Differential outcomes of outpatient only versus combined inpatient/outpatient treatment in early intervention for adolescent borderline personality disorder

Clinical guidelines for adults with borderline personality disorder (BPD) recommend outpatient psychotherapy as first-line treatment. Little is known whether this recommendation is also applicable to adolescents. The current study examined the relationship between treatment setting and the outcome of early intervention for adolescents with BPD pathology. One-hundred and seventy-eight adolescents from a specialized outpatient clinic were assessed at baseline, and at 1- and 2-year follow-up. Sixty-three participants who received inpatient treatment during the first year were assigned to the "combined inpatient/outpatient group", 115 participants to the "outpatient only group". Generalized linear and mixed models with inverted probability weights to adjust for baseline differences were applied to examine the impact of group on clinical changes over time. Both groups demonstrated a significant decrease in BPD features, depressive symptoms, psychopathological distress, non-suicidal self-injury (NSSI), suicidal thoughts, suicide attempts, and overall illness severity, and a significant increase in quality of life and psychosocial functioning from baseline to follow-up 2. The decrease in NSSI and overall illness severity, and the increase in psychosocial functioning from baseline to follow-up 1 were greater in the outpatient only group, with comparable improvements between groups from follow-up 1 to follow-up 2. Both outpatient treatment and combined outpatient/inpatient treatment resulted in clinical improvements over time, with some indication for faster changes in the outpatient only setting. The findings provide preliminary evidence that the recommendation of outpatient psychotherapy as the first-line treatment for BPD also holds true for adolescents.

Epidemiology of multidrug-resistant Klebsiella pneumoniae infection in clinical setting in South-Eastern Asia: a systematic review and meta-analysis

The rising prevalence of multidrug-resistant (MDR) and extended-spectrum beta lactamase-resistant (ESBL) Klebsiella pneumoniae (K. pneumoniae) is an important global public health challenge. This threat is even more pertinent in clinical settings. Morbidity and mortality associated with this condition are alarming particularly in the developing regions of the world. A comprehensive evaluation of the epidemiology of this phenomenon will assist towards the global effort of reducing its burden. So, this systematic review and meta-analysis was conducted to evaluate the epidemiology of MDR K. pneumoniae in South-Eastern Asia (SEA). The study was done under the PRISMA guidelines and was preceded by the development of a priori protocol. The protocol was then registered in PROSPERO-the public registry for systematic reviews. Seven important outcomes which include the assessment of the overall MDR K. pneumoniae prevalence were designed to be evaluated. A literature search was carried out in five selected electronic databases and 4389 were screened. Of these articles, 21 studies that met the eligibility criteria were included in the review. Relevant data were extracted from the included studies. By conducting a quality effect meta-analysis, the pooled prevalence for MDR and ESBL K. pneumoniae in SEA was estimated at 55% (CI 9-96) and 27% (CI 32-100) respectively. The review also identified ESBL genes types of allodemic situations occurring mostly in respiratory tract infections. The high prevalence of MDR and ESBL K. pneumoniae in this subregion is highly significant and of both public health and clinical relevance. Overall, the findings of this review will assist in the effective prevention and control of this threat in SEA.

The ideal intravitreal injection setting: office, ambulatory surgery room or operating theatre? A narrative review and international survey

PURPOSE

This study reviews evidence and provides recommendations for the ideal setting of intravitreal injection (IVI) administration of vascular endothelial growth factor (VEGF) inhibitors.

METHODS

A multi-step approach was employed, including content analysis of regulations and guidelines, a systematic literature review, and an international survey assessing perioperative complications and endophthalmitis incidence in relation to injection settings. The literature review searched PubMed and Cochrane databases from 2006 to 2022, focusing on studies reporting correlations between complications and treatment settings. The survey utilized a web-based questionnaire distributed to clinical sites and the international ophthalmic community, with data managed using electronic capture tools.

RESULTS

We reviewed regulations and guidelines from 23 countries across five continents, finding significant variation in IVI administration settings. In most countries, IVI is primarily administered in outpatient clean rooms (96%) or offices (39%), while in others, it is restricted to ambulatory surgery rooms or hospital-based operating theatres (4%). The literature review found that endophthalmitis risk after IVI is generally low (0.01% to 0.26% per procedure), with no significant difference between office-based and operating room settings. The international survey (20 centers, 96,624 anti-VEGF injections) found low overall incidences of severe perioperative systemic adverse events and endophthalmitis, independent of injection settings.

CONCLUSION

No significant differences in perioperative complications were observed among various settings, including operating theatres, ambulatory surgery rooms, offices, hospitals, or extra-hospital environments. Choosing the appropriate clinical setting can optimize patient management, potentially increasing effectiveness, quality, productivity, and capacity.

Identifying setting factors associated with improved ibogaine safety: a systematic review of clinical studies

Ibogaine is a psychoactive alkaloid derived from the west-African shrub Tabernanthe iboga. Western cultures are increasing the interest for the substance due to its claimed anti addictive properties, although the evidence supporting this effect is still preliminary. The use of ibogaine often occurs with no medical supervision in uncontrolled settings, and its use has been associated with several reports of severe adverse events. This review aims to evaluate the clinical studies of ibogaine, with a focus on administration settings, to elucidate specific criteria that may promote safer contexts for ibogaine use. A systematic review of the literature was conducted based on PRISMA guidelines. PubMed, Scielo, ClinicalTrials.gov and Core.ac.uk electronic databases were searched, and clinical studies published until November 17, 2022, were retrieved. The final synthesis included 12 sources. Information about general characteristics of the studies, adverse effects, screening of participants and setting characteristics were summarized and discussed. It is concluded that the use of controlled settings, supported by trained professionals and equipment allowing for rigorous medical, psychiatric, and cardiac monitoring, are essential to promote the safety of patients receiving ibogaine.

