteria for PTSD. The major predictor of perceived stress was PTSD symptomatology (B = .09; p < .001). The process of home eviction in Spain is having an alarming impact on mental health of affected people calling for effective measures to provide psychological and social support.
A new three-dimensional finite-element model of the steady-state dynamics of temperate glaciers has been developed and applied to Johnsons Glacier, Livingston Island, Antarctica, with the aim of determining the velocity and stress fields for the present glacier configuration. It solves the full Stokes system of differential equations without recourse to simplifications such as those involved in the shallow-ice approximation. Rather high values of the stiffness parameter B (∼0.19–0.23MPaa1/3) are needed to match the observed ice surface velocities, although these results do not differ much from those found by other authors for temperate glaciers. Best-fit values of the coefficient k in the sliding law (*2.2–2.7 x 103m a–1MPa–2) are also of the same order of magnitude as those found by other authors. The results for velocities are satisfactory, though locally there exist significant discrepancies between computed and observed ice surface velocities, particularly for the vertical ones. This could be due to failures in the sliding law (in particular, the lack of information on water pressure), the use of an artificial down-edge boundary condition and the fact that bed deformation is not considered. For the whole glacier system, the driving stress is largely balanced by the basal drag (80% of the driving stress). Longitudinal stress gradients are only important in the divide areas and near the glacier terminus, while lateral drag is only important at both sides of the terminal zone.
Calving from tidewater glaciers and ice shelves accounts for around half the mass loss from both polar ice sheets, yet the process is not well represented in prognostic models of ice dynamics. Benn and others proposed a calving criterion appropriate for both grounded and floating glacier tongues or ice shelves, based on the penetration depth of transverse crevasses near the calving front, computed using Nye’s formula. The criterion is readily incorporated into glacier and ice-sheet models, but has not been fully validated with observations. We apply a three-dimensional extension of Benn and others’ criterion, incorporated into a full-Stokes model of glacier dynamics, to estimate the current position of the calving front of Johnsons Glacier, Antarctica. We find that two improvements to the original model are necessary to accurately reproduce the observed calving front: (1) computation of the tensile deviatoric stress opening the crevasse using the full-stress solution and (2) consideration of such a tensile stress as a function of depth. Our modelling results also suggest that Johnsons Glacier has a polythermal structure, rather than the temperate structure suggested by earlier studies.
Background: Pre-treatment role induction interventions have been suggested to potentially enhance attendance and clinical outcomes in psychotherapy. Aims: This study aimed to evaluate the effects of a programme of three transdiagnostic seminars (TDS) for patients with common mental disorders accessing cognitive behavioural therapy (CBT) in primary care. TDS included CBT psychoeducation and role induction. Method: A random sample of patients (n = 49) participated in TDS followed by CBT (TDS+CBT) and they were compared with matched controls (n = 49) accessing usual CBT. TDS participants rated the relevance and quality of this intervention using an acceptability questionnaire (AQ). Treatment completion (vs dropout) rates were compared across groups using chi-square tests. Post-treatment changes in depression (PHQ-9) and anxiety (GAD-7) symptoms were compared between groups using analysis of covariance controlling for potential confounders. Analyses were based on intention-to-treat principles. Results: Mean AQ ratings of the TDS intervention were comparable across diagnostic groups (p = .05). Treatment completion rates were significantly higher (p = .02) in the TDS+CBT group (87.8%) by comparison with usual CBT (68.8%). However, no significant differences in post-treatment symptom changes were found for depression (p = .34) or anxiety measures (p = .71). Conclusions: Incorporating a psychoeducational role induction prior to CBT significantly improved treatment retention, but not overall symptom reductions.
Haemosporidian parasites are widespread in avian species and modulate their ecology, behaviour, life-history and fitness. The prevalence of these vector-transmitted parasites varies with host intrinsic and extrinsic factors, such as host resistance and behaviour, and habitat-related characteristics. In this study, we evaluated the prevalence of avian haemosporidians in great tit Parus major populations inhabiting two areas with different degrees of exposure to aerial emissions from pulp mills, to assess if this type of pollution impacted parasite prevalence. We also compared the physiological condition of infected and uninfected individuals. Haemosporidian infection prevalence was high (58%), varied seasonally, but was not associated with air pollution exposure. Fledged birds presented higher infection rates than nestlings and infected fledged birds had higher levels of blood glutathione peroxidase activity. These results allow us to infer that infection by blood parasites may activate antioxidant defences, possibly to protect the organism from the negative oxidative stress side-effects of immune activation against parasites. Because oxidative stress is one of the mechanisms responsible for ageing and senescence and may affect fitness, the relationship between parasitism and oxidative stress markers should be further investigated through studies that include experimental manipulation of infection in model organisms.
Skeletal remains from a burial in New South Wales exhibit evidence of fatal
trauma, of a kind normally indicative of sharp metal weapons, yet the burial
dates to the mid thirteenth century—600 years before European settlers
reached the area. Could sharp-edged wooden weapons from traditional
Aboriginal culture inflict injuries similar to those resulting from later,
metal blades? Analysis indicates that the wooden weapons known as
‘Lil-lils’ and the fighting boomerangs
(‘Wonna’) both have blades that could fit within the
dimensions of the major trauma and are capable of having caused the fatal
wounds.
