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First-line managers' experience of the use of audit and feedback cycle in specialist mental health care: A qualitative case study
Get PDFAbstract Background Audit and feedback was the main strategy to facilitate implementation of The National Guideline for Persons with Concurrent Substance Use Disorders and Mental Disorders in specialist mental health services. Studies have shown that leadership support contributes to implementation success. The aim of the study was to explore how first-line managers in a District Psychiatric Centre experienced using audit and feedback cycle. Method The study had a qualitative case study design with individual interviews with five first-line managers from a District Psychiatric Centre in Norway. Qualitative content analysis was conducted. Results First-line managers were positive to contribute to better practice for the patient group and apply available tools. Four themes emerged: 1) Lack of endurance, where first-line managers saw their role as being process leaders, but failed to persist, 2) Lack of support in the process, where first-line managers called for a stronger organisational focus 3) Lack of ownership, where first-line managers felt the process was imposed on them, and 4) Lack of leader autonomy, where first-line managers seemed insecure about their role between professional leadership and own management. Conclusion First-line managers were not sufficiently experienced or equipped to solve the implementation process satisfactorily. They were torn between different commitments, without the autonomy to act as process drivers or facilitators, and without taking the necessary leadership role. The potential impact of the use of audit and feedback may thus not be fully realized, in part, because of limited organisational support and capacity to respond effectively.submittedVersio
Autism spectrum disorder polygenic scores are associated with every day executive function in children admitted for clinical assessment
Get PDFAutism spectrum disorder (ASD) and other neurodevelopmental disorders (NDs) are behaviorally defined disorders with overlapping clinical features that are often associated with higher-order cognitive dysfunction, particularly executive dysfunction. Our aim was to determine if the polygenic score (PGS) for ASD is associated with parent-reported executive dysfunction in everyday life using the Behavior Rating Inventory of Executive Function (BRIEF). Furthermore, we investigated if PGS for general intelligence (INT) and attention deficit/hyperactivity disorder (ADHD) also correlate with BRIEF. We included 176 children, adolescents and young adults aged 5-22 years with full-scale intelligence quotient (IQ) above 70. All were admitted for clinical assessment of ASD symptoms and 68% obtained an ASD diagnosis. We found a significant difference between low and high ASD PGS groups in the BRIEF behavior regulation index (BRI) (P = 0.015, Cohen's d = 0.69). A linear regression model accounting for age, sex, full-scale IQ, Social Responsiveness Scale (SRS) total score, ASD, ADHD and INT PGS groups as well as genetic principal components, significantly predicted the BRI score; F(11,130) = 8.142, P < 0.001, R2 = 0.41 (unadjusted). Only SRS total (P < 0.001), ASD PGS 0.1 group (P = 0.018), and sex (P = 0.022) made a significant contribution to the model. This suggests that the common ASD risk gene variants have a stronger association to behavioral regulation aspects of executive dysfunction than ADHD risk or INT variants in a clinical sample with ASD symptoms. Autism Res 2020, 13: 207-220. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: People with autism spectrum disorder (ASD) often have difficulties with higher-order cognitive processes that regulate thoughts and actions during goal-directed behavior, also known as executive function (EF). We studied the association between genetics related to ASD and EF and found a relation between high polygenic score (PGS) for ASD and difficulties with behavior regulation aspects of EF in children and adolescents under assessment for ASD. Furthermore, high PGS for general intelligence was related to social problems.National Research Council of Norway. Grant Number: Grant #213694
South‐Eastern Norway Regional Health Authority. Grant Number: Grant #39763
Vestre Viken Hospital Trust. Grant Number: Grant #6903002publishedVersio
Atrial fibrillation in cryptogenic stroke and transient ischaemic attack – The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Rationale and design
No full textPurpose: Paroxysmal atrial fibrillation is often suspected as a probable cause of cryptogenic stroke. Continuous long-term ECG monitoring using insertable cardiac monitors is a clinically effective technique to screen for atrial fibrillation and superior to conventional follow-up in cryptogenic stroke. However, more studies are needed to identify factors which can help selecting patients with the highest possibility of detecting atrial fibrillation with prolonged rhythm monitoring. The clinical relevance of short-term atrial fibrillation, the need for medical intervention and the evaluation as to whether intervention results in improved clinical outcomes should be assessed.
