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Although ethics is increasingly integrated in the curriculum of U.S. medical schools, it remains not well integrated with system issues, and social and structural contexts of illness. Moreover, ethical analysis is not often taught as a clinical skill. To address these issues, an outcomes driven course in Social Sciences, Humanities, Ethics and Professionalism (SHEP) was created. Within the course, a web-based concept mapping device, SHEP Case Analysis Tool (SCAT), was created which schematizes the structure and flow of clinical cases from diagnosis to treatment options, to shared decision making to outcome, and includes key stakeholders, influences, and structural features of the health system. In the course, each student analyzes a case in which they were directly involved using SCAT and presents their analysis to faculty and peers. This exercise 1) reinforces knowledge-based portions of the course pedagogy, 2) supports meta-cognition and critical thinking through concept mapping, 3) applies multidimensional analysis to identify ethical, social, and system issues that impact patient-care. 4) develops problem solving skills, 5) counters the hidden curriculum/support professional identity formation, and 6) develops skills in reflective discourse. This paper outlines the development and use of this concept mapping case analysis tool in an undergraduate medical education curriculum.
Diagnostic criteria for major depressive disorder allow for heterogeneous symptom profiles but genetic analysis of major depressive symptoms has the potential to identify clinical and etiological subtypes. There are several challenges to integrating symptom data from genetically informative cohorts, such as sample size differences between clinical and community cohorts and various patterns of missing data.
Methods
We conducted genome-wide association studies of major depressive symptoms in three cohorts that were enriched for participants with a diagnosis of depression (Psychiatric Genomics Consortium, Australian Genetics of Depression Study, Generation Scotland) and three community cohorts who were not recruited on the basis of diagnosis (Avon Longitudinal Study of Parents and Children, Estonian Biobank, and UK Biobank). We fit a series of confirmatory factor models with factors that accounted for how symptom data was sampled and then compared alternative models with different symptom factors.
Results
The best fitting model had a distinct factor for Appetite/Weight symptoms and an additional measurement factor that accounted for the skip-structure in community cohorts (use of Depression and Anhedonia as gating symptoms).
Conclusion
The results show the importance of assessing the directionality of symptoms (such as hypersomnia versus insomnia) and of accounting for study and measurement design when meta-analyzing genetic association data.
Haemodynamic changes in caval venous flow distribution occurring during bidirectional cavopulmonary anastomosis operation are still largely unknown.
Methods:
Transit time flow measurements were performed in 15 cavopulmonary anastomosis operations. Superior and inferior caval vein flows were measured before and after the cavopulmonary anastomosis. Ratio of superior caval vein to overall caval veins flow was calculated.
Results:
Mean superior caval vein flow ratio before cavopulmonary anastomosis was higher than previously reported for healthy children. Superior caval vein flow ratio decreased in 14/15 patients after cavopulmonary anastomosis: mean 0.63 ± 0.12 before versus 0.43 ± 0.14 after. No linear correlation between intraoperative superior caval vein pressure and superior caval vein flow after cavopulmonary anastomosis was found. Neither Nakata index nor pulmonary vascular resistance measured at preoperative cardiac catheterisation correlated with intraoperative flows. None of patients died or required a take down.
Conclusions:
The higher mean superior caval vein flow ratio before cavopulmonary anastomosis compared to healthy children suggests flow redistribution in univentricular physiology to protect brain and neurodevelopment. The decrease of superior caval vein flow ratio after cavopulmonary anastomosis may reflect the flow redistribution related to trans-pulmonary gradient. The lack of correlation between superior caval vein pressure and superior caval vein flow could be explained by limited sample size and multifactorial determinants of caval veins flow, although pressure remain essential. Larger sample of measurements are needed to find flow range potentially predictive for clinical failure. To authors’ knowledge, this is the first intraoperative flow measurement of both caval veins during cavopulmonary operations.
