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This study explored the prospective use of the Ages and Stages Questionnaires-3 in follow-up after cardiac surgery.
Materials and Method:
For children undergoing cardiac surgery at 5 United Kingdom centres, the Ages and Stages Questionnaires-3 were administered 6 months and 2 years later, with an outcome based on pre-defined cut-points: Red = 1 or more domain scores >2 standard deviations below the normative mean, Amber = 1 or more domain scores 1–2 standard deviations below the normal range based on the manual, Green = scores within the normal range based on the manual.
Results:
From a cohort of 554 children <60 months old at surgery, 306 participated in the postoperative assessment: 117 (38.3%) were scored as Green, 57 (18.6%) as Amber, and 132 (43.1%) as Red. Children aged 6 months at first assessment (neonatal surgery) were likely to score Red (113/124, 85.6%) compared to older age groups (n = 32/182, 17.6%). Considering risk factors of congenital heart complexity, univentricular status, congenital comorbidity, and child age in a logistic regression model for the outcome of Ages and Stages score Red, only younger age was significant (p < 0.001). 87 children had surgery in infancy and were reassessed as toddlers. Of these, 43 (49.2%) improved, 30 (34.5%) stayed the same, and 13 (16.1%) worsened. Improved scores were predominantly in those who had a first assessment at 6 months old.
Discussion:
The Ages and Stages Questionnaires results are most challenging to interpret in young babies of 6 months old who are affected by complex CHD.
Published evidence on health service interventions should inform decision-making in local health services, but primary effectiveness studies and cost-effectiveness analyses are unlikely to reflect contexts other than those in which the evaluations were undertaken. A ten-step framework was developed and applied to use published evidence as the basis for local-level economic evaluations that estimate the expected costs and effects of new service intervention options in specific local contexts.
Methods
Working with a multidisciplinary group of local clinicians, the framework was applied to evaluate intervention options for preventing hospital-acquired hypoglycemia. The framework included: clinical audit and analyses of local health systems data to understand the local context and estimate baseline event rates; pragmatic literature review to identify evidence on relevant intervention options; expert elicitation to adjust published intervention effect estimates to reflect the local context; and modeling to synthesize and calibrate data derived from the disparate data sources.
Results
From forty-seven studies identified in the literature review, the working group selected three interventions for evaluation. The local-level economic evaluation generated estimates of intervention costs and a range of cost, capacity and patient outcome-related consequences, which informed working group recommendations to implement two of the interventions.
Conclusions
The applied framework for modeled local-level economic evaluation was valued by local stakeholders, in particular the structured, formal approach to identifying and interpreting published evidence alongside local data. Key methodological issues included the handling of alternative reported outcomes and the elicitation of the expected intervention effects in the local context.
For more than a decade, Improving Access to Psychological Therapies (IAPT) has been training a new workforce of psychological therapists. Despite evidence of stress and burnout both in trainee mental health professionals, and qualified IAPT clinicians, little is known about these topics in IAPT trainees. Consequently, this systematic review sought to establish the current state of the literature regarding stress and burnout in IAPT trainees. Electronic databases were searched to identify all published and available unpublished work relating to the topic. On the basis of pre-established eligibility criteria, eight studies (including six unpublished doctoral theses) were identified and assessed for quality. This review identifies that research into the experience of IAPT trainees is under-developed. Existing evidence tentatively suggests that IAPT trainees may experience levels of stress and burnout that are higher than their qualified peers and among the higher end of healthcare professionals more generally. The experience of fulfilling dual roles as mental health professionals and university students concurrently appears to be a significant source of stress for IAPT trainees. More research regarding the levels and sources of stress and burnout in IAPT trainees is urgently needed to confirm and extend these findings. Recommendations for future research in the area are given.
Key learning aims
(1) To establish the current state of the literature regarding stress and burnout in IAPT trainees.
(2) To raise practitioner, service and education-provider awareness regarding the levels and perceived sources of stress and burnout in IAPT trainees.
(3) To make recommendations regarding future research on the topic.
