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المكتبة البحثية42 results
Peer-reviewed works with DOI and abstract, discovered from MEDLINE-indexed literature. Candidates: no tier, no stated finding, not yet read.
Pediatric obesity treatment, self-esteem, and body image: A systematic review with meta-analysis.
Background: Pediatric obesity impacts on multiple domains of psychological health, including self-esteem and body image.
Objective: To determine the effect of multicomponent pediatric obesity treatment interventions on self-esteem and body image.
Methods: A systematic search of published literature up to June 2019 was undertaken using electronic databases MEDLINE, EMBASE, Cochrane Library, and PsychINFO. Eligible studies implemented an obesity treatment intervention, including a dietary and physical activity component with/without a behavioral component, in children and adolescents with overweight/obesity, and assessed self-esteem and/or body image. Data were extracted by one reviewer and cross-checked. Meta-analysis was used to combine outcome data and moderator analysis conducted to identify intervention characteristics influencing outcomes.
Results: 64 studies were identified. Meta-analysis of 49 studies (n = 10471) indicated that pediatric obesity treatment results in increased self-esteem postintervention (standardized mean difference, [SE] 0.34 [0.03], P < .001, I2 87%), maintained at follow-up (0.35 [0.05] P < .001, I2 79%, 17 studies). Similarly, meta-analysis of 40 studies (n = 2729) indicated improvements in body image postintervention (0.40 [0.03], P < .001, I2 73%), maintained at follow-up (0.41 [0.08], P < .001, I2 89%, 16 studies).
Conclusions: Pediatric obesity treatment improves self-esteem and body image in the short and medium term. These findings may underpin improvements in other psychological outcomes.
Pediatric obesity · meta-analysis · 76 citationsread the source →
Dhall G, Grodman H, Ji L, Sands S, Gardner S, Dunkel IJ, McCowage GB, Diez B, Allen JC, Gopalan A, Cornelius AS, Termuhlen A, Abromowitch M, Sposto R, Finlay JL. (2008)MEDLINE-indexed journal, not yet read by usPediatric blood & cancer · randomised controlled trial Outcome of children less than three years old at diagnosis with non-metastatic medulloblastoma treated with chemotherapy on the "Head Start" I and II protocols.
Purpose: To determine the survival of infants and young children with non-metastatic medulloblastoma using intensive myeloablative chemotherapy and autologous hematopoietic progenitor cell rescue (AuHCR).
Methods: Twenty-one children less than 3 years old at diagnosis with non-metastatic medulloblastoma were enrolled on two identical serial studies, "Head Start" I and "Head Start" II. After surgery, patients received five cycles of induction chemotherapy consisting of vincristine, cisplatin, cyclophosphamide and etoposide. Following induction, all patients underwent myeloablative chemotherapy using carboplatin, thiotepa and etoposide with AuHCR. Irradiation was used only at relapse.
Results: The 5-year event-free (EFS) and overall survival (OS) rates (+/-SE) for all patients, patients with gross total resection, and patients with residual tumor were 52 +/- 11% and 70 +/- 10%, 64 +/- 13% and 79 +/- 11%, and 29 +/- 17% and 57 +/- 19%, respectively. The 5-year EFS and OS ( +/- SE) for patients with desmoplastic and classical medulloblastoma were 67 +/- 16% and 78 +/- 14%, and 42 +/- 14 and 67 +/- 14%, respectively. There were four treatment related deaths. The majority of survivors (71%) avoided irradiation completely. Mean intellectual functioning and quality of life (QoL) for children surviving without irradiation was within average range for a majority of survivors tested.
Conclusion: This strategy of brief intensive chemotherapy for young children with non-metastatic medulloblastoma eliminated the need for craniospinal irradiation 52% of the patients, and may preserve QoL and intellectual functioning. The excellent survival rates are somewhat dampened by high toxic mortality.
Pediatric blood & cancer · randomised controlled trial · 155 citationsread the source →
Assessing depression symptoms in those with insomnia: an examination of the beck depression inventory second edition (BDI-II).
Background: Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the beck depression inventory (BDI-II) has been assessed in various medical populations. Although major depressive disorder (MDD) and primary insomnia (PI) share some daytime symptoms, the BDI-II has not been evaluated for use with insomnia patients.
Method: Participants (N=140) were screened for the presence of insomnia using the Duke structured clinical interview for sleep disorders (DSISD), and evaluated for diagnosis of MDD using the structured clinical interview for DSM-IV-TR (SCID). Participants' mean BDI-II item responses were compared across two groups [insomnia with or without MDD) using multivariate analysis of variance (MANOVA), and the accuracy rates of suggested clinical cutoffs for the BDI-II were evaluated using a receiver operating characteristic (ROC) curve analysis.
Results: The insomnia with depression group had significantly higher scores on several items; however, the groups did not differ on insomnia, fatigue, concentration problems, irritability, libido, increased appetite, and thoughts relating to suicide, self-criticism and punishment items. The ROC curve analysis revealed moderate accuracy for the BDI-II's identification of depression in those with insomnia. The suggested BDI cutoff of >or=17 had 81% sensitivity and 79% specificity. Use of the mild cutoff for depression (>or=14) had high sensitivity (91%) but poor specificity (66%).
Conclusion: Several items on the BDI-II might reflect sleep disturbance symptoms rather than depression per se. The recommended BDI-II cutoffs in this population have some support but a lower cutoff could result in an overclassification of depression in insomnia patients, a documented problem in the clinical literature. Understanding which items discriminate insomnia patients without depression may help address this nosological issue.
Journal of psychiatric research · cohort or longitudinal · 67 citationsread the source →
Emotional responses and psychological health among young people amid climate change, Fukushima's radioactive water release, and wars in Ukraine and the Middle East, and the mediating roles of media exposure and nature connectedness: a cross-national analysis.
Background: New global crises are emerging, while existing global crises remain unabated. Coping with climate change, the radioactive water released into the Pacific Ocean subsequent to the Fukushima nuclear accident in Japan, and the wars in Ukraine and the Middle East (hereafter referred to as the wars) as individual crises can negatively affect the psychological health of young people, but little is known about the compounded impact of multiple crises. We aimed to examine: (1) the emotional responses of young people towards each individual crisis, (2) how aggregate levels of emotional engagement in global crises might pose different potential trajectories in psychological health, and (3) the protective or exacerbating role of media exposure and nature connectedness as mediators on psychological health outcomes of young people.
Methods: We conducted a cross-national online survey among young people (aged 18-29 years) from China, Portugal, South Africa, the USA, and the UK. We adopted stratified purposive sampling and distributed the survey using online platforms (www.wenjuan.com and www.prolific.com). Individuals were eligible for inclusion in our analysis if they were literate in Chinese or English and had no mental disorders diagnosed within the past 12 months. Participants were asked questions on their demographic characteristics and time spent on social media, including proportion of time exposed to media pertaining to global crises of interest, and they completed surveys based on validated scales that measure depression, anxiety, stress, and wellbeing, as well as emotional responses to each global crisis and nature relatedness. We assessed the survey results using descriptive statistics, ANOVA tests, cluster analysis for individual emotional responses, and structural equation modelling for the aggregate measure of emotional engagement towards individual global crises.
Findings: Between Oct 20 and Nov 3, 2023, 2579 individuals participated in the survey, of whom 400 participants from each country (200 male and 200 female participants) were included in our analysis (mean age 24·36 years [SD 2·86]). The mean emotional engagement varied between the global crises of interest (on a scale from 0 to 68, where 0 indicates no emotional response and 68 indicates strong emotional responses across 17 different emotions; wars: 32·42 [SD 14·57]; climate change: 28·79 [14·17]; radioactive water: 21·26 [16·08]), and emotional engagement also varied by country; for instance, for respondents from China, mean emotional engagement in radioactive water was relatively high (39·15 [10·72]) compared with the other countries, and for respondents from the USA, engagement with the wars was relatively low (29·45 [15·78]). We found significant variations in the level of emotional engagement between different crises, with distinct emotional profiles observed among individual countries. To assess the role of media exposure and nature connectedness on psychological outcomes, using structural equation modelling, we constructed a multi-country model comprising Portugal, South Africa, the USA, and the UK, and a standalone model for China. These models elucidated associations between emotional engagement and psychological distress and wellbeing, explaining substantial portions of the variance in both. Notably, while greater emotional engagement in the ecological crises (ie, climate change and radioactive water) generally predicted worse psychological health outcomes, we found the direction of effect for war crises to have positive outcomes for mental health in the standalone China model. Additionally, we found that media exposure mediated the negative effect of wars on psychological distress in the multi-country model, and positive psychological wellbeing in the standalone China model. Moreover, nature connectedness emerged as a potent mediator, effectively mitigating the adverse mental health effects of emotional engagement with some crises, such as radioactive water and climate change.
Interpretation: Our findings offer valuable insights into the nuanced dynamics of emotional engagement in global crises and its implications for mental health outcomes among young people across diverse global contexts. Further research is needed to understand the contribution of ongoing and new global crises towards a compounded negative future outlook on young people's mental health to identify effective communication and intervention strategies that can mitigate the effect of this global challenge.
Funding: Research Grants Council of Hong Kong, China.
The Lancet. Planetary health · 9 citationsread the source →
Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, Il Shin J, Kirkbride JB, Jones P, Kim JH, Kim JY, Carvalho AF, Seeman MV, Correll CU, Fusar-Poli P. (2022)MEDLINE-indexed journal, not yet read by usMolecular psychiatry · meta-analysis Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies.
Promotion of good mental health, prevention, and early intervention before/at the onset of mental disorders improve outcomes. However, the range and peak ages at onset for mental disorders are not fully established. To provide robust, global epidemiological estimates of age at onset for mental disorders, we conducted a PRISMA/MOOSE-compliant systematic review with meta-analysis of birth cohort/cross-sectional/cohort studies, representative of the general population, reporting age at onset for any ICD/DSM-mental disorders, identified in PubMed/Web of Science (up to 16/05/2020) (PROSPERO:CRD42019143015). Co-primary outcomes were the proportion of individuals with onset of mental disorders before age 14, 18, 25, and peak age at onset, for any mental disorder and across International Classification of Diseases 11 diagnostic blocks. Median age at onset of specific disorders was additionally investigated. Across 192 studies (n = 708,561) included, the proportion of individuals with onset of any mental disorders before the ages of 14, 18, 25 were 34.6%, 48.4%, 62.5%, and peak age was 14.5 years (k = 14, median = 18, interquartile range (IQR) = 11-34). For diagnostic blocks, the proportion of individuals with onset of disorder before the age of 14, 18, 25 and peak age were as follows: neurodevelopmental disorders: 61.5%, 83.2%, 95.8%, 5.5 years (k = 21, median=12, IQR = 7-16), anxiety/fear-related disorders: 38.1%, 51.8%, 73.3%, 5.5 years (k = 73, median = 17, IQR = 9-25), obsessive-compulsive/related disorders: 24.6%, 45.1%, 64.0%, 14.5 years (k = 20, median = 19, IQR = 14-29), feeding/eating disorders/problems: 15.8%, 48.1%, 82.4%, 15.5 years (k = 11, median = 18, IQR = 15-23), conditions specifically associated with stress disorders: 16.9%, 27.6%, 43.1%, 15.5 years (k = 16, median = 30, IQR = 17-48), substance use disorders/addictive behaviours: 2.9%, 15.2%, 48.8%, 19.5 years (k = 58, median = 25, IQR = 20-41), schizophrenia-spectrum disorders/primary psychotic states: 3%, 12.3%, 47.8%, 20.5 years (k = 36, median = 25, IQR = 20-34), personality disorders/related traits: 1.9%, 9.6%, 47.7%, 20.5 years (k = 6, median = 25, IQR = 20-33), and mood disorders: 2.5%, 11.5%, 34.5%, 20.5 years (k = 79, median = 31, IQR = 21-46). No significant difference emerged by sex, or definition of age of onset. Median age at onset for specific mental disorders mapped on a time continuum, from phobias/separation anxiety/autism spectrum disorder/attention deficit hyperactivity disorder/social anxiety (8-13 years) to anorexia nervosa/bulimia nervosa/obsessive-compulsive/binge eating/cannabis use disorders (17-22 years), followed by schizophrenia, personality, panic and alcohol use disorders (25-27 years), and finally post-traumatic/depressive/generalized anxiety/bipolar/acute and transient psychotic disorders (30-35 years), with overlap among groups and no significant clustering. These results inform the timing of good mental health promotion/preventive/early intervention, updating the current mental health system structured around a child/adult service schism at age 18.
Molecular psychiatry · meta-analysis · 2420 citationsread the source →
Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries.
Background: Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age or HIV infection) are a type of social protection intervention that addresses a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided so long as the recipient engages in prescribed behaviours such as using a health service or attending school) is unknown.
Objectives: To assess the effects of UCTs for improving health services use and health outcomes in vulnerable children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure and to compare to effects of UCTs versus CCTs.
Search methods: We searched 17 electronic academic databases, including the Cochrane Public Health Group Specialised Register, the Cochrane Database of Systematic Reviews (the Cochrane Library 2017, Issue 5), MEDLINE and Embase, in May 2017. We also searched six electronic grey literature databases and websites of key organisations, handsearched key journals and included records, and sought expert advice.
Selection criteria: We included both parallel group and cluster-randomised controlled trials (RCTs), quasi-RCTs, cohort and controlled before-and-after (CBAs) studies, and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (18 years or older) in LMICs. Comparison groups received either no UCT or a smaller UCT. Our primary outcomes were any health services use or health outcome.
Data collection and analysis: Two reviewers independently screened potentially relevant records for inclusion criteria, extracted data and assessed the risk of bias. We tried to obtain missing data from study authors if feasible. For cluster-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method with random effects. We assessed the quality of evidence using the GRADE approach.
