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We aimed to describe the demographic and clinical profile, and management of frequent attenders to a psychiatric liaison service.
Frequent Attenders to emergency departments contribute significantly to the burden on health services and by definition are subjectively highly stressed. It is therefore important that mental health services develop effective responses to this group of patients. A systematic literature search indicated a paucity of information on this group of patients.
We conducted a case series of 49 frequently attending patients to the Psychiatric Liaison service in Tower Hamlets, East London NHS Foundation Trust.
We defined frequent attenders as seeing the Psychiatric Liaison Service 5 or more times in 2018. We excluded 4 patients aged <18 years or >65 years.
For each patient we collected data regarding their demographics; the details of each attendance to the Psychiatric Liaison Service; and their use of other psychiatric services.
We then conducted a multivariate analysis, including stratification of patients based on number of attendances to identify correlation between frequency of attendance and the other information.
Demographic: The 45 patients reviewed had a mean age of 37 and a mean of 7 attendances during the study period.
Clinical: 89% had a history of emotional trauma, 71% of substance misuse, and 49% of any personality disorder. Only 9% of the patients were under the care of the locality Personality Disorder Service.
73% of the patients were under the care of any other psychiatric service. There was no correlation between being under other services and the frequency of attendance.
Only 31% had contact with the locality Frequent Attenders Service during the study period, as this was established recently.
Psychiatric Frequent Attenders have complex needs, which do not fit neatly into existing psychiatric diagnoses and services.
The high frequency of emotional trauma, substance misuse and personality disorder indicates a need for training of clinicians in these services to manage these patients, as well as planning for referral pathways for this group of patients who provide services with major challenges in appropriate pathways to care and follow-up
The aim of this paper is to describe key findings and recommendations of SUI reports regarding patients with a diagnosis of PD in East London NHS Foundation Trust (ELFT). Patients with a diagnosis of PD are often involved in SUIs with regards to risk to themselves or others. Contributing factors might be the nature of their disorder in terms of mood instability and impulsivity, self-harming or antisocial behaviour, and the difficulties posed to assessing clinicians in predicting risk.
Patients with PD present severe challenges to services. SUI findings thus serve as a lightning rod for issues in their management. With the emergence of NICE guidelines for borderline PD  and antisocial PD  regarding risk assessments, there has been greater optimism for management of PDs.
A case series of 50 SUI reports of patients with a diagnosis of PD were identified from the governance and risk management team of ELFT. Themes were categorized as positive practice, contributory factors, and recommendations. Findings are related to guidelines in NICE and RCPsychiatry. Any patient with a diagnosis of PD (of any sub-type) that was involved in a SUI in ELFT met the inclusion criteria. There were no exclusion criteria.
The most frequent themes in positive practice were ‘continuity of care’ and ‘clinical practice’. The most frequent subthemes in clinical practice were ‘assessments’ and ‘follow-up’. ‘Continuity of care’ included examples of collaborative working between various teams, as in joint assessments, good communication, and timely referrals. In contributory factors ‘poor documentation’ was the most frequent theme. 14 reports found no contributory factors. In recommendations the most frequent theme was the need for development and implementation of PD policies and for improved risk management.
NICE guidelines stress the importance of continuity of care and good clinical care and it is commendable that these were findings in positive practice. The importance of documentation being accurate and timely needs underlining in hard pressed time poor clinicians. Services would do well to review PD policies specifically regarding risk management at a wider Trust and local service level. Our findings point to the ongoing need for workforce development as recommended in the RCPSych position statement on PD published in January 2020.
Liaison psychiatry services (LPSs) provide psychiatric care to general medical patients. This paper aims to evaluate LPS provision for children and young people In England.
The annual Liaison Psychiatry Surveys of England (LPSEs) included questions on paediatric services from 2015 (LPSE-2). Questions were developed in consultation with NHS England and the Liaison Faculty of the Royal College of Psychiatrists. We analysed data from LPSE-2 and three subsequent surveys.
