Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america.

Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.

Behavioral Perspectives on Organizational Change: Practice Adoption, Product Culling, and Technological Search

This dissertation explores the complex process of organizational change, applying a behavioral lens to understand change in processes, products, and search behaviors. Chapter 1 examines new practice adoption, exploring factors that predict the extent to which routines are adopted “as designed” within the organization. Using medical record data obtained from the hospital’s Electronic Health Record (EHR) system I develop a novel measure of the “gap” between routine “as designed” and routine “as realized.” I link this to a survey administered to the hospital’s professional staff following the adoption of a new EHR system and find that beliefs about the expected impact of the change shape fidelity of the adopted practice to its design. This relationship is more pronounced in care units with experienced professionals and less pronounced when the care unit includes departmental leadership. This research offers new insights into the determinants of routine change in organizations, in particular suggesting the beliefs held by rank-and-file members of an organization are critical in new routine adoption. Chapter 2 explores changes to products, specifically examining culling behaviors in the mobile device industry. Using a panel of quarterly mobile device sales in Germany from 2004-2009, this chapter suggests that the organization’s response to performance feedback is conditional upon the degree to which decisions are centralized. While much of the research on product exit has pointed to economic drivers or prior experience, these central finding of this chapter—that performance below aspirations decreases the rate of phase-out—suggests that firms seek local solutions when doing poorly, which is consistent with behavioral explanations of organizational action. Chapter 3 uses a novel text analysis approach to examine how the allocation of attention within organizational subunits shapes adaptation in the form of search behaviors in Motorola from 1974-1997. It develops a theory that links organizational attention to search, and the results suggest a trade-off between both attentional specialization and coupling on search scope and depth. Specifically, specialized unit attention to a more narrow set of problems increases search scope but reduces search depth; increased attentional coupling also increases search scope at the cost of depth. This novel approach and these findings help clarify extant research on the behavioral outcomes of attention allocation, which have offered mixed results.

The Role of Home Practice Engagement in a Mindfulness-Based Intervention

Over the last three decades, there has been a precipitous rise in curiosity regarding the clinical use of mindfulness meditation for the self-management of a broad range of chronic health conditions. Despite the ever-growing body of evidence supporting the use of mindfulness-based therapies for both medical and psychological concerns, data on the active ingredients of these mind-body interventions are relatively scarce. Regular engagement in formal mindfulness practice is considered by many to be requisite for generating therapeutic change; however, previous investigations of at-home practice in MBIs have produced mixed results. The equivocal nature of these findings has been attributed to significant methodological limitations, including the lack of standardized, systematic practice monitoring tools, and a singular focus on practice time, with little attention paid to the nature and quality of one’s practice. The present study used a prospective, observational design to assess the effects of home-based practice on dispositional mindfulness, self-compassion, and psychological functioning in twenty-eight people enrolled in an MBSR or MBCT program. To address some of the aforementioned limitations, the present study collected detailed weekly accounts of participants’ home-based practice engagement, including information about practice time (i.e., frequency and duration), exercise type, perceived effort and barriers to participation, and practice quality. Hierarchical multiple regression was used to examine the relative contribution of practice time and practice quality on treatment outcomes, and to explore possible predictors of adherence to at-home practice recommendations. As anticipated, practice quality and perceived effort improved with time; however, rather unexpectedly, practice quality was not a significant predictor of treatment-related improvements in psychological health. Home practice engagement, however, was predictive of change in dispositional mindfulness, in the expected direction. Results of our secondary analyses demonstrated that employment status was predictive of home practice engagement, with those who were unemployed completing more at-home practice on average. Mindfulness self-efficacy at baseline and previous experience with meditation or other contemplative practices were independently predictive of mean practice quality. The results of this study suggest that home practice helps generate meaningful change in dispositional mindfulness, which is purportedly a key mechanism of action in mindfulness-based interventions.