Method: The Nordic Atrial Fibrillation and Stroke Study is an international, multicentre, prospective, observational trial evaluating the occurrence of occult atrial fibrillation in cryptogenic stroke and transient ischaemic attack. Patients with cryptogenic stroke or transient ischaemic attack from the Nordic countries are included and will have the Reveal LINQ® Insertable cardiac monitor system implanted for 12 months for atrial fibrillation detection. Biomarkers which can be used as predictors for atrial fibrillation and may identify patients, who could derive the most clinical benefit from the detection of atrial fibrillation by prolonged monitoring, are being studied.
Conclusion: The primary endpoint is atrial fibrillation burden within 12 months of continuous rhythm monitoring. Secondary endpoints are atrial fibrillation burden within six months, levels of biomarkers predicting atrial fibrillation, CHA2DS2-VASc score, incidence of recurrent stroke or transient ischaemic attack, use of anticoagulation and antiarrhythmic drugs, and quality of life measurements. The clinical follow-up period is 12 months. The study started in 2017 and the completion is expected at the end of 2020.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: NOR-FIB is an investigator driven academic study. Of the 500 devices, 400 are supported by Medtronic. The study is supported by the research infrastructure of the European Cerebrovascular Research Infrastructure (ECRI).acceptedVersio
Engagement in agriculture protects against food insecurity and malnutrition in peri-urban Nepal
Get PDFAbstract Background Urbanization is occurring rapidly in many low- and middle-income countries, which may affect households’ livelihoods, diet, and food security and nutritional outcomes. Objective The main objective of our study was to explore whether agricultural activity among a peri-urban population in Nepal was associated with better or worse food household security, household and maternal dietary diversity, and nutritional outcomes for children and women. Methods A cross-sectional survey was administered to 344 mother–child pairs in Bhaktapur district, Nepal, including data on household agricultural practices, livestock ownership, food security, dietary diversity and expenditures, anthropometric measurements of children (aged 5–6 y), maternal body mass index (BMI), and maternal anemia. Multivariable adjusted odds ratios (AORs) and unadjusted odds ratios were calculated using logistic regression. Results Our findings suggest that in this sample, cultivation of land was associated with lower odds of child stunting (AOR: 0.55; 95% CI: 0.33, 0.93) and household food insecurity (AOR: 0.33; 95% CI: 0.18, 0.63), but not low (or high) maternal BMI or anemia. Livestock ownership (mostly chickens) was associated with lower food insecurity (AOR: 0.34; 95% CI: 0.16, 0.73) but not with nutrition outcomes. Women in farming households were significantly more likely to eat green leafy vegetables than were women in nonfarming households, and children living in households that grew vegetables had a lower odds of stunting than children in households that cultivated land but did not grow vegetables (AOR: 0.49; 95% CI: 0.25, 0.98). Conclusions Our study suggests that households involved in cultivation of land in peri-urban Bhaktapur had lower odds of children's stunting and of food insecurity than noncultivating households, and that vegetable consumption is higher among those households. Given Nepal's rapid urbanization rate, more attention is needed on the potential role of peri-urban agriculture in shaping diets and nutrition.This study was funded by the USAID Feed the Future
Security Innovation Lab for Nutrition—Asia (award
number AIDOAA-l-10-00005) through a subcontract
to the Harvard T.H. Chan School of Public Health and
the Johns Hopkins Bloomberg School of Public
Health from the Friedman School of Nutrition Science
and Policy, Tufts University; and by the GC Rieber
Foundation.publishedVersio
Early life risk factors of motor, cognitive and language development: a pooled analysis of studies from low/middle-income countries
Get PDFObjective: To determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs).
Design: Meta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data.
Data sources: We searched Medline, bibliographies of key articles and reviews, and grey literature to identify studies from LMICs that collected data on early life exposures and child development. The most recent search was done on 4 November 2014. We then invited the first authors of the publications and investigators of unpublished studies to participate in the study.
Eligibility criteria for selecting studies: Studies that assessed at least one domain of child development in at least 100 children under 7 years of age and collected at least one early life factor of interest were included in the study.
Analyses: Linear regression models were used to assess SMDs in child development by parental and child factors within each study. We then produced pooled estimates across studies using random effects meta-analyses.
