Mindfulness interventions for psychosis: a systematic review of the literature.

WHAT IS KNOWN ON THE SUBJECT?: Psychosis and the more specific diagnosis of schizophrenia constitute a major psychiatric disorder which impacts heavily on the self-esteem, functioning and quality of life of those affected. A number of mindfulness therapies have been developed in recent years, showing promising results when used with people with the disorder. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review of the literature included only randomized controlled trials (RCTs), rather than other typically less robust methods of research (e.g. case studies, noncontrolled studies). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: We concluded that mindfulness therapies can be safely used with people with psychosis and that they provide a number of therapeutic benefits compared with routine care and, in some cases, other interventions. Larger, methodologically improved trials are now recommended to evaluate the benefits of mindfulness therapies further. ABSTRACT: Introduction A growing number of mindfulness interventions are being used with individuals with psychosis. These therapies employ elements of acceptance and compassion in addition to mindfulness. A number of randomized controlled trials (RCTs) of these interventions have emerged in recent years, but no review of these latest trials exists. Question 'For individuals with psychosis, are mindfulness interventions more effective than treatment as usual or an alternative intervention, in improving patient-related outcomes as demonstrated in RCTs?' Method We undertook a systematic review of randomized controlled studies of mindfulness interventions for psychosis and schizophrenia (MIps). Studies were identified by searching the databases Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Allied and Complementary Medicine. Findings The review identified 11 RCTs investigating eight mindfulness interventions. Significant improvements were reported on a number of measures, although gains were mostly smaller in trials employing well-designed controls and where assessors were blind to treatment allocation. There was considerable heterogeneity amongst trials in the diversity of treatments reviewed and the range of outcomes assessed. Implications for Practice The findings suggest MIps are feasible for individuals with psychosis and provide a number of significant benefits over routine care and, in some cases, other interventions.

The impact of operative complexity on patient risk factors.

OBJECTIVE: The VA National Surgical Quality Improvement Program (NSQIP) formula for risk factors was applied to the University of Texas Health Science Center at San Antonio (UTHSCSA)/University Hospital (UH) database. Its applicability to a civilian organization was established. Logistic regression analysis of the UH database revealed that operative complexity was significantly related to mortality only at high complexity levels. Patient risk factors were the major determinants of operative mortality for most civilian surgical cases. SUMMARY BACKGROUND DATA: Since 1994, the NSQIP has collected preoperative risk factors, intraoperative data, 30-day morbidity, and mortality within the VA health system. The VA formula to predict 30-day postoperative mortality was applied to our UH patients (N = 8593). The c-index of .907, a statistical measure of accuracy, compared favorably to the VA patient c-index of .89. The UH database did not include a surrogate for operative complexity. We were elated by the predictive accuracy but had concern that operative complexity needed further evaluation. METHODS: Operative complexity was ascribed to each of the 8593 UH cases, and logistic regression analyses were compared with and without operative complexity. Operative complexity was graded on a scale of 1 to 5; 5 was the most complex. RESULTS: Without operative complexity, a c-index was .915. With operative complexity: an even higher c-index of .941 was reached. The large volume of level 2-3 operative cases obscured to a degree the effect of operative difficulty on mortality. CONCLUSION: Operative complexity played a major role in risk estimation, but only at the extreme. The dominance of cases of midlevel complexity masked the effect of higher complexity cases on mortality. In any individual case, operative complexity must be added to estimate operative mortality accurately. Patient risk factors alone accounted for operative mortality for operations less than level 4 (95% of patients).

Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs.

OBJECTIVE: To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. SUMMARY BACKGROUND DATA: The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. METHODS: The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. RESULTS: Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. CONCLUSION: Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.

Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.

