21 results
All the Sickly People, Where Do They All Come From? An OLD Problem (Off Load Delay) Rising Ambulance Presentations to an Irish Emergency Department
- Phillip Jordaan, Marco Smit, Robin Andrews, Phillip Jordaan, Keith Kennedy, Ria Abraham, Brendan Orsmond, Rochelle Jansen van Rensburg, Fahd Fayyaz, Yuni Neduchelyn, Andrea van der Vegte, Ashleigh Dowle, Darshini Vythilingam, Bryce Wickham, Thomas Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, pp. s124-s125
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- May 2023
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Introduction:
Demand for prehospital emergency services has been increasing worldwide. Significant challenges exist in meeting response times in rural environments when faced with surges in demand related to weather events or sustained demand surge such as the pandemic environment. Significant pressure also exists in the hospital environment receiving such large volumes of patients with short duration handovers to allow prehospital assets return to their primary roles. The aim of this study is to determine trends for ambulance presentations in a rural emergency department over seven years with absolute numbers and percentage of overall attendances.
Method:A retrospective analysis of anonymized electronic registration data on the iPMS system from initiation in 2014 to 2022 including total registration numbers, presentation by ambulance, and handover times. Excel is used to record and examine data.
Results:ED attendances rose from 29,236 in 2014 to 43,184 in 2021 with total ambulance presentations ranging from 4,859 in 2014 (16.62% of attendances), maxing in 2019 at 10,326 out of total attendances of 42,637 (24.22% of attendances).Lowest monthly ambulance presentations occurred in April 2014 (441 or 15.82% of 2788 attendances) and maximal monthly presentations was 1,023 in May 2022 (23.38% of 4376 attendances). Lowest percentage of attendances arriving by ambulance occurred in May 2014 with 14.97% (468) out of 3,127 ED presentations. Highest percentage of attendances arriving by ambulance occurred in January 2021 with 33.67% (875) of 2,599 ED presentations which was during the lockdown phase of COVID in Ireland.
Conclusion:Overall total numbers of patients arriving by ambulance has been steadily increasing for years but numbers (and percentages) dramatically increased during COVID and this has been sustained in the POST Lockdown pandemic phase. Strategies are required to manage demand, increase turnaround and educate the public on appropriate use of prehospital emergency services.
Evaluation of Inconclusive Results on the Cepheid X-Pert Xpress Platform (GXP) for the Diagnosis of Severe Acute Respiratory Syndrome-2: A Narrative Literature Review
- Andrea van der Vegte, Maria Conradie, Brendan Orsmond, Marco Smit, Rochelle Kleinhans, Ria Abraham, Ashleigh Dowle, Philip Jordaan, Keith Kennedy, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s203
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- May 2023
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Introduction:
Molecular assay for diagnosing and detecting SARS-COV-2 is an essential tool in pandemic management, allowing for early informed decision-making. Worldwide, the gold standard for testing SARS-COV-2 includes real-time reverse transcription-polymerase chain reaction assay (RT-PCR). The Cepheid Xpert-Xpress was authorized for emergency diagnosis of SARS-COV-2. This platform demonstrated various advantages, including faster results, due to a decreased turnaround time, and decreased contamination risk. However, inconclusive results often leave clinicians uncertain regarding individual patient management decisions. Often leading to more confusion than answers.
The aim of this literature review includes the following:
identify the frequency and clinical implications of inconclusive results for SARS-COV-2 diagnosis utilizing GeneXpert assay
whether inconclusive results should be interpreted as negative
assessing the reliability of the GeneXpert platform to diagnose SARS-COV-2
Method:A narrative literature review was conducted with eight critically appraised articles which met the inclusion criteria.
After the initial data collection, the SANRA Framework was implemented to aid in the sorting and filtering of data. The analysis of data was conducted with a critical appraisal tool.
Results:The GeneXpert SARS-COV-2 assay demonstrated high sensitivity and specificity. Studies indicated that inconclusive results associated with a high cycle-threshold value (CT-value) of more than thirty-five on the Cepheid Xpert Xpress were associated with a decreased viral load and, thus, decreased infectivity. However, numerous factors influence the CT-value, such as specimen integrity. Thus, results must not be interpreted in isolation.
Conclusion:This narrative literature review demonstrated the need for institutions to assist clinicians with decision-making regarding inconclusive results. A flow diagram grading a patient’s risk of having SARS-COV-2 with an inconclusive result could be of immense value. The flow diagram should incorporate the current epidemiology in the area, patient symptomology and risk and duration of exposure.
Compliance with The National Institute for Health and Care Excellence (NICE) Guideline (NG158) Venous Thromboembolic Diseases: Diagnosis, Management, and Thrombophilia Testing; Proximal Lower Limb Venous Ultrasound Time Standards at Wexford General Hospital
- Ria Abraham, Brendan Orsmond, Ashleigh Dowle, Darshini Vythilingam, Robin Andrews, Marco Smit, Keith Kennedy, Rochelle Janse van Rensburg, Andrea van der Vegte, Maria Conradie, Philip Jordaan, Bryce Wickham, T Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s127
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- May 2023
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Introduction:
The consequences of missed lower-limb deep vein thromboses (DVT) can be life-threatening. Similarly, inappropriate treatment with anticoagulation in low-risk patients carries a significant risk of harm. Early diagnosis and appropriate treatment with anticoagulation rely on timely ultrasound access. The National Institute for Health and Care Excellence (NICE) recommends timeframes for ultrasound acquisition based on Well’s score and D-dimer value.
If rapid ultrasound (Point of care Ultrasound POCUS in our context) demonstrates no features of DVT, it is safe to arrange follow-up scan within eight days without empiric anticoagulation. If, however, no bedside ultrasound is performed, anticoagulation is commenced until a formal scan excludes DVT. NG158 recommends this scan be performed within 24 hours. This audit investigated our compliance with NG158 time standards at Wexford General Hospital (WGH) emergency department (ED).
Method:Electronic records for patients undergoing formal ultrasound for suspected DVT between 08/01/2022-10/13/2022 were reviewed using the hospital’s databases. Charts were reviewed to determine if POCUS was performed. In total, 42 records met selection criteria. Audit Committee governance review was obtained. Fisher’s exact test was used to compare compliance rates between those that underwent bedside ultrasound and those that did not.
Results:Overall compliance with NG158 was 40.5%. Compliance rates for those offered bedside ultrasound were significantly higher than those that weren’t (58.3% vs. 16.7% p<0.0106). The mean waiting time for a radiology department ultrasound is six days, 12 hours, and 16 minutes.
