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Qualitative methods allow in-depth exploration of patient experiences and can provide context for healthcare decision making. Frameworks for patient-based evidence in health technology assessment (HTA) are expanding; yet, how extensively qualitative methods are currently used is unclear. This review characterized the extent and quality of qualitative data submitted to National Institute for Health and Care Excellence (NICE) and Canadian Agency for Drugs and Technologies in Health (CADTH) for HTA.
Methods
NICE and CADTH submissions from September 2019 to August 2021 were reviewed. Submission characteristics and features of patient-based evidence included within submissions were extracted. The quality of qualitative reporting was assessed using the CASP checklist.
Results
Patient-based evidence was included in 83/107 NICE and 119/124 CADTH submissions. A small proportion described qualitative data collection (NICE=14; CADTH=24) and analysis (NICE=6; CADTH=9) methods. One-to-one interviews were the most common data collection method, and thematic analysis was exclusively used. Thirty-three percent of NICE submissions scored >7 yes responses on CASP, versus 78 percent of CADTH submissions.
Conclusions
Although patient-based evidence was common in the submissions reviewed, only 14/107 NICE and 24/124 CADTH submissions involved formal qualitative data collection. Use of formal analysis methods was even rarer and reporting tended to be brief. At present, there is little guidance about qualitative evidence most likely to be informative and therefore to potentially impact decision making. Ensuring, however, that qualitative data are collected and analyzed in a systematic, rigorous way will maximize their usefulness and ensure that patient voices are clearly heard.
Cats living long-term (over one month) in shelters were assessed for behavioural indicators of stress, using a stress scoring method in combination with behavioural observation. It is hypothesised that because of the inappropriate social grouping of unrelated adult cats and group instability, communal housing creates more stress than discrete-unit housing. Seventy-two cats were observed: 36 were housed communally with unfamiliar conspecifics, and 36 were housed in discrete units, either alone or with other previously familiar conspecifics. The mean stress score was greater in communal housing than in discrete-unit housing. Stress scores range from 1 to 7, with 1 indicating no stress experienced, and 7 indicating extreme stress. Individual scores showed that cats in discrete units, in comparison to those in communal housing, gained a significantly higher percentage of observations in the score 2 category, indicating that no stress was being experienced. Cats in communal housing gained a significantly higher percentage in the score 4 category (stressed). Score 5 was found exclusively in communal housing, but only in 2% of instances. Extreme stress was not found in cats housed under either condition. Cats in the different types of housing differed in their frequencies of hiding, play, sleeping/resting in close contact with one another, and agonistic behaviour. There was no difference between housing types in frequency of eating, drinking, grooming, and toilet use. In this study, cats housed communally experienced moderately higher levels of stress than cats housed in discrete units. Further research is recommended to determine the effect on stress levels of longer shelter residence time and of changes in group size and/or density.
Major depressive disorder (MDD) was previously associated with negative affective biases. Evidence from larger population-based studies, however, is lacking, including whether biases normalise with remission. We investigated associations between affective bias measures and depressive symptom severity across a large community-based sample, followed by examining differences between remitted individuals and controls.
Methods
Participants from Generation Scotland (N = 1109) completed the: (i) Bristol Emotion Recognition Task (BERT), (ii) Face Affective Go/No-go (FAGN), and (iii) Cambridge Gambling Task (CGT). Individuals were classified as MDD-current (n = 43), MDD-remitted (n = 282), or controls (n = 784). Analyses included using affective bias summary measures (primary analyses), followed by detailed emotion/condition analyses of BERT and FAGN (secondary analyses).
Results
For summary measures, the only significant finding was an association between greater symptoms and lower risk adjustment for CGT across the sample (individuals with greater symptoms were less likely to bet more, despite increasingly favourable conditions). This was no longer significant when controlling for non-affective cognition. No differences were found for remitted-MDD v. controls. Detailed analysis of BERT and FAGN indicated subtle negative biases across multiple measures of affective cognition with increasing symptom severity, that were independent of non-effective cognition [e.g. greater tendency to rate faces as angry (BERT), and lower accuracy for happy/neutral conditions (FAGN)]. Results for remitted-MDD were inconsistent.
Conclusions
This suggests the presence of subtle negative affective biases at the level of emotion/condition in association with depressive symptoms across the sample, over and above those accounted for by non-affective cognition, with no evidence for affective biases in remitted individuals.
