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Individuals with co-occurring mental and physical health issues have worse health outcomes in both domains. Integration improves outcomes and aligns with patient preference, but health services tend to be siloed. The Mental Health in Medicine Clinic (MHiM) supports patients receiving inpatient or outpatient medical or surgical care at a tertiary academic hospital in Toronto, Canada. The predominantly virtual clinic has an interdisciplinary team offering services via stepped care, matching patient need with service intensity. Measurement-based care (MBC), the systematic evaluation of patient reported outcomes, was not initially used routinely in the clinic, but its implementation may improve treatment decision-making and may be useful in allocating patients within a stepped care model.
Objectives
1) To describe the stepped care model, referral patterns, diagnoses, and level of care provided since implementation of stepped care. 2) To conduct a quality improvement initiative to implement MBC in the clinic, with a goal of 50% of patients completing at the time of first assessment and prior to discharge from the clinic.
Methods
We reviewed the electronic medical record for referral source, diagnoses, and level of stepped care within the clinic. We conducted semi-structured interviews with stakeholders (clinicians, administrative staff, patients) to explore barriers to implementation of MBC. Interviews were analyzed for themes around barriers and facilitators to MBC. Plan, Do, Study, Act cycles were carried out around change concepts informed by stakeholder interviews and relevant literature.
Results
The MHiM clinic began operations in August 2020. The clinic operated on a physician-only model until March 2022 and then shifted to a stepped care model with an interdisciplinary team. The most frequent referral sources were internal medicine, COVID19 clinics, consultation-liaison psychiatry, red blood cell disorders clinic and cardiology. Since the implementation of stepped care, 250 referrals were assessed. 58% of new referrals were assessed by the psychiatrist, 42% were managed by the NP, and 25% consulted with the social worker. Referrals consisted of trauma and stress-related disorders (32%), depression (21%) or anxiety disorders (20%). Personality, substance use, and psychotic disorders accounted for less than 10% of referrals combined. Some patients did not have any diagnosis (6%). Results from the quality improvement initiative to implement MBC will also be presented.
Conclusions
The MHiM clinic provides an integrated care pathway addressing comorbid mental and physical health conditions. We describe a novel stepped care model and the implementation of MBC. Future directions include ongoing quality improvement of MBC and its integration within the clinic to assess and re-assess service intensity.
Recent excavations by the Ancient Southwest Texas Project of Texas State University sampled a previously undocumented Younger Dryas component from Eagle Cave in the Lower Pecos Canyonlands of Texas. This stratified assemblage consists of bison (Bison antiquus) bones in association with lithic artifacts and a hearth. Bayesian modeling yields an age of 12,660–12,480 cal BP, and analyses indicate behaviors associated with the processing of a juvenile bison and the manufacture and maintenance of lithic tools. This article presents spatial, faunal, macrobotanical, chronometric, geoarchaeological, and lithic analyses relating to the Younger Dryas component within Eagle Cave. The identification of the Younger Dryas occupation in Eagle Cave should encourage archaeologists to revisit previously excavated rockshelter sites in the Lower Pecos and beyond to evaluate deposits for unrecognized, older occupations.
The availability of large healthcare datasets offers the opportunity for researchers to navigate the traditional clinical and translational science research stages in a nonlinear manner. In particular, data scientists can harness the power of large healthcare datasets to bridge from preclinical discoveries (T0) directly to assessing population-level health impact (T4). A successful bridge from T0 to T4 does not bypass the other stages entirely; rather, effective team science makes a direct progression from T0 to T4 impactful by incorporating the perspectives of researchers from every stage of the clinical and translational science research spectrum. In this exemplar, we demonstrate how effective team science overcame challenges and, ultimately, ensured success when a diverse team of researchers worked together, using healthcare big data to test population-level substance use disorder (SUD) hypotheses generated from preclinical rodent studies. This project, called Advancing Substance use disorder Knowledge using Big Data (ASK Big Data), highlights the critical roles that data science expertise and effective team science play in quickly translating preclinical research into public health impact.
In studies of adult patients with attention deficit hyperactivity disorder (ADHD) atomoxetine (ATX) has demonstrated substantial improvements in ADHD symptomatology using Conners’ Adult ADHD Rating Scales (CAARS). The pattern suggests incremental response over time with no clear plateau of response.