Main results: We included 21 studies (16 cluster-RCTs, 4 CBAs and 1 cohort study) involving 1,092,877 participants (36,068 children and 1,056,809 adults) and 31,865 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative synthesis. The 17 types of UCTs we identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 53.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT, and three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection and/or performance bias). Most studies were funded by national governments and/or international organisations. Throughout the review, we use the words 'probably' to indicate moderate-quality evidence, 'may/maybe' for low-quality evidence, and 'uncertain' for very low-quality evidence. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09, P = 0.07, 5 cluster-RCTs, N = 4972, I² = 2%, low-quality evidence). At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (odds ratio (OR) 0.73, 95% CI 0.57 to 0.93, 5 cluster-RCTs, N = 8446, I² = 57%, moderate-quality evidence). Evidence from five cluster-RCTs on food security was too inconsistent to be combined in a meta-analysis, but it suggested that at 13 to 24 months' follow-up, UCTs could increase the likelihood of having been food secure over the previous month (low-quality evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01, 4 cluster-RCTs, N = 9347, I² = 79%, low-quality evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. No evidence was available on the effect of a UCT on the likelihood of having died. UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.03 to 1.09, 6 cluster-RCTs, N = 4800, I² = 0%, moderate-quality evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, extreme poverty, participation in child labour, adult employment or parenting quality. Evidence from six cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 24 months into the intervention (low-quality evidence). The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services, the likelihood of having had any illness or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.
Authors' conclusions: This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.
The Cochrane database of systematic reviews · meta-analysis · 78 citationsread the source →
Neurobiological Markers of Resilience to Depression Following Childhood Maltreatment: The Role of Neural Circuits Supporting the Cognitive Control of Emotion.
Background: Childhood adversity is strongly linked to negative mental health outcomes, including depression and anxiety. Leveraging cognitive neuroscience to identify mechanisms that contribute to resilience in children with a history of maltreatment may provide viable intervention targets for the treatment or prevention of psychopathology. We present a conceptual model of a potential neurobiological mechanism of resilience to depression and anxiety following childhood adversity. Specifically, we argue that neural circuits underlying the cognitive control of emotion may promote resilience, wherein a child's ability to recruit the frontoparietal control network to modulate amygdala reactivity to negative emotional cues-such as during cognitive reappraisal-buffers risk for internalizing symptoms following exposure to adversity.
Methods: We provide preliminary support for this model of resilience in a longitudinal sample of 151 participants 8 to 17 years of age with (n = 79) and without (n = 72) a history of childhood maltreatment who completed a cognitive reappraisal task while undergoing functional magnetic resonance imaging.
Results: Among maltreated youths, those who were better able to recruit prefrontal control regions and modulate amygdala reactivity during reappraisal exhibited lower risk for depression over time. By contrast, no association was observed between neural functioning during reappraisal and depression among youths without a history of maltreatment.
Conclusions: These preliminary findings support the hypothesis that children who are better able to regulate emotion through recruitment of the frontoparietal network exhibit greater resilience to depression following childhood maltreatment. Interventions targeting cognitive reappraisal and other cognitive emotion regulation strategies may have potential for reducing vulnerability to depression among children exposed to adversity.
Biological psychiatry · 109 citationsread the source →
Fathers' Representation in Observational Studies on Parenting and Childhood Obesity: A Systematic Review and Content Analysis.
Background: The involvement of fathers in caregiving has increased substantially over the past 30 years. Yet in child and adolescent psychopathology, few studies include fathers as research participants and few present results for fathers separate from those for mothers. We test for the first time whether a similar pattern exists in research on parenting and childhood obesity.
Objectives: To conduct a systematic review and quantitative content analysis of observational studies on parenting and childhood obesity to (1) document the inclusion of fathers, relative to mothers, as research participants and (2) examine characteristics of studies that did and did not include fathers. This study presents new data on the number and gender of parent research participants.
Search methods: We searched title, abstract, and Medical Subject Headings term fields in 5 research databases (PubMed, EMBASE, Academic Search Premier, PsycINFO, and CINAHL) using terms combining parents or parenting (e.g., mother, father, caregiver, parenting style, food parenting) and obesity (e.g., obesity, body weight, overweight) or obesity-related lifestyle behaviors (e.g., diet, snacking, physical activity, outdoor play, exercise, media use).
Selection criteria: We identified and screened studies as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) published between January 2009 and December 2015, examining links between parenting and childhood obesity, including parents or caregivers as research participants, and written in English. We excluded interventions, nonhuman studies, dissertations, conference abstracts, and studies on youths with specific medical conditions. Of 5557 unique studies, 667 studies were eligible.
Data collection and analysis: For each of the 667 studies, 4 coders were trained to code characteristics of the study (e.g., publication year, geographic region, journal, study focus) and parent research participants (e.g., parent gender, demographic background, biological relationship with child, and residential status). We established intercoder reliability before coding the full sample of studies (mean Krippendorf's alpha = .79; average percentage agreement = 94%).
Main results: Of the studies, 1% included only fathers. By contrast, 36% included only mothers. Although slightly more than 50% of studies (n = 347) included at least 1 father, only 57 studies reported results for fathers separate from those for mothers. When we combined them with studies including only fathers, 10% of studies overall reported results for fathers. Samples sizes of fathers were small compared with mothers. Of studies with fathers, 59% included 50 or fewer fathers, whereas 22% of studies with mothers included 50 or fewer mothers. The mean sample size for fathers across all eligible studies was 139, compared with 672 for mothers. Overall, fathers represented 17% of parent participants across all eligible studies.
Conclusions: This study unequivocally demonstrates that fathers are underrepresented in recent observational research on parenting and childhood obesity. Public health implications. The underrepresentation of fathers in obesity research compromises the development of effective family interventions for childhood obesity prevention. Targeted opportunities and incentives are needed to support research with fathers.
American journal of public health · systematic review · 129 citationsread the source →
Recruiting and retaining young adults: what can we learn from behavioural interventions targeting nutrition, physical activity and/or obesity? A systematic review of the literature.
Objective: To describe strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention studies, and quantify the success and efficiency of these strategies.
Design: A systematic review was conducted. The search included six electronic databases to identify randomised controlled trials (RCT) published up to 6 December 2019 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17-35 years). Recruitment was considered successful if the pre-determined sample size goal was met. Retention was considered acceptable if ≥80 % retained for ≤6-month follow-up or ≥70 % for >6-month follow-up.
Results: From 21 582 manuscripts identified, 107 RCT were included. Universities were the most common recruitment setting used in eighty-four studies (79 %). Less than half (46 %) of the studies provided sufficient information to evaluate whether individual recruitment strategies met sample size goals, with 77 % successfully achieving recruitment targets. Reporting for retention was slightly better with 69 % of studies providing sufficient information to determine whether individual retention strategies achieved adequate retention rates. Of these, 65 % had adequate retention.
Conclusions: This review highlights poor reporting of recruitment and retention information across trials. Findings may not be applicable outside a university setting. Guidance on how to improve reporting practices to optimise recruitment and retention strategies within young adults could assist researchers in improving outcomes.
Public health nutrition · systematic review · 35 citationsread the source →
Viner R, Russell S, Saulle R, Croker H, Stansfield C, Packer J, Nicholls D, Goddings AL, Bonell C, Hudson L, Hope S, Ward J, Schwalbe N, Morgan A, Minozzi S. (2022)MEDLINE-indexed journal, not yet read by usJAMA pediatrics · systematic review School Closures During Social Lockdown and Mental Health, Health Behaviors, and Well-being Among Children and Adolescents During the First COVID-19 Wave: A Systematic Review.
Importance: School closures as part of broader social lockdown measures during the COVID-19 pandemic may be associated with the health and well-being of children and adolescents.
Objective: To review published reports on the association of school closures during broader social lockdown with mental health, health behaviors, and well-being in children and adolescents aged 0 to 19 years, excluding associations with transmission of infection.
Evidence review: Eleven databases were searched from inception to September 2020, and machine learning was applied for screening articles. A total of 16 817 records were screened, 151 were reviewed in full text, and 36 studies were included. Quality assessment was tailored to study type. A narrative synthesis of results was undertaken because data did not allow meta-analysis.
Findings: A total of 36 studies from 11 countries were identified, involving a total of 79 781 children and adolescents and 18 028 parents, which occurred during the first wave of the COVID-19 pandemic (February to July 2020). All evaluated school closure as part of broader social lockdown during the first COVID-19 wave, and the duration of school closure ranged from 1 week to 3 months. Of those, 9 (25%) were longitudinal pre-post studies, 5 (14%) were cohort, 21 (58%) were cross-sectional, and 1 (3%) was a modeling study. Thirteen studies (36%) were high quality, 17 (47%) were medium quality, and 6 (17%) were low quality. Twenty-three studies (64%) were published, 8 (22%) were online reports, and 5 (14%) were preprints. Twenty-five studies (69%) concerning mental health identified associations across emotional, behavioral, and restlessness/inattention problems; 18% to 60% of children and adolescents scored above risk thresholds for distress, particularly anxiety and depressive symptoms, and 2 studies reported no significant association with suicide. Three studies reported that child protection referrals were lower than expected number of referrals originating in schools. Three studies suggested higher screen time usage, 2 studies reported greater social media use, and 6 studies reported lower physical activity. Studies on sleep (10 studies) and diet (5 studies) provided inconclusive evidence on harms.
Conclusions and relevance: In this narrative synthesis of reports from the first wave of the COVID-19 pandemic, studies of short-term school closures as part of social lockdown measures reported adverse mental health symptoms and health behaviors among children and adolescents. Associations between school closure and health outcomes and behaviors could not be separated from broader lockdown measures.
JAMA pediatrics · systematic review · 426 citationsread the source →
A web-based psychoeducational program for informal caregivers of patients with Alzheimer's disease: a pilot randomized controlled trial.
Background: Although several face-to-face programs are dedicated to informal caregivers of persons with dementia, they are not always accessible to overburdened or isolated caregivers. Based on a face-to-face intervention program, we adapted and designed a Web-based fully automated psychoeducational program (called Diapason) inspired by a cognitive approach.
Objective: This study aimed to evaluate through a pilot unblinded randomized controlled trial the efficacy and acceptability of a Web-based psychoeducational program for informal caregivers of persons with Alzheimer's disease (PWAD) based on a mixed methods research design.
Methods: We recruited and randomized offline 49 informal caregivers of a PWAD in a day care center in Paris, France. They either received the Web-based intervention and usual care for 3 months (experimental group, n=25) or only usual care (control group, n=24). Caregivers' perceived stress (PSS-14, primary outcome), self-efficacy, burden, perceived health status, and depression (secondary outcomes) were measured during 3 face-to-face on-site visits: at baseline, at the end of the program (month 3), and after follow-up (month 6). Additionally, semistructured interviews were conducted with experimental group caregivers at month 6 and examined with thematic analysis.
Results: Intention-to-treat analysis did not show significant differences in self-perceived stress between the experimental and control groups (P=.98). The experimental group significantly improved their knowledge of the illness (d=.79, P=.008) from baseline to month 3. Of the 25 participants allocated to the experimental group, 17 (71%) finished the protocol and entirely viewed at least 10 of 12 online sessions. On average, participants used the website 19.72 times (SD 12.88) and were connected for 262.20 minutes (SD 270.74). The results of the satisfaction questionnaire showed that most participants considered the program to be useful (95%, 19/20), clear (100%, 20/20), and comprehensive (85%, 17/20). Significant correlations were found between relationship and caregivers' program opinion (P=.01). Thus, positive opinions were provided by husbands and sons (3/3), whereas qualified opinions were primarily reported by daughters (8/11). Female spouses expressed negative (2/3) or neutral opinions (1/3). Caregivers expected more dynamic content and further interaction with staff and peers.
Conclusions: In this study, quantitative results were inconclusive owing to small sample size. Qualitative results indicated/showed little acceptance of the program and high expectations from caregivers. Caregivers did not rule out their interest in this kind of intervention provided that it met their needs. More dynamic, personalized, and social interventions are desirable. Our recruitment issues pointed out the necessity of in-depth studies about caregivers' help-seeking behaviors and readiness factors.
Trial registration: Clinicaltrials.gov NCT01430286; http://clinicaltrials.gov/ct2/show/NCT01430286 (Archived by WebCite at http://www.webcitation/6KxHaRspL).
Journal of medical Internet research · randomised controlled trial · 152 citationsread the source →
Wirth M, Benson G, Schwarz C, Köbe T, Grittner U, Schmitz D, Sigrist SJ, Bohlken J, Stekovic S, Madeo F, Flöel A. (2018)MEDLINE-indexed journal, not yet read by usCortex; a journal devoted to the study of the nervous system and behavior · randomised controlled trial The effect of spermidine on memory performance in older adults at risk for dementia: A randomized controlled trial.
Introduction: Nutritional intervention with the natural polyamine spermidine, an autophagy-enhancing agent, can prevent memory loss in aging model organisms. This is the first human study to evaluate the impact of spermidine supplementation on memory performance in older adults at risk for the development of Alzheimer's disease.
Methods: Cognitively intact participants with subjective cognitive decline (n = 30, 60-80 years of age) were included in this three-months, randomized, placebo-controlled, double-blind Phase IIa pilot trial with a spermidine-rich plant extract supplement. Effects of intervention were assessed using the behavioral mnemonic similarity task, measured at baseline and post-intervention visits. Data analysis was focused on reporting and interpreting effectiveness based on effect sizes.
Results: Memory performance was moderately enhanced in the spermidine group compared with placebo at the end of intervention [contrast mean = .17, 95% confidence interval (CI): -.01, .35, Cohen's d = .77, 95% CI: 0, 1.53]. Mnemonic discrimination ability improved in the spermidine-treated group with a medium effect size (mean difference = -.11, 95% CI: -.19, -.03, Cohen's d = .79, 95% CI: .01, 1.55). A similar effect was not found in the placebo-treated group (mean difference = .07, 95% CI: -.13, .27, Cohen's d = -.20, 95% CI: -.94, .54).
Discussion: In this pilot trial, nutritional spermidine was associated with a positive impact on memory performance in older adults with subject cognitive decline. The beneficial effect might be mediated by stimulation of neuromodulatory actions in the memory system. A follow-up Phase IIb randomized controlled trial will help validate the therapeutic potential of spermidine supplementation and delineate possible neurophysiological mechanisms of action.
Trial registration: Registered in ClinicalTrials.gov with the Identifier NCT02755246.
Cortex; a journal devoted to the study of the nervous system and behavior · randomised controlled trial · 121 citationsread the source →
Goldstein LH, Robinson EJ, Mellers JDC, Stone J, Carson A, Reuber M, Medford N, McCrone P, Murray J, Richardson MP, Pilecka I, Eastwood C, Moore M, Mosweu I, Perdue I, Landau S, Chalder T, CODES study group. (2020)MEDLINE-indexed journal, not yet read by usThe lancet. Psychiatry · randomised controlled trial Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.
