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Decisions often involve a sequence of acts, events, and outcomes. First comes the act of making the decision and implementing it. Next comes the event which is out of the control of the decision maker. Following that is the outcome, which is a result of the decision made and the event that followed. Depending on the details of the situation, second, third, or more act-event-outcome sequences may follow the first.
Decision trees are a means to logically layout the structure and architecture of single- or multiple-sequence decisions. Decision trees produce prescriptive solutions to multi-stage decisions and indicate in advance the optimum strategy to be taken and optimal decisions to be made based on unfolding events.
Psychosocial treatments are central to effective delivery of Child and Adolescent Mental Health Services (CAMHS), with a strong evidence base for a range of interventions targeting many of the common and complex mental health presentations in children and young people. Practitioner knowledge of the range of psychosocial interventions offered by CAMHS is fundamental to making informed, shared decisions with children, young people and families about their care. In addition knowledge of how psychosocial interventions need to be adapted to meet the needs of diverse populations is central to ensuring equity of access.Demand for services will continue to increase, along with increasing complexity and severity for many children and young people, and services must ensure that they continue to offer a range of psychosocial interventions, tailored to individual need and choice, delivered by a well-trained workforce, with effective means to demonstrate outcomes. Transformation models such as THRIVE will be instrumental in ensuring that access to psychosocial intervention is broadened beyond existing services, supporting others in community and education settings to offer earlier intervention, greater choice and diversity and ensure that CAMHS is able to deliver specialist treatments to those who can benefit the most.
We examined cognitive performance in children with complicated mild-severe traumatic brain injury (TBI) versus orthopedic injury (OI) using the National Institutes of Health Toolbox Cognitive Battery (NIH TB-CB).
Method:
We recruited children ages 3–18, hospitalized with complicated mild-severe TBI (n = 231) or orthopedic injury (OI, n = 146). Cognition was assessed using the NIH TB-CB at six and twelve months post-injury. We used linear mixed models to assess associations of injury group (TBI versus OI), timepoint (six versus twelve months), and the interaction of injury group and timepoint with NIH TB-CB Total Cognition, Fluid Cognition, and Crystallized Cognition composites, adjusted for sex and socioeconomic status (SES), with Bonferroni correction. We evaluated differences in cognition stratified by injury severity (complicated mild–moderate TBI vs severe TBI) using ANCOVA, adjusting for sex and SES.
Results:
Neither injury group nor the interaction of group and timepoint were associated with Total (group: p = 0.50; timepoint*group: p = 0.185), Fluid (group: p = 0.297; timepoint*group: p = 0.842), or Crystallized Cognition (group: p = 0.039; timepoint*group: p = 0.017). However, children with severe TBI performed significantly worse on Fluid and Total Cognition than children with complicated mild–moderate TBI at six months (Fluid: p = 0.004, partial η2 = 0.06, moderate effect, Total: p = 0.012 partial η2 = 0.03, small–moderate effect) and twelve months post-injury (Fluid: p < 0.001, partial η2 = 0.11, moderate–large effect, Total: p = 0.002, partial η2 = 0.06, moderate effect).
Conclusions:
The NIH TB-CB detects worse cognitive functioning in children with severe TBI six-twelve months post-injury, largely driven by differences in Fluid Cognition. Our findings suggest the NIH TB-CB may be suitable for monitoring cognition in children with TBI.
Here, the significance of mandates is shown for the initiation, pursuit, and outcome of mediation, as demonstrated by the Nordic cases of mediation from the past seventy-five years. Mandates influence the selection of mediator, but we argue that mediators can influence the mandate and develop it, within the confines set by the warring parties and the mandator. Some mandates are vague, which can allow space for the mediator, and mandates may change over time. Either way, they are important for the pursuit and outcome of the mediation. Five general conclusions are proposed for research and practice, including the mismatch between mandates and support for mediation efforts. In particular, the chapter emphasizes the utility of the mediation staircase for assessing outcomes. It also encourages the study of non-Nordic cases of mediation.