Objectives:
To identify patterns of response to ATX in adult ADHD patients and to describe those trajectories over time
Aims:
To determine if patients have distinct response trajectories using CAARS in two populations, short term (12 weeks) and long term (24 weeks) treatment data.
Methods:
Data from 2502 ATX patients, who had an investigator-rated CAARS total score at ≥ short or long term time point, The numbers of trajectory clusters for short term (n=2502) and long term (n=1139) data were identified using hierarchical clustering methods. Linear mixed modelling was used to describe those different trajectories over time.
Results:
Using CAARS total, 4 trajectory clusters were identified in short term treated patients and 5 in long term. Three out of 4 short term trajectory clusters (representing 84% of patients) and 4 out 5 long term (representing 96%) showed more successful trajectories. In general clusters with less improvement were those with the worst baseline CAARS and minimal initial improvement. Distinct trajectory patterns of response were found that were incremental over time in all clusters.
Conclusions:
Adult ADHD patients receiving atomoxetine have individual trajectories of response that can be divided into 4 short term trajectories and 5 long term trajectories. Further analysis is ongoing to describe these cohorts.
We present the results of a combined experimental and theoretical study of the spin coating of the inner surface of capillary tubes with viscous liquids, and the modified Rayleigh–Plateau instability that arises when the spinning stops. We show that during the spin coating, the thinning of the film is governed by the balance of viscous and centrifugal forces, resulting in the film thickness scaling as $h\sim t^{-1/2}$. We demonstrate that the method enables us to reach uniform micrometre-scale films on the tube walls. Finally, we discuss potential applications with curable polymers that enable precise control of film geometry and wettability.
The taxonomic and ecologic composition of Earth's biota has shifted dramatically through geologic time, with some clades going extinct while others diversified. Here, we derive a metric that quantifies the change in biotic composition due to extinction or origination and show that it equals the product of extinction/origination magnitude and selectivity (variation in magnitude among groups). We also define metrics that describe the extent to which a recovery (1) reinforced or reversed the effects of extinction on biotic composition and (2) changed composition in ways uncorrelated with the extinction. To demonstrate the approach, we analyzed an updated compilation of stratigraphic ranges of marine animal genera. We show that mass extinctions were not more selective than background intervals at the phylum level; rather, they tended to drive greater taxonomic change due to their higher magnitudes. Mass extinctions did not represent a separate class of events with respect to either strength of selectivity or effect. Similar observations apply to origination during recoveries from mass extinctions, and on average, extinction and origination were similarly selective and drove similar amounts of biotic change. Elevated origination during recoveries drove bursts of compositional change that varied considerably in effect. In some cases, origination partially reversed the effects of extinction, returning the biota toward the pre-extinction composition; in others, it reinforced the effects of the extinction, magnifying biotic change. Recoveries were as important as extinction events in shaping the marine biota, and their selectivity deserves systematic study alongside that of extinction.
The objective of this study was to systematically assess the literature regarding postnatal healthcare utilization and barriers/facilitators of healthcare in neonatal abstinence syndrome (NAS) children.
Methods:
A systematic search was performed in PubMed, Cochrane Database of Systematic Reviews, PsychINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on broad aspects of primary and specialty healthcare utilization and access in NAS children. Three investigators independently reviewed all articles and extracted data. Study bias was assessed using the Newcastle–Ottawa Assessment Scale and the National Institute of Health Study Quality Assessment Tool.
Results:
This review identified 14 articles that met criteria. NAS children have poorer outpatient appointment adherence and have a higher rate of being lost to follow-up. These children have overall poorer health indicated by a significantly higher risk of ER visits, hospital readmission, and early childhood mortality compared with non-NAS infants. Intensive multidisciplinary support provided through outpatient weaning programs facilitates healthcare utilization and could serve as a model that could be applied to other healthcare fields to improve the health among this population.
Conclusions:
This review investigated the difficulties in accessing outpatient care as well as the utilization of such care for NAS infants. NAS infants tend to have decreased access to and utilization of outpatient healthcare following hospital birth discharge. Outpatient weaning programs have proven to be effective; however, these programs require intensive resources and care coordination that has yet to be implemented into other healthcare areas for NAS children.
