Cognitive-Behavioral and Dialectical Behavior Therapy in High-Intensity Settings.

Youth mental health is a major public health concern. Adolescents experiencing mental health crises are increasingly presenting to high-intensity settings such as inpatient and partial hospitalization programs. These services offer a multimodal approach involving medication management, cognitive-behavioral therapy (CBT), and dialectical behavior therapy (DBT).1 Treating these distressed youth in intense settings is challenging due to their high acuity, limited lengths of stay, and frequent lack of resources. However, CBT/DBT are typically evaluated in outpatient settings, leaving clinicians in high-intensity programs to adapt models with limited guidance.2 While traditional CBT/DBT interventions are not new or unfamiliar, and various literature reviews report their effectiveness, few reports offer specific guidance and practical tips for implementing these procedures.1-6 This Clinical Perspectives article highlights the necessary adaptations of traditional CBT/DBT for these intense settings in which high acuity, shorter stays, limited resource allocation, and a lack of staff involvement/training are limiting factors.

Public opinion, racial bias and labour market outcomes in the USA.

Here we study the role of negative shifts in public opinion in the economic lives of under-represented racial groups by investigating sudden changes in views towards Asian people following the anti-Chinese rhetoric that emerged with the COVID-19 pandemic, and associated changes in employment status and earnings in the US labour market. Using data from the Current Population Survey, we find that, unlike other under-represented groups, Asian workers in occupations or industries with a higher likelihood of face-to-face interactions before the pandemic were more likely to become unemployed afterwards. While widespread along the political spectrum, negative shifts in the perceived favourability of Asian people, and not of other under-represented groups, were much stronger among those who voted for Donald Trump in 2016 and could have been more influenced by the anti-Asian rhetoric.

Factors affecting anatomical and visual outcomes in Terson syndrome managed by surgery or observation.

OBJECTIVES: To investigate visual outcomes and prognostic factors of patients with Terson syndrome (TS) managed with observation or pars plana vitrectomy (PPV). METHODS: retrospective review of medical records of 117 eyes from 81 patients (43 females) with TS. Main outcome measures were final best corrected visual acuity (BCVA), intraoperative findings and long-term sequelae. RESULTS: 46 (39.3%) eyes were managed conservatively and 71 (60.7%) eyes underwent PPV. Median follow-up was 8.4 months. The PPV group had significantly worse (p < 0.001) baseline BCVA (median 2.3 versus 0.7 logMAR, Snellen equivalent 20/4000 versus 20/100). Final BCVA did not differ between the two groups (p = 0.38). Final BCVA ≥ 0.3 logMAR (20/40) in the surgery group was associated with post-operative retinal detachment (p = 0.013) and macular abnormalities (p = 0.014), and in the observation group with ocular comorbidity (p = 0.008). Retinal breaks were detected intraoperatively in 25 (35.2%) eyes and were associated with an interval longer than 3 months between ocular diagnosis and surgery (p = 0.04), but not with larger gauge instrumentation and posterior vitreous detachment. Incidence of ERM did not differ among patients managed conservatively and after PPV (p = 0.9) and between eyes undergoing early or delayed surgery (p = 0.09). The most common post-operative complications were cataract in 16 (22.5%) eyes and ERM in 8 (11.3%) eyes. CONCLUSIONS: visual outcomes in TS are similar with both management strategies. Surgery allows faster and greater visual recovery but carries high risk of intraoperative retinal tears if delayed for longer than 3 months from initial presentation. ERM and retinal detachment are not correlated with timing of surgery or management strategy.

Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study.

