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It remains unclear which individuals with subthreshold depression benefit most from psychological intervention, and what long-term effects this has on symptom deterioration, response and remission.
Aims
To synthesise psychological intervention benefits in adults with subthreshold depression up to 2 years, and explore participant-level effect-modifiers.
Method
Randomised trials comparing psychological intervention with inactive control were identified via systematic search. Authors were contacted to obtain individual participant data (IPD), analysed using Bayesian one-stage meta-analysis. Treatment–covariate interactions were added to examine moderators. Hierarchical-additive models were used to explore treatment benefits conditional on baseline Patient Health Questionnaire 9 (PHQ-9) values.
Results
IPD of 10 671 individuals (50 studies) could be included. We found significant effects on depressive symptom severity up to 12 months (standardised mean-difference [s.m.d.] = −0.48 to −0.27). Effects could not be ascertained up to 24 months (s.m.d. = −0.18). Similar findings emerged for 50% symptom reduction (relative risk = 1.27–2.79), reliable improvement (relative risk = 1.38–3.17), deterioration (relative risk = 0.67–0.54) and close-to-symptom-free status (relative risk = 1.41–2.80). Among participant-level moderators, only initial depression and anxiety severity were highly credible (P > 0.99). Predicted treatment benefits decreased with lower symptom severity but remained minimally important even for very mild symptoms (s.m.d. = −0.33 for PHQ-9 = 5).
Conclusions
Psychological intervention reduces the symptom burden in individuals with subthreshold depression up to 1 year, and protects against symptom deterioration. Benefits up to 2 years are less certain. We find strong support for intervention in subthreshold depression, particularly with PHQ-9 scores ≥ 10. For very mild symptoms, scalable treatments could be an attractive option.
Objectives/Goals: Poor visual memory and perceptual organization task performance predicts cognitive decline and is sensitive to dementia severity. No genome-wide association study (GWAS) has assessed the genomic basis of cognitive visual-spatial phenotypes. We aimed to identify common genetic variants associated with visual memory and spatial organization. Methods/Study Population: We included dementia- and stroke-free participants aged 45 years or older from up to seven cohorts in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium, who performed cognitive tasks assessing delayed visual memory (e.g., Benton Visual Retention Test (BVRT, n = 10,934) and visual reproductions (VR, n = 5,527)) or spatial organization (i.e., Hooper Visual Organization Test (HVOT, n = 5,024)). Each cohort used linear regression models to relate common genetic variants imputed to the 1000 Genomes panel to each cognitive phenotype, adjusting for age, sex, population stratification, and education. Summary statistics for the BVRT were meta-analyzed using METAL. Combined GWAS was used for a joint analysis of all traits. Results/Anticipated Results: We identified a genome-wide significant variant related to BVRT performance located near the TSHZ3 gene (rs10425277, p = 6.76×10–9). TSHZ3 is important for the development and function of cortical projecting neurons and may be implicated in Alzheimer’s disease progression by repressing CASP4 transcription. Multitrait analyses, including BVRT, VR, and HVOT, identified two additional variants of interest in SMYD3 gene (rs10802275, p = 5.58×10–7) and near ZFPM2 (rs2957459, p = 2.03×10–7), both of which are overexpressed in the brain and have important implications for neurodevelopment. SMYD3 may be directly involved in synaptic dysfunction and has been shown to be upregulated in the prefrontal cortex of Alzheimer’s disease patients. Discussion/Significance of Impact: Our findings suggest that variants related to visual memory and spatial organization are involved in neurodevelopmental and degenerative pathways. This GWAS adds to the growing body of GWAS literature on the genetic basis of cognitive function. Additional analyses are underway to replicate these findings and extend functional annotation.