Despite the growing potential for multiplexity in our complex social world, social network methodology often does not adequately capture this phenomenon. Most commonly in research on egocentric social networks, when respondent designate a tie as both family member and friend, the tendency is to default to “family” prior to aggregation for analysis, potentially ignoring important and meaningful variation. As a result, relatively little is known about multiplexity in personal social networks, and particularly about individuals who are simultaneously kin and friends. To address this gap, we assess the rate of occurrence of kinship/friendship multiplexity, and examine characteristics of alters nominated as friends and kin in comparison to those with unidimensional functionality. We find that this kind of multiplexity is fairly common–comprising about one-fifth of kinship ties and one-fourth of friendship ties. Moreover, cross–listed alters are significantly different from those characterized in one function, serving in greater capacity in terms of provision of support, frequency of contact, closeness, and as resources for discussion of important matters. Our findings underscore the critical need to appropriately classify multiplex kinship/friendship ties to avoid making incorrect inferences about support processes and their effects on outcomes across different relationship types.
Patients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.
Atomoxetine is a well-established pharmacotherapy for adult ADHD. Long-term studies show incremental reductions in symptoms over time. However, clinical experience suggests that patients differ in their response patterns.
Methods
From 13 Eli Lilly-sponsored studies, we pooled and analyzed data for adults with ADHD who completed atomoxetine treatment at long-term (24 weeks; n = 1443) and/or short-term (12 weeks; n = 2830) time-points, and had CAARS-Inv:SV total and CGI-S data up to or after these time-points and at Week 0 (i.e. at baseline, when patients first received atomoxetine). The goal was to identify and describe distinct trajectories of response to atomoxetine using hierarchical clustering methods and linear mixed modelling.
Results
Based on the homogeneity of changes in CAARS-Inv:SV total scores, 5 response clusters were identified for patients who completed long-term (24 weeks) treatment with atomoxetine, and 4 clusters were identified for patients who completed short-term (12 weeks) treatment. Four of the 5 long-term clusters (comprising 95% of completer patients) showed positive trajectories: 2 faster responding clusters (L1 and L2), and 2 more gradually responding clusters (L3 and L4). Responses (i.e. ≥ 30% reduction in CAARS-Inv:SV total score, and CGI-S score ≤ 3) were observed at 8 and 24 weeks in 80% and 95% of completers in Cluster L1, versus 5% and 48% in Cluster L4.
Conclusions
While many adults with ADHD responded relatively rapidly to atomoxetine, others responded more gradually without a clear plateau at 24 weeks. Longer-term treatment may be associated with greater numbers of responders.
Ergot alkaloids in endophyte-infected (Neotyphodium coenophialum) tall fescue (Lolium arundinaceum) have been shown to cause a reduction in blood flow to the rumen epithelium as well as a decrease in volatile fatty acids (VFA) absorption from the washed rumen of steers. Previous data also indicates that incubating an extract of endophyte-infected tall fescue seed causes an increase in the amount of VFA absorbed per unit of blood flow, which could result from an alteration in the absorptive or barrier function of the rumen epithelium. An experiment was conducted to determine the acute effects of an endophyte-infected tall fescue seed extract (EXT) on total, passive or facilitated acetate and butyrate flux across the isolated bovine rumen as well as the barrier function measured by inulin flux and tissue conductance (Gt). Flux of ergovaline across the rumen epithelium was also evaluated. Rumen tissue from the caudal dorsal sac of Holstein steers (n=6), fed a common diet, was collected and isolated shortly after slaughter and mounted between two halves of Ussing chambers. In vitro treatments included vehicle control (80% methanol, 0.5% of total volume), Low EXT (50 ng ergovaline/ml) and High EXT (250 ng ergovaline/ml). Results indicate that there is no effect of acute exposure to ergot alkaloids on total, passive or facilitated flux of acetate or butyrate across the isolate bovine rumen epithelium (P>0.51). Inulin flux (P=0.16) and Gt (P>0.17) were not affected by EXT treatment, indicating no alteration in barrier function due to acute ergot alkaloid exposure. Ergovaline was detected in the serosal buffer of the High EXT treatment indicating that the flux rate is ~0.25 to 0.44 ng/cm2 per hour. Data indicate that specific pathways for VFA absorption and barrier function of the rumen epithelium are not affected by acute exposure to ergot alkaloids from tall fescue at the concentrations tested. Ergovaline has the potential to be absorbed from the rumen of cattle that could contribute to reduced blood flow and motility and lead to reduced growth rates of cattle.