This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention. An interrupted time series design was used to evaluate impact on patient outcomes, including 15 618 admissions for 8951 patients. Mixed-effects multiple Poisson and log-linear regression models were fitted for count and continuous outcomes, respectively. Effect sizes are slope change ratios pre-intervention and post-intervention. The intervention was associated with reductions in emergency readmissions between 7 and 90 days (0.98, 95% CI 0.97 to 1.00), although not readmissions between 0 and 7 days post-discharge. Improvements were seen in in-hospital mortality (0.96, 95% CI 0.95 to 0.98), and there was no change in trend for hospital length of stay. Care process changes were also evaluated. Compliance with NT-proBNP testing was already high in 2014/2015 (162 of 163, 99.4%) and decreased slightly, with increased numbers audited, to 2016/2017 (1082 of 1101, 98.2%). Over this period, rates of echocardiography (84.7-98.9%) and specialist input (51.6-90.4%) improved. Care quality and outcomes can be improved for patients with acute heart failure using a care bundle approach. A systematic approach to quality improvement, and robust evaluation design, can be beneficial in supporting successful improvement and learning.

Comparative Analysis of Predetermined Axillary Crutch Length Settings to Individualized Fittings.

Axillary crutches are the most common assistive devices given to individuals with musculoskeletal injuries in an acute care setting. Nurses are frequently the care provider fitting injured individuals with crutches. This study compared the crutch length determined by the crutch manufacturer's height setting with the crutch length attained after applying a standard clinical protocol for crutch fitting. A total of 116 adults with lower extremity injuries were enrolled. Self-reported height was documented as well as initial crutch length as indicated by the numbers on the push-button feature of the crutches. Subject height with and without shoes was measured. Proper crutch length was then determined using the method described by Bauer et al. (1991). No change between the initial and adjusted crutch settings was made in 43% of the subjects. Change was made in 57% of the subjects: lengthening in 40% and shortening in 17% of subjects. This study revealed the predetermined crutch settings are unreliable and should simply be used as a starting point during a personalized fitting.

Network approaches and interventions in healthcare settings: A systematic scoping review.

INTRODUCTION: The growing interest in networks of interactions is sustained by the conviction that they can be leveraged to improve the quality and efficiency of healthcare delivery systems. Evidence in support of this conviction, however, is mostly based on descriptive studies. Systematic evaluation of the outcomes of network interventions in healthcare settings is still wanting. Despite the proliferation of studies based on Social Network Analysis (SNA) tools and techniques, we still know little about how intervention programs aimed at altering existing patterns of social interaction among healthcare providers affect the quality of service delivery. We update and extend prior reviews by providing a comprehensive assessment of available evidence. METHODS AND FINDINGS: We searched eight databases to identify papers using SNA in healthcare settings published between 1st January 2010 and 1st May 2022. We followed Chambers et al.'s (2012) approach, using a Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. We distinguished between studies relying on SNA as part of an intervention program, and studies using SNA for descriptive purposes only. We further distinguished studies recommending a possible SNA-based intervention. We restricted our focus on SNA performed on networks among healthcare professionals (e.g., doctors, nurses, etc.) in any healthcare setting (e.g., hospitals, primary care, etc.). Our final review included 102 papers. The majority of the papers used SNA for descriptive purposes only. Only four studies adopted SNA as an intervention tool, and measured outcome variables. CONCLUSIONS: We found little evidence for SNA-based intervention programs in healthcare settings. We discuss the reasons and challenges, and identify the main component elements of a network intervention plan. Future research should seek to evaluate the long-term role of SNA in changing practices, policies and behaviors, and provide evidence of how these changes affect patients and the quality of service delivery.

Care and support networks of community-dwelling frail individuals in North West London: a comparison of patient and healthcare workers' perceptions.

BACKGROUND: Evidence suggests that successful assessment and care for frail individuals requires integrated and collaborative care and support across and within settings. Understanding the care and support networks of a frail individual could therefore prove useful in understanding need and designing support. This study explored the care and support networks of community-dwelling older people accessing a falls prevention service as a marker of likely frailty, by describing and comparing the individuals' networks as perceived by themselves and as perceived by healthcare providers involved in their care. METHODS: A convenience sample of 16 patients and 16 associated healthcare professionals were recruited from a community-based NHS 'Falls Group' programme within North-West London. Individual (i.e., one on one) semi-structured interviews were conducted to establish an individual's perceived network. Principles of quantitative social network analysis (SNA) helped identify the structural characteristics of the networks; qualitative SNA and a thematic analysis aided data interpretation. RESULTS: All reported care and support networks showed a high contribution level from family and friends and healthcare professionals. In patient-reported networks, 'contribution level' was often related to the 'frequency' and 'helpfulness' of interaction. In healthcare professional reported networks, the reported frequency of interaction as detailed in patient records was used to ascertain 'contribution level'. CONCLUSION: This study emphasises the importance of the role of informal carers and friends along with healthcare professionals in the care of individuals living with frailty. There was congruence in the makeup of 'patient' and 'provider' reported networks, but more prominence of helper/carers in patients' reports. These findings also highlight the multidisciplinary makeup of a care and support network, which could be targeted by healthcare professionals to support the care of frail individuals.

