Step Approach Research Articles

Fever of unknown origin in pediatrics: causes and clinical characteristics in a single centre experience

BackgroundFever of unknown origin (FUO) is a common condition worldwide in children that remains a diagnostic challenge. The causes of FUO vary depending on the patient's age, residency, and the time of study. Therefore, this study aimed to identify the common aetiologies of FUO at Alexandria University Children’s Hospital under the current diagnostic abilities and newly emerging diseases.MethodsThe current prospective observational study included all children fulfilling the definition of FUO admitted at Alexandria University Children's Hospital from January 2020 to December 2021 using a steps approach for investigations.ResultsA total of 110 children with fever of unknown origin (FUO) were included in this study; the average duration of fever was 36.76 ± 31.73 days. In most of the enrolled cases 105/110 (95.4%) the definite etiology of FUO was identified. The common causes were collagen vascular diseases (30.9%), infectious diseases (28.2%), miscellaneous conditions (19.1%), and malignancy (17.3%). Among collagen vascular diseases, systemic lupus erythematosus (SLE) (47.1%) and systemic onset juvenile idiopathic arthritis (sJIA) (38.2%) were the most common. In the infectious category, Katayama fever (16.1%), brucellosis (12.9%), and urinary tract infection (UTI) (12.9%) were the most frequently observed. Post-Covid MIS-C (52.4%) was the most common in the miscellaneous category. Children in the infectious category had significantly higher neutrophil [5.76 (2.28–7.92) × 10^3/µl] and lymphocytic counts [ 4.2 (2.04–5.91) × 10^3/µl]; (P < 0.001 and < 0.010 respectively). Moreover, in the collagen category the median lymphocytic count was lower [1.95 (1.47–2.73) × 10^3/µl] with a significantly (P < 0.010) higher neutrophil/ lymphocyte ratio [2.30 (1.53–3.91)].ConclusionCollagen vascular diseases, infectious diseases, miscellaneous, and malignancy were the most common causes of FUO. Katayama fever, urinary tract infections (UTI), and brucellosis were the most common causes in the infectious category. Post-Covid MIS-C and hemophagocytic lymphohistiocytosis were the most common diagnoses in the miscellaneous category.

Levels and outcomes of 12-step participation among sexual and gender minority subgroups

IntroductionSexual minority (e.g., bisexual, gay, lesbian, queer) and gender minority (e.g., transgender, non-binary, gender expansive) individuals (SGMI) experience higher rates of alcohol and other substance use disorders than their heterosexual and cisgender (i.e., non-transgender) counterparts. 12-Step programs are currently the most common source of support for alcohol and other substance use-related problems in the United States. Little is known about rates and levels of participation and outcomes of SGMI in 12-Step programs. Examining SGMI with a lifetime alcohol or other substance use disorder, this study aims to: 1) describe lifetime attendance rates (any vs. none) and levels of participation (number of program activities) in 12-Step groups among SGMI overall and compare rates of attendance and levels of participation across sexual and gender minority identities and 2) determine how lifetime level of participation in 12-Step programs relates to past-year alcohol and other substance use outcomes. MethodsWe used data collected through The PRIDE Study, a national, large-scale, longitudinal health study of adult SGMI, administering supplemental questions to assess alcohol and other substance use disorders and 12-step participation. Zero-Inflated Negative Binomial models (N = 1353) run with sexual and gender identities as predictors of lifetime 12-step attendance (yes/no) and level of 12-Step participation determine if greater levels of 12-Step participation were associated with lower levels of past-year Alcohol and Substance Use Disorder (AUD & SUD) symptoms. The study ran models for those with lifetime AUD (n = 1074) and SUD (n = 659) separately. ResultsParticipants who engaged in greater levels of 12-Step participation had lower levels of past-year AUD and SUD symptoms. Gay and queer respondents with AUD were more likely and lesbian respondents with SUD were less likely than other participants to have ever participated in 12-Step programs. All other associations between sexual/gender identities and 12-Step participation disappeared when age was added to the model. ConclusionsThis study provides preliminary evidence that 12-Step participation may be an effective resource for reducing AUD and SUD symptoms among SGMI. Younger SGMI and SGMI holding sexual/gender identities other than gay and queer may require additional support to initiate participation in 12-Step programs.

