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Multiple biologic agents are approved for the treatment of severe persistent asthma not controlled by inhaled corticosteroid/beta-agonist therapy. Appropriate phenotyping can aid in picking the right biologic for the right patient. Here is a unique case of a patient with severe asthma and respiratory arrest, with fraction of exhaled nitric oxide >300 ppb whose asthma became completely controlled with dupilumab., Competing Interests: The planner and faculty for this activity have no relevant financial relationships to disclose. The author reports no funding. The patient consented to publication of this case report., (Copyright © 2024 Baylor University Medical Center.)

The ability to express diverse behaviors is a key requirement for most biological systems. Underpinning behavioral diversity in the natural world is the embodied interaction between the brain, body, and environment. Dynamical systems form the basis of embodied agents, and can express complex behavioral modalities without any conventional computation. While significant study has focused on designing dynamical systems agents with complex behaviors, for example, passive walking, there is still a limited understanding about how to drive diversity in the behavior of such systems. In this article, we present a novel hardware platform for studying the emergence of individual and collective behavioral diversity in a dynamical system. The platform is based on the so-called Bernoulli ball, an elegant fluid dynamics phenomenon in which spherical objects self-stabilize and hover in an airflow. We demonstrate how behavioral diversity can be induced in the case of a single hovering ball via modulation of the environment. We then show how more diverse behaviors are triggered by having multiple hovering balls in the same airflow. We discuss this in the context of embodied intelligence and open-ended evolution, suggesting that the system exhibits a rudimentary form of evolutionary dynamics in which balls compete for favorable regions of the environment and exhibit intrinsic "alive" and "dead" states based on their positions in or outside of the airflow., (© 2023 Massachusetts Institute of Technology.)

Background: Medication-related problems (MRPs) occur across the continuum of emergency department (ED) care: they may contribute to ED presentation, occur in the ED/short-stay unit (SSU), at hospital admission, or shortly after discharge to the community. This project aimed to determine predictors for MRPs across the continuum of ED care and incorporate these into screening tools (one for use at ED presentation and one at ED/SSU discharge), to identify patients at greatest risk, who could be targeted by ED pharmacists. Methods: A prospective, observational, multicenter study was undertaken in nine EDs, between July 2016 and August 2017. Blocks of ten consecutive adult patients presenting at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine a medication history, patient understanding of treatment, risk factors for MRPs and to manage the MRPs. Logistic regression was undertaken to determine predictor variables. Multivariable regression beta coefficients were used to develop a scoring system for the two screening tools. Results: Of 1,238 patients meeting all inclusion criteria, 904 were recruited. Characteristics predicting MRPs related to ED presentation were: patient self-administers regular medications (OR = 7.95, 95%CI = 3.79-16.65), carer assists with medication administration (OR = 15.46, 95%CI = 6.52-36.67), or health-professional administers (OR = 5.01, 95%CI = 1.77-14.19); medication-related ED presentation (OR = 9.95, 95%CI = 4.92-20.10); age ≥80 years (OR = 3.63, 95%CI = 1.96-6.71), or age 65-79 years (OR = 2.01, 95%CI = 1.17-3.46); potential medication adherence issue (OR = 2.27, 95%CI = 1.38-3.73); medical specialist seen in past 6-months (OR = 2.02, 95%CI = 1.42-2.85); pharmaceutical benefit/pension/concession cardholder (OR = 1.89, 95%CI = 1.28-2.78); inpatient in previous 4-weeks (OR = 1.60, 95%CI = 1.02-2.52); being male (OR = 1.48, 95%CI = 1.05-2.10); and difficulties reading labels (OR = 0.63, 95%CI = 0.40-0.99). Characteristics predicting MRPs related to ED discharge were: potential medication adherence issue (OR = 6.80, 95%CI = 3.97-11.64); stay in ED > 8 h (OR = 3.23, 95%CI = 1.47-7.78); difficulties reading labels (OR = 2.33, 95%CI = 1.30-4.16); and medication regimen changed in ED (OR = 3.91, 95%CI = 2.43-6.30). For ED presentation, the model had a C-statistic of 0.84 (95% CI 0.81-0.86) (sensitivity = 80%, specificity = 70%). For ED discharge, the model had a C-statistic of 0.78 (95% CI 0.73-0.83) (sensitivity = 82%, specificity = 57%). Conclusion: Predictors of MRPs are readily available at the bedside and may be used to screen for patients at greatest risk upon ED presentation and upon ED/SSU discharge to the community. These screening tools now require external validation and implementation studies to evaluate the impact of using such tools on patient care outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Taylor, Mitri, Harding, Taylor, Weeks, Abbott, Lambros, Lawrence, Strumpman, Senturk-Raif, Louey, Crisp, Tomlinson and Manias.)

