Sampling is central to the practice of qualitative methods, but compared with data collection and analysis its processes have been discussed relatively little. A four-point approach to sampling in ...qualitative interview-based research is presented and critically discussed in this article, which integrates theory and process for the following: (1) defining a sample universe, by way of specifying inclusion and exclusion criteria for potential participation; (2) deciding upon a sample size, through the conjoint consideration of epistemological and practical concerns; (3) selecting a sampling strategy, such as random sampling, convenience sampling, stratified sampling, cell sampling, quota sampling or a single-case selection strategy; and (4) sample sourcing, which includes matters of advertising, incentivising, avoidance of bias, and ethical concerns pertaining to informed consent. The extent to which these four concerns are met and made explicit in a qualitative study has implications for its coherence, transparency, impact and trustworthiness.
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BFBNIB, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Objective:Although anxiety can be an adaptive response to unpredictable threats, pathological anxiety disorders occur when symptoms adversely affect daily life. Whether or not adaptive and ...pathological anxiety share mechanisms remains unknown, but if they do, induced (adaptive) anxiety could be used as an intermediate translational model of pathological anxiety to improve drug development pipelines. The authors therefore compared meta-analyses of functional neuroimaging studies of induced and pathological anxiety.Methods:A systematic search of the PubMed database was conducted in June 2019 for whole-brain functional MRI articles. Eligible articles contrasted either anxious patients to control subjects or an unpredictable-threat condition to a safe condition in healthy participants. Five anxiety disorders were included: posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, panic disorder, and specific phobia. A total of 3,433 records were identified, 181 articles met selection criteria, and the largest subset of task type was emotional (N=138). Seed-based d-mapping software was used for all analyses.Results:Induced anxiety (N=693 participants) and pathological anxiety (N=2,554 patients and 2,348 control subjects) both showed increased activation in the left and right insula (coordinates, 44, 14, −14 and −38, 20, −8; k=2,102 and k=1,305, respectively) and cingulate cortex/medial prefrontal cortex (−12, −8, 68; k=2,217). When the analyses were split by disorder, specific phobia appeared the most, and generalized anxiety disorder the least, similar to induced anxiety.Conclusions:This meta-analysis indicates a consistent pattern of activation across induced and pathological anxiety, supporting the proposition that some neurobiological mechanisms overlap and that the former may be used as a model for the latter. Induced anxiety might nevertheless be a better model for some anxiety disorders than others.
Background
The use of anaesthetics in the elderly surgical population (more than 60 years of age) is increasing. Postoperative delirium, an acute condition characterized by reduced awareness of the ...environment and a disturbance in attention, typically occurs between 24 and 72 hours after surgery and can affect up to 60% of elderly surgical patients. Postoperative cognitive dysfunction (POCD) is a new‐onset of cognitive impairment which may persist for weeks or months after surgery.
Traditionally, surgical anaesthesia has been maintained with inhalational agents. End‐tidal concentrations require adjustment to balance the risks of accidental awareness and excessive dosing in elderly people. As an alternative, propofol‐based total intravenous anaesthesia (TIVA) offers a more rapid recovery and reduces postoperative nausea and vomiting. Using TIVA with a target controlled infusion (TCI) allows plasma and effect‐site concentrations to be calculated using an algorithm based on age, gender, weight and height of the patient.
TIVA is a viable alternative to inhalational maintenance agents for surgical anaesthesia in elderly people. However, in terms of postoperative cognitive outcomes, the optimal technique is unknown.
Objectives
To compare maintenance of general anaesthesia for elderly people undergoing non‐cardiac surgery using propofol‐based TIVA or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthesia care unit (PACU), and hospital stay.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE (1946 to November 2017), Embase (1974 to November 2017), PsycINFO (1887 to November 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.
Selection criteria
We included randomized controlled trials (RCTs) with participants over 60 years of age scheduled for non‐cardiac surgery under general anaesthesia. We planned to also include quasi‐randomized trials. We compared maintenance of anaesthesia with propofol‐based TIVA versus inhalational maintenance of anaesthesia.
Data collection and analysis
Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesized findings.
Main results
We included 28 RCTs with 4507 randomized participants undergoing different types of surgery (predominantly cardiovascular, laparoscopic, abdominal, orthopaedic and ophthalmic procedures). We found no quasi‐randomized trials. Four studies are awaiting classification because we had insufficient information to assess eligibility.