Exploring heterogeneity in coxarthrosis medication use patterns before total hip replacement: a State Sequence Analysis

ObjectiveEvidence of geographical variation in total hip replacement (THR) and deviations from treatment guidelines persists. In this exploratory study, we aim to gain an in-depth understanding of patients’ healthcare trajectories...

공유의사결정: 무엇을 공유하고 누가 어떻게 결정하는가?

In this article, I analyze the concept of shared decision-making to explain what is shared, who decides, how the decision is made, and how shared decision-making differs from informed consent. Building on the work of Veatch and Charles, I argue that shared decision-making has two essential features: (a) it helps patients make decisions while respecting their right to self-determination, and (b) it maintains the integrity of both physicians and patients. Furthermore, using the three-talk model and the six steps approach to shared decision-making, I explicate the concept of “mutual acceptance,” which is central to this process. Mutual acceptance of the final decision is a two-step process: physicians first formulate options that align with their own integrity, and then patients deliberate and choose the options that best suit their needs, wishes, and constraints. Thus, I argue that mutual acceptance represents physicians’ acceptance of their patients’ final decisions. Furthermore, the closer the original options are to equipoise, the less psychological burden physicians will experience regarding the choices their patients make.

A Power Law Reconstruction of Ultrasound Backscatter Images

Ultrasound B-scan images are traditionally formed from the envelope of the received radiofrequency echoes, but the image texture is dominated by granular speckle patterns. Longstanding efforts at speckle reduction and deconvolution have been developed to lessen the detrimental aspects of speckle. However, we now propose an alternative approach to estimation (and image rendering) of the underlying fine grain scattering density of tissues based on power law constraints. The key steps are a whitening of the spectrum of the received signal while conforming to the original envelope shape and statistics, followed by a power law filtering in accordance with the known scattering behavior of tissues. This multiple step approach results in a high-spatial-resolution map of scattering density that is constrained by the most important properties of scattering from tissues. Examples from in vivo liver scans are shown to illustrate the change in image properties from this framework.

Protocol for the development and validation of a trigger tool for antiretroviral ADE detection among adult HIV/AIDS patients: A short communication

Antiretroviral therapy (ART) is a lifelong combination therapy which has been very promising in managing HIV/AIDs but reported to have several adverse events on the recipients, affecting the desired antiretroviral therapeutic goals. Adverse drug event detection and prevention therefore become very important safety culture maintenance tools among patients living with HIV/AIDS. The designed protocol provided step by step approaches to develop and validate a trigger tool for detection of adverse drug events (ADE) among adult HIV/AIDS patients. The approaches involved include a baseline (Pre-trigger tool development) retrospective clinical record review to establish a baseline ADE detection capacity of a conventional non-trigger tool method; the Delphi panel process to develop the trigger tool in question; Face and content validity approach for validation of the developed trigger tool; Pilot test of the trigger tool using small clinical record sample; determining the effectiveness of the developed trigger tool through the retrospective clinical record review of same samples reviewed at the baseline. Finally, the protocol described the process of determining the feasibility of the developed trigger tool through the survey of the clinical record review team members.

Putting person-centred psychosocial diabetes care into practice: two psychosocial care pathways based on outcome preferences of people with diabetes and healthcare professionals

BackgroundDiabetes increases the risk of psychosocial health problems. Person-centred psychosocial care is therefore advocated. However, several barriers to implementation exist, including uncertainty about how to approach psychosocial problems in consultations.ObjectiveWe...