LPSs were systematically identified by contacting all acute hospitals with Type 1 emergency departments listed by NHS England. All identified LPSs were emailed a copy of the questionnaire, with follow-up emails and telephone contact for non-responders. Responses by email, post or telephone were accepted.
The number of acute hospitals with access to paediatric LPSs increased from 29 (16%) in 2015 to 46 (27%) in 2019; all of these hospitals had access to adult LPSs. The number of paediatric LPSs with at least 11 full time equivalent (FTE) mental health practitioners (MHPs) has increased from 6% to 24% and from none to 16% with 13 FTE or more MHPs. For both LPSE-4 and LPSE-5, there were only two acute hospitals where both 8 FTE MHPs and 1.5 FTE consultants were present. For LPSE-4, only one site met the Core 24 criteria (for adults - there are no criteria for paediatric LPSs) of 11 FTE MHPs and 1.5 FTE consultants, and for LPSE-5, both these sites exceeded them. Other paediatric services did not meet the adult core 24 criteria for a LPS.
Acute hospitals with access to 24/7 paediatric LPSs increased from 12% to 19% between LPSE-4 and LPSE-5. In LPSE-5 68% of paediatric LPS worked to a one-hour response time target to the ED. This is an increase from 42% (14/33) in LPSE-4.
There are still far fewer paediatric than adult LPSs, but the provision of paediatric LPSs improved from 2015 to 2019, with more services, more staffing, and faster response times. Services need to continue to improve as few services match the adult core 24 criteria for an LPS.
People with CHD are at increased risk for executive functioning deficits. Meta-analyses of these measures in CHD patients compared to healthy controls have not been reported.
To examine differences in executive functions in individuals with CHD compared to healthy controls.
We performed a systematic review of publications from 1 January, 1986 to 15 June, 2020 indexed in PubMed, CINAHL, EMBASE, PsycInfo, Web of Science, and the Cochrane Library.
Inclusion criteria were (1) studies containing at least one executive function measure; (2) participants were over the age of three.
Data extraction and quality assessment were performed independently by two authors. We used a shifting unit-of-analysis approach and pooled data using a random effects model.
The search yielded 61,217 results. Twenty-eight studies met criteria. A total of 7789 people with CHD were compared with 8187 healthy controls. We found the following standardised mean differences: −0.628 (−0.726, −0.531) for cognitive flexibility and set shifting, −0.469 (−0.606, −0.333) for inhibition, −0.369 (−0.466, −0.273) for working memory, −0.334 (−0.546, −0.121) for planning/problem solving, −0.361 (−0.576, −0.147) for summary measures, and −0.444 (−0.614, −0.274) for reporter-based measures (p < 0.001).
Our analysis consisted of cross-sectional and observational studies. We could not quantify the effect of collinearity.
Individuals with CHD appear to have at least moderate deficits in executive functions. Given the growing population of people with CHD, more attention should be devoted to identifying executive dysfunction in this vulnerable group.
ABSTRACT IMPACT: Identifying factors associated with opioid overdoses will enable better resource allocation in communities most impacted by the overdose epidemic. OBJECTIVES/GOALS: Opioid overdoses often occur in hotspots identified by geographic and temporal trends. This study uses principles of community engaged research to identify neighborhood and community-level factors associated with opioid overdose within overdose hotspots which can be targets for novel intervention design. METHODS/STUDY POPULATION: We conducted an environmental scan in three overdose hotspots’‘ two in an urban center and one in a small city’‘ identified by the Rhode Island Department of Health as having the highest opioid overdose burden in Rhode Island. We engaged hotspot community stakeholders to identify neighborhood factors to map within each hotspot. Locations of addiction treatment, public transportation, harm reduction programs, public facilities (i.e., libraries, parks), first responders, and social services agencies were converted to latitude and longitude and mapped in ArcGIS. Using Esri Service Areas, we will evaluate the service areas of stationary services. We will overlay overdose events and use logistic regression identify neighborhood factors associated with overdose by comparing hotspot and non-hotspot neighborhoods. RESULTS/ANTICIPATED RESULTS: We anticipate that there will be differing neighborhood characteristics associated with overdose events in the densely populated urban area and those in the smaller city. The urban area hotspots will have overlapping social services, addiction treatment, and transportation service areas, while the small city will have fewer community resources without overlapping service areas and reduced public transportation access. We anticipate that overdoses will occur during times of the day when services are not available. Overall, overdose hotspots will be associated with increased census block level unemployment, homelessness, vacant housing, and low food security. DISCUSSION/SIGNIFICANCE OF FINDINGS: Identifying factors associated with opioid overdoses will enable better resource allocation in communities most impacted by the overdose epidemic. Study results will be used for novel intervention design to prevent opioid overdose deaths in communities with high burden of opioid overdose.