In what settings and social contexts do young adults vape or smoke cannabis? Findings from a web-based diary pilot study

BACKGROUND

Vaping is an increasingly common mode of cannabis use among young adults. Despite potential to inform targeted prevention, settings and social contexts where young adults vape and/or smoke cannabis have rarely been investigated. We addressed this question in a diverse young adult sample.

METHODS

Data were collected weekly in a web-based daily diary format for six weeks. The analytic sample consisted of the 108 participants (of the 119 enrolled) who used cannabis during the assessment period (mean age = 22.06; 23.78% college students; 65.74% female; 5.56% Asian, 22.22% Black, 16.67% Latinx, 2.78% Multi-racial or Other and 52.77% White). Cannabis use was queried separately for vaping and smoking; respondents reported all settings (14 options) and social contexts (7 options) where they used.

RESULTS

For both vaping and smoking cannabis, the most common settings were home (vaping: 56.97%, smoking: 68.72% [significantly lower for vaping]), friend's home (vaping: 22.49%, smoking: 21.49%), and car (vaping: 18.80%, smoking: 12.99%). The most common social contexts were with friends (vaping: 55.96%, smoking: 50.61%), with significant other (vaping: 25.19%, smoking: 28.53%), and alone (vaping: 25.92%, smoking: 22.62%). Compared to non-students, college students reported vaping on a significantly higher proportion (27.88% vs. 16.50%) of cannabis use days.

CONCLUSIONS

Very similar patterns in settings and social contexts were observed for vaping as smoking and in prevalence of vaping and smoking cannabis across demographic groups. The few notable exceptions have implications for vaping related public health measures: targeting reducing vaping outside the home, particularly in cars, and implementing prevention programming on college campuses.

Two clinicians for one patient, is it worth it? Patients' perspective on receiving treatment from a pair of clinicians, in a psychiatric emergency and crisis unit

BACKGROUND

In the field of psychiatric crisis interventions, treatment is commonly provided by multidisciplinary teams in Western countries. However, empirical data on the processes involved in this type of intervention are lacking, in particular from a patient perspective. Our study aims to gain a better understanding of the patients' experience of a treatment setting provided by a pair of clinicians in a psychiatric emergency and crisis intervention unit. Patients' perspective could provide a broader understanding of its advantages (or disadvantages), as well as bring new insight on elements influencing patients' treatment adherence.

METHODS

We conducted 12 interviews with former patients treated by a pair of clinicians. The participants' experience, explored with semi-structured questions on their views of the treatment setting, was analyzed by means of thematic analysis using an inductive approach.

RESULTS

The majority of participants experienced this setting as advantageous. A broader comprehension of their issues is the benefit most often expressed. A minority experienced seeing two clinicians as disadvantageous (having to talk to several clinicians at a time, change interlocutors, repeat one's story). Participants attributed joint sessions (with both clinicians) mainly to clinical reasons and separate sessions (with one clinician at a time) mainly to logistical ones.

CONCLUSIONS

This qualitative study provides first insights into patients' experience of a setting including two clinicians providing emergency and crisis psychiatric care. The results show a perceived clinical gain of such a treatment setting for highly in crisis patients. However, further research is needed to evaluate the benefit of this setting, including the indication for joint or separate sessions as the patient's clinical course evolves.

Some Questions Raised by the Practice of Online Analysis

In this paper the author explores some of the issues raised by the practice of online analysis. In particular, he emphasizes the difference between the setting and the frame and proposes a theoretical approach of the latter as emerging within the transferential dynamic.

Continuities, discontinuities and transformations in the psychotherapy of a psychotic adolescent during the time of coronavirus

The author describes the evolution of the psychotherapy of a psychotic adolescent in the period when the pandemic induced their national authorities to impose lockdown. The difficulty of coming to terms with an ever-present reality that proved to be distressing for both the patient and the analyst, as well as with the violence and rapidity with which the external situation developed, leading to a change in the therapy setting, are at the heart of the reflections in this paper. The "choice" of whether to continue the sessions over the phone determined the emergence of some distinctive issues related to discontinuity and to the impossibility of relying on visual perception. However, to the analyst's surprise, it also favoured the possibility of working through the meaning of some autistic mental areas which, up to that moment, had never really been accessible to verbalization. Questioning the meaning of these changes, the author develops a broader reflection about the way that, for analysts and patients, modifications in the frames of our daily lives and clinical practice have enabled the deployment of undifferentiated parts of the personality which had previously been secretly deposited in the "body" of the setting and therefore were inaccessible.

Considering equity in priority setting using transmission models: Recommendations and data needs

OBJECTIVES

Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity.

METHODS

We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations.

RESULTS

We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration.

CONCLUSIONS

Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

Effects of Setting on Psychedelic Experiences, Therapies, and Outcomes: A Rapid Scoping Review of the Literature

The health and well-being impacts of art and aesthetic experiences have been rigorously studied by a range of disciplines, including cognitive neuroscience, psychiatry, public health, and translational clinical research. These experiences, encompassed in the concepts of set and setting, have long been claimed to be pivotal in determining the acute and enduring effects of psychedelic experiences. Responding to the field's longstanding emphasis on the role and value of setting, a rapid scoping review was undertaken to identify the extent to which effects of setting and aesthetics on psychedelic experiences and therapies have been explicitly studied. It offers an analysis of the strengths and limitations of the extant literature and discusses evidentiary gaps as well as evidentiary opportunities for the field. The 43 included studies indicate apparent consensus regarding the importance of setting in psychedelic therapies, as well as consistent interest in theorizing about these effects. However, this consensus has yet to generate consistent, prospective, rigorous tests of setting and its complexities. As a result, the field continues to lack understanding or agreement regarding the effects of various specific elements of setting, the mechanisms by which they affect outcomes, for whom these effects occur, under what circumstances, given what conditions, and other critical factors. Further studies of setting and aesthetics in the context of psychedelic therapies are likely to not only improve these therapies and their delivery, but also inform considerations of setting and aesthetics for non-psychedelic interventions.

