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Concept: The Downward Spiral


BACKGROUND: There has been a large increase in treatment and in research on chronic obstructive pulmonary disease (COPD) from the common starting point of the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) study. There is currently little evidence on the degree of similarity and difference between national programmes or on the linkage between research and policy. AIMS: To review the evidence on programme development and the effectiveness gap from the UK, France, Germany, and Finland. METHODS: Visits and literature reviews were undertaken for regional centres in Lancashire, Nord-Pas de Calais, and Finland, and Eurostat data on mortality and hospital discharges were analysed. And telephone interviews in Nord-Rhein Westphalia. RESULTS: There have been very significant differences in programme development from the original GOLD starting point. The UK has national strategies but they are without consistent local delivery. The French Affection de Longue Durée (ALD) programme limits special help to at most 10% of patients and there is little use of spirometry in primary care. Germany has a more general Disease Management Programme with COPD as a late starter. Finland has had a successful 10-year programme. The results for the effectiveness gap on hospital discharges show a major difference between Finland (40.7% fall in discharges) and others (increases of 6.0-43.7%). CONCLUSIONS: The results show the need for a simpler programme in primary care to close the effectiveness gap. Such a programme is outlined based on preventing the downward spiral for high-risk patients.

Concepts: Pulmonology, Asthma, Pneumonia, Chronic obstructive pulmonary disease, Spirometry, Obstructive lung disease, Respiratory diseases, The Downward Spiral


This paper is a qualitative analysis of the effects ofaccompagnement, a support framework, on recovery trajectories of people with long-term homelessness and severe psychiatric disorders during 24 months in a Housing First-type program in France. A comprehensive methodology based on grounded theory was used to construct an interview guide, conduct multiple interviews with 35 Housing First participants sampled for heterogeneity, and produce memos on their trajectories before and after entering the program based on interview information. Thematic analysis of a representative subsample (n= 13) of memos identified 12 objective factors and 6 subjective factors key to the recovery process. An in-depth re-analysis of the memos generated four recovery themes: (1) the need for secure space favorable to self-reflexivity; (2) a “honeymoon” effect; (3) the importance of even weak social ties; (4) support from and hope among peers. Three challenges to recovery were identified: (1) finding a balance between protection and risk; (2) breaking downward spirals; (3) bifurcating the trajectory. This study provides new insight into the recovery process, understood as a non-linear transformation of an experience-the relationship between objective life conditions and subjective perception of those conditions-which reinforces protective support over risk elements.

Concepts: Scientific method, Psychology, Research methods, Qualitative research, Mental disorder, Grounded theory, Recovery model, The Downward Spiral


Clinical and epidemiological observations have revealed that alcohol abuse and alcoholism are associated with widespread disruptions in sleep and other circadian biological rhythms. As with other psychiatric disorders, animal models have been very useful in efforts to better understand the cause and effect relationships underlying the largely correlative human data. This review summarizes the experimental findings indicating bidirectional interactions between alcohol (ethanol) consumption and the circadian timing system, emphasizing behavioral studies conducted in the author’s laboratory. Together with convergent evidence from multiple laboratories, the work summarized here establishes that ethanol intake (or administration) alters fundamental properties of the underlying circadian pacemaker. In turn, circadian disruption induced by either environmental or genetic manipulations can alter voluntary ethanol intake. These reciprocal interactions may create a vicious cycle that contributes to the downward spiral of alcohol and drug addiction. In the future, such studies may lead to the development of chronobiologically based interventions to prevent relapse and effectively mitigate some of the societal burden associated with such disorders.

Concepts: Alcohol, Biology, Alcoholism, Drug addiction, Addiction, Circadian rhythm, Chronotype, The Downward Spiral


The convergence between mental ill health and homelessness is well documented, but critical events that precipitate the downward spiral into homelessness, and promote personal recovery remain only partially explored in India.

Concepts: Health care, Illness, Mental disorder, The Downward Spiral, March of the Pigs, Closer


There are two types of damage pattern of human hair cuticle: type L, where the cell membrane complex is split and the cuticle lifts up, and type E, where the fragile substructure of the cuticle cell (endocuticle) is broken. In our previous paper, it was reported that the dominant damage pattern shifts from type L to E with the subjects' age around the 40s. Loss of the cuticle due to daily grooming stresses increases with the subjects' age and is related to the level of type E damage. It is supposed that deterioration of endocuticle advances the loss of cuticle. S100A3 protein, located at the endocuticle, was found to be citrullinated and transformed into tetramer to improve its Ca(2+) -binding ability. It is postulated that this biochemical property affects the maturation of cuticle and contributes to its reinforcement.