Conclusion:Overall compliance is low, and delays to obtaining formal ultrasound are long. We observed that compliance rates for those who underwent bedside ultrasound were significantly higher than for those who did not. This suggests that bedside ultrasound is under-utilized in our ED. Training more staff to perform bedside scans would alleviate current delays to ultrasound diagnosis and reduce risks associated with empiric anticoagulation.
Review of Psychiatric Patient Transfer Times in an Emergency Department with Limited Psychiatric Services
- Maria Conradie, Brendan Orsmond, Robin Andrews, Muhammad Bilal, Andrea van der Vegte, Ria Abraham, Rochelle Janse van Rensburg, Syed Taqvi, Phillip Jordaan, Marco Smit, Ashleigh Dowle, Darshini Vythilingam, Bryce Wickham, Keith Kennedy, Thomas Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s207
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- May 2023
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Introduction:
The National Ambulance Service (NAS) must transport patients with acute psychiatric needs to their nearest emergency department for assessment. Wexford General Hospital (WGH) does not have on-site medical psychiatric services after hours, in-patient psychiatric beds, or dedicated psychiatric doctors. Patients requiring formal acute psychiatric assessment and/or admission after ED review need to be transferred 60-80 km to other healthcare facilities.
Aimed to assess average ED stays of psychiatric patients and determine what degree transfer time contributed to their total time would help to determine what delay there was to providing acute psychiatric care due to the lack of after hours/on-site services.
Method:Data was collected from the iPMS system. A total of 125 patients presented with primary psychiatric complaints between January 1, 2021 and December 31, 2021 and required onward transfer for acute psychiatric assessment or admission. Patients were excluded if less than 18 years or had been admitted to another WGH service before transfer. There are no existing guidelines in the National Clinical Program for Psychiatry or NICE guidelines for acute psychiatric patient transfer times or ED stays.
Results:The average WGH ED attendance time was 15h 27min (range 0h08min and 19h22min). The longest interval contributing to overall time was Transfer Booked to Transfer Time (average 3h 27min). The time from Psychiatric Referral to Transfer accounted for 30% (on average) of patients’ attendance time.
Conclusion:There are significant delays in accessing acute psychiatric care due to the absence of Ambulance Service Bypass Protocols to transport patients to the most appropriate rather than the nearest ED. Proposed Trauma bypass system changes offer unique opportunities to review such inequity of access to acute psychiatric services.
Retrospective Analysis to Assess the Admission Rate Trends in an Irish Public Hospital between February 2014-September 2022
- Rochelle Janse van Rensburg, Maria Conradie, Phillip Jordaan, Marco Smit, Andrea Van Der Vegte, Syed Taqvi, Brendan Orsmond, Robin Andrews, Ria Abraham, Ashleigh Dowle, Darshini Vythilingam, Keith Kennedy, Muhammad Bilal, Bryce Wickham, Thomas Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s177
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- May 2023
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Introduction:
As the population in the Republic of Ireland increases, the number of Emergency Department (ED) attendances and admission rates increase, placing significant pressure on the health care system, the limited staff and hospital resources.
The aim of this study is to assess the admission rates in an Irish Public Hospital Emergency Department between 2014 and 2022.
Method:This retrospective study was done using information provided by the Health Service Executive Integrated Patient Management System. Data for the period between February 2014 to September 2022 were collected. From the data, the admission rate can be calculated and trends observed.
Results:Emergency department attendance rates have increased from 29,236 to 42,637 between 2014 and 2019, with a decline noticed in 2020 to 37,751 and a drastic increase in 2021 at 43,182. Currently up until September 2022 there has been 35,503 attendances and 8,570 admissions, with an admission rate of 24.14%. The number of admissions has ranged from 9,056 in 2014 to the highest being 12,175 in 2019. This means the admission rate is averaging between 24% to 31% per annum, with the highest being 31,04% in 2015, and the lowest in 2017 at 24,99%.
Conclusion:This study showed a steady increase in attendances per annum, which correlates to an increase in the total admissions from 2014 to 2022, with approximately one third of all ED attendances resulting in admission. The increase in attendances and admission rate could be related to the population growth from 4.6 to 5.1 million from 2014 to 2022. The decrease in attendances during 2020 could be attributed to the Covid-19 pandemic restrictions being implemented, and lifted in 2021 which showed a drastic increase in ED numbers. Ultimately, the increase in admissions will place a burden on the Public Hospitals in Ireland.
Festina Lente: Bradycardia as a Presenting Feature of Life-Threatening Intra-Abdominal Hemorrhage
- Robin Andrews, Brendan Orsmond, Ria Abraham, Muhammad Bilal, Maria Conradie, Ashleigh Dowle, Rochelle Janse Van Rensburg, Phillip Jordaan, Thomas Kelly, Keith Kennedy, Marco Smit, Syed Yousuf Raza Taqvi, Andrea Van Der Vegte, Darshini Vythilingam, Bryce Wickham, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s125
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- May 2023
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Introduction:
Trauma is one of the leading causes of death in patients under 40 years of age. The Advanced Trauma Life Support (ATLS) Guidelines are widely accepted as the standardized approach to trauma and classify hemorrhagic shock according to heart rate (HR), blood pressure (BP), urinary output, and mental status. Paradoxical bradycardia (defined as HR <60 bpm) in hemorrhagic shock is an uncommon presenting feature and presents a diagnostic challenge to the physician; its true incidence is unknown.
Method:A case of paradoxical bradycardia was examined as a presenting feature in hemorrhagic shock.
Results:A 17-year-old male patient presented to our Emergency Department (ED) with collapse and abdominal pain following a collision with another player during a sports match.
The patient was hypotensive (BP 92/42) and bradycardic at triage, with a heart rate of 50. He was pale and diaphoretic with a Glasgow Coma Scale of 13/15, thready pulses, and localized peritonitis in the left upper quadrant of his abdomen.
An increase in blood pressure was observed following initial fluid resuscitation; however, this was transient and preceded the onset of profound hypotension (BP 64/30). Bradycardia with a heart rate between 50-60bpm was persistent despite resuscitative efforts.
Abdominal ultrasound demonstrated intraperitoneal free-fluid, and Computerized Tomography confirmed the presence of a grade V splenic laceration. He was taken to the operating theater for emergency laparotomy and underwent splenectomy. A 2.3 liter hemoperitoneum was found intraoperatively. There were no further complications post-operatively, and he made a full recovery.
Conclusion:Tachycardia is a potentially unreliable marker of blood loss, especially in young, healthy patients. A high index of suspicion is necessary to prevent this uncommon but life-threatening feature of hemorrhagic shock from being overlooked.
