"I must make the grade!": the role of cognitive appraisals, irrational beliefs, exam anxiety, and affect, in the academic self-concept of undergraduate students.

BACKGROUND AND OBJECTIVES: Examination anxiety is a common occurrence, and is potentially detrimental to student attainment. In recent theorizing, it has been suggested that cognitive appraisals, as put forth in cognitive appraisal theory, and irrational beliefs, as put forth in rational emotive behavior therapy, may interact to predict affectivity. The current research examines the antecedents and associates of examination affect and academic self-concept in undergraduate students. DESIGN: A preliminary study applied confirmatory factor analysis (CFA) to test the factor structure of an irrational beliefs inventory. Study 1 utilized a cross-sectional and correlational approach to testing core theoretical assumptions. Study 2 took a two-wave longitudinal and path analytical approach to examine temporal effects between target variables. METHOD: All self-report data collection took place in the United Kingdom with university students. We recruited n = 1150, n = 362, n = 662 for preliminary, study 1, and study 2, respectively. RESULTS: Across studies, data indicated that a pattern of adaptive cognitive appraisal was associated with more advantageous affectivity, and better academic self-concept. CONCLUSIONS: Reciprocal temporal relationships were revealed between many variables, supporting an interactive and bidirectional view of how cognition and affect are related pertaining to examination anxiety.

Executive function in children with sickle cell anemia on transfusion: NIH toolbox utility in the clinical context.

Objective: The aim of this study was to establish the utility of the NIH Toolbox as a cognitive screener of executive functions in the clinical context. Additionally, we aimed to investigate whether age and time on transfusion were related to executive function performance. Method: Twenty-eight children and adolescents with sickle cell anemia (SCA) between 8 and 18 years (M = 13.28, SD = 3.05) on transfusion treatment were included. Participants completed five NIH Toolbox tasks (three executive function tasks and two non-executive function control tasks). Results: Mean scores on one of the three executive function measures (inhibitory control) fell below the average range (M = 81.36, SD = 14.01) with approximately 70% of children from both groups below the average range. Scores for processing speed (M = 86.82, SD = 22.01) and cognitive flexibility (M = 85.75, SD = 12.67) were low averages. As expected, scores on non-executive measures (language and memory) fell within the average range. No significant differences were observed between children with silent stroke and no stroke on executive function measures. Older age (p < .01) and length of time on transfusion (p < .05) predicted lower inhibitory control scores. Conclusions: Findings provide evidence for poor development of inhibitory control with age in this patient population. As the NIH Toolbox successfully highlighted expected deficits in this patient population, this study supports the use of this tool as a brief screening measure for children with SCD. The clinical and theoretical implications of the findings are discussed.

The Development of a National Paediatric Psycho-Oncology Service.

Aims To investigate the psychological care provided to children and young adolescents with cancer and their families within the National Children's Cancer Service (NCCS), Ireland, in respect of the national and international standards of care. Methods A retrospective audit of 316 referrals made over 32 months by the NCCS to the psychology service in malignant haematology and oncology was performed. Results The audit revealed that out of 316 patients, a yearly average of 189 (50%) of urgently referred patients received psychological support within the NCCS between January 2013 and August 2016. Furthermore only 20 (22%) undergoing haematopoietic stem cell transplantation (HSCT), 14 (22%) referred to the paediatric palliative care team, and 84 (62%) of teenage patients received psychological input during this timeframe. Conclusion The audit revealed that the current psychology service provision is failing to meet the international standards of care. Due to the data provided by this audit, in conjunction with a clinical risk assessment of the service, funds for the post of principal psychologist have been secured. Further psychology posts (HSCT, late-effects and neuropsychology), and development of the psycho-oncology model of care are required to ensure equality of access and evidence-based psychological care for all children with cancer.

The economic cost of nonepileptic attack disorder in Ireland.

