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One in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.
We surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is required
We had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.
Our national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.
Despite substantial research attention on obsessive beliefs, more research is needed to understand how these beliefs serve as aetiological or maintaining factors for obsessive-compulsive (OC) symptoms. Magical thinking may allow individuals to gain a sense of control when experiencing intrusive thoughts and corresponding obsessive beliefs, potentially accounting for why OC belief domains are often related to OC symptoms.
This study examines magical thinking as a mediating variable in the relationship between OC belief domains and symptoms.
Undergraduate students (n = 284) reported their obsessive beliefs, magical thinking, and OC symptoms.
As expected, there were significant indirect effects for the belief domain of inflated responsibility and over-estimation of threat on OC symptoms via magical thinking. There was also an indirect effect for the belief domain of importance and control of thoughts on OC symptoms via magical thinking. Unexpectedly, there was no indirect effect involving the belief domain of perfectionism and intolerance of uncertainty.
Magical thinking may be one mechanism through which certain OC beliefs lead to OC symptoms. It may be that magical thinking serves as a coping mechanism in response to elevated beliefs. Future studies should extend these findings across time and clinical samples.
National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.
To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.
Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.
A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.
SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.
Hypoplastic left heart syndrome is a single ventricle defect. While staged surgical palliative treatments have revolutionised care, patients with hypoplastic left heart syndrome continue to have significant morbidity and mortality. In 2017, the National Pediatric Cardiology Quality Improvement Collaborative recommended all single ventricle patients to receive a prenatal palliative care consult. This study aimed to elucidate provider perspectives on the implementation of prenatal palliative care consults for families expecting a child with hypoplastic left heart syndrome.
An online survey was administered to obstetric and paediatric providers of relevant disciplines to assess their experience with palliative care involvement in hypoplastic left heart syndrome cases.
Nearly, all physicians (97%) and most registered nurses (79%) agreed that the initial palliative care consult for patients with hypoplastic left heart syndrome should occur during the prenatal period. Respondents also indicated that prenatal palliative care consults should also be offered in a variety of other CHD conditions. Participants believed positive aspects of this new referral protocol included an expanded support network for families, decreased family stress during the postnatal period, increased patient education about what to expect during the postnatal period, and continuity of care.
Multidisciplinary healthcare professionals believe that prenatal palliative care consults provide a variety of benefits for patients and families with hypoplastic left heart syndrome. Additional, multi-centre research is necessary to evaluate whether prenatal palliative care consults should become standard of care for families expecting a child with a single ventricle defect.
The mechanism through which developmental programming of offspring overweight/obesity following in utero exposure to maternal overweight/obesity operates is unknown but may operate through biologic pathways involving offspring anthropometry at birth. Thus, we sought to examine to what extent the association between in utero exposure to maternal overweight/obesity and childhood overweight/obesity is mediated by birth anthropometry. Analyses were conducted on a retrospective cohort with data obtained from one hospital system. A natural effects model framework was used to estimate the natural direct effect and natural indirect effect of birth anthropometry (weight, length, head circumference, ponderal index, and small-for-gestational age [SGA] or large-for-gestational age [LGA]) for the association between pre-pregnancy maternal body mass index (BMI) category (overweight/obese vs normal weight) and offspring overweight/obesity in childhood. Models were adjusted for maternal and child socio-demographics. Three thousand nine hundred and fifty mother–child dyads were included in analyses (1467 [57.8%] of mothers and 913 [34.4%] of children were overweight/obese). Results suggest that a small percentage of the effect of maternal pre-pregnancy BMI overweight/obesity on offspring overweight/obesity operated through offspring anthropometry at birth (weight: 15.5%, length: 5.2%, head circumference: 8.5%, ponderal index: 2.2%, SGA: 2.9%, and LGA: 4.2%). There was a small increase in the percentage mediated when gestational diabetes or hypertensive disorders were added to the models. Our study suggests that some measures of birth anthropometry mediate the association between maternal pre-pregnancy overweight/obesity and offspring overweight/obesity in childhood and that the size of this mediated effect is small.