Unbraiding the effect of policy benefits on subjective well-being: the mediating role of work-related well-being

PurposeThis piece of research attempts to find out the association between work-related well-being (WWB), benefits of scheme (BoS) and subjective well-being (SWB). The study was conducted on handloom weavers in Uttar Pradesh (UP), India.Design/methodology/approachThe association among the variables was studied using structural equation modeling on Amos 22. The tripartite relationship of WWB, BoS and SWB was explored using causal steps approach. Bootstrapping of a sample size of 2,000 was performed. A cross-sectional survey was conducted on 403 weavers, and convenient sampling was done.FindingsA direct link was found by the structural equation modeling (SEM) results between benefits of schemeBoS and SWB, which was reflected by a value of rˆ2 (0.33) at significance level p &lt; 0.001. The standardized indirect effect of BoS on SWB was found to be 0.158 (p &lt; 0.001). In the presence of WWB, the relationship between BoS and SWB (direct effect) stands significant, thus making this a case of partial mediation. The value of Rˆ2 is increased to 48.1% in presence of a mediating variable.Research limitations/implicationsThe study indicated the importance of WWB and how it can enhance SWB.Originality/valueThe relationship between SWB, WWB and policy benefits has still not been explored.

Dialectical behavior therapy (DBT) in an assertive community treatment structure (ACT): testing integrated care borderline (ICB) in a randomized controlled trial (RECOVER)

BackgroundThough Dialectical Behavior Therapy (DBT) and other treatment models for individuals with Borderline Personality Disorder (BPD) have shown to be efficient in inpatient and outpatient settings, there is a general shortage of these treatments. In Germany, most resources are spent on inpatient treatments and unspecific crisis interventions, while it is difficult to implement the necessary team structures in an outpatient setting. This study is testing an alternative approach focussing on outpatient treatment: Integrated Care Borderline (ICB) provides DBT for persons with severe BPD within the structures of an Assertive Community Treatment (ACT). ICB is team-based, integrating psychiatric and social support as well as crisis interventions into a DBT-strategy.MethodsICB was compared to TAU in a prospective, randomized controlled trial. This study is part of RECOVER, a comprehensive stepped care approach in Germany, which enrolled a total of 891 participants. 146 persons were diagnosed with BPD as main diagnosis. Of these, 100 were allocated to the highest level of severe mental illness (SMI) and randomly assigned to either ICB (n = 50) or TAU (n = 50). Data were collected at baseline and 12 months later. The main outcomes were psychosocial functioning (GAF), severity of BPD (BSL-23) and other mental symptoms (BSI, PHQ-9, GAD-7, self-harm), employment status (VILI), as well as hospital days and associated costs.ResultsData show a significant increase of psychosocial functioning and a significant decrease of BPD and other psychiatric symptoms in both groups (r = .28 – .64), without any significant differences between the groups. The proportion of self-harming persons decreased in both groups without statistical significance. Patients were significantly more likely to be employed after a year of treatment in ICB (p = .001), but not in the TAU group (p = .454). Analyses showed a significant difference between the groups (p = .032). Moreover, psychiatric hospital days were significantly reduced in ICB (-89%, p < .001, r = .61), but not in TAU (-41%, p = .276, r = .15), resulting in a significant difference between the groups (p = .016) and in lower annual hospital costs in ICB (5,546€ vs. 10,726€, -48%, p = .011) compared to TAU.ConclusionOur results replicate earlier studies, showing that DBT can be efficient in outpatient settings. Furthermore, they indicate additional effects on employment and hospital days. The ICB-approach seems to offer a viable framework for multiprofessional outpatient DBT-teams. Future research will have to test whether the additional effects are brought about by the additional features of ICB compared to standard outpatient DBT.Trial registrationRegistration number with ClinicalTrials.gov (NCT03459664), RECOVER.

AA, Bill Wilson, Carl Jung and LSD.