Youth Top Problems in an Acute Psychiatric Sample: Describing Consumer-Nominated Treatment Needs in an Adolescent Partial Hospital Setting.

Given the wide range of diagnostic presentations treated in partial hospital programs, finding efficient ways to identify and measure progress on the chief concerns of consumers in these settings is important. The current study uses a self-administered version of the Top Problems Assessment to describe treatment targets identified by youth and their caregivers presenting for care at an adolescent partial hospital setting. Caregiver-youth agreement on these chief concerns upon admission and predictors of agreement were explored. About one-third (34.65%) of caregiver-youth pairs did not match on any target problems. Although anxiety and depression were the most commonly cited top problems in this sample, caregivers and youth exhibited disagreement on these domains. Treatment teams in acute care settings such as a partial hospital program can benefit from careful assessment surrounding the initial goals of treatment as youth and their caregivers may not agree on the referral problems upon entering a program.

The Risk of Sympathetic Ophthalmia after Vitreoretinal Surgery.

PURPOSE: To investigate the clinical course and outcomes of sympathetic ophthalmia (SO) and correlate these with the nature of the inciting event and the number of vitreoretinal (VR) procedures undergone by patients. DESIGN: A retrospective case review. SUBJECTS: All patients diagnosed with SO who had been treated or monitored at a single center over a 15-year period. METHODS: A search of the electronic patient record system at Moorfields Eye Hospital, London, over a 15-year period (between January 2000 and December 2015) was carried out using the search terms "sympathetic," "ophthalmia," and "ophthalmitis." Sixty-one patients with available records were identified, and data were collected from their complete electronic and paper records. MAIN OUTCOME MEASURES: The main outcome measures were best-corrected visual acuity at 1 year and at the end of follow-up and the number of VR surgical procedures preceding the diagnosis of SO. Data on patient age, sex, disease duration, ocular and systemic manifestations, ocular complications, retinal angiography, and treatment were also collected. RESULTS: There was a wide age range at presentation (2-84 years), and the length of follow-up ranged from 1 to 75 years. The first ocular event was trauma in 40 patients and surgery in 21 patients. Vitreoretinal surgery accounted for 13 of the 21 (62%) surgical first-event triggers. Twenty-three of 61 (38%) patients underwent VR surgery (1-7 operations) at some point before diagnosis. Surgical details were available for 15 patients, who had undergone a total of 25 VR procedures. Based on the surgical activity of the unit, the risk of developing SO after a single VR procedure was estimated to be 0.008%, rising to 6.67% with 7 procedures. A total of 23 (38%) patients experienced a decrease in acuity at the end of the follow-up period, vs. 9 (15%) patients experiencing an improvement and 18 (30%) remaining unchanged. CONCLUSIONS: We feel that the most significant finding in this study is the calculated risk of SO development after a single VR procedure, which was significantly lower in our cohort than that previously reported in the literature. This was seen to rise exponentially with additional procedures.

How to Respond to a Ransomware Attack? One Radiation Oncology Department's Response to a Cyber-Attack on Their Record and Verify System.