OBJECTIVE: To examine, in the Veterans Health Administration (VHA), the relation between surgical volume and outcome in eight commonly performed operations of intermediate complexity. SUMMARY BACKGROUND DATA: In multihospital health care systems such as VHA, consideration is often given to closing low-volume surgical services, with the assumption that better surgical outcomes are achieved in hospitals with larger surgical volumes. Literature data to support this assumption in intermediate-complexity operations are either limited or controversial. METHODS: The VHA National Surgical Quality Improvement Program data on nonruptured abdominal aortic aneurysmectomy, vascular infrainguinal reconstruction, carotid endarterectomy (CEA), lung lobectomy/pneumonectomy, open and laparoscopic cholecystectomy, partial colectomy, and total hip arthroplasty were used. Pearson correlation, analysis of variance, mixed effects hierarchical logistic regression, and automatic interaction detection analysis were used to assess the association of annual procedure/specialty volume with risk-adjusted 30-day death (and stroke in CEA). RESULTS: Eight major surgical procedures (68,631 operations) were analyzed. No statistically significant associations between procedure or specialty volume and 30-day mortality rate (or 30-day stroke rate in CEA) were found. CONCLUSIONS: In VHA hospitals, the procedure and surgical specialty volume in eight prevalent operations of intermediate complexity are not associated with risk-adjusted 30-day mortality rate from these operations, or with the risk-adjusted 30-day stroke rate from CEA. Volume of surgery in these operations should not be used as a surrogate for quality of surgical care.

Domain-engineered pyroelectric radiometer.

We built a large-area domain-engineered pyroelectric radiometer with high spatial and spectral response uniformity that is an excellent primary transfer standard for measurements in the near- and the mid-infrared wavelength regions. The domain engineering consisted of inverting the spontaneous polarization over a 10-mm-diameter area in the center of a uniformly poled, 15.5 mm x 15.5 mm square, 0.25-mm-thick LiNbO(3) plate. Gold black was used as the optical absorber on the detector surface, and an aperture was added to define the optically sensitive detector area. Our results indicate that we significantly reduced the acoustic sensitivity without loss of optical sensitivity. The detector noise equivalent power was not exceptionally low but was nearly constant for different acoustic backgrounds. In addition, the detector's spatial-response uniformity variation was less than 0.1% across the 7.5-mm-diameter aperture, and reflectance measurements indicated that the gold-black coating was spectrally uniform within 2%, from 800 to 1800 nm. Other detailed evaluations of the detector include detector responsivity as a function of temperature, electrical frequency response, angular response, and field of view.

van't Hoff-Le Bel Stranger: Formation of a Phosphonium Cation with a Planar Tetracoordinate Phosphorus Atom.

A novel intriguing type of coordination mode in phosphorus chemistry has been established that is of fundamental interest in the understanding of chemical bonding. Besides the synthesis of the first planar phosphonium cation PR(4)(+) 1 by a surprisingly simple metathesis reaction, a potentially general experimental method that reaches the seemingly impossible high-energy region of basic molecular and isoelectronic ER(4) systems (E=B(-), C, N(+), Al(-), Si, P(+)) is provided.

The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program.

OBJECTIVE: To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. SUMMARY BACKGROUND DATA: Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. METHODS: This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). RESULTS: The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. CONCLUSIONS: Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.

Multivariate optical computation for predictive spectroscopy.

A novel optical approach to predicting chemical and physical properties based on principal component analysis (PCA) is proposed and evaluated using a data set from earlier work. In our approach, a regression vector produced by PCA is designed into the structure of a set of paired optical filters. Light passing through the paired filters produces an analog detector signal that is directly proportional to the chemical/physical property for which the regression vector was designed. This simple optical computational method for predictive spectroscopy is evaluated in several ways, using the example data for numeric simulation. First, we evaluate the sensitivity of the method to various types of spectroscopic errors commonly encountered and find the method to have the same susceptibilities toward error as standard methods. Second, we use propagation of errors to determine the effects of detector noise on the predictive power of the method, finding the optical computation approach to have a large multiplex advantage over conventional methods. Third, we use two different design approaches to the construction of the paired filter set for the example measurement to evaluate manufacturability, finding that adequate methods exist to design appropriate optical devices. Fourth, we numerically simulate the predictive errors introduced by design errors in the paired filters, finding that predictive errors are not increased over conventional methods. Fifth, we consider how the performance of the method is affected by light intensities that are not linearly related to chemical composition (as in transmission spectroscopy) and find that the method is only marginally affected. In summary, we conclude that many types of predictive measurements based on use of regression (or other) vectors and linear mathematics can be performed more rapidly, more effectly, and at considerably lower cost by the proposed optical computation method than by traditional dispersive or interferometric instrumentation. Although our simulations have used Raman experimental data, the method is equally applicable to Near-IR, UV-vis, IR, fluorescence, and other spectroscopies.