Alcoholics Anonymous (AA) is an established resource for people suffering from alcohol use disorder (AUD). However, Bill Wilson, the co-founder of AA, in his second letter to Jung referred to its low success rate. One evidence-based alternative, dating back to the 1950s, is the clinical use of lysergic acid diethylamide (LSD) for treating AUD. Bill Wilson was a strong advocate of using LSD as a preparation for alcoholics who had difficulty grasping the spiritual aspect of the 12-step programme. Bill Wilson wrote a "secret" four-page letter to Carl Jung detailing his own use of LSD and the success two psychiatrists in Canada had in treating alcoholics and asked for his advice on using LSD to help alcoholics. Aniela Jaffé, a Jungian analyst and co-worker of Jung, replied to Wilson on May 29, 1961, "… as soon as Dr. Jung feels better and has enough strength to begin again his mail, I will show it to him." Jung died a week later. This article quotes Jung's previous hostile opinions on psychedelics and asks: Just as Jung overcame his negative views on groups when giving "complete instructions" on extending the 12-step programme of AA to "general neurotics", might he similarly have changed his mind when he saw the documented success of using LSD with recalcitrant alcoholics?

Great leap forward famine exposure and urban-rural migration convolute the modern prevalence of diabetes in China

BackgroundAlthough evidence from birth cohort analysis has indicated the metabolic risk of early-life exposure to the Great Leap Forward Famine (GLFF) in China, three confounding effects, including the exposure windows, aging, and geographical variations in famine severity, have been brought to debates for a decade. This study aimed to address these confounding effects and extensively examine how GLFF exposure is associated with diabetes risk in mid-to-late life and its interaction with urban-rural migration.MethodsData from the China Health and Retirement Longitudinal Study (CHARLS) were analyzed with age-stratification and stepped wedge approaches. Weighted prevalence and multivariable logistic regression were used to investigate the effects of GLFF exposure and urban-rural migration on mid-to-late life diabetes risk and the interaction between GLFF exposure and urban-rural migration. Birth provinces were controlled as a fixed effect to account for variations in famine severity across provinces.ResultsCompared to those who were never exposed to GLFF, fetal GLFF exposure was associated with a higher risk of adult-onset diabetes after controlling for provinces, demographics, and health statuses. Yet, after adding the proxy of childhood growth environments into the model, fetal exposure to GLFF was not significantly associated with adult-onset diabetes risk (OR = 1.22, p = 0.10), compared to those who were never exposed to GLFF. Across the three age-stratification groups, static urban residents, in general, had a higher risk of diabetes compared to static rural residents. Interaction effects between GLFF exposure and urban-rural migration were insignificant across all three age-stratification groups.ConclusionFetal exposure to GLFF might have a traceable effect on adult-onset diabetes risk. Yet, the growth environment and urban lifestyle outweigh and further confound the impact of GLFF exposure on adult-onset diabetes risk.

What the hay: predicting equine voluntary forage intake using a meta-analysis approach

To properly formulate diets, the ability to accurately estimate feed intake is critical as the amount of feed consumed will influence the amount of nutrients delivered to the animal. Inaccurate intake estimates may lead to under- or over-feeding of nutrients to the animal. Individual differences in equine forage intake are well-known, but predictive equations based on animal and nutritional factors are not comprehensive. The objective of the present study was to consolidate the current body of knowledge in the published literature on voluntary forage DM intake (VFDMI) in equines and conduct a meta-analysis to identify driving factors, sources of heterogeneity, and develop predictive equations. Therefore, a systematic literature search was applied and identified 61 publications which met the inclusion criteria. From each study, the outcomes of interest (e.g., forage intake), diet composition (e.g., forage information, nutrient composition), and animal factors (e.g., sex, age, breed, BW, exercise level) were extracted. Forage intake was analyzed as two different outcome variables: (1) VFDMI in kg/d and (2) VFDMI in g/kg BW. Linear mixed model analysis treating study as a random effect was applied, using a backward−stepping approach to identifying potential driving variables for VFDMI (both units) where all terms have P < 0.1. The best fitting models for VFDMI included similar factors (also across kg/d and g/kg BW) such as forage quality (i.e., neutral detergent fiber or CP content), forage type (i.e., grass, legume, or mixed), the animals’ size category (i.e., horses vs ponies), and some management factors (i.e., pasture access). As anticipated, forage intake increased when higher quality forages were fed (i.e., lower neutral detergent fiber or higher CP), potentially due to improved digestibility. Additionally, VFDMI increased as BW increased but ponies increased their VFDMI more per every kg increase in BW compared to horses. Lastly, pasture access (i.e., grazing) may influence VFDMI such that pastured animals consume less than stalled animals, possibly due to the time it takes to graze forage. In conclusion, equations to predict equine VFDMI with high accuracy and precision (concordance correlation coefficient = 0.82 – 0.95; root mean squared error RMSE = 0.82–5.49) were developed which could be applied in practice by equine nutritionists or owners and managers. The results of this meta-analysis confirm that animal traits and forage quality have a significant impact on the VFDMI of equines and should be accounted for when formulating diets to ensure nutritional requirements are met.