This paper presents detailed analyses of the Reynolds stresses and their budgets in temporally evolving stratified wakes using direct numerical simulation. Ensemble averaging is employed to mitigate statistical errors in the data, and the results are presented as functions of both the transverse and vertical coordinates – at time instants across the near-wake, non-equilibrium, and quasi-two-dimensional regimes for wakes in weakly and strongly stratified environments. Key findings include the identification of dominant terms in the Reynolds stress transport equations and their spatial structures, the generation and destruction processes of the Reynolds stresses, and the energy transfer between the Reynolds stress and the mean flow. The study also clarifies the effects of the Reynolds number and the Froude number. Additionally, we assess the validity of the eddy-viscosity type models and some existing closures for the Reynolds stress model, highlighting the limitations of isotropy and return-to-isotropy hypotheses in stratified flows.
For binary plug nozzle, the plug cone is exposed to high-temperature mainstream flow, making it one of the nozzle’s high-temperature components. This paper uses the Realizable k-ε turbulence model and the reverse Monte Carlo method to numerically investigate the aerodynamic and infrared radiation characteristics of the plug nozzle. Various slot cooling configurations were adopted to study the nozzle’s infrared radiation in detail. Results indicate that compared to the baseline nozzle, the plug nozzle’s performance is slightly reduced due to the decrease in effective area of flow over the plug cone. Introducing slot cooling at the rear edge provides significant infrared suppression benefits at low detection angles and notably reduces infrared radiation discrepancy with baseline nozzle at high detection angles. The cooling air from slots causes the nozzle jet to exhibit a ‘thermal layered’ feature. With the same total coolant mass flow, the ‘leading edge + trailing edge’ cooling configuration can lower the area-averaged wall temperature of the plug cone by 5.5% – 12.3%. However, its infrared radiation intensity at each detection angle on the pitch detection plane is higher than that of the ‘trailing edge’ configuration. The significance of leading-edge cooling is focused more on thermal protection for the plug. Thus, it is essential to balance coolant mass flow distribution between infrared radiation suppression and thermal protection.
The depth-integrated horizontal momentum equations and continuity equation are employed to develop a new model. The vertical velocity and pressure can be expressed exactly in terms of horizontal velocities and free-surface elevation, which are the only unknowns in the model. Dividing the water column into elements and approximating horizontal velocities using linear shape function in each element, a set of model equations for horizontal velocities at element nodes is derived by adopting the weighted residual method. These model equations can be applied for transient or steady free-surface flows by prescribing appropriate lateral boundary conditions and initial conditions. Here, only the wave–current–bathymetry interaction problems are investigated. Theoretical analyses are conducted to examine various linear wave properties of the new models, which outperform the Green–Naghdi-type models for the range of water depth to wavelength ratios and the Boussinesq-type models as they are capable of simulating vertically sheared currents. One-dimensional horizontal numerical models, using a finite-difference method, are applied to a wide range of wave–current–bathymetry problems. Numerical validations are performed for nonlinear Stokes wave and bichromatic wave group propagation in deep water, sideband instability, regular wave transformation over a submerged shoal and focusing wave group interacting with linearly sheared currents in deep water. Very good agreements are observed between numerical results and laboratory data. Lastly, numerical experiments of wave shoaling from deep to shallow water are conducted to further demonstrate the capability of the new model.
The cyst nematodes, subfamily Heteroderinae, are plant pathogens of worldwide economic significance. A new cyst nematode of the genus Cactodera within the Heteroderinae, Cactodera xinanensis n. sp., was isolated from rhizospheres of crops in the Guizhou and Sichuan provinces of southwest China. The new species was characterized by having the cyst with a length/width = 1.3 ± 0.1 (1.1–1.6), a fenestral diameter of 28.1 ± 4.3 (21.3–38.7) μm, vulval denticles present; second-stage juvenile with stylet 21.5 ± 0.5 (20.3–22.6) μm long, tail 59.4 ± 2.0 (55.9–63.8) μm long and hyaline region 28.7 ± 2.7 (25.0–36.3) μm long, lateral field with four incisures; the eggshell with punctations. The new species can be differentiated from other species of Cactodera by a longer tail and hyaline region of second-stage juveniles. Phylogenetic relationships within populations and species of Cactodera are given based on the analysis of the internal transcribed spacer (ITS-rRNA), the large subunit of the nuclear ribosomal RNA (28S-rRNA) D2-D3 region and the partial cytochrome oxidase subunit I (COI) gene sequences here. The ITS-rRNA, 28S-rRNA and COI gene sequences clearly differentiated Cactodera xinanensis n. sp. from other species of Cactodera. A key and a morphological identification characteristic table for the species of Cactodera are included in the study.
