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The future of community engagement with the trans+ community
This essay reflects on ethical and inclusive research practices with the trans+ community, particularly young people, and the challenges posed by discrimination in doing such research. The essay centres the importance of trust, lived experience, and the wellbeing of researchers and research partners in creating meaningful community engagement in research.
Death and the Doctor: the museum as a tool for understanding the needs of the dying
Over the past several years, the Ashmolean Museum at Oxford has been part of a multi- disciplinary team examining the question of how we train medical students to deal with those parts of their profession which are concerned primarily with the humanity of their patients. In collaboration with colleagues from Neuroscience, Psychiatry, History and Theology, the Museum has participated in an ongoing teaching experiment in which medical history, ethics and the visual arts are brought to bear on an understanding of medical professionalism - what it means to be a doctor and how to be a better one. Bringing together museum professionals, Expert Patient Tutors and doctors in curriculum planning and delivery, the work has been delivered online, using images from the museum’s collections, and live, using the Ashmolean galleries as spaces for the consideration of issues around death, dying and end-of-life care. This article and its preface reflect broadly on a decade of medical collaboration at the Ashmolean and specifically on the processes of both making and delivering teaching on dealing with death, in a cross-disciplinary, non-medical context, asking not only what the Museum can do for medical education but why medical education needs the museum.
Temporal Dynamics of Subtle Cognitive Change: Validation of a User-Friendly Multidomain Digital Assessment Using an Alcohol Challenge.
BackgroundClinical trials in neurological and psychiatric indications are hampered by poor measurement fidelity in currently used "standardized" rating scales. Digital, repeatable tests that can be remotely administered offer a more fine-grained understanding of the patient's clinical trajectory. Several such tools are being developed, but only a few have been validated in terms of their ability to discern and describe change over time-a critical element of clinical trials.ObjectiveFour cognitive tasks from a digital battery (delivered via tablet) are administered at high frequency following an alcohol challenge to assess sensitivity to change. The tasks are novel, repeatable, and self-administered implementations of classic neurobehavioral paradigms.MethodsThirty healthy younger adults were assessed on 2 separate days, once under the influence of alcohol and once under a placebo, with order counterbalanced. Each day included 8 assessments. The tasks comprised novel, engaging implementations of the Digit Symbol Substitution Task (DSST), reaction time, N-back working memory, and visual associative/episodic memory, and were compared with benchmark measures. In-laboratory assessments were preceded by massed practice (3 sessions), and blood alcohol concentration was monitored throughout using a breathalyzer and a Visual Analog Scale.ResultsAlcohol-related impairment was observed across multiple measures, followed by a return to baseline as blood alcohol concentration declined. A slight practice effect was noted between the first and second sessions for the digital DSST, along with a longer-term effect across the 2 days. Moderate to strong correlations between digital and benchmark measures were observed at peak intoxication.ConclusionsUnder alcohol challenge, this battery, along with benchmark standardized tests, demonstrates sensitivity to subtle changes in cognitive performance over time. Practice effects are minimal within this condensed protocol. Patient-friendly, repeatable tests administered via a digital platform, such as those in the current battery, warrant further investigation in the context of remote clinical studies that require methodological approaches capable of discerning and describing small changes over time. The availability of validated single tests or test batteries as sensitive tools that can be easily and frequently administered (eg, daily) would address a critical gap: the lack of descriptors with sufficient sensitivity, specificity, and reliability to detect cognitive changes over time in clinical trials of new therapies for neurological and psychiatric conditions.
The Adoption of Digital Games Among Older Adults
The revolution of technology brings many benefits towards diverse population. Digital game is one of the digital technologies that has potential to facilitate older adults’ daily routine. However, some of them faces challenges to adopt the usage of digital games in their daily lives, one of which is that most commercial games are not suitable for older people. This paper discusses the investigation into the challenges associated with the older adults’ adoption of digital games, their interaction, and experiences with digital games and specifically explores the andragogical perspectives, and game design attributes. A set of questionnaires consisted of open-ended and close-ended questions were distributed, targeting the older adults across Malaysia, using online and non-probability sampling technique. 81 respondents were recruited, and 56 respondents (n=56) were eligible in this study. Four participants were recruited for informal interview session. The analysis of the results indicates that the older adults’ perception of digital games and game design aspects are the major factors influencing their digital game adoption. Game designs are important to attract many older adults to experience and interact with digital games
Antidepressant Switching as a Proxy Phenotype for Drug Nonresponse: Investigating Clinical, Demographic, and Genetic Characteristics.
BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are a first-line pharmacological therapy in major depressive disorder (MDD), but treatment response rates are low. Clinical trials lack the power to study the genetic contribution to SSRI response. Real-world evidence from electronic health records provides larger sample sizes, but novel response definitions are needed to accurately define SSRI nonresponders. METHODS: In the UK Biobank (UKB) (N = 38,813) and Generation Scotland (N = 1777) datasets, SSRI switching was defined using ≤90-day gap between prescriptions for an SSRI and another antidepressant in primary care. Nonswitchers were participants with ≥3 consecutive prescriptions for an SSRI. In the UKB, clinical, demographic, and polygenic score (PGS) associations with switching were determined, and the common-variant heritability was estimated. RESULTS: In the UKB, 5133 (13.2%) SSRI switchers and 33,680 nonswitchers were defined. The mean time to switch was 28 days (interquartile range, 17-49). Switching patterns were consistent across the UKB and Generation Scotland (n = 498 switchers). Higher annual income and educational levels (odds ratio [OR] [95% CI] for a university degree, 0.73 [0.67-0.79] compared with no qualifications) were associated with lower levels of switching. PGSs for nonremission, based on clinical studies, were associated with increased risk of switching (OR, 1.07 [1.02-1.12], p = .007). MDD PGSs and family history of depression were not significantly associated with switching. Using genome-wide complex trait Bayesian, the single nucleotide polymorphism-based heritability was approximately 4% (SE 0.016) on the observed scale. CONCLUSIONS: This study identified SSRI switching as a proxy for nonresponse, scalable across biobanks with electronic health records, capturing demographics and genetics of treatment nonresponse, and independent of MDD genetics.
The effect of D-cycloserine on brain connectivity over a course of pulmonary rehabilitation - A randomised control trial with neuroimaging endpoints.
Combining traditional therapies such as pulmonary rehabilitation with brain-targeted drugs may offer new therapeutic opportunities for the treatment of chronic breathlessness. Recently, we asked whether D-cycloserine, a partial NMDA-receptor agonist which may enhance behavioural therapies, modifies the relationship between breathlessness related brain activity and breathlessness anxiety over pulmonary rehabilitation. However, whether any changes are supported by alterations to underlying brain structure remains unknown. Here we examine the effect of D-cycloserine over a course of pulmonary rehabilitation on the connectivity between key brain regions associated with the processing of breathlessness anxiety. 72 participants with mild-to-moderate COPD took part in a longitudinal study in parallel to their pulmonary rehabilitation course. Diffusion tensor brain imaging and clinical measures of respiratory function were collected at three time points (before, during and after pulmonary rehabilitation). Participants were assigned to 250mg of D-cycloserine or placebo, which they were administered with on four occasions in a randomised, double-blind procedure. Following the first four sessions of pulmonary rehabilitation (visit 2), during which D-cycloserine was administered, improvements in breathlessness anxiety were linked with increased insula-hippocampal structural connectivity in the D-cycloserine group when compared to the placebo group. No differences were found between the two groups following the completion of the full pulmonary rehabilitation course 4-6 weeks later (visit 3). The action of D-cycloserine on brain connectivity appears to be restricted to within a short time-window of its administration. This temporary boost of the brain connectivity of two key regions associated with the evaluation of how unpleasant an experience is may support the re-evaluation of breathlessness cues, illustrated improvements in breathlessness anxiety. Trial registration ClinicalTrials.gov (NCT01985750).
Collaborative risk assessment and management planning in secure mental health services in England: protocol for a realist review.
INTRODUCTION: Secure mental health pathways are complex. They are typically based around secure hospitals, but also interface with justice agencies and other clinical services, including in the community. Consideration of risk is fundamental to clinical care and to decisions relating to a patient's stepwise journey through the pathway. Patient autonomy and involvement in decision-making are policy priorities for health services. However, improving collaboration in risk-related decisions in secure services is complicated by potential issues with insight and capacity and the necessary involvement of other agencies. In addition, although some collaborative approaches are feasible and effective, their impact, mechanisms and the contexts in which they work are not well understood. Therefore, using realist methodology, this review will outline what works, for whom, why and under what circumstances in terms of collaborative risk assessment and management in secure services. METHODS AND ANALYSIS: The review will consist of four stages: (1) Development of an initial programme theory to explain how and why collaborative risk assessment and management works for different groups of people, (2) search for evidence, (3) data selection and extraction and (4) evidence synthesis and development of a final programme theory. Our initial programme theory will be informed by an informal search of the literature and consultation with experts and patient and public involvement and engagement representatives. Following this, our formal literature search will include both the published and unpublished literature. During full text screening, each document will be assessed according to the principles of rigour and relevance and, if included, data will be extracted and synthesised to refine the programme theory. ETHICS AND DISSEMINATION: This protocol is for a review of published literature and so does not require ethical approval. The main output will be the final programme theory. Remaining gaps will inform planned future work to further refine the theory using mixed methods. Our dissemination strategy will be codeveloped with our public and patient involvement group and will include publishing findings in a peer-reviewed journal and presenting findings at relevant professional conferences, as well as engaging patient, carer and clinician groups directly.