Use of Bedside Ultrasound at Wexford General Hospital Emergency Department: Compliance to NICE Guidelines [NG158] for Venous Thromboembolic Disease
- Ashleigh Dowle, Brendan Orsmond, Darshini Vythilingam, Ria Abraham, Robin Andrews, Rochelle Janse Van Rensburg, Marco Smit, Andrea Van der Vegte, Philip Jordaan, Maria Conradie, Keith Kennedy, Bryce Wickham, Thomas Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, pp. s154-s155
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- May 2023
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Introduction:
Ultrasound is the standard imaging technique for diagnosing lower limb deep venous thrombosis (DVT). The National Institute for Health and Care Excellence (NICE) guidance 158 recommendation 1.1.3 states that all patients with sufficient pretest probability for DVT should be offered a proximal leg vein ultrasound within four hours. However, due to high patient volumes, formal radiology department ultrasound wait times often exceed one week. Point-of-care ultrasound (POCUS) is used to bridge diagnostic delay in our emergency department (ED) .
This study aimed to quantify numbers offered POCUS for suspected proximal lower DVT in our ED and accuracy of such studies.
Method:A retrospective review of electronic records was conducted for patients who underwent formal lower-limb ultrasound for suspected DVT at our hospital over a three-month period (August 1, 2022-October 12, 2022). Patient charts for all ED presentations were assessed to determine whether POCUS was offered and whether DVT was diagnosed.
Statistical analysis was conducted using PRISM v9.
Results:80 formal ultrasound scans were performed at our hospital for lower limb DVT. 58 were requested for patients presenting to ED, of which 42 had complete records available meeting selection criteria.
POCUS was offered to 24 patients in ED (57.1%). Sensitivity was 66% (95% CI 12%- 98%), and specificity was 94.1% (95% CI 75%-99%). Overall accuracy was 90%, with only one false negative study identified at formal follow-up ultrasound.
Conclusion:Although sample size was small, our results suggest that POCUS is an accurate but underused tool to diagnose lower limb DVT. Developing a standardized protocol for performing and reporting POCUS DVT scans in ED should allow for earlier diagnosis and initiation of appropriate treatment where necessary.
Under Pressure–TrolleyGar, a Metric Reflecting a Hospital System at Crisis-Capacity
- Maria Conradie, Marco Smit, Rochelle Janse van Rensburg, Sayed Taqvi, Brendan Orsmond, Robin Andrews, Andrea van der Vegte, Aishleigh Dowle, Bryce Wickham, Darshini Vythilingam, Fahd Fayyaz, Keith Kennedy, Phillip Jordaan, Ria Abraham, Yuni Neduchelyn, Thomas Kelly, Michael Molloy
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s153
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- May 2023
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Introduction:
Health service capacity has been an issue in Ireland since the 1980s swinging cuts. Government reports from 2003 have consistently identified a requirement for 3,000-5,000 extra beds on top of the current approximately 10,500 capacity. Acute hospital bed capacity issues have escalated, the formal system of recording “over capacity” patients or “patients on trolleys” has developed. A “Trolleygar” reports issues from the Health Service Executive (HSE) three times daily. This count is an underestimate as patients temporarily housed in day care units, surgical, or medical assessment units, discharge lounges and other clinical areas which have a bed space are not counted in this overcapacity measure. This study's aim is to calculate the annual number of days on which no patients were lodged on trolleys in Wexford General Hospital.
Method:Descriptive study using anonymized freely available data from the national HSE Trolley GAR reports on trolley patients in Wexford General Hospital from January 2019 until September 2022. A Golden Zero trolley day was stated as a day on which there were no reported trolley-patients at the three time points, Silver Zero trolley day when two of the time periods recorded no trolleys and a Bronze Zero Trolley day when one period recorded a zero trolley count.
Results:Data was collected on 1,369 days, with 90 days excluded due to missing data sets. There were 162 Golden days recorded (12.67% of total days). The year 2020 recorded the highest number of Golden days at 28.69% (105 days), followed by 2021 with 11.23% (41 days). During 2019 there were 3.84% (14 days) Golden days and 2022 had the lowest number (January-September) with 0.73% (2 days).
Conclusion:Despite a zero-tolerance policy, Golden days are disappearing rapidly, capacity is urgently required with post-pandemic ED attendance surges worldwide. True recording of overcapacity patients is required for appropriate capacity modeling.
Emergency Department Attendance Gap during COVID-19 Pandemic: A Comparison of Attendance Trends at Wexford General Hospital from 2014 to 2022
- Marco Smit, Brendan Orsmond, Michael Molloy, Robin Andrews, Muhammad Bilal, Andrea Van Der Vegte, Ria Abraham, Rochelle Janse van Rensberg, Syed Taqvi, Phillip Jordaan, Maria Conradie, Ashleigh Dowle, Darshini Vythilingam, Bryce Wickham, Thomas Kelly, Keith Kennedy, Fahd Fayyaz, Yuni Neduchelyn
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s188
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- May 2023
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Introduction:
COVID-19 resulted in 1.8 million reported deaths in 2020 and an excess mortality of at least 3,000,000 to date. Following the announcement of emergency measures mandating various public health interventions, international studies demonstrated a decline in ED attendances, potentiating a delay in seeking health services.
The objective was to examine ED attendance trends by age group and to categorize the attendances following the implementation of regulations related to COVID-19.
Method:A single-center retrospective observational study of ED attendances from 2014 to 2022 at Wexford General Hospital, a 225-bed acute general hospital. Monthly attendance trends were analyzed covering all phases of the national response. Information was extracted from the electronic health record system iPMS.
Results:Overall attendances decreased by 11.5% {42,637 (2019) to 37,751 (2020)}, well below expected annual growth projections from 2019 to 2020. A significant reduction in pediatric attendance (≤16 years) occurred, with 31.68% negative growth (10,351 to 7,071) in 2020 and sustained decrease of 15.3% (8,767 attendances) in 2021. In contrast, geriatric (≥65 years) attendances were unchanged in 2020 (17,751), with a surge of 8.9% to 19,333 attendances in 2021, the largest year-on-year growth since 2018. Comparisons of month-to-month trends in relation to public health measures correlated to a marked decline in attendances at the extremes of age during “lockdown” periods.
Conclusion:The reduction in attendances is likely multifactorial, such as a reduction in school-related stress and patients deciding to stay home for fear of attending during the pandemic with non-emergent conditions. The increase in geriatric presentations in 2021 may reflect continuing restricted access to primary care and GP services, or neglect of prior conditions. Examining changing demographic attendances may offer opportunities to develop alternative ways of supporting frail populations and families in community care avoiding ED presentations.