The purpose of the present study was to explore the experience of being asked for reassurance from the perspective of carers of obsessive compulsive disorder (OCD) sufferers, and to examine its relationship to sufferers’ reassurance seeking by a direct comparison with data obtained from the person they normally offer reassurance to. Forty-two individuals with OCD and their carers completed alternate versions of the Reassurance Seeking Questionnaire. Result suggest that carers report most commonly providing reassurance when asked to do so, and the frequency of their reassurance provision is associated with how carefully sufferers seek reassurance, rather than their OCD symptom severity. The carer's perspectives on the impact of reassurance provision was accurate; both sufferers and carers perceive that reassurance works only temporarily, but even if the anxiety-relieving effect of reassurance decreases in the medium term, it is likely to be perceived as beneficial because carers accurately perceived that sufferers would feel much worse if they refused to provide reassurance. The present study is the first to quantitatively investigate carer's experiences of reassurance provision, and elucidate why carers feel the need to provide it.
A suspected chemical means of habitat selection by Diaeretiella rapae, a primary parasite of aphids on crucifer plants, was investigated in the laboratory with the aid of an olfactometer. Females (and, to a lesser extent, males) were found to be attracted by odor to leaves and leaf juices of a crucifer host plant and to dilute solutions of the mustard oil allyl isothiocyanate. Given a choice of aphid colonies (Myzus persicae) on leaves of beet (Chenopodiaceae — mustard oils not present) and collard (Cruciferae — mustard oils present), female D. rapae displayed a marked preference to oviposit in aphids feeding on collard. It is concluded that female D. rapae parasites locate their hosts initially by a response to an odor emanating from the aphid host-plant, followed by visual searching. Male D. rapae were attracted by odor from female D. rapae, suggesting the existence of a sex pheromone in this species.Neither males nor females of Charips brassicae, a hyperparasite of D. rapae, were attracted to collard leaves, though females showed apparent attraction to female D. rapae. As with D. rapae, males of C. brassicae are attracted by odor to females of the same species.The host finding behavior of D. rapae is discussed in relation to that of other insect species belonging to the fauna associated with the plant family Cruciferae.
The intriguing processes of sleep and dreaming have attracted attention from philosophers and artists for centuries, if not millennia. However, only in the past few decades has sleep medicine emerged as a credible and important scientific discipline worthy of attention both clinically and from research perspectives. Even now, it occupies a ‘Cinderella’ position within medical practice, despite increasing evidence that a disturbed sleep–wake cycle can directly damage physical, mental and emotional well-being. It is also clear that there is a circular relationship between sleep disruption and many ‘sleep toxins’, such as pain and disturbed mental health, which are, in turn, exaggerated by any resulting sleep deprivation. For example, insomnia may precipitate depression, anxiety or even psychosis rather than simply acting as a comorbid marker. Obesity, raised inflammatory markers and impaired cognition are further examples of common problems inextricably linked with chronically abnormal sleep (see Box 15.1 for proposed adverse effects of sleep disruption).
Paradoxically, the low profile of sleep disorders in medical education seems particularly apparent in psychiatry. Hopefully, this is changing. Most clinicians and, indeed, members of the public generally appreciate the importance of good-quality sleep, although the majority have little more than a basic understanding of its neurobiology. This chapter gives a broad outline of sleep and its disorders, with particular emphasis on those aspects germane to neuropsychiatry.
Normal v. abnormal sleep
Advances in our understanding of the neurobiology of sleep have challenged the traditional view that sleep is a passive or necessarily restful process. By contrast, rather than simply reflecting the absence of wakefulness, sleep is actively orchestrated with a highly reproducible and complex internal architecture (Frank, 2006). A typical pattern seen in a healthy adult is shown in Fig. 15.1. Episodes of rapid eye movement (REM) and nonrapid eye movement (non-REM) sleep recur through the night in four or five discrete cycles.
