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Depression is an important, potentially modifiable dementia risk factor. However, it is not known whether effective treatment of depression through psychological therapies is associated with reduced dementia incidence. The aim of this study was to investigate associations between reduction in depressive symptoms following psychological therapy and the subsequent incidence of dementia.
National psychological therapy data were linked with hospital records of dementia diagnosis for 119808 people aged 65+. Participants received a course of psychological therapy treatment in Improving Access to Psychological Therapies (IAPT) services between 2012 and 2019. Cox proportional hazards models were run to test associations between improvement in depression following psychological therapy and incidence of dementia diagnosis up to eight years later.
Improvements in depression following treatment were associated with reduced rates of dementia diagnosis up to 8 years later (HR = 0.88, 95% CI 0.83–0.94), after adjustment for key covariates. Strongest effects were observed for vascular dementia (HR = 0.86, 95% CI 0.77–0.97) compared with Alzheimer's disease (HR = 0.91, 95% CI 0.83–1.00).
Reliable improvement in depression across psychological therapy was associated with reduced incidence of future dementia. Results are consistent with at least two possibilities. Firstly, psychological interventions to improve symptoms of depression may have the potential to contribute to dementia risk reduction efforts. Secondly, psychological therapies may be less effective in people with underlying dementia pathology or they may be more likely to drop out of therapy (reverse causality). Tackling the under-representation of older people in psychological therapies and optimizing therapy outcomes is an important goal for future research.
Clozapine is the only drug licensed for treatment-resistant schizophrenia (TRS) but the real-world clinical and cost-effectiveness of community initiation of clozapine is unclear.
The aim was to assess the feasibility and cost-effectiveness of community initiation of clozapine.
This was a naturalistic study of community patients recommended for clozapine treatment.
Of 158 patients recommended for clozapine treatment, 88 (56%) patients agreed to clozapine initiation and, of these, 58 (66%) were successfully established on clozapine. The success rate for community initiation was 65.4%; which was not significantly different from that for in-patient initiation (58.82%, χ2(1,88) = 0.47, P = 0.49). Following clozapine initiation, there was a significant reduction in median out-patient visits over 1 year (from 24.00 (interquartile range (IQR) = 14.00–41.00) to 13.00 visits (IQR = 5.00–24.00), P < 0.001), and 2 years (from 47.50 visits (IQR = 24.75–71.00) to 22.00 (IQR = 11.00–42.00), P < 0.001), and a 74.71% decrease in psychiatric hospital bed days (z = −2.50, P = 0.01). Service-use costs decreased (1 year: –£963/patient (P < 0.001); 2 years: –£1598.10/patient (P < 0.001). Subanalyses for community-only initiation also showed significant cost reductions (1 year: –£827.40/patient (P < 0.001); 2 year: –£1668.50/patient (P < 0.001) relative to costs prior to starting clozapine. Relative to before initiation, symptom severity was improved in patients taking clozapine at discharge (median Positive and Negative Syndrome Scale total score: initial visit: 80 (IQR = 71.00–104.00); discharge visit 50.5 (IQR = 44.75–75.00), P < 0.001) and at 2 year follow-up (Health of Nation Outcome Scales total score median initial visit: 13.00 (IQR = 9.00–15.00); 2 year follow-up: 8.00 (IQR = 3.00–13.00), P = 0.023).
These findings indicate that community initiation of clozapine is feasible and is associated with significant reductions in costs, service use and symptom severity.
