Decision-Making on the Defensive Line: A CCO-Analysis of Decision-Making, Authority, and Ventriloquism

Working alongside a suicide prevention nonprofit in its early stages of formal organizing, this project utilizes qualitative research methodology to explore the roles of authority and ventriloquism in decision-making situations. Specifically focused on partnership and collaboration-related decisions, the analysis utilized participant observation, textual analysis, and semi-structured interviews to analyze questions regarding decision-making moments. Exploring these moments of decision-making from a Communication Constitutes Organization (CCO) framework, this study contributes to understanding authority and ventriloquism in decision-making. It emphasizes the importance of both human and nonhuman elements that (re)constitute the organization itself. Some of the important nonhuman elements this study draws attention to are emotions. Additionally, the study highlights the presence of multiple vents at play in the same decision-making situation. Finally, the analysis complicates notions of authority, understanding it both as communicatively negotiated and as a resource that can be assigned and transferred depending on the situation at hand.</p

Transformation through adaptation: a grounded theory of the patient experience of Alcohol-Related Brain Damage

Background: Alcohol Related Brain Damage (ARBD) is an umbrella term used to describe the range of effects that long-term consumption of alcohol can have on the structure and function of the brain. Despite the increasing prevalence of ARBD, there is a lack of research in this area, and as a result, there are no current guidelines and few services available for the treatment of this condition. There is therefore a need to increase the evidence base in this area, which will assist in the understanding, and ultimately treatment, of ARBD. Aims: This thesis consists of two parts. The first is a systematic review journal article which asks the question: “What is the impact of alcohol-abuse on memory function within the first three weeks of alcohol withdrawal?” The second part is a qualitative research project which aims to develop a grounded theory regarding the patient experience of ARBD, identifying and highlighting themes and concepts that are central to the experience. Methods: For the systematic review, four databases were searched. Studies that were included in the review had to have participants with alcohol-dependence; abstinence of less than or equal to three weeks; and to have undergone some form of neuropsychological assessment of memory function. Data from 15 articles were extracted and assessed for quality. For the qualitative study, participants (n=10) were interviewed regarding their experiences of ARBD and the data was then analysed using grounded theory methodology. Results: The results of the systematic review were somewhat ambiguous with some studies reporting impairments in verbal and visual memory, while other studies found no impairments. Episodic memory deficits were present in all studies reviewed. The results of the qualitative study propose a tentative model which describes “transformation through adaptation”. This model hypothesises that successful negotiation of the journey through ARBD hinges on the adaptations that need to be made in order to progress towards transformation. The model is understood in the framework of a number of phases, “Being diagnosed with ARBD, “Focusing on abstinence”, “Taking ownership of life with ARBD” and “Creating a valuable life”, all of which exist within a framework of being supported by specialist services. Conclusions and implications: The systematic review demonstrated some support for deficits in visual and episodic memory within the first three weeks of abstinence, while it appeared that verbal memory was relatively preserved. The heterogeneity of the studies, coupled with the methodological variability, meant that all conclusions need to be considered as tentative, and be interpreted with caution. The main difficulties with interpretation were to do with the confounding factors often found within this client group. The results reinforce the concept of tailored treatment programmes for individuals due to the large variability of the effect of alcohol (and other factors). The qualitative study proposes a model that shows how adaptation appears to play a key role in the successful negotiation of a diagnosis of ARBD. The study describes a series of categories that can be used as a framework to identify and support the changes that are necessary for recovery and reintegration. The value in this study is that the results are directly attributable to individuals who have been diagnosed, and are now successfully living, with ARBD

Exploring the effectiveness of a screening measure to identify subtle cognitive and functional problems in a sample of acquired brain injury patients admitted to a neurological hospital in the UK: A feasibility study.