Results: We retrieved data from 21 studies including 20 882 children across 13 LMICs, to assess the associations of exposure to 14 major risk factors with child development. Children of mothers with secondary schooling had 0.14 SD (95% CI 0.05 to 0.25) higher cognitive scores compared with children whose mothers had primary education. Preterm birth was associated with 0.14 SD (-0.24 to -0.05) and 0.23 SD (-0.42 to -0.03) reductions in cognitive and motor scores, respectively. Maternal short stature, anaemia in infancy and lack of access to clean water and sanitation had significant negative associations with cognitive and motor development with effects ranging from -0.18 to -0.10 SDs.
Conclusions: Differential parental, environmental and nutritional factors contribute to disparities in child development across LMICs. Targeting these factors from prepregnancy through childhood may improve health and development of children.This study was supported by Grand Challenges Canada under the Saving
Brains program (grant # 0073-03) to Harvard T H Chan School of Public Health.
AS was supported by National Institute of Allergy and Infectious Diseases of the
National Institutes of Health under award number T32AI114398.publishedVersio
Corticosteroid therapy for sepsis: A clinical practice guideline
Get PDFDo corticosteroids reduce death or improve recovery in people with sepsis or septic shock? Our panel make a weak recommendation to give corticosteroids to people with all types and severity of sepsis, based on new evidence. Because we are not certain that they are beneficial, it is also reasonable not to prescribe them. Patients’ values and preferences may guide this decision-making process. This rapid recommendation was triggered by two
trials, with differing conclusions whose results might change practice: • ADRENAL (3658 patients who had septic shock) found no statistically significant difference in 90 day mortality between the hydrocortisone and placebo groups.1
• APROCCHSS (1241 patients who had septic shock) found that hydrocortisone plus fludrocortisone reduced 90 day mortality.2 The trials are incorporated into a linked systematic review comparing corticosteroids with placebo.3
This BMJ Rapid Recommendation promptly
and transparently translates this evidence using GRADE methodology for trustworthy guidelines. Sepsis is a life threatening organ dysfunction from infection. C urrently most guidelines advise against
WHAT YOU NEED TO KNOW
• Sepsis is a syndrome of life threatening infection with organ dysfunction, and most guidelines do not advise use of corticosteroids to treat it in the absence of refractory shock
• Two new trials of corticosteroid treatment for sepsis came to differing conclusions
• Corticosteroids may reduce the risk of death by a small amount and increase neuromuscular weakness by a small amount, but the evidence is not definitive
• This guideline makes a weak recommendation for corticosteroids in patients with sepsis; both steroids and no steroids are reasonable management options
• Fully informed patients who value avoiding death over quality of life and function would likely choose corticosteroids
No commercial reuse: See rights and reprints http://www.bmj.com/permissions
giving corticosteroids in sepsis in the absence of refractory shock, but these guidelines have not taken into account the new evidence. We do not anticipate that new clinical trials will substantively alter the evidence suggesting a small but uncertain mortality reduction. The box below shows publications linked in this Rapid Recommendation package. The main infographic provides an overview of the absolute benefits and harms. The table at the end of the article shows any evidence that has emerged since the publication of this guideline.This guideline was not funded
Facet arthropathy evaluation: CT or MRI?
Get PDFAbstract
OBJECTIVE:
To assess the reliability of lumbar facet arthropathy evaluation with computed tomography (CT) or magnetic resonance imaging (MRI) in patients with and without lumbar disc prosthesis and to estimate the reliability for individual CT and MRI findings indicating facet arthropathy.
METHODS:
Metal-artifact reducing CT and MRI protocols were performed at follow-up of 114 chronic back pain patients treated with (n = 66) or without (n = 48) lumbar disc prosthesis. Three experienced radiologists independently rated facet joint space narrowing, osteophyte/hypertrophy, erosions, subchondral cysts, and total grade facet arthropathy at each of the three lower lumbar levels on both CT and MRI, using Weishaupt et al's rating system. CT and MRI examinations were randomly mixed and rated independently. Findings were dichotomized before analysis. Overall kappa and (due to low prevalence) prevalence- and bias-adjusted kappa were calculated to assess interobserver agreement.
RESULTS:
Interobserver agreement on total grade facet arthropathy was moderate at all levels with CT (kappa 0.47-0.48) and poor to fair with MRI (kappa 0.20-0.32). Mean prevalence- and bias-adjusted kappa was lower for osteophyte/hypertrophy versus other individual findings (CT 0.58 versus 0.79-0.86, MRI 0.35 versus 0.81-0.90), higher with CT versus MRI when rating osteophyte/hypertrophy (0.58 versus 0.35) and total grade facet arthropathy (0.54 versus 0.31), and generally similar at levels with versus levels without disc prosthesis.