Acute drug effects differentially predict desire to take dextroamphetamine again for work and recreation

RATIONALE

Misuse of dextroamphetamine occurs in work and recreational contexts. While acute drug effects broadly predict abuse liability, few studies have considered the relationship between acute effects and context.

OBJECTIVES

This study examined how individual differences in acute effects of dextroamphetamine relate to desire to take dextroamphetamine again in different contexts.

METHODS

This secondary analysis used data from healthy adults with no history of moderate-to-severe substance use disorder, who received oral doses of placebo and dextroamphetamine (10 and 20 mg) over 3 sessions under double-blind, randomized conditions. Subjects rated subjective effects and completed reward-related behavioral tasks. Subjects rated their desire to take dextroamphetamine again in hypothetical work and recreational contexts. Multilevel models examined within-subjects change scores (10 mg-placebo; 20 mg-placebo) to determine how subjective effects and behavioral outcomes predicted desire to take dextroamphetamine again for work versus recreation.

RESULTS

Subjects reported more desire to take 20 mg dextroamphetamine again for work than for recreation. At 20 mg, there was an interaction between context and liking/wanting, such that liking/wanting predicted desire to use dextroamphetamine for work only. There was also an interaction at 20 mg between context and psychomotor speed, such that psychomotor speed predicted interest in using dextroamphetamine for recreation only.

CONCLUSIONS

We found that positive subjective effects predicted desire to use dextroamphetamine again for work, while increased motor effects predicted desire to use dextroamphetamine recreationally. Hedonic effects may be perceived as advantageous when working, while increased physical energy may be preferred during recreation, suggesting that context of intended use is important when examining abuse liability.

(Re)thinking the Residential in Residency: Modern Surgical Practice Continues to Move Away From the Inpatient Setting

PURPOSE

Despite the overall shift in care delivery to an ambulatory setting, the majority of general surgical education still relies on the experience of caring for inpatients. We aimed to investigate how the inpatient practice patterns of newly minted general surgeons (GS) have changed since 2008, in order to better inform education policies regarding both training approach and setting for modern surgical trainees.

METHODS

State discharge data from NY and FL (2008-2017) were linked to data on GS from the American Medical Association Masterfile, and to hospital data from the American Hospital Association annual survey. Mean annual inpatient case volume (CV) and case type breadth (CB) were compared between surgeons who were new-to-practice (0-3 years of experience) in 2008 and in 2013. Each new surgeon cohort was followed for 5 years. Case type was classified by organ system.

RESULTS

The 2008 cohort included 328 GS with a mean age of 37.1, 79.6% male and 94.2% board-certified. The 2013 cohort included 359 GS with a mean age of 36.2, 73.0% male and 93.9% board-certified. CV was higher among the 2008 cohort than the 2013 cohort for each year of practice in the study period. CB included at least 4 organ system types for all new GS with greater breadth among the 2008 cohort for each year in the study period.

CONCLUSIONS

Declining rates of inpatient surgery affect general surgeons who were new-to-practice in 2013 significantly more than those entering practice only 5 years ahead of them. New surgeons continue to start their practices broadly, suggesting a need to continue broad training while expanding formal educational policies to include the full spectrum of ambulatory surgery.

Epidemiological analysis of 3,219 COVID-19 outbreaks in the state of Baden-Wuerttemberg, Germany

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has emerged as an unprecedented global crisis challenging health systems. This paper aims to assess and characterise SARS-CoV-2 outbreaks in the state of Baden-Wuerttemberg to identify groups at greatest risk, to establish early measures to curb transmission. We analysed all mandatory notified (i.e. laboratory-confirmed) coronavirus disease (COVID-19) outbreaks with more than two cases in Baden-Wuerttemberg from calendar weeks 18-49 (from 27 April to 6 December 2020). We used the following classification for settings: asylum and refugee accommodation, care homes, care facilities, day care child centres, hobby-related, hospitality, hospitals, households, other, residence halls, schools, supported housing, training schools, transportation, treatment facilities and workplace (occupational). We used R program version 3.6.3 for analysis. In our analysis, 3219 outbreaks with 22 238 individuals were included. About 48% were in household and hobby-related settings. Care homes accounted for 9.5% of outbreaks and 21.6% of cases. The median age across all settings was 43 (interquartile range (IQR) 24-63). The median age of cases in care homes was 81 (IQR 56-88). Of all reported cases in care homes, 72.1% were women. Over 30% (466/1511) of hospitalisations were among cases in care homes compared to 17.7% (268/1511) in households. Overall, 70% (500/715) of all deceased persons in outbreaks in the study period were in care homes compared to 4.2% in household settings (30/715). We observed an exponential increase in the number of notified outbreaks starting around the 41st week with N = 291 outbreaks reported in week 49. The median number of cases in outbreaks in care homes and care facilities after the 40th week was 14 (IQR 5-29) and 11 (IQR 5-20), respectively, compared to 3 (IQR 3-5) in households. We observed an increase in hospitalisations, and mortality associated with COVID-19 outbreaks in care homes after the 40th week. We found the care home demographic to be at greatest risk after the 40th week, based on the exponential increase in outbreaks, the number of cases, hospitalisations and mortality trends. Our analysis highlights the necessity of targeted, setting-specific approaches to control transmission in this vulnerable population. Regular screening of staff members and visitors' using rapid antigen point-of-care-tests could be a game-changer in curbing transmission in this setting.