Loeys–Dietz syndrome is a connective tissue disorder known to cause aggressive aortopathy in paediatric patients, but it is extremely rare for cardiovascular events to present during infancy. We report the first successful aortic repair in a neonate with LDS presenting in extremis with an early onset, massive aortic aneurysm.
Social and economic changes associated with new roads can bring about rapid nutritional transitions. To study this process, we: (1) describe trends in adult overweight and obesity (OW/OB) among rural Afro-Ecuadorians over time and across a gradient of community remoteness from the nearest commercial centre; (2) examine the relationship between male and female adult OW/OB and factors associated with market integration such as changing livelihoods and (3) examine the co-occurrence of adult OW/OB and under-five stunting and anaemia.
Adult anthropometry was collected through serial case–control studies repeated over a decade across twenty-eight communities. At the same time, anthropometry and Hb were measured for all children under 5 years of age in every community.
Northern coastal Ecuador.
Adults (n 1665) and children under 5 years of age (n 2618).
From 2003 and 2013, OW/OB increased from 25·1 % to 44·8 % among men and 59·9 % to 70·2 % among women. The inverse relationship between remoteness and OW/OB in men was attenuated when adjusting for urban employment, suggesting that livelihoods mediated the remoteness–OW/OB relationship. No such relationship was observed among women. Communities with a higher prevalence of male OW/OB also had a greater prevalence of stunting, but not anaemia, in children under 5 years of age.
The association between male OW/OB and child stunting at the community level, but not the household level, suggests that changing food environments, rather than household- or individual-level factors, drove these trends. A closer examination of changing socio-economic structures and food environments in communities undergoing rapid development could help mitigate future public health burdens.
This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.
We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.
Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.
These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are endemic in the Chicago region. We assessed the regional impact of a CRE control intervention targeting high-prevalence facilities; that is, long-term acute-care hospitals (LTACHs) and ventilator-capable skilled nursing facilities (vSNFs). Methods: In July 2017, an academic–public health partnership launched a regional CRE prevention bundle: (1) identifying patient CRE status by querying Illinois’ XDRO registry and periodic point-prevalence surveys reported to public health, (2) cohorting or private rooms with contact precautions for CRE patients, (3) combining hand hygiene adherence, monitoring with general infection control education, and guidance by project coordinators and public health, and (4) daily chlorhexidine gluconate (CHG) bathing. Informed by epidemiology and modeling, we targeted LTACHs and vSNFs in a 13-mile radius from the coordinating center. Illinois mandates CRE reporting to the XDRO registry, which can also be manually queried or generate automated alerts to facilitate interfacility communication. The regional intervention promoted increased automation of alerts to hospitals. The prespecified primary outcome was incident clinical CRE culture reported to the XDRO registry in Cook County by month, analyzed by segmented regression modeling. A secondary outcome was colonization prevalence measured by serial point-prevalence surveys for carbapenemase-producing organism colonization in LTACHs and vSNFs. Results: All eligible LTACHs (n = 6) and vSNFs (n = 9) participated in the intervention. One vSNF declined CHG bathing. vSNFs that implemented CHG bathing typically bathed residents 2–3 times per week instead of daily. Overall, there were significant gaps in infection control practices, especially in vSNFs. Also, 75 Illinois hospitals adopted automated alerts (56 during the intervention period). Mean CRE incidence in Cook County decreased from 59.0 cases per month during baseline to 40.6 cases per month during intervention (P < .001). In a segmented regression model, there was an average reduction of 10.56 cases per month during the 24-month intervention period (P = .02) (Fig. 1), and an estimated 253 incident CRE cases were averted. Mean CRE incidence also decreased among the stratum of vSNF/LTACH intervention facilities (P = .03). However, evidence of ongoing CRE transmission, particularly in vSNFs, persisted, and CRE colonization prevalence remained high at intervention facilities (Table 1). Conclusions: A resource-intensive public health regional CRE intervention was implemented that included enhanced interfacility communication and targeted infection prevention. There was a significant decline in incident CRE clinical cases in Cook County, despite high persistent CRE colonization prevalence in intervention facilities. vSNFs, where understaffing or underresourcing were common and lengths of stay range from months to years, had a major prevalence challenge, underscoring the need for aggressive infection control improvements in these facilities.