The present study endeavored to calculate a conservative estimate of both incidence- and prevalence-based costs of nonepileptic attack disorder (NEAD) in Ireland by applying previously identified prevalence figures to Irish population figures. Variables related to the economic cost of NEAD were identified based on a retrospective chart review of patients diagnosed with NEAD at Beaumont Hospital, Dublin. The annual cost per patient of undiagnosed NEAD was calculated as €20,995.30. The combined cost of diagnosis and psychological treatment of NEAD was estimated at €8728. Although it is difficult to determine precise economic costings, early diagnosis and intervention would result in a significant economic saving to the exchequer, a reduction in hospital waiting-list times, and a better prognosis for patients.

Deep brain stimulation in ireland for Parkinson's disease and essential tremor.

Deep brain stimulation (DBS) is highly effective neurosurgery for idiopathic Parkinson's disease (IPD), essential tremor (ET) and primary dystonia. DBS involves stereotactic surgical implantation of a battery-operated stimulator into deep brain nuclei. Irish patients are referred abroad for DBS and have to travel repeatedly for pre and post-operative care resulting in stress, anxiety and hardship. Safe pre and post-operative care of these complex, ageing patients is compromised by the absence of a DBS service in Ireland. Moreover, both DBS surgery and the subsequent post-operative care abroad incurs substantial cost to the state. The Dublin Neurological Institute at the Mater Misericordiae University Hospital (DNI) is a non-profit institute for the care of patients with neurological diseases. The DNI developed, in collaboration with the Mater Private Hospital (MPH) and the Walton Centre, Liverpool, a DBS programme in 2008/2009. We performed DBS at the Mater Campus on three carefully selected patients from a cohort of movement disorder patients attending the DNI and continue to provide pre-operative assessment and post operative care for patients following DBS in Ireland and abroad.

Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation.

BACKGROUND AND PURPOSE: Antithrombotic therapy can prevent strokes and transient ischemic attacks (TIAs) in carefully selected patients who have chronic nonvalvular atrial fibrillation (NVAF). Our objectives were 3-fold: to document the use of warfarin and aspirin therapy in Missouri Medicare beneficiaries with chronic NVAF; to identify factors associated with warfarin and aspirin underuse; and to determine the association between prescription of warfarin and aspirin at hospital discharge and adverse outcomes in this elderly, frail population. METHODS: We linked chart reviews from all Missouri hospitals to Medicare claims data from 1993 to 1996. From chart reviews, we documented Medicare beneficiaries' demographic factors, comorbid conditions, and antithrombotic therapy prescribed at the time of hospital discharge. From Medicare claims, we determined the date of outcomes-death from any cause or hospitalization for an ischemic event (a stroke, a TIA, or a myocardial infarction). RESULTS: Only 328 (55%) of the 597 Medicare beneficiaries were prescribed antithrombotic therapy at hospital discharge: 34% received warfarin and 21% received aspirin. Advanced age, female gender, and rural residency predicted underuse of antithrombotic therapy. After controlling for these factors, as well as stroke risk factors and contraindications to anticoagulation, the prescription of warfarin was associated with a 24% relative risk reduction (RRR) in adverse outcomes (P=0.003). Prescription of aspirin was associated with a nonsignificant 5% RRR in these events (P=0.56). CONCLUSIONS: The underuse of antithrombotic therapy in Medicare beneficiaries who have NVAF is associated with measurable adverse outcomes. The benefit of warfarin therapy may extend to frail, elderly patients, a group that was excluded from randomized controlled trials. The role of antiplatelet therapy in this population deserves further study because many of these patients have relative contraindications to warfarin.

Underutilization of antithrombotic therapy in elderly rural patients with atrial fibrillation.

BACKGROUND: Antithrombotic agents are underutilized in elderly patients with atrial fibrillation. In a peer-review audit of antithrombotic use in Missouri, rural patients were given antithrombotic therapy less often than rural patients for unclear reasons. METHODS AND RESULTS: The charts of 597 hospitalized Medicare patients discharged between October 1, 1993, and December 31, 1994, from urban and rural hospitals in Missouri were reviewed. In addition to antithrombotic therapy prescribed at the time of discharge, patient and physician information, relative contraindications to antithrombotic therapy, and risk factors for stroke were identified. Rural and urban patients were similar in terms of age, sex, and risk factors for stroke. At least one stroke risk factor was noted in 87% of rural patients and in 84% of urban patients. Urban patients were more likely to have a relative contraindication to antithrombotic therapy compared with rural patients (66% vs 54%, P =.04) but received antithrombotic therapy more often (58% vs 47%, P =.02). Cardiologists prescribed antithrombotic therapy significantly more often than noncardiologists (69% vs 52%, P =.003). CONCLUSIONS: Elderly rural patients with atrial fibrillation receive antithrombotic therapy less frequently than urban patients despite having a similar high-risk profile and fewer relative contraindications. Primary care physicians prescribe antithrombotic therapy less often than cardiologists, which is one of the reasons for this underutilization.