Tokamak start-up is characterized by low electron densities and strong electric fields, in order to quickly raise the plasma current and temperature, allowing the plasma to fully ionize and magnetic flux surfaces to form. Such conditions are ideal for the formation of superthermal electrons, which may reduce the efficiency of ohmic heating and prevent the formation of a healthy thermal fusion plasma. This is of particular concern in ITER where engineering limitations put restrictions on the allowable electric fields and limit the prefill densities during start-up. In this study, we present a new 0D burn-through simulation tool called STREAM (STart-up Runaway Electron Analysis Model), which self-consistently evolves the plasma density, temperature and electric field, while accounting for the generation and loss of relativistic runaway electrons. After verifying the burn-through model, we investigate conditions under which runaway electrons can form during tokamak start-up as well as their effects on the plasma initiation. We find that Dreicer generation plays a crucial role in determining whether a discharge becomes runaway-dominated or not, and that a large number of runaway electrons could limit the ohmic heating of the plasma, thus preventing successful burn-through or further ramp-up of the plasma current. The runaway generation can be suppressed by raising the density via gas fuelling, but only if done sufficiently early. Otherwise a large runaway seed may have already been built up, which can avalanche even at relatively low electric fields and high densities.
The aim of this study was to examine the long-term efficacy and safety of a monotherapy with quetiapine or sodium valproate (VPA) in patients with rapid cycling bipolar disorder.
This open-label trial was conducted at three German centers. A sample of 38 remitted or partly remitted bipolar patients with rapid cycling (quetiapine n = 22; VPA n = 16) were treated with quetiapine or VPA (flexible-dose design) up to 12 months. Analyses were based on the ITT-LOCF principle.
41 % of the patients with quetiapine and 50 % with VPA completed the trial. According to the Clinical Global Impression Scale responder rates tended to be higher for quetiapine than for VPA: i.e. 43 % vs. 25 % (depression), 48 % vs. 36 % (mania), and 43 % vs. 19 % (improvement in both mania and depression). There were no differences found between the treatment groups evaluating the HRSD, MADRS and YMRS. In contrast, Life Chart Method data showed that patients being treated with quetiapine had significantly less depressive days than patients on VPA whilst they did not differ in the number of days with manic symptoms. The incidence of adverse events, especially of orthostatic dysregulation and sedation was higher in the quetiapine group.
Quetiapine may be more effective than VPA regarding depressive symptoms and as effective as VPA in the treatment of manic symptoms in the long-term treatment of rapid cycling bipolar disorder. The side effect profile of quetiapine tends to be less favorable than the one of VPA.
Attention Deficit Hyperactivity Disorder (ADHD) is a serious risk factor for co-occurring psychiatric disorders and negative psychosocial consequences in adulthood. Given this background, there is great need for an effective treatment of adult ADHD patients.
Therefore, our research group has conducted a first controlled randomized multicenter study on the evaluation of disorder-tailored DBT-based group program in adult ADHD compared to a psychophar-macological treatment.
Between 2007 and 2010, in a four-arm-design 433 patients were randomized to a manualized dialectical behavioural therapy (DBT) based group program plus methylphenidate or placebo or clinical management plus methylphenidate or placebo with weekly sessions in the first twelve weeks and monthly sessions thereafter. Therapists are graduated psychologists or physicians. Treatment integrity is established by independent supervision. Primary endpoint (ADHD symptoms measured by the Conners Adult ADHD Rating Scale) is rated by interviewers blind to the treatment allocation (Current Controlled Trials ISRCTN54096201). The trial is funded by the German Federal Ministry of Research and Education (01GV0606) and is part of the German network for the treatment of ADHD in children and adults (ADHD-NET). In the lecture the first data of our interim analysis are presented (baseline data, results of treatment compliance and adherence).
Internet-based self-help for social phobia with minimal therapist support via email have shown efficacy in several controlled trials by independent research teams. The role and necessity of therapist guidance is, however, still largely unclear. The present study compared the benefits of a 10-week web-based unguided self-help treatment for social phobia with the same intervention complemented with minimal, although weekly, therapist support via email. Further, a third treatment arm was included, in which the level of support was flexibly stepped up, from no support to email or telephone contact, on demand of the participants. Eighty-one individuals meeting diagnostic criteria for social phobia were randomly assigned to one of the three conditions. Results showed significant symptom reductions in all three treatment groups with large effect sizes for primary social phobia measures (Cohen's d = 1.47) and for secondary outcome measures (d = 1.16). No substantial and significant between-groups effects were found on any of the measures (Cohen's d = .00−.36). Moreover, no difference between the three conditions was found regarding diagnosis-free status, clinically significant change, dropout rates, or adherence measures such as sessions or exercises completed.
