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Exercise training for bronchiectasis.

Background: Bronchiectasis is characterised by excessive sputum production, chronic cough, and acute exacerbations and is associated with symptoms of dyspnoea and fatigue, which reduce exercise tolerance and impair quality of life. Exercise training in isolation or in conjunction with other interventions is beneficial for people with other respiratory diseases, but its effects in bronchiectasis have not been well established. Objectives: To determine effects of exercise training compared to usual care on exercise tolerance (primary outcome), quality of life (primary outcome), incidence of acute exacerbation and hospitalisation, respiratory and mental health symptoms, physical function, mortality, and adverse events in people with stable or acute exacerbation of bronchiectasis. Search methods: We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, and the World Health Organization trials portal, from their inception to October 2020. We reviewed respiratory conference abstracts and reference lists of all primary studies and review articles for additional references. Selection criteria: We included randomised controlled trials in which exercise training of at least four weeks' duration (or eight sessions) was compared to usual care for people with stable bronchiectasis or experiencing an acute exacerbation. Co-interventions with exercise training including education, respiratory muscle training, and airway clearance therapy were permitted if also applied as part of usual care. Data collection and analysis: Two review authors independently screened and selected trials for inclusion, extracted outcome data, and assessed risk of bias. We contacted study authors for missing data. We calculated mean differences (MDs) using a random-effects model. We used the GRADE approach to assess the certainty of evidence. Main results: We included six studies, two of which were published as abstracts, with a total of 275 participants. Five studies were undertaken with people with clinically stable bronchiectasis, and one pilot study was undertaken post acute exacerbation. All studies included co-interventions such as instructions for airway clearance therapy and/or breathing strategies, provision of an educational booklet, and delivery of educational sessions. The duration of training ranged from six to eight weeks, with a mix of supervised and unsupervised sessions conducted in the outpatient or home setting. No studies of children were included in the review; however we identified two studies as currently ongoing. No data were available regarding physical activity levels or adverse events. For people with stable bronchiectasis, evidence suggests that exercise training compared to usual care improves functional exercise tolerance as measured by the incremental shuttle walk distance, with a mean difference (MD) between groups of 87 metres (95% confidence interval (CI) 43 to 132 metres; 4 studies, 161 participants; low-certainty evidence). Evidence also suggests that exercise training improves six-minute walk distance (6MWD) (MD between groups of 42 metres, 95% CI 22 to 62; 1 study, 76 participants; low-certainty evidence). The magnitude of these observed mean changes appears clinically relevant as they exceed minimal clinically important difference (MCID) thresholds for people with chronic lung disease. Evidence suggests that quality of life improves following exercise training according to St George's Respiratory Questionnaire (SGRQ) total score (MD -9.62 points, 95% CI -15.67 to -3.56 points; 3 studies, 160 participants; low-certainty evidence), which exceeds the MCID of 4 points for this outcome. A reduction in dyspnoea (MD 1.0 points, 95% CI 0.47 to 1.53; 1 study, 76 participants) and fatigue (MD 1.51 points, 95% CI 0.80 to 2.22 points; 1 study, 76 participants) was observed following exercise training according to these domains of the Chronic Respiratory Disease Questionnaire. However, there was no change in cough-related quality of life as measured by the Leicester Cough Questionnaire (LCQ) (MD -0.09 points, 95% CI -0.98 to 0.80 points; 2 studies, 103 participants; moderate-certainty evidence), nor in anxiety or depression. Two studies reported longer-term outcomes up to 12 months after intervention completion; however exercise training did not appear to improve exercise capacity or quality of life more than usual care. Exercise training reduced the number of acute exacerbations of bronchiectasis over 12 months in people with stable bronchiectasis (odds ratio 0.26, 95% CI 0.08 to 0.81; 1 study, 55 participants). After an acute exacerbation of bronchiectasis, data from a single study (N = 27) suggest that exercise training compared to usual care confers little to no effect on exercise capacity (MD 11 metres, 95% CI -27 to 49 metres; low-certainty evidence), SGRQ total score (MD 6.34 points, 95%CI -17.08 to 29.76 points), or LCQ score (MD -0.08 points, 95% CI -0.94 to 0.78 points; low-certainty evidence) and does not reduce the time to first exacerbation (hazard ratio 0.83, 95% CI 0.31 to 2.22). Authors' conclusions: This review provides low-certainty evidence suggesting improvement in functional exercise capacity and quality of life immediately following exercise training in people with stable bronchiectasis; however the effects of exercise training on cough-related quality of life and psychological symptoms appear to be minimal. Due to inadequate reporting of methods, small study numbers, and variation between study findings, evidence is of very low to moderate certainty. Limited evidence is available to show longer-term effects of exercise training on these outcomes.

The Cochrane database of systematic reviews · meta-analysis · 29 citationsread the source →

Modifiable early-life risk factors for childhood adiposity and overweight: an analysis of their combined impact and potential for prevention.