Patients considered asymptomatic after acquired brain injury (ABI) may be exhibiting undetected cognitive deficits which can lead to problems with everyday tasks. Current screening tools focus on cognitive deficits and not functional impact. This cross-sectional feasibility study aimed to explore the use of a bedside screening tool: Cognitive Functional Performance Measure (CFPM). Drawing on occupational therapy theory and principles, the CFPM offers the multi-disciplinary team a unique tool to trigger referral to occupational therapy. A sample of patients with ABI (n = 34) were recruited and their CFPM scores were compared with scores on the Montreal Cognitive Assessment (MoCA) and the Kettle Test. Spearman’s rank and Chi-square were used to analyse the data. A moderate correlation was found between the MoCA and CFPM. There was no significant association between the type of ABI and performance on the CFPM. The unique design of the CFPM offers an alternative to existing screening tools, placing emphasis on the identification of cognitive impairment and functional deficits with the ultimate goal to develop a tool that is ecologically valid. Further studies exploring the feasibility and validity of the CFPM is recommended

Direct to public peer support and e-therapy program versus information to aid self-management of depression and anxiety: protocol for a randomized controlled trial

Regardless of geography or income, effective help for depression and anxiety only reaches a small proportion of those who might benefit from it. The scale of the problem suggests a role for effective, safe, anonymised public health driven online services such as Big White Wall which offers immediate peer support at low cost. Objectives: Using RE-AIM methodology we will aim to determine the population reach, effectiveness, cost effectiveness, and barriers and drivers to implementation of Big White Wall (BWW) compared to online information compiled by the UK’s National Health Service (NHS Choices Moodzone) in people with probable mild to moderate depression and anxiety disorder. Method/Design: A pragmatic, parallel group, single blind RCT is being conducted using a fully automated trial website in which eligible participants are randomised to receive either 6 months access to BWW or signposted to the NHS Moodzone site. The recruitment of 2200 people to the study will be facilitated by a public health engagement campaign involving general marketing and social media, primary care clinical champions, healthcare staff, large employers and third sector groups. People will refer themselves to the study and will be eligible if they are over 16 years, have probable mild to moderate depression or anxiety disorders and have access to the internet. The primary outcome will be the Warwick-Edinburgh Mental Well-being Scale at six weeks. We will also explore the reach, maintenance, cost-effectiveness, barriers and drivers to implementation and possible mechanisms of actions using a range of qualitative and quantitative methods. Discussion: This will be the first fully digital trial of a direct to public on line peer support programme for common mental disorders. The potential advantages of adding this to current NHS mental health services and the challenges of designing a public health campaign and randomised controlled trial of two digital interventions using a fully automated digital enrolment and data collection process are considered for people with depression and anxiety

Protocol investigating the clinical outcomes and cost-effectiveness of cognitive–behavioural therapy delivered remotely for unscheduled care users with health anxiety: randomised controlled trial

Background Health anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable. Aims To investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive–behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036). Method A multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6–12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome. Results This trial will be the first to test the clinical outcomes and costeffectiveness of remotely delivered CBT for the treatment of high health anxiety. Conclusions The findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care

Effect of COVID-19 on presentations of decompensated liver disease in Scotland

BACKGROUND AND AIMS: SARS-CoV-2 and consequent pandemic has presented unique challenges. Beyond the direct COVID-related mortality in those with liver disease, we sought to determine the effect of lockdown on people with liver disease in Scotland. The effect of lockdown on those with alcohol-related disease is of interest; and whether there were associated implications for a change in alcohol intake and consequent presentations with decompensated disease. METHODS: We performed a retrospective analysis of patients admitted to seven Scottish hospitals with a history of liver disease between 1 April and 30 April 2020 and compared across the same time in 2017, 2018 and 2019. We also repeated an intermediate assessment based on a single centre to examine for delayed effects between 1 April and 31 July 2020. RESULTS: We found that results and outcomes for patients admitted in 2020 were similar to those in previous years in terms of morbidity, mortality, and length of stay. In the Scotland-wide cohort: admission MELD (Model for End-stage Liver Disease) (16 (12–22) vs 15 (12–19); p=0.141), inpatient mortality ((10.9% vs 8.6%); p=0.499) and length of stay (8 days (4–15) vs 7 days (4–13); p=0.140). In the Edinburgh cohort: admission MELD (17 (12–23) vs 17 (13–21); p=0.805), inpatient mortality ((13.7% vs 10.1%; p=0.373) and length of stay (7 days (4–14) vs 7 days (3.5–14); p=0.525)). CONCLUSION: This assessment of immediate and medium-term lockdown impacts on those with chronic liver disease suggested a minimal effect on the presentation of decompensated liver disease to secondary care