There are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities.
Method
The 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18–64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants.
Results
The 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18–64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence.
Conclusions
Our findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.
Ecology, the study of interactions among organisms and their surroundings, can be approached on multiple scales ranging from the organism to the biosphere (Fig. 1), with unique processes governing interactions and dynamics at each scale. Individual organisms interact with their environment in many ways, including feeding, movement, and respiration. Populations are groups of individuals of a single species living in a local area, and population ecology relates to the dynamics of population size, density, and demographic structure. Communities consist of the populations living and interacting in an area; community ecologists study interactions within communities and their effects on the abundance, diversity, and distribution of species and populations. Ecosystems consist of communities of organisms plus their chemical and physical environment, and ecosystems are typically studied in terms of the movement of energy and nutrients among organisms and the environment. The biosphere encompasses all ecosystems (Fig. 1).
We have developed a simple, rapid method to screen carbonates for survey applications, which provides radiocarbon dates with decreased precision at lower cost. The method is based on previous work by Longworth et al. (2011) and involves mixing pulverized CaCO3 with Fe powder, followed by pressing into aluminum target holders for direct 14C accelerator mass spectrometry (AMS) measurements. An optimum beam current averaging ∼10% of those produced by >0.7 mg C graphite targets was obtained for carbonate samples of 0.3–0.5 mg (0.04–0.06 mg C). The precision of the method was evaluated by measuring triplicates of 14C reference materials, as well as by comparing results from this rapid method with results from high-precision AMS measurements on graphite (typically 0.2–0.3%). Measurement reproducibility was ∼1.8% (1σ) for samples <10 ka BP, and it increased drastically for older samples. However, t tests on paired samples resulted in p values greater than 0.05, indicating a good correlation between this survey method and the conventional one. An average blank (calcite) of 0.0075 Fm (∼39 ka BP) was achieved. The simplicity of the technique allowed us to process and measure 72 deep-sea coral samples in less than 25 hr.
We present the results of a combined experimental and theoretical investigation of the dynamics of water-walking insects and spiders. Using high-speed videography, we describe their numerous gaits, some analogous to those of their terrestrial counterparts, others specialized for life at the interface. The critical role of the rough surface of these water walkers in both floatation and propulsion is demonstrated. Their waxy, hairy surface ensures that their legs remain in a water-repellent state, that the bulk of their leg is not wetted, but rather contact with the water arises exclusively through individual hairs. Maintaining this water-repellent state requires that the speed of their driving legs does not exceed a critical wetting speed. Flow visualization reveals that the wakes of most water walkers are characterized by a series of coherent subsurface vortices shed by the driving stroke. A theoretical framework is developed in order to describe the propulsion in terms of the transfer of forces and momentum between the creature and its environment. The application of the conservation of momentum to biolocomotion at the interface confirms that the propulsion of water walkers may be rationalized in terms of the subsurface flows generated by their driving stroke. The two principal modes of propulsion available to small water walkers are elucidated. At driving leg speeds in excess of the capillary wave speed, macroscopic curvature forces are generated by deforming the meniscus, and the surface behaves effectively as a trampoline. For slower speeds, the driving legs need not substantially deform the surface but may instead simply brush it: the resulting contact or viscous forces acting on the leg hairs crossing the interface serve to propel the creature forward.