Considerations for applying bioethics norms to a biopharmaceutical industry setting

Background

The biopharmaceutical industry operates at the intersection of life sciences, clinical research, clinical care, public health, and business, which presents distinct operational and ethical challenges. This setting merits focused bioethics consideration to complement legal compliance and business ethics efforts. However, bioethics as applied to a biopharmaceutical industry setting often is construed either too broadly or too narrowly with little examination of its proper scope.

Main text

Any institution with a scientific or healthcare mission should engage bioethics norms to navigate ethical issues that arise from the conduct of biomedical research, delivery of clinical care, or implementation of public health programs. It is reasonable to assume that while bioethics norms must remain constant, their application will vary depending on the characteristics of a given setting. Context “specification” substantively refines ethics norms for a particular discipline or setting and is an expected, needed and progressive ethical activity. In order for this activity to be meaningful, the scope for bioethics application and the relevant contextual factors of the setting need to be delineated and appreciated. This paper defines biopharmaceutical bioethics as: the application of bioethics norms (concepts, principles, and rules) to the research, development, supply, commercialization, and clinical use of biopharmaceutical healthcare products. It provides commentary on this definition, and presents five contextual factors that need to be considered when applying bioethics norms to a biopharmaceutical industry setting: (1) dual missions; (2) timely and pragmatic guidance; (3) resource stewardship; (4) multiple stakeholders; and (5) operational complexity.

Conclusion

Understanding the scope of the biopharmaceutical enterprise and contextual factors of a biopharmaceutical industry setting is foundational for the application of bioethics norms. Establishing a common language and approach for biopharmaceutical bioethics will facilitate breadth and depth of discussion and subsequent implementation to benefit patients, the healthcare system and society.

Patterns of adaptive servo-ventilation settings in a real-life multicenter study: pay attention to volume! : Adaptive servo-ventilation settings in real-life conditions

Backgrounds

To explain the excess cardiovascular mortality observed in the SERVE-HF study, it was hypothesized that the high-pressure ASV default settings used lead to inappropriate ventilation, cascading negative consequences (i.e. not only pro-arrythmogenic effects through metabolic/electrolyte abnormalities, but also lower cardiac output). The aims of this study are: i) to describe ASV-settings for long-term ASV-populations in real-life conditions; ii) to describe the associated minute-ventilations (MV) and therapeutic pressures for servo-controlled-flow versus servo-controlled-volume devices (ASV-F Philips®-devices versus ASV-V ResMed®-devices).

Methods

The OTRLASV-study is a cross-sectional, 5-centre study including patients who underwent ASV-treatment for at least 1 year. The eight participating clinicians were free to adjust ASV settings, which were compared among i) initial diagnosed sleep-disordered-breathing (SBD) groups (Obstructive-Sleep-Apnea (OSA), Central-Sleep-Apnea (CSA), Treatment-Emergent-Central-Sleep-Apnea (TECSA)), and ii) unsupervised groups (k-means clusters). To generate these clusters, baseline and follow-up variables were used (age, sex, body mass index (BMI), initial diagnosed Obstructive-Apnea-Index, initial diagnosed Central-Apnea-Index, Continuous-Positive-Airway-Pressure used before ASV treatment, presence of cardiopathy, and presence of a reduced left-ventricular-ejection-fraction (LVEF)). ASV-data were collected using the manufacturer’s software for 6 months.

Results

One hundred seventy-seven patients (87.57% male) were analysed with a median (IQ_25–75) initial Apnea-Hypopnea-Index of 50 (38–62)/h, an ASV-treatment duration of 2.88 (1.76–4.96) years, 61.58% treated with an ASV-V. SDB groups did not differ in ASV settings, MV or therapeutic pressures. In contrast, the five generated k-means clusters did (generally described as follows: (C1) male-TECSA-cardiopathy, (C2) male-mostly-CSA-cardiopathy, (C3) male-mostly-TECSA-no cardiopathy, (C4) female-mostly-elevated BMI-TECSA-cardiopathy, (C5) male-mostly-OSA-low-LVEF). Of note, the male-mostly-OSA-low-LVEF-cluster-5 had significantly lower fixed end-expiratory-airway-pressure (EPAP) settings versus C1 (p = 0.029) and C4 (p = 0.007). Auto-EPAP usage was higher in the male-mostly-TECSA-no cardiopathy-cluster-3 versus C1 (p = 0.006) and C2 (p < 0.001). MV differences between ASV-F (p = 0.002) and ASV-V (p < 0.001) were not homogenously distributed across clusters, suggesting specific cluster and ASV-algorithm interactions. Individual ASV-data suggest that the hyperventilation risk is not related to the cluster nor the ASV-monitoring type.

Conclusions

Real-life ASV settings are associated with combinations of baseline and follow-up variables wherein cardiological variables remain clinically meaningful. At the patient level, a hyperventilation risk exists regardless of cluster or ASV-monitoring type, spotlighting a future role of MV-telemonitoring in the interest of patient-safety.

Trial registration

The OTRLASV study was registered on ClinicalTrials.gov (Identifier: NCT02429986). 1 April 2015.

Tripping on nothing: placebo psychedelics and contextual factors

RATIONALE

Is it possible to have a psychedelic experience from a placebo alone? Most psychedelic studies find few effects in the placebo control group, yet these effects may have been obscured by the study design, setting, or analysis decisions.