All studies compared maintenance with propofol‐based TIVA versus inhalational maintenance of anaesthesia. Six studies were multi‐arm and included additional TIVA groups, additional inhalational maintenance or both. Inhalational maintenance agents included sevoflurane (19 studies), isoflurane (eight studies), and desflurane (three studies), and was not specified in one study (reported as an ). Some studies also reported use of epidural analgesia/anaesthesia, fentanyl and remifentanil.
We found insufficient reporting of randomization methods in many studies and all studies were at high risk of performance bias because it was not feasible to blind anaesthetists to study groups. Thirteen studies described blinding of outcome assessors. Three studies had a high of risk of attrition bias, and we noted differences in the use of analgesics between groups in six studies, and differences in baseline characteristics in five studies. Few studies reported clinical trials registration, which prevented assessment of risk of selective reporting bias.
We found no evidence of a difference in incidences of postoperative delirium according to type of anaesthetic maintenance agents (odds ratio (OR) 0.59, 95% confidence interval (CI) 0.15 to 2.26; 321 participants; five studies; very low‐certainty evidence); we noted during sensitivity analysis that using different time points in one study may influence direction of this result. Thirteen studies (3215 participants) reported POCD, and of these, six studies reported data that could not be pooled; we noted no difference in scores of POCD in four of these and in one study, data were at a time point incomparable to other studies. We excluded one large study from meta‐analysis because study investigators had used non‐standard anaesthetic management and this study was not methodologically comparable to other studies. We combined data for seven studies and found low‐certainty evidence that TIVA may reduce POCD (OR 0.52, 95% CI 0.31 to 0.87; 869 participants).
We found no evidence of a difference in mortality at 30 days (OR 1.21, 95% CI 0.33 to 4.45; 271 participants; three studies; very low‐certainty evidence). Twelve studies reported intraoperative hypotension. We did not perform meta‐analysis for 11 studies for this outcome. We noted visual inconsistencies in these data, which may be explained by possible variation in clinical management and medication used to manage hypotension in each study (downgraded to low‐certainty evidence); one study reported data in a format that could not be combined and we noted little or no difference between groups in intraoperative hypotension for this study. Eight studies reported length of stay in the PACU, and we did not perform meta‐analysis for seven studies. We noted visual inconsistencies in these data, which may be explained by possible differences in definition of time points for this outcome (downgraded to very low‐certainty evidence); data were unclearly reported in one study. We found no evidence of a difference in length of hospital stay according to type of anaesthetic maintenance agent (mean difference (MD) 0 days, 95% CI ‐1.32 to 1.32; 175 participants; four studies; very low‐certainty evidence).
We used the GRADE approach to downgrade the certainty of the evidence for each outcome. Reasons for downgrading included: study limitations, because some included studies insufficiently reported randomization methods, had high attrition bias, or high risk of selective reporting bias; imprecision, because we found few studies; inconsistency, because we noted heterogeneity across studies.
Authors' conclusions
We are uncertain whether maintenance with propofol‐based TIVA or with inhalational agents affect incidences of postoperative delirium, mortality, or length of hospital stay because certainty of the evidence was very low. We found low‐certainty evidence that maintenance with propofol‐based TIVA may reduce POCD. We were unable to perform meta‐analysis for intraoperative hypotension or length of stay in the PACU because of heterogeneity between studies. We identified 11 ongoing studies from clinical trials register searches; inclusion of these studies in future review updates may provide more certainty for the review outcomes.
In this article, I present a structured approach to thematic analysis that is designed for working with brief texts. It is grounded in both the ecumenical thematic analysis of Boyatzis (1998) and the ...reflexive thematic analysis of Braun and Clarke (2006). The process of structured tabular thematic analysis (ST-TA) is best conducted in spreadsheet software such as Microsoft Excel. As with other forms of thematic analysis, it permits inductive, deductive, or hybrid approaches to theme development and analysis. Its logistical processes are well suited to working with the large samples that can be achieved when gathering brief text data. It can be used to conduct purely qualitative analyses and can also elicit frequency data that can, in principle, be analyzed quantitatively too. The process of checking agreement between analysts is an integral feature of the method. I discuss the practical implications of the approach and its applicability to various qualitative and mixed-methods research designs.