Development of a model to predict antidepressant treatment response for depression among Veterans
- Victor Puac-Polanco, Hannah N. Ziobrowski, Eric L. Ross, Howard Liu, Brett Turner, Ruifeng Cui, Lucinda B. Leung, Robert M. Bossarte, Corey Bryant, Jutta Joormann, Andrew A. Nierenberg, David W. Oslin, Wilfred R. Pigeon, Edward P. Post, Nur Hani Zainal, Alan M. Zaslavsky, Jose R. Zubizarreta, Alex Luedtke, Chris J. Kennedy, Andrea Cipriani, Toshiaki A. Furukawa, Ronald C. Kessler
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- Psychological Medicine / Volume 53 / Issue 11 / August 2023
- Published online by Cambridge University Press:
- 15 July 2022, pp. 5001-5011
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Background
Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).
MethodsA 2018–2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.
ResultsIn total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.
ConclusionsAlthough these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.
“A Wanderer's Tale”: The development of a virtual reality application for pain and quality of life in Australian burns and oncology patients
- Mathilde R. Desselle, Lucy R. Holland, Andrea McKittrick, Glen Kennedy, Patsy Yates, Jason Brown
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- Palliative & Supportive Care / Volume 21 / Issue 3 / June 2023
- Published online by Cambridge University Press:
- 09 June 2022, pp. 454-460
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Objectives
The primary objective of this study was to co-design and conduct a pilot evaluation of a novel, immersive virtual reality (VR) experience for procedural pain and anxiety in an Australian healthcare setting. The secondary objective was to identify key parameters that can facilitate the development and implementation of VR experiences in clinical practice.
MethodA qualitative, Design Box method was selected for co-design. It was used with adult burns survivors and adolescents and young adults (AYAs) with cancer, and healthcare professionals from these fields to identify the practical and design parameters required for the application of VR technology within the clinical setting. Results informed the development of the VR experience that was evaluated by consumers and healthcare professionals, who completed qualitative surveys. Thematic analysis was conducted on co-design notes and survey data.
ResultsProcedural pain and management was a challenge for both cohorts, but particularly the burns cohort. Anxiety was significant challenge for both cohorts. Boredom and quality of life was a significant challenge, particularly for the AYA oncology cohort. These results informed the development of “A Wanderers Tale,” an Australiana-themed, gaze-controlled VR application for Oculus Quest platforms. Thematic analysis results suggest that cultural preferences, procedural contexts of use, and agency through customization and interaction are three parameters to consider when creating or selecting VR experiences for application in health.
Significance of resultsThis work describes a novel method for the use VR as an adjuvant pain management tool in patients with burns and cancer. The VR experience may provide a culturally, practice and procedure-appropriate tool in comparable settings of care. The study also describes interdisciplinary co-design and evaluation approaches that can help maximize the use of VR to improve healthcare approaches that address clinical challenges in pain, anxiety, and quality of life for patients while in hospital.
Mapping anorexia nervosa genes to clinical phenotypes
- Jessica S. Johnson, Alanna C. Cote, Amanda Dobbyn, Laura G. Sloofman, Jiayi Xu, Liam Cotter, Alexander W. Charney, Eating Disorders Working Group of the Psychiatric Genomics Consortium, Andreas Birgegård, Jennifer Jordan, Martin Kennedy, Mikaél Landén, Sarah L. Maguire, Nicholas G. Martin, Preben Bo Mortensen, Laura M. Thornton, Cynthia M. Bulik, Laura M. Huckins
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- Psychological Medicine / Volume 53 / Issue 6 / April 2023
- Published online by Cambridge University Press:
- 05 April 2022, pp. 2619-2633
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Background
Anorexia nervosa (AN) is a psychiatric disorder with complex etiology, with a significant portion of disease risk imparted by genetics. Traditional genome-wide association studies (GWAS) produce principal evidence for the association of genetic variants with disease. Transcriptomic imputation (TI) allows for the translation of those variants into regulatory mechanisms, which can then be used to assess the functional outcome of genetically regulated gene expression (GReX) in a broader setting through the use of phenome-wide association studies (pheWASs) in large and diverse clinical biobank populations with electronic health record phenotypes.
MethodsHere, we applied TI using S-PrediXcan to translate the most recent PGC-ED AN GWAS findings into AN-GReX. For significant genes, we imputed AN-GReX in the Mount Sinai BioMe™ Biobank and performed pheWASs on over 2000 outcomes to test the clinical consequences of aberrant expression of these genes. We performed a secondary analysis to assess the impact of body mass index (BMI) and sex on AN-GReX clinical associations.
ResultsOur S-PrediXcan analysis identified 53 genes associated with AN, including what is, to our knowledge, the first-genetic association of AN with the major histocompatibility complex. AN-GReX was associated with autoimmune, metabolic, and gastrointestinal diagnoses in our biobank cohort, as well as measures of cholesterol, medications, substance use, and pain. Additionally, our analyses showed moderation of AN-GReX associations with measures of cholesterol and substance use by BMI, and moderation of AN-GReX associations with celiac disease by sex.
ConclusionsOur BMI-stratified results provide potential avenues of functional mechanism for AN-genes to investigate further.