Perioperative antibiotics in nonemergency bowel surgery: a quality improvement project.

BACKGROUND: Guideline development has received considerable attention recently; guideline implementation less. For various reasons, reports of guideline implementations are not common in the published literature. In this paper, we report the results of a multisite quality improvement project undertaken as part of Health Care Financing Administration's Heath Care Quality Improvement Program. METHODS: Six acute care hospitals were selected for participation according to the number of procedures during the calendar year 1993. Baseline and postintervention data were abstracted from the medical records of patients having bowel surgery. Performance feedback, education, and process improvement facilitation were the principal interventions used by the investigators; quality improvement plans varied by participant. Baseline and postintervention indicators were calculated. RESULTS: Statistically significant and practically meaningful improvement was observed in the primary indicator and in 4 of 11 subindicators. Conservative estimates indicated modest cost savings. CONCLUSIONS: Administration of perioperative antibiotics in bowel surgery can be improved by guideline implementations based on a continuous quality improvement model.

Influenza immunization cooperative project.

During the 1994 flu season, the Missouri Patient Care Review Foundation (MPCRF) began working on a systems-oriented, hospital-focused influenza immunization project for the 1995-96 flu season with four acute care hospitals. The results of the project indicate that a combination of hospital policies, nurse-driven standing order protocols for immunization, and emphasis on beneficiary education resulted in the highest rate of influenza vaccination.

Opportunities for improving the care of patients with community-acquired pneumonia.

In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia.

The Occupational Health Partnership Program: a new paradigm for occupational health services.

For a variety of reasons, occupational health services at Army Material Command installations became severely strained during the 1980s. The Occupational Health Partnership Program, developed to improve this support, describes control, responsibility, and cost sharing between Army Materiel Command and Army Medical Command. This innovative approach is finding new solutions to challenging problems. The authors describe the history, principles, status, and possible future of the partnership program.

Model systems for detecting the hepatic toxicity of pyrrolizidine alkaloids and pyrrolizidine alkaloid N-oxides.

Indicine N-oxide (INO) is a pyrrolizidine alkaloid (PA) with antitumor activity in animals and humans. Prior studies showed that despite the known hepatic toxicity of the PAs, INO did not produce hepatic toxicity in animals but caused unpredictable lethal hepatic toxicity in humans. In this study we have attempted to find a model system for predicting the hepatotoxic potential of antitumor PAs. Primary cultures of rat hepatocytes showed toxicity only with the most hepatotoxic PAs such as lasiocarpine, but did not detect toxicity with other PAs. Subchronic intraperitoneal administration of PAs to weanling rats and adult mice produced, in surviving animals, hepatic megalocytosis and centrilobular necrosis with heliotrine (H) and 9-O-(R(-)-2-(4'-chlorophenyl)-2-hydroxybutyryl)retronecine N-oxide (RC1NO) but only megalocytosis with INO. Thus, despite previous reports, weanling rats offered no advantage over adult mice for detecting significant hepatic toxicity with PAs. Phenobarbital pretreatment of the mice did not increase the hepatic toxicity of any of the PAs. Subchronic oral administration of PAs to adult mice produced hepatic megalocytosis and centrilobular necrosis in surviving animals with H and RC1NO and megalocytosis with INO. Animals that died acutely following oral administration of INO showed hepatic centrilobular necrosis. Administration of several courses of INO intravenously to dogs produced histological evidence of centrilobular hemorrhagic necrosis. It is concluded that there is no single animal model that will predict hepatic toxicity of the type seen in humans with the antitumor PAs. A combination of studies using adult mice and dogs and lethal doses of the PAs offers the best way of detecting potential hepatic toxicity.