This study aimed to compare the outcome of the standard trans-cervical approach and modified trans-cervical approach regarding cosmesis and complications outcomes in a tertiary hospital in Nigeria.
Methods
In this study, 25 patients with submandibular salivary gland lesions adjudged not to be malignant neoplasia were included. They were randomised into the two groups by balloting method.
Results
Twelve (48 per cent) patients had the traditional transcervical approach while 13 (52per cent) had the modified approach. There was no statistically significant difference between the groups in terms of general complication, transient paresthesia and wound infection (p > 0.05). The presence of a non-visible scar was reported in almost 85 per cent of patients in the modified trans-cervical approach group compared to 50 per cent in the standard trans-cervical approach group.
Conclusions
Though by observation the modified trans-cervical approach was superior to the standard trans-cervical approach, the differences were statistically insignificant.
Chapter 23 synthesizes the information presented in the book to explain why tenure matters not only for the current and aspiring faculty who are directly impacted by it, but for the students, parents, administrators, politicians, and citizens who may think that tenure is the peculiar concern of professors. The chapter also draws on higher education expenditure statistics to show why arguments sounding in budgetary shortfalls are inadequate justifications for reductions in tenure-stream employment.
Politics is an inevitable feature of organisational life, particularly in large bureaucratic organisations such as hospitals or government departments. Political activities arise when there is a lack of consensus about how an organisation should be managed. They are typically employed to reconcile these divergent interests, which may be the result of competition for resources within the organisation, the pursuit of personal goals by individuals or a high level of uncertainty within the organisation.
To estimate the coexistence of autism spectrum disorder (ASD) traits in an adult sample diagnosed with attention-deficit/hyperactivity disorder (ADHD); to compare individuals with ASD traits to those without, in terms of functionality, quality life and clinical outcomes; to explore the effects of ADHD medication on three main outcomes (clinical, quality of life, and functionality) in those with only ADHD and in those with coexistence of ASD and ADHD
Methods:
Prospective longitudinal study of an adult sample diagnosed with ADHD. Data were collected on age, gender, medications and on scales: Autism Spectrum Quotient (AQ-10); Adult ADHD Clinical Outcome Scale; Adult ADHD Quality of Life Questionnaire; Weiss Functional Impairment Rating Scale.
Results:
A sample of 165 participants was recruited. The AQ-10 showed that almost half, n = 74 (44.8%) of the participants had traits of ASD. Longitudinal analyses demonstrated that people with ADHD and ASD traits have worse clinical outcomes, quality of life, social skills, and family functioning, compared to those with ADHD only.
Conclusions:
The study shows a high rate of co-existence of ASD in adults with ADHD. Comorbid ASD traits were associated with poorer overall clinical and functional outcomes, quality of life, social skills, and family functioning. Study limitations with particular reference to dropout rate are considered. Implications for improving services are discussed.
Efficacy of gastric inlet patch (GIP) ablation using argon plasma coagulation (APC) for patients presenting with persistent throat symptoms was evaluated.
Methods
Retrospective observational study from a single university hospital. Consecutive patients who had GIP ablation for persistent throat symptoms between 01/10/2018-31/10/2023 were reviewed and patients who met all of the set inclusion and exclusion criteria were included in this study for analysis.
Results
50% (n = 18/36) of patients responded to APC ablation (median follow-up 3 months) with their post-ablation GETS score decreasing by 30-100%. Long-term follow-up results could be obtained from 22 patients (n = 22/36) and 75% (n = 9/12) had their clinical effects maintained (median follow-up 4.5 years; range 2.7–5.8 years).
Conclusion
GIP ablation can be a very effective treatment for patients with persistent throat symptoms with its therapeutic effects long-lasting. Future studies should focus on evaluating the optimal patient selection process for GIP ablation for persistent throat symptoms.
