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Electronic health records (EHRs), increasingly available in low- and middle-income countries (LMICs), provide an opportunity to study transdiagnostic features of serious mental illness (SMI) and its trajectories.
Aims
Characterise transdiagnostic features and diagnostic trajectories of SMI using an EHR database in an LMIC institution.
Method
We conducted a retrospective cohort study using EHRs from 2005–2022 at Clínica San Juan de Dios Manizales, a specialised mental health facility in Colombia, including 22 447 patients with schizophrenia (SCZ), bipolar disorder (BPD) or severe/recurrent major depressive disorder (MDD). Using diagnostic codes and clinical notes, we analysed the frequency of suicidality and psychosis across diagnoses, patterns of diagnostic switching and the accumulation of comorbidities. Mixed-effect logistic regression was used to identify factors influencing diagnostic stability.
Results
High frequencies of suicidality and psychosis were observed across diagnoses of SCZ, BPD and MDD. Most patients (64%) received multiple diagnoses over time, including switches between primary SMI diagnoses (19%), diagnostic comorbidities (30%) or both (15%). Predictors of diagnostic switching included mentions of delusions (odds ratio = 1.47, 95% CI 1.34–1.61), prior diagnostic switching (odds ratio = 4.01, 95% CI 3.7–4.34) and time in treatment, independent of age (log of visit number; odds ratio = 0.57, 95% CI 0.54–0.61). Over 80% of patients reached diagnostic stability within 6 years of their first record.
Conclusions
Integrating structured and unstructured EHR data reveals transdiagnostic patterns in SMI and predictors of disease trajectories, highlighting the potential of EHR-based tools for research and precision psychiatry in LMICs.
In this work, we develop a method for robust single-cycle measurement velocity vector estimation for automotive radar. Building upon our previous work, we introduce a methodology that leverages spatial diversity for accurate estimation of the velocity vector of targets in the medium to close ranges. We extend our initial conceptual framework, addressing limitations from our first approach and proposing necessary enhancements for real-world applicability. Our improved process excels in target separation, identification, and velocity vector estimation, proving effective across various scenarios and minimizing errors. The system, tested on pedestrians and metal targets, presents a promising avenue for exploring its performance with varying target sizes. Simultaneously, our in-depth study on Doppler-multiplex modulation reveals new relevant constraints, prompting a modulation change for improved response separation. Despite the necessity of increasing module numbers for enhanced performance, our structured approach to target itemization and classification positions our methodology as a valuable framework for future systems, offering a comprehensive solution to diverse challenges in target estimation and classification within the automotive landscape.
This paper introduces a lower limb exoskeleton for gait rehabilitation, which has been designed to be adjustable to a wide range of patients by incorporating an extension mechanism and series elastic actuators (SEAs). This configuration adapts better to the user’s anatomy and the natural movements of the user’s joints. However, the inclusion of SEAs increases actuator mass and size, while also introducing nonlinearities and changes in the dynamic response of the exoskeletons. To address the challenges related to the human–exoskeleton dynamic interaction, a nonsingular terminal sliding mode control that integrates an adaptive parameter adjustment strategy is proposed, offering a practical solution for trajectory tracking with uncertain exoskeleton dynamics. Simulation results demonstrate the algorithm’s ability to estimate unknown parameters. Experimental tests analyze the performance of the controller against uncertainties and external disturbances.
We propose a method for cutting down a random recursive tree that focuses on its higher-degree vertices. Enumerate the vertices of a random recursive tree of size n according to the decreasing order of their degrees; namely, let $(v^{(i)})_{i=1}^{n}$ be such that $\deg(v^{(1)}) \geq \cdots \geq \deg (v^{(n)})$. The targeted vertex-cutting process is performed by sequentially removing vertices $v^{(1)}, v^{(2)}, \ldots, v^{(n)}$ and keeping only the subtree containing the root after each removal. The algorithm ends when the root is picked to be removed. The total number of steps for this procedure, $K_n$, is upper bounded by $Z_{\geq D}$, which denotes the number of vertices that have degree at least as large as the degree of the root. We prove that $\ln Z_{\geq D}$ grows as $\ln n$ asymptotically and obtain its limiting behavior in probability. Moreover, we obtain that the kth moment of $\ln Z_{\geq D}$ is proportional to $(\!\ln n)^k$. As a consequence, we obtain that the first-order growth of $K_n$ is upper bounded by $n^{1-\ln 2}$, which is substantially smaller than the required number of removals if, instead, the vertices were selected uniformly at random.