Addressing rural health disparities has unique challenges that require cross-sector collaborations to address social determinants of health and help those in need to get connected to care continuum. We brought the Clinical and Translational Science Award, Institutional Development Award Program Infrastructure for Clinical and Translational Research, and Cooperative Extension System Programs together for a one-day semi-structured meeting to discuss collaborative opportunities to address rural health disparities. Session notes and event materials were analyzed for themes to facilitate collaboration such as defining rural, critical issues, and organizational strengths in support of collaboration. Across 16 sessions, there were 26 broad topics of discussion. The most frequent topics included “barriers and challenges,” “strategies and opportunities,” and “defining rural.” There is a growing understanding of the opportunity that collaboration between these large programs provides in addressing rural health disparities.
Perfectionism is a transdiagnostic risk factor across psychopathology. The Clinical Perfectionism Questionnaire (CPQ) was developed to assess change in order to provide clinical utility, but currently the psychometric properties of the CPQ with adolescents is unknown.
To assess the factor structure and construct validity of the CPQ in female adolescents.
The CPQ was administered to 267 females aged 14–19 years of age. Confirmatory factor analysis (CFA) was used to examine the validity of the two-factor model and a second-order factor model. Pearson correlations were used to evaluate the relationships between the CPQ and a wide range of measures of perfectionism, psychopathology and personality traits.
The study demonstrated internal consistency, construct validity and incremental validity of the CPQ in a sample of female adolescents. The CFA in the present study confirmed the two-factor model of the CPQ with Factor 1 relating to perfectionistic strivings and Factor 2 representing perfectionistic concerns. The second-order two factor model indicated no deterioration in fit.
The two-factor model of the CPQ fits with the theoretical definition of clinical perfectionism where the over-dependence of self-worth on achievement and concern over mistakes are key elements. The CPQ is suitable for use with female adolescents in future research that seeks to better understand the role of perfectionism in the range of mental illnesses that impact youth.
Decades of research have highlighted the significance of parenting in children's development, yet few studies have focused specifically on the development of parental monitoring strategies in diverse families living in at-risk neighborhoods. The current study investigated the development of active (i.e., parental discussions and curfew rules) and passive (i.e., child communication with parents) parental monitoring strategies across different developmental periods (middle childhood and adolescence; Grades 4–5 and 7–11) as well as individual (child, parent), family, and contextual antecedents (measured in kindergarten) of this parenting behavior. Using an ecological approach, this study evaluated longitudinal data from 753 participants in the Fast Track Project, a multisite study directed at the development and prevention of conduct problems in at-risk children. Latent trajectory modeling results identified little to no mean growth in these monitoring strategies over time, suggesting that families living in at-risk environments may engage in consistent levels of monitoring strategies to ensure children's safety and well-being. Findings also identified several kindergarten antecedents of the growth factors of these parental monitoring strategies including (a) early child conduct problems; (b) parental warmth/involvement, satisfaction, and efficacy; and (c) parent–child relationship quality. These predictive effects largely highlighted the important role of early parenting behaviors on later levels of and growth in parental monitoring strategies. These findings have important implications for potential prevention and intervention targets to promote the development of parental monitoring strategies among families living in more at-risk contexts.
Parasites directly and indirectly influence the important interactions among hosts such as competition and predation through modifications of behaviour, reproduction and survival. Such impacts can affect local biodiversity, relative abundance of host species and structuring of communities and ecosystems. Despite having a firm theoretical basis for the potential effects of parasites on ecosystems, there is a scarcity of experimental data to validate these hypotheses, making our inferences about this topic more circumstantial. To quantitatively test parasites' role in structuring host communities, we set up a controlled, multigenerational mesocosm experiment involving four sympatric freshwater crustacean species that share up to four parasite species. Mesocosms were assigned to either of two different treatments, low or high parasite exposure. We found that the trematode Maritrema poulini differentially influenced the population dynamics of these hosts. For example, survival and recruitment of the amphipod Paracalliope fluviatilis were dramatically reduced compared to other host species, suggesting that parasites may affect their long-term persistence in the community. Relative abundances of crustacean species were influenced by parasites, demonstrating their role in host community structure. As parasites are ubiquitous across all communities and ecosystems, we suggest that the asymmetrical effects we observed are likely widespread structuring forces.