Somatic symptoms and anxiety symptoms are often disregarded in the detection of depression in primary care. The present investigation examined to what extent somatic and anxiety symptoms recorded with the Composite International Diagnostic Interview—Primary Health Care Version (CIDI—PHC) can improve the detection of depression as compared to the General Health Questionnaire—12-item version alone. Data from the World Health Organization study on Psychological Problems in General Health Care were used. The study sample consisted of primary care attenders from 15 centres from all over the world who underwent a psychiatric examination with the CIDI—PHC. Medically unexplained somatic symptoms (back pain, feelings of heaviness/lightness in parts of the body, periods of bodily weakness, seizures/convulsions, permanent tiredness, exhaustion after a minimum of effort) and—to a smaller extent—diverse anxiety symptoms (e.g. feelings of anxiousness/nervousness, feelings of tension, difficulties relaxing) significantly contributed to the detection of depression in a logistic regression analysis. The results confirm the observation that in primary care somatic symptoms play an important role in the manifestation of depressive disorders. The items investigated herein could prove beneficial for future depression screening instruments to improve the detection of depressive disorders in primary care.
Today, internet-based technologies are used in all phases of psychosocial services. Current psychotherapeutic applications focus on the implementation of traditional approaches in the Internet. For instance, self-help material is posted onto the net, therapies are conducted via email, and groups meet in virtual chatrooms. However, recent advancements in web-based technologies are providing even greater opportunities for psychotherapy on the Internet. Today, many different aspects of psychotherapy on the Internet can be provided on a single integrated Web platform.
Recently, we have created an Internet platform that offers various aspects of a cognitive behavioral approach to social phobia. This includes an interactive self-help guide, contact with therapists, a continuous monitoring and feedback of patient response, as well as collaborative elements, offering patients the opportunity to share their experiences with other patients. The aim of this presentation is to provide insight into the concrete application of such a platform. Experiences, pitfalls and opportunities are discussed along with the primary results of a controlled study.
Les AVP sont le principal pourvoyeur d’ESPT (Kupchik et al., 2007), dont la prévalence fluctue de 6 à 45 % entre les études (Heron-Delaney et al., 2013). En l’absence de repérage clinique, l’ESPT peut se chroniciser (Kessler et al., 1995). Les outils actuels permettent son diagnostic (Jackson et al., 2011), mais pas de dépister précocement les sujets à risque de développer un ESPT post-AVP en aigu (8 semaines) comme en chronique (6 mois) ou en tardif (1 an). Nous présentons une étude longitudinale réalisée sur 274 patients répartis sur 6 centres de traumatologie ayant pour objectif principal de valider un outil infirmier de dépistage précoce d’ESPT après un AVP (DEPITAC). Dix questions ont été soumises à tout patient hospitalisé dans les 15 jours après un AVP, ainsi qu’une PDI et un MINI DSM-IV. La PCL-S (cut-off à 44) a permis le diagnostic à 8 semaines, 6 mois et 1 an. L’analyse statistique a été réalisée avec le logiciel SAS Institute 9.4. Le score total DEPITAC était significativement associé au diagnostic d’ESPT à 1 an (OR : 1,43 ; IC95 % : 1,14–1,79) avec un pouvoir discriminant de 0,64 (IC95 % : 0,56–0,72). DEPITAC était corrélé à l’échelle PDI (p < 0,0001) avec un faible coefficient de corrélation (r = 0,32) montrant une faible redondance. Seules 3 questions après analyses bivariées s’avèrent significatives : « présence d’autres blessés ou décédés lors de l’AVP », « présence d’une dissociation post-AVP » et « s’être vu mourir lors de l’AVP » avec un pouvoir discriminant de 0,65 (IC95 % : 0,57–0,73). Aucun effet centre n’a été mis en évidence (p = 0,90). Nos résultats semblent montrer qu’à l’aide de seulement 3 questions de dépistage, les équipes infirmières pourraient repérer les patients à risque de développer un ESPT aigu ou tardif, leur permettant ainsi d’alerter précocement les équipes psychiatriques de liaison ou de pschotraumatologie.