The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.
Methods
The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.
Results
About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15–20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.
Conclusions
The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.
The aim of this contribution is to provide a new methodology regarding the use of photogrammetry and 3D modelling in the classroom. By means of a practicum taught at Complutense University of Madrid and a survey conducted afterwards, we show the different steps of the activity, as well as the reception of the students, who learnt to elaborate 3D figures.
Doses of 40, 80, 120, and 160 Gy were applied to 5-, 6-, 7-, and 8-day-old Anastrepha obliqua larvae, which were exposed to the Neotropical-native braconids Doryctobracon crawfordi and Utetes anastrephae and the Asian braconid Diachasmimorpha longicaudata. These tests were performed to know the effect of the increase in host radiation on the emergence of the aforementioned parasitoids and the related consequences of oviposition on the host. The study was based on the fact that higher radiation doses may cause a decrease in the host immune activity. There was a direct relationship between the increase in radiation dose and the parasitoid emergence. Both, the weight and the mortality of the host larvae were not affected by radiation. Although the larval weight of the larvae was lower and the mortality was higher in the younger larvae. Both, the number of scars and immature stages per host puparium originated from the younger larvae were lower than those from older larvae. Only U. anastrephae superparasitized more at lower radiation. Superparasitism by D. longicaudata was more frequent at 160 Gy. Qualitative measurements of melanin in the larvae parasitized showed that the levels were lower with increasing radiation. As radiation doses increased, the antagonistic response of the A. obliqua larva was reduced. Host larvae aged 5- and 6-day-old irradiated at 120–160 Gy significantly improve parasitoid emergence. This evidence is relevant for the mass production of the three tested parasitoid species.
The current study investigated employees' weekly responses to experienced job insecurity. Based on appraisal theory, it was postulated that employees may adopt three coping strategies in response to job insecurity (i.e., remaining silent, adapting, or being proactive) in order to maintain or improve their weekly well-being. We introduced a multilevel moderated mediation model, explaining how weekly job insecurity would be related to well-being in the following weeks through these three behaviors. We also expected that subordinate emotional regulation and supervisor prosocial motivation (both defined as trait variables) would function as contextual factors moderating the relationships of job insecurity with employee behavior and well-being. A 5-week diary study of 149 subordinates partially supported the model. The results showed longitudinal conditional indirect effects of job insecurity on subordinate well-being depending on subordinate emotional regulation style and supervisor prosocial motivation. In doing so, the study offers two main contributions to the job insecurity literature. First, employees are not passive responders to perceived job insecurity, but active shapers through coping depending on the context. Subordinates' emotional regulation strategy and supervisors' prosocial motivation, as trait variables, impact on how subordinates respond to perceived job insecurity over weeks. From a practical point of view, the dynamic nature of perceived job insecurity suggests implications for interventions to maintain subordinates' well-being.
We present the first report of Amblycerus dispar (Sharp) attacking stored almonds [Prunus dulcis (Mill.) D. A. Webb] in Argentina. A summarized diagnosis, illustrations, and photographs of the adult and mature larva are provided to facilitate identification. We performed species distribution models for A. dispar and its main host plant Geoffroea decorticans (Gillies ex Hook. & Arn.) Burkart. We include A. dispar into a previous morphological character matrix and conduct a phylogenetic analysis to infer its phylogenetic position. The evolution of host plant associations of the genus Amblycerus is herein re-analyzed. A. dispar and its main host shows high suitability areas especially in central-west Argentina and Chile, whereas for the USA, high suitability areas were found for the south-western which include the area of almond production in this country. Although the presence of A. dispar in the USA region is very unlikely, we recommend some awareness as other bruchines are present in the area. Although A. dispar is unlikely to become an economically important risk, monitoring for early detection is recommended to avoid productivity loss, especially when the native host is nearby cultivated areas. A. dispar is hypothesized to be the sister species of A. schwarzi Kingsolver. The colonization of a Rosaceae species is a novelty for this genus, being host shifts known as an important factor affecting both natural and agricultural systems.