To detect modest associations of dietary intake with disease risk, observational studies need to be large and control for moderate measurement errors. The reproducibility of dietary intakes of macronutrients, food groups and dietary patterns (vegetarian and Mediterranean) was assessed in adults in the UK Biobank study on up to five occasions using a web-based 24-h dietary assessment (n 211 050), and using short FFQ recorded at baseline (n 502 655) and after 4 years (n 20 346). When the means of two 24-h assessments were used, the intra-class correlation coefficients (ICC) for macronutrients varied from 0·63 for alcohol to 0·36 for polyunsaturated fat. The ICC for food groups also varied from 0·68 for fruit to 0·18 for fish. The ICC for the FFQ varied from 0·66 for meat and fruit to 0·48 for bread and cereals. The reproducibility was higher for vegetarian status (κ > 0·80) than for the Mediterranean dietary pattern (ICC = 0·45). Overall, the reproducibility of pairs of 24-h dietary assessments and single FFQ used in the UK Biobank were comparable with results of previous prospective studies using conventional methods. Analyses of diet–disease relationships need to correct for both measurement error and within-person variability in dietary intake in order to reliably assess any such associations with disease in the UK Biobank.
Public health strategies have focused largely on physical health. However, there is increasing recognition that raising mental health awareness and tackling stigma is crucial to reduce disease burden. National campaigns have had some success but tackling issues locally is particularly important.
To assess the public's awareness and perception of the monthly BBC Cornwall mental health phone-in programmes that have run for 8.5 years in Cornwall, UK (population 530 000).
A consultation, review and feedback process involving a multiagency forum of mental and public health professionals, people with lived experience and local National Health Service trust's media team was used to develop a brief questionnaire. This was offered to all attendees at two local pharmacies covering populations of 27 000 over a 2-week period.
In total, 14% (95% CI 11.9–16.5) were aware of the radio show, 11% (95% CI 9.0–13.1) have listened and the majority (76%) of those who listened did so more than once. The estimated reach is 70 000 people in the local population, of whom approximately 60 000 listen regularly. The show is highly valued among respondents with modal and median scores of 4 out of 5.
Local radio is a successful, cost-effective and impactful way to reach a significant proportion of the population and likely to raise awareness, reduce stigma and be well received. The format has been adopted in other regions thus demonstrating easy transferability. It could form an essential part of a public health strategy to improve a population's mental well-being.
Declaration of interest
W.H. received support from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula UK. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. L.R. and D.S. were involved in delivering the programmes but had no role in their evaluation.
We investigated whether neurobehavioral markers of risk for emotion dysregulation were evident among newborns, as well as whether the identified markers were associated with prenatal exposure to maternal emotion dysregulation. Pregnant women (N = 162) reported on their emotion dysregulation prior to a laboratory assessment. The women were then invited to the laboratory to assess baseline respiratory sinus arrhythmia (RSA) and RSA in response to an infant cry. Newborns were assessed after birth via the NICU Network Neurobehavioral Scale. We identified two newborn neurobehavioral factors—arousal and attention—via exploratory factor analysis. Low arousal was characterized by less irritability, excitability, and motor agitation, while low attention was related to a lower threshold for auditory and visual stimulation, less sustained attention, and poorer visual tracking abilities. Pregnant women who reported higher levels of emotion dysregulation had newborns with low arousal levels and less attention. Larger decreases in maternal RSA in response to cry were also related to lower newborn arousal. We provide the first evidence that a woman's emotion dysregulation while pregnant is associated with risks for dysregulation in her newborn. Implications for intergenerational transmission of emotion dysregulation are discussed.
All Fire and Emergency Services (FES) personnel must balance FES work with their other responsibilities. Given that women tend to take on a greater responsibility for management of household/domestic activities than men, the on-call component of their FES work may be associated with very different challenges. Despite this, women have rarely been the focus of on-call research.
To explore women’s on-call experiences in the FES by examining coping styles and strategies, with the goal of helping to innovate the way women are supported in FES roles.