Funding: The Centers for Disease Control and Prevention (SHEPheRD Contract No. 200-2011-42037)
Disclosures: M.Y.L. has received research support in the form of contributed product from OpGen and Sage Products (now part of Stryker Corporation), and has received an investigator-initiated grant from CareFusion Foundation (now part of BD).
To conduct international comparisons of self-reports, collateral reports, and cross-informant agreement regarding older adult psychopathology.
We compared self-ratings of problems (e.g. I cry a lot) and personal strengths (e.g. I like to help others) for 10,686 adults aged 60–102 years from 19 societies and collateral ratings for 7,065 of these adults from 12 societies.
Data were obtained via the Older Adult Self-Report (OASR) and the Older Adult Behavior Checklist (OABCL; Achenbach et al., 2004).
Cronbach’s alphas were .76 (OASR) and .80 (OABCL) averaged across societies. Across societies, 27 of the 30 problem items with the highest mean ratings and 28 of the 30 items with the lowest mean ratings were the same on the OASR and the OABCL. Q correlations between the means of the 0–1–2 ratings for the 113 problem items averaged across all pairs of societies yielded means of .77 (OASR) and .78 (OABCL). For the OASR and OABCL, respectively, analyses of variance (ANOVAs) yielded effect sizes (ESs) for society of 15% and 18% for Total Problems and 42% and 31% for Personal Strengths, respectively. For 5,584 cross-informant dyads in 12 societies, cross-informant correlations averaged across societies were .68 for Total Problems and .58 for Personal Strengths. Mixed-model ANOVAs yielded large effects for society on both Total Problems (ES = 17%) and Personal Strengths (ES = 36%).
The OASR and OABCL are efficient, low-cost, easily administered mental health assessments that can be used internationally to screen for many problems and strengths.
The principal aim of this study was to optimize the diagnosis of canine neuroangiostrongyliasis (NA). In total, 92 cases were seen between 2010 and 2020. Dogs were aged from 7 weeks to 14 years (median 5 months), with 73/90 (81%) less than 6 months and 1.7 times as many males as females. The disease became more common over the study period. Most cases (86%) were seen between March and July. Cerebrospinal fluid (CSF) was obtained from the cisterna magna in 77 dogs, the lumbar cistern in f5, and both sites in 3. Nucleated cell counts for 84 specimens ranged from 1 to 146 150 cells μL−1 (median 4500). Percentage eosinophils varied from 0 to 98% (median 83%). When both cisternal and lumbar CSF were collected, inflammation was more severe caudally. Seventy-three CSF specimens were subjected to enzyme-linked immunosorbent assay (ELISA) testing for antibodies against A. cantonensis; 61 (84%) tested positive, titres ranging from <100 to ⩾12 800 (median 1600). Sixty-one CSF specimens were subjected to real-time quantitative polymerase chain reaction (qPCR) testing using a new protocol targeting a bioinformatically-informed repetitive genetic target; 53/61 samples (87%) tested positive, CT values ranging from 23.4 to 39.5 (median 30.0). For 57 dogs, it was possible to compare CSF ELISA serology and qPCR. ELISA and qPCR were both positive in 40 dogs, in 5 dogs the ELISA was positive while the qPCR was negative, in 9 dogs the qPCR was positive but the ELISA was negative, while in 3 dogs both the ELISA and qPCR were negative. NA is an emerging infectious disease of dogs in Sydney, Australia.