Transcatheter pulmonary valve implantation has emerged as a minimally invasive and preferred therapeutic option for patients with dysfunction of previously repaired right ventricular outflow tracts. The Myval™ Octacor valve is a new device designed for this purpose, though limited reports exist regarding its use in the pulmonary position.
Aims:
To report the immediate and short-term outcomes of percutaneous pulmonary valve implantation using the Myval™ Octacor valve in patients with severe right ventricular–pulmonary artery conduit or pulmonary valve bioprosthesis dysfunction.
Methods:
This was a single-centre retrospective review of data obtained from case files.
Results:
The Myval™ Octacor valve was used in ten patients with a mean age of 34.5 ± 7.4 years. The median procedure duration and fluoroscopy time were 146 minutes and 30.5 minutes, respectively. The median Z-score for valves used was −0.5. The median right ventricular systolic pressure decreased from 68.5 mmHg pre-procedure to 33 mmHg post-procedure. The median peak instantaneous gradient across the right ventricular outflow tract or conduit decreased from 30 mmHg to 6.5 mmHg. There were no reported incidences of frame fracture, conduit rupture, device embolisation, or endocarditis.
Conclusion:
This is the first UK experience of using the new-generation Myval™ Octacor valve in percutaneous pulmonary valve implantation. The results demonstrate the valve’s safety and clinical efficacy, with favourable outcomes in terms of procedural success, haemodynamic improvement, and echocardiographic findings.
Understanding the factors influencing alcohol use disorder (AUD) treatment outcomes is essential. More knowledge about patient characteristics that predict treatment outcomes can help personalise interventions, improve treatment planning and address the needs of specific subgroups. The frequency of treatment attendance may also affect drinking outcomes after treatment. Despite research efforts, uncertainty remains about how patient factors and treatment attendance influence treatment outcomes.
Aims
To examine how patient factors and treatment attendance predict high- or low-risk drinking at the end of treatment.
Method
We used data (N = 92) from a multisite observational study of treatment-seeking individuals with AUD attending group treatment. Sociodemographic measures, alcohol and substance use measures, cognitive functioning, psychological distress, personality functioning and quality of life were screened in univariate analyses. Significant variables were entered into a binary logistic regression model.
Results
Individuals with a higher percentage of treatment attendance (odds ratio 0.96 [95% CI 0.93, 0.96]) and with greater responsiblity scores on the Severity Indices of Personality Functioning (odds ratio 0.30 [95% CI 0.14, 0.64]) had a decreased likelihood of high-risk drinking at treatment end. Substance use, psychological distress and cognitive functioning were not associated with drinking levels at the end of treatment.
Conclusion
A higher percentage of treatment attendance has a minor effect on drinking levels. Being more responsible, as reflected in higher scores on the responsibility domain, reduces the likelihood of high-risk drinking at the end of treatment. Clinicians are encouraged to screen and assess personality functioning when planning treatment for individuals with AUD.
Roger was a 60-year-old man living with both HIV and schizophrenia who was admitted to the hospital for treatment of a chronic obstructive pulmonary disease exacerbation. He was referred to the psychiatry consultation-liaison team due to persistent psychotic symptoms that had not responded to multiple antipsychotic trials. Roger’s psychiatric history revealed a diagnosis of schizophrenia in early adulthood, marked by hallucinations and delusions of grandeur. Over the next 4 decades, he cycled through jails, prisons, shelters, and periods of homelessness. Though intermittently connected with outpatient care, his illness remained poorly controlled.
Improving Access to Psychological Therapies (IAPT), an NHS England service providing talking therapies, is meeting its target recovery rate of 50%. However, engagement in treatment, as well as recovery rates, may be lower for some groups.
Aims
To assess variation in treatment completion and recovery rates by demographic and socioeconomic group and to describe rates of further referrals for patients to IAPT and secondary mental health services.
Method
Using 121 548 administrative records for 2019–2020 and 2022–2023 for the Norfolk and Waveney area, we estimated associations of age, gender, ethnicity and deprivation with the likelihood of treatment completion and recovery using logistic regression modelling. We also described rates of further referrals.