The digitization of healthcare for patient safety and efficiency introduced third party networks into closed hospital systems increasing the probability of cyberattacks and their consequences(1). In April 2021, a major vendor of a Radiation Oncology (RO) record and verify system (RVS) suffered a ransomware attack, affecting our department and many others across the United States. This article summarizes our response to the ransomware event including workflows, team member roles, responsibilities, communications and departmental recovery. The RVS created or housed accurate patient dose records for 6 locations. The immediate response to the ransomware attack was to shut down the system including the ability to treat patients. With the utilization of the hospital EMR and pre-existing interfaces with RVS, the department was able to safely continue patient radiotherapy treatments innovatively utilizing a direct Digital Imaging and Communications in Medicine (DICOM) transfer of patient data to the linear accelerators and implementing paper charting. No patients were treated in the first 24 hours of the attack. Within 48 hours of the ransomware event, 50% of patients were treated, and within 1 week, 95% of all patients were treated using direct DICOM transfer and paper charts. The RVS was completely unavailable for 2.5 weeks and full functionality was not restored for 4.5 weeks. A phased approach was adopted for re-introduction of patient treatments back into the RVS. Human capital costs included communication, outreach, workflow creation, quality assurance and extended clinical hours. Key lessons learned were to have a back-up of essential information, employ 'dry run' emergency training, having consistent parameter requirements across different vendor hardware and software, and having a plan for the recovery effort of restoring normal operations once software is operational. The provided report presents valuable information for the development of cyber-attack preparedness for RO departments.

In vivo application of an implantable tri-anchored methylene blue-based electrochemical pH sensor.

The development of robust implantable sensors is important in the successful advancement of personalised medicine as they have the potential to provide in situ real-time data regarding the status of health and disease and the effectiveness of treatment. Tissue pH is a key physiological parameter and herein, we report the design, fabrication, functionalisation, encapsulation and protection of a miniaturised, self-contained, electrochemical pH sensor system and characterisation of sensor performance. Notably for the first time in this environment the pH sensor was based on a methylene blue redox reporter which showed remarkable robustness, accuracy and sensitivity. This was achieved by encapsulation of a self-assembled monolayer containing methylene blue entrapped within a Nafion layer. Another powerful feature was the incorporation, within the same implanted device, of a fabricated on-chip Ag/AgCl reference electrode - vital in any electrochemical sensor, but often ignored. When utilised in vivo, the sensor allowed accurate tracking of externally induced pH changes within a naturally occurring ovine lung cancer model, and correlated well with single point laboratory measurements made on extracted arterial blood, whilst enabling in vivo time-dependent measurements. The sensors functioned robustly whilst implanted, and maintained in vitro function once extracted and together, these results demonstrate proof-of-concept of the ability to sense real-time intratumoral tissue pH changes in vivo.

Metastatic and locally aggressive BCC: Current treatment options.

The treatment of locally advanced and metastatic BCC presents a significant clinical challenge. Treatment options have evolved recently to include the use of hedgehog inhibitors Vismodigib and Sonidigib and immunotherapy with Cemiplimab.

An Early Oligocene age for the oldest known monkeys and rodents of South America.

The Santa Rosa fossil locality in eastern Perú produced the first Paleogene vertebrate fauna from the Amazon Basin, including the oldest known monkeys from South America. This diverse paleofauna was originally assigned an Eocene age based largely on the stage of evolution of the site's caviomorph rodents and marsupials. Here, we present detrital zircon dates that indicate that the maximum composite age of Santa Rosa is 29.6 ± 0.08 Ma (Lower Oligocene), although several zircons from Santa Rosa date to the Upper Oligocene. The first appearance datum for Caviomorpha in South America is purported to be the CTA-27 site in the Contamana region of Perú, which is hypothesized to be ∼41 Ma (Middle Eocene) in age. However, the presence of the same caviomorph species and/or genera at both CTA-27 and at Santa Rosa is now difficult to reconcile with a >11-My age difference. To further test the Middle Eocene age estimate for CTA-27, we ran multiple Bayesian tip-dating analyses of Caviomorpha, treating the ages of all Paleogene species from Perú as unknown. These analyses produced mean age estimates for Santa Rosa that closely approximate the maximum 29.6 ± 0.08 Ma composite date provided by detrital zircons, but predict that CTA-27 is much younger than currently thought (∼30 Ma). We conclude that the ∼41 Ma age proposed for CTA-27 is incorrect, and that there are currently no compelling Eocene records of either rodents or primates in the known fossil record of South America.

