The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline.

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

What medical students think about measurement of their well-being: cross-sectional survey and qualitative interviews.

OBJECTIVES: To find out how medical students think well-being should be measured. DESIGN: A mixed-methods study comprising a cross-sectional online survey (November 2020-March 2021) and semi-structured online interviews. Views on the frequency of availability for measurement, the format, type and purpose of measurement, and with whom well-being should be discussed were measured. When an outcome was scored 7-9 on a 9-point Likert scale of agreement by ≥75% of participants it was considered critical. Inductive thematic analysis was undertaken on the interview transcripts. SETTING: All medicine programmes at University of Southampton. PARTICIPANTS: Medical students from all years took part in the survey (n=118) and interviews (n=16). RESULTS: Most participants (94%) felt able to give 5 min to measure their well-being at least once per month. Research, governance and individual feedback were all considered critically important. Only subjective assessments undertaken by the individual in real-time were rated critically important (78.1%) measurement tools. Students selected that they would discuss their well-being with other medical students (n=87) nearly as often as they selected a member of the faculty (n=104). Five interview themes further explained these findings: (1) well-being is mental well-being; (2) exercise and support from friends and family are most important; (3) isolation and the design of the medicine programme are detrimental to well-being; (4) there are advantages to surveys, and conversations; (5) personal academic tutors and medical students in later years are the best to discuss well-being with. CONCLUSIONS: Medical students thought that measurement of their well-being was critically important for governance showing their support for quality assurance of well-being and peer support. They wanted to be able to choose surveys, or conversations, to measure their well-being, as well as the person they discussed well-being with. Four recommendations are discussed in light of these findings.

A critical review of the definition of 'wellbeing' for doctors and their patients in a post Covid-19 era.

BACKGROUND: There is no international consensus definition of 'wellbeing'. This has led to wellbeing being captured in many different ways. AIMS: To construct an inclusive, global operational definition of wellbeing. METHODS: The differences between wellbeing components and determinants and the terms used interchangeably with wellbeing, such as health, are considered from the perspective of a doctor. The philosophies underpinning wellbeing and modern wellbeing research theories are discussed in terms of their appropriateness in an inclusive definition. RESULTS: An operational definition is proposed that is not limited to doctors, but universal, and inclusive: 'Wellbeing is a state of positive feelings and meeting full potential in the world. It can be measured subjectively and objectively, using a salutogenic approach'. CONCLUSIONS: This operational definition allows the differentiation of wellbeing from terms such as quality of life and emphasises that in the face of global challenges people should still consider wellbeing as more than the absence of pathology.

Clinical bleeding and thrombin generation in admissions to critical care with prolonged prothrombin time: an exploratory study.

BACKGROUND: Prolongation of prothrombin time (PT) is often recorded in critical illness, but has limited ability to predict risk of bleeding. This exploratory study was aimed at assessing a role for thrombin generation (TG) to predict bleeding. STUDY DESIGN AND METHODS: TG was measured by calibrated automated thrombography in admissions to intensive care with prolonged PT. Bleeding events were recorded up to Day 5 after enrollment and correlated with results of PT ratio (PTR) and variables of TG. RESULTS: A total of 306 patients were recruited. A total of 101 bleeding events developed in 46 patients during the period of observation. Many patients with prolonged PT had endogenous thrombin potential (ETP), which was within the normal range (120/251 patients, 47.8%) or even elevated (8%). Although some patients had a reduction in ETP or peak thrombin, these were present over a wide range of PTR. There was no suggestion by receiver operating characteristic analysis that variables of conventional TG were sensitive at predicting bleeding. No bleeding events were documented in patients defined as ETP high, despite elevated PTR. CONCLUSION: Future studies need to explore a role for alternatives tests of coagulation in critical illness. Development of TG assays is required to positively identify more patients at increased bleeding risk or to exclude a larger number at low risk and how this relates to subgroups, such as patients with liver disease, and the need for prophylactic plasma transfusion.