To investigate methods for in vitro assessment of anthelmintic efficacy against the chicken nematode Ascaridia galli this study firstly evaluated sample preparation methods including recovery of eggs from excreta using different flotation fluids and induced larval hatching by the deshelling–centrifugation method and the glass-bead method with or without bile. It then evaluated two in vitro assays, the in-ovo larval development assay (LDA) and larval migration inhibition assay (LMIA), for anthelmintic efficacy testing against A. galli using fresh eggs and artificially hatched larvae, respectively. Four anthelmintics, thiabendazole (TBZ), fenbendazole (FBZ), levamisole (LEV) and piperazine (PIP) were employed using an A. galli isolate of known susceptibility. The results suggested that the LDA and LMIA could successfully be used to generate concentration response curves for the tested drugs. The LDA provided EC50 values for inhibition of egg embryonation of 0.084 and 0.071 μg/ml for TBZ and FBZ, respectively. In the LMIA, the values of effective concentration (EC50) of TBZ, FBZ, LEV and PIP were 105.9, 6.32, 349.9 and 6.78 × 107 nM, respectively. For such in vitro studies, a saturated sugar solution showed high egg recovery efficiency (67.8%) and yielded eggs of the highest morphological quality (98.1%) and subsequent developmental ability (93.3%). The larval hatching assays evaluated did not differ in hatching efficiency but the deshelling–centrifugation method yielded larvae that had slightly better survival rates. For final standardization of these tests and establishment of EC50 reference values, tests using isolates of A. galli of defined resistance status need to be performed.
The surgical treatment of insular gliomas requires specialized knowledge. Over the last three decades, increased momentum in surgical resection of insular gliomas shifted the focus from one of expectant management to maximal safe resection to establish a diagnosis, characterize tumor genetics, treat preoperative symptoms (i.e., seizures), and delay malignant transformation through tumor cytoreduction. A comprehensive review of the literature was performed regarding insular glioma classification/genetics, insular anatomy, surgical approaches, and patient outcomes. Modern large, published series of insular resections have reported a median 80% resection, 80% improvement in preoperative seizures, and postsurgical permanent neurologic deficits of less than 10%. Major complication avoidance includes recognition and preservation of eloquent cortex for language and respecting the lateral lenticulostriate arteries.
To identify: 1) best practice aged care principles and practices for Aboriginal and Torres Strait Islander older peoples, and 2) actions to integrate aged care services with Aboriginal community-controlled primary health care.
There is a growing number of older Aboriginal and Torres Strait Islander peoples and an unmet demand for accessible, culturally safe aged care services. The principles and features of aged care service delivery designed to meet the unique needs of Aboriginal and Torres Strait Islander peoples have not been extensively explored and must be understood to inform aged care policy and primary health care planning into the future.
The research was governed by leaders from across the Aboriginal community-controlled primary health care sector who identified exemplar services to explore best practice in culturally aligned aged care. In-depth case studies were undertaken with two metropolitan Aboriginal community-controlled services. We conducted semi-structured interviews and yarning circles with 46 staff members to explore key principles, ways of working, enablers and challenges for aged care service provision. A framework approach to thematic analysis was undertaken with emergent findings reviewed and refined by participating services and the governance panel to incorporate national perspectives.
A range of principles guided Aboriginal community-controlled aged care service delivery, such as supporting Aboriginal and Torres Strait Islander identity, connection with elders and communities and respect for self-determination. Strong governance, effective leadership and partnerships, Aboriginal and Torres Strait Islander workforce and culturally safe non-Indigenous workforce were among the identified enablers of aged care. Nine implementation actions guided the integration of aged care with primary health care service delivery. Funding limitations, workforce shortages, change management processes and difficulties with navigating the aged care system were among the reported challenges. These findings contribute to an evidence base regarding accessible, integrated, culturally safe aged care services tailored to the needs of Aboriginal and Torres Strait Islander peoples.
In the crowded field of leadership research, Indigenous leadership remains under-researched. This article explores the Leadership Model of an Aboriginal Community Controlled Primary Health Care Organisation providing services to the Yolngu people of remote northern Australia: the Miwatj Health Aboriginal Corporation (Miwatj).
The limited research which does exist on Indigenous leadership points to unique challenges for Indigenous leaders. These challenges relate to fostering self-determination in their communities, managing significant community expectations, and navigating a path between culturally divergent approaches to management and leadership.
Guided by Indigenous methodology and using a mixed methods approach, semi-structured interviews, self-reported health service data, organisational and publicly available documents, and literature were analysed using a framework method of thematic analysis to identify key themes of the Miwatj Leadership Model.