Background: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency.
Methods: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.
Findings: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events.
Interpretation: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach.
Funding: National Institute for Health Research, Health Technology Assessment programme.
The lancet. Psychiatry · randomised controlled trial · 192 citationsread the source →
Ader F, Bouscambert-Duchamp M, Hites M, Peiffer-Smadja N, Poissy J, Belhadi D, Diallo A, Lê MP, Peytavin G, Staub T, Greil R, Guedj J, Paiva JA, Costagliola D, Yazdanpanah Y, Burdet C, Mentré F, DisCoVeRy Study Group. (2022)MEDLINE-indexed journal, not yet read by usThe Lancet. Infectious diseases · randomised controlled trial Remdesivir plus standard of care versus standard of care alone for the treatment of patients admitted to hospital with COVID-19 (DisCoVeRy): a phase 3, randomised, controlled, open-label trial.
Background: The antiviral efficacy of remdesivir against SARS-CoV-2 is still controversial. We aimed to evaluate the clinical efficacy of remdesivir plus standard of care compared with standard of care alone in patients admitted to hospital with COVID-19, with indication of oxygen or ventilator support.
Methods: DisCoVeRy was a phase 3, open-label, adaptive, multicentre, randomised, controlled trial conducted in 48 sites in Europe (France, Belgium, Austria, Portugal, Luxembourg). Adult patients (aged ≥18 years) admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and illness of any duration were eligible if they had clinical evidence of hypoxaemic pneumonia, or required oxygen supplementation. Exclusion criteria included elevated liver enzymes, severe chronic kidney disease, any contraindication to one of the studied treatments or their use in the 29 days before random assignment, or use of ribavirin, as well as pregnancy or breastfeeding. Participants were randomly assigned (1:1:1:1:1) to receive standard of care alone or in combination with remdesivir, lopinavir-ritonavir, lopinavir-ritonavir and interferon beta-1a, or hydroxychloroquine. Randomisation used computer-generated blocks of various sizes; it was stratified on severity of disease at inclusion and on European administrative region. Remdesivir was administered as 200 mg intravenous infusion on day 1, followed by once daily, 1-h infusions of 100 mg up to 9 days, for a total duration of 10 days. It could be stopped after 5 days if the participant was discharged. The primary outcome was the clinical status at day 15 measured by the WHO seven-point ordinal scale, assessed in the intention-to-treat population. Safety was assessed in the modified intention-to-treat population and was one of the secondary outcomes. This trial is registered with the European Clinical Trials Database, EudraCT2020-000936-23, and ClinicalTrials.gov, NCT04315948.
Findings: Between March 22, 2020, and Jan 21, 2021, 857 participants were enrolled and randomly assigned to remdesivir plus standard of care (n=429) or standard of care only (n=428). 15 participants were excluded from analysis in the remdesivir group, and ten in the control group. At day 15, the distribution of the WHO ordinal scale was: (1) not hospitalised, no limitations on activities (61 [15%] of 414 in the remdesivir group vs 73 [17%] of 418 in the control group); (2) not hospitalised, limitation on activities (129 [31%] vs 132 [32%]); (3) hospitalised, not requiring supplemental oxygen (50 [12%] vs 29 [7%]); (4) hospitalised, requiring supplemental oxygen (76 [18%] vs 67 [16%]); (5) hospitalised, on non-invasive ventilation or high flow oxygen devices (15 [4%] vs 14 [3%]); (6) hospitalised, on invasive mechanical ventilation or extracorporeal membrane oxygenation (62 [15%] vs 79 [19%]); (7) death (21 [5%] vs 24 [6%]). The difference between treatment groups was not significant (odds ratio 0·98 [95% CI 0·77-1·25]; p=0·85). There was no significant difference in the occurrence of serious adverse events between treatment groups (remdesivir, 135 [33%] of 406 vs control, 130 [31%] of 418; p=0·48). Three deaths (acute respiratory distress syndrome, bacterial infection, and hepatorenal syndrome) were considered related to remdesivir by the investigators, but only one by the sponsor's safety team (hepatorenal syndrome).
Interpretation: No clinical benefit was observed from the use of remdesivir in patients who were admitted to hospital for COVID-19, were symptomatic for more than 7 days, and required oxygen support.
Funding: European Union Commission, French Ministry of Health, Domaine d'intérêt majeur One Health Île-de-France, REACTing, Fonds Erasme-COVID-Université Libre de Bruxelles, Belgian Health Care Knowledge Centre, Austrian Group Medical Tumor, European Regional Development Fund, Portugal Ministry of Health, Portugal Agency for Clinical Research and Biomedical Innovation.
Translation: For the French translation of the abstract see Supplementary Materials section.
The Lancet. Infectious diseases · randomised controlled trial · 264 citationsread the source →
Salum GA, Petersen CS, Jarros RB, Toazza R, DeSousa D, Borba LN, Castro S, Gallegos J, Barrett P, Abend R, Bar-Haim Y, Pine DS, Koller SH, Manfro GG. (2018)MEDLINE-indexed journal, not yet read by usJournal of child and adolescent psychopharmacology · randomised controlled trial Group Cognitive Behavioral Therapy and Attention Bias Modification for Childhood Anxiety Disorders: A Factorial Randomized Trial of Efficacy.
Background: The objective of this study is to assess group differences in symptom reduction between individuals receiving group cognitive behavioral therapy (G-CBT) and attention bias modification (ABM) compared to their respective control interventions, control therapy (CT), and attention control training (ACT), in a 2 × 2 factorial design.
Methods: A total of 310 treatment-naive children (7-11 years of age) were assessed for eligibility and 79 children with generalized, separation or social anxiety disorder were randomized and received G-CBT (n = 42) or CT (n = 37). Within each psychotherapy group, participants were again randomized to ABM (n = 38) or ACT (n = 41) in a 2 × 2 factorial design resulting in four groups: G-CBT + ABM (n = 21), G-CBT + ACT (n = 21), CT + ABM (n = 17), and CT + ACT (n = 20). Primary outcomes were responder designation as defined by Clinical Global Impression-Improvement (CGI-I) scale (≤2) and change on the Pediatric Anxiety Rating Scale (PARS).
Results: There were significant improvements of symptoms in all groups. No differences in response rates or mean differences in PARS scores were found among groups: G-CBT + ABM group (23.8% response; 3.9 points, 95% confidence interval [CI] -0.3 to 8.1), G-CBT + ACT (42.9% response; 5.6 points, 95% CI 2.2-9.0), CT + ABM (47.1% response; 4.8 points 95% CI 1.08-8.57), and CT + ACT (30% response; 0.8 points, 95% CI -3.0 to 4.7). No evidence or synergic or antagonistic effects were found, but the combination of G-CBT and ABM was found to increase dropout rate.
Conclusions: We found no effect of G-CBT or ABM beyond the effects of comparison groups. Results reveal no benefit from combining G-CBT and ABM for anxiety disorders in children and suggest potential deleterious effects of the combination on treatment acceptability.
Journal of child and adolescent psychopharmacology · randomised controlled trial · 15 citationsread the source →
An online healthy relationship tool and safety decision aid for women experiencing intimate partner violence (I-DECIDE): a randomised controlled trial.
Background: Evidence for online interventions to help women experiencing intimate partner violence is scarce. We assessed whether an online interactive healthy relationship tool and safety decision aid (I-DECIDE) would increase women's self-efficacy and improve depressive symptoms compared with an intimate partner violence information website.
Methods: In this two-group pragmatic randomised controlled trial, we enrolled women who had screened positive for any form of intimate partner violence or fear of a partner in the 6 months before recruitment. Women aged 16-50 years currently residing in Australia, who had safe access to a computer and an internet connection, and who answered positively to one of the screening questions in English were eligible for inclusion. Participants were randomly assigned (1:1) by computer to receive either the intervention or control website. The intervention website consisted of modules on healthy relationships, abuse and safety, and relationship priority setting, and a tailored action plan. The control website was a static intimate partner violence information website. As the initial portion of the website containing the baseline questions was identical for both groups, there was no way for women to tell which group they had been allocated to, and the research team were also masked to participant allocation until after analysis of the 12-month data. Data were collected at baseline, immediately after completion of the website, at 6 months, and 12 months. Primary outcomes were mean general self-efficacy score (immediately after website completion, and at 6 months and 12 months) and mean depression score (at 6 months and 12 months). Data analyses were done according to intention-to-treat principles, accounting for missing data, and adjusted for outcome baseline scores. This trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN 12614001306606.
Findings: Between Jan 16, and Aug 28, 2015, 584 patients registered for the study and were assessed for eligibility. 422 eligible participants were randomly allocated to the intervention group (227 patients) or control group (195 patients). 179 (79%) participants in the intervention group and 156 (80%) participants in the control group completed 12-month follow-up. Mean self-efficacy at 6 months and 12 months was lower for participants in the intervention group than for participants in the control group, although this did not meet the prespecified mean difference (6 months: 27·5 [SD 5·1] vs 28·1 [4·4], imputed mean difference 1·3 [95% CI 0·3 to 2·3]; 12 months: 27·8 [SD 5·4] vs 29·0 [5·0], imputed mean difference 1·6 [95% CI 0·5 to 2·7]). We found no difference between groups in depressive symptoms at 6 months or 12 months (6 months: 22·5 [SD 17·1] vs 24·2 [17·2], imputed mean difference -0·3 [95% CI -3·5 to 3·0]; 12 months: 21·9 [SD 19·3] vs 21·5 [19·3], imputed mean difference -1·9 [95% CI -5·6 to 1·7]). Qualitative findings indicated that participants found the intervention supportive and a motivation for action.
Interpretation: Our findings highlight the need for further research, development, and refinement of online interventions for women experiencing intimate partner violence, particularly into the duration needed for interventions. Although we detected no meaningful differences between groups, our qualitative results indicated that some women find an online tool a helpful source of motivation and support.
Funding: Australian Research Council.
The Lancet. Public health · randomised controlled trial · 43 citationsread the source →
Jolstedt M, Wahlund T, Lenhard F, Ljótsson B, Mataix-Cols D, Nord M, Öst LG, Högström J, Serlachius E, Vigerland S. (2018)MEDLINE-indexed journal, not yet read by usThe Lancet. Child & adolescent health · randomised controlled trial Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial.
Background: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders.
Methods: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257.
Findings: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported.
Interpretation: ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.
Funding: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.
The Lancet. Child & adolescent health · randomised controlled trial · 51 citationsread the source →
A family planning clinic-based intervention to address reproductive coercion: a cluster randomized controlled trial.
Objective: We assessed the effectiveness of a provider-delivered intervention targeting reproductive coercion, an important factor in unintended pregnancy.
Study design: We randomized 25 family planning clinics (17 clusters) to deliver an education/counseling intervention or usual care. Reproductive coercion and partner violence victimization at 1 year follow-up were primary outcomes. Unintended pregnancy, recognition of sexual and reproductive coercion, self-efficacy to use and use of harm reduction behaviors to reduce victimization and contraception nonuse, and knowledge and use of partner violence resources were secondary outcomes. Analyses included all available data using an intention-to-treat approach.
Results: Among 4009 females ages 16 to 29 years seeking care, 3687 completed a baseline survey prior to clinic visit from October 2011 to November 2012; 3017 provided data at 12-20weeks post-baseline (T2) and 2926 at 12months post-baseline (T3) (79% retention). Intervention effects were not significant for reproductive coercion [adjusted risk ratio (ARR) 1.50 (95% confidence interval 0.95-2.35)] or partner violence [ARR 1.07 (0.84-1.38)]. Intervention participants reported improved knowledge of partner violence resources [ARR 4.25 (3.29-5.50)] and self-efficacy to enact harm reduction behaviors [adjusted mean difference 0.06 (0.02-0.10)]. In time point-specific models which included moderating effects of exposure to reproductive coercion at baseline, a higher reproductive coercion score at baseline was associated with a decrease in reproductive coercion 1 year later (T3). Use and sharing of the domestic violence hotline number also increased.
Conclusion: This brief clinic intervention did not reduce partner violence victimization. The intervention enhanced two outcomes that may increase safety for women, specifically awareness of partner violence resources and self-efficacy to enact harm reduction behaviors. It also appeared to reduce reproductive coercion among women experiencing multiple forms of such abuse.
Contraception · randomised controlled trial · 93 citationsread the source →
Ni Mhurchu C, Te Morenga L, Tupai-Firestone R, Grey J, Jiang Y, Jull A, Whittaker R, Dobson R, Dalhousie S, Funaki T, Hughes E, Henry A, Lyndon-Tonga L, Pekepo C, Penetito-Hemara D, Tunks M, Verbiest M, Humphrey G, Schumacher J, Goodwin D. (2019)MEDLINE-indexed journal, not yet read by usThe Lancet. Digital health · randomised controlled trial A co-designed mHealth programme to support healthy lifestyles in Māori and Pasifika peoples in New Zealand (OL@-OR@): a cluster-randomised controlled trial.
Background: The OL@-OR@ mobile health programme was co-designed with Māori and Pasifika communities in New Zealand, to support healthy lifestyle behaviours. We aimed to determine whether use of the programme improved adherence to health-related guidelines among Māori and Pasifika communities in New Zealand compared with a control group on a waiting list for the programme.
Methods: The OL@-OR@ trial was a 12-week, two-arm, cluster-randomised controlled trial. A cluster was defined as any distinct location or setting in New Zealand where people with shared interests or contexts congregated, such as churches, sports clubs, and community groups. Members of a cluster were eligible to participate if they were aged 18 years or older, had regular access to a mobile device or computer, and had regular internet access. Clusters of Māori and of Pasifika (separately) were randomly assigned (1:1) to either the intervention or control condition. The intervention group received the OL@-OR@ mHealth programme (smartphone app and website). The control group received a control version of the app that only collected baseline and outcome data. The primary outcome was self-reported adherence to health-related guidelines, which were measured with a composite health behaviour score (of physical activity, smoking, alcohol intake, and fruit and vegetable intake) at 12 weeks. The secondary outcomes were self-reported adherence to health-related behaviour guidelines at 4 weeks; self-reported bodyweight at 12 weeks; and holistic health and wellbeing status at 12 weeks, in all enrolled individuals in eligible clusters; and user engagement with the app, in individuals allocated to the intervention. Adverse events were not collected. This study is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12617001484336.