Characterisation of age and polarity at onset in bipolar disorder
- Janos L. Kalman, Loes M. Olde Loohuis, Annabel Vreeker, Andrew McQuillin, Eli A. Stahl, Douglas Ruderfer, Maria Grigoroiu-Serbanescu, Georgia Panagiotaropoulou, Stephan Ripke, Tim B. Bigdeli, Frederike Stein, Tina Meller, Susanne Meinert, Helena Pelin, Fabian Streit, Sergi Papiol, Mark J. Adams, Rolf Adolfsson, Kristina Adorjan, Ingrid Agartz, Sofie R. Aminoff, Heike Anderson-Schmidt, Ole A. Andreassen, Raffaella Ardau, Jean-Michel Aubry, Ceylan Balaban, Nicholas Bass, Bernhard T. Baune, Frank Bellivier, Antoni Benabarre, Susanne Bengesser, Wade H Berrettini, Marco P. Boks, Evelyn J. Bromet, Katharina Brosch, Monika Budde, William Byerley, Pablo Cervantes, Catina Chillotti, Sven Cichon, Scott R. Clark, Ashley L. Comes, Aiden Corvin, William Coryell, Nick Craddock, David W. Craig, Paul E. Croarkin, Cristiana Cruceanu, Piotr M. Czerski, Nina Dalkner, Udo Dannlowski, Franziska Degenhardt, Maria Del Zompo, J. Raymond DePaulo, Srdjan Djurovic, Howard J. Edenberg, Mariam Al Eissa, Torbjørn Elvsåshagen, Bruno Etain, Ayman H. Fanous, Frederike Fellendorf, Alessia Fiorentino, Andreas J. Forstner, Mark A. Frye, Janice M. Fullerton, Katrin Gade, Julie Garnham, Elliot Gershon, Michael Gill, Fernando S. Goes, Katherine Gordon-Smith, Paul Grof, Jose Guzman-Parra, Tim Hahn, Roland Hasler, Maria Heilbronner, Urs Heilbronner, Stephane Jamain, Esther Jimenez, Ian Jones, Lisa Jones, Lina Jonsson, Rene S. Kahn, John R. Kelsoe, James L. Kennedy, Tilo Kircher, George Kirov, Sarah Kittel-Schneider, Farah Klöhn-Saghatolislam, James A. Knowles, Thorsten M. Kranz, Trine Vik Lagerberg, Mikael Landen, William B. Lawson, Marion Leboyer, Qingqin S. Li, Mario Maj, Dolores Malaspina, Mirko Manchia, Fermin Mayoral, Susan L. McElroy, Melvin G. McInnis, Andrew M. McIntosh, Helena Medeiros, Ingrid Melle, Vihra Milanova, Philip B. Mitchell, Palmiero Monteleone, Alessio Maria Monteleone, Markus M. Nöthen, Tomas Novak, John I. Nurnberger, Niamh O'Brien, Kevin S. O'Connell, Claire O'Donovan, Michael C. O'Donovan, Nils Opel, Abigail Ortiz, Michael J. Owen, Erik Pålsson, Carlos Pato, Michele T. Pato, Joanna Pawlak, Julia-Katharina Pfarr, Claudia Pisanu, James B. Potash, Mark H Rapaport, Daniela Reich-Erkelenz, Andreas Reif, Eva Reininghaus, Jonathan Repple, Hélène Richard-Lepouriel, Marcella Rietschel, Kai Ringwald, Gloria Roberts, Guy Rouleau, Sabrina Schaupp, William A Scheftner, Simon Schmitt, Peter R. Schofield, K. Oliver Schubert, Eva C. Schulte, Barbara Schweizer, Fanny Senner, Giovanni Severino, Sally Sharp, Claire Slaney, Olav B. Smeland, Janet L. Sobell, Alessio Squassina, Pavla Stopkova, John Strauss, Alfonso Tortorella, Gustavo Turecki, Joanna Twarowska-Hauser, Marin Veldic, Eduard Vieta, John B. Vincent, Wei Xu, Clement C. Zai, Peter P. Zandi, Psychiatric Genomics Consortium (PGC) Bipolar Disorder Working Group, International Consortium on Lithium Genetics (ConLiGen), Colombia-US Cross Disorder Collaboration in Psychiatric Genetics, Arianna Di Florio, Jordan W. Smoller, Joanna M. Biernacka, Francis J. McMahon, Martin Alda, Bertram Müller-Myhsok, Nikolaos Koutsouleris, Peter Falkai, Nelson B. Freimer, Till F.M. Andlauer, Thomas G. Schulze, Roel A. Ophoff
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- Journal:
- The British Journal of Psychiatry / Volume 219 / Issue 6 / December 2021
- Published online by Cambridge University Press:
- 25 August 2021, pp. 659-669
- Print publication:
- December 2021
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Background
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
AimsTo examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
MethodGenome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
ResultsEarlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
ConclusionsAAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Science and the CBRNE Science Medical Operations Science Support Expert (CMOSSE)
- C. Norman Coleman, Judith L. Bader, John F. Koerner, Chad Hrdina, Kenneth D. Cliffer, John L. Hick, James J. James, Monique K. Mansoura, Alicia A. Livinski, Scott V. Nystrom, Andrea DiCarlo-Cohen, Maria Julia Marinissen, Lynne Wathen, Jessica M. Appler, Brooke Buddemeier, Rocco Casagrande, Derek Estes, Patrick Byrne, Edward M. Kennedy, Ann A. Jakubowski, Cullen Case, Jr, David M. Weinstock, Nicholas Dainiak, Dan Hanfling, Andrew L. Garrett, Natalie N. Grant, Daniel Dodgen, Irwin Redlener, Thomas F. MacKAY, Meghan Treber, Mary J. Homer, Tammy P. Taylor, Aubrey Miller, George Korch, Richard Hatchett
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- Journal:
- Disaster Medicine and Public Health Preparedness / Volume 13 / Issue 5-6 / December 2019
- Published online by Cambridge University Press:
- 17 June 2019, pp. 995-1010
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A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
12 - Energy Transformation in Cities
- from Part III - Urban Infrastructure Systems
- Edited by Cynthia Rosenzweig, William D. Solecki, Hunter College, City University of New York, Patricia Romero-Lankao, National Center for Atmospheric Research, Boulder, Colorado, Shagun Mehrotra, New School University, New York, Shobhakar Dhakal, Somayya Ali Ibrahim
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- Book:
- Climate Change and Cities
- Published online:
- 12 April 2018
- Print publication:
- 29 March 2018, pp 443-490
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Ketamine: stimulating antidepressant treatment?
- Part of
- Gin S. Malhi, Yulisha Byrow, Frederick Cassidy, Andrea Cipriani, Koen Demyttenaere, Mark A. Frye, Michael Gitlin, Sidney H. Kennedy, Terence A. Ketter, Raymond W. Lam, Rupert McShane, Alex J. Mitchell, Michael J. Ostacher, Sakina J. Rizvi, Michael E. Thase, Mauricio Tohen
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- Journal:
- BJPsych Open / Volume 2 / Issue 3 / May 2016
- Published online by Cambridge University Press:
- 02 January 2018, pp. e5-e9
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The appeal of ketamine – in promptly ameliorating depressive symptoms even in those with non-response – has led to a dramatic increase in its off-label use. Initial promising results await robust corroboration and key questions remain, particularly concerning its long-term administration. It is, therefore, timely to review the opinions of mood disorder experts worldwide pertaining to ketamine's potential as an option for treating depression and provide a synthesis of perspectives – derived from evidence and clinical experience – and to consider strategies for future investigations.