Surgery for Trapeziometacarpal Joint Osteoarthritis: A Meta-Analysis on Efficacy and Safety.

Background: Osteoarthritis of the thumb base is the second most prevalent arthritis of the hand. Management is primarily conservative, consisting of analgesia, splinting, physiotherapy, and steroid injections. Surgery is considered when conservative measures fail. Methods: The primary objective was to assess the safety and efficacy of the surgical interventions and therein, evaluate whether any superiority exists among the available interventions. Efficacy was evaluated by examining four parameters: pain, function, range of movement and strength of the joint postoperatively. Safety was determined by comparing the rate and severity of postoperative complications. A systematic search of MEDLINE (2014-2019), EMBASE (2014-2019), CINAHL (2014-2019) and CENTRAL (2014-2019) databases was carried out. Abstracts were screened for relevant studies. Randomised controlled trials were only considered. Results: Eight studies were included in the quantitative synthesis. The procedures evaluated are: Trapeziectomy (T), trapeziectomy with ligament reconstruction (T + LR), trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI), trapeziectomy with allograft suspension (T + ALS) and joint arthrodesis (A). Low-moderate quality evidence suggests that T + LRTI yields better range of movement (palmar abduction) when compared with (T) alone; (SMD 0.61, 95% CI 0.22 to 1.00, random-effects, p = 0.002). Comparing adverse events showed that arthrodesis carries a greater risk of adverse events when compared with T + LRTI; (RR 0.33, 95% CI 0.17 to 0.61, random-effects, p = 0.0005). In addition, T + LRTI is preferred over arthrodesis by patients (OR 0.29 95% CI 0.09 to 0.95; p = 0.04). This difference was no seen in the other comparison groups. Conclusions: It is difficult to declare with any degree of certainty which procedure offers the best functional outcome and safety profile. Results suggest T + LRTI yields good postoperative range of movement. Arthrodesis demonstrated an unacceptably high rate of moderate-severe complications and should be considered with careful consideration.

Os Intermetatarseum and Polymetatarsia Without Polydactyly: A Case Report.

Nontraumatic bony abnormalities of the foot occur at different rates, according to the literature. However, it is uncommon to see rare variations presenting together in one patient. This article discusses two less common anomalies: fused os intermetatarseum and polymetatarsia without polydactyly. Etiology, symptomology, diagnosis, and treatment are reviewed, in addition to the relationship of the two conditions to each other. We then discuss a case where both anomalies are present at the same time in a 17-year-old patient.

Contemporary Outcomes and Prognostic Factors of 23-Gauge Vitrectomy for Retained Lens Fragments After Phacoemulsification.

PURPOSE: To provide data on visual acuity (VA) outcomes and prognostic factors of microincision (23-gauge) vitrectomy surgery (MIVS) for retained lens fragments after complicated cataract surgery. DESIGN: Retrospective, interventional case series from 2012 to 2017. METHODS: Precataract surgery and intraoperative (vitrectomy) parameters, postvitrectomy complications, and best-corrected visual acuities (BCVAs) were identified. Vitrectomy was performed as early as corneal clarity permitted. Univariate and multivariate logistic regression were used to characterize factors associated with achieving VA better than 20/40, or worse than 20/200 at 6 months. RESULTS: This study included 291 consecutive eyes (291 patients). LogMAR BCVA improved from 0.73 ± 0.70 before cataract surgery to 0.46 ± 0.63 (P < .001) after vitrectomy. The previtrectomy VA was 1.43 ± 0.79. At 6 months, 183 (62.9%) and 45 patients (15.5%) achieved BCVAs better than 20/40 and worse than 20/200, respectively. Most frequent complications were de novo ocular hypertension (29 eyes, 10%) and transient cystoid macular edema (25 eyes, 8.6%). Postvitrectomy retinal detachment occurred in 9 eyes (3.1%). Final VA of 20/40 or better was independently associated only with better precataract surgery VA, age <75 years, absence of preexisting diabetic macular edema (DME) or postvitrectomy persistent cystoid macular edema (P < .05). Only poorer precataract surgery VA, delaying vitrectomy to later than 2 weeks, and final aphakic status were independently predictive of 20/200 or worse VA (P < .05). CONCLUSION: Contemporary VA outcomes of 23-gauge vitrectomy for retained lens fragments are comparable with that of prior predominantly non-MIVS cohorts, but fall short of benchmarks for uncomplicated cataract surgery. IOL type or timing of placement do not impact final VA.