Bicell Pyroelectric Optical Detector Made from a Single LiNbO(3) Domain-Reversed Electret.

Using electric-field poling at room temperature, we selectively reversed the direction of the spontaneous polarization in a 200-mum-thick, z-cut LiNbO(3) electret to produce a bicell pyroelectric detector. The detector required only a single set of electrodes, one electrode on the front surface and one on the back surface. Microphonic noise that is typical of monocell pyroelectric detectors is reduced in the present device. Our spatial uniformity data indicate that the optical response of one half of the bicell detector area was equal to and opposite the other half within 1.2%. The microphonic suppression of the bicell pyroelectric detector was less than -36 dB from 10 to 50 Hz and less than -118 dB at 35 Hz of that of a reference monocell pyroelectric detector. The substrate thickness is significantly greater than those of other domain-engineered pyroelectric detector designs and allows us to build practical, large-area detectors for radiometric applications.

Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality rates for surgical services in Veterans Health Administration. STUDY DESIGN: This cohort study was conducted in 44 Veterans Affairs Medical Centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measure was all-cause mortality within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. Risk-adjusted surgical mortality rates were expressed as observed-to-expected ratios and were compared with unadjusted 30-day postoperative mortality rates. RESULTS: Patient risk factors predictive of postoperative mortality included serum albumin level, American Society of Anesthesia class, emergency operation, and 31 additional preoperative variables. Considerable variability in unadjusted mortality rates for all operations was observed across the 44 hospitals (1.2-5.4%). After risk adjustment, observed-to-expected ratios ranged from 0.49 to 1.53. Rank order correlation of the hospitals by unadjusted and risk-adjusted mortality rates for all operations was 0.64. Ninety-three percent of the hospitals changed rank after risk adjustment, 50% by more than 5 and 25% by more than 10. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of risk-adjusted postoperative mortality rates after major noncardiac operations. Risk adjustment had an appreciable impact on the rank ordering of the hospitals and provided a means for monitoring and potentially improving the quality of surgical care.

Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.

BACKGROUND: The National Veterans Affairs Surgical Risk Study was designed to collect reliable, valid data on patient risk and outcomes for major surgery in the Veterans Health Administration and to report comparative risk-adjusted postoperative mortality and morbidity rates for surgical services in the Veterans Health Administration. STUDY DESIGN: This was a cohort study conducted at 44 Veterans Affairs Medical Centers closely affiliated with university medical centers. Included were 87,078 major noncardiac operations performed under general, spinal, or epidural anesthesia between October 1, 1991, and December 31, 1993. The main outcomes measures in this report are 21 postoperative adverse events (morbidities) occurring within 30 days after the index procedure. Multivariable logistic regression risk-adjustment models for all operations and for eight surgical subspecialties were developed. RESULTS: Patient risk factors predictive of postoperative morbidity included serum albumin level, American Society of Anesthesia class, the complexity of the operation, and 17 other preoperative risk variables. Wide variation in the unadjusted rates of one or more postoperative morbidities for all operations was observed across the 44 hospitals (7.4-28.4%). Risk-adjusted observed-to-expected ratios ranged from 0.49 to 1.46. The Spearman rank order correlation between the ranking of the hospitals based on unadjusted morbidity rates and risk-adjusted observed-to-expected ratios for all operations was 0.87. There was little or no correlation between the rank order of the hospitals by risk-adjusted morbidity and risk-adjusted mortality. CONCLUSIONS: The Department of Veterans Affairs has successfully implemented a system for the prospective collection and comparative reporting of postoperative mortality and morbidity rates after major noncardiac operations. Risk adjustment had only a modest effect on the rank order of the hospitals.

Postsurgical adjuvant chemotherapy of stage II breast carcinoma with or without crossover to a non-cross-resistant regimen: a Cancer and Leukemia Group B study.