The Miwatj Leadership Model is underpinned by three distinctive elements: it offers Yolngu people employment opportunities; it supports staff who want to move into leadership positions and provides capacity building through certificates and diplomas; and it provides for the physical, emotional, and cultural wellbeing of all Yolngu staff. Furthermore, the model respects traditional Yolngu forms of authority and empowers the community to develop, manage and sustain their own health. The Miwatj Leadership Model has been successful in providing formal pathways to support Indigenous staff to take on leadership roles, and has improved the accessibility and acceptability of health care services as a result of Yolngu employment and improved cultural safety.
Translating the Miwatj Leadership Model into other health services will require considerable thought and commitment. The Miwatj Leadership Model can be adapted to meet the needs of other health care services in consideration of the unique context within which they operate. This study has demonstrated the importance of having a formal leadership model that promotes recruitment, retention, and career progression for Indigenous staff.
Repeated antigen testing of 12 severe acute respiratory coronavirus virus 2 (SARS-CoV-2)–positive nursing home residents using Abbott BinaxNOW identified 9 of 9 (100%) culture-positive specimens up to 6 days after initial positive test. Antigen positivity lasted 2–24 days. Antigen positivity might last beyond the infectious period, but it was reliable in residents with evidence of early infection.
Quality is an important issue for the software industry, though there is a balance between cost and quality. Starting with a few examples of software failures, this chapter discusses the need for testing, and uses an example to demonstrate why heuristics are needed to test software. A seven-step approach to testing software is introduced: analysis, identifying test coverage items and test cases, verifying the test design, implementing and executing the tests, and interpreting the test results. Key concepts are defined as used throughout the book, with a reference to the key IEEE/ISO software testing standard.
Random testing presents three main chanllenges: the test oracle problem, the test data selection problem, and the problem of when to finish testing. These are discussed in detail, and unit-test and application-test examples are worked using a simple but effective solution to these. Barriers to full automation are presented along with an overview of more advanced types of random testing. Some of the limitations are examined through the introduction of faults.
Testing with equivalence partitions introduces the reader to the first and simplest form of black-box and unit testing. First a worked example is used to demonstrate how to progress from a specification of the software to a fully automated test. The steps of the process are then examined in more detail, and the strengths and weaknesses examined through the introduction of faults into the software. The chapter ends, as do all the chapters which introduce new testing techniques, with notes for the experienced tester.
Testing object-oriented software is a significant topic in its own right, and this chapter presents the user with the essential underlying test techniques: testing in class context, and inheritance testing. As in the previous chapters, a worked example is used to introduce the reader to the concepts, which are then subsequently discussed in more detail. The chapter then summarises some more advanced techniques; state-based testing, UML-based testing, and built-in testing. Some of the limitations are examined through the introduction of faults into the working code.
Some forms of testing are significantly more time consuming to develop, and all-paths coverage is one of these. Is introduced to the reader as it is one of the most powerful forms of white-box testing, ensuring that every path from the beginning to the end of the code is exercised during testing. It is unlikely that a tester will use this technique in practice, but an understanding of this technique provides a baseline to compare other white-box tests against.
Parents who receive a diagnosis of a severe, life-threatening CHD for their foetus or neonate face a complex and stressful decision between termination, palliative care, or surgery. Understanding how parents make this initial treatment decision is critical for developing interventions to improve counselling for these families.
We conducted focus groups in four academic medical centres across the United States of America with a purposive sample of parents who chose termination, palliative care, or surgery for their foetus or neonate diagnosed with severe CHD.
Ten focus groups were conducted with 56 parents (Mage = 34 years; 80% female; 89% White). Results were constructed around three domains: decision-making approaches; values and beliefs; and decision-making challenges. Parents discussed varying approaches to making the decision, ranging from relying on their “gut feeling” to desiring statistics and probabilities. Religious and spiritual beliefs often guided the decision to not terminate the pregnancy. Quality of life was an important consideration, including how each option would impact the child (e.g., pain or discomfort, cognitive and physical abilities) and their family (e.g., care for other children, marriage, and career). Parents reported inconsistent communication of options by clinicians and challenges related to time constraints for making a decision and difficulty in processing information when distressed.
This study offers important insights that can be used to design interventions to improve decision support and family-centred care in clinical practice.