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CEKLJ, FFLJ, NUK, ODKLJ, PEFLJ, UPUK
Anxiety disorders constitute a sizeable worldwide health burden with profound social and economic consequences. The symptoms are wide-ranging; from hyperarousal to difficulties with concentrating. ...This latter effect falls under the broad category of altered cognitive performance which is the focus of this review. Specifically, we examine the interaction between anxiety and cognition focusing on the translational threat of unpredictable shock paradigm; a method previously used to characterize emotional responses and defensive mechanisms that is now emerging as valuable tool for examining the interaction between anxiety and cognition. In particular, we compare the impact of threat of shock on cognition in humans to that of pathological anxiety disorders. We highlight that both threat of shock and anxiety disorders promote mechanisms associated with harm avoidance across multiple levels of cognition (from perception to attention to learning and executive function)-a "hot" cognitive function which can be both adaptive and maladaptive depending upon the circumstances. This mechanism comes at a cost to other functions such as working memory, but leaves some functions, such as planning, unperturbed. We also highlight a number of cognitive effects that differ across anxiety disorders and threat of shock. These discrepant effects are largely seen in "cold" cognitive functions involving control mechanisms and may reveal boundaries between adaptive (e.g., response to threat) and maladaptive (e.g., pathological) anxiety. We conclude by raising a number of unresolved questions regarding the role of anxiety in cognition that may provide fruitful avenues for future research.
Background
The intensive care unit (ICU) stay has been linked with a number of physical and psychological sequelae, known collectively as post‐intensive care syndrome (PICS). Specific ICU follow‐up ...services are relatively recent developments in health systems, and may have the potential to address PICS through targeting unmet health needs arising from the experience of the ICU stay. There is currently no single accepted model of follow‐up service and current aftercare programmes encompass a variety of interventions and materials. There is uncertain evidence about whether follow‐up services effectively address PICS, and this review assesses this.
Objectives
Our main objective was to assess the effectiveness of follow‐up services for ICU survivors that aim to identify and address unmet health needs related to the ICU period. We aimed to assess effectiveness in relation to health‐related quality of life (HRQoL), mortality, depression and anxiety, post‐traumatic stress disorder (PTSD), physical function, cognitive function, ability to return to work or education and adverse effects.
Our secondary objectives were to examine different models of follow‐up services. We aimed to explore: the effectiveness of service organisation (physician‐ versus nurse‐led, face‐to‐face versus remote, timing of follow‐up service); differences related to country (high‐income versus low‐ and middle‐income countries); and effect of delirium, which can subsequently affect cognitive function, and the effect of follow‐up services may differ for these participants.
Search methods
We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2017. We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.
Selection criteria
We included randomised and non‐randomised studies with adult participants, who had been discharged from hospital following an ICU stay. We included studies that compared an ICU follow‐up service using a structured programme and co‐ordinated by a healthcare professional versus no follow‐up service or standard care.
Data collection and analysis
Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We used the GRADE approach to assess the certainty of the evidence.
Main results
We included five studies (four randomised studies; one non‐randomised study), for a total of 1707 participants who were ICU survivors with a range of illness severities and conditions. Follow‐up services were led by nurses in four studies or a multidisciplinary team in one study. They included face‐to‐face consultations at home or in a clinic, or telephone consultations or both. Each study included at least one consultation (weekly, monthly, or six‐monthly), and two studies had up to eight consultations. Although the design of follow‐up service consultations differed in each study, we noted that each service included assessment of participants' needs with referrals to specialist support if required.
It was not feasible to blind healthcare professionals or participants to the intervention and we did not know whether this may have introduced performance bias. We noted baseline differences (two studies), and services included additional resources (two studies), which may have influenced results, and one non‐randomised study had high risk of selection bias.
We did not combine data from randomised studies with data from one non‐randomised study. Follow‐up services for improving long‐term outcomes in ICU survivors may make little or no difference to HRQoL at 12 months (standardised mean difference (SMD) ‐0.0, 95% confidence interval (CI) ‐0.1 to 0.1; 1 study; 286 participants; low‐certainty evidence). We found moderate‐certainty evidence from five studies that they probably also make little or no difference to all‐cause mortality up to 12 months after ICU discharge (RR 0.96, 95% CI 0.76 to 1.22; 4 studies; 1289 participants; and in one non‐randomised study 79/259 deaths in the intervention group, and 46/151 in the control group) and low‐certainty evidence from four studies that they may make little or no difference to PTSD (SMD ‐0.05, 95% CI ‐0.19 to 0.10, 703 participants, 3 studies; and one non‐randomised study reported less chance of PTSD when a follow‐up service was used).
It is uncertain whether using a follow‐up service reduces depression and anxiety (3 studies; 843 participants), physical function (4 studies; 1297 participants), cognitive function (4 studies; 1297 participants), or increases the ability to return to work or education (1 study; 386 participants), because the certainty of this evidence is very low. No studies measured adverse effects.