Relevant findings from two studies are included. The first study involved FES personnel from two agencies in Australia (n=24) who participated in a semi-structured interview. The second study was an anonymous online survey to determine work characteristics, sleep, stress, and coping in on-call workers more broadly, with workers from all industries across Australia (n=228) invited to participate.
Interview data identified two major themes in terms of coping with on-call work. Support (from family, social, and work), planning, and preparation were identified as important in helping women cope in the context of on-call unpredictability. Results from the survey (43% women) showed that on-call workers were an engaged group in terms of their coping, with 67% classified as having a positive coping style and 58% of women indicating that they agreed/strongly agreed with the statement, “I cope well with on-call work.”
Taken together, these data highlight engagement with positive coping by women who do on-call work, including in the FES. Importantly, positive coping strategies, such as talking about emotions, problem-solving, and seeking support have been linked to increased shift work tolerance in other populations. Coping style and strategies represent modifiable variables which could be specifically applied to assist women to manage the unique challenges associated with on-call work in the FES.
Translocation of species to areas of former habitat after threats have been mitigated is a common conservation action. However, the long-term success of reintroduction relies on identification of currently available habitat and areas that will remain, or become, habitat in the future. Commonly, a short-term view is taken, focusing on obvious and assumed threats such as predators and habitat degradation. However, in areas subject to significant climate change, challenges include correctly identifying variables that define habitat, and considering probable changes over time. This poses challenges with species such as the western ground parrot Pezoporus flaviventris, which was once relatively common in near-coastal south-western Australia, an area subject to major climate change. This species has declined to one small population, estimated to comprise < 150 individuals. Reasons for the decline include altered fire regimes, introduced predators and habitat clearing. The establishment of new populations is a high priority, but the extent to which a rapidly changing climate has affected, and will continue to affect, this species remains largely conjecture, and understanding probable climate change impacts is essential to the prioritization of potential reintroduction sites. We developed high-resolution species distribution models and used these to investigate climate change impacts on current and historical distributions, and identify locations that will remain, or become, bioclimatically suitable habitat in the future. This information has been given to an expert panel to identify and prioritize areas suitable for site-specific management and/or translocation.
Acute aortic dissection (AAD) is a time sensitive, difficult to diagnose, aortic emergency. We sought to explore the quality of history taking in AAD and assess its impact on misdiagnosis.
We studied a retrospective cohort of patients >18 years old who presented to two tertiary care emergency departments from January 1st 2004 – December 31st 2012 and were diagnosed with an acute aortic dissection (AAD) on CT, MRI or TEE. Trained reviewers’ extracted data using a standardized data collection form. The definitions of 5 pain characteristics – character, onset, duration, quality, and radiation were defined a priori.
Data were collected for 194 cases of acute aortic dissection with a mean age of 65(SD 14.1) and 66.7% male, 34(17.6%) missed on initial presentation. Only 20(14.8%) patients were asked all 5 questions. The most common initial incorrect diagnosis were acute coronary syndrome (16, 47%), pulmonary embolism (5, 14.7%) and stroke (4, 11.7%). If <2 questions were asked 1 in 5 cases were missed, 4 times greater than if >2 were asked (P < 0.01).
Clinicians should ask and document the character, onset, duration, radiation and severity of pain in any patient presenting with chest, abdominal or flank pain. A focused history still remains the keystone to reducing misdiagnosis.
