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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.
Virtual reality has emerged as a unique educational modality for medical trainees. However, incorporation of virtual reality curricula into formal training programmes has been limited. We describe a multi-centre effort to develop, implement, and evaluate the efficacy of a virtual reality curriculum for residents participating in paediatric cardiology rotations.
A virtual reality software program (“The Stanford Virtual Heart”) was utilised. Users are placed “inside the heart” and explore non-traditional views of cardiac anatomy. Modules for six common congenital heart lesions were developed, including narrative scripts. A prospective case–control study was performed involving three large paediatric residency programmes. From July 2018 to June 2019, trainees participating in an outpatient cardiology rotation completed a 27-question, validated assessment tool. From July 2019 to February 2020, trainees completed the virtual reality curriculum and assessment tool during their cardiology rotation. Qualitative feedback on the virtual reality experience was also gathered. Intervention and control group performances were compared using univariate analyses.
There were 80 trainees in the control group and 52 in the intervention group. Trainees in the intervention group achieved higher scores on the assessment (20.4 ± 2.9 versus 18.8 ± 3.8 out of 27 questions answered correctly, p = 0.01). Further analysis showed significant improvement in the intervention group for questions specifically testing visuospatial concepts. In total, 100% of users recommended integration of the programme into the residency curriculum.
Virtual reality is an effective and well-received adjunct to clinical curricula for residents participating in paediatric cardiology rotations. Our results support continued virtual reality use and expansion to include other trainees.
Alcohol misuse is common in bipolar disorder and is associated with worse outcomes. A recent study evaluated integrated motivational interviewing and cognitive behavioural therapy for bipolar disorder and alcohol misuse with promising results in terms of the feasibility of delivering the therapy and the acceptability to participants.
Here we present the experiences of the therapists and supervisors from the trial to identify the key challenges in working with this client group and how these might be overcome.
Four therapists and two supervisors participated in a focus group. Topic guides for the group were informed by a summary of challenges and obstacles that each therapist had completed at the end of therapy for each individual client. The audio recording of the focus group was transcribed and data were analysed using thematic analysis.
We identified five themes: addressing alcohol use versus other problems; impact of bipolar disorder on therapy; importance of avoidance and overcoming it; fine balance in relation to shame and normalising use; and ‘talking the talk’ versus ‘walking the walk’.
Findings suggest that clients may be willing to explore motivations for using alcohol even if they are not ready to change their drinking, and they may want help with a range of mental health problems. Emotional and behavioural avoidance may be a key factor in maintaining alcohol use in this client group and therapists should be aware of a possible discrepancy between clients’ intentions to reduce misuse and their actual behaviour.
Canada is experiencing population aging, and given the heterogeneity of older adults, there is increasing diversity in late life. The purpose of this study was to help fill the research gaps on LGBT aging and end-of-life. Through focus groups, we sought to better understand the lived experience of older LGBT individuals and to examine their concerns associated with end-of-life. Our analysis highlights the idea that identifying as LGBT matters when it comes to aging and end-of-life care. In particular, gender identity and sexual orientation matter when it comes to social connections, in the expectations individuals have for their own care, and in the unique fear related to staying out of the closet and maintaining identity throughout aging and end-of-life. This study underscores the need to consider gender identity and sexual orientation at end-of-life. In particular, recognition of intersectionality and social locations is crucial to facilitating positive aging experiences and end-of-life care.
The Care Act 2014 represents a significant change in legislation in England. For the first time it brings together various aspects of adult social care into a single statute succeeding earlier acts and policy. Given its importance to the lives of service users and carers, clinicians need to have a clear understanding of its implications. We provide an overview of why it was developed, its underlying principles and international comparisons, as well as implications for assessments, interventions and outcomes. The impact on the lives of patients and carers is discussed, as well as dilemmas and challenges the Act presents. While it addresses other important aspects of social care, including safeguarding, Mental Health Act section 117 aftercare and duty of candour, we focus on personalisation because of the opportunities it provides to enhance management plans for people experiencing mental health problems.
Training for the clinical research workforce does not sufficiently prepare workers for today’s scientific complexity; deficiencies may be ameliorated with training. The Enhancing Clinical Research Professionals’ Training and Qualifications developed competency standards for principal investigators and clinical research coordinators.
Clinical and Translational Science Awards representatives refined competency statements. Working groups developed assessments, identified training, and highlighted gaps.
Forty-eight competency statements in 8 domains were developed.
Training is primarily investigator focused with few programs for clinical research coordinators. Lack of training is felt in new technologies and data management. There are no standardized assessments of competence.