Commentary-A Military Health Care Ethics Framework.

Ethical practice within military health care is a significant topic of professional and academic debate. The term "military health care ethics" enfranchises the entire health care team. Military health care professionals are subject to tension between their duties as military personnel, and their ethical duties as health care professionals, so-called "Dual Loyalty." Some military health care practitioners have suffered moral injury because of the psychological stress associated with ethical challenges on military operations. It is important to define military health care ethics and also to consider how it should be taught. The essence of ethical practice is ethical decision-making. It has become self-evident from our experience of teaching military health care ethics that a simple and agreed framework for analyzing an ethical problem is required. This paper describes the development of the King's Military Healthcare Ethics Framework in support of a military health care ethics policy on behalf of the NATO Military Healthcare Working Group. There is logic to using a stepped approach to analyze an ethical problem in military health care. These steps are: "Identify" the problem, "Analyze" the problem including consideration of perspectives, "Fuse" the analysis, and "Decide". Step 1-Identify-is intended to orientate the decision-making group, and to articulate the problem specifically and clearly in order to determine the exact ethical issue and the secondary issues that arise. Step 2-Analyse-considers the problem from 4 perspectives: patient, clinical, legal, and societal/military. These reflect the breadth of perspectives that impact on health care practice within a military context. Step 3-Fuse-is the culminating step. The conclusions from the analysis of perspectives should be summarized and key references cited. This will determine the exact decision(s) to be made. Step 4-Decide-clearly articulates the decision made and provides the record of the key reasons for making that decision. This may include areas of enduring uncertainly and any planned review of the decision. The King's Military Healthcare Ethics Analytical Framework has been evaluated for content validity through iterative discussion at 4 meetings of the NATO MHCWG and a specific workshop on military health care ethics over 2022/2023. It is included within the draft NATO Standardization Agreement on Military Healthcare Ethics.

Harmonic balance applied to a 2D nonlinear finite‐element magnetic model with motion and circuit coupling

AbstractIn this work, the harmonic balance approach is applied to a 2D nonlinear finite‐element magnetic model with motion, coupled to a nonlinear circuit. The case study comprises a six‐pole three‐phase surface‐mounted permanent magnet generator connected to a six‐pulse full‐wave diode bridge rectifier. Simulations are performed at fixed generator speed in two operating cases: with an open‐circuit DC bus and supplying a load resistance. Both time stepping and harmonic balance approaches are deeply discussed focusing on the model under study, along with relevant implementation details. Harmonic balance results are compared with benchmark time stepping simulations in terms of voltage and current waveforms, progressively expanding the harmonic spectrum. The computational cost of the two approaches is reported as well. Simulation accuracy is satisfying with regard to time stepping benchmark results: relative errors on total harmonic distortion and global root‐mean‐square values are lower than 3% and 1%, respectively. However, the time stepping approach outperforms the harmonic balance one, due to the relatively short initial transient of the chosen case study. Further improvements on practical implementation are needed to exploit the potentialities of harmonic balance technique.