PURPOSE: To compare two cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone (CMFVP) regimens with a doxorubicin-based regimen--vinblastine, doxorubicin, thiotepa, and Halotestin (Upjohn, Kalamazoo, MI) (VATH)--in patients with stage II node-positive breast carcinoma. METHODS: Nine hundred forty-five women were treated with a 6-week induction course of CMFVP. They were then randomized to receive one of two consolidation CMFVP regimens: 6-week courses or 2-week courses. Following completion of CMFVP consolidation, patients were again randomized to either continue the CMFVP regimen or to receive six escalating doses of VATH. RESULTS: Among all patients, with a median follow-up time of 11.5 years, there is no statistically significant difference in disease-free survival (DFS) between the two consolidation CMFVP regimens. VATH intensification treatment is statistically significantly superior to CMFVP in terms of DFS (P = .0040). For patients with one to three involved nodes, there is currently no significant difference between VATH and CMFVP; however, among those with four or more positive lymph nodes, there is a significant difference in favor of VATH (P = .0037). There is also improved overall survival with VATH (P = .043; median, > 14 years v 10 years). This difference is also statistically significant in patients with four or more involved lymph nodes, among postmenopausal patients, and among postmenopausal estrogen receptor-positive patients. CONCLUSION: Chemotherapy with crossover to escalating doses of VATH following CMFVP was well tolerated and effective. Inauguration of VATH as a treatment intensification at the eighth month produced a major increase in relapse-free and overall survival. The observation that sensitivity to VATH is retained so long after mastectomy raises questions about the proper duration of adjuvant chemotherapy and lends support to further investigation of cross-over designs in future trials to postoperative adjuvant chemotherapy regimens.

Complications of needle catheter jejunostomy in 2,022 consecutive applications.

BACKGROUND: We commonly use needle catheter jejunostomy (NCJ) for early enteral feeding in selected patients. Review of our approach was prompted by the suggestion that enteral feeding represents a "stress test" for the bowel and may be associated with a high complication rate. MATERIALS AND METHODS: We reviewed patients with NCJ inserted over the past 16 years by prospective database, chart review, and conference minutes, with emphasis on complications. RESULTS: During the conduct of 28,121 laparotomies, 2,022 NCJs inserted in 1,938 patients (7.2%) resulted in 34 NCJ-related complications in 29 patients (1.5%) The most common complication was premature loss of the catheter from occlusion or dislodgment (n = 15; 0.74%), and the most serious was bowel necrosis (n = 3; 0.15%). CONCLUSIONS: Needle catheter jejunostomy may be inserted and used with a low complication rate. Most complications were preventable through greater attention to detail and better monitoring of physical examination of patients with marginal gut function.

Nd:LiTaO(3) waveguide laser.

Waveguide lasers operating near 1092 and 1076 nm were fabricated in Z-cut Nd-Ti codiffused LiTaO(3). The Nd diffusion was at 14000 degrees C for 120 h. Samples from two wafers were examined. The Nd film starting thickness was 7 nm in wafer 1 and 15 nm in wafer 2. Ti stripes, 8-15 microm wide, were diffused at 1500 degrees C for 4 h for wafer 1 (130-nm stripe thickness) and 2 h forwafer 2 (100-nm stripe thickness). Pumping was at 750 nm. Threshold occurred at 330 mW of absorbedpump power for the best waveguides from wafer 1 and100 mW for the best waveguides from wafer 2. The slope efficiency of the latter was 0.07%.

Biliary pancreatitis. Operative outcome with a selective approach.

To evaluate the efficacy of a selective approach to biliary pancreatitis, we reviewed the outcomes in 276 consecutive patients undergoing operations for this diagnosis during a 7-year period. Initial conservative therapy resulted in elective operations in 63% and urgent operations in 37%. Only 10 patients (3.6%) required primary pancreatic operations, 50% of them as emergencies. The proportion of common duct surgical explorations fell from 70% of those operated immediately after hospital admission to 20% by the third hospital day. Overall mortality was 1.8% but was increased to 30% in patients having an initial pancreatic operation. We conclude that a selective approach to biliary pancreatitis allows the operation to be performed electively in most patients and is associated with a low mortality and an acceptable length of stay. Most common duct stones pass spontaneously permitting cholecystectomy alone.