CONCLUSION:
Interobserver agreement on facet arthropathy was moderate with CT and better with CT than with MRI. Disc prosthesis did not influence agreement. A more reliable grading of facet arthropathy requires a more consistent evaluation of osteophytes/hypertrophy.
KEY POINTS:
• In this study, interobserver agreement on facet arthropathy (FA) severity-based on facet joint space narrowing, osteophyte/hypertrophy, erosions, and subchondral cysts-was better with CT versus MRI. • Metal-artifact reducing CT and MRI protocols helped to improve visibility and maintain agreement when evaluating severity of FA at levels with metallic disc prosthesis. • Agreement was poorer for severity of osteophytes/hypertrophy than for the other evaluated FA findings; improved agreement on total grade FA evaluated with CT or MRI thus requires more consistent grading of osteophytes/hypertrophy between different radiologists.acceptedVersio
Prenatal exposure to perfluoroalkyl substances and associations with symptoms of attention-deficit/hyperactivity disorder and cognitive functions in preschool children
Get PDFBACKGROUND:
Perfluoroalkyl substances (PFASs) are persistent organic pollutants that are suspected to be neurodevelopmental toxicants, but epidemiological evidence on neurodevelopmental effects of PFAS exposure is inconsistent. We investigated the associations between prenatal exposure to PFASs and symptoms of attention-deficit/hyperactivity disorder (ADHD) and cognitive functioning (language skills, estimated IQ and working memory) in preschool children, as well as effect modification by child sex.
MATERIAL AND METHODS:
This study included 944 mother-child pairs enrolled in a longitudinal prospective study of ADHD symptoms (the ADHD Study), with participants recruited from The Norwegian Mother, Father and Child Cohort Study (MoBa). Boys and girls aged three and a half years, participated in extensive clinical assessments using well-validated tools; The Preschool Age Psychiatric Assessment interview, Child Development Inventory and Stanford-Binet (5th revision). Prenatal levels of 19 PFASs were measured in maternal blood at week 17 of gestation. Multivariable adjusted regression models were used to examine exposure-outcome associations with two principal components extracted from the seven detected PFASs. Based on these results, we performed regression analyses of individual PFASs categorized into quintiles.
RESULTS:
PFAS component 1 was mainly explained by perfluoroheptane sulfonate (PFHpS), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS) and perfluorooctanoic acid (PFOA). PFAS component 2 was mainly explained by perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA) and perfluorononanoic acid (PFNA). Regression models showed a negative association between PFAS component 1 and nonverbal working memory [β = -0.08 (CI: -0.12, -0.03)] and a positive association between PFAS component 2 and verbal working memory [β = 0.07 (CI: 0.01, 0.12)]. There were no associations with ADHD symptoms, language skills or IQ. For verbal working memory and PFAS component 2, we found evidence for effect modification by child sex, with associations only for boys. The results of quintile models with individual PFASs, showed the same pattern for working memory as the results in the component regression analyses. There were negative associations between nonverbal working memory and quintiles of PFOA, PFNA, PFHxS, PFHpS and PFOS and positive associations between verbal working memory and quintiles of PFOA, PFNA, PFDA and PFUnDA, with significant relationships mainly in the highest concentration groups.
CONCLUSIONS:
Based on our results, we did not find consistent evidence to conclude that prenatal exposure to PFASs are associated with ADHD symptoms or cognitive dysfunctions in preschool children aged three and a half years, which is in line with the majority of studies in this area. Our results showed some associations between PFASs and working memory, particularly negative relationships with nonverbal working memory, but also positive relationships with verbal working memory. The relationships were weak, as well as both positive and negative, which suggest no clear association - and need for replication.This research was funded by the Research Council of Norway (MILJØFORSK, project no. 267984/E50 “NeuroTox”), National Institutes of Health (NIH) R01ES021777, and National Institute of Environmental Health Sciences (NIEHS) P30 ES010126. The ADHD Study, from which the present data were drawn, was supported by funds and grants from the Norwegian Ministry of Health, the Norwegian Health Directorate, the South-Eastern Health Region, G&PJ Sorensen Fund for Scientific Research, and from the Norwegian Resource Centre for ADHD, Tourette syndrome and Narcolepsy. The Norwegian Mother, Father and Child Cohort Study is supported by the Norwegian Ministry of Health and Care Services and the Ministry of Education and Research, NIH, and National Institute of Neurological Disorders and Stroke (NINDS) (grant no.1 UO1 NS 047537-01 and grant no.2 UO1 NS 047537-06A1). We are grateful to all the participating families in Norway who take part in this on-going cohort study, and to the staff of the ADHD Study.publishedVersio
Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: A national register study
Get PDFBACKGROUND:
Mortality rates and causes of death among individuals in opioid agonist treatment (OAT) vary according to several factors such as geographical region, age, gender, subpopulations, drug culture and OAT status. Patients in OAT are ageing due to effective OAT as well as demographic changes, which has implications for morbidity and mortality. Norway has one of the oldest OAT populations in Europe. Because of the varying mortality rates and causes of death in different subgroups and countries, research gaps still exist. The aims of this study were to describe the causes of death among OAT patients in Norway, to estimate all-cause and cause-specific crude mortality rates (CMRs) during OAT and to explore characteristics associated with drug-induced cause of death compared with other causes of death during OAT.