OBJECTIVE

We examined individual variation in placebo effects in a naturalistic environment resembling a typical psychedelic party.

METHODS

Thirty-three students completed a single-arm study ostensibly examining how a psychedelic drug affects creativity. The 4-h study took place in a group setting with music, paintings, coloured lights, and visual projections. Participants consumed a placebo that we described as a drug resembling psilocybin, which is found in psychedelic mushrooms. To boost expectations, confederates subtly acted out the stated effects of the drug and participants were led to believe that there was no placebo control group. The participants later completed the 5-Dimensional Altered States of Consciousness Rating Scale, which measures changes in conscious experience.

RESULTS

There was considerable individual variation in the placebo effects; many participants reported no changes while others showed effects with magnitudes typically associated with moderate or high doses of psilocybin. In addition, the majority (61%) of participants verbally reported some effect of the drug. Several stated that they saw the paintings on the walls "move" or "reshape" themselves, others felt "heavy… as if gravity [had] a stronger hold", and one had a "come down" before another "wave" hit her.

CONCLUSION

Understanding how context and expectations promote psychedelic-like effects, even without the drug, will help researchers to isolate drug effects and clinicians to maximise their therapeutic potential.

Circumstances of overdose among street-involved, opioid-injecting women: Drug, set, and setting

INTRODUCTION

Current discourses about the causes of the overdose crisis largely focus on the harmful effects of drugs. Prior research, however, indicates that drug use experience is shaped by complex interactions of drugs with physiological and mental "sets" of people who use drugs and the wider social and physical "setting." Zinberg's "drug, set, and setting" theoretical framework was applied to identify patterns in circumstances leading up to women's overdose.

METHODS

In-depth semi-structured interviews were conducted with 29 opioid-injecting street-involved women, clients of a Philadelphia harm reduction program. Qualitative analysis with deductive and inductive coding was utilized to examine transcripts for theory-driven and emerging themes.

RESULTS

Ten out of 29 women attributed their overdose to "drugs," reporting the unpredictable quality of street opioids, concurrent use of benzodiazepines, or chasing the "high." Thirteen women reported "set" as a type of circumstance where their emotional states were affected by a "good" or "bad" day, leading them to unusual drug consumption practices. Six women described "setting" type of circumstances where their overdose was preceded by a recent change in context, such as release from prison, which prompted unsafe drug use to address physiological or psychological dependence on drugs.

CONCLUSION

While all overdoses result from the pharmacological action of drugs, some overdoses were triggered by circumstances occurring in women's set or setting. Overdose prevention policies should embrace not only individual-level behavioral interventions, but also structural measures to address stress, social isolation, and risky drug use contexts that plague the lives of street-involved women who inject opioids.

A comprehensive guide to set up correctly an electrofishing gear

This study aimed to describe the influence of different electrofishing engine configurations on electric field dispersion in water. Several experiments with original results are included. The aims were to (i) assess the equivalent electrode resistances and the output voltage at the anode, (ii) assess the influence of electrode misuse on the dispersal of the electric field in water, (iii) assess the influence of the duty cycle and the frequency on the radius of attraction around the anode, and (iv) set the voltage and the duty cycle based on information from models for backpack and bankside electrofishing engines. A synthesis of equivalent electrode resistances from different studies was created. Using an oxidised anode induced a decrease in the radius of attraction. Frequency had no influence on the radius of attraction, in contrast to the duty cycle. Models including the voltage and the duty cycle were created to enable the configuration of electrofishing engines.

Malnutrition and related risk factors in older adults from different health-care settings: an enable study

Objective:

The origin of malnutrition in older age is multifactorial and risk factors may vary according to health and living situation. The present study aimed to identify setting-specific risk profiles of malnutrition in older adults and to investigate the association of the number of individual risk factors with malnutrition.

Design:

Data of four cross-sectional studies were harmonized and uniformly analysed. Malnutrition was defined as BMI < 20 kg/m² and/or weight loss of >3 kg in the previous 3–6 months. Associations between factors of six domains (demographics, health, mental function, physical function, dietary intake-related problems, dietary behaviour), the number of individual risk factors and malnutrition were analysed using logistic regression.

Setting:

Community (CD), geriatric day hospital (GDH), home care (HC), nursing home (NH).

Participants:

CD older adults (n 1073), GDH patients (n 180), HC receivers (n 335) and NH residents (n 197), all ≥65 years.

Results:

Malnutrition prevalence was lower in CD (11 %) than in the other settings (16–19 %). In the CD sample, poor appetite, difficulties with eating, respiratory and gastrointestinal diseases were associated with malnutrition; in GDH patients, poor appetite and respiratory diseases; in HC receivers, younger age, poor appetite and nausea; and in NH residents, older age and mobility limitations. In all settings the likelihood of malnutrition increased with the number of potential individual risk factors.

Conclusions:

The study indicates a varying relevance of certain risk factors of malnutrition in different settings. However, the relationship of the number of individual risk factors with malnutrition in all settings implies comprehensive approaches to identify persons at risk of malnutrition early.

Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series

BACKGROUND

Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique.

METHODS

We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure.

RESULTS

Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery.

CONCLUSIONS

Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

Children and youth in out-of-home care: What can predict an initial change in placement?

BACKGROUND

A significant proportion of children placed in out of-home care experience placement disruptions in the United States. Placement instability has deleterious effects on children's well-being.

OBJECTIVES

(a) To measure the time-to-initial placement change in different types of settings, including non-relative foster homes, kinship care, residential treatment centers (RTC), group homes and other types of settings; and (b) To identify predictors of the initial placement change.