We compare laboratory observations of equilibrated baroclinic waves in the rotating two-layer annulus, with numerical simulations from a quasi-geostrophic model. The laboratory experiments lie well outside the quasi-geostrophic regime: the Rossby number reaches unity; the depth-to-width aspect ratio is large; and the fluid contains ageostrophic inertia–gravity waves. Despite being formally inapplicable, the quasi-geostrophic model captures the laboratory flows reasonably well. The model displays several systematic biases, which are consequences of its treatment of boundary layers and neglect of interfacial surface tension and which may be explained without invoking the dynamical effects of the moderate Rossby number, large aspect ratio or inertia–gravity waves. We conclude that quasi-geostrophic theory appears to continue to apply well outside its formal bounds.
Expert clinical judgement combines technical proficiency with humanistic qualities.
Aims
To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback.
Method
Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients.
Results
Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbach's alpha > 0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Eρ2) of 0.75.
Conclusions
Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.
Subscribers to the medical model of the causation of madness and distressemphasise the role of genes and can severely underestimate the impact oftraumatic events on the development of the human mind. This bias persistsdespite the worldwide popular wisdom that mental illness arises when badthings happen to people. Childhood physical and sexual abuse and neglect areextremely common experiences among those who develop serious mental healthproblems. Unfortunately, victims are typically reluctant to disclose theirhistories of abuse and practitioners are often reluctant to seek it. Weexplore the nature and extent of the problem and the apparent reasons forthe pervasive neglect of this important area of care. Then, on the basis ofour experience in New Zealand, we provide guidelines on asking patientsabout childhood abuse and describe an ongoing initiative in the UK tofurther advance our understanding of the impact of abuse and our skills todetect it and treat survivors.
We report on the results of a laboratory investigation using a rotating two-layer annulus experiment, which exhibits both large-scale vortical modes and short-scale divergent modes. A sophisticated visualization method allows us to observe the flow at very high spatial and temporal resolution. The balanced long-wavelength modes appear only when the Froude number is supercritical (i.e. $F\,{>}\,F_\mathrm{critical}\,{\equiv}\, \upi^2/2$), and are therefore consistent with generation by a baroclinic instability. The unbalanced short-wavelength modes appear locally in every single baroclinically unstable flow, providing perhaps the first direct experimental evidence that all evolving vortical flows will tend to emit freely propagating inertia–gravity waves. The short-wavelength modes also appear in certain baroclinically stable flows.
We infer the generation mechanisms of the short-scale waves, both for the baro-clinically unstable case in which they co-exist with a large-scale wave, and for the baroclinically stable case in which they exist alone. The two possible mechanisms considered are spontaneous adjustment of the large-scale flow, and Kelvin–Helmholtz shear instability. Short modes in the baroclinically stable regime are generated only when the Richardson number is subcritical (i.e. $\hbox{\it Ri}\,{<}\,\hbox{\it Ri}_\mathrm{critical}\,{\equiv}\, 1$), and are therefore consistent with generation by a Kelvin–Helmholtz instability. We calculate five indicators of short-wave generation in the baroclinically unstable regime, using data from a quasi-geostrophic numerical model of the annulus. There is excellent agreement between the spatial locations of short-wave emission observed in the laboratory, and regions in which the model Lighthill/Ford inertia–gravity wave source term is large. We infer that the short waves in the baroclinically unstable fluid are freely propagating inertia–gravity waves generated by spontaneous adjustment of the large-scale flow.
The fecundity and occurrence of intersexuality in the amphipod, Echinogammarus marinus, collected from populations on the east coast of Scotland are reported. Intersex specimens have significantly smaller mean brood sizes than normal specimens. Embryo survival, as measured by the ratio of eggs/embryos in early and late stages of development, is lower in intersex specimens than normal specimens. Greater differences in the number of early stage eggs compared with late stage eggs in intersex specimens is suggested to arise by the active ejection of non-viable eggs, or from the passive loss of eggs through malformed brood plates in females. An apparent reduction in brood sizes between early and late stages of development in ‘normal’ specimens, emphasizes the importance of quantifying different egg/embryo stages in amphipod toxicology and fecundity studies.