The interplay between convective, rotational and magnetic forces defines the dynamics within the electrically conducting regions of planets and stars. Yet their triadic effects are separated from one another in most studies, arguably due to the richness of each subset. In a single laboratory experiment, we apply a fixed heat flux, two different magnetic field strengths and one rotation rate, allowing us to chart a continuous path through Rayleigh–Bénard convection (RBC), two regimes of magnetoconvection, rotating convection and two regimes of rotating magnetoconvection, before finishing back at RBC. Dynamically rapid transitions are determined to exist between jump rope vortex states, thermoelectrically driven magnetoprecessional modes, mixed wall- and oscillatory-mode rotating convection and a novel magnetostrophic wall mode. Thus, our laboratory ‘pub crawl’ provides a coherent intercomparison of the broadly varying responses arising as a function of the magnetorotational forces imposed on a liquid-metal convection system.
Near-term risk factors for suicidal behavior, referred to as ‘warning signs’ (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt.
Methods
Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period).
Results
Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses.
Conclusions
The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.
Quercus species are ecologically and economically important components of deciduous forests of the eastern United States. However, knowledge pertinent to a thorough understanding of acorn germination dynamics for these species is lacking. The objectives of this research were to determine dormancy break and germination requirements for acorns of two eastern United States bottomland species, Quercus nigra and Quercus phellos (Section Lobatae), and to present results within ecological and phylogenetic contexts. Three replicates of 50 acorns of each species received 0 (control), 6, 12 or 18 weeks of cold stratification, followed by incubation in alternating temperature regimes of 15/6, 20/10, 25/15 and 30/20°C. Eighteen weeks of cold stratification were not sufficient for dormancy break in Q. nigra acorns. Cumulative germination percentages at 4 weeks of incubation were ≥77%, but only in incubation temperatures of 25/15 and 30/20°C. Dormancy break in Q. phellos acorns was achieved with 18 weeks of cold stratification, and cumulative germination percentages were ≥87% at 4 weeks of incubation in all test temperature regimes. Gibberellic acid solutions were not an effective substitute for cold stratification in either species. Phylogenetically, Q. nigra and Q. phellos are closely related species and, ecologically, both grow in the same habitat. Acorns of both species possess deep physiological dormancy (PD), but dormancy break and germination requirements differ in acorns of these two Quercus species.
Health care policies should be implemented to provide the proper care for children with mental health disorders and there is a need for improved infant and early childhood mental health assessment. In this paper we examine how system data reflecting program practice meet to inform advances in developing infant mental health policy.
Methods
Data from the Collaborative Mental Health Care (CMHC) program, a consultation based service in the focusing on the early identification of children (aged 0-5) at significant risk for developing mental health problems, was analyzed in comparison to those not coming into contact with such specialized services.
Results
Compared to others of the same age, those with CMHC involvement waited less time [mean days 13.7 (S.D. 32.3) vs. mean days 69.3 (S.D. 180.3] and had shorter lengths of stay [mean days 139.9 (S.D. 119.3) vs. mean days 232.4 (S.D. 329.7] and proportionately fewer registrations.
Conclusions
Early identification of children's mental health concerns through supporting the community through specialized consultation and promoting resiliency can significantly reduce mental health service utilization by offering more specific and specialized information, referral or treatment services for infants and very young children. The policy implications are self-evident: All provinces require specialized mental health services for infants and very young children in order to better serve children and increase service capacity.
Methadone, a long-acting opioid agonist commonly used in the treatment of opiate dependence, has been reported to cause QTc interval prolongation, increasing the risk of a fatal cardiac arrhythmia – Torsades-de-Pointes (TdP). This effect seems to be attributable to methadone's inhibitory effect on the cardiac “hERG”-K+ ion channel and is dose-dependent. There is a lack of consensus regarding when to perform an ECG for patients on methadone.
Objectives
Identifying other TdPPRFs in a cohort of patients receiving ≥ 85 mg (high dose) methadone daily to inform local clinical safety guidelines.
Methods
Our outpatient caseload was filtered to select opiate-dependent patients receiving more than 85 mg methadone daily. Primary care summaries and laboratory results databases were analysed for the presence of other TdPPRFs: female sex a documented history of ECG abnormalities, electrolyte imbalance, liver or renal failure, and concomitant use of other QT prolonging medication or stimulants.
Results
Fourteen opiate-dependent patients (10.29% of patients on methadone) were maintained on ≥ 85 mg methadone daily. Gender distribution was F:M = 1:1.8; 64% misused illicit stimulants; 57% were prescribed other QTc prolonging medication and 29% had a documented history of liver/renal failure or electrolyte imbalance. Only 14% had previous ECGs documented in primary care summaries. Of patients on high dose methadone, 85.7% had at least one TdPPRFs present and 64.3% had at least two.
Conclusions
These results demonstrate an increased rate of TdPPRFs in this patient group and highlight the importance of ECG monitoring which ideally should be offered to patients receiving even lower doses of methadone.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
To describe an investigation into 5 clinical cases of carbapenem-resistant Acinetobacter baumannii (CRAB).