OBJECTIVES/SPECIFIC AIMS: I would like to make clinicians aware about prescription opioid use and glycemic control among patients with diabetes. This is a quality of care issue that increases the disease burden for two conditions opioid dependence and diabetic complications. Big data analytics can bring out this quality of care issue and help in changing clinical practice through precision medicine METHODS/STUDY POPULATION: This is a population health study of patients on prescription opioid pain medications in Erie county medical center and local out patient clinic. The electronic data from the hospital records and Outpatient were collected, merged and de identified. The database was saved in a protected environment and made accessible to researchers through a secure login. The data was queried for the number of patients with diabetes. The glycohemoglobin levels were collected and then the analysis was made RESULTS/ANTICIPATED RESULTS: It was found that only 63 of the 89 patients with DPN and 156 of the 570 patients without DPN had any measurement of HbA1c in our data. It was found that 86 out of 156 patients without DPN had suboptimal glycemic control with a glycohemoglobin level > 7% while 36 out of 63 patients with DPN had a glycohemoglobin > 6.7%. The odds of patients with DPN having poor glycemic control is 0.57 while the odds of having poor glycemic control without DPN is.55. The relative risk being 1.03. DISCUSSION/SIGNIFICANCE OF IMPACT: Our population study revealed suboptimal glycemic control among a large set of patients in Western New York with a diagnosis of diabetes mellitus and a concurrent prescription for an opioid pain medication. A significant percentage of patients in our study population with a diagnosis of DPN might benefit in terms of decreased painful symptoms of neuropathy from monitoring and attempting to improve glycemic control. Additionally, in our patient population, there were no patients with diabetic peripheral neuropathy prescribed pregabalin or duloxetine, the first-line FDA-approved medications for painful DPN, Based on our population study, the quality of care for diabetic patients with DPN who are prescribed opioid pain medications should be monitored closely. First-line, FDA approved anticonvulsants and antidepressants should be considered for the treatment of painful symptoms when necessary. Attention should be directed towards monitoring and improving glycemic control in patients without DPN receiving opioid pain medications to attempt to prevent or delay the microvascular complications of diabetes, including the onset of painful peripheral neuropathy.
Background: Intensive care unit-acquired weakness (ICU-AW) is associated with poorer outcome of critically ill patients. Microcirculatory changes and altered vascular permeability of skeletal muscles might contribute to the pathogenesis of ICU-AW. Muscular ultrasound (MUS) displays increased muscle echogenicity, although its pathogenesis is uncertain. Objective: We investigated the combined measurement of serum and ultrasound markers to assess ICU-AW and clinical patient outcome. Methods: Fifteen patients and five healthy controls were longitudinally assessed for signs of ICU-AW at study days 3 and 10 using a muscle strength sum score. The definition of ICU-AW was based on decreased muscle strength assessed by the muscular research council-sum score. Ultrasound echogenicity of extremity muscles was assessed using a standardized protocol. Serum markers of inflammation and endothelial damage were measured. The 3-month outcome was assessed on the modified Rankin scale. Results: ICU-AW was present in eight patients, and seven patients and the control subjects did not develop ICU-AW. The global muscle echogenicity score (GME) differed significantly between controls and patients (mean GME, 1.1 ± 0.06 vs. 2.3 ± 0.41; p = 0.001). Mean GME values significantly decreased in patients without ICU-AW from assessment 1 (2.30 ± 0.48) to assessment 2 (2.06 ± 0.45; p = 0.027), which was not observed in patients with ICU-AW. Serum levels of syndecan-1 at day 3 significantly correlated with higher GME values at day 10 (r = 0.63, p = 0.012). Furthermore, the patients’ GME significantly correlated with mRS at day 100 (r = 0.67, p = 0.013). Conclusion: The combined use of muscular ultrasound and inflammatory biomarkers might be helpful to diagnose ICU-AW and to predict long-term outcome in critical illness.
Background: Mindfulness-based cognitive therapy (MBCT) has evidence of efficacy in a range of populations, but few studies to date have reported on MBCT for treatment of anxious and depressive symptoms in Parkinson's disease (PD). Aims: The aim of this study was to examine the efficacy of modified MBCT in reducing symptoms of anxiety and depression and improving quality of life in PD. Method: Thirty-six individuals with PD were randomly assigned to either modified MBCT or a waitlist control. Changes in symptoms of anxiety, depression and quality of life were compared at group level using generalized linear mixed models and at individual level using reliable change analysis. Results: At post-treatment, there was a significant reduction in depressive symptoms for people undertaking modified MBCT at both group and individual levels compared with controls. There was no significant effect on anxiety or quality of life at the group level, although significantly more people had reliable improvement in anxiety after modified MBCT than after waitlist. Significantly more waitlist participants had reliable deterioration in symptoms of anxiety and depression than those completing modified MBCT. Most participants stayed engaged in modified MBCT, with only three drop-outs. Discussion: This proof-of-concept study demonstrates the potential efficacy of modified MBCT as a treatment for depressive symptoms in Parkinson's disease and suggests further research is warranted.