Implementing and Evaluating a National Integrated Digital Registry and Clinical Decision Support System in Early Intervention in Psychosis Services (Early Psychosis Informatics Into Care): Co-Designed Protocol.

BACKGROUND: Early intervention in psychosis (EIP) services are nationally mandated in England to provide multidisciplinary care to people experiencing first-episode psychosis, which disproportionately affects deprived and ethnic minority youth. Quality of service provision varies by region, and people from historically underserved populations have unequal access. In other disease areas, including stroke and dementia, national digital registries coupled with clinical decision support systems (CDSSs) have revolutionized the delivery of equitable, evidence-based interventions to transform patient outcomes and reduce population-level disparities in care. Given psychosis is ranked the third most burdensome mental health condition by the World Health Organization, it is essential that we achieve the same parity of health improvements. OBJECTIVE: This paper reports the protocol for the program development phase of this study, in which we aimed to co-design and produce an evidence-based, stakeholder-informed framework for the building, implementation, piloting, and evaluation of a national integrated digital registry and CDSS for psychosis, known as EPICare (Early Psychosis Informatics into Care). METHODS: We conducted 3 concurrent work packages, with reciprocal knowledge exchange between each. In work package 1, using a participatory co-design framework, key stakeholders (clinicians, academics, policy makers, and patient and public contributors) engaged in 4 workshops to review, refine, and identify a core set of essential and desirable measures and features of the EPICare registry and CDSS. Using a modified Delphi approach, we then developed a consensus of data priorities. In work package 2, we collaborated with National Health Service (NHS) informatics teams to identify relevant data currently captured in electronic health records, understand data retrieval methods, and design the software architecture and data model to inform future implementation. In work package 3, observations of stakeholder workshops and individual interviews with representative stakeholders (n=10) were subject to interpretative qualitative analysis, guided by normalization process theory, to identify factors likely to influence the adoption and implementation of EPICare into routine practice. RESULTS: Stage 1 of the EPICare study took place between December 2021 and September 2022. The next steps include stage 2 building, piloting, implementation, and evaluation of EPICare in 5 demonstrator NHS Trusts serving underserved and diverse populations with substantial need for EIP care in England. If successful, this will be followed by stage 3, in which we will seek NHS adoption of EPICare for rollout to all EIP services in England. CONCLUSIONS: By establishing a multistakeholder network and engaging them in an iterative co-design process, we have identified essential and desirable elements of the EPICare registry and CDSS; proactively identified and minimized potential challenges and barriers to uptake and implementation; and addressed key questions related to informatics architecture, infrastructure, governance, and integration in diverse NHS Trusts, enabling us to proceed with the building, piloting, implementation, and evaluation of EPICare. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50177.

Antipsychotic Medication and Risk of Metabolic Disorders in People With Schizophrenia: A Longitudinal Study Using the UK Clinical Practice Research Datalink.

BACKGROUND AND HYPOTHESIS: Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics. STUDY DESIGN: A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose. STUDY RESULTS: Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found. CONCLUSIONS: Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study.

Childhood Trauma As a Mediator of the Association Between Autistic Traits and Psychotic Experiences: Evidence From the Avon Longitudinal Study of Parents and Children Cohort.

BACKGROUND: Little is known on whether associations between childhood autistic traits and psychotic experiences persist into adulthood and whether genetic confounding and childhood trauma influence them. Here we investigate the associations between childhood autistic traits and psychotic experiences until young adulthood and assess the influence of schizophrenia polygenic risk and childhood traumatic experiences, using the Avon Longitudinal Study of Parents and Children (ALSPAC) population-based birth cohort. STUDY DESIGN: We used a measure of broad autistic traits (autism factor mean score), and four dichotomised measures of autistic traits capturing social communication difficulties (age 7), repetitive behaviours (age 5), sociability (age 3), and pragmatic language (age 9). Psychotic experiences were assessed at ages 18 and 24 using the semi-structured Psychosis-Like Symptoms interview (PLIKSi). Traumatic experiences between ages 5 and 11 were assessed with questionnaires and interviews administered to children and parents at multiple ages. STUDY RESULTS: Broad autistic traits, as well as social communication difficulties, were associated with psychotic experiences that were distressing and/or frequent until age 24 (autism factor mean score, n = 3707: OR 1.19, 95%CI 1.01-1.39; social communication difficulties, n = 3384: OR 1.54, 95%CI 0.97-2.45). Childhood trauma mediated a substantial proportion of the identified associations (~28% and 36% respectively, maximum n = 3577). Schizophrenia polygenic risk did not appear to confound the associations. Multiple imputation analyses (maximum n = 13 105) yielded comparable results. CONCLUSIONS: Childhood trauma may be an important, potentially modifiable pathway between autistic features and later onset of psychotic psychopathology.