Triploidization plays an important role in aquaculture and surrogate technologies. In this study, we induced triploidy in the matrinxã fish (Brycon amazonicus) using a heat-shock technique. Embryos at 2 min post fertilization (mpf) were heat shocked at 38°C, 40°C, or 42°C for 2 min. Untreated, intact embryos were used as a control. Survival rates during early development were monitored and ploidy status was confirmed using flow cytometry and nuclear diameter analysis of erythrocytes. The hatching rate reduced with heat-shock treatment, and heat-shock treatments at 42°C resulted in no hatching events. Optimal results were obtained at 40°C with 95% of larvae exhibiting triploidy. Therefore, we report that heat-shock treatments of embryos (2 mpf) at 40°C for 2 min is an effective way to induce triploid individuals in B. amazonicus.
To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults.
Design:
A 5-year prospective cohort study.
Setting:
Tertiary-care teaching hospital in Seville, Spain.
Patients:
Adult patients undergoing PICC insertion.
Methods:
Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis.
Results:
In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77–6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25–10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49–62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77–35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications.
Conclusions:
PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.
Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved.
Methods
We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up.
Results
Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = −0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results.
Conclusions
Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.
Tuberous sclerosis complex is a rare genetic disorder leading to the growth of hamartomas in multiple organs, including cardiac rhabdomyomas. Children with symptomatic cardiac rhabdomyoma require frequent admissions to intensive care units, have major complications, namely, arrhythmias, cardiac outflow tract obstruction and heart failure, affecting the quality of life and taking on high healthcare cost. Currently, there is no standard pharmacological treatment for this condition, and the management includes a conservative approach and supportive care. Everolimus has shown positive effects on subependymal giant cell astrocytomas, renal angiomyolipoma and refractory seizures associated with tuberous sclerosis complex. However, evidence supporting efficacy in symptomatic cardiac rhabdomyoma is limited to case reports. The ORACLE trial is the first randomised clinical trial assessing the efficacy of everolimus as a specific therapy for symptomatic cardiac rhabdomyoma.
Methods:
ORACLE is a phase II, prospective, randomised, placebo-controlled, double-blind, multicentre protocol trial. A total of 40 children with symptomatic cardiac rhabdomyoma secondary to tuberous sclerosis complex will be randomised to receive oral everolimus or placebo for 3 months. The primary outcome is 50% or more reduction in the tumour size related to baseline. As secondary outcomes we include the presence of arrhythmias, pericardial effusion, intracardiac obstruction, adverse events, progression of tumour reduction and effect on heart failure.
Conclusions:
ORACLE protocol addresses a relevant unmet need in children with tuberous sclerosis complex and cardiac rhabdomyoma. The results of the trial will potentially support the first evidence-based therapy for this condition.
The Spanish network of health technology assessment (HTA) agencies (REDETS) is a collaboration of eight agencies, units and services, commissioned by the national and regional governments. The network coordinates work within a common methodological and work framework, guided by the principles of mutual recognition and cooperation. In 2016, a common self-assessment quality tool was developed for the implementation of an overall Quality Management System. Currently we are working on the second step that deals with actions about management, joint activities as a network, and organizational aspects of the network.
Methods
A structured search strategy in the main electronic databases and a manual search in websites of networks national and international agencies were carried out in June 2017, in order to gather previous knowledge and developed standards. Through the information included in this review, and with the collaboration of all members, a group of standards for REDETS was developed. Finally, standards proposed were discussed in a face-to face meeting until an agreement was reached.
Results
A proposal of 31 standards was put forward taking all the collected information. The aim of each standard was defined, and its level of compliance was specified. Those standards were grouped under nine quality criteria structured in four dimensions: (i) Responsibility and Resources, (ii) Performance and Membership, (iii) Procedures, and (iv) Relations.
Conclusions
Based on the gathered information and the agreement of the all members, we developed a toolkit embracing a group of standards for the joint activities within the Spanish Network, network administration and management. It is a complementary instrument of the previous self-evaluating tool, following the establishment of an overall quality management system and under the philosophy of continuous improvement processes.