Our study was designed to characterize the patterns of growth, in the medium term, of children with functionally univentricular hearts managed with a hemi-Fontan procedure in infancy, followed by a modified Fontan operation in early childhood. Failure of growth is common in patients with congenital cardiac malformations, and may be related to congestive heart failure and hypoxia. Repair of simple lesions appears to reverse the retardation in growth. Palliation of the functionally single ventricular physiology with a staged Fontan operation reduces the adverse effects of hypoxemia and prolonged ventricular volume overload. The impact of this approach on somatic growth is unknown. Retrospectively, we reviewed the parameters of growth of all children with functionally univentricular hearts followed primarily at our institution who had completed a staged construction of the Fontan circulation between January 1990 and December 1995. Measurements were available on all children prior to surgery, and annually for three years following the Fontan operation. Data was obtained on siblings and parents for comparative purposes. The criterions of eligibility for inclusion were satisfied by 65 patients. The mean Z score for weight was-1·5± 1·2 at the time of the hemi-Fontan operation. Weight improved by the time of completion of the Fontan circulation (−0·91 ±0·99), and for the first two years following the Fontan operation, but never normalized. The mean Z scores for height at the hemi-Fontan and Fontan operations were −0·67 ±1·1 and −0·89±1·2 respectively. At most recent follow-up, with a mean age of 6·1 ± 1·3 years, and a mean time from the Fontan operation of 4·4±1·4 years, the mean Z score for height was −1·15 ±1·2, and was significantly less than comparable Z scores for parents and siblings. In our experience, children with functionally univentricular hearts who have been palliated with a Fontan operation are significantly underweight and shorter than the general population and their siblings
Although attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) co-occur frequently and represent a particularly morbid clinical form of both disorders, neuroimaging research addressing this co-morbidity is scarce. Our aim was to evaluate the morphometric magnetic resonance imaging (MRI) underpinnings of the co-morbidity of ADHD with BPD, testing the hypothesis that subjects with this co-morbidity would have neuroanatomical correlates of both disorders.
Method
Morphometric MRI findings were compared between 31 adults with ADHD and BPD and with those of 18 with BPD, 26 with ADHD, and 23 healthy controls. The volumes (cm3) of our regions of interest (ROIs) were estimated as a function of ADHD status, BPD status, age, sex, and omnibus brain volume using linear regression models.
Results
When BPD was associated with a significantly smaller orbital prefrontal cortex and larger right thalamus, this pattern was found in co-morbid subjects with ADHD plus BPD. Likewise, when ADHD was associated with significantly less neocortical gray matter, less overall frontal lobe and superior prefrontal cortex volumes, a smaller right anterior cingulate cortex and less cerebellar gray matter, so did co-morbid ADHD plus BPD subjects.
Conclusions
Our results support the hypothesis that ADHD and BPD independently contribute to volumetric alterations of selective and distinct brain structures. In the co-morbid state of ADHD plus BPD, the profile of brain volumetric abnormalities consists of structures that are altered in both disorders individually. Attention to co-morbidity is necessary to help clarify the heterogeneous neuroanatomy of both BPD and ADHD.
Middle Archaic earthen mound complexes in the lower Mississippi valley are remote antecedents of the famous but much younger Poverty Point earthworks. Watson Brake is the largest and most complex of these early mound sites. Very extensive coring and stratigraphic studies, aided by 25 radiocarbon dates and six luminescence dates, show that minor earthworks were begun here at ca. 3500 B.C. in association with an oval arrangement of burned rock middens at the edge of a stream terrace. The full extent of the first earthworks is not yet known. Substantial moundraising began ca. 3350 B.C. and continued in stages until some time after 3000 B.C. when the site was abandoned. All 11 mounds and their connecting ridges were occupied between building bursts. Soils formed on some of these temporary surfaces, while lithics, fire-cracked rock, and fired clay/loam objects became scattered throughout the mound fills. Faunal and floral remains from a basal midden indicate all-season occupation, supported by broad-spectrum foraging centered on nuts, fish, and deer. All the overlying fills are so acidic that organics have not survived. The area enclosed by the mounds was kept clean of debris, suggesting its use as ritual space. The reasons why such elaborate activities first occurred here remain elusive. However, some building bursts covary with very well-documented increases in El Niño/Southern Oscillation events. During such rapid increases in ENSO frequencies, rainfall becomes extremely erratic and unpredictable. It may be that early moundraising was a communal response to new stresses of droughts and flooding that created a suddenly more unpredictable food base.