Little is known about the determinants of community integration (i.e. recovery) for individuals with a history of homelessness, yet such information is essential to develop targeted interventions.
We recruited homeless Veterans with a history of psychotic disorders and evaluated four domains of correlates of community integration: perception, non-social cognition, social cognition, and motivation. Baseline assessments occurred after participants were engaged in supported housing services but before they received housing, and again after 12 months. Ninety-five homeless Veterans with a history of psychosis were assessed at baseline and 53 returned after 12 months. We examined both cross-sectional and longitudinal relationships with 12-month community integration.
The strongest longitudinal association was between a baseline motivational measure and social integration at 12 months. We also observed cross-sectional associations at baseline between motivational measures and community integration, including social, work, and independent living. Cross-lagged panel analyses did not suggest causal associations for the motivational measures. Correlations with perception and non-social cognition were weak. One social cognition measure showed a significant longitudinal correlation with independent living at 12 months that was significant for cross-lagged analysis, consistent with a causal relationship and potential treatment target.
The relatively selective associations for motivational measures differ from what is typically seen in psychosis, in which all domains are associated with community integration. These findings are presented along with a partner paper (Study 2) to compare findings from this study to an independent sample without a history of psychotic disorders to evaluate the consistency in findings regarding community integration across projects.
OBJECTIVES/GOALS: Diverse medication-based studies require longitudinal drug dose information. EHRs can provide such data, but multiple mentions of a drug in the same clinical note can yield conflicting dose. We aimed to develop statistical methods which address this challenge by predicting the valid dose in the event that conflicting doses are extracted. METHODS/STUDY POPULATION: We extracted dose information for two test drugs, tacrolimus and lamotrigine, from Vanderbilt EHRs using a natural language processing system, medExtractR, which was developed by our team. A random forest classifier was used to estimate the probability of correctness for each extracted dose on the basis of subject longitudinal dosing patterns and extracted EHR note context. Using this feasibility measure and other features such as a summary of subject dosing history, we developed several statistical models to predict the dose on the basis of the extracted doses. The models developed based on supervised methods included a separate random forest regression, a transition model, and a boosting model. We also considered unsupervised methods and developed a Bayesian hierarchical model. RESULTS/ANTICIPATED RESULTS: We compared model-predicted doses to physician-validated doses to evaluate model performance. A random forest regression model outperformed all proposed models. As this model is a supervised model, its utility would depend on availability of validated dose. Our preliminary result from a Bayesian hierarchical model showed that it can be a promising alternative although performing less optimally. The Bayesian hierarchical model would be especially useful when validated dose data are not available, as it was developed in unsupervised modeling framework and hence does not require validated dose that can be difficult and time consuming to obtain. We evaluated the feasibility of each method for automatic implementation in our drug dosing extraction and processing system we have been developing. DISCUSSION/SIGNIFICANCE OF IMPACT: We will incorporate the developed methods as a part of our complete medication extraction system, which will allow to automatically prepare large longitudinal medication dose datasets for researchers. Availability of such data will enable diverse medication-based studies with drastically reduced barriers to data collection.
In an initial study (Study 1), we found that motivation predicted community integration (i.e. functional recovery) 12 months after receiving housing in formerly homeless Veterans with a psychotic disorder. The current study examined whether the same pattern would be found in a broader, more clinically diverse, homeless Veteran sample without psychosis.
We examined four categories of variables as potential predictors of community integration in non-psychotic Veterans: perception, non-social cognition, social cognition, and motivation at baseline (after participants were engaged in a permanent supported housing program but before receiving housing) and a 12-month follow-up. A total of 82 Veterans had a baseline assessment and 41 returned for testing after 12 months.
The strongest longitudinal association was between an interview-based measure of motivation (the motivation and pleasure subscale from the Clinical Assessment Interview for Negative Symptoms) at baseline and measures of social integration at 12 months. In addition, cross-lagged panel analyses were consistent with a causal influence of general psychiatric symptoms at baseline driving social integration at 12 months, and reduced expressiveness at baseline driving independent living at 12 months, but there were no significant causal associations with measures of motivation.