PARTICIPANTS AND SETTING

Data were obtained from the State Automated Child Welfare Information System operated by the child welfare agency in a Mid-Atlantic state. The sample included 4177 children who entered into the foster care and were followed over three years.

METHOD

Descriptive, bivariate, and survival Cox regression models were conducted.

RESULTS

More than half (53%) of the children had experienced placement change within 3 years. The mean length for an initial change in placement was longer for children in RTC and kinship care compared to children in foster and group homes, and other placements (χ2 = 322.31, p < 0.001). Several factors significantly increased the likelihood of an initial change, including: older children (p < 0.001, HR = 1.01), children with behavioral problems (p < 0.001, HR = 1.26), parental substance abuse (p < 0.05, HR = 1.12), and cases in which the parents voluntarily gave up their parental rights (p < 0.05, HR = 1.12). The type of placement also increased the risk for placement change.

CONCLUSIONS

Providing early interventions and services to these children and their families is essential to increase placement stability.

Effect of graphene on setting and mechanical behaviour of tricalcium phosphate bioactive cements

The potential reinforcing effect of graphene on calcium phosphate cements (CPCs) for injectable bone substitutes and scaffolds is presented. The influence of graphene (0-3.84 vol%) on the microstructural development during setting and the resultant mechanical properties of CPCs constituted by α + β-tricalcium phosphate is analysed. Optimum setting conditions were established using uniaxial compression strength of CPC and composites with pristine and functionalized graphene and liquid/solid ratios (L/S = 0.5-0.6 mL/g) that allowed the mixing and spatulation of the powders. Tensile strength of optimised materials has been determined using the Diametric Compression of Discs Test (DCDT). X-ray diffraction, Raman spectroscopy and FE-SEM-EDS on fracture surfaces were used to investigate phase composition and morphological changes in set specimens. Strengthening occurs for functionalized graphene additions up to 1.96 vol% due to different toughening mechanisms. Crack deflection, bridging and branching by graphene and, finally, the pull-out of the unbroken graphene sheets have been identified. Interlayer sliding between the graphene before pulling-out is an additional toughening process. Main effect of graphene on strength is the increase of reliability.

Quality of life in cancer patients-a comparison of inpatient, outpatient, and rehabilitation settings

PURPOSE

The aim of this study was to compare quality of life (QoL) data from cancer patients in different clinical settings with data from the general population.

METHODS

A sample of 4020 German cancer patients (1735 inpatients, 1324 outpatients, 961 participants in rehabilitation treatment) was tested with the EORTC QLQ-C30.

RESULTS

Compared with the general population, cancer patients reported markedly worse QoL. There were clinically significant differences on all 15 scales of the EORTC QLQ-C30 (except one). For the sum score, averaging across 13 scales, the effect size of the difference between cancer patients and the general population was d = 1.16. Inpatients reported the greatest detriments to QoL, followed by the rehabilitation patients and the outpatients (mean sum scores 68.6, 71.0, and 72.3, respectively, compared with 89.2 in the general population). Mean scores for different groups of cancer sites are given separately for the three settings.

CONCLUSION

The detriments to QoL were stronger than in comparable studies conducted on data from clinical trials. Since these detriments were found in all three settings to a similar degree, health care providers should offer their services not only to inpatients but to outpatients and patients treated in rehabilitation clinics as well. The data can be used for QoL comparisons of assessments from different settings.

[Le Tibetan Singing Bowls e l'intervento musicoterapeutico.]

OBJECTIVES

The use of idiofonic ethnical istruments known as "Tibetan Singing Bowls", characterized by a fascinating sound and a deep vibration, have been for millennials part of a culture including music, rythuals, theory of Chakra and oriental Ayurvedical medicine.

METHODS

The practice of utilization of the Bowls is related to Sound Therapy rather than to Music Therapy, since the therapeutic effects appears to be a consequence of the vibrations of the Bowls, and not from their music. Besides, the lack of a therapeutic relationship (terapist/patient) makes not possible to include this kind of treatment in the field of Music Therapy.

RESULTS

Therapeutic use of the Bowls has been especially focused in the treatment of "pain". Up to know, not enough research has been developed in this field.

Nonlinear Oscillatory Dynamics of the Hardening of Calcium Phosphate Bone Cements

Here we report on the nonlinear, oscillatory dynamics detected in the evolution of phase composition during the setting of different calcium phosphate cements, two of which evolved toward brushite and one toward hydroxyapatite as the final product. Whereas both brushite-forming cements contained ion-doped β-tricalcium phosphate as the initial phase, the zinc-containing one yielded scholzite as an additional phase during setting and the oscillations between these two products were pronounced throughout the entire 80 h setting period, long after the hardening processes was over from the mechanical standpoint. Oscillations in the copper-containing system involved the amount of brushite as the main product of the hardening reaction and they progressed faster toward an equilibrium point than in the zinc-containing system. Initially detected with the use of in situ energy-dispersive X-ray diffractometry, the oscillations were confirmed with a sufficient level of temporal matching in an in situ Fourier transform infrared spectroscopic analysis. The kinetic reaction analysis based on the Johnson-Mehl-Avrami-Kolmogorov model indicated an edge-controlled nucleation mechanism for brushite. The hydroxyapatite-forming cement comprised gelatin as an additional phase with a role of slowing down diffusion and allowing the detection of otherwise rapid oscillations in crystallinity and in the amount of the apatitic phase on the timescale of minutes. A number of possible causes for these dynamic instabilities were discussed. The classical chemical oscillatory model should not apply to these systems unless in combination with less exotic mechanisms of physicochemical nature. One possibility is that the variations in viscosity, directly affecting diffusion and nucleation rates and accompanying growth and transformation from the lower to the higher interfacial energy per the Ostwald-Lussac rule, are responsible for the oscillatory dynamics. The conception of bone replacement materials and tissue engineering constructs capable of engaging in the dynamics of integration with the natural tissues in compliance with this oscillatory nature may open a new avenue for the future of this type of medical devices. To succeed in this goal, the mechanism of these and similar instabilities must be better understood.