Folate metabolism is involved in the development and progression of various cancers. We investigated the association of single nucleotide polymorphisms (SNP) in folate-metabolising genes and their interactions with serum folate concentrations with overall survival (OS) and liver cancer-specific survival (LCSS) of newly diagnosed hepatocellular carcinoma (HCC) patients. We detected the genotypes of six SNP in three genes related to folate metabolism: methylenetetrahydrofolate reductase (MTHFR), 5-methyltetrahydrofolate-homocysteine methyltransferase reductase (MTRR) and 5-methyltetrahydrofolate-homocysteine methyltransferase (MTR). Cox proportional hazard models were used to calculate multivariable-adjusted hazard ratios (HR) and 95 % CI. This analysis included 970 HCC patients with genotypes of six SNP, and 864 of them had serum folate measurements. During a median follow-up of 722 d, 393 deaths occurred, with 360 attributed to HCC. In the fully-adjusted models, the MTRR rs1801394 polymorphism was significantly associated with OS in additive (per G allele: HR = 0·84, 95 % CI: 0·71, 0·99), co-dominant (AG v. AA: HR = 0·77; 95 % CI: 0·62, 0·96) and dominant (AG + GG v. AA: HR = 0·78; 95 % CI: 0·63, 0·96) models. Carrying increasing numbers of protective alleles was linked to better LCSS (HR10–12 v. 2–6 = 0·70; 95 % CI: 0·49, 1·00) and OS (HR10–12 v. 2–6 = 0·67; 95 % CI: 0·47, 0·95). Furthermore, we observed significant interactions on both multiplicative and additive scales between serum folate levels and MTRR rs1801394 polymorphism. Carrying the variant G allele of the MTRR rs1801394 is associated with better HCC prognosis and may enhance the favourable association between higher serum folate levels and improved survival among HCC patients.
Indoor ventilation is underutilized for the control of exposure to infectious pathogens. Occupancy restrictions during the pandemic showed the acute need to control detailed airflow patterns, particularly in heavily occupied spaces, such as lecture halls or offices, and not just to focus on air changes. Displacement ventilation is increasingly considered a viable energy efficient approach. However, control of airflow patterns from displacement ventilation requires us to understand them first. The challenge in doing so is that, on the one hand, detailed numerical simulations – such as direct numerical simulations (DNSs) – enable the most accurate assessment of the flow, but they are computationally prohibitively costly, thus impractical. On the other hand, large eddy simulations (LES) use parametrizations instead of explicitly capturing small-scale flow processes critical to capturing the inhomogeneous mixing and fluid–boundary interactions. Moreover, their use for generalizable insights requires extensive validation against experiments or already validated gold-standard DNSs. In this study, we start to address this challenge by employing efficient monotonically integrated LES (MILES) to simulate airflows in large-scale geometries and benchmark against relevant gold-standard DNSs. We discuss the validity and limitations of MILES. Via its application to a lecture hall, we showcase its emerging potential as an assessment tool for indoor air mixing heterogeneity.
Social determinants of health (SDoH), such as socioeconomics and neighborhoods, strongly influence health outcomes. However, the current state of standardized SDoH data in electronic health records (EHRs) is lacking, a significant barrier to research and care quality.
Methods:
We conducted a PubMed search using “SDOH” and “EHR” Medical Subject Headings terms, analyzing included articles across five domains: 1) SDoH screening and assessment approaches, 2) SDoH data collection and documentation, 3) Use of natural language processing (NLP) for extracting SDoH, 4) SDoH data and health outcomes, and 5) SDoH-driven interventions.
Results:
Of 685 articles identified, 324 underwent full review. Key findings include implementation of tailored screening instruments, census and claims data linkage for contextual SDoH profiles, NLP systems extracting SDoH from notes, associations between SDoH and healthcare utilization and chronic disease control, and integrated care management programs. However, variability across data sources, tools, and outcomes underscores the need for standardization.