Developing and internally validating a prognostic model (P Risk) to improve the prediction of psychosis in a primary care population using electronic health records: The MAPPED study.

BACKGROUND: An accurate risk prediction algorithm could improve psychosis outcomes by reducing duration of untreated psychosis. OBJECTIVE: To develop and validate a risk prediction model for psychosis, for use by family doctors, using linked electronic health records. METHODS: A prospective prediction study. Records from family practices were used between 1/1/2010 to 31/12/2017 of 300,000 patients who had consulted their family doctor for any nonpsychotic mental health problem. Records were selected from Clinical Practice Research Datalink Gold, a routine database of UK family doctor records linked to Hospital Episode Statistics, a routine database of UK secondary care records. Each patient had 5-8 years of follow up data. Study predictors were consultations, diagnoses and/or prescribed medications, during the study period or historically, for 13 nonpsychotic mental health problems and behaviours, age, gender, number of mental health consultations, social deprivation, geographical location, and ethnicity. The outcome was time to an ICD10 psychosis diagnosis. FINDINGS: 830 diagnoses of psychosis were made. Patients were from 216 family practices; mean age was 45.3 years and 43.5 % were male. Median follow-up was 6.5 years (IQR 5.6, 7.8). Overall 8-year psychosis incidence was 45.8 (95 % CI 42.8, 49.0)/100,000 person years at risk. A risk prediction model including age, sex, ethnicity, social deprivation, consultations for suicidal behaviour, depression/anxiety, substance abuse, history of consultations for suicidal behaviour, smoking history and prescribed medications for depression/anxiety/PTSD/OCD and total number of consultations had good discrimination (Harrell's C = 0.774). Identifying patients aged 17-100 years with predicted risk exceeding 1.0 % over 6 years had sensitivity of 71 % and specificity of 84 %. FUNDING: NIHR, School for Primary Care Research, Biomedical Research Centre.

Parental inflammatory bowel disease and autism in children.

Evidence linking parental inflammatory bowel disease (IBD) with autism in children is inconclusive. We conducted four complementary studies to investigate associations between parental IBD and autism in children, and elucidated their underlying etiology. Conducting a nationwide population-based cohort study using Swedish registers, we found evidence of associations between parental diagnoses of IBD and autism in children. Polygenic risk score analyses of the Avon Longitudinal Study of Parents and Children suggested associations between maternal genetic liability to IBD and autistic traits in children. Two-sample Mendelian randomization analyses provided evidence of a potential causal effect of genetic liability to IBD, especially ulcerative colitis, on autism. Linkage disequilibrium score regression did not indicate a genetic correlation between IBD and autism. Triangulating evidence from these four complementary approaches, we found evidence of a potential causal link between parental, particularly maternal, IBD and autism in children. Perinatal immune dysregulation, micronutrient malabsorption and anemia may be implicated.

Precursors and correlates of transient and persistent longitudinal profiles of psychotic experiences from late childhood through early adulthood.