Measuring the adoption of internet and communication technologies among practitioners in routine disability services: a stepped inclusive approach

Purpose Existing measurements of the use of information and communication technologies (ICTs) among practitioners in disability services often treat ICT adoption as a monolithic concept, overlooking its multifaceted nature within the disability field. This study introduces a stepped, inclusive approach to capturing this complexity, elucidating disparities in the utilization of various ICT dimensions, the present vs. anticipated use, and variations among different clinical-demographic groups. Materials and methods A cross-sectional survey was conducted in Hong Kong, gathering valid data from 324 practitioners spanning diverse disciplines and disability services. Results Data analysis produced a three-factor model categorizing ICT tools into (1) information and communication tools, (2) screening and monitoring tools, and (3) treatment and rehabilitation tools. The first category was identified as the predominant ICT utilized currently, with significant projected growth in the latter two categories’ usage. Variances in current ICT adoption were influenced by practitioners’ roles, clientele, positions, affiliating agencies, and educational attainments. Conclusions This research provides a deeper understanding of the key dimensions of ICT adoption within disability services. It underscores the importance of devising specific and customized strategies for the effective integration of ICTs, ensuring a more tailored approach to meeting the unique demands of the disability field.

Self-Help Movement and the Change Process of Recovery

The path of recovery from both addiction and trauma to resilience and transformation is rooted in the concept that all life is a balance between spirit and matter. Caring for the spiritual and physical selves requires self-reflection regarding life experiences and personal constructs. The central issue to positive mental health and the resolution of life problems, such as alcohol or drug addiction, gambling, abuse, etc., is partly vested in a robust management system that impacts an individual’s cultural and social support system. The demise of supportive communities is one of the significant losses of modern life. The self-help movement of Alcoholics Anonymous and other 12-step programs have always provided social support and encouragement to reflect on behaviors, motivations, and patterns that support healthy lifestyle changes. While it is not necessary for a recovering person to be religious, the movement may draw parallels to various spiritual and religious doctrines that recovering persons subscribe to; therefore, drawing these parallels only strengthens a person’s chances for long-term recovery

Evaluating the effectiveness of brief anti-speeding messages disseminated within warning notices to driving offenders

Road safety messaging represents a long-standing strategy in efforts to reduce speeding, a behaviour which accounts for an estimated 30 % of all road crashes on Australian roads. This study aimed to further examine the effectiveness of such a strategy via the use of a novel message medium that included anti-speeding messaging disseminated to speeding offenders via warning notices issued by a Start Government Transport agency. Informed by the Step approach to Message Design and Testing (SatMDT), survey content was devised to compare the effectiveness of the messages across various outcome measures including intentions to stay within the posted speed limit. A total of 219 speeding offenders completed the online survey. Overall, the results found some positive responses regarding Intervention condition participants’ responses to the anti-speeding messaging featured within the warning notices. Among some of the key findings were that the Intervention condition participants reported relatively low levels of message rejection. Additionally, females responded more favourably to both messages than males. Collectively, the findings suggest that there is no harm in including such messages within warning notices providing such messages are concept-tested prior to use. Overall, the findings suggest this approach may represent a low-cost option for targeted message delivery.

The evaluation of a stepped care approach for early intervention of borderline personality disorder

BackgroundThe current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist.MethodsThe sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17).ResultsCDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3.DiscussionThe findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.

Palladium-Catalyzed Cyanations of Aryl Imidazolylsulfonates with K4[Fe(CN)6]: A Pragmatic Approach to Benzonitriles from Phenols

AbstractA general Pd-catalyzed approach for the conversion of phenols into benzonitriles via aryl imidazolylsulfonates with a non-toxic cyanide source, potassium ferrocyanide, has been developed. Salient features of this method include low palladium precatalyst loadings (as low as 1.0 mol% total Pd), mild reaction conditions, and environmentally benign by-products compared to other (pseudo)halide aryl electrophiles. The initial scope of the reaction on a range of phenolic precursors is demonstrated including a one-pot, two-step approach to convert phenols directly into benzonitriles.

Stepped care approaches for people with personality disorder

Stepped care approaches for people with personality disorder