Results
Younger people and those living in deprived areas were less likely to recover or complete treatment, with those aged 16–17 years (n = 735) having the lowest adjusted odds for recovery (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6) compared with those aged 36–70 years, and those aged 18–24 years (n = 23 563) having the lowest rate of completion (adjusted odds ratio = 0.5, 95% CI: 0.5–0.6). Further referrals before April 2022 were recorded for 45.4% of 6513 patients who had completed treatment and 68.8% of 9469 who had not completed treatment, and for 39.4% of 2007 recovered patients in 2019–2020 and 53.1% of 1586 who had not recovered. Non-completers had relatively more further referrals to secondary mental health services compared with completers (43.6% v. 22.8%; P < 0.01).
Conclusions
Younger people and those living in deprived areas have lower recovery and completion rates. Those who have completed treatment and not recovered have higher rates of further referrals.
Predicting long-term outcome trajectories in psychosis remains a crucial and challenging goal in clinical practice. The identification of reliable neuroimaging markers has often been hindered by the clinical and biological heterogeneity of psychotic disorders and the limitations of traditional case-control methodologies, which often mask individual variability. Recently, normative brain charts derived from extensive magnetic resonance imaging (MRI) data-sets covering the human lifespan have emerged as a promising biologically driven solution, offering a more individualised approach.
Aims
To examine how deviations from normative cortical and subcortical grey matter volume (GMV) at first-episode psychosis (FEP) onset relate to symptom and functional trajectories.
Method
We leveraged the largest available brain normative model (N > 100 000) to explore normative deviations in a sample of over 240 patients with schizophrenia spectrum disorders who underwent MRI scans at the onset of FEP and received clinical follow-up at 1, 3 and 10 years.
Results
Our findings reveal that deviations in regional normative GMV at FEP onset are significantly linked to overall long-term clinical trajectories, modulating the effect of time on both symptom and functional outcome. Specifically, negative deviations in the left superior temporal gyrus and Broca’s area at FEP onset were notably associated with a more severe progression of positive and negative symptoms, as well as with functioning trajectories over time.
Conclusions
These results underscore the potential of brain developmental normative approaches for the early prediction of disorder progression, and provide valuable insights for the development of preventive and personalised therapeutic strategies.
Older adults are more likely to develop delirium with COVID-19 infection. This cross-sectional cohort study was designed to explore the risk factors of delirium in hospitalized older adults with COVID-19 and to evaluate whether delirium is an independent predictor of mortality in this cohort of patients.
Methods:
Data were collected through a retrospective clinical chart review of patients aged 65 years or older who were admitted to St. James’s Hospital between March 2020 and 2021 who tested positive for SARS-CoV-2 infection.
Results:
A total of 261 patients (2.8 % of total admissions 65 years or older) were included in this study. Patients who developed delirium were older (80.8 v. 75.8 years, p < 0.001), more likely to have pre-existing cognitive impairment (OR = 3.97 [95% CI 2.11–7.46], p < 0.001), and were more likely to be nursing home residents (OR = 12.32 [95% CI 2.54–59.62], p = 0.0018). Patients who developed delirium had a higher Clinical Frailty score (mean 5.31 v. 3.67, p < 0.001) and higher Charlson Co-morbidity index (mean 2.38 v. 1.82, p = .046). There was no significant association between in-hospital mortality and delirium in the patient cohort (p = 0.13). Delirium was associated with longer hospital stay (40.5 days v. 21 days, P = 0.001) and patients with delirium were more likely to be discharged to nursing homes or convalescence instead of home (OR = 8.46 [95% CI 3.60–19.88], p < 0.001).
Conclusions:
Delirium is more likely to occur in COVID-19 patients with pre-existing risk factors for delirium, resulting in prolonged admission and functional decline requiring increased support for discharge.