BACKGROUND: Psychotic experiences are reported by 5-10% of young people, although only a minority persist and develop into psychotic disorders. It is unclear what characteristics differentiate those with transient psychotic experiences from those with persistent psychotic experiences that are more likely to be of clinical relevance. AIMS: To investigate how longitudinal profiles of psychotic experiences, created from assessments at three different time points, are influenced by early life and co-occurring factors. METHOD: Using data from 8045 individuals from a birth cohort study, longitudinal profiles of psychotic experiences based on semi-structured interviews conducted at 12, 18 and 24 years were defined. Environmental, cognitive, psychopathological and genetic determinants of these profiles were investigated, along with concurrent changes in psychopathology and cognition. RESULTS: Following multiple imputations, the distribution of longitudinal profiles of psychotic experiences was none (65.7%), transient (24.1%), low-frequency persistent (8.4%) and high-frequency persistent (1.7%). Individuals with high-frequency persistent psychotic experiences were more likely to report traumatic experiences, other psychopathology, a more externalised locus of control, reduced emotional stability and conscientious personality traits in childhood, compared with those with transient psychotic experiences. These characteristics also differed between those who had any psychotic experiences and those who did not. CONCLUSIONS: These findings indicate that the same risk factors are associated with incidence as with persistence of psychotic experiences. Thus, it might be that the severity of exposure, rather than the presence of specific disease-modifying factors, is most likely to determine whether psychotic experiences are transient or persist, and potentially develop into a clinical disorder over time.

Implementing a Digital Tool to Support Shared Care Planning in Community-Based Mental Health Services: Qualitative Evaluation.

BACKGROUND: Mental health services aim to provide recovery-focused care and facilitate coproduced care planning. In practice, mental health providers can find supporting individualized coproduced care with service users difficult while balancing administrative and performance demands. To help meet this aim and using principles of coproduction, an innovative mobile digital care pathway tool (CPT) was developed to be used on a tablet computer and piloted in the West of England. OBJECTIVE: The aim of this study was to examine mental health care providers' views of and experiences with the CPT during the pilot implementation phase and identify factors influencing its implementation. METHODS: A total of 20 in-depth telephone interviews were conducted with providers participating in the pilot and managers in the host organization. Interviews were audio recorded, transcribed, anonymized, and thematically analyzed guided by the Consolidated Framework for Implementation Research. RESULTS: The tool was thought to facilitate coproduced recovery-focused care planning, a policy and organizational as well as professional priority. Internet connectivity issues, system interoperability, and access to service users' health records affected use of the tool during mobile working. The organization's resources, such as information technology (IT) infrastructure and staff time and IT culture, influenced implementation. Participants' levels of use of the tool were dependent on knowledge of the tool and self-efficacy; perceived service-user needs and characteristics; and perceptions of impact on the therapeutic relationship. Training and preparation time influenced participants' confidence in using the tool. CONCLUSIONS: Findings highlight the importance of congruence between staff, organization, and external policy priorities and digital technologies in aiding intervention engagement, and the need for ongoing training and support of those intended to use the technology during and after the end of implementation interventions.

A Population-Based Cohort Study Examining the Incidence and Impact of Psychotic Experiences From Childhood to Adulthood, and Prediction of Psychotic Disorder.

OBJECTIVE: The authors investigated the incidence, course, and outcome of psychotic experiences from childhood through early adulthood in the general population and examined prediction of psychotic disorder. METHODS: This was a population-based cohort study using the semistructured Psychosis-Like Symptoms Interview at ages 12, 18, and 24 (N=7,900 with any data). Incidence rates were estimated using flexible parametric modeling, and positive predictive values (PPVs), sensitivity, specificity, and area under the curve were estimated for prediction. RESULTS: The incidence rate of psychotic experiences increased between ages 13 and 24, peaking during late adolescence. Of 3,866 participants interviewed at age 24, 313 (8.1%, 95% CI=7.2, 9.0) had a definite psychotic experience since age 12. A total of 109 individuals (2.8%) met criteria for a psychotic disorder up to age 24, of whom 70% had sought professional help. Prediction of current psychotic disorder at age 24 (N=47, 1.2%), by both self-report and interviewer-rated measures of psychotic experiences at age 18 (PPVs, 2.9% and 10.0%, respectively), was improved by incorporating information on frequency and distress (PPVs, 13.3% and 20.0%, respectively), although sensitivities were low. The PPV of an at-risk mental state at age 18 predicting incident disorder at ages 18-24 was 21.1% (95% CI=6.1, 45.6) (sensitivity, 14.3%, 95% CI=4.0, 32.7). CONCLUSIONS: The study results show a peak in incidence of psychotic experiences during late adolescence as well as an unmet need for care in young people with psychotic disorders. Because of the low sensitivity, targeting individuals in non-help-seeking samples based only on more severe symptom cutoff thresholds will likely have little impact on population levels of first-episode psychosis.