Findings: Between Jan 24 and Aug 14, 2018, we enrolled 337 Māori participants from 19 clusters and 389 Pasifika participants from 18 clusters (n=726 participants) in the intervention group and 320 Māori participants from 15 clusters and 405 Pasifika participants from 17 clusters (n=725 participants) in the control group. Of these participants, 227 (67%) Māori participants and 347 (89%) Pasifika participants (n=574 participants) in the intervention group and 281 (88%) Māori participants and 369 (91%) Pasifika participants (n=650 participants) in the control group completed the 12-week follow-up and were included in the final analysis. Relative to baseline, adherence to health-related behaviour guidelines increased at 12 weeks in both groups (315 [43%] of 726 participants at baseline to 329 [57%] of 574 participants in the intervention group; 331 [46%] of 725 participants to 369 [57%] of 650 participants in the control group); however, there was no significant difference between intervention and control groups in adherence at 12 weeks (odds ratio [OR] 1·13; 95% CI 0·84-1·52; p=0·42). Furthermore, the proportion of participants adhering to guidelines on physical activity (351 [61%] of 574 intervention group participants vs 407 [63%] of 650 control group participants; OR 1·03, 95% CI 0·73-1·45; p=0·88), smoking (434 [76%] participants vs 501 [77%] participants; 1·12, 0·67-1·87; p=0·66), alcohol consumption (518 [90%] participants vs 596 [92%] participants; 0·73, 0·37-1·44; p=0·36), and fruit and vegetable intake (194 [34%] participants vs 196 [30%] participants; 1·08, 0·79-1·49; p=0·64) did not differ between groups. We found no significant differences between the intervention and control groups in any secondary outcome. 147 (26%) intervention group participants engaged with the OL@-OR@ programme (ie, set at least one behaviour change goal online).
Interpretation: The OL@-OR@ mobile health programme did not improve adherence to health-related behaviour guidelines amongst Māori and Pasifika individuals.
Funding: Healthier Lives He Oranga Hauora National Science Challenge.
The Lancet. Digital health · randomised controlled trial · 45 citationsread the source →
Intergenerational Transmission of Emotion Dysregulation Through Parental Invalidation of Emotions: Implications for Adolescent Internalizing and Externalizing Behaviors.
We examined parent emotion dysregulation as part of a model of family emotion-related processes and adolescent psychopathology. Participants were 80 parent-adolescent dyads (mean age = 13.6; 79 % African-American and 17 % Caucasian) with diverse family composition and socioeconomic status. Parent and adolescent dyads self-reported on their emotion regulation difficulties and adolescents reported on their perceptions of parent invalidation (i.e., punishment and neglect) of emotions and their own internalizing and externalizing behaviors. Results showed that parents who reported higher levels of emotion dysregulation tended to invalidate their adolescent's emotional expressions more often, which in turn related to higher levels of adolescent emotion dysregulation. Additionally, adolescent-reported emotion dysregulation mediated the relation between parent invalidation of emotions and adolescent internalizing and externalizing behaviors. Potential applied implications are discussed.
Journal of child and family studies · 119 citationsread the source →
A Randomized Controlled Trial of Cognitive Therapy, a Self-help Booklet, and Repeated Assessments as Early Interventions for Posttraumatic Stress Disorder
BACKGROUND: It is unclear what psychological help should be offered in the aftermath of traumatic events. Similarly, there is a lack of clarity about the best way of identifying people who are unlikely to recover from early posttraumatic symptoms without intervention. OBJECTIVE: To determine whether cognitive therapy or a self-help booklet given in the initial months after a traumatic event is more effective in preventing chronic posttraumatic stress disorder (PTSD) than repeated assessments. DESIGN: Randomized controlled trial. Patients Motor vehicle accident survivors (n = 97) who had PTSD in the initial months after the accident and met symptom criteria that had predicted persistent PTSD in a large naturalistic prospective study of a comparable population. SETTING: Patients were recruited from attendees at local accident and emergency departments. INTERVENTIONS: Patients completed a 3-week self-monitoring phase. Those who did not recover with self-monitoring (n = 85) were randomly assigned to receive cognitive therapy (n = 28), a self-help booklet based on principles of cognitive behavioral therapy (n = 28), or repeated assessments (n = 29). MAIN OUTCOME MEASURES: Symptoms of PTSD as assessed by self-report and independent assessors unaware of the patient's allocation. Main assessments were at 3 months (posttreatment, n = 80) and 9 months (follow-up, n = 79). RESULTS: Twelve percent (n = 12) of patients recovered with self-monitoring. Cognitive therapy was more effective in reducing symptoms of PTSD, depression, anxiety, and disability than the self-help booklet or repeated assessments. At follow-up, fewer cognitive therapy patients (3 [11%]) had PTSD compared with those receiving the self-help booklet (17 [61%]; odds ratio, 12.9; 95% confidence interval, 3.1-53.1) or repeated assessments (16 [55%]; odds ratio, 10.3; 95% confidence interval, 2.5-41.7). There was no indication that the self-help booklet was superior to repeated assessments. On 2 measures, high end-state functioning at follow-up and request for treatment, the outcome for the self-help group was worse than for the repeated assessments group. CONCLUSIONS: Cognitive therapy is an effective intervention for recent-onset PTSD. A self-help booklet was not effective. The combination of an elevated initial symptom score and failure to improve with self-monitoring was effective in identifying a group of patients with early PTSD symptoms who were unlikely to recover without intervention.
Archives of General Psychiatry · randomised controlled trial · 486 citationsread the source →
Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, Yeo LLL, Ahmad A, Ahmed Khan F, Napolean Shanmugam G, Sharma AK, Komalkumar RN, Meenakshi PV, Shah K, Patel B, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH, Sagayanathan R, Chen JT, Ying Ng AY, Teoh HL, Tsivgoulis G, Ho CS, Ho RC, Sharma VK. (2020)MEDLINE-indexed journal, not yet read by usBrain, behavior, and immunity · cohort or longitudinal A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak.
Objective: Since the declaration of the coronavirus 2019 (COVID-19) outbreak as pandemic, there are reports on the increased prevalence of physical symptoms observed in the general population. We investigated the association between psychological outcomes and physical symptoms among healthcare workers.
Methods: Healthcare workers from 5 major hospitals, involved in the care for COVID-19 patients, in Singapore and India were invited to participate in a study by performing a self-administered questionnaire within the period of February 19 to April 17, 2020. Healthcare workers included doctors, nurses, allied healthcare workers, administrators, clerical staff and maintenance workers. This questionnaire collected information on demographics, medical history, symptom prevalence in the past month, Depression Anxiety Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) instrument. The prevalence of physical symptoms displayed by healthcare workers and the associations between physical symptoms and psychological outcomes of depression, anxiety, stress, and post-traumatic stress disorder (PTSD) were evaluated.
Results: Out of the 906 healthcare workers who participated in the survey, 48 (5.3%) screened positive for moderate to very-severe depression, 79 (8.7%) for moderate to extremely-severe anxiety, 20 (2.2%) for moderate to extremely-severe stress, and 34 (3.8%) for moderate to severe levels of psychological distress. The commonest reported symptom was headache (32.3%), with a large number of participants (33.4%) reporting more than four symptoms. Participants who had experienced symptoms in the preceding month were more likely to be older, have pre-existing comorbidities and a positive screen for depression, anxiety, stress, and PTSD. After adjusting for age, gender and comorbidities, it was found that depression (OR 2.79, 95% CI 1.54-5.07, p = 0.001), anxiety (OR 2.18, 95% CI 1.36-3.48, p = 0.001), stress (OR 3.06, 95% CI 1.27-7.41, p = 0.13), and PTSD (OR 2.20, 95% CI 1.12-4.35, p = 0.023) remained significantly associated with the presence of physical symptoms experienced in the preceding month. Linear regression revealed that the presence of physical symptoms was associated with higher mean scores in the IES-R, DASS Anxiety, Stress and Depression subscales.
Conclusions: Our study demonstrates a significant association between the prevalence of physical symptoms and psychological outcomes among healthcare workers during the COVID-19 outbreak. We postulate that this association may be bi-directional, and that timely psychological interventions for healthcare workers with physical symptoms should be considered once an infection has been excluded.
Brain, behavior, and immunity · cohort or longitudinal · 983 citationsread the source →
Schmidt M, Zogheib E, Rozé H, Repesse X, Lebreton G, Luyt CE, Trouillet JL, Bréchot N, Nieszkowska A, Dupont H, Ouattara A, Leprince P, Chastre J, Combes A. (2013)MEDLINE-indexed journal, not yet read by usIntensive care medicine · clinical trial The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.
Purpose: This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors' health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies.
Methods: Data from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008-2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status.
Results: Main ARDS etiologies were bacterial (45%), influenza A[H₁N₁] (26%) and post-operative (17%) pneumonias. Six months post-ICU discharge, 84 (60%) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0-14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16% for PRESERVE classes 0-2, 3-4, 5-6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80% of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16%, respectively.
Conclusions: The PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population.
Intensive care medicine · clinical trial · 441 citationsread the source →
Pattern of psychiatry morbidity during Hajj period at Al-Noor Specialist Hospital.
Objective: To study the pattern and extent of psychiatric morbidity in the Hajj period (pilgrimage to Mecca by a Muslim).
Method: Study was conducted by psychiatry department and Health Research Centre, Al-Noor Specialist Hospital. We recorded demographic and clinical characteristics of all patients presenting during first two weeks of Zulhajjah, 1425H (11th to 24th of January 2005). Detailed clinical interviews were conducted by qualified psychiatrists and findings were recorded in semi-structured form. Diagnoses were made following the guidelines in clinical version of chapter V (Mental and Behavioral Disorders) of International Classification of Diseases (ICD-10). In difficult cases diagnosis was assigned by consensus between three psychiatrists.
Results: During study period 92 patients presented. Males were dominant (54%). Mean age was 43 +/- 17. Highest proportion (52%) belonged to young adults followed by middle-aged (20%). Majority (48%) belonged to Saudi Arabia. Self-referrals were 66% and 52% presented as first episodes. Behavior, mood, and sleep were affected more commonly (65%, 63%, and 59% respectively). Physical symptoms were reported by 28% of patients. Highest number (34%) belonged to "Neurotic, stress-related and somatoform disorders" followed by "Mood disorders" (22%). Medical disorder was reported by 33% of patients. Medications were advised to 79% and psychiatric admission to 6.5% of patients.
Conclusions: In our study, important findings are outlined and discussed. Replication of study with increased sample size and planning of psychiatric services according to established need of population served particularly during hajj period is needed.
International journal of psychiatry in medicine · cohort or longitudinal · 9 citationsread the source →
Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow HH, Lippert A, Maia P, Cohen S, Baras M, Hovilehto S, Ledoux D, Phelan D, Wennberg E, Schobersberger W. (2008)MEDLINE-indexed journal, not yet read by usIntensive care medicine · cohort or longitudinal Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study.
Objective: To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs).
Design: A prospective observational study.
Setting: Thirty-seven ICUs in 17 European countries.
Patients and participants: A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients.
Measurements and results: Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92-93% of cases.
Conclusions: European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.
Intensive care medicine · cohort or longitudinal · 90 citationsread the source →
Effectiveness of Technology Interventions in Addressing Social Isolation, Connectedness, and Loneliness in Older Adults: Systematic Umbrella Review.
Background: The global population of older adults (aged >60 years) is expected to triple to 2 billion by 2050. Proportionate rises in older adults affected by loneliness and social isolation (or social connectedness) are expected. Rapid deployability and social changes have increased the availability of technological devices, creating new opportunities for older adults.
Objective: This study aimed to identify, synthesize, and critically appraise the effectiveness of technology interventions improving social connectedness in older adults by assessing the quality of reviews, common observations, and derivable themes.
Methods: Following the guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), 4 databases (PsycINFO, PubMed, Embase, and MEDLINE) were searched between February 2020 and March 2022. We identified reviews with adults aged ≥50 years in community and residential settings, reporting outcomes related to the impact of technologies on social disconnectedness with inclusion criteria based on the population, intervention, context, outcomes, and study schema-review-type articles (systematic, meta-analyses, integrative, and scoping)-and with digital interventions included. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to measure the strength of outcome recommendations including the risk of bias. The reviews covered 326 primary studies with 79,538 participants. Findings were extracted, synthesized, and organized according to emerging themes.
Results: Overall, 972 publications met the initial search criteria, and 24 met our inclusion criteria. Revised Assessment of Multiple Systematic Reviews was used to assess the quality of the analysis. Eligible reviews (3/24, 12%) were excluded because of their low Revised Assessment of Multiple Systematic Reviews scores (<22). The included reviews were dedicated to information and communications technology (ICT; 11/24, 46%), videoconferencing (4/24, 17%), computer or internet training (3/24, 12%), telecare (2/24, 8%), social networking sites (2/24, 8%), and robotics (2/27, 8%). Although technology was found to improve social connectedness, its effectiveness depended on study design and is improved by shorter durations, longer training times, and the facilitation of existing relationships. ICT and videoconferencing showed the best results, followed by computer training. Social networking sites achieved mixed results. Robotics and augmented reality showed promising results but lacked sufficient data for informed conclusions. The overall quality of the studies based on GRADE was medium low to very low.
Conclusions: Technology interventions can improve social connectedness in older adults. The specific effectiveness rates favor ICT and videoconferencing, but with limited evidence, as indicated by low GRADE ratings. Future intervention and study design guidelines should carefully assess the methodological quality of studies and the overall certainty of specific outcome measures. The lack of randomized controlled trials in underlying primary studies (<28%) and suboptimal methodologies limited our findings. Robotics and augmented or virtual reality warrant further research. Low GRADE scores highlight the need for high-quality research in these areas.
Trial registration: PROSPERO CRD42022363475; https://tinyurl.com/mdd6zds.
JMIR aging · review · 66 citationsread the source →
Mapping Psychosocial Challenges, Mental Health Difficulties, and MHPSS Services for Unaccompanied Asylum-Seeking Children in Greece: Insights from Service Providers.