In the study approaches we have looked at, the main purpose of investigation has been to understand and quantify relationships – relationships between exposures and outcomes, or between interventions and effects. And, just like the common plot line of a romantic tale, in this chapter we will consider how we can work out if those relationships are the ‘real deal’. How do we know we have measured what we think we have (is this really love?) and how much of the effect we have measured is entirely due to the exposure or intervention (or just a holiday thing)?
As we progress through this part and the next, you will be introduced to the different ways in which epidemiologists go about analysing the factors that are associated with people becoming ill or getting better. Each of these has a role to play in building up our knowledge about what influences human health. Our objective here is to provide an overview of the range of techniques that are available and to develop your understanding of which of these might be more appropriate in any given situation. One way to think about these techniques is as a set of tools for tackling a range of problems, much as a carpenter has a box full of tools for tackling different aspects of building a house. No one tool is useful in every situation, and some are more useful at certain stages of the construction process than others. Some even have features that make them useful in a variety of situations. Of course, context is everything, so even when a tool might not look like it’s the ‘right’ one in a particular situation, if the results are robust and reliable then that might be all that matters.
This study investigates the seasonal and regional distribution of paediatric laryngomalacia admissions in the United States, hypothesizing higher admission rates in winter and colder regions due to reduced sunlight exposure affecting vitamin D levels.
Methods
We analyzed data from the 2016 Kids’ Inpatient Database (KID), focusing on children under three years old. Laryngomalacia cases were identified using International Classification of Diseases and Related Health Problems 10th Revision (ICD-10) code Q31.5. Seasonal and regional differences in admission rates were assessed using Pearson’s chi-squared test, with a significance level of p less than 0.05.
Results
Of 4,512,196 estimated national admissions, 11,638 were due to laryngomalacia. Admissions increased by 10.0 per cent in winter and decreased by 10.9 per cent in summer (p < 0.005). Regionally, admissions were higher in the Midwest/Central (18.6 per cent) and Northeast (9.3 per cent) and lower in the South (7.4 per cent) and West (11.1 per cent) (p < 0.005).
Conclusion
Laryngomalacia admissions are significantly influenced by seasonal and regional factors, likely related to environmental conditions affecting vitamin D synthesis.
We use healthcare in an effort to live longer or feel better. Yet many evaluations do not consider these outcomes, which are of high importance to patients. Instead, they concentrate on variables that are considered surrogates for what treatment is attempting to achieve. Prevention of heart disease, for example, might be estimated from changes in LDL cholesterol levels. These surrogate markers are often poorly correlated with the outcomes of most importance to patients. Understanding the basic biological mechanisms is valuable, but sometimes irrelevant. The chapter reviews patient-reported outcomes that are becoming more commonly used to evaluate health care. These measures are used to create indexes that combine how long people live with the quality of life during the years that precede death. The measures are generic and can be used to compare the value of investing in interventions that have different specific objectives. Cost-effectiveness analysis can directly compare health gain associated with treatments as different as exercise training versus organ transplantation. The public policy implications associated with these metrics are discussed.
The current study examines the application of the Pediatric-Buccal-Epigenetic (PedBE) clock, designed for buccal epithelial cells, to endothelia. We evaluate the association of PedBE epigenetic age and age acceleration estimated from human umbilical vein endothelial cells (HUVECs) with length of gestation and birthweight in a racially and ethnically diverse sample (analytic sample n = 333). PedBE age was positively associated with gestational age at birth (r = 0.22, p < .001) and infant birth weight (r = 0.20, p < .001). Multivariate models revealed infants with higher birth weight (adjusted for gestational age) had greater PedBE epigenetic age acceleration (b = 0.0002, se = 0.0007, p = 0.002), though this effect was small; findings were unchanged excluding preterm infants born before 37 weeks’ gestation. In conclusion, the PedBE clock may have application to endothelial cells and provide utility as an anchoring sampling point at birth to examine epigenetic aging in infancy.