Crisis resolution and home treatment in the UK: A survey of model fidelity using a novel review methodology.

Crisis resolution teams (CRTs) provide treatment at home to people experiencing mental health crises, as an alternative to hospital admission. Previous UK research, based on self-report surveys, suggests that a loosely specified model has resulted in wide variations in CRTs' service delivery, organization and outcomes. A fidelity scale (developed through evidence review and stakeholder consensus) provided a means of objectively measuring adherence to a model of good practice for CRTs, via one-day fidelity reviews of UK crisis teams. Reviews included interviews with service users, carers, staff and managers, and examination of data, policies, protocols and anonymized case notes. Of the 75 teams reviewed, 49 (65%) were assessed as being moderate fidelity and the rest as low fidelity, with no team achieving high fidelity. The median score was 122 (range: 73-151; inter-quartile range: 111-132). Teams achieved higher scores on items about structure and organization, for example ease of referral, medication and safety systems, but scored poorly on items about the content of care and interventions. Despite a national mandate to implement the CRT model, there are wide variations in implementation in the UK and no teams in our sample achieved overall high fidelity. This suggests that a mandatory national policy is not in itself sufficient to achieve good quality implementation of a service model. The CRT Fidelity Scale provides a feasible and acceptable means to objectively assess model fidelity in CRTs. There is a need for development and testing of interventions to enhance model fidelity and facilitate improvements to these services.

Improving the Detection of Individuals at Clinical Risk for Psychosis in the Community, Primary and Secondary Care: An Integrated Evidence-Based Approach.

Background: The first rate-limiting step for improving outcomes of psychosis through preventive interventions in people at clinical high risk for psychosis (CHR-P) is the ability to accurately detect individuals who are at risk for the development of this disorder. Currently, this detection power is sub-optimal. Methods: This is a conceptual and nonsystematic review of the literature, focusing on the work conducted by leading research teams in the field. The results will be structured in the following sections: understanding the CHR-P assessment, validity of the CHR-P as a universal risk state for psychosis, and improving the detection of at-risk individuals in secondary mental health care, in primary care, and in the community. Results: CHR-P instruments can provide adequate prognostic accuracy for the prediction of psychosis provided that they are employed in samples who have undergone risk enrichment during recruitment. This substantially limits their detection power in real-world settings. Furthermore, there is initial evidence that not all cases of psychosis onset are preceded by a CHR-P stage. A transdiagnostic individualized risk calculator could be used to automatically screen secondary mental health care medical notes to detect those at risk of psychosis and refer them to standard CHR-P assessment. Similar risk estimation tools for use in primary care are under development and promise to boost the detection of patients at risk in this setting. To improve the detection of young people who may be at risk of psychosis in the community, it is necessary to adopt digital and/or sequential screening approaches. These solutions are based on recent scientific evidence and have potential for implementation internationally. Conclusions: The best strategy to improve the detection of patients at risk for psychosis is to implement a clinical research program that integrates different but complementary detection approaches across community, primary, and secondary care. These solutions are based on recent scientific advancements in the development of risk estimation tools and e-health approaches and have the potential to be applied across different clinical settings.

Duration of untreated psychosis and clinical outcomes of first episode psychosis: An observational and an instrumental variables analysis.