We could not assess our secondary objectives because we found insufficient studies to justify subgroup analysis.
Authors' conclusions
We found insufficient evidence, from a limited number of studies, to determine whether ICU follow‐up services are effective in identifying and addressing the unmet health needs of ICU survivors. We found five ongoing studies which are not included in this review; these ongoing studies may increase our certainty in the effect in future updates. Because of limited data, we were unable to explore whether one design of follow‐up service is preferable to another, or whether a service is more effective for some people than others, and we anticipate that future studies may also vary in design. We propose that future studies are designed with robust methods (for example randomised studies are preferable) and consider only one variable (the follow‐up service) compared to standard care; this would increase confidence that the effect is due to the follow‐up service rather than concomitant therapies.
IMPORTANCE: Computational psychiatry studies have investigated how reinforcement learning may be different in individuals with mood and anxiety disorders compared with control individuals, but ...results are inconsistent. OBJECTIVE: To assess whether there are consistent differences in reinforcement-learning parameters between patients with depression or anxiety and control individuals. DATA SOURCES: Web of Knowledge, PubMed, Embase, and Google Scholar searches were performed between November 15, 2019, and December 6, 2019, and repeated on December 3, 2020, and February 23, 2021, with keywords (reinforcement learning) AND (computational OR model) AND (depression OR anxiety OR mood). STUDY SELECTION: Studies were included if they fit reinforcement-learning models to human choice data from a cognitive task with rewards or punishments, had a case-control design including participants with mood and/or anxiety disorders and healthy control individuals, and included sufficient information about all parameters in the models. DATA EXTRACTION AND SYNTHESIS: Articles were assessed for inclusion according to MOOSE guidelines. Participant-level parameters were extracted from included articles, and a conventional meta-analysis was performed using a random-effects model. Subsequently, these parameters were used to simulate choice performance for each participant on benchmarking tasks in a simulation meta-analysis. Models were fitted, parameters were extracted using bayesian model averaging, and differences between patients and control individuals were examined. Overall effect sizes across analytic strategies were inspected. MAIN OUTCOMES AND MEASURES: The primary outcomes were estimated reinforcement-learning parameters (learning rate, inverse temperature, reward learning rate, and punishment learning rate). RESULTS: A total of 27 articles were included (3085 participants, 1242 of whom had depression and/or anxiety). In the conventional meta-analysis, patients showed lower inverse temperature than control individuals (standardized mean difference SMD, −0.215; 95% CI, −0.354 to −0.077), although no parameters were common across all studies, limiting the ability to infer differences. In the simulation meta-analysis, patients showed greater punishment learning rates (SMD, 0.107; 95% CI, 0.107 to 0.108) and slightly lower reward learning rates (SMD, −0.021; 95% CI, −0.022 to −0.020) relative to control individuals. The simulation meta-analysis showed no meaningful difference in inverse temperature between patients and control individuals (SMD, 0.003; 95% CI, 0.002 to 0.004). CONCLUSIONS AND RELEVANCE: The simulation meta-analytic approach introduced in this article for inferring meta-group differences from heterogeneous computational psychiatry studies indicated elevated punishment learning rates in patients compared with control individuals. This difference may promote and uphold negative affective bias symptoms and hence constitute a potential mechanistic treatment target for mood and anxiety disorders.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
Our main objective is to assess the effectiveness of follow‐up services for ICU survivors that aim to identify ...and address unmet health needs related to the ICU period. We aim to assess the effectiveness in relation to health‐related quality of life, mortality, depression and anxiety, post‐traumatic stress disorder, physical function, cognitive function, ability to return to work or education and adverse events.
Our secondary objectives are, in general, to examine both the various ways that follow‐up services are provided and any major influencing factors. Specifically, we aim to explore: the effectiveness of service organisation (physician versus nurse led, face to face versus remote, timing of follow‐up service); possible differences in services related to country (developed versus developing country); and whether participants had delirium within the ICU setting.
The translational neural circuitry of anxiety Robinson, Oliver J; Pike, Alexandra C; Cornwell, Brian ...