Background/objectives: Evidence-based information is crucial for policymakers and providers of mental health and psychosocial services (MHPSS) for unaccompanied asylum-seeking children (UASC). However, there is a scarcity of national-level studies investigating the MHPSS needs of UASC and how these are addressed in Greece. The research objectives of this study were to explore: (a) the psychosocial and mental health needs of UASC living in Greek long-term accommodation facilities as perceived by MHPSS providers, and (b) the range of services across the country, highlighting gaps and best practices in service delivery.
Method: An exploratory, predominantly quantitative design was adopted to map UASC's psychosocial difficulties, mental health problems, and MHPSS delivery. Purposive sampling was implemented, with 16 of 17 NGOs operating long-term accommodation facilities for UASC and 16 child and adolescent mental health services (CAMHS) participating. The sample included 79 participants (34 facility coordinators, 28 field psychologists, and 16 CAMHS directors). A 5-W mapping tool (Who, Where, What, When, and Which) was used for data collection, through an online survey. Data analysis involved quantitative and qualitative methods (content analysis).
Results: Of 798 minors, almost 59% showed signs of behavioral or emotional disturbance, with over half referred for psychiatric assessment and 27.7% needing inpatient care. Aggression, disruptive behaviors, self-harm, and suicidal ideation were the most challenging issues. CAMHS directors reported a high rate of crisis-driven responses, with 42.1% of UASC needing emergency psychiatric evaluation. Psychosocial support was hindered by communication difficulties, lack of a shared care philosophy, understaffing, job insecurity, and limited resources.
Conclusions: Our findings highlight the mental health needs of UASC, and the challenges faced by facility coordinators, psychologists, and community mental health specialists. Future research should focus on the institutional and organizational factors influencing service delivery to improve support for UASC.
Children (Basel, Switzerland) · 2 citationsread the source →
The neuromodulatory and hormonal effects of transcutaneous vagus nerve stimulation as evidenced by salivary alpha amylase, salivary cortisol, pupil diameter, and the P3 event-related potential.
Background: Transcutaneous vagus nerve stimulation (tVNS) is a new, non-invasive technique being investigated as an intervention for a variety of clinical disorders, including epilepsy and depression. It is thought to exert its therapeutic effect by increasing central norepinephrine (NE) activity, but the evidence supporting this notion is limited.
Objective: In order to test for an impact of tVNS on psychophysiological and hormonal indices of noradrenergic function, we applied tVNS in concert with assessment of salivary alpha amylase (SAA) and cortisol, pupil size, and electroencephalograph (EEG) recordings.
Methods: Across three experiments, we applied real and sham tVNS to 61 healthy participants while they performed a set of simple stimulus-discrimination tasks. Before and after the task, as well as during one break, participants provided saliva samples and had their pupil size recorded. EEG was recorded throughout the task. The target for tVNS was the cymba conchae, which is heavily innervated by the auricular branch of the vagus nerve. Sham stimulation was applied to the ear lobe.
Results: P3 amplitude was not affected by tVNS (Experiment 1A: N = 24; Experiment 1B: N = 20; Bayes factor supporting null model = 4.53), nor was pupil size (Experiment 2: N = 16; interaction of treatment and time: p = .79). However, tVNS increased SAA (Experiments 1A and 2: N = 25) and attenuated the decline of salivary cortisol compared to sham (Experiment 2: N = 17), as indicated by significant interactions involving treatment and time (p = .023 and p = .040, respectively).
Conclusion: These findings suggest that tVNS modulates hormonal indices but not psychophysiological indices of noradrenergic function.
Brain stimulation · 116 citationsread the source →
Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress.
Objective: Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI.
Method: This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively.
Results: Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS.
Conclusions: Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Psychological trauma : theory, research, practice and policy · 2 citationsread the source →
Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial
Background Web-based cognitive-behavioral therapeutic (CBT) apps have demonstrated efficacy but are characterized by poor adherence. Conversational agents may offer a convenient, engaging way of getting support at any time. Objective The objective of the study was to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression. Methods In an unblinded trial, 70 individuals age 18-28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) (n=34) or were directed to the National Institute of Mental Health ebook, “Depression in College Students,” as an information-only control group (n=36). All participants completed Web-based versions of the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Positive and Negative Affect Scale at baseline and 2-3 weeks later (T2). Results Participants were on average 22.2 years old (SD 2.33), 67% female (47/70), mostly non-Hispanic (93%, 54/58), and Caucasian (79%, 46/58). Participants in the Woebot group engaged with the conversational agent an average of 12.14 (SD 2.23) times over the study period. No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly reduced their symptoms of depression over the study period as measured by the PHQ-9 (F=6.47; P=.01) while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7 (F1,54= 9.24; P=.004). Participants’ comments suggest that process factors were more influential on their acceptability of the program than content factors mirroring traditional therapy. Conclusions Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT.
JMIR Mental Health · 2643 citationsread the source →
Griffiths F, Bryce C, Cave J, Dritsaki M, Fraser J, Hamilton K, Hamilton K, Huxley C, Ignatowicz A, Kim SW, Kimani PK, Madan J, Slowther AM, Sujan M, Sturt J. (2017)MEDLINE-indexed journal, not yet read by usJournal of medical Internet research Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People: A Mixed-Methods Study (The LYNC Study).
Background: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues.
Objective: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards.
Methods: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs.
Results: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches.
Conclusions: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety.
Journal of medical Internet research · 41 citationsread the source →
Suicide in children and young people in England: a consecutive case series.
Background: There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies.
Methods: This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death.
Findings: 145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18-19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 [27%] individuals), bullying (28 [22%]), bereavement (36 [28%]), suicide in family or friends (17 [13%]), physical health conditions (47 [36%]), family problems (44 [34%]), social isolation or withdrawal (33 [25%]), child abuse or neglect (20 [15%]), excessive drinking (34 [26%]), and illicit drug use (38 [29%]). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies.
Interpretation: Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system.
Funding: The Healthcare Quality Improvement Partnership.
The lancet. Psychiatry · 71 citationsread the source →
Conrad N, Misra S, Verbakel JY, Verbeke G, Molenberghs G, Taylor PN, Mason J, Sattar N, McMurray JJV, McInnes IB, Khunti K, Cambridge G. (2023)MEDLINE-indexed journal, not yet read by usLancet (London, England) Incidence, prevalence, and co-occurrence of autoimmune disorders over time and by age, sex, and socioeconomic status: a population-based cohort study of 22 million individuals in the UK.
Background: A rise in the incidence of some autoimmune disorders has been described. However, contemporary estimates of the overall incidence of autoimmune diseases and trends over time are scarce and inconsistent. We aimed to investigate the incidence and prevalence of 19 of the most common autoimmune diseases in the UK, assess trends over time, and by sex, age, socioeconomic status, season, and region, and we examine rates of co-occurrence among autoimmune diseases.
Methods: In this UK population-based study, we used linked primary and secondary electronic health records from the Clinical Practice Research Datalink (CPRD), a cohort that is representative of the UK population in terms of age and sex and ethnicity. Eligible participants were men and women (no age restriction) with acceptable records, approved for Hospital Episodes Statistics and Office of National Statistics linkage, and registered with their general practice for at least 12 months during the study period. We calculated age and sex standardised incidence and prevalence of 19 autoimmune disorders from 2000 to 2019 and used negative binomial regression models to investigate temporal trends and variation by age, sex, socioeconomic status, season of onset, and geographical region in England. To characterise co-occurrence of autoimmune diseases, we calculated incidence rate ratios (IRRs), comparing incidence rates of comorbid autoimmune disease among individuals with a first (index) autoimmune disease with incidence rates in the general population, using negative binomial regression models, adjusted for age and sex.
Findings: Among the 22 009 375 individuals included in the study, 978 872 had a new diagnosis of at least one autoimmune disease between Jan 1, 2000, and June 30, 2019 (mean age 54·0 years [SD 21·4]). 625 879 (63·9%) of these diagnosed individuals were female and 352 993 (36·1%) were male. Over the study period, age and sex standardised incidence rates of any autoimmune diseases increased (IRR 2017-19 vs 2000-02 1·04 [95% CI 1·00-1·09]). The largest increases were seen in coeliac disease (2·19 [2·05-2·35]), Sjogren's syndrome (2·09 [1·84-2·37]), and Graves' disease (2·07 [1·92-2·22]); pernicious anaemia (0·79 [0·72-0·86]) and Hashimoto's thyroiditis (0·81 [0·75-0·86]) significantly decreased in incidence. Together, the 19 autoimmune disorders examined affected 10·2% of the population over the study period (1 912 200 [13·1%] women and 668 264 [7·4%] men). A socioeconomic gradient was evident across several diseases, including pernicious anaemia (most vs least deprived area IRR 1·72 [1·64-1·81]), rheumatoid arthritis (1·52 [1·45-1·59]), Graves' disease (1·36 [1·30-1·43]), and systemic lupus erythematosus (1·35 [1·25-1·46]). Seasonal variations were observed for childhood-onset type 1 diabetes (more commonly diagnosed in winter) and vitiligo (more commonly diagnosed in summer), and regional variations were observed for a range of conditions. Autoimmune disorders were commonly associated with each other, particularly Sjögren's syndrome, systemic lupus erythematosus, and systemic sclerosis. Individuals with childhood-onset type 1 diabetes also had significantly higher rates of Addison's disease (IRR 26·5 [95% CI 17·3-40·7]), coeliac disease (28·4 [25·2-32·0]), and thyroid disease (Hashimoto's thyroiditis 13·3 [11·8-14·9] and Graves' disease 6·7 [5·1-8·5]), and multiple sclerosis had a particularly low rate of co-occurrence with other autoimmune diseases.
Interpretation: Autoimmune diseases affect approximately one in ten individuals, and their burden continues to increase over time at varying rates across individual diseases. The socioeconomic, seasonal, and regional disparities observed among several autoimmune disorders in our study suggest environmental factors in disease pathogenesis. The inter-relations between autoimmune diseases are commensurate with shared pathogenetic mechanisms or predisposing factors, particularly among connective tissue diseases and among endocrine diseases.
Funding: Research Foundation Flanders.
Lancet (London, England) · 508 citationsread the source →
Mental Health Response to the COVID-19 Outbreak in China
Back to table of contents Previous article Next article CommentaryFull AccessMental Health Response to the COVID-19 Outbreak in ChinaJunying Zhou, M.D., Ph.D., Liu Liu, M.D., Pei Xue, M.D., Xiaorong Yang, B.N., Xiangdong Tang, M.D., Ph.D.Junying Zhou, M.D., Ph.D., Liu Liu, M.D., Pei Xue, M.D., Xiaorong Yang, B.N., Xiangdong Tang, M.D., Ph.D.Published Online:7 May 2020https://doi.org/10.1176/appi.ajp.2020.20030304AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Transmission of the 2019 novel coronavirus (COVID-19) (1) has now widely and rapidly spread around the world. On March 11, 2020, the World Health Organization announced that COVID-19 is a pandemic (2). The rapid transmission and mortality risk of the COVID-19 infection may increase the risk of mental health problems among healthy individuals in the general public and worsen preexisting psychiatric problems in psychiatric patients, although data are still being gathered. A constellation of difficult feelings and psychological distress, including panic, worries, and depression, could be triggered by the fear of possible infection, being quarantined at hospitals and home, social isolation, and even the shortage of protective gear.A number of mental health surveys associated with the COVID-19 outbreak are being conducted in different vulnerable populations, which include infected patients, medical staff, students, and the general population. Liu et al. have reported results from a multicenter survey conducted among 1,563 medical staff members and found that the prevalence of depression and anxiety was 51% and 45%, respectively (3). So far, data on the mental health repercussions of the COVID-19 pandemic in outpatient populations have not been available. Thus, we conducted a questionnaire survey, from February 25 to March 9, 2020, among outpatients who sought care in the Departments of Psychiatry, Neurology, and Sleep Medicine in West China Hospital of Sichuan University (Chengdu, China). A self-report questionnaire was completed by outpatients, who provided consent, via the WeChat-based survey program Questionnaire Star. A total of 2,065 out of 3,441 patients completed the survey, including 589 new patients and 1,476 existing patients. The prevalence rates of mental health problems related to the COVID-19 outbreak, including anxiety (defined as a total score ≥5 on the Generalized Anxiety Disorder 7-item scale), depression (defined as a total score ≥5 on the Patient Health Questionnaire 9-item scale), and insomnia (defined as a total score ≥8 on the Insomnia Severity Index), were 25.5%, 16.9%, and 26.2%, respectively. Furthermore, 20.9% of patients (N=300) with preexisting psychiatric disorders (N=1,434) reported a deterioration of their mental health condition related to the pandemic. In particular, transportation restrictions, isolation at home, and fear of cross-infection in hospitals have inevitably become major concerns and barriers to treatment for these patients during the outbreak. Our survey also showed that 24.5% of new patients, including those with anxiety (N=46), depression (N=37), insomnia (N=79), and psychosis (N=21), could not receive timely diagnoses and treatment. Similarly, 22.0% of existing patients with diagnosed mental disorders, including depression, bipolar disorders, and schizophrenia (N=315), could not receive routine psychiatric care because of suspended hospital visits. Consequently, 18.1% of patients (N=259) have self-reduced medication dosages, and 17.2% of patients (N=247) stopped taking their medication because they could not gain access to prescriptions from physicians during the outbreak. As the lifetime prevalence of mental disorders is 16.6% among adults in China (4), millions of psychiatric patients may face barriers to help seeking for timely management of their mental health condition. The long-term repercussions of the viral pandemic on the management of psychiatric patients warrant further investigation. Nonetheless, our data reiterate the importance of implementing appropriate mental health care measures in the face of the COVID-19 pandemic. In response to the COVID-19 outbreak, there have been ongoing measures and concerted efforts in China that emphasize the importance of dealing with the potentially concurrent mental health crisis. On January 26, 2020, the National Health Commission of China released principles for emergency psychological crisis intervention for the COVID-19 pandemic (5). Mental health hotlines were quickly established across China and provided the public with counseling and psychological services. The telephone and Internet have been widely used to deliver mental health care services, and social media platforms (e.g., WeChat, Weibo) have been used to share strategies, guidelines, and education programs for managing potential mental distress. In addition, a series of self-help handbooks for psychological care associated with COVID-19 have been published by the China Association for Mental Health, medical institutions, and universities. Furthermore, a number of hospitals in China have initiated telemedicine services for patients in need during the outbreak of COVID-19. On January 26, 2020, West China Hospital of Sichuan University, as one of the leading hospitals in China, opened a free online outpatient service involving more than 100 medical doctors across specialties. This online outpatient service was created mainly to provide prescriptions to existing patients and to offer consultation to new patients. Our hospital collaborated with commercial courier services to deliver medication to patients' homes at no cost. To date, thousands of patients have received health care provided by this online outpatient service. Interestingly, only 7.4% of patients with mental disorders (N=136) in our survey have sought online help for medical care. Thus, there is a need to promote online mental health care services across China to manage mental health problems during the pandemic. The long-term outcomes of the mental health interventions in both community and hospital settings need further evaluation to determine how we can ameliorate the negative effects of viral outbreaks in the general public, especially among vulnerable patients with mental health problems. Sleep Medicine Center (Zhou, Xue, Tang), Department of Anesthesiology, Translational Neuroscience Center (Liu), and Outpatient Department (Yang), West China Hospital, Sichuan University, Chengdu, China. Send correspondence to Dr. Zhou ([email protected]).The authors report no financial relationships with commercial interests. The authors thank the clinic nurses in the Departments of Psychiatry, Neurology, and Sleep Medicine, West China Hospital, Sichuan University. References1 Lu R, Zhao X, Li J, et al.: Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 2020; 395:565–574Crossref, Medline, Google Scholar2 World Health Organization (WHO): WHO director-general's opening remarks at the media briefing on COVID-19: 11 March 2020 (https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020)Google Scholar3 Liu S, Yang L, Zhang C, et al.: Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17–e18Crossref, Medline, Google Scholar4 Huang Y, Wang Y, Wang H, et al.: Prevalence of mental disorders in China: a cross-sectional epidemiological study. 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Internet Research, Vol. 22, No. an Outpatient Psychiatric to During the COVID-19 Pandemic: A October 2020 | Journal of Internet Research, Vol. 22, No. disorders in people infected with the coronavirus September 2020 | Journal of Public Health, Vol. No. 4 July authors thank the clinic nurses in the Departments of Psychiatry, Neurology, and Sleep Medicine, West China Hospital, Sichuan April 2020 online May 2020 in 1 July 2020
American Journal of Psychiatry · 294 citationsread the source →
Flavonoid Intakes in the US Diet Are Linked to Higher Socioeconomic Status and to Tea Consumption: Analyses of NHANES 2011-16 Data.