Dopamine receptor D2 (DRD2), dopamine transporter solute carrier family C6, member 4 (SLC6A3), and catechol-O-methyltransferase (COMT) genes as moderators of the relation between maternal history of maltreatment and infant emotion regulation
- Vanessa Villani, Jaclyn Ludmer, Andrea Gonzalez, Robert Levitan, James Kennedy, Mario Masellis, Vincenzo S. Basile, Christine Wekerle, Leslie Atkinson
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- Journal:
- Development and Psychopathology / Volume 30 / Issue 2 / May 2018
- Published online by Cambridge University Press:
- 14 August 2017, pp. 581-592
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Although infants less than 18 months old are capable of engaging in self-regulatory behavior (e.g., avoidance, withdrawal, and orienting to other aspects of their environment), the use of self-regulatory strategies at this age (as opposed to relying on caregivers) is associated with elevated behavioral and physiological distress. This study investigated infant dopamine-related genotypes (dopamine receptor D2 [DRD2], dopamine transporter solute carrier family C6, member 4 [SLC6A3], and catechol-O-methyltransferase [COMT]) as they interact with maternal self-reported history of maltreatment to predict observed infant independent emotion regulation behavior. A community sample (N = 193) of mother–infant dyads participated in a toy frustration challenge at infant age 15 months, and infant emotion regulation behavior was coded. Buccal cells were collected for genotyping. Maternal maltreatment history significantly interacted with infant SLC6A3 and COMT genotypes, such that infants with more 10-repeat and valine alleles of SLC6A3 and COMT, respectively, relative to infants with fewer or no 10-repeat and valine alleles, utilized more independent (i.e., maladaptive) regulatory behavior if mother reported a more extensive maltreatment history, as opposed to less. The findings indicate that child genetic factors moderate the intergenerational impact of maternal maltreatment history. The results are discussed in terms of potential mechanism of Gene × Environment interaction.
Design and initial results of a programme for routine standardised longitudinal follow-up after congenital heart surgery
- Sara K. Pasquali, Chitra Ravishankar, Jennifer C. Romano, Kristin Kane, Suzanne Viers, Andrea Kennedy, Nancy Burnham, Ray Lowery, Karen Uzark, Lauren Retzloff, Jonathon J. Rome, Joseph W. Rossano, John R. Charpie, Thomas L. Spray, Michael G. Gaies, Richard G. Ohye, J. William Gaynor
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- Journal:
- Cardiology in the Young / Volume 26 / Issue 8 / December 2016
- Published online by Cambridge University Press:
- 02 February 2017, pp. 1590-1596
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Background
With improvements in early survival following congenital heart surgery, it has become increasingly important to understand longer-term outcomes; however, routine collection of these data is challenging and remains very limited. We describe the development and initial results of a collaborative programme incorporating standardised longitudinal follow-up into usual care at the Children’s Hospital of Philadelphia (CHOP) and University of Michigan (UM).
MethodsWe included children undergoing benchmark operations of the Society of Thoracic Surgeons. Considerations regarding personnel, patient/parent engagement, funding, regulatory issues, and annual data collection are described, and initial follow-up rates are reported.
ResultsThe present analysis included 1737 eligible patients undergoing surgery at CHOP from January 2007 to December 2014 and 887 UM patients from January 2010 to December 2014. Overall, follow-up data, of any type, were obtained from 90.8% of patients at CHOP (median follow-up 4.3 years, 92.2% survival) and 98.3% at UM (median follow-up 2.8 years, 92.7% survival), with similar rates across operations and institutions. Most patients lost to follow-up at CHOP had undergone surgery before 2010. Standardised questionnaires assessing burden of disease/quality of life were completed by 80.2% (CHOP) and 78.4% (UM) via phone follow-up. In subsequent pilot testing of an automated e-mail system, 53.4% of eligible patients completed the follow-up questionnaire through this system.
ConclusionsStandardised follow-up data can be obtained on the majority of children undergoing benchmark operations. Ongoing efforts to support automated electronic systems and integration with registry data may reduce resource needs, facilitate expansion across centres, and support multi-centre efforts to understand and improve long-term outcomes in this population.
Data integrity of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry
- Michael Gaies, Janet E. Donohue, Gina M. Willis, Andrea T. Kennedy, John Butcher, Mark A. Scheurer, Jeffrey A. Alten, J. William Gaynor, Jennifer J. Schuette, David S. Cooper, Jeffrey P. Jacobs, Sara K. Pasquali, Sarah Tabbutt
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- Journal:
- Cardiology in the Young / Volume 26 / Issue 6 / August 2016
- Published online by Cambridge University Press:
- 11 September 2015, pp. 1090-1096
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Background
Clinical databases in congenital and paediatric cardiac care provide a foundation for quality improvement, research, policy evaluations and public reporting. Structured audits verifying data integrity allow database users to be confident in these endeavours. We report on the initial audit of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry.
Materials and methodsParticipants reviewed the entire registry to determine key fields for audit, and defined major and minor discrepancies for the audited variables. In-person audits at the eight initial participating centres were conducted during a 12-month period. The data coordinating centre randomly selected intensive care encounters for review at each site. The audit consisted of source data verification and blinded chart abstraction, comparing findings by the auditors with those entered in the database. We also assessed completeness and timeliness of case submission. Quantitative evaluation of completeness, accuracy, and timeliness of case submission is reported.
ResultsWe audited 434 encounters and 29,476 data fields. The aggregate overall accuracy was 99.1%, and the major discrepancy rate was 0.62%. Across hospitals, the overall accuracy ranged from 96.3 to 99.5%, and the major discrepancy rate ranged from 0.3 to 0.9%; seven of the eight hospitals submitted >90% of cases within 1 month of hospital discharge. There was no evidence for selective case omission.
ConclusionsBased on a rigorous audit process, data submitted to the PC4 clinical registry appear complete, accurate, and timely. The collaborative will maintain ongoing efforts to verify the integrity of the data to promote science that advances quality improvement efforts.