METHODS:
This was a national, observational register study. Data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry were combined with data from medical records. We included all patients in the Norwegian OAT programme who died not more than 5 days after the last intake of OAT medication, between 1 January 2014 and 31 December 2015.
RESULTS:
In the 2-year observation period, 200 (1.4%) of the OAT patients died. A forensic or medical autopsy was performed in 63% of the cases. The mean age at the time of death was 48.9 years (standard deviation 8.4), and 74% were men. Somatic disease was the most common cause of death (45%), followed by drug-induced death (42%), and violent death (12%). In general, CMRs increased with age, and they were higher in men and in patients taking methadone compared with buprenorphine. Increasing somatic comorbidity, measured by the Charlson comorbidity index, reduced the odds of dying of a drug-induced cause of death compared with other causes of death.
CONCLUSIONS:
Both somatic and drug-induced causes of death were common during OAT. Improved treatment and follow-up of chronic diseases, especially in patients aged > 40 years, and continuous measures to reduce drug-induced deaths appear to be essential to reduce future morbidity and mortality burdens in this population.The study was funded by Innlandet Hospital Trust (grant no. 150351). The funder had no involvement in the design of the study or in the collection, analysis and interpretation of data or in the writing of the manuscript.publishedVersio
Irritable bowel syndrome-like symptoms and health related quality of life two years after Roux-en-Y gastric bypass - a prospective cohort study
Get PDFBACKGROUND: Irritable bowel syndrome (IBS) is prevalent in patients with morbid obesity. After Roux-en-Y gastric bypass (RYGB) chronic abdominal pain is common, however the etiology is largely unknown. We aimed to study the change in the prevalence of IBS-like symptoms 2 years after RYGB and possible preoperative predictors of such symptoms. Secondly, to evaluate changes in symptoms of constipation and diarrhea, and Health related quality of life (HRQoL). METHODS: Patients with morbid obesity were included at two obesity centers in South-Eastern Norway. IBS was diagnosed according to the Rome III criteria. Predictors were evaluated in a multivariable logistic regression analysis. RESULTS: Of 307 participants operated with RYGB, 233 (76%) completed the study questionnaires. Preoperatively 27/233 participants (12%) had IBS, 2 years after RYGB 61/233 (26%) had IBS-like symptoms (p < 0.001). Eleven participants with IBS preoperatively (41%) did not report such symptoms after RYGB. New onset IBS-like symptoms was identified in 45/206 (22%) after RYGB. Fibromyalgia, low LDL levels, high vitamin B1 levels and IBS before RYGB were independent preoperative predictors of IBS-like symptoms at the follow-up visit. Symptom scores for constipation preoperatively and 2 year after RYGB were 1.5 (0.9) and 1.8 (1.2), and for diarrhea 1.4 (0.9) and 1.8 (1.1), respectively (p < 0.001). We observed a significant improvement in the physical component score for all participants. However, participants with new onset IBS-like symptoms had a significant worsening of the mental component score. CONCLUSIONS: The prevalence of IBS-like symptoms doubled 2 years after RYGB, and these symptoms were associated with reduced HRQoL. Preoperative IBS and fibromyalgia were strong predictors of postoperative IBS-like symptoms.The first author (IKBH) has received a PhD grant from South-Eastern Norway
Regional Health authority, project nr 2014073. The project has received a
financial grant from the Norwegian Gastroenterology Association, but had
no role in the design of the study, data collection, analysis and interpretation
of data or in writing the manuscript.publishedVersio