The findings from this study complement and reinforce those in Veterans with psychosis. Across these two studies, our findings suggest that motivational factors are associated at baseline and at 12 months and are particularly important for understanding and improving community integration in recently-housed Veterans across psychiatric diagnoses.
When prolonged social withdrawal was first described in Japan as ‘hikikomori’, many studies examining its etiology suggested it to be related to factors unique to Japan and thus a culture-bound syndrome. However, existing research has suffered from a lack of standardised definitions, impeding comparability between studies. We summarise existing research and discuss its relevance to psychiatric practice today.
We present studies of a protocluster at z =2.5, an overdense region found close to a radio galaxy, 4C 23.56, using ALMA. We observed 1.1 mm continuum, two CO lines (CO (4–3) and CO (3–2)) and the lower atomic carbon line transition ([CI](3P1-3P0)) at a few kpc (0″.3-0″.9) resolution. The primary targets are 25 star-forming galaxies selected as Hα emitters (HAEs) that are identified with a narrow band filter. These are massive galaxies with stellar masses of > 1010Mʘ that are mostly on the galaxy main sequence at z =2.5. We measure the molecular gas mass from the independent gas tracers of 1.1 mm, CO (3–2) and [CI], and investigate the gas kinematics of galaxies from CO (4–3). Molecular gas masses from the different measurements are consistent with each other for detection, with a gas fraction (fgas = Mgas/(Mgas+ Mstar)) of ≃ 0.5 on average but with a caveat. On the other hand, the CO line widths of the protocluster galaxies are typically broader by ˜50% compared to field galaxies, which can be attributed to more frequent, unresolved gas-rich mergers and/or smaller sizes than field galaxies, supported by our high-resolution images and a kinematic model fit of one of the galaxies. We discuss the expected scenario of galaxy evolution in protoclusters at high redshift but future large surveys are needed to get a more general view.
UK Biobank is a well-characterised cohort of over 500 000 participants including genetics, environmental data and imaging. An online mental health questionnaire was designed for UK Biobank participants to expand its potential.
Describe the development, implementation and results of this questionnaire.
An expert working group designed the questionnaire, using established measures where possible, and consulting a patient group. Operational criteria were agreed for defining likely disorder and risk states, including lifetime depression, mania/hypomania, generalised anxiety disorder, unusual experiences and self-harm, and current post-traumatic stress and hazardous/harmful alcohol use.
A total of 157 366 completed online questionnaires were available by August 2017. Participants were aged 45–82 (53% were ≥65 years) and 57% women. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status. Lifetime depression was a common finding, with 24% (37 434) of participants meeting criteria and current hazardous/harmful alcohol use criteria were met by 21% (32 602), whereas other criteria were met by less than 8% of the participants. There was extensive comorbidity among the syndromes. Mental disorders were associated with a high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The UK Biobank questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed because of selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
This replication study was invited by the Editor in Chief of Management and Organization Review, Arie Y. Lewin. The original study by Judge, Fainshmidt, and Brown (2014) spanned the global financial crisis (2005–2010), and as such, this anomalous time period may not have been representative of most economies, or even the overall global economy. In this replication study we refine and extend Judge et al. (2014) which explored the provocative question – which form of capitalism works best in terms of ‘equitable wealth creation’? Similar to the earlier study, we find that there are multiple paths to macro-economic success. Notably, effective institutional configurations tend to combine high-quality regulatory institutions, effective skill development systems, and social cultures largely unaffected by corruption so there is some commonality amongst effective configurations. In contrast, ineffective institutional configurations tend to be relatively weak in one or several of these three critical sets of institutions. Importantly, we find some novel patterns emerging from the most recent data, including potentially new forms of capitalism associated with equitable wealth creation. In addition, we find that effective credit market institutions are more important, and collective bargaining institutions are less important than the original study suggested. We discuss implications for the comparative capitalism literature, policy makers, and the future of capitalism in the global economy.