Background: Many of the health benefits of tea have been attributed to its flavonoid content. Tea consumption in US adults varies by socioeconomic status (SES).
Objectives: The present objective was to explore intakes of total flavonoids and flavonoid subclasses by participant sociodemographics and by patterns of tea consumption.
Methods: The present analyses were based on 2 d of dietary recalls for 17,506 persons aged >9 y in the 2011-2016 NHANES. The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid database, which included total flavonoids and flavan-3-ols (including catechins), flavanones, flavonols, anthocyanidins, flavones, and isoflavones. Flavonoid intakes were compared by sex, age, race/ethnicity, education, and income-to-poverty ratio (IPR) in univariate analyses. Flavonoid intakes of children and adults were also compared by tea consumption status. Time trends in flavonoid intakes were also examined.
Results: Mean total flavonoid intake was 219 mg/d, of which flavan-3-ols provided 174 mg/d, or 79%. The highest total flavonoid intakes were found in adults aged 51-70 y (293 mg/d), non-Hispanic whites (251 mg/d) and in groups with college education (251 mg/d) and higher income (IPR >3.5: 249 mg/d) (P < 0.001 for all). The socioeconomic gradient was significant for anthocyanidins, flavonols, and flavones (P < 0.001 for all) but not for flavan-3-ols, and persisted across 3 cycles of NHANES. Adult tea consumers had higher intakes of total flavonoids (610 mg/d compared with 141 mg/d) and flavan-3-ols (542 mg/d compared with 97.8 mg/d) than did nonconsumers (P < 0.001). Time trend analyses showed that both tea consumption and flavonoid intakes were unchanged from 2011 to 2016.
Conclusions: Flavonoid intakes in children and adults in the NHANES 2011-16 sample were associated with higher SES and were largely determined by tea consumption. Studies of diet and disease risk need to take sociodemographic gradients and eating and drinking habits into account.
The Journal of nutrition · 26 citationsread the source →
Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.
Background: Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.
Methods: We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.
Findings: In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rates increased by 15·0% (12·0-18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5-3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5-3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57-8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97-3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01-1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7-90·8] DALYs or 55·5% [48·2-62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3-48·6] DALYs or 24·3% [15·7-33·2]), high fasting plasma glucose (28·9 million [19·8-41·5] DALYs or 20·2% [13·8-29·1]), ambient particulate matter pollution (28·7 million [23·4-33·4] DALYs or 20·1% [16·6-23·0]), and smoking (25·3 million [22·6-28·2] DALYs or 17·6% [16·4-19·0]).
Interpretation: The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.
Funding: Bill & Melinda Gates Foundation.
The Lancet. Neurology · 5441 citationsread the source →
Lewis N, McCaffrey K, Sage K, Cheng CJ, Green J, Goldstein L, Campbell H, Ferrell D, Malan N, LaCross N, Maldonado A, Board A, Hanchey A, Harris D, Callahan S, Aberegg S, Risk I, Willardson S, Carter A, Nakashima A, Duncan J, Burnett C, Atkinson-Dunn R, Dunn A. (2019)MEDLINE-indexed journal, not yet read by usMMWR. Morbidity and mortality weekly report E-cigarette Use, or Vaping, Practices and Characteristics Among Persons with Associated Lung Injury - Utah, April-October 2019.
In August 2019, the Utah Department of Health (UDOH) received reports from health care providers of several cases of lung injury in persons who reported use of electronic cigarette (e-cigarette), or vaping, products (1,2). To describe the characteristics of medical care, potentially related conditions, and exposures among 83 patients in Utah, detailed medical abstractions were completed for 79 (95%) patients. Among patients receiving chart abstractions, 70 (89%) were hospitalized, 39 (49%) required breathing assistance, and many reported preexisting respiratory and mental health conditions. Interviews were conducted by telephone or in person with 53 (64%) patients or their proxies, and product samples from eight (15%) of the interviewed patients or proxies were tested. Among 53 interviewed patients, all of whom reported using e-cigarette, or vaping, products within 3 months of acute lung injury, 49 (92%) reported using any products containing tetrohydrocannabinol (THC), the principal psychoactive component of cannabis; 35 (66%) reported using any nicotine-containing products, and 32 (60%) reported using both. As reported in Wisconsin and Illinois (1), most THC-containing products were acquired from informal sources such as friends or illicit in-person and online dealers. THC-containing products were most commonly used one to five times per day, whereas nicotine-containing products were most commonly used >25 times per day. Product sample testing at the Utah Public Health Laboratory (UPHL) showed evidence of vitamin E acetate in 17 of 20 (89%) THC-containing cartridges, which were provided by six of 53 interviewed patients. The cause or causes of this outbreak is currently unknown (2); however, the predominant use among patients of e-cigarette, or vaping, products with prefilled THC-containing cartridges suggests that the substances in these products or the way in which they are heated and aerosolized play an important role in the outbreak. At present, persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific cause or causes of lung injury are not yet known and while the investigation continues, persons should consider refraining from use of all e-cigarette, or vaping, products.
MMWR. Morbidity and mortality weekly report · 54 citationsread the source →
Caregiver characteristics are associated with neuropsychiatric symptoms of dementia.
Objectives: To determine whether caregiver characteristics are independently associated with neuropsychiatric symptoms of dementia (NPS) after accounting for patient characteristics.
Design: Cross-sectional analysis of data from the Medicare Alzheimer's Disease Demonstration and Evaluation study.
Setting: Community-dwelling residents in eight U.S. cities.
Participants: Five thousand seven hundred eighty-eight patients with dementia and their caregivers.
Measurements: Caregivers were asked about the presence of 12 NPS in patients with dementia. Caregiver predictors included age, sex, education, income, marital status, relationship to the patient, whether they lived with patient, number of hours per week spent caregiving, self-reported health, dependency in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), depression, and burden. Multivariate linear regression was used to determine which caregiver characteristics were independently associated with reports of more NPS in patients after controlling for the patient's age, sex, dementia severity, level of ADL dependency, and dementia type.
Results: Caregivers were on average 64 years old, 72% female, and 49% were the spouse of the patient (32% wives, 17% husbands). The mean burden score of caregivers was 15 (range 0-32, with higher scores indicating more burden), and 32% had significant depressive symptoms. Patients were on average 79 years old, 60% were female, and most had moderate to severe dementia. The mean number of NPS+/-standard deviation was 4.8+/-2.8. After adjusting for patient characteristics, caregivers who were younger, less educated, more depressed, more burdened, or spent more hours per week giving care reported more NPS in care recipients (all P< or =.005).
Conclusion: Certain caregiver characteristics are associated with NPS, independent of patient characteristics, including dementia severity. Clinicians should consider the dynamics between patients and caregivers when managing NPS. Understanding how different caregiver characteristics influence NPS may help tailor caregiver education and interventions.
Journal of the American Geriatrics Society · 116 citationsread the source →
Quenot JP, Rigaud JP, Prin S, Barbar S, Pavon A, Hamet M, Jacquiot N, Blettery B, Hervé C, Charles PE, Moutel G. (2012)MEDLINE-indexed journal, not yet read by usIntensive care medicine Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices.
Purpose: Burnout syndrome (BOS) has frequently been reported in healthcare workers, and precipitating factors include communication problems in the workplace and stress related to end-of-life situations. We evaluated the effect of an intensive communication strategy on BOS among caregivers working in intensive care (ICU).
Methods: Longitudinal, monocentric, before-and-after, interventional study. BOS was evaluated using the Maslach Burnout Inventory (MBI) and depression using the Centre for Epidemiologic Studies Depression Scale (CES-D) in 2007 (period 1) and 2009 (period 2). Between periods, an intensive communication strategy on end-of-life practices was implemented, based on improved organisation, better communication, and regular staff meetings.
Results: Among 62 caregivers in the ICU, 53 (85%) responded to both questionnaires in period 1 and 49 (79%) in period 2. We observed a significant difference between periods in all three components of the MBI (emotional exhaustion, p = 0.04; depersonalization p = 0.04; personal accomplishment, p = 0.01). MBI classified burnout as severe in 15 (28%) caregivers in period 1 versus 7 (14%) in period 2, p < 0.01, corresponding to a 50% risk reduction. Symptoms of depression as evaluated by the CES-D were present in 9 (17%) caregivers in period 1 versus 3 (6%) in period 2, p < 0.05, corresponding to a risk reduction of almost 60%.
Conclusion: The implementation of an active, intensive communication strategy regarding end-of-life care in the ICU was associated with a significant reduction in the rate of burnout syndrome and depression in a stable population of caregiving staff.
Intensive care medicine · 72 citationsread the source →
Prediction and prevention of schizophrenia: what has been achieved and where to go next?