Design:
Epidemiological investigation supplemented by whole-genome sequencing (WGS) of clinical and environmental isolates.
Setting:
A tertiary-care academic health center in Boston, Massachusetts.
Patients or participants:
Individuals identified with CRAB clinical infections.
Methods:
A detailed review of patient demographic and clinical data was conducted. Clinical isolates underwent phenotypic antimicrobial susceptibility testing and WGS. Infection control practices were evaluated, and CRAB isolates obtained through environmental sampling were assessed by WGS. Genomic relatedness was measured by single-nucleotide polymorphism (SNP) analysis.
Results:
Four clinical cases spanning 4 months were linked to a single index case; isolates differed by 1–7 SNPs and belonged to a single cluster. The index patient and 3 case patients were admitted to the same room prior to their development of CRAB infection, and 2 case patients were admitted to the same room within 48 hours of admission. A fourth case patient was admitted to a different unit. Environmental sampling identified highly contaminated areas, and WGS of 5 environmental isolates revealed that they were highly related to the clinical cluster.
Conclusions:
We report a cluster of highly resistant Acinetobacter baumannii that occurred in a burn ICU over 5 months and then spread to a separate ICU. Two case patients developed infections classified as community acquired under standard epidemiological definitions, but WGS revealed clonality, highlighting the risk of burn patients for early-onset nosocomial infections. An extensive investigation identified the role of environmental reservoirs.
Recruitment of the limpet Patella ulyssiponensis was investigated in relation to the presence of living crustose coralline algae (CCA) in rocky-shore habitats. Juvenile limpets (≤10 mm maximum shell length) were counted in CCA-present and CCA-absent habitats, on three shores in SW Portugal during summer 2007 and winter 2009. Furthermore, the settling response of laboratory-reared larvae of P. ulyssiponensis to CCA-covered substratum, and bare-rock, was examined. Across the intertidal zone, we found a clear association between the distribution and abundance of juveniles and the presence of CCA. Although the presence of CCA was not an absolute requisite for juvenile occurrence, null juvenile densities were mostly recorded in CCA-absent areas. The highest juvenile densities (maximum of 64 individuals in 15 × 15 cm) were consistently found in CCA-dominated habitats, namely steep wave-exposed areas at low-shore and rock-pools. The hypothesis of CCA-enhanced settlement was not supported, as settlement intensities of laboratory-reared larvae were similar between chips of rock encrusted by CCA and chips of bare-rock. From the overall number of settlers onto CCA-encrusted rock chips, 51% were found in tiny pits lacking CCA. This was the first study of the settlement patterns of larvae of the genus Patella using naturally occurring rocky substrata. These results are preliminary and should be confirmed with choice-experiments and improved monitoring of the position of settlers. We suggest that CCA plays a role in the recruitment of P. ulyssiponensis, potentially promoting survivorship of early benthic stages, but possibly not enhancing settlement.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
Intertidal biofilms are a diverse mixture of bacteria, algae as well as sporelings of macroalgae embedded in a polysaccharid matrix. As the primary colonisers of newly formed surfaces, biofilms undergo a succession of different microbe assemblage until the mature state is reached. A biofilm can act as primary producers and as such recycle nutrients in a habitat. It will influence macrobiota by providing a food source or sending out cues to settlers. Biofilms themselves will be controlled by these settlers. This interaction between bottom-up and top-down plays a crucial part for the functioning of the rocky shore ecosystems. However, the diversity of biolfilms as well as it nature to react quickly to environmental changes makes identification and quantification of the individual compounds a difficult task. Subsequently, the understanding of biofilms in general and intertidal, rocky shore microbe assemblages has always tied to techniques and methods available at the time of study. This chapter focusses on the techniques that have greatly contributed to increasing knowledge of biofilms and discusses their findings. Nonetheless, newly developed methods promise to further this knowledge of the ecological role of biofilms on rocky coastlines.
Molecular characterization of pediatric low-grade glioma (pLGG) over the last decade has identified recurrent alterations, most commonly involving BRAF, and less frequently other pathways including MYB and MYBL1. Many of these molecular markers have been exploited clinically to aid in diagnosis and treatment decisions. However, their frequency and prognostic significance remain unknown. Further, a significant portion of cases do not have any of these alterations and what underlies these cases remains unknown. To address this we compiled a cohort of 562 patients diagnosed at SickKids from 1990-2017. We identified molecular alterations in 454 cases (81% of the cohort). The most frequent events were those involving BRAF; either as fusions (most commonly with KIAA1549 (30%)) or V600E mutations (17%) and NF-1 (22%). Less frequently, we identified recurrent FGFR1 fusions and mutations (3%), MYB/MYBL alterations (2%), H3F3AK27M (2%) or IDH1R132H (0.5%) mutations, as well as other novel rare events. Survival analysis revealed significantly better progression-free survival (PFS) and overall survival (OS) of KIAA1549-BRAF fused patients compared to BRAFV600E with 10-year OS 97.7% (95%, CI 95.5-100) and 83.9% (95%, CI 72.5-95.6), respectively. In addition to survival, molecular alterations predicted differences in response to conventional therapeutics; BRAF fused patients showed a 46% response-rate, versus only 14% in V600E patients. pLGGs harboring H3F3AK27M progressed early with median PFS of 11 months. In patients with MYB/MYBL1, FGFR1/FGFR2 alterations, we observed only one death (FGFR1N546K case). The work here represents the largest cohort of pLGGs with molecular profiling and their impact on the clinical behaviour of the disease.