[Setting up medical support clinics during the G20 summit in Hangzhou]

This paper described the principles and the arrangements on setting-up new clinics in the venues and designated hotels during the G20 Summit of Hangzhou. Personnel allocation, combination of equipment, disposal process and supporting tasks of the clinics were introduced to provide reference for setting similar medically supporting-clinics during the international conference activities.

[Settings-based prevention of overweight in childhood and adolescents : Theoretical foundation, determinants and intervention planning]

BACKGROUND

Childhood and adolescent overweight can still be seen as a global public health problem. Based on our socioeconomic understanding, overweight is the result of a complex interplay of a diverse array of factors acting on different levels. Hence, in addition to individual level determinants overweight prevention should also address environmental related factors as part of a holistic and integrated setting approach.

OBJECTIVE

This paper aims to discuss the setting approach with regard to overweight prevention in childhood and adolescence. In addition to a summary of environmental factors and their empirical influence on the determinants of overweight, theoretical approaches and planning models of settings-based overweight prevention are discussed.

RESULTS

While settings can be characterized as specific social-spatial subsystems (e. g. kindergarten, schools), living environments relate to complex subject-oriented environments that may include various subsystems. Direct social contexts, educational contexts and community contexts as relevant systems for young people contain different evidence-based influences that need to be taken into account in settings based overweight prevention. To support a theory-driven intervention, numerous planning models exist, which are presented here.

DISCUSSION

Given the strengthening of environments for health within the prevention law, the underlying settings approach also needs further development with regard to overweigth prevention. This includes the improvement of the theoretical foundation by aligning intervention practice of planning models, which also has a positive influence on the ability to measure its success.

Changes in sport and physical activity participation for adolescent females: a longitudinal study

BACKGROUND

Participation in sport and physical activity is reported to decline during adolescence, particularly for females. However we do not have a clear understanding of changes in the context (i.e., modes and settings) of participation throughout adolescence. This study investigated longitudinal changes in physical activity participation and the specific modes and settings of physical activity, together with cross-sectional comparisons, for two age cohorts of female adolescents.

METHODS

Survey of 729 adolescent girls (489 recruited in Year 7 and 243 in Year 11). Participation in eight different modes/settings was reported. PA was measured using 24-h recall diary and metabolic equivalent weighted energy expenditure (MET-min) in Leisure Time Moderate and Vigorous Physical Activity (LTMVPA) on the previous day was calculated.

RESULTS

There were no significant changes in duration or total MET-min of LTMVPA on previous day. However, there were significant changes in the modes/settings of participation across time. Participation in school physical education rose during early adolescence before decreasing significantly, and participation in competitive sport and club sport significantly decreased over time; however there were increases in non-competitive forms of physical activity.

CONCLUSIONS

Overall levels of physical activity did not significantly decrease over adolescence, which is positive for physical health. However, the transition from structured sport to non-organised physical activity may effect social and psychological health, which needs to be further examined.

Execution of a participatory supportive return to work program within the Dutch social security sector: a qualitative evaluation of stakeholders' perceptions

Background

A process evaluation of a participatory supportive return to work program, aimed at workers without a (permanent) employment contract who are sick-listed due to a common mental disorder, revealed that this program was executed less successfully than similar programs evaluated in earlier studies. The program consisted of a participatory approach, integrated care and direct placement in competitive employment. Aim of this study was to get a better understanding of the execution of the program by evaluating stakeholders’ perceptions. In the absence of an employer, the program was applied by the Dutch Social Security Agency, in collaboration with vocational rehabilitation agencies. Together with the sick-listed workers, these were the main stakeholders. Our research questions involved stakeholders’ perceptions of the function(s) of the program, and their perceptions of barriers and facilitators for a successful execution of the program within the Dutch social security sector.

Methods

Semi-structured interviews were held with five sick-listed workers, eight professionals of the Social Security Agency, and two case managers of vocational rehabilitation agencies. Interview topics were related to experiences with different components of the program. Selection of respondents was based on purposive sampling and continued until data saturation was reached. Content analysis was applied to identify patterns in the data. Two researchers developed a coding system, based on predefined topics and themes emerging from the data.

Results

Although perceived functions of some components of the program were as intended, all stakeholders stressed that the program often had not resulted in return to work. Perceived barriers for a successful execution were related to a poor collaboration between the Dutch Social Security Agency, vocational rehabilitation agencies and healthcare providers, the type of experienced (health) problems, time constraints, and limited job opportunities.

Conclusions

For future implementation of the program, it will be important to consider how a better integration of services by the Dutch Social Security Agency, vocational rehabilitation agencies and the mental healthcare sector can be improved in order to address treatment and vocational needs simultaneously, and to better match the sick-listed worker with the limited opportunities in the Dutch labor market.

Trial registration

NTR3563

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2997-x) contains supplementary material, which is available to authorized users.

Ultrasonic vocalization in rats self-administering heroin and cocaine in different settings: evidence of substance-specific interactions between drug and setting

RATIONALE

Clinical and preclinical evidence indicates that the setting of drug use affects drug reward in a substance-specific manner. Heroin and cocaine co-abusers, for example, indicated distinct settings for the two drugs: heroin being used preferentially at home and cocaine preferentially outside the home. Similar results were obtained in rats that were given the opportunity to self-administer intravenously both heroin and cocaine.