Contributors
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- By Mitchell Aboulafia, Frederick Adams, Marilyn McCord Adams, Robert M. Adams, Laird Addis, James W. Allard, David Allison, William P. Alston, Karl Ameriks, C. Anthony Anderson, David Leech Anderson, Lanier Anderson, Roger Ariew, David Armstrong, Denis G. Arnold, E. J. Ashworth, Margaret Atherton, Robin Attfield, Bruce Aune, Edward Wilson Averill, Jody Azzouni, Kent Bach, Andrew Bailey, Lynne Rudder Baker, Thomas R. Baldwin, Jon Barwise, George Bealer, William Bechtel, Lawrence C. Becker, Mark A. Bedau, Ernst Behler, José A. Benardete, Ermanno Bencivenga, Jan Berg, Michael Bergmann, Robert L. Bernasconi, Sven Bernecker, Bernard Berofsky, Rod Bertolet, Charles J. Beyer, Christian Beyer, Joseph Bien, Joseph Bien, Peg Birmingham, Ivan Boh, James Bohman, Daniel Bonevac, Laurence BonJour, William J. Bouwsma, Raymond D. Bradley, Myles Brand, Richard B. Brandt, Michael E. Bratman, Stephen E. Braude, Daniel Breazeale, Angela Breitenbach, Jason Bridges, David O. Brink, Gordon G. Brittan, Justin Broackes, Dan W. Brock, Aaron Bronfman, Jeffrey E. Brower, Bartosz Brozek, Anthony Brueckner, Jeffrey Bub, Lara Buchak, Otavio Bueno, Ann E. Bumpus, Robert W. Burch, John Burgess, Arthur W. Burks, Panayot Butchvarov, Robert E. Butts, Marina Bykova, Patrick Byrne, David Carr, Noël Carroll, Edward S. Casey, Victor Caston, Victor Caston, Albert Casullo, Robert L. Causey, Alan K. L. Chan, Ruth Chang, Deen K. Chatterjee, Andrew Chignell, Roderick M. Chisholm, Kelly J. Clark, E. J. Coffman, Robin Collins, Brian P. Copenhaver, John Corcoran, John Cottingham, Roger Crisp, Frederick J. Crosson, Antonio S. Cua, Phillip D. Cummins, Martin Curd, Adam Cureton, Andrew Cutrofello, Stephen Darwall, Paul Sheldon Davies, Wayne A. Davis, Timothy Joseph Day, Claudio de Almeida, Mario De Caro, Mario De Caro, John Deigh, C. F. Delaney, Daniel C. Dennett, Michael R. DePaul, Michael Detlefsen, Daniel Trent Devereux, Philip E. Devine, John M. Dillon, Martin C. Dillon, Robert DiSalle, Mary Domski, Alan Donagan, Paul Draper, Fred Dretske, Mircea Dumitru, Wilhelm Dupré, Gerald Dworkin, John Earman, Ellery Eells, Catherine Z. Elgin, Berent Enç, Ronald P. Endicott, Edward Erwin, John Etchemendy, C. Stephen Evans, Susan L. Feagin, Solomon Feferman, Richard Feldman, Arthur Fine, Maurice A. Finocchiaro, William FitzPatrick, Richard E. Flathman, Gvozden Flego, Richard Foley, Graeme Forbes, Rainer Forst, Malcolm R. Forster, Daniel Fouke, Patrick Francken, Samuel Freeman, Elizabeth Fricker, Miranda Fricker, Michael Friedman, Michael Fuerstein, Richard A. Fumerton, Alan Gabbey, Pieranna Garavaso, Daniel Garber, Jorge L. A. Garcia, Robert K. Garcia, Don Garrett, Philip Gasper, Gerald Gaus, Berys Gaut, Bernard Gert, Roger F. Gibson, Cody Gilmore, Carl Ginet, Alan H. Goldman, Alvin I. Goldman, Alfonso Gömez-Lobo, Lenn E. Goodman, Robert M. Gordon, Stefan Gosepath, Jorge J. E. Gracia, Daniel W. Graham, George A. Graham, Peter J. Graham, Richard E. Grandy, I. Grattan-Guinness, John Greco, Philip T. Grier, Nicholas Griffin, Nicholas Griffin, David A. Griffiths, Paul J. Griffiths, Stephen R. Grimm, Charles L. Griswold, Charles B. Guignon, Pete A. Y. Gunter, Dimitri Gutas, Gary Gutting, Paul Guyer, Kwame Gyekye, Oscar A. Haac, Raul Hakli, Raul Hakli, Michael Hallett, Edward C. Halper, Jean Hampton, R. James Hankinson, K. R. Hanley, Russell Hardin, Robert M. Harnish, William Harper, David Harrah, Kevin Hart, Ali Hasan, William Hasker, John Haugeland, Roger Hausheer, William Heald, Peter Heath, Richard Heck, John F. Heil, Vincent F. Hendricks, Stephen Hetherington, Francis Heylighen, Kathleen Marie Higgins, Risto Hilpinen, Harold T. Hodes, Joshua Hoffman, Alan Holland, Robert L. Holmes, Richard Holton, Brad W. Hooker, Terence E. Horgan, Tamara Horowitz, Paul Horwich, Vittorio Hösle, Paul Hoβfeld, Daniel Howard-Snyder, Frances Howard-Snyder, Anne Hudson, Deal W. Hudson, Carl A. Huffman, David L. Hull, Patricia Huntington, Thomas Hurka, Paul Hurley, Rosalind Hursthouse, Guillermo Hurtado, Ronald E. Hustwit, Sarah Hutton, Jonathan Jenkins Ichikawa, Harry A. Ide, David Ingram, Philip J. Ivanhoe, Alfred L. Ivry, Frank Jackson, Dale Jacquette, Joseph Jedwab, Richard Jeffrey, David Alan Johnson, Edward Johnson, Mark D. Jordan, Richard Joyce, Hwa Yol Jung, Robert Hillary Kane, Tomis Kapitan, Jacquelyn Ann K. Kegley, James A. Keller, Ralph Kennedy, Sergei Khoruzhii, Jaegwon Kim, Yersu Kim, Nathan L. King, Patricia Kitcher, Peter D. Klein, E. D. Klemke, Virginia Klenk, George L. Kline, Christian Klotz, Simo Knuuttila, Joseph J. Kockelmans, Konstantin Kolenda, Sebastian Tomasz Kołodziejczyk, Isaac Kramnick, Richard Kraut, Fred Kroon, Manfred Kuehn, Steven T. Kuhn, Henry E. Kyburg, John Lachs, Jennifer Lackey, Stephen E. Lahey, Andrea Lavazza, Thomas H. Leahey, Joo Heung Lee, Keith Lehrer, Dorothy Leland, Noah M. Lemos, Ernest LePore, Sarah-Jane Leslie, Isaac Levi, Andrew Levine, Alan E. Lewis, Daniel E. Little, Shu-hsien Liu, Shu-hsien Liu, Alan K. L. Chan, Brian Loar, Lawrence B. Lombard, John Longeway, Dominic McIver Lopes, Michael J. Loux, E. J. Lowe, Steven Luper, Eugene