Simpson's paradox and calculation of number needed to treat from meta-analysis

BACKGROUND: Calculation of numbers needed to treat (NNT) is more complex from meta-analysis than from single trials. Treating the data as if it all came from one trial may lead to misleading results when the trial arms are imbalanced. DISCUSSION: An example is shown from a published Cochrane review in which the benefit of nursing intervention for smoking cessation is shown by formal meta-analysis of the individual trial results. However if these patients were added together as if they all came from one trial the direction of the effect appears to be reversed (due to Simpson's paradox). Whilst NNT from meta-analysis can be calculated from pooled Risk Differences, this is unlikely to be a stable method unless the event rates in the control groups are very similar. Since in practice event rates vary considerably, the use a relative measure, such as Odds Ratio or Relative Risk is advocated. These can be applied to different levels of baseline risk to generate a risk specific NNT for the treatment. SUMMARY: The method used to calculate NNT from meta-analysis should be clearly stated, and adding the patients from separate trials as if they all came from one trial should be avoided

The impact of outpatient <i>versus</i> inpatient management on health-related quality of life outcomes for patients with malignant pleural effusion: the OPTIMUM randomised clinical trial

Background: The principal aim of malignant pleural effusion (MPE) management is to improve health-related quality of life (HRQoL) and symptoms.Methods: In this open-label randomised controlled trial, patients with symptomatic MPE were randomly assigned to either indwelling pleural catheter (IPC) insertion with the option of talc pleurodesis or chest drain and talc pleurodesis. The primary end-point was global health status, measured with the 30-item European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at 30 days post-intervention. 142 participants were enrolled from July 2015 to December 2019.Results: Of participants randomly assigned to the IPC (n=70) and chest drain (n=72) groups, primary outcome data were available in 58 and 56 patients, respectively. Global health status improved in both groups at day 30 compared with baseline: IPC (mean difference 13.11; p=0.001) and chest drain (mean difference 10.11; p=0.001). However, there was no significant between-group difference at day 30 (mean intergroup difference in baseline-adjusted global health status 2.06, 95% CI −5.86–9.99; p=0.61), day 60 or day 90. No significant differences were identified between groups in breathlessness and chest pain scores. All chest drain arm patients were admitted (median length of stay 4 days); seven patients in the IPC arm required intervention-related hospitalisation.Conclusions: While HRQoL significantly improved in both groups, there were no differences in patient-reported global health status at 30 days. The outpatient pathway using an IPC was not superior to inpatient treatment with a chest drain

Habitat use affects morphological diversification in dragon lizards

Habitat use may lead to variation in diversity among evolutionary lineages because habitats differ in the variety of ways they allow for species to make a living. Here, we show that structural habitats contribute to differential diversification of limb and body form in dragon lizards (Agamidae). Based on phylogenetic analysis and ancestral state reconstructions for 90 species, we find that multiple lineages have independently adopted each of four habitat use types: rock-dwelling, terrestriality, semi-arboreality and arboreality. Given these reconstructions, we fit models of evolution to species’ morphological trait values and find that rock-dwelling and arboreality limit diversification relative to terrestriality and semi-arboreality. Models preferred by Akaike information criterion infer slower rates of size and shape evolution in lineages inferred to occupy rocks and trees, and model-averaged rate estimates are slowest for these habitat types. These results suggest that ground-dwelling facilitates ecomorphological differentiation and that use of trees or rocks impedes diversification