Working Memory Predicts Long-Term Recognition of Auditory Sequences: Dissociation Between Confirmed Predictions and Prediction Errors.
Memory is a crucial cognitive process involving several subsystems: sensory memory (SM), short-term memory (STM), working memory (WM), and long-term memory (LTM). While each has been extensively studied, the interaction between subsystems, particularly in relation to predicting temporal sequences, remains largely unexplored. This study investigates the association between WM and LTM, and how these relate to aging and musical training. Using three datasets with a total of 243 healthy volunteers across various age groups, we examined the impact of WM, age, and musical training on LTM recognition of novel and previously memorized musical sequences. Our results show that WM abilities are positively associated with the identification of novel sequences, but not with the recognition of memorized sequences. Additionally, musical training has a similar positive impact on the identification of novel sequences, while increasing age is associated with reduced memory performance. Different cognitive processes are involved in handling prediction errors compared to confirmatory predictions, and WM contributes to these processes differently. Future research should extend our investigation to populations with memory impairments and explore the underlying neural substrates.
Introduction of point-of-care blood testing in early intervention in psychosis services: effects on physical health screening.
BACKGROUND: There is a significant mortality gap between the general population and people with psychosis. Completion rates of regular physical health assessments for cardiovascular risk in this group are suboptimal. Point-of-care testing (POCT) for diabetes and hyperlipidaemia - providing an immediate result from a finger-prick - could improve these rates. AIMS: To evaluate the impact on patient-clinician encounters and on physical health check completion rates of implementing POCT for cardiovascular risk markers in early intervention in psychosis (EIP) services in South East England. METHOD: A mixed-methods, real-world evaluation study was performed, with 40 POCT machines introduced across EIP teams in all eight mental health trusts in South East England from March to May 2021. Clinician training and support was provided. Numbers of completed physical health checks, HbA1c and lipid panel blood tests completed 6 and 12 months before and 6 months after introduction of POCT were collected for individual patients. Data were compared with those from the South West region, which acted as a control. Clinician questionnaires were administered at 2 and 8 months, capturing device usability and impacts on patient interactions. RESULTS: Post-POCT, South East England saw significant increases in HbA1c testing (odds ratio 2.02, 95% CI 1.17-3.49), lipid testing (odds ratio 2.38, 95% CI 1.43-3.97) and total completed health checks (odds ratio 3.61, 95% CI 1.94-7.94). These increases were not seen in the South West. Questionnaires revealed improved patient engagement, clinician empowerment and patients' preference for POCT over traditional blood tests. CONCLUSIONS: POCT is associated with improvements in the completion and quality of physical health checks, and thus could be a tool to enhance holistic care for individuals with psychosis.
The therapeutic potential of exercise in post-traumatic stress disorder and its underlying mechanisms: A living systematic review of human and non-human studies
Background Exercise for post-traumatic stress disorder (PTSD) is a potentially effective adjunct to psychotherapy. However, the biopsychosocial mechanisms of exercise are not well understood. This co-produced living systematic review synthesizes evidence from human and non-human studies. Methods We Included controlled human and non-human studies involving searches of multiple electronic databases (until 31.10.23). Records were screened, extracted, assessed for risk of bias, and reconciled by two independent reviewers. The primary outcome for human studies was PTSD symptom severity, while outcomes of interest for non-human studies included freezing behaviour, fear memory, fear generalization, startle response, and locomotion. Data were synthesised with random-effects meta-analysis. Results Eleven human studies and 14 non-human studies met the eligibility criteria. Results of human studies showed that exercise was not associated with symptom severity improvement compared to control (standardized mean difference [SMD] -0.08, 95% confidence interval [CI] -0.24 to 0.07). High-intensity exercise reduced PTSD symptoms scores more than moderate-intensity exercise. There was insufficient data to examine the effects of exercise on functional impairment, PTSD symptom clusters, and PTSD remission. Only three studies, all at high risk of bias, examined mechanisms of exercise with inconclusive results. Results of non-human studies showed that exercise was associated with improvement in all behavioural outcomes, including locomotor activity (SMD 1.30, 95% CI 0.74 to 1.87, 14 studies), and changes in several neurobiological markers, including increase in brain-derived neurotrophic factor (SMD 1.79, 95% CI 0.56 to 3.01). Conclusions While non-human studies provide compelling evidence for the beneficial effects of exercise, human trials do not. Evidence from non-human studies suggest that exercise might increase the levels of brain-derived neurotrophic factor, enhance cognitive appraisal, and improve perceived exertion. Overall, the paucity of data on the effectiveness of exercise in PTSD and mechanisms of action underscore the need for rigorous trials. Registration The protocol was registered with PROSPERO (ID:453615; 22.08.2023).