AIM: Duration of untreated psychosis (DUP) is considered as a key prognostic variable in psychosis. Yet, it is unclear whether a longer DUP causes worse outcomes or whether reported associations have alternative explanations. METHODS: Data from 2 cohorts of patients with first episode psychosis were used (n = 2134). Measures of DUP were assessed at baseline and outcomes at 12 months. Regression models were used to investigate the associations between DUP and outcomes. We also investigated whether any associations were replicated using instrumental variables (IV) analysis to reduce the effect of residual confounding and measurement bias. RESULTS: There were associations between DUP per 1-year increase and positive psychotic symptoms (7.0% in symptom score increase 95% confidence interval (CI) 4.0%, 10.0%, P < .001), worse recovery (risk difference [RD] 0.78, 95%, CI 0.68, 0.83, P < .001) and worse global functioning (0.62 decrease in functioning score 95% CI -1.19, -0.04, P = .035). There was no evidence of an association with negative psychotic symptoms (1.0%, 95%, CI -2.0%, 5.0%, P = .455). The IV analysis showed weaker evidence of associations in the same direction between DUP per 1-year increase and positive psychotic symptoms, recovery and global functioning. However, there was evidence of an inverse association with negative psychotic symptoms (decrease of 15.0% in symptom score 95% CI -26.0%, -3.0%, P = .016). CONCLUSIONS: We have confirmed previous findings of a positive association between positive psychotic symptoms, global functioning and recovery and DUP using regression analysis. IV analysis shows some support for these findings. Future investigation using IV analysis should be repeated in large data sets.

Measuring Competence in Surgical Training through Assessment of Surgical Entrustable Professional Activities.

OBJECTIVE: To assess competency in surgical residents with bundled assessments using a surgical entrustable professional activity (SEPA) framework. DESIGN: A pilot study was conducted using a combination of validated assessment tools (multiple choice exam (MCE) questions from the Surgical Council on Resident Education [SCORE], the Clinical Assessment and Management Examination - Outpatient (CAMEO) form, the Virtual Surgical Patient (VSP) website, and a procedure-specific Operative Performance Rating System [OPRS]) to determine competency in surgical residents in the treatment of breast cancer and gallbladder disease, respectively. SETTING: A large academic institution with a surgical training program in the Mid West of the United States. PARTICIPANTS: A total of 10 categorical surgical residents were invited to participate. Five completed the breast surgical EPA (SEPA) and 5 different residents completed the gallbladder SEPA. RESULTS: In terms of performance on the assessments, for the breast SEPA, scores did not appear to be related to PGY level, and residents' performance in general was the least strong on the MCE and the VSP case. The gallbladder SEPA showed a more expected pattern, distinguishing between junior and senior residents. As expected, all junior residents were required to remediate the OPRS assessment, while the senior residents passed. For the OPRS, senior level residents consistently were rated as "excellent" in terms of operative flow (5/5), while junior residents were all given a score of "good" (3/5). CONCLUSIONS: Assessing competence among surgical residents has been a discussion for several years. Varying methods of assessing competence have been proposed, but surgical competence is presently defined in a very general way through both the ACGME and American Board of Surgery (ABS). Using a SEPA format, as proposed, we could ensure specific understanding of each graduating resident's ability. These results show that the SEPA may be a valid tool for defining and capturing multiple areas of competence that are associated with different disease processes.

Maintenance antipsychotic treatment versus discontinuation strategies following remission from first episode psychosis: systematic review.

BACKGROUND: Understanding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis (FEP) is an important area of practice. METHOD: A systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment with total discontinuation or medication discontinuation strategies following remission in FEP. RESULTS: Seven studies were included. Relapse rates were higher in the discontinuation group (53%; 95% CIs: 39%, 68%; N = 290) compared with maintenance treatment group (19%; 95% CIs: 0.05%, 37%; N = 230). In subgroup analyses, risk difference of relapse was lower in studies with a longer follow-up period, a targeted discontinuation strategy, a higher relapse threshold, a larger sample size, and samples with patients excluded for drug or alcohol dependency. Insufficient studies included psychosocial functioning outcomes for a meta-analysis. CONCLUSIONS: There is a higher risk of relapse for those who undergo total or targeted discontinuation strategies compared with maintenance antipsychotics in FEP samples. The effect size is moderate and the risk difference is lower in trials of targeted discontinuation strategies. DECLARATION OF INTEREST: A.T. has received honoraria and support from Janssen-Cilag and Otsuka Pharmaceuticals for meetings and has been has been an investigator on unrestricted investigator-initiated trials funded by AstraZeneca and Janssen-Cilag. He has also previously held a Pfizer Neurosciences Research Grant. S.M. has received sponsorship from Otsuka and Lundbeck to attend an academic congress and owns shares in GlaxoSmithKline and AstraZeneca. J.H. has attended meetings supported by Sunovion Pharmaceuticals.