Since the traditional clinical paradigm has been replaced by the modern molecular one, medicine set off into new directions. “Prediction”, “prevention” and “personalization” are the programmatic key words of this new approach. Like other medical disciplines, psychiatry has broadened its focus from diagnosis and treatment to the detection and estimation of the risk of disease development, the prediction of its onset and strategies to avoid its manifestation 1,2,3,4. Although treatment of schizophrenia has greatly advanced over the last decades, a significant number of patients continue to take an unfavorable chronic course 5,6. This makes schizophrenia the leading cause for permanent occupational disability among people under 40 years of age in Germany 7, and the 8th most common cause for disability adjusted life years (DALYs) lost among the 15 to 34-year olds worldwide 8, despite its low prevalence. Moreover, schizophrenia involves tremendous direct and indirect societal costs 9 and a huge burden on patients and their families 8,10. It is becoming increasingly clear that schizophrenia is a complex disorder with polygenic heredity and that its pathogenesis is greatly influenced by interactions between different genes and between genes and environment. Associations to variants of the genes for dysbindin and neuregulin-1, the genetic locus G72 and the DAOA (D-amino acid oxidase activator) gene have now been repeatedly confirmed. As with all other complex diseases, research is focusing now on characterizing the polygenetic predisposition and clarifying its influence on the development of the phenotype 11. Research methods range from molecular genetics via proteome research to cell biology, neurophysiology, brain structural and functional imaging and neuropsychology. With all these methods, several indicators for an increased risk of schizophrenia have been identified. However, the currently recognized neurobiological risk factors are not sufficiently predictive to allow the development and application of “selective” prevention measures targeting asymptomatic persons at risk. For neuro-psychological risk factors, this has just become evident in the large-scale attempt of the North American Prodrome Longitudinal Study (NAPLS) group to improve their multivariate model by integrating the examined neurocognitive variables 12. There are also established environmental risk factors for schizophrenia, such as pregnancy or birth complications, growing up in a large city, IQ low but normal and drug consumption. However, with odds ratios around 2, each of these factors appears to increase the lifetime risk of the disease only slightly 13. Thus, the currently known risk factors, either alone or taken together, cannot be used for prediction and prevention without knowledge of the complete predispositional basis and the gene-gene and gene-environment interactions, which are probably numerous. In view of this situation, it may be argued that the current efforts towards prediction and prevention are still premature and that further progress of etiological research is needed. However, a different perspective has emerged from the work of the centers for early recognition and prevention, established first in Melbourne, Australia and in Cologne, Germany in the mid 1990s, and later on in many other places around the world. This resulted from retrospective research of the early course of psychosis, in which the pathophysiologically active disturbances in brain development extend beyond early abnormalities in behavior into psychopathologically definable early risk and ultra high risk (UHR) symptoms, depending on the individual combination of stressors and resilience factors. First episode psychosis (FEP) research has shown that the outbreak of the disease is preceded in about 70% to nearly 100% of cases by an initial prodrome, which lasts for an average of five to six years. Even in highly developed health care systems, an average of one year thereafter elapses from the first manifestation of psychotic positive symptoms to the initiation of adequate treatment 14,15. The period over which the FEP remains untreated (duration of untreated psychosis, DUP) correlates with: delayed and incomplete remission of the symptoms; necessity of more protracted treatment and greater risk of relapse; lower compliance, greater burden on the family, and a higher level of “expressed emotion”; increased risk of depression and suicide; greater impact on the individual's employment or education; increased drug abuse and delinquent behavior; markedly increased costs of treatment 16. These correlations have recently been confirmed by a meta-analysis 17, with coefficients ranging from 0.285 to 0.434 (95% CI). This does not only provide strong arguments in favor of treating the FEP as early as possible, but has also led to a systematic effort to decrease the incidence of psychosis through indicated prevention. Two important studies concerning the early stage prior to the conversion to FEP have demonstrated that the earliest and most common symptoms, which generally dominate during the prodrome, are unspecific and cannot be distinguished from impairment in mood, drive, contact, and concentration of depressive episodes. These are the Age-Beginning-Course (ABC) study of schizophrenia, a retrospective study with optimized methods 14, and the Cologne Early Recognition (CER) Study, a long-term prospective study with an average follow-up period just below 10 years 18. These studies also found striking cognitive impairments in the form of self-experienced disturbances in thought, speech, and perception processes. This subgroup of so-called basic symptoms, which were found in more than a quarter of patients, had high specificity and a high positive predictive power, accompanied by only low rates of false positive predictions 19,20,21. Basic symptoms were first operationalized in the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Shorter versions of the scale for adults and for children and adolescents — the Schizophrenia Proneness Instrument, Adult version (SPI-A) and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) — were later developed from dimensional analyses 22,23,24. While the BSABS only allows an assessment of the current state, the SPI-A and the SPI-CY also allow severity ratings according to the maximum frequency of occurrence within the past 3 months. In the CER study, 385 patients who were presumably in the prodromal phase of schizophrenia were followed up for an average of 9.6 (±7.6) years past baseline. Twenty percent of the initial criterion-positive cases (1 of 66 basic symptoms) who agreed to be followed up developed schizophrenia after 12 months, a further 17% after 24 months, a further 13% after 36 months, and finally a total of 70% after an average of 4.5 years. Thus, only 30% did not convert to schizophrenia. The overall presence/absence of at least one basic symptom correctly predicted presence/absence of a subsequent transition to schizophrenia in 78.1% of cases. From further analyses, two partially overlapping basic symptom criteria for defining at risk mental states (ARMS) for psychosis, primarily schizophrenia, were developed (Table 1). The first criterion, which consists of ten cognitive-perceptive basic symptoms and is abbreviated as COPER, was based on findings concerning the predictive accuracy of individual basic symptoms 18,25. The second was based on a methodological re-analysis of the same data set, in which a cluster of nine cognitive basic symptoms had repeatedly been selected as the most predictive. This cluster was called “cognitive disturbances” (COGDIS). In terms of general predictive accuracy, the two criteria slightly differed in the CER study, as COGDIS tended to be more conservative than COPER, i.e. to perform better in ruling in subsequent schizophrenia at the cost of performing worse in ruling it out. The transition rate throughout the average follow-up period of roughly 10 years was 65% for COPER and 79% for COGDIS, with the majority of transitions occurring within the first 3 years past baseline. In a second prospective study 26, conducted with the SPI-A and with a systematic follow-up of 24 months, 38% of the initially included 146 at-risk subjects developed a frank psychosis, mainly schizophrenia, within 12.3 (±10.4) months on average (1–48; median=9) according to COPER. Thus, the positive results of the CER study were confirmed. Again, COGDIS appeared to be more specific but less sensitive than COPER. As a consequence of these findings, predictive basic symptoms have been established as a set of criteria for risk assessment in international research on the early recognition of psychosis. In particular, the German Research Network on Schizophrenia used these symptoms, together with a combined criterion of functional deterioration and biological risk, in defining an “early at-risk of psychosis state” (ERPS), thereby suggesting a clinical risk staging model (Figure 1). Early and late initial prodromal state: a clinical staging approach The positive symptoms typical of schizophrenia — such as delusions, hallucinations or formal thought disorders — often first appear in an attenuated or transient form during the initial prodromal phase. These symptoms provide a valid prediction of conversion into FEP, particularly in the short term. Warning signs of this sort have been used as ultra-high risk (UHR) criteria 27,28. Notwithstanding their differences across studies, these criteria are generally composed of three alternative elements: attenuated positive symptoms (APS), brief limited intermittent psychotic symptoms (BLIPS), or a combination of one or more risk factors (always including genetic risk) and functional decline within a certain recent period. For the ascertainment of the UHR criteria, the Melbourne group gradually developed a specific instrument, the Comprehensive Assessment of At Risk Mental States (CAARMS) 29. Based on the Australian definition of the UHR criteria, the Structured Interview for Prodromal Syndromes (SIPS), the Scale for Prodromal Syndromes (SOPS) and, subsequently, the Criteria of Prodromal Syndromes (COPS) were developed 30,31. Different UHR-related approaches to an early detection of FEP, particularly schizophrenia, were developed by the Hillside Recognition and Prevention (RAP) program in New York 32 and the Basel Früherkennung von Psychosen (FEPSY) study 33. There have been at least 15 prediction studies using UHR criteria, some of which with large samples 34,35,36,37,38,39,40,41. The 12-month rates of transition into FEP published so far range between approximately 13% and 50%. A substantial variance is even observed with comparable observation periods in the same center 34,35. Yet, as the annual incidence for all forms of psychosis in the general population is only about 0.034% 42, even the lowest conversion rates still indicate a dramatic increase in the relative risk of illness, at least in the help-seeking samples of specialized centers. Table 2 depicts the predictive accuracy measures published so far, with the last five listed studies representing secondary predictor analyses of samples meeting at risk criteria. As a result, in the German Research Network on Schizophrenia, the UHR approach was combined with the basic symptom approach and applied in a slightly modified form for the definition of “late at-risk of psychosis state” (LRPS) (Figure 1). This clinical staging model, which suggests a syndromal sequence for the development of FEP progressing from unspecific prodromal symptoms to predictive basic symptoms, and then to APS, to BLIPS and to full-blown psychotic symptoms, was recently strongly supported 15. Universal or selective prevention measures target healthy population groups or clinically still healthy risk carriers, respectively 43. Indicated prevention, instead, targets individuals with basic symptoms and UHR symptoms. Even at the early stages when these individuals seek advice and help at the early recognition and prevention centers, they must be regarded as ill and in need of treatment. Furthermore, the impending deterioration of psychosocial performance in schizophrenia often already occurs in the initial prodromal phase, even prior to the conversion into FEP 14,15. These clinical and psychosocial impairments justify defining the interventions in EPRS and LPRS as indicated prevention, pursuing the following three objectives: a) improvement in the current burden of prodromal symptoms; b) avoidance or perhaps delay in the development of psychosocial handicap; c) prevention of or at least delay or attenuation of psychosis. Five international intervention studies have attempted to find out whether or to what extent these three objectives can be reached 44,45,46,47,48,49,50,51 (Table 3). The preventive measures used were either cognitive behavioral therapy (CBT), adapted to the requirements of the persons at risk, or atypical antipsychotics (risperidone, olanzapine, and amisulpride). These were randomized controlled studies, but there were problems with the blinding condition in the two CBT interventions. This and other methodological shortcomings currently limit conclusions and have encouraged the research groups working in this area to set up new, optimized intervention studies. For example, the protocol of the ongoing parallel group PREVENT study includes careful comparative analyses and superiority and inferiority tests of the psychological and pharmacological treatments 52. A staging of risk, thereby implying a temporal dimension, was considered for the first time in the two intervention studies of the German Research Network on Schizophrenia. One of these studies covered ERPS and only offered CBT as a preventive measure 49,50. The other study was designed for LRPS and used only preventive treatment with amisul-pride 51. When the symptom development in the initial prodromal state follows the sequence shown in Figure 1, it would be beneficial for scientific and especially ethical reasons to focus on psychological interventions in ERPS, which are well tolerated and highly accepted. As soon as the first attenuated or transient psychotic symptoms occur, it seems justifiable to apply well tolerated antipsychotics with few side effects. This differential prevention strategy is now pursued in all German early recognition centers and is also increasingly gaining support in other countries. Another pharmacological option is aripiprazole, tested in a pilot study in UHR states 53. Its possible preventive effects are currently being analyzed in the PREVENT study. Antidepressants were used in a naturalistic, non-randomized observational study of an adolescent sample employing only the APS criterion for inclusion, but, for methodological reasons, this study does not allow any conclusion about differential preventive effects of these medications 54. A critical evaluation of the achievements over the past 15 years through continuous efforts to enhance prediction and prevention of psychoses, particularly of schizophrenia, reveals quite impressive results. However, the results achieved thus far need to be evaluated in the light of the ambitious, initially mentioned objectives of modern predictive and preventive medicine. Once predictive basic symptoms and UHR symptoms have occurred, the underlying pathophysiological process might have already progressed. For such a complex disease with a long-term course and a pre-dispositional basis, this kind of risk identification and risk-oriented prevention may possibly come too late. A more substantial reduction in incidence could be reached with selective and universal prevention measures. Therefore, symptom-based prediction and prevention need to be further developed into the direction of selective prevention for symptom-free risk carriers. In the future, it is necessary to strive for: a) an improvement of risk enrichment with the inclusion of biological risk factors; b) a stronger individualization of the risk estimation by stratification; c) the inclusion of sub-psychotic mental states, as cross-sectionally by current at risk criteria, in the the application of prevention strategies more with the of the the initial prodromal phase for as as then most of the follow-up periods shown in Table 2 are not to the transition A significant number of later may be as and, the predictive of the risk may be 12. Therefore, the first and most important is to out new, optimized large-scale studies with follow-up periods the of the initial prodromal phase, as in the CER study 18. The risk enrichment can also be advanced through the inclusion of following the of recent research on the prediction of through the cognitive impairment This condition a risk for with a conversion rate comparable to the risk for the patients certain imaging and the predictive risk enrichment may be possible for using brain but also impairments of and which are with the psychosis risk and are more and in cases with a later transition to schizophrenia and other new large-scale studies with sufficiently observation periods could whether the risk enrichment can be achieved by of such The of this strategy is on the progress of research on biological and environmental risk factors and their interactions, as is currently attempted in the Network of schizophrenia study In other medical disciplines, such as or a risk which does not in a of is using for multivariate clinical staging by risk In the of study, this approach was into psychosis prediction research for the first time A clinical model was developed based on a including six variables positive disturbances Assessment of in the past and years of Based on the individual a multivariate for further the risk of transition to psychosis into risk was each a increased relative risk to the general with each This model was argued to improve the prediction of psychosis by a of the individual risk in terms of and a more risk estimation or clinical staging of risk, in studies, could the development of risk adapted inclusion criteria for randomized preventive In the first application of this approach in the only clinical and variables were It remains to be whether a model including or environmental variables would increase the predictive accuracy even In studies have to whether such can also be applied to the prediction of psychosis within different time The currently ongoing of the has a about the inclusion of a risk for psychosis in to prevention initially argued this and to the that the application of as criteria could that the high rate of predictions in would be to increase up to in general This is and prior to whether to the in the of the The on the predictive of at risk criteria, thereby the persons meeting at risk criteria already from mental and functional for which they seek Moreover, they psychological and cognitive with and functional the majority of help-seeking at risk persons general criteria for mental disorder a clinically significant behavioral or psychological with disability and have to be considered as i.e. as people with the need and to be these in there are reasons for the inclusion of a clinical in the as by current at risk criteria, not as a prodromal risk for first psychosis, but as an to medical the of such an diagnosis would have the of the by the current mental state to a and Although an increased risk of psychosis would continue to be a of such a the psychological and medical focus would be from an to and At this current state of the criteria would be the for the inclusion of this A for the and of a new of international and studies would be with this inclusion in and later on also in A new prevention approach is by the of and studies a of the onset of psychosis the with the first results are for and The transition rate was lower in an group of UHR adolescents than in a group and this was at a an was evaluated in 10 patients in an pilot and a significant improvement in different was In an study, time was in an UHR group with as with a group suggesting a of This was the first study imaging data on effects in individuals at risk. The preventive of is currently in the process of in the Australian Prodrome study With the of schizophrenia is the first mental disorder to which the prediction and prevention program of modern medicine has been The results are and justify the that in the years to come it be possible to provide preventive strategies to the individual risk of of each In to a reduction in risk assessment has to be by neurobiological and psychosocial risk factors, and indicated prevention has to be further developed towards selective prevention. This a new of large sample studies for prediction as well as prevention, with observation In these studies, of risk selected to predictive must be psychological and pharmacological interventions need to be on a long-term basis, more prevention strategies have to be In to be to and such studies, it would be to mental states, as by the currently used risk symptoms, in the of the
World Psychiatry · 127 citationsread the source →
Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center.
Purpose: We assessed the long-term efficacy, complications and patient perceptions of microsurgical denervation of the spermatic cord in the treatment of chronic orchialgia.
Materials and methods: Microsurgical denervation of the spermatic cord was performed on 95 testicular units in 79 men (mean age 40.3 years, mean duration of pain 62 months, 16 bilateral) for chronic orchialgia. Conservative management failed in all, and patients were evaluated with an extensive medical history and physical examination. To be a candidate for microsurgical denervation of the spermatic cord each man would have responded either completely or partially to spermatic cord block (greater than 50% decrease in pain) and had no identifiable reversible etiology. Postoperative pain rating scales (0 to 10) were used to determine efficacy.
Results: Mean followup was 20.3 months (range 1 to 102 months) and complete, durable relief was noted in 67 (71%) testicular units, partial relief in 17 (17%), and unchanged in 11 (12%). No patients reported worse pain. Complications included testicular atrophy without hypogonadism in 2 patients, superficial wound infection in 2, hydrocele in 2 and an incisional hematoma in 1.
Conclusions: Microsurgical denervation of the spermatic cord is a minimally invasive, effective and durable management option for treatment of chronic orchialgia refractory to medical management, preserving the physiological function and psychological role of the testes.