Background: Early life may be a "critical period" when appetite and regulation of energy balance are programmed, with lifelong consequences for obesity risk. Insight into the potential impact of modifying early-life risk factors on later obesity can be gained by evaluating their combined effects. Objective: The objective was to examine the relation between the number of early-life risk factors and obesity outcomes among children in a prospective birth cohort (Southampton Women's Survey). Design: Five risk factors were defined: maternal obesity [prepregnant body mass index (BMI; in kg/m(2)) >30], excess gestational weight gain (Institute of Medicine, 2009), smoking during pregnancy, low maternal vitamin D status (<64 nmol/L), and short duration of breastfeeding (none or <1 mo). Obesity outcomes examined when the children were aged 4 and 6 y were BMI, dual-energy X-ray absorptiometry-assessed fat mass, overweight, or obesity (International Obesity Task Force). Data were available for 991 mother-child pairs, with children born between 1998 and 2003. Results: Of the children, 148 (15%) had no early-life risk factors, 330 (33%) had 1, 296 (30%) had 2, 160 (16%) had 3, and 57 (6%) had 4 or 5. At both 4 and 6 y, there were positive graded associations between number of early-life risk factors and each obesity outcome (all P < 0.001). After taking account of confounders, the relative risk of being overweight or obese for children who had 4 or 5 risk factors was 3.99 (95% CI: 1.83, 8.67) at 4 y and 4.65 (95% CI: 2.29, 9.43) at 6 y compared with children who had none (both P < 0.001). Conclusions: Having a greater number of early-life risk factors was associated with large differences in adiposity and risk of overweight and obesity in later childhood. These findings suggest that early intervention to change these modifiable risk factors could make a significant contribution to the prevention of childhood obesity.

The American journal of clinical nutrition · 85 citationsread the source →

Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial.

Importance: During hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL). Objective: To assess the effect of inpatient palliative care on patient- and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation. Design, setting, and participants: Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016. Interventions: Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request. Main outcomes and measures: Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT. Results: Among 160 enrolled patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week follow-up, and 149 patients (93.1%) completed 3-month follow-up. Patients in the intervention group reported a smaller decrease in QOL from baseline to week 2 (mean baseline score, 110.26; week 2 score, 95.46; mean change, -14.72) compared with patients in the control group (mean baseline score, 106.83; week 2 score, 85.42; mean change, -21.54; difference between groups, -6.82; 95% CI, -13.48 to -0.16; P = .045). Among the secondary outcomes, from baseline to week 2, patients in the intervention group vs those in the control group had less increase in depression (mean, 2.43 vs 3.94; mean difference, 1.52; 95% CI, 0.23-2.81; P = .02), lower anxiety (mean, -0.80 vs 1.12; mean difference, 1.92; 95% CI, 0.83-3.01; P < .001), no difference in fatigue (mean, -10.30 vs -13.65; mean difference, -3.34; 95% CI, -7.25 to 0.56; P = .09), and less increase in symptom burden (mean, 17.35 vs 23.14; mean difference, 5.80; 95% CI, 0.49-11.10; P = .03). At 3 months after HCT, intervention patients vs control patients had higher QOL scores (mean, 112.00 vs 106.66; mean difference, 5.34; 95% CI, 0.04-10.65; P = .048) and less depression symptoms (mean, 3.49 vs 5.19; mean difference, -1.70; 95% CI, -2.75 to -0.65; P = .002) but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of patients in the intervention group vs caregivers of patients in the control group reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96; P = .03). Conclusions and relevance: Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications. Trial registration: clinicaltrials.gov Identifier: NCT02207322.

JAMA · randomised controlled trial · 309 citationsread the source →

The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales.

Background: Despite the emphasis placed on childhood trauma in psychiatry, comparatively little is known about the epidemiology of trauma and trauma-related psychopathology in young people. We therefore aimed to evaluate the prevalence, clinical features, and risk factors associated with trauma exposure and post-traumatic stress disorder (PTSD) in young people. Methods: We carried out a comprehensive epidemiological study based on participants from the Environmental Risk Longitudinal Twin Study, a population-representative birth-cohort of 2232 children born in England and Wales in 1994-95. At the follow-up home visit at age 18 years, participants were assessed with structured interviews for trauma exposure, PTSD, other psychopathology, risk events, functional impairment, and service use. Risk factors for PTSD were measured prospectively over four previous assessments between age 5 and 12 years. The key outcomes were the prevalence, clinical features, and risk factors associated with trauma exposure and PTSD. We also derived and tested the internal validity of a PTSD risk calculator. Findings: We found that 642 (31·1%) of 2064 participants reported trauma exposure and 160 (7·8%) of 2063 experienced PTSD by age 18 years. Trauma-exposed participants had high rates of psychopathology (187 [29·2%] of 641 for major depressive episode, 146 [22·9%] of 638 for conduct disorder, and 102 [15·9%] of 641 for alcohol dependence), risk events (160 [25·0%] of 641 for self-harm, 53 [8·3%] of 640 for suicide attempt, and 42 [6·6%] of 640 for violent offence), and functional impairment. Participants with lifetime PTSD had even higher rates of psychopathology (87 [54·7%] of 159 for major depressive episode, 43 [27·0%] of 159 for conduct disorder, and 41 [25·6%] of 160 for alcohol dependence), risk events (78 [48·8%] of 160 for self-harm, 32 [20·1%] of 159 for suicide attempt, and 19 [11·9%] of 159 for violent offence), and functional impairment. However, only 33 (20·6%) of 160 participants with PTSD received help from mental health professionals. The PTSD risk calculator had an internally validated area under the receiver operating characteristic curve of 0·74, indicating adequate discrimination of trauma-exposed participants with and without PTSD, and internally validated calibration-in-the-large of -0·10 and calibration slope of 0·90, indicating adequate calibration. Interpretation: Trauma exposure and PTSD are associated with complex psychiatric presentations, high risk, and significant impairment in young people. Improved screening, reduced barriers to care provision, and comprehensive clinical assessment are needed to ensure that trauma-exposed young people and those with PTSD receive appropriate treatment. Funding: The Medical Research Council, the National Institute of Child Health and Development, the Jacobs Foundation, the Nuffield Foundation, the National Society for Prevention of Cruelty to Children, the Economic and Social Research Council, the National Institute for Health Research, MQ, and Canadian Institutes for Advanced Research.