Behaviours of concern (e.g. aggression) are often present in residents of long-term care (LTC) facilities diagnosed with dementia and may impact quality of life. Prior uncontrolled research has shown that an intervention involving sharing resident life histories may be effective in reducing aggressive behaviours and improving quality of life, perhaps by increasing staff empathy. We used a randomised controlled design, involving a considerably larger sample than previous investigations. We also examined staff perceptions of LTC resident personhood in relation to aggressive behaviour. Seventy-three residents were randomised to either a life history intervention (N = 38) or a control condition (N = 35). Ninety-nine nurses and care aides answered questionnaires about their own attitudes and the residents' behaviours and quality of life at baseline, post-intervention and at follow-up. Results of mixed-effects modelling indicated significant differences between groups in personhood perception and resident quality of life. Personhood perception mediated the relationship between the intervention and improved quality of life. We identified significant negative correlations between resident cognitive impairment and staff perceptions of resident personhood. Qualitative findings suggested that staff primarily changed their verbal interactions with residents following the intervention, which may be particularly helpful for residents with the most severe dementia. Our results indicate that LTC residents benefit when life histories are constructed with their families and shared with nursing staff.
To present and discuss the dietary guidelines issued by the Brazilian government in 2014.
Design
The present paper describes the aims of the guidelines, their shaping principles and the approach used in the development of recommendations. The main recommendations are outlined, their significance for the cultural, socio-economic and environmental aspects of sustainability is discussed, and their application to other countries is considered.
Setting
Brazil in the twenty-first century.
Subjects
All people in Brazil, now and in future.
Results
The food- and meal-based Brazilian Dietary Guidelines address dietary patterns as a whole and so are different from nutrient-based guidelines, even those with some recommendations on specific foods or food groups. The guidelines are based on explicit principles. They take mental and emotional well-being into account, as well as physical health and disease prevention. They identify diet as having cultural, socio-economic and environmental as well as biological and behavioural dimensions. They emphasize the benefits of dietary patterns based on a variety of natural or minimally processed foods, mostly plants, and freshly prepared meals eaten in company, for health, well-being and all relevant aspects of sustainability, as well as the multiple negative effects of ready-to-consume ultra-processed food and drink products.
Conclusions
The guidelines’ recommendations are designed to be sustainable personally, culturally, socially, economically and environmentally, and thus fit to face this century. They are for foods, meals and dietary patterns of types that are already established in Brazil, which can be adapted to suit the climate, terrain and customs of all countries.
We study the long-time behaviour of a Markov process evolving in N and conditioned not to hit 0. Assuming that the process comes back quickly from ∞, we prove that the process admits a unique quasistationary distribution (in particular, the distribution of the conditioned process admits a limit when time goes to ∞). Moreover, we prove that the distribution of the process converges exponentially fast in the total variation norm to its quasistationary distribution and we provide a bound for the rate of convergence. As a first application of our result, we bring a new insight on the speed of convergence to the quasistationary distribution for birth-and-death processes: we prove that starting from any initial distribution the conditional probability converges in law to a unique distribution ρ supported in N* if and only if the process has a unique quasistationary distribution. Moreover, ρ is this unique quasistationary distribution and the convergence is shown to be exponentially fast in the total variation norm. Also, considering the lack of results on quasistationary distributions for nonirreducible processes on countable spaces, we show, as a second application of our result, the existence and uniqueness of a quasistationary distribution for a class of possibly nonirreducible processes.
Continuous population aging has raised international policy interest in promoting active aging (AA). AA theoretical models have been defined from a biomedical or a psychosocial perspective. These models may be expanded including components suggested by lay individuals. This paper aims to study the correlates of AA in three European countries, namely, Spain, Poland, and Finland using four different definitions of AA.
Methods:
The EU COURAGE in Europe project was a cross-sectional general adult population survey conducted in a representative sample of the noninstitutionalized population of Finland, Poland, and Spain. Participants (10,800) lived in the community. This analysis focuses on individuals aged 50 years old and over (7,987). Four definitions (two biomedical, one psychosocial, and a complete definition including biomedical, psychosocial, and external variables) of AA were analyzed.
Results:
Differences in AA were found for country, age, education, and occupation. Finland scored consistently the highest in AA followed by Spain and Poland. Younger age was associated with higher AA. Higher education and occupation was associated with AA. Being married or cohabiting was associated with better AA compared to being widowed or separated in most definitions. Gender and urbanicity were not associated with AA, with few exceptions. Men scored higher in AA only in Spain, whereas there was no gender association in the other two countries. Being widowed was only associated with lower AA in Poland and not being married was associated with lower AA in Poland and Finland but not Spain.
Conclusions:
Associations with education, marital status, and occupation suggest that these factors are the most important components of AA. These association patterns, however, seem to vary across the three countries. Actions to promote AA in these countries may be addressed at reducing inequalities in occupation and education or directly tackling the components of AA lacking in each country.
Previous studies have shown that in the so-called opaque languages (those in which spelling does not correspond to pronunciation), there are relatively independent routes for lexical and nonlexical processing, that is, for words and nonwords, both in spoken and in written language. On the other hand, in the so-called transparent languages (those in which pronunciation corresponds to written forms), empirical evidence is scarcer. In this study of a neurological patient (parieto-temporal lesion), speaker of a transparent language (Spanish) showing a specific deficit in nonlexical reading processing, linguistic analysis for words was relatively preserved. This finding suggests the use of various routes in the processing of transparent languages.