Association of Primary Care Consultation Patterns With Early Signs and Symptoms of Psychosis.

Importance: Primary care is an important part of the care pathway for patients with psychosis; therefore, primary care physicians need to be able to accurately identify those at clinical high risk of psychosis. The difficulty of this task is increased because clinical high-risk symptoms are frequently nonspecific to psychosis. Objective: To determine whether the consultation patterns for a prespecified set of symptoms can be used to identify primary care patients who later developed a psychotic illness. Design, Setting, and Participants: This nested case-control study used primary care consultation data collected from 530 primary care practices in 13 UK regions from January 1, 2000, through September 30, 2009. Participants included 11 690 adults with a diagnosis of psychosis and 81 793 control participants who did not have a diagnosis of psychosis individually matched by age group, sex, and primary care practice. Data were analyzed from July 1, 2015, through June 2, 2017. Exposures: Prespecified symptoms selected from literature included attention-deficit/hyperactivity disorder-like symptoms, bizarre behavior, blunted affect, problems associated with cannabis, depressive symptoms, role functioning problems, social isolation, symptoms of mania, obsessive-compulsive disorder-like symptoms, disordered personal hygiene, sleep disturbance, problems associated with cigarette smoking, and suicidal behavior (including self-harm). Main Outcomes and Measures: Case (diagnosis of psychosis) or control (no diagnosis of psychosis) status. Conditional logistic regression was used to investigate the association between symptoms and case-control status in the 5 years before diagnosis. Positive predictive values (PPVs) were calculated using the Bayes theorem for symptoms stratified by age group and sex. Repeated-measures Poisson regression was used to investigate symptom consultation rate. Results: Of the total sample of 93 483 participants, 57.4% were female and 40.0% were older than 60 years (mean [SD] age, 51.34 [21.75] years). Twelve symptoms were associated with a later psychotic diagnosis (all prespecified symptoms except disordered personal hygiene). The strongest association was with suicidal behavior (odds ratio [OR], 19.06; 95% CI, 16.55-21.95). Positive predictive values were heterogeneous across age and sex. The highest PPVs were for suicidal behavior (33.0% in men 24 years or younger [95% CI, 24.2%-43.2%] and 19.6% in women aged 25-34 years [95% CI, 13.7%-27.2%]). Pairs of symptoms were associated with an increase in PPV. Consultation rates were higher in cases and increased 3 months before diagnosis. Conclusions and Relevance: Most of the preselected nonspecific symptoms were associated with a later psychotic diagnosis, particularly among young men consulting for suicidal behavior, especially if consulting with increasing frequency. These symptoms should alert physicians to patients who may benefit from a further assessment of psychotic symptoms.

The longitudinal association between external locus of control, social cognition and adolescent psychopathology.

PURPOSE: To investigate the longitudinal associations between social cognitive ability an external locus of control (externality) and adolescent psychopathology. METHODS: 7058 participants from a prospective population-based cohort provided data on externality, social communication, and emotion perception between 7 and 16 years and psychotic experiences and depressive symptoms at 12 and 18 years. Bivariate probit modelling was used to investigate associations between these risk factors and psychopathological outcomes. RESULTS: Externality was associated with psychopathology at 12 (psychotic experiences OR 1.23 95% CI 1.14, 1.33; depression OR 1.12 95% CI 1.02, 1.22) and 18 years (psychotic experiences OR 1.38 95% CI 1.23, 1.55; depression OR 1.40 95% CI 1.28, 1.52). Poor social communication was associated with depression at both ages (12 years OR 1.22 95% CI 1.11, 1.34; 18 years OR 1.21 95% CI 1.10, 1.33) and marginally associated with psychotic experiences. There was marginal evidence of a larger association between externality and psychotic experiences at 12 years (p = 0.06) and between social communication and depression at 12 years (p = 0.03). CONCLUSIONS: Externality was more strongly associated with psychotic experiences. At 18 years change in externality, between 8 and 16 years were associated with a larger increase in the risk of depression. Poor social communication was more strongly associated with depression.