The translation of discoveries to drugs, devices, and behavioral interventions requires well-prepared study teams. Execution of clinical trials remains suboptimal due to varied quality in design, execution, analysis, and reporting. A critical impediment is inconsistent, or even absent, competency-based training for clinical trial personnel.
In 2014, the National Center for Advancing Translational Science (NCATS) funded the project, Enhancing Clinical Research Professionals’ Training and Qualifications (ECRPTQ), aimed at addressing this deficit. The goal was to ensure all personnel are competent to execute clinical trials. A phased structure was utilized.
This paper focuses on training recommendations in Good Clinical Practice (GCP). Leveraging input from all Clinical and Translational Science Award hubs, the following was recommended to NCATS: all investigators and study coordinators executing a clinical trial should understand GCP principles and undergo training every 3 years, with the training method meeting the minimum criteria identified by the International Conference on Harmonisation GCP.
We anticipate that industry sponsors will acknowledge such training, eliminating redundant training requests. We proposed metrics to be tracked that required further study. A separate task force was composed to define recommendations for metrics to be reported to NCATS.
We conducted a time-series analysis to evaluate the impact of the ASP over a 6.25-year period (July 1, 2008–September 30, 2014) while controlling for trends during a 3-year preintervention period (July 1, 2005–June 30, 2008). The primary outcome measures were total antibacterial and antipseudomonal use in days of therapy (DOT) per 1,000 patient-days (PD). Secondary outcomes included antimicrobial costs and resistance, hospital-onset Clostridium difficile infection, and other patient-centered measures.
During the preintervention period, total antibacterial and antipseudomonal use were declining (−9.2 and −5.5 DOT/1,000 PD per quarter, respectively). During the stewardship period, both continued to decline, although at lower rates (−3.7 and −2.2 DOT/1,000 PD, respectively), resulting in a slope change of 5.5 DOT/1,000 PD per quarter for total antibacterial use (P=.10) and 3.3 DOT/1,000 PD per quarter for antipseudomonal use (P=.01). Antibiotic expenditures declined markedly during the stewardship period (−$295.42/1,000 PD per quarter, P=.002). There were variable changes in antimicrobial resistance and few apparent changes in C. difficile infection and other patient-centered outcomes.
In a hospital with low baseline antibiotic use, implementation of an ASP was associated with sustained reductions in total antibacterial and antipseudomonal use and declining antibiotic expenditures. Common ASP outcome measures have limitations.
WideStrike® Acala cotton is a two-gene, in-plant trait that provides broad-spectrum and season-long control of lepidopteran insect pests, and the varieties available in California also have resistance to glyphosate. There have been indications that WideStrike cotton has some glufosinate tolerance as well, so the level of tolerance to glufosinate needed to be ascertained. A 2-yr (2008 and 2009) study was conducted in California to evaluate the potential crop injury caused by three different rates (0.59, 0.88, and 1.76 kg ai ha−1) of glufosinate–ammonium at four different growth stages (cotyledon, 2-node, 5- to 6-node, and 18- to 19-node stages) of WideStrike Acala cotton. The effects of these treatments on the cotton plants and yield were closely monitored. Glyphosate at 1.54 kg ae ha−1 was applied at all cotton growth stages as a standard application, and a nontreated control was included. The greatest level of injury (58%) was observed with the highest rate of glufosinate applied at both the cotyledon and the two-node stage of cotton. However, injury was less than 10% following glufosinate at 0.59 kg ha−1 applied at the 18- to 19-node stage. The level of injury increased with the higher application rate of glufosinate at all crop growth stages. In 2008 and 2009, the glufosinate treatments had no effect on cotton lint yield. Therefore, the study showed that glufosinate can be applied safely topically at 0.59 kg ha−1 at the cotyledon- to 2-node stage or as POST-directed spray between the 5- to 19-node stages. Although injury occurred at this rate, the plants recovered within 2 to 3 wk of the treatment. Increasing glufosinate rates beyond 0.59 kg ha−1 can increase the possibility of greater crop injury.