Research into mechanisms of interaction between growth and inhibitory proteins of the CNS and behavioral expressions of healthy and disordered brain is one of the contemporary topics. A knockdown model with decreased expression of Nogo-A protein in neurons was developed on the genetic background of Sprague-Dawley wildtypes. Disruption of this inhibitory factor was hypothesized to result in behavioral abnormalities, which were studied both in young, middle age (6 months) and aged (12 months) rats.
Methods:
Animals were tested in a battery of Carousel maze variants with various demands for segregation of spatial information and flexibility; animals avoided an unmarked sector of either stable or rotating arena; moreover the sector could be defined in room- or arena-frame. A shortened Carousel maze battery and Morris water maze (MWM) including one- trial matching-to-place and reversal configurations was used.
Results:
Nogo-A-deficient rats were impaired in the final phases of the Carousel maze battery but their spatial working memory tested in the MWM was intact. Middle-aged and aged groups were differently affected in the battery, but deficits in young animals were observed not to be worsened with ageing. Concept of multidirectional age-related alterations in this animal model is further supported by biochemical brain changes.
Conclusion:
Nogo-A-deficient rats may serve as an extremely useful model of neurodevelopmental deficit, which may manifest by behavioral changes accessible to phenotyping and in-depth analysis. Relevance of this approach for animal models of neuropsychiatric models will be discussed.
To measure fatty acid composition, particularly whole-blood PUFA content, in acutely malnourished children and identify associations with markers of nutritional and health status.
Design:
PUFA were assessed in dried blood spots obtained from a cross-sectional study. Nutritional and health status were assessed by anthropometry, haemoglobinopathies, inflammation and blood counts.
Setting:
Cambodia.
Participants:
The study was conducted with 174 children aged 0·5–18 years with acute malnutrition.
Results:
Among total fatty acids (FA), the relative percentage of total PUFA was 20 % FA, with 14 % of the children having very low PUFA (mead acid (MA):arachidonic acid (AA) >0·02, n-6 docosapentaenoic acid:DHA >0·2 and total n-6:n-3 PUFA >10·5). Wasting was not associated with any PUFA. Stunting and low height were consistently positively associated with total PUFA and positively with n-6 PUFA. Height was positively associated with n-3 long-chain PUFA (LCPUFA). The presence of haemoglobinopathies or inflammation was positively associated with MA:AA, but not total PUFA. Elevated blood platelet counts were positively correlated with linoleic acid and appeared to be influenced by anaemia (P = 0·010) and inflammation (P = 0·002). Monocyte counts were high during inflammation (P = 0·052) and correlated positively with n-6 LCPUFA and n-3 LCPUFA.
Conclusions:
Children with acute malnutrition or stunting had low PUFA, while elevated platelets and monocytes were associated with high PUFA. In acutely malnourished children, inflammation could lead to elevated blood cell counts resulting in increased whole-blood PUFA which does not reflect dietary intake or nutritional status.
The study aimed at assessing stunting, wasting and breast-feeding as correlates of body composition in Cambodian children. As part of a nutrition trial (ISRCTN19918531), fat mass (FM) and fat-free mass (FFM) were measured using 2H dilution at 6 and 15 months of age. Of 419 infants enrolled, 98 % were breastfed, 15 % stunted and 4 % wasted at 6 months. At 15 months, 78 % were breastfed, 24 % stunted and 11 % wasted. Those not breastfed had lower FMI at 6 months but not at 15 months. Stunted children had lower FM at 6 months and lower FFM at 6 and 15 months compared with children with length-for-age z ≥0. Stunting was not associated with height-adjusted indexes fat mass index (FMI) or fat-free mass index (FFMI). Wasted children had lower FM, FFM, FMI and FFMI at 6 and 15 months compared with children with weight-for-length z (WLZ) ≥0. Generally, FFM and FFMI deficits increased with age, whereas FM and FMI deficits decreased, reflecting interactions between age and WLZ. For example, the FFM deficits were –0·99 (95 % CI –1·26, –0·72) kg at 6 months and –1·44 (95 % CI –1·69; –1·19) kg at 15 months (interaction, P<0·05), while the FMI deficits were –2·12 (95 % CI –2·53, –1·72) kg/m2 at 6 months and –1·32 (95 % CI –1·77, –0·87) kg/m2 at 15 months (interaction, P<0·05). This indicates that undernourished children preserve body fat at the detriment of fat-free tissue, which may have long-term consequences for health and working capacity.