Extra-articular synovial chondromatosis of the ankle: Unusual case with radiologic-pathologic correlation.

Extra-articular synovial chondromatosis is a rare entity in the foot and ankle. We present a case of a 49-year-old female who presented for evaluation of a palpable concern following trauma; which was found to represent synovial chondromatosis. This case demonstrates the multimodality imaging findings, including ultrasound and MRI, with histopathologic correlation.

Pedagogical Violence.

In this paper, we consider the phenomenon of "pedagogical violence" - infliction of physical, social, emotional, or psychological pains, or threat of such pains that is either the means for or non-accidental by-products of education used on a systematic basis. Pedagogical violence is often used for promoting certain desired learning in students. Alternatively, it can emerge as a violent reaction in students and teachers to particular educational settings directed against other students or teachers. In this paper, we review some of the debates and controversial issues around pedagogical violence, and we use a variety of illustrative examples to explore in more detail what pedagogical violence means in particular contexts. We argue that pedagogical violence is a natural consequence of alienated instrumental education. We will look at teachers' desire to avoid physical and psychosocial pedagogical violence. We specifically consider diverse forms of psychosocial pedagogical violence and its issues such as: summative assessment, epistemological pedagogical violence, students' ambivalence around pedagogical violence, rehabilitating/avoiding pedagogical violence through a carnival. We finish with a reflection about what can be done to minimize pedagogical violence. Our analysis heavily relies on the Bakhtinian theoretical framework of critical ontological dialogism.

Objective Evaluation of Proliferative Diabetic Retinopathy Using OCT.

PURPOSE: To present the routine use of OCT and OCT angiography (OCTA) for the objective diagnosis and monitoring of proliferative diabetic retinopathy (PDR). DESIGN: Retrospective, observational case series. PARTICIPANTS: Patients with diabetic retinopathy imaged using a standardized PDR protocol. METHODS: Patients routinely imaged with a standardized PDR protocol between March 2017 and January 2019 were included. This included a 12×9-mm structural OCT volume centered on the macula and a 6×6-mm OCTA scan centered on the optic nerve head obtained using a Topcon swept-source system (DRI OCT-1 Triton, Topcon, Tokyo, Japan). Ultra-widefield fluorescein angiography (FA) was also performed when clinically indicated. The ground truth for each case was determined by merging the findings from biomicroscopy and imaging modalities to generate the maximum level of detection for each finding. MAIN OUTCOME MEASURES: Detection rates of new-onset, regression, and reactivation of neovascularization of the disc (NVD) and neovascularization elsewhere (NVE) using different modalities (biomicroscopy/color photography, structural OCT, B-scan OCTA, en face OCTA). Detection of progression of tractional retinal detachment (TRD). RESULTS: A total of 383 eyes of 204 patients were evaluated. After excluding patients without PDR or with insufficient image quality, 47 eyes of 35 patients were included. For the detection of new-onset NVD and NVE, structural OCT had the highest detection rate (100%) of all modalities. However, for the detection of regression or reactivation of neovascularization (NV), B-scan OCTA had the highest detection rate (100%). Structural OCT detected regression only in 45.5% of cases, resulting in a low detection rate of reactivation (12.5%). Among 10 eyes with TRD, OCT detected fovea-threatening TRD during follow-up in 7 eyes, resulting in vitrectomy. CONCLUSIONS: This study demonstrates the utility of novel multimodal imaging in the daily management of patients with PDR. Posterior pole structural OCT had the best detection rate for NV, and B-scan OCTA showed the most potential for objective monitoring of disease after treatment.