Weeds are a major challenge for organic farmers, yet we know little about the factors influencing organic farmers’ weed management decisions. We hypothesized that farmers and scientist ‘experts’ differ in fundamental areas of knowledge and perceptions regarding weeds and weed management. Moreover, these differences prevent effective communication, outreach programming and research prioritization. An expert mental model, constructed primarily from interviews with research scientists and extension professionals, revealed expert emphasis on knowledge of ecological weed management as crucial for successfully implementing such strategies. We interviewed 23 organic farmers in northern New England, yielding an aggregate farmer mental model to compare with the expert model. Farmers demonstrated knowledge of the major concepts discussed by experts, but differed in emphasis. Farmers placed less emphasis on ecological complexity than experts. One-third of farmers interviewed discussed the potential role of weeds as indicators of soil nutrient status, a concept of which experts were skeptical. Farmer beliefs about the weed seedbank highlighted potential misconceptions regarding seed persistence, with one-fourth of farmers focusing on the concept that seeds can live for an exceptionally long time in the soil, while experts focused on the concept of the seed half-life. Farmers emphasized the role of experience, both their own and that of other farmers, rather than knowledge derived from scientific research. Farmers considered yield and the cost of time and labor as equally at risk because of weeds, whereas experts predominantly discussed yield loss. During discussions of management, both farmers and experts most emphasized risks associated with cultivation and benefits associated with cover cropping. These results have prompted us, first, to develop new educational materials focused on weed seed longevity and management of the weed seedbank, and, second, to conduct regional focus groups with farmers who prioritize fertility management in their efforts to control weeds, especially manipulations of soil calcium and magnesium.
There is increasing recognition that set-shifting, a form of cognitive control, is mediated by different neural structures. However, these regions have not yet been carefully identified as many studies do not account for the influence of component processes (e.g., motor speed). We investigated gray matter correlates of set-shifting while controlling for component processes. Using the Design Fluency (DF), Trail Making Test (TMT), and Color Word Interference (CWI) subtests from the Delis-Kaplan Executive Function System (D-KEFS), we investigated the correlation between set-shifting performance and gray matter volume in 160 subjects with neurodegenerative disease, mild cognitive impairment, and healthy older adults using voxel-based morphometry. All three set-shifting tasks correlated with multiple, widespread gray matter regions. After controlling for the component processes, set-shifting performance correlated with focal regions in prefrontal and posterior parietal cortices. We also identified bilateral prefrontal cortex and the right posterior parietal lobe as common sites for set-shifting across the three tasks. There was a high degree of multicollinearity between the set-shifting conditions and the component processes of TMT and CWI, suggesting DF may better isolate set-shifting regions. Overall, these findings highlight the neuroanatomical correlates of set-shifting and the importance of controlling for component processes when investigating complex cognitive tasks. (JINS, 2010, 16, 640–650.)
The differences between pediatric (≤17 years of age) and adult clinical field encounters were analyzed from four deployments of Disaster Medical Assistance Teams(DMATs).
A retrospective cohort review of all patients who presented to DMAT field clinics during two hurricanes, one earthquake, and one flood was conducted. Descriptive statistics were used to analyze: (1) age; (2) gender; (3) severity category level; (4) chief complaint; (5) treatments provided; (6) discharge diagnosis; and (7) disposition. Five subsets of pediatric patients were analyzed further.
Of the 2,196 patient encounters reviewed, 643 (29.5%) encounters were pediatric patients. Pediatric patients had a greater number of blank severity category levels than adults. Pediatric patients also were: (1) more likely to present with chief complaints of upper respiratory infections or wounds; (2) less likely to present with musculoskeletal pain or abdominal pain; and (3) equally likely to present with rashes. Pediatric patients were more likely to receive antibiotics, pain medication, and antihistamines, but were equally likely to need treatment for wounds. Dispositions to the hospital were less frequent for pediatric patients than for adults.
Pediatric patients represent a substantial proportion of disaster victims at DMAT field clinics. They often necessitate special care requirements different from their adult counterparts. Pediatric-specific severity category criteria, treatment guidelines, equipment/medication stocks, and provider training are warranted for future DMAT response preparations.
This case Study attempts to quantify the amount and timing of the import, export and through-flow of old ice in the Peary Channel–sverdrup Channel area of the northern Canadian Arctic Archipelago during the period 1998–2005. The Study combines quantitative weekly area-averaged ice coverage evaluations from the Canadian Ice Service (CIS) Digital Archive with detailed analysis of Radarsat imagery and ice-motion results from the CIS ice-motion algorithm. The results Show that in 1998 more than 70% of the old ice in Peary–sverdrup was lost, half by melt and export to the South and the other half by export north into the Arctic Ocean, and that no Arctic Ocean old ice was imported into Peary–sverdrup. A net import of 10% old ice was Seen in 1999, with Some indication of through-flow into Southern channels. In 2000, no net import of old ice occurred in Peary–sverdrup, but there was Significant through-flow, with evidence of old ice reaching the Northwest Passage by November. Full recovery of the old-ice regime was complete by the end of 2001. More than two-thirds of the recovery was due to the in Situ formation of Second-year ice. Conditions in the following 3 years were near normal.
Experiences arising from the work of a multi-disciplinary psychotherapy liaison team in the primary care setting are described. Special emphasis is given to the difficulties encountered in working relationships. Attention is drawn to the complexity of the inter-professional relationship, its unconscious roots, and its influence on the quality of patient care.
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