Evaluating the effectiveness of a mock oral educational program.

BACKGROUND: To obtain board certification, the American Board of Surgery requires graduates of general surgery training programs to pass both the written qualifying examination (QE) and the oral certifying examination (CE). In 2015, the pass rates for the QE and CE were 80% and 77%, respectively. In the 2011-2012 academic year, the University of Wisconsin instituted a mandatory, faculty-led, monthly CE preparation educational program (CE prep) as a supplement to their existing annual mock oral examination. We hypothesized that the implementation of these sessions would improve the first-time pass rate for residents taking the ABS CE at our institution. Secondary outcomes studied were QE pass rate, correlation with American Board of Surgery In-Training Examination (ABSITE) and mock oral examination scores, cost, and type of study materials used, perception of examination difficulty, and applicant preparedness. METHODS: A sixteen question survey was sent to 57 of 59 residents who attended the University of Wisconsin between the years of 2007 and 2015. Email addresses for two former residents could not be located. De-identified data for the ABSITE and first-time pass rates for the QE and CE examination were retrospectively collected and analyzed along with survey results. Statistical analysis was performed using SPSS version 22 (IBM Corp., Armonk, NY). P values < 0.05 were considered significant. RESULTS: Survey response rate was 77.2%. Of the residents who have attempted the CE, first-time pass rate was 76.0% (19 of 25) before the implementation of the formal CE Prep and 100% (22 of 22) after (P = 0.025). Absolute ABSITE score, and mock oral annual examination grades were significantly improved after the CE Prep was initiated (P values < 0.001 and 0.003, respectively), however, ABSITE percentile was not significantly different (P = 0.415). ABSITE raw score and percentile, as well as mock oral annual examination scores were significantly associated with passing the QE (0.032, 0.027, and 0.020, respectively), whereas mock oral annual examination scores alone were associated with passing the CE (P = 0.001). Survey results showed that residents perceived the CE to be easier than the annual mock oral after the institution of the CE prep course (P = 0.036), however, there was no difference in their perception of preparedness. Overall, applicants felt extremely prepared for the CE (4.70 ± 0.5, Likert scale 1-5). CONCLUSIONS: Formal educational programs instituted during residency can improve resident performance on the ABS certifying examination. The institution of a formal, faculty-led monthly CE preparation educational program at the University of Wisconsin has significantly improved the first-time pass rate for the ABS CE. Mock oral annual examination scores were also significantly improved. Furthermore, ABSITE scores correlate with QE pass rates, and mock oral annual examination scores correlate with pass rates for both QE and CE.

The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial.

BACKGROUND: As an alternative to hospital admission, crisis resolution teams (CRTs) provide intensive home treatment to people experiencing mental health crises. Trial evidence supports the effectiveness of the CRT model, but research suggests that the anticipated reductions in inpatient admissions and increased user satisfaction with acute care have been less than hoped for following the scaling up of CRTs nationally in England, as mandated by the National Health Service (NHS) Plan in 2000. The organisation and service delivery of the CRTs vary substantially. This may reflect the lack of a fully specified CRT model and the resources to enhance team model fidelity and to improve service quality. We will evaluate the impact of a CRT service improvement programme over a 1-year period on the service users' experiences of care, service use, staff well-being, and team model fidelity. METHODS/DESIGN: Twenty-five CRTs from eight NHS Trusts across England will be recruited to this cluster-randomised trial: 15 CRTs will be randomised to receive the service improvement programme over a 1-year period, and ten CRTs will not receive the programme. Data will be collected from 15 service users and all clinical staff from each participating CRT at baseline and at the end of the intervention. Service use data will be collected from the services' electronic records systems for two 6-month periods: the period preceding and the period during months 7-12 of the intervention. The study's primary outcome is service user satisfaction with CRT care, measured using a client satisfaction questionnaire. Secondary outcomes include the following: perceived continuity of care, hospital admission rates and bed use, rates of readmission to acute care following CRT support, staff morale, job satisfaction, and general health. The adherence of the services to a model of best practice will be assessed at baseline and follow-up. Outcomes will be compared between the intervention and control teams, adjusting for baseline differences and participant characteristics using linear random effects modelling. Qualitative investigations with participating CRT managers and staff and programme facilitators will explore the experiences of the service improvement programme. DISCUSSION: Our trial will show whether a theoretically underpinned and clearly defined package of resources are effective in supporting service improvement and improving outcomes for mental health crisis resolution teams. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47185233.