The Journal of urology · 78 citationsread the source →
Aging in Australia
An aging population, growing awareness of chronic disease, and access and navigation of health care services prompt much discussion regarding aging in Australia. Debate within academic and policy circles directs attention toward preventive health, with a growing interest in “healthy aging” and “active aging” where quality of life, rather than years of life, is important. There is little doubt that an aging population places pressure on governments and broader society, but these challenges also present opportunities for positive change. People older than 65 years of age account for 13% of the almost 20 million Australians, with projections suggesting an increase to 26%–28% by 2051 (Australian Bureau of Statistics [ABS], 2008). Those older than 85 years currently represent 1.6% of the population but will increase to 7%–10% by 2101 (ABS, 2008). Australians enjoy one of the longest life expectancies, 79 years for men and 84 years for women (Australian Institute of Health and Welfare [AIHW], 2006), projected to rise to 100 years by 2060 (Oeppen & Vaupel, 2002). As the population ages, there will be increased demands on the health system and on family members to care for their older relatives. The health system will be strained due to increased numbers of older people, increased expectations of older people to have control of how and where they live their lives, decreased informal caregivers and workforce shortages (Productivity Commission, 2011). Health care in Australia is delivered via the public and private sectors, with responsibility for public health policy and funding divided between the Commonwealth and the states and territories. The Australian Commonwealth government sets national health policies through the Department of Health and Ageing and funds universal medical services (Medicare) and pharmaceuticals (Pharmaceutical Benefits Scheme). It provides financial assistance to public hospitals, residential aged care facilities, and home and community care for older people as well as being the major source of funds for health research. In contrast, state and territory governments provide acute and psychiatric hospital services, and community and public health services. In 2008, the prime minister and minister for health announced the establishment of the National Health and Hospitals Reform Commission. The commission was established to develop a long-term health reform plan for Australia. As part of this reform, provision has been made for nationally consistent legislation allowing health professionals to move freely between states and territories, previously prohibitive due to cost and administrative issues (Australian Health Practitioner Regulation Agency, 2011). Activity-based funding will use the Australian-Refined Diagnostic Related Groups classification to define and count hospital “activity” in relation to the treatment of acute admitted patients. Concern has been raised that older patients may be discharged early, as this approach rewards reduced expenditure and shorter hospital stays (Eagar, 2010). Under the auspices of the Australian government, as the sole funder of a nationally consistent aged care system, the Productivity Commission’s inquiry “Caring for Older Australians” presents the greatest opportunity for radical review (Productivity Commission, 2011). Although Australians enjoy one of the longest life expectancies in the world, there continue to be many Australians dying prematurely or living with disabilities that compromise quality of life. Australia has witnessed an increased focus on healthy aging, defined as “a lifelong process of optimizing opportunities for improving and preserving health and physical, social and mental wellness, independence, quality of life and enhancing successful life-course transitions” (Health Canada, 2002). The Australian Healthy Ageing research agenda was reviewed in 2000, with an acknowledgment of a need for the promotion of more holistic healthy aging research (Kendig, Andrews, Browning, Quine, & Parsons, 2000). The National Preventive Health Strategy, released in 2009, builds on this work, espousing shared responsibility, early action that continues throughout life, engagement of communities, the influence of markets and policy direction, reducing inequity (particularly in relation to Indigenous Australians), and refocusing primary health care toward prevention (Preventative Health Taskforce, 2009). The National Chronic Disease Strategy, centered on asthma, cancer, diabetes, cardiovascular disease, and arthritis and musculoskeletal diseases, fits well with the preventive health message for older Australians. Research has focused on identifying cost-effective treatments to reduce the burden of these diseases and improve quality of life. Many innovative campaigns exist, including the “Go Red for Women,” uniting women in the fight against heart disease, simple waist measurements to highlight risk of developing diabetes, and Daffodil Day, raising awareness of cancer. The SunSmart campaign has been successful in promoting safe sun exposure and reducing skin cancer; yet, some older people who are housebound or in institutional care are at risk of vitamin D deficiency. As such, sun recommendations have been revised (Cancer Council Australia, 2010). Aged care services fall broadly under the acute, subacute, community, and residential care sectors. Residential aged care is predominantly provided by the nongovernmental sector, by religious, not-for-profit, and private sector providers. However, the Australian federal government through the Aged Care Act 1997 still governs all aspects of the provision of residential care, flexible care, and Community Aged Care Packages (CACP), including the licensing of aged care beds. Although the goal for many older Australians is to remain living independently at home, there will most likely be occasions where community and/or acute services are needed. Most community aged care services are moving toward a strengths-based, person-centered approach to maintaining or improving the independence of older people, focusing on setting achievable goals in the realm of personal, domestic, and instrumental activities of daily living (Department of Health, 2008). Community-based services are delivered to individuals after assessment. Aged Care Assessment Teams (ACAT), unique to Australia, comprise various health professionals (geriatricians, physiotherapists, occupational therapists, and social workers) (Department of Health and Ageing, 2005). The comprehensive assessment identifies the services or referrals that may be needed to enable an older person to remain living independently at home (AIHW, 2007). These packages of care include Home and Community Care services, CACP, Extended Aged Care at Home, or Extended Aged Care at Home for Dementia. Services are implemented in consultation with an individual’s general practitioner who oversees care in the community. There is a strong emphasis on promoting capacity building and restorative care. Minimizing functional decline and maintaining the ability to undertake activities of daily living is pivotal to improving outcomes for older persons in the acute hospital sector. The Department of Health in Victoria, Australia, has supported research aimed at addressing nutrition, mobility, continence, cognition, medication, skin integrity, pain management, and falls (Department of Health, 2011). Short-term transition care (up to 12 weeks) helps to enhance the functional independence of older people leaving hospital and avoid the need for longer term residential care. Under the Aged Care Act 1997, the Australian government subsidizes aged care homes, providing residential aged care to older people who can no longer remain in their own homes. Approximately 70% of the funding for residential aged care is provided by the government. Residential aged care facilities (RACFs) provide care ranging from independent living units to 24-hr nursing care. Aging in place is an option for some people. Residential aged care is predominantly provided by the nongovernmental sector, by religious, not-for-profit, and private sector providers (Cubit, 2009), but all RACFs funded by the Australian government must meet compulsory accreditation standards and show continuous improvement in the quality of care and services provided to residents (Department of Health and Ageing, 2007). Funding for RACFs is determined by the Aged Care Funding Instrument, a formula that matches funding to the care needs of residents. Quality care at the end of life is a crucial area for Australia. The National Palliative Care Strategy—Supporting Australians to Live Well at the End of Life was endorsed in November 2010 by the Australian Health Minister’s Conference. The strategy is designed to improve awareness and understanding of palliative care, building capacity in services to provide appropriate effective care (Department of Health and Ageing, 2010b). Advanced care planning, based on the principles of patient autonomy and consent, allows older Australians to express their wishes about any future health care, providing choice and control for future care options (Royal Australian College of General Practitioners, 2010). The most significant issue relating to the aged care workforce is the recruitment and retention of appropriately qualified nurses (Cubit, 2009). Within the residential care sector, the number of registered nurses has declined (AIHW, 2003), resulting in nationwide shortages (AIHW, 2007). At the same time, there has been an increase in the number of personal care assistants who provide the bulk of the hands-on care (Hogan, 2004). The resulting mix of staff makes it difficult to provide adequate care to the growing number of older people (Robinson et al., 2005, 2007). Several strategies for combating this problem have been recommended, including creating supportive work environments, increasing organizational support, generating greater acknowledgment of knowledge and skills, improving rates of pay and staffing levels, improving the image of aged care, achieving the appropriate skills mix minimizing and clarifying documentation requirements, developing a national career progression framework for nurses and carers, and developing a national research program in aged care (Pearson et al., 2002). The National Aged Care Workforce Strategy (2005) provides a framework for a sustainable and viable aged care sector, addressing these recommendations (Department of Health and Ageing, 2005). Although many of these recommendations have been implemented, the Productivity Commission concluded that recruitment and retention of appropriately qualified health professionals into the aged case sector remains problematic (Productivity Commission, 2011). Many older Australians wishing to live independently in their own home can do so only with the assistance of an informal caregiver. Australia has almost 2.6 million caregivers, of which 500,000 are primary caregivers, from diverse English and non-English-speaking backgrounds. Caregivers are usually family members (Carers Victoria, 2011) who provide about 74% of all support to older people in Australia. Their efforts save our economy more than $30.5 billion per year (Access Economics Pty Limited, 2005). Caring for an older person often takes its toll, both physically and psychologically. The Australian Unity Wellbeing Index revealed that caregivers have the lowest level of well-being recorded (Cummins et al., 2007). To assist in addressing the well-being of many caregivers, the National Respite for Carers program provides the opportunity for a break from caring, with respite available in the home, in day centers, with a host family, or in overnight residential care. The future of aged care within Australia is at a crucial juncture. Underpinning the vision of an equitable, efficient, and sustainable aged care system is evidenced-based research. The Australian government has committed $10 million to the Ageing Well, Ageing Productively Research Program, which has as its focus policy and practice outcomes that tangibly improve the lives of older Australians (National Health and Medical Research Council, 2005). The research landscape is rich with longitudinal studies that focus on the health and well-being of Australians across the life span. Dynamic Analyses to Optimise Ageing is a pooled data set of nine existing longitudinal studies (Table 1), with more than 50,000 participants. Studies Comprising the Dynamic Analyses to Optimise Ageing Project Studies Comprising the Dynamic Analyses to Optimise Ageing Project From a broader perspective, the Australian Association of Gerontology (AAG), Australia’s largest multidisciplinary professional association of people who work in, or have an interest in, aging helps to shape the research agenda by representing the views of multidisciplinary professionals across numerous sectors. Health and medical research underpins an effective and efficient aged care system, allowing individuals and the wider community to benefit from preventing or treating ill health, improving well-being, and accessing quality aged care services. The National Health and Hospitals Reform Commission (2009) supports research creating an agile self-improving health system. Its focus is on building a “vibrant culture of innovation and research” (National Health and Hospitals Reform Commission, 2009, p. 209) that permeates health services. The National Health and Medical Research Council (2010) promotes translational research, multidisciplinary approaches to research, and collaborations of research institutes across Australia. Bridging the gap between research and practice is an area for improvement within gerontology in Australia. The uptake of evidence-based practice for health professionals such as falls prevention in the hospital setting (Barker, Kamar, & Morton, 2009) and translating dementia research into practice (Draper, Low, Vickland, Withall, & Ward, 2009) together with adherence of older people to programs (Nyman & Victor, 2011) are examples of ongoing challenges. Australia has two Indigenous populations—Aboriginals and Torres Strait Islanders. First counted in the National Census in 1971, they currently number 517,200, representing 2.5% of the total Australian population (2006 Census), with approximately 90% of the Indigenous population of Aboriginal origin, 6% of Torres Strait Islander origin only, and 4% of both Aboriginal and Torres Strait Islander origin (ABS, 2007). There is an urgent need to address the health concerns of Indigenous Australians, who experience poorer health and a much lower life expectancy (a gap of 17 years) than the wider Australian community (AIHW, 2010a; Department of Health and Ageing, 2010a). This is partly attributable to chronic diseases including cardiovascular disease and diabetes, to poor access to primary health care, and to risk factors such as smoking, poor nutrition, and lack of exercise. Tobacco smoking is responsible for 20% of all deaths of Aboriginal and Torres Strait Islander peoples (Department of Health and Ageing, 2010a). These people experience a fivefold increase in the prevalence of dementia. The Koori Growing Old Well Study through Neuroscience Research Australia explores healthy aging and cognition in urban Indigenous communities. Preliminary findings suggest that negative early life experiences and lack of educational opportunities have a major impact on the brains of Indigenous children, leading to a range of health and socioeconomic problems in later life. Study leader, Professor Tony Broe (University of New South Wales), believes childhood neural defects, additional social and education deficits, and involvement in the criminal justice system are major determinants of poor adult health, possibly accelerating dementia in older Indigenous people (Broe et al., 2010). Substantial research gaps include variations in understanding about dementia, meaning and experience of caregiving, best practice for identification and assessment, and best practice for the provision of formal care (Arkles et al., 2010). Research funding is currently available through the Australian Research Council to conduct Aboriginal health-related research through the Australian National University’s Centre for Aboriginal Economic Policy Research (http://caepr.anu.edu.au). In addition, the federal government has initiated several health care programs including a Petrol Sniffing Prevention Program and a Strong Fathers Strong Families Program. More than two thirds (15.1 million) of Australians live in major cities, one in five (4.3 million) live in inner regional areas, 1 in 10 (2.1 million) in outer regional areas, and 2.3% live in remote or very remote areas (ABS, 2010). Despite having better social cohesion, people living in rural and remote areas of Australia have poorer health outcomes and less access to quality health services than their counterparts in major cities (AIHW, 2010b). Several key issues negatively affect rural and remote health care, including geographical isolation, sparse population distribution, an aging population, migration factors, poor socioeconomic status, workforce recruitment, and limited services (Henderson & Caplan, 2008). An example of current research addressing these issues is the “Linking Rural Older People to Community Through Technology” project, aiming to explore how access and connection to the wider community for older Australians in rural and remote locations could be achieved through the use of new communication technologies. Results highlighted low levels of comfort with new advances in communication technology for older people in the Murraylands region of South Australia, while offering opportunities to overcome issues of distance for older people living at home in rural regions (Feist, Parker, Howard, & Hugo, 2010). Mental health is an emerging area for older Australians. A report recently undertaken by the National Ageing Research Institute for “Beyond Blue” recommended that there be an awareness raising campaign for older age depression and anxiety among aged care service providers, mandatory mental health training for the aged care sector, improved access to information for older people and their families, and consideration of minimum guidelines for mental health training among undergraduates intending to work in the aged care sector (Dow et al., 2010). Currently, there are approximately 200,000 Australians diagnosed with dementia. Within the next 5 years, it is expected that dementia will be the leading cause of disability within Australia, surpassing cardiovascular disease, cancer, and depression (Department of Health and Ageing, 2006). The National Framework for Action on Dementia (2006–2010) was established in 2005 to address one of the most significant challenges facing an aging Australian population. The Dementia Collaborative Research Centres, set up in response to the challenge of translating research into practice in order that better care may be provided, has three sites—Assessment and Better Care, Early Diagnosis and Prevention, and Carers and Consumers (Alzheimer's Australia, 2011). Emphasis is placed on the person with dementia being valued and respected, with improved quality of life for people with dementia, their caregivers, and their families. There are numerous other areas of research being undertaken within Australia, such as E-health, falls prevention, housing and homelessness, culturally and linguistically diverse communities, nutrition, continence, veterans’ health issues, and medications/polypharmacy. This is not a comprehensive list, and it is recommended that readers approach the AAG should they wish for further information, particularly regarding the key researchers in each field. The AAG Web site can be found at http://www.aag.asn.au
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