OBJECTIVES

The goal of the present study was to investigate the possibility that the positive affective state induced by cocaine is enhanced when the drug is taken at home relative to a non-home environment, and vice versa for heroin.

METHODS

To test this hypothesis, we trained male rats to self-administer both heroin and cocaine on alternate days and simultaneously recorded the emission of ultrasonic vocalizations (USVs), as it has been reported that rats emit 50-kHz USVs when exposed to rewarding stimuli, suggesting that these USVs reflect positive affective states.

RESULTS

We found that Non-Resident rats emitted more 50-kHz USVs when they self-administered cocaine than when self-administered heroin whereas Resident rats emitted more 50-kHz USVs when self-administering heroin than when self-administering cocaine. Differences in USVs in Non-Resident rats were more pronounced during the first self-administration (SA) session, when the SA chambers were completely novel to them. In contrast, the differences in USVs in Resident rats were more pronounced during the last SA sessions.

CONCLUSION

These findings indicate that the setting of drug taking exerts a substance-specific influence on the ability of drugs to induce positive affective states.

Surface microhardness of three thicknesses of mineral trioxide aggregate in different setting conditions

Objectives

This study aimed to compare the surface microhardness of mineral trioxide aggregate (MTA) samples having different thicknesses and exposed to human blood from one side and with or without a moist cotton pellet on the other side.

Materials and Methods

Ninety cylindrical molds with three heights of 2, 4, and 6 mm were fabricated. In group 1 (dry condition), molds with heights of 2, 4, and 6 mm (10 molds of each) were filled with ProRoot MTA (Dentsply Tulsa Dental), and the upper surface of the material was not exposed to any additional moisture. In groups 2 and 3, a distilled water- or phosphate-buffered saline (PBS)-moistened cotton pellet was placed on the upper side of MTA, respectively. The lower side of the molds in all the groups was in contact with human blood-wetted foams. After 4 day, the Vickers microhardness of the upper surface of MTA was measured.

Results

In the dry condition, the 4 and 6 mm-thick MTA samples showed significantly lower microhardness than the 2 mm-thick samples (p = 0.003 and p = 0.001, respectively). However, when a distilled water- or PBS-moistened cotton pellet was placed over the MTA, no significant difference was found between the surface microhardness of samples having the abovementioned three thicknesses of the material (p = 0.210 and p = 0.112, respectively).

Conclusions

It could be concluded that a moist cotton pellet must be placed over the 4 to 6 mm-thick MTA for better hydration of the material. However, this might not be necessary when 2 mm-thick MTA is used.

Recent advances of ultrasonic testing of cement based materials at early ages

To summarize some of the most important findings in the field of ultrasonic (US) testing of early age hydration and formation of structure of different cement based materials (CBMs), a review of literature with focus on US P-wave transmission and S-wave reflection methods is presented in this paper. The review shows a great ability of both US techniques to observe setting phenomena and to determine different milestones during the early age formation of CBM's microstructure. Clear physical basis, high accuracy, and non-destructive nature of the method indicate that US methods could become standardized in the near future.

Unintentional opioid overdose deaths in New York City, 2005-2010: a place-based approach to reduce risk

BACKGROUND

Drug poisoning is the leading cause of death from injuries in the United States. In New York City (NYC), unintentional drug poisoning death is the third leading cause of premature death, and opioids are the most commonly occurring class of drugs. Opioid overdose prevention efforts aim to decrease the number of people at risk for overdose and to decrease fatality rates among those using opioids by improving overdose response. These strategies can be enhanced with a comprehensive understanding of the settings in which overdoses occur.

METHODS

A cross-sectional analysis of unintentional opioid poisoning deaths in NYC from 2005 to 2010 (n=2649). Bivariate and multivariate analyses were performed to identify factors associated with settings of fatal opioid overdose.

RESULTS

Three-quarters of the sample overdosed in a home; one-tenth in an institution, and the remaining in a public indoor setting, the outdoors or another non-home setting. Factors associated with overdosing at home include female gender, college degree, residence in the borough of Staten Island, and combined use of opioid analgesics and benzodiazepines. Factors associated with overdosing outside of the home include ages 35-64, residence in Manhattan, and use of heroin.

CONCLUSION

The sample represents a near census of unintentional opioid overdose deaths in NYC during the study period, and allows for the identification of demographic and drug-using patterns by setting of overdose. Because most opioid overdoses occur inside the home, opioid overdose response programs can most efficiently address the epidemic by both reducing the risk of overdose in the home and targeting those who may be in the home at the time of an overdose for overdose response training. Approaches include minimizing risk of misuse and diversion through safe storage and safe disposal programs, physician education on prescribing of opioid analgesics and benzodiazepines, prescription of take-home naloxone, and Good Samaritan laws.

Heat-induced denaturation and aggregation of actomyosin and myosin from yellowcheek carp during setting

Thermal inactivation kinetics of Ca²⁺-ATPase, changes in turbidity and rheological properties of actomyosin and myosin from yellowcheek carp during setting at different temperatures were investigated. Actomyosin and myosin setting at 40-45 °C exhibited greater extent and more rapid Ca²⁺-ATPase inactivation compared to at 25-30 °C. Formation of protein aggregates and three-dimensional network structures of actomyosin and myosin at 25-30 °C was far less than those at 40-45 °C. Thermal stability of actomyosin was higher than that of myosin as revealed by its higher activation energy for the inactivation of Ca²⁺-ATPase. Actomyosin and myosin also exhibited different dynamic rheological properties, especially when the setting temperatures were 40 and 45 °C.