Introduced species can have strong ecological, social and economic effects on their non-native environment. Introductions of megafaunal species are rare and may contribute to rewilding efforts, but they may also have pronounced socio-ecological effects because of their scale of influence. A recent introduction of the hippopotamus Hippopotamus amphibius into Colombia is a novel introduction of a megaherbivore onto a new continent, and raises questions about the future dynamics of the socio-ecological system into which it has been introduced. Here we synthesize current knowledge about the Colombian hippopotamus population, review the literature on the species to predict potential ecological and socio-economic effects of this introduction, and make recommendations for future study. Hippopotamuses can have high population growth rates (7–11%) and, on the current trajectory, we predict there could be 400–800 individuals in Colombia by 2050. The hippopotamus is an ecosystem engineer that can have profound effects on terrestrial and aquatic environments and could therefore affect the native biodiversity of the Magdalena River basin. Hippopotamuses are also aggressive and may pose a threat to the many inhabitants of the region who rely upon the Magdalena River for their livelihoods, although the species could provide economic benefits through tourism. Further research is needed to quantify the current and future size and distribution of this hippopotamus population and to predict the likely ecological, social and economic effects. This knowledge must be balanced with consideration of social and cultural concerns to develop appropriate management strategies for this novel introduction.
Newly discovered archaeological sites in the Uribe Kosta region of northern Spain are illuminating the establishment of late prehistoric coastal farming settlements and specialised tool-production activities.
The Spanish Network of Agencies for Health Technology Assessment (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. In this work, guided by the necessity of implementing a Quality Management System, we present the process to achieve this objective.
METHODS:
As an initial step, a review was carried out based on a structured search strategy in the main electronic databases Medline and EMBASE, and a manual search in websites of national and international agencies (March 2016) in order to collate previous knowledge and experiences. Through the information included in this review, a proposal to create a quality, self-evaluating tool is necessary.
RESULTS:
In total, 800 references were found and finally 6 studies were included in the review (1-3). All had a similar structure. Some lists of good practices, classified in dimensions related to different quality aspects in Health Technology Assessment (HTA) organizations, were found. Also some information about questions for evaluating quality standards was indicated. Taking all this information, a proposal of sixty-six standard titles was put forward. These standards were then grouped into twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process and IV Resources.
CONCLUSIONS:
Based on the systematic review, we developed a proposal for a self-evaluating tool and this is the baseline for a common Quality Management System for the Spanish Network of HTA Agencies. The quality management process will require the development of a handbook by each member of REDETS that will be based on agreed quality standards.
The Spanish National Network (REDETS) is a group of eight agencies, units and services, depending on National and Regional Governments that coordinate their work within a common methodological framework, guided by the principles of mutual recognition and cooperation. The necessity of considering a Quality Management System has been detected and, consequently, a common tool for all the members needs to be developed. We describe in this study the process to achieve that goal.
METHODS:
Based on both a review of previous literature and the proposal for a self-evaluating tool, a group of experts from each agency through consensus have developed a tool for self-evaluation in Health Technology Assessment (HTA) agencies. Through the structure described in the handbook of the Andalusian Agency for Healthcare Quality (ACSA), each standard should have a statement or proposal that needs to also include evidence or good practices, and the corresponding evaluation questions. In separate workgroups, the definition of these proposals, evidence and evaluation questions were developed. One face-to-face meeting and two meetings via teleconference were necessary to achieve a final document with all the quality standards.
RESULTS:
From a proposed structure of sixty-six standards, the titles, definitions, statements and evidence as well as good practices and evaluation questions were established in workgroups with consensus among all of the members (1 - 3). The final version of the self-assessment tool was composed of sixty-eight standards, grouped in twelve quality criteria structured in four dimensions: I Responsibility, II Clients and Stakeholders, III Production Process, and IV Resources.
CONCLUSIONS:
Quality management requires an evaluation tool and this version, based on a systematic review and consensus, is a useful and practical instrument for developing a handbook by each member of REDETS. An online version of the tool is in process of development.
When delegating governing tasks to a coalition partner, the president would like to give a minister ample administrative powers to be able to effectively accomplish the political mission. Due to information asymmetries, the president runs the risk that this discretion might be used to pursue policy outcomes that may harm the president's preferences. This trade-off between delegation and control is key to understanding governance strategies the president chooses to minimize agency risks and coordinate public policies. With Brazil as a case study, this article demonstrates that presidents have strategically made frequent use of junior ministers as watch-dogs of coalition partners, especially when coalition allies are ideologically distant from the president's preferences. Yet neither the portfolio salience nor the president's decision to share powers with coalition partners proportionally seems to interfere in such strategic decisions.