By
Paul W. Read, University of Virginia Health Science Center, Charlottesville,
Maria Kelly, University of Virginia Health Science Center, Charlottesville
Edited by
Michael J. Fisch, University of Texas, M. D. Anderson Cancer Center,Eduardo Bruera, University of Texas, M. D. Anderson Cancer Center
Superior vena cava syndrome (SVCS) is the clinical manifestation of obstructed blood flow through the superior vena cava (SVC) secondary to extrinsic compression, tumor invasion, or thrombosis. The SVC is the main venous conduit of blood return from the head, upper extremities, and upper torso. It begins at the confluence of the right and left innominate veins and continues in the middle mediastinum 6–8 cm to drain into the right atrium. During its course the SVC is surrounded by rigid structures including the trachea, right bronchus, sternum, aorta, and pulmonary artery. Due to the physiologic requirements of high volume and low pressure flow it is a large diameter vessel with a thin wall making it susceptible to extrinsic compression by tumor against its rigid surroundings. SVC obstruction results in increased collateral blood flow through the azygos, internal mammary, lateral thoracic, paraspinous, and esophageal veins.
Over 90% of cases of SVCS result from a neoplastic process. Approximately 65–80% of cases are due to lung cancer with small cell cancer being the most common histology, 10–15% of cases are due to lymphoma, and the remainder are caused by thymomas, germ cell tumors, and metastatic disease. Benign causes include mediastinal fibrosis, histoplasmosis, and iatrogenic thrombosis of the SVC secondary to central venous catheters and cardiac pacemakers.
SVCS is a relatively easy clinical diagnosis to make. The presenting symptoms in decreasing order of frequency include dyspnea (63%), facial swelling or head fullness (50%), cough (24%), arm swelling (18%), chest pain (15%), and dysphagia (9%).
The Orion-KL nebula is the closest (450pc) site of high-mass star formation and exhibits powerful outflows associated with protostars. It is also one of only three known star forming regions to exhibit SiO maser emission. Emission in three SiO maser transitions (v=1 J=1 → 0, v=1 J=2 → 1, and v=2 J=1 → 0) imaged by VLBI exhibits an “X” morphology suggesting that the Orion masers form along the outlines of two opposing conical outflows to the NW and SE. At the center of this “X”, VLA observations find emission from an HII region presumably associated with a young star whose wind drives the outflow. The SiO masers probably form along the interface between the stellar wind and surrounding parent cloud. We find that SiO maser emission from different transitions preferentially occurs at different radii from the central star implying that the masers are tracers for physical conditions in the wind-cloud interaction region. On the smallest scales, some individual maser features in each transition overlap both spatially and in velocity providing strong evidence that more than one transition can mase within the same volume of gas.
The human small GTPase, RhoA, expressed in Saccharomyces cerevisiae is post-translationally processed and, when co-expressed with its cytosolic inhibitory protein, RhoGDI, spontaneously forms a heterodimer in vivo. The RhoA/RhoGDI complex, purified to greater than 98% at high yield from the yeast cytosolic fraction, could be stoichiometrically ADP-ribosylated by Clostridium botulinum C3 exoenzyme, contained stoichiometric GDP, and could be nucleotide exchanged fully with [3H]GDP or partially with GTP in the presence of submicromolar Mg2+. The GTP-RhoA/RhoGDI complex hydrolyzed GTP with a rate constant of 4.5 × 10−5 s−1, considerably slower than free RhoA. Hydrolysis followed pseudo-first-order kinetics indicating that the RhoA hydrolyzing GTP was RhoGDI associated. The constitutively active G14V-RhoA mutant expressed as a complex with RhoGDI and purified without added nucleotide also bound stoichiometric guanine nucleotide: 95% contained GDP and 5% GTP. Microinjection of the GTP-bound G14V-RhoA/RhoGDI complex (but not the GDP form) into serum-starved Swiss 3T3 cells elicited formation of stress fibers and focal adhesions. In vitro, GTP-bound-RhoA spontaneously translocated from its complex with RhoGDI to liposomes, whereas GDP-RhoA did not. These results show that GTP-triggered translocation of RhoA from RhoGDI to a membrane, where it carries out its signaling function, is an intrinsic property of the RhoA/RhoGDI complex that does not require other protein factors or membrane receptors.