Journal of neurology, neurosurgery and psychiatry,
12/2019, Volume:
90, Issue:
12
Journal Article
Peer reviewed
Open access
Anxiety is an adaptive response that promotes harm avoidance, but at the same time excessive anxiety constitutes the most common psychiatric complaint. Moreover, current treatments for anxiety-both ...psychological and pharmacological-hover at around 50% recovery rates. Improving treatment outcomes is nevertheless difficult, in part because contemporary interventions were developed without an understanding of the underlying neurobiological mechanisms that they modulate. Recent advances in experimental models of anxiety in humans, such as threat of unpredictable shock, have, however, enabled us to start translating the wealth of mechanistic animal work on defensive behaviour into humans. In this article, we discuss the distinction between fear and anxiety, before reviewing translational research on the neural circuitry of anxiety in animal models and how it relates to human neuroimaging studies across both healthy and clinical populations. We highlight the roles of subcortical regions (and their subunits) such as the bed nucleus of the stria terminalis, the amgydala, and the hippocampus, as well as their connectivity to cortical regions such as dorsal medial and lateral prefrontal/cingulate cortex and insula in maintaining anxiety responding. We discuss how this circuitry might be modulated by current treatments before finally highlighting areas for future research that might ultimately improve treatment outcomes for this common and debilitating transdiagnostic symptom.
Background
A stroke occurs when the blood supply to part of the brain is cut off. Activities of daily living (ADL) are daily home‐based activities that people carry out to maintain health and ...well‐being. ADLs include the ability to: eat and drink unassisted, move, go to the toilet, carry out personal hygiene tasks, dress unassisted, and groom. Stroke causes impairment‐related functional limitations that may result in difficulties participating in ADLs independent of supervision, direction, or physical assistance.
For adults with stroke, the goal of occupational therapy is to improve their ability to carry out activities of daily living. Strategies used by occupational therapists include assessment, treatment, adaptive techniques, assistive technology, and environmental adaptations. This is an update of the Cochrane review first published in 2006.
Objectives
To assess the effects of occupational therapy interventions on the functional ability of adults with stroke in the domain of activities of daily living, compared with no intervention or standard care/practice.
Search methods
For this update, we searched the Cochrane Stroke Group Trials Register (last searched 30 January 2017), the Cochrane Controlled Trials Register (The Cochrane Library, January 2017), MEDLINE (1946 to 5 January 2017), Embase (1974 to 5 January 2017), CINAHL (1937 to January 2017), PsycINFO (1806 to 2 November 2016), AMED (1985 to 1 November 2016), and Web of Science (1900 to 6 January 2017). We also searched grey literature and clinical trials registers.
Selection criteria
We identified randomised controlled trials of an occupational therapy intervention (compared with no intervention or standard care/practice) where people with stroke practiced activities of daily living, or where performance in activities of daily living was the focus of the occupational therapy intervention.
Data collection and analysis
Two review authors independently selected trials, assessed risk of bias, and extracted data for prespecified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living and performance in activities of daily living at the end of follow‐up.
Main results
We included nine studies with 994 participants in this update. Occupational therapy targeted towards activities of daily living after stroke increased performance scores (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) 0.03 to 0.31, P = 0.02; 7 studies; 749 participants; low‐quality evidence) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio (OR) 0.71, 95% CI 0.52 to 0.96; P = 0.03; 5 studies; 771 participants; low‐quality evidence). We also found that those who received occupational therapy were more independent in extended activities of daily living (OR 0.22 (95% CI 0.07 to 0.37); P = 0.005; 5 studies; 665 participants; low‐quality evidence). Occupational therapy did not influence mortality (OR: 1.02 (95% CI 0.65 to 1.61); P = 0.93; 8 studies; 950 participants), or reduce the combined odds of death and institutionalisation (OR 0.89 (95% CI 0.60 to 1.32); P = 0.55; 4 studies; 671 participants), or death and dependency (OR 0.89 (95% CI 0.64 to 1.23); P = 0.47; 4 trials; 659 participants). Occupational therapy did not improve mood or distress scores (SMD 0.08 (95% CI ‐0.09 to 0.26); P = 0.35; 4 studies; 519 participants; low‐quality evidence). There were insufficient data to determine the effects of occupational therapy on health‐related quality of life. We found no studies of consenting carers prior to study participation and therefore there were no carer‐related outcomes in our review. There were insufficient data to determine participants' and carers' satisfaction with services.
Using GRADE, the quality of evidence was low. The major limitation was the number of studies at unclear risk of selection bias and an inevitable high risk of performance and detection bias, as both participants and occupational therapists could not be blinded to the intervention. In addition, there was a sparseness of data for our outcomes of interest and we downgraded the quality of our evidence for these reasons.
Authors' conclusions
We found low‐quality evidence that occupational therapy targeted towards activities of daily living after stroke can improve performance in activities of daily living and reduce the risk of deterioration in these abilities. Because the included studies had methodological flaws, this research does not provide a reliable indication of the likely effect of occupational therapy for adults with stroke.
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