Discussion:
Despite progress in identifying patient social needs, further development of standards, predictive models, and coordinated interventions is critical for SDoH-EHR integration. Additional database searches could strengthen this scoping review. Ultimately, widespread capture, analysis, and translation of multidimensional SDoH data into clinical care is essential for promoting health equity.
Mass Casualty Incidents (MCIs) involving high-speed passenger ferries (HSPFs) may result in the dual-wave phenomenon, in which the emergency department (ED) is overwhelmed by an initial wave of minor injuries, followed by a second wave of more seriously injured victims. This study aimed to characterize the time pattern of ED presentation of victims in such accidents in Hong Kong.
Methods
All HSPF MCIs from 2005 to 2015 were reviewed retrospectively, with the time interval from accident to ED registration determined for each victim. Multivariable linear regression was used to identify independent factors associated with the time of ED presentation after the accidents.
Results
Eight MCIs involving 492 victims were identified. Victims with an Injury Severity Score (ISS) ≥ 9 had a significantly shorter median time interval compared to those with minor injuries. An ISS ≥ 9 and evacuation by emergency service vessels were associated with a shorter delay in ED arrival, whereas ship sinking, accident at nighttime, and a longer linear distance between the accident and receiving ED were associated with a longer delay.
Conclusion
The dual-wave phenomenon was not present in HSPF MCIs. Early communication is the key to ensure early resource mobilisation and a well-timed response.
Sometimes patients and clinicians don’t agree and there is conflict. Many people prefer to avoid conflict, however working through it allows us to discuss our differences of opinion, explore the options, and come up with an agreement that we all can live with. Good communication skills can help shift the focus from “Who’s right?” to “What’s our shared interest?” This roadmap is different as it is about how you find your path amidst conflict. Start by noticing there is a disagreement. Prepare yourself by pausing, being curious, and assuming positive intent. Invite the other person’s perspective and listen to their story, emotion, and what it means to their sense of self. Identify what is at the root of the conflict and if possible, articulate it as a shared interest. Brainstorm to address the shared interest, and look for options that address everyone’s goals. Remember that conflicts occur because people care deeply, which means that resolving the conflict will take time and effort. Even in instances where it is not possible to agree, skillful communication can allow for graceful disagreement.
Conflict with our colleagues is stressful and evokes strong emotion, yet handled well can improve outcomes and relationships and enhance collaboration. There are issues of hierarchy, power, and respect. Similar to dealing with conflict with patients is the need to establish a safe space, practice deep listening, and earn trust. Being open to exploring the breadth of the problem, both parties perspectives, your role in the conflict, how you feel about events, and what it means to you will help you approach the situation with a more open mind. Keeping a focus on improving the situation and relationship rather than solely on being right will help maintain calm. The roadmap for conflict with colleagues includes noticing when conflict is bubbling up, preparing your approach instead of jumping in reactively, starting softly to avoid provoking defensiveness, inviting the other person’s perspective before you share yours, using neutral language to reframe emotionally charged issues, acknowledging the emotion of the situation (rather than handling your colleague’s emotions directly), and finding a path forward that addresses both parties’ concerns, creating new options where needed.
To hone your skills, one needs to observe what “good” looks like, practice, and receive feedback. We recommend setting a communication skills goal before the encounter, and then debriefing how it went, celebrating what you did well, and considering what to do differently next time, as well as what you learned in the process. Practicing skills in conversation roadmaps is incomplete without building of our internal capacities, like curiosity and emotional awareness, which help us foster more authentic connection. Learning new skills is not linear. Be kind to yourself when you’re having a bad day or feeling burnt out. Better communication skills can help they leads to more engaged clinical encounters which provide positive feedback making patient care more rewarding. Also, the roadmaps in this book are a kind of scaffold for learning, intended to provide support until you get your foundation settled. After a while, you may no longer need them. True expertise requires building both skills and capacities, practicing regularly, and caring for oneself in the process.