Objective: To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management., Methods: A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ 2 association, and regression models., Results: Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years ( SD =11.1). Gastrointestinal tract bleeding was the most common ( n =48, 33.3%), followed by epistaxis ( n =32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy ( n =65, 45.1%). Warfarin was commonly used ( n =74, 51.4%), followed by aspirin (n =29, 20.1%), rivaroxaban ( n =26, 18.1%), and apixaban ( n =12, 8.3%). The majority had increased blood urea nitrogen ( n =67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal ( B = -1.7, P =<.001), and with a shorter LoS ( B = -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy., Conclusion: Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice., Competing Interests: Competing interests: The authors declare no conflict of Interest.

Objective: Patients present to EDs with various medication-related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED., Methods: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre-specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs., Results: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3-53.5%) of moderate-high significance. Most highly significant MRPs involved high-risk medications, particularly strong opioids, insulin and anti-coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9-45.5%) had at least one MRP; 31.4% (95% CI 28.4-34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4-14.8%) had MRPs that could be identified or managed by screening at ED discharge., Conclusions: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs., (© 2020 Australasian College for Emergency Medicine.)

Narcissistic personality disorder is a pleomorphic entity that requires the psychodynamically oriented therapist to tailor the approach to the characteristics of the individual patient. Psychodynamic principles encompass a broad range of interventions depending on the patient's specific characteristics. The therapist's interventions range from interpretation of the transference to supportive approaches that emphasize empathic validation and direct advice. In the absence of systematic data on these variations, this article attempts to offer clinically based principles. Several themes are emphasized: the experience of shame, the predictable transference-countertransference developments, the role of comorbidity with other personality disorders and traits, and the approach to resistances.

The Health Foundation is an independent charity working to improve healthcare in the UK, so that we have a system of the highest possible quality-safe, effective, person-centred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work. The Foundation conducts research and evaluation, puts ideas into practice through improvement programmes, develops leaders and shares evidence to drive wider change. The work is a focused around two priority areas: patient safety and person-centred care. The Foundation has supported work to improve services for patients with kidney disease and, in common with other quality improvement projects, there have been challenges to overcome. Awareness of these common challenges can help others to be more prepared when planning service improvements., (© 2013 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Objective: Because there have been no previously published national surveys on teaching psychiatry residents about how to teach, the authors surveyed United States psychiatry program directors on what and how residents are taught about teaching., Methods: All psychiatry training programs across the United States were mailed a semistructured questionnaire; 95 responded (response rate: 53%). The survey included questions on what, if anything, was provided in the way of formal instruction; the number of seminars offered each year; texts and other materials that were used for teaching; and how seminars were evaluated., Results: The majority (N=69, 73%) of all responding programs provided formal instruction to residents about how to teach. Topics most commonly taught included evaluation and feedback (N=57; 60%), lecturing skills (N=43; 45%), small-group skills (N=40; 42%), learning theory (N=37; 39%), and problem-based learning (N=36; 38%). Instructional methods used were predominantly group discussion (N=62; 65%), lecturing (N=59; 62%), reading of relevant literature (N=35; 37%), role-playing (N=33; 35%), and audiovisual instruction (N=32; 34%). There was a heterogeneity of texts and materials used for teaching. Few of the programs utilized formal validated and reliable tools for evaluating their teaching., Conclusion: Although most programs provided formal teaching, there remains a need to further develop teaching programs and to create model ones.

Background: The declining numbers of clinician-researchers in psychiatry and other medical specialties has been a subject of growing concern. Residency training has been cited as an important factor in recruiting new researchers, but there are essentially no data to support this assertion. This study aimed to explore which factors have influenced motivation to conduct research among senior psychiatry residents., Methods: The authors surveyed senior residents, inquiring about their level of interest in research, demographics, background, research experiences, and factors influencing motivation for research. The authors had confirmed participation from 16 of 33 residency programs with a class size of 10 or more. They received 127 responses, a 67% response rate, from participating programs., Results: Residents with high stated interest in research differed from those with low and moderate interest in their research-intense post-residency plans. They were more likely to have graduate degrees. Those planning research careers had a consistent pattern of interest and involvement in research, starting well before residency. The majority of residents had had research exposure in college, but research involvement of those with very high versus lower interest diverged sharply thereafter. Those with high research interest were overwhelmingly male and tended to have lower debt than those with less interest., Conclusion: The great majority of residents appear to have decided whether or not to pursue a research career by the time they reached residency, and few of those with less than the highest research interest were enrolled in research tracks. Efforts to increase recruitment into research should center on identifying early developmental influences, eliminating barriers specific to women, and ensuring adequate funding to provide secure careers for talented potential researchers.