A longitudinal investigation of childhood communication ability and adolescent psychotic experiences in a community sample.

BACKGROUND: Some childhood speech and language impairments precede psychosis but it is not clear whether they also precede adolescent psychotic experiences and whether this association is specific to psychotic experiences. METHODS: Pragmatic language and expressive speech and language (parent-assessed using the Children's Communication Checklist) at age 9 and psychotic experiences and depression at ages 12 and 18 were investigated in 7659 participants from the Avon Longitudinal Study of Parents and Children. Associations were investigated using multivariate modelling. RESULTS: Poorer pragmatic language at 9years was associated with psychotic experiences at both ages (12years OR 1.22, 95% CI 1.11, 1.34; 18years OR 1.25, 95% CI 1.10, 1.41) but only with depression at 18years (OR 1.10, 95% CI 1.00, 1.22). Poorer expressive speech and language ability was not associated with psychotic experiences or depression at either age. There was evidence that pragmatic language was specifically associated with psychotic experiences at age 12 but no evidence that the strength of any of the associations changed over time. CONCLUSIONS: Deficits in pragmatic language precede early and late adolescent psychotic experiences and early adolescent depression. Interventions aimed at helping children improve pragmatic language skills may reduce the incidence of adolescent psychopathology and associated psychological disorder and dysfunction later in life.

Piloting Virtual Surgical Patient Cases with 3rd-year medical students during the surgery rotation.

BACKGROUND: Surgical education programs are increasingly challenged to make medical students' learning experiences in their surgery rotation meaningful while making the most of limited faculty resources and maximizing patient safety. Simulations and virtual environments are potential resources for providing meaningful clinical learning experiences. METHODS: Ninety-eight 3rd-year medical students used the Virtual Surgical Patient Cases software as a part of their surgery clerkship. We used a mixed-methods approach to data collection and analyses to investigate how students and faculty engaged with cases as teaching and learning tools. RESULTS: Students improved their clinical reasoning skills significantly at each case attempt, but made some errors consistently across attempts. Faculty used the information provided about students' decisions during the cases to guide their teaching during case discussions. CONCLUSIONS: Including more cases in the surgical clerkship could allow students additional practice with making diagnoses and facilitate an interactive role in discussing cases with faculty.

Development of Technical Skills: Education, Simulation, and Maintenance of Certification.

The goal of this article is to provide a focused overview of technical skills education inside the operating room (OR), opportunities for learning outside of the OR (with a focus on simulation), and methods for measuring technical skills. In addition, the authors review the role of maintenance of certification in continuing education and quality improvement and consider the role that simulation plays in this process. The perspectives on teaching in the OR of both residents and faculty going into the case affect the learning environment, and preoperative interactions between attendings and residents to establish learning needs and goals are important. Furthermore, in regards to attending surgeons improving their skills, interaction with more experienced peers and feedback during and after a procedure can be beneficial. Simulation is increasingly being utilized as an education tool outside of the OR. Training in plastic surgery is poised to exploit simulation in multiple technical areas. There is potential to utilize these simulation environments to collect real-time data, such as motion, visual focus, and pressure. How to incorporate technical skill evaluation results in ways that are most beneficial for learning should be the focus of future research and curriculum development. Finally, simulation could be better utilized as a mechanism for both self and peer evaluation and assessment for continuing education and quality improvement. Professional development for faculty and surgery trainees on how to engage with simulation for teaching and learning and how to translate these experiences into improving patient care will be required.