Multiple family members means multiple perspectives, agendas, emotions, and values. And, families are more than a collection of individuals. They have with their own way of functioning as a whole. When meeting with family about their loved one’s care, there are important steps similar to the maps we used with patients themselves. First, pre-meet to decide who’s going to be invited. The team should also agree upon a big picture headline. During the conference, introduce all participants and the purpose of meeting. Assess what the family knows and their different perspectives. Update the family using a headline, and address questions and concerns. Empathize and respond to the various emotions in the room. Prioritize the patient’s values. Align with the patient’s values and support the family. Finally, summarize and provide a concrete follow-up plan. An effective family conference can get everyone on the same page, ensure that the patient and family understand the medical situation, and help the family and care team come together to make treatment decisions that align with the patient’s values.
Some situations are particularly challenging. These include high-stakes, high-emotion conversations, like when patients talk about miracles or when they request hastened death. In the case of miracles, it is because they understand how bad things are that miracles are invoked. In the case of requests for hastened death, the request is brought on by suffering or fear of suffering. In both cases, the first thing is to do is take a breath and then explore, rather than react from a place of emotion. Another challenge is when responding to emotion isn’t enough. This can occur when a patient really does want information, when patients are coping through intellectualizing, when the emotion is too overwhelming, or when the level of emotion (and sometimes physical agitation) is elevated to the point of feeling or being unsafe. Each of these requires a tailored response like giving information, nonconfrontation, or containment before being able to move forward. Finally, in situations when our own emotions become elevated, it is important to allow ourselves to feel while being mindful we remain of service to the patient, and that we get support from trusted team members and colleagues.
Discussing treatment options is more complex than giving information and making a recommendation. Today, shared decision making includes patient access to the electronic medical record and internet searches, however patients still turn to their clinicians as the most important and trusted source. In addition to balancing information and emotion, clinicians need to take into account how involved patients wish to be in decision making. A roadmap for discussing treatment decisions is: 1. Prepare for the visit, 2. Frame the decision to be made, 3. Ask about decision-making preferences explicitly, 4. Adapt the discussion and recommendations based on patient decision-making preferences (shared decision making, clinician-led decision making, pros/cons), 5. Check for patient understanding, 6. Establish how the patient wants to proceed with the decision-making process. Take care with how statistics are presented and consider providing decision aides. Asking patients how they want to make decisions will help ground decisions in their values.
When prolonging life with acceptable quality of life becomes difficult, goals of care discussion are necessary. For clinicians and patients, the discontinuation of disease-modifying therapy can feel like a failure. This can lead clinicians to offer treatments we don’t believe are good options or offering treatment on the condition that our patients make an improbable recovery. The roadmap for late stage goals of care discussions is REMAP. Reframe why the status quo isn’t working, expect emotion and respond with empathy, map big picture values, align with the patient’s values, and finally plan medical treatments based on what’s important to your patient. Some things to note: Mapping thoroughly will help you make sure you don’t miss something important. A useful shift in thinking for many clinicians is first talking about what you will do before talking about what should be stopped or you won’t offer. And, clearly linking your recommendations to the patient’s values will help your proposed plan be more acceptable. By grounding ourselves in what is medically possible and using the patient’s values to guide our next steps, we can cocreate a plan that is both possible and meaningful.
Most clinicians prefer that patients plan for their future illness care before things become urgent or they lose the ability to make decisions. Completing an advance directive form by itself does not always impact future care decisions. Rather than focusing on hypothetical specific treatment decisions in the future or the completion of forms, conversations early in serious illness focusing on what matters most to patients may help guide care decisions over time and prepare patients and families for future conversations about specifics in real time when things do progress. The key is to plan on multiple small conversations over time. A roadmap for having these early goals of care discussion is PAUSE (Pause to make time for the conversation, Ask permission to discuss the topic and explain why, Uncover values first (don’t lead with code status), Suggest selecting a surrogate, Expect emotion/End). Some patients shy away from considering a future state when their disease has worsened, and are not interested in talking about what matters to them. Exploring why using a motivational approach and focusing on your relationship may help plant the seed and make future conversations easier.