Objective: The authors sought to determine the prevalence of threats and assaults by patients on psychiatry residents, their consequences, and the perceived adequacy of supports and institutional responses., Method: Authors conducted an anonymous survey of 519 psychiatry residents in 13 psychiatry programs across the United States. The survey questionnaire inquired about residents' experiences of threats and assaults by patients during their residency training., Results: The response rate for this survey was 39% (N=204). Residents were most commonly threatened (N=175; 86%), physically intimidated (N=145; 71%) or received unwanted advances (N=118; 58%). One-quarter (N=51; 25%) were physically assaulted. Most of the incidents occurred in inpatient settings (N=92; 45%)., Conclusion: This study, like previous studies on this topic, calls attention to the high number of residents that are affected by violence during their training, and it underscores the need to protect the safety of psychiatry residents and to support those who have been victimized.

Increasing attention has been focused on mental health problems of clergy in light of long work hours, extraordinary demands, and diversity of tasks. In this communication we report findings from the psychiatric evaluation of 70 Episcopal priests. We describe psychiatric diagnoses, but our focus is on two common themes that emerged: difficulties maintaining professional boundaries and problems with mentalizing, i.e., imagining the impact of their behavior and words on others. Recommendations for education and prevention are addressed.

Objective: The authors demonstrate that the teaching of professional boundaries in psychiatry is an essential component of training to prevent harm to patients and to the profession., Methods: The authors illustrate overarching principles that apply to didactic teaching in seminars and to psychotherapy supervision., Results: The teaching of boundaries must be based in sound clinical theory and technique so that transference, countertransference, and frame theory are seen as interwoven with the concept of boundaries and must use case-based learning so that a "one-size-fits-all" approach is avoided., Conclusion: The emphasis in teaching should be on both the clinician's temptations and the management of the patient's wish to transgress therapeutic boundaries.

This column uses the tools of normative ethics-analysis and argument-to provide a reasoned account of and to identify ethically justified responses by the psychiatrist to psychiatric inpatients' refusal of medical or surgical diagnostic work-up. There are three relevant ethical considerations when psychiatric inpatients refuse medical or surgical diagnostic tests: balancing autonomy with beneficence, surrogate decision making and confidentiality, and managing strong feelings. Assisted decision making and assent are key management strategies for promoting patients' autonomy and for protecting against adverse consequences of decision making.

Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe.

This study evaluated the psychometric properties of the Social Experience Questionnaire (SEQ) in a sample of 1158 adolescents aged 13-17 years. Confirmatory factor analysis fit indices supported the hypothesized three-factor model of the SEQ that assesses overt and relational victimization, and prosocial behaviors from peers. Analyses of gender differences revealed that boys reported being overtly victimized more than girls, and girls reported greater receipt of prosocial behaviors from peers than boys. No gender differences in relational victimization were found. The internal consistency was adequate across gender, and test-retest stability over 12 months was modest. Intercorrelations among overt and relational victimization subscales suggest that these subscales assess related, but relatively independent constructs of peer victimization. These findings support the use of the SEQ with adolescents.

Aim: To determine whether image analysis of ploidy status and immunohistochemical analysis of p57KIP2 (a paternally imprinted, maternally expressed gene) can be used to refine the diagnosis of molar pregnancy., Methods and Results: The original histological diagnosis in 40 randomly selected cases of hydatidiform mole was reviewed and confirmed in 38 cases (22 complete moles, 16 partial moles). These cases were anonymized and submitted for further analysis. Tissue from each case was submitted for flow cytometric assessment of DNA ploidy using a FACSort flow cytometer and for automated image cytometric assessment using a novel digital imaging system. Tissue sections from each case were immunostained with a monoclonal mouse antibody to p57KIP2. Correlations between the histopathological diagnosis, image cytometry, flow cytometry and p57KIP2 immunohistochemistry were determined using kappa statistics. The concordance between histological diagnosis and p57KIP2 was very good (kappa = 0.89). Twenty of the 22 (90.9%) complete moles showed no immunoreactivity for p57KIP2. The remaining two cases showed nuclear immunoreactivity in villous cytotrophoblast. In one of these, the pattern of staining resembled that of a partial mole. In the other, the staining pattern supported the diagnosis of a twin molar/non-molar pregnancy. All 16 partial moles were p57KIP2 immunoreactive. On flow cytometry, all 22 complete moles were diploid and 12/16 partial moles were triploid (the remaining four cases originally diagnosed as partial moles were found to be diploid). On image cytometry, one case originally diagnosed as complete mole was found to contain a triploid population. Thus, by using a combination of image cytometry and p57KIP2 status we were able to refine the diagnosis of molar pregnancy in five (13%) of the cases studied., Conclusions: Automated image cytometry is a readily performed investigation which is comparable to, but more sensitive than, flow cytometry. Complementary use of ploidy analysis and p57KIP2 status can now help to distinguish a diploid hydropic miscarriage (p57KIP2-positive), diploid complete mole (p57KIP2-negative) and triploid partial mole (p57KIP2-positive).