C. Luschei, William G. Lycan, David Lyons, David Macarthur, Danielle Macbeth, Scott MacDonald, Jacob L. Mackey, Louis H. Mackey, Penelope Mackie, Edward H. Madden, Penelope Maddy, G. B. Madison, Bernd Magnus, Pekka Mäkelä, Rudolf A. Makkreel, David Manley, William E. Mann (W.E.M.), Vladimir Marchenkov, Peter Markie, Jean-Pierre Marquis, Ausonio Marras, Mike W. Martin, A. P. Martinich, William L. McBride, David McCabe, Storrs McCall, Hugh J. McCann, Robert N. McCauley, John J. McDermott, Sarah McGrath, Ralph McInerny, Daniel J. McKaughan, Thomas McKay, Michael McKinsey, Brian P. McLaughlin, Ernan McMullin, Anthonie Meijers, Jack W. Meiland, William Jason Melanson, Alfred R. Mele, Joseph R. Mendola, Christopher Menzel, Michael J. Meyer, Christian B. Miller, David W. Miller, Peter Millican, Robert N. Minor, Phillip Mitsis, James A. Montmarquet, Michael S. Moore, Tim Moore, Benjamin Morison, Donald R. Morrison, Stephen J. Morse, Paul K. Moser, Alexander P. D. Mourelatos, Ian Mueller, James Bernard Murphy, Mark C. Murphy, Steven Nadler, Jan Narveson, Alan Nelson, Jerome Neu, Samuel Newlands, Kai Nielsen, Ilkka Niiniluoto, Carlos G. Noreña, Calvin G. Normore, David Fate Norton, Nikolaj Nottelmann, Donald Nute, David S. Oderberg, Steve Odin, Michael O’Rourke, Willard G. Oxtoby, Heinz Paetzold, George S. Pappas, Anthony J. Parel, Lydia Patton, R. P. Peerenboom, Francis Jeffry Pelletier, Adriaan T. Peperzak, Derk Pereboom, Jaroslav Peregrin, Glen Pettigrove, Philip Pettit, Edmund L. Pincoffs, Andrew Pinsent, Robert B. Pippin, Alvin Plantinga, Louis P. Pojman, Richard H. Popkin, John F. Post, Carl J. Posy, William J. Prior, Richard Purtill, Michael Quante, Philip L. Quinn, Philip L. Quinn, Elizabeth S. Radcliffe, Diana Raffman, Gerard Raulet, Stephen L. Read, Andrews Reath, Andrew Reisner, Nicholas Rescher, Henry S. Richardson, Robert C. Richardson, Thomas Ricketts, Wayne D. Riggs, Mark Roberts, Robert C. Roberts, Luke Robinson, Alexander Rosenberg, Gary Rosenkranz, Bernice Glatzer Rosenthal, Adina L. Roskies, William L. Rowe, T. M. Rudavsky, Michael Ruse, Bruce Russell, Lilly-Marlene Russow, Dan Ryder, R. M. Sainsbury, Joseph Salerno, Nathan Salmon, Wesley C. Salmon, Constantine Sandis, David H. Sanford, Marco Santambrogio, David Sapire, Ruth A. Saunders, Geoffrey Sayre-McCord, Charles Sayward, James P. Scanlan, Richard Schacht, Tamar Schapiro, Frederick F. Schmitt, Jerome B. Schneewind, Calvin O. Schrag, Alan D. Schrift, George F. Schumm, Jean-Loup Seban, David N. Sedley, Kenneth Seeskin, Krister Segerberg, Charlene Haddock Seigfried, Dennis M. Senchuk, James F. Sennett, William Lad Sessions, Stewart Shapiro, Tommie Shelby, Donald W. Sherburne, Christopher Shields, Roger A. Shiner, Sydney Shoemaker, Robert K. Shope, Kwong-loi Shun, Wilfried Sieg, A. John Simmons, Robert L. Simon, Marcus G. Singer, Georgette Sinkler, Walter Sinnott-Armstrong, Matti T. Sintonen, Lawrence Sklar, Brian Skyrms, Robert C. Sleigh, Michael Anthony Slote, Hans Sluga, Barry Smith, Michael Smith, Robin Smith, Robert Sokolowski, Robert C. Solomon, Marta Soniewicka, Philip Soper, Ernest Sosa, Nicholas Southwood, Paul Vincent Spade, T. L. S. Sprigge, Eric O. Springsted, George J. Stack, Rebecca Stangl, Jason Stanley, Florian Steinberger, Sören Stenlund, Christopher Stephens, James P. Sterba, Josef Stern, Matthias Steup, M. A. Stewart, Leopold Stubenberg, Edith Dudley Sulla, Frederick Suppe, Jere Paul Surber, David George Sussman, Sigrún Svavarsdóttir, Zeno G. Swijtink, Richard Swinburne, Charles C. Taliaferro, Robert B. Talisse, John Tasioulas, Paul Teller, Larry S. Temkin, Mark Textor, H. S. Thayer, Peter Thielke, Alan Thomas, Amie L. Thomasson, Katherine Thomson-Jones, Joshua C. Thurow, Vzalerie Tiberius, Terrence N. Tice, Paul Tidman, Mark C. Timmons, William Tolhurst, James E. Tomberlin, Rosemarie Tong, Lawrence Torcello, Kelly Trogdon, J. D. Trout, Robert E. Tully, Raimo Tuomela, John Turri, Martin M. Tweedale, Thomas Uebel, Jennifer Uleman, James Van Cleve, Harry van der Linden, Peter van Inwagen, Bryan W. Van Norden, René van Woudenberg, Donald Phillip Verene, Samantha Vice, Thomas Vinci, Donald Wayne Viney, Barbara Von Eckardt, Peter B. M. Vranas, Steven J. Wagner, William J. Wainwright, Paul E. Walker, Robert E. Wall, Craig Walton, Douglas Walton, Eric Watkins, Richard A. Watson, Michael V. Wedin, Rudolph H. Weingartner, Paul Weirich, Paul J. Weithman, Carl Wellman, Howard Wettstein, Samuel C. Wheeler, Stephen A. White, Jennifer Whiting, Edward R. Wierenga, Michael Williams, Fred Wilson, W. Kent Wilson, Kenneth P. Winkler, John F. Wippel, Jan Woleński, Allan B. Wolter, Nicholas P. Wolterstorff, Rega Wood, W. Jay Wood, Paul Woodruff, Alison Wylie, Gideon Yaffe, Takashi Yagisawa, Yutaka Yamamoto, Keith E. Yandell, Xiaomei Yang, Dean Zimmerman, Günter Zoller, Catherine Zuckert, Michael Zuckert, Jack A. Zupko (J.A.Z.)
- Edited by Robert Audi, University of Notre Dame, Indiana
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- Book:
- The Cambridge Dictionary of Philosophy
- Published online:
- 05 August 2015
- Print publication:
- 27 April 2015, pp ix-xxx
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