Clay from the Fuller's Earth formation is shown to contain mainly illite, kaolinite and calcite, in contrast to the Fuller's Earth Bed in which montmorillonite is the main clay mineral. A negative correlation has been demonstrated between the calcite content and the plasticity as measured by the Atterberg limits. Fresh samples from the Fuller's Earth Bed have a higher plasticity than those of the fuller's earth clay with similar calcite percentages, due to the relative increases in the expanding lattice clay mineral. Weathering of the fuller's earth clay typically reduces the calcite content and increases the percentage of montmorillonite, resulting in a higher plasticity.
Introduction: Hypertensive disorders of pregnancy (HDP), including preeclampsia, can develop or worsen in the early postpartum period, often following discharge from hospital, resulting in severe preventable maternal morbidity and mortality. Due to a lack of routine early out-patient follow-up, many women with postpartum HDP present to the emergency department (ED) with severe hypertension or symptoms of preeclampsia (e.g., headache). In the ED, postpartum HDP can be difficult for clinicians to recognize (due to vague presenting symptom) and manage (due to lower blood pressure targets and concern of medication safety). ED clinicians recognized a need for timely recognition and effective treatments for postpartum HDP in the ED to improve maternal outcomes. As such, as part of a multi-step quality improvement initiative, an interdisciplinary team developed and implemented a postpartum HDP management protocol (consisting of nursing and physician protocols and an electronic order set embedded in the electronic medical record). The aims of this specific project were to assess: 1) the use of this clinical management protocol in the ED; and 2) its impacts on clinical care. Methods: This quality improvement project used electronic medical records to identify: 1) ED visits for postpartum HDP for postpartum women ages 20-50; 2) utilization of the postpartum HDP order set; and 3) clinical care outcomes (consultation and admission). Patient population characteristics and clinical care measures were summarized with descriptive statistics and compared using a before and after design. Changes in the utilization of the protocol were assessed using run charts. Results: 540 women with postpartum HDP were seen in the four Calgary EDs in the 16-month period following protocol implementation compared with 335 women in the preceding 12 months. The protocol was used in 46% of these 540 women, and increased over the 16 month follow-up period. We found an increase in the frequency of consultation of specialists (47% to 52%) and admissions (26% to 29%) amongst these women after protocol implementation. Conclusion: This initial assessment demonstrated good uptake of a postpartum HDP management protocol including referral for consultation and admission to hospital for blood pressure management. Future steps include evaluation of the impacts of this management protocol on important patient outcomes.
For livestock production systems to play a positive role in global food security, the balance between their benefits and disbenefits to society must be appropriately managed. Based on the evidence provided by field-scale randomised controlled trials around the world, this debate has traditionally centred on the concept of economic-environmental trade-offs, of which existence is theoretically assured when resource allocation is perfect on the farm. Recent research conducted on commercial farms indicates, however, that the economic-environmental nexus is not nearly as straightforward in the real world, with environmental performances of enterprises often positively correlated with their economic profitability. Using high-resolution primary data from the North Wyke Farm Platform, an intensively instrumented farm-scale ruminant research facility located in southwest United Kingdom, this paper proposes a novel, information-driven approach to carry out comprehensive assessments of economic-environmental trade-offs inherent within pasture-based cattle and sheep production systems. The results of a data-mining exercise suggest that a potentially systematic interaction exists between ‘soil health’, ecological surroundings and livestock grazing, whereby a higher level of soil organic carbon (SOC) stock is associated with a better animal performance and less nutrient losses into watercourses, and a higher stocking density with greater botanical diversity and elevated SOC. We contend that a combination of farming system-wide trials and environmental instrumentation provides an ideal setting for enrolling scientifically sound and biologically informative metrics for agricultural sustainability, through which agricultural producers could obtain guidance to manage soils, water, pasture and livestock in an economically and environmentally acceptable manner. Priority areas for future farm-scale research to ensure long-term sustainability are also discussed.