Concepts: Protein, Gene, Cell, Cell membrane, Cytoplasm, Hair, Nine Inch Nails, The Downward Spiral


In this study, using four wave longitudinal data, we examined problem gambling severity trajectories in a sample of young adults. Using latent growth curve modeling, we examined how initial level of problem gambling severity and the rate of change were affected by 11 time-invariant predictors: gender, age of onset of gambling, experiencing a big win early in gambling career, experiencing a big loss early in gambling career, alcohol dependence, drug dependence, anxiety, depression, perceived social support, illusion of control, and impulsiveness. Five of the eleven predictors affected initial levels of problem gambling severity; however only impulsiveness affected the rate of change across time. The mean trajectory was negative (lessening of problem gambling risk severity across time), but there was significant inter-individual variation in trajectories and initial levels of problem gambling severity. The main finding of problem gambling risk diminishing over time challenges the conventional picture of problem gambling as an inevitable “downward spiral,” at least among young adults, and suggests that targeted prevention campaigns may be a cost-effective alternative for reaching treatment resistant youth.

Concepts: Longitudinal study, Alcoholism, Sociology, Drug addiction, Addiction, Trajectory, Substance abuse, The Downward Spiral


Study design:Longitudinal cohort study.Objectives:To estimate socioeconomic and work outcomes over 2 and a half years following spinal cord injury (SCI), and to compare those in receipt of compensation (Accident Compensation Corporation, ACC) and those not.Setting:People admitted to the two spinal units in 2007-2009 in New Zealand, where there is a unique no-fault compensation scheme for injury.Methods:Interviews were conducted at ∼6, 18 and 30 months after SCI and data collected on pre-SCI and post-SCI health and socioeconomic characteristics. Poisson regression, quantile regression and a linear mixed model regression were used to compare differences in outcomes.Results:Of the 162 eligible people, 118 (73%) participated and 91(77%) were followed to 30 months; 79% received ACC. Median personal income, self-reported standard of living and household income adequacy all fell slightly to 18 months and then stabilized at 30 months. At that time, 49% had returned to paid work. Among those not eligible for ACC, income fell to less than half the ACC group (P<0.006 after adjustment), and return to work was lower (29% versus 54%).Conclusion:The findings that most people retained their economic status and that return to work was relatively high appear to be due to the proportion entitled to the ACC no-fault compensation scheme for injury; with earnings-related compensation, a focus on rehabilitation to work and non-means-tested support services. This situation should mitigate against the downward spiral into poverty and further ill-health.Spinal Cord advance online publication, 1 October 2013; doi:10.1038/sc.2013.110.

Concepts: Regression analysis, Cohort study, Longitudinal study, Sociology, Household income in the United States, The Downward Spiral, March of the Pigs, Personal income in the United States


Oil and natural gas are highly valuable natural resources, but many countries with large untapped reserves suffer from poor economic and social-welfare performance. This conundrum is known as the resource curse. The resource curse is a result of poor governance and wealth distribution structures that allow the elite to monopolize resources for self-gain. When rival social groups compete for natural resources, civil unrest soon follows. While conceptually easy to follow, there have been few formal attempts to study this phenomenon. Thus, we develop a mathematical model that captures the basic elements and dynamics of this dilemma. We show that when resources are monopolized by the elite, increased exportation leads to decreased domestic production. This is due to under-provision of the resource-embedded energy and industrial infrastructure. Decreased domestic production then lowers the marginal return on productive activities, and insurgency emerges. The resultant conflict further displaces human, built, and natural capital. It forces the economy into a vicious downward spiral. Our numerical results highlight the importance of governance reform and productivity growth in reducing oil-and-gas-related conflicts, and thus identify potential points of intervention to break the downward spiral.

Concepts: Mathematics, Physics, Economics, Natural resource, Capital, Resource, The Downward Spiral, Productive forces


Paranoia embodies altered representation of the social environment, fuelling altered feelings of social acceptance leading to further mistrust. Mindfulness-based cognitive therapy (MBCT) may relieve paranoia and reduce its impact on social acceptance.

Concepts: Randomized controlled trial, Clinical psychology, Major depressive disorder, Cognitive therapy, Mindfulness-based cognitive therapy, The Downward Spiral, March of the Pigs, Closer


Despite significant advances in the management of heart failure, short-term mortality due to advanced heart failure and cardiogenic shock remains high. Developed over the past few decades, percutaneous circulatory support devices offer a rapid and effective approach to slow the downward spiral of hemodynamic instability in patients presenting with decompensated heart failure until a more definitive strategy is pursued or patients recover. This review will discuss the goals of percutaneous circulatory support, the types of devices currently available, and the most recent clinical datasets examining the utility of these devices.

Concepts: Cardiology, Heart failure, Heart, Cardiogenic shock, Acute decompensated heart failure, The Downward Spiral, Sean Beavan, March of the Pigs