Authigenic quartz overgrowths and hydrothermal quartz crystals from locations in Oman and Switzerland have been investigated with SIMS, EPMA, SEM-CL and SEM-CC. All techniques reveal similar zonation patterns with SEM-CL having the best resolution followed by SEM-CC, EPMA and finally SIMS. The observed zonations reflect chemical and/or physical changes during growth in the precipitation environment or disequilibrium precipitation at the crystal surface (i.e. sectoral and intrasectoral zonation). Based on the total Al content, two types of authigenic quartz are distinguishable. When the Al concentration is <500 μg g–1 the predominant CL emission is at ~630 nm; in such quartzes, SEM-CL and SEM-CC are directly correlated, and signal intensities drop as a function of increasing Al concentration. In contrast, authigenic quartz with Al concentrations between 500 μg g–1 and 1000 μg g–1 has CL emission maxima at both ~630 nm and ~380—400 nm, at which point the panchromatic SEM-CL and SEM-CC intensities become decoupled.
Over the past decade, NASA, under a succession of rotary-wing programs, has been moving towards coupling multiple discipline analyses to evaluate rotorcraft conceptual designs. Handling qualities is one of the component analyses to be included in such a future Multidisciplinary Analysis and Optimization framework for conceptual design of Vertical Take-Off and Landing (VTOL) aircraft. Similarly, the future vision for the capability of the Concept Design and Assessment Technology Area of the U.S Army Aviation Development Directorate also includes a handling qualities component. SIMPLI-FLYD is a tool jointly developed by NASA and the U.S. Army to perform modelling and analysis for the assessment of the handling qualities of rotorcraft conceptual designs. Illustrative scenarios of a tiltrotor in forward flight and a single-main rotor helicopter at hover are analysed using a combined process of SIMPLI-FLYD integrated with the conceptual design sizing tool NDARC. The effects of variations of input parameters such as horizontal tail and tail rotor geometry were evaluated in the form of margins to fixed- and rotary-wing handling qualities metrics and the computed vehicle empty weight. The handling qualities Design Margins are shown to vary across the flight envelope due to both changing flight dynamics and control characteristics and changing handling qualities specification requirements. The current SIMPLI-FLYD capability, lessons learned from its use and future developments are discussed.
To assess the impact of the acute-phase response (APR) during inflammation on Fe, Zn and vitamin A biomarkers to allow accurate evaluation of micronutrient status in populations.
Design
Ferritin (FER), soluble transferrin receptor (TfR), retinol-binding protein (RBP), Zn, α1-acid glycoprotein and C-reactive protein concentrations were measured. Correction factors (CF) for each biomarker were calculated as the ratio for groups at different stages of inflammation v. the reference group without inflammation.
Setting/Subjects
Senegalese (n 594) and Cambodian schoolchildren (n 2471); Cambodian women of reproductive age (n 2117).
Results
TfR was higher during the incubation phase (CF=1·17) and lower during early and late convalescence (CF=0·87 and 0·78). FER was higher during all phases (CF=0·83, 0·48 and 0·65, respectively). RBP was higher during incubation (CF=0·88) and lower during early convalescence (CF=1·21). No effect of inflammation on Zn status was found.
Conclusions
Inflammation led to overestimation of Fe status and underestimation of vitamin A status. The response of the biomarker for vitamin A status to inflammation depended on the vitamin A status of the populations. Surprisingly, the assessment of Zn status was hardly affected by inflammation. Different phases of the APR had opposite effects on the assessment of Fe status using TfR. More research is needed to define the correct methods to adjust for inflammation in nutritional studies.