The lancet. Psychiatry · cohort or longitudinal · 287 citationsread the source →

Internet-Delivered Cognitive Behavior Therapy for Young Taiwanese Female Nursing Students with Irritable Bowel Syndrome-A Cluster Randomized Controlled Trial.

Irritable Bowel Syndrome (IBS) is prevalent within the general population. Studies have shown that stress and anxiety co-exist with IBS. Young Taiwanese women commonly exhibit physical and psychological health problems caused by academic stress. The purpose of our current study was to evaluate the efficacy of short-term Internet-delivered cognitive-behavioral therapy (ICBT) on female nursing students in practicum. We performed a cluster randomized controlled trial comprised of 160 participants who met the inclusion criteria, which were divided into three groups: (1) ICBT, (2) expressive writing (EW), and (3) wait-list control. Treatment interventions lasted for 6 weeks. Levels of anxiety, depression, and IBS symptoms were assessed at four time points, baseline assessment at T0, 2 weeks after T0 (T1), at the end of practicum (T2), and at 3-month follow-up (T3). The results showed that ICBT and EW groups exhibited a significant, yet small, reduction in anxiety and depression at T2 and T3 compared to the wait-list control group. The EW group exhibited significantly greater reduction in anxiety and depression compared to the ICBT group at T2. However, the ICBT group demonstrated greater improvements in alleviating anxiety and depression at T3 compared to the EW group. These data indicate that ICBT and EW groups exhibited small effects on anxiety and depression reduction at T2 and T3 compared to the wait-list control group, with no effects on IBS symptoms in young Taiwanese female nursing students.

International journal of environmental research and public health · randomised controlled trial · 13 citationsread the source →

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

Background: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. Objective: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. Methods: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. Results: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. Conclusions: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. Trial registration: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Journal of medical Internet research · randomised controlled trial · 22 citationsread the source →

Effect of a behavioural intervention in obese pregnant women (the UPBEAT study): a multicentre, randomised controlled trial.

Background: Behavioural interventions might improve clinical outcomes in pregnant women who are obese. We aimed to investigate whether a complex intervention addressing diet and physical activity could reduce the incidence of gestational diabetes and large-for-gestational-age infants. Methods: The UK Pregnancies Better Eating and Activity Trial (UPBEAT) is a randomised controlled trial done at antenatal clinics in eight hospitals in multi-ethnic, inner-city locations in the UK. We recruited pregnant women (15-18 weeks plus 6 days of gestation) older than 16 years who were obese (BMI ≥30 kg/m(2)). We randomly assigned participants to either a behavioural intervention or standard antenatal care with an internet-based, computer-generated, randomisation procedure, minimising by age, ethnic origin, centre, BMI, and parity. The intervention was delivered once a week through eight health trainer-led sessions. Primary outcomes were gestational diabetes (diagnosed with an oral glucose tolerance test and by criteria from the International Association of Diabetes in Pregnancy Study Groups) and large-for-gestational-age infants (≥90th customised birthweight centile). Analysis was by intention to treat. This trial is registered with Current Controlled Trials, ISCRTN89971375. Recruitment and pregnancy outcomes are complete but childhood follow-up is ongoing. Findings: Between March 31, 2009, and June 2, 2014, we assessed 8820 women for eligibility and recruited 1555, with a mean BMI of 36·3 kg/m(2) (SD 4·8). 772 were randomly assigned to standard antenatal care and 783 were allocated the behavioural intervention, of which 651 and 629 women, respectively, completed an oral glucose tolerance test. Gestational diabetes was reported in 172 (26%) women in the standard care group compared with 160 (25%) in the intervention group (risk ratio 0·96, 95% CI 0·79-1·16; p=0·68). 61 (8%) of 751 babies in the standard care group were large for gestational age compared with 71 (9%) of 761 in the intervention group (1·15, 0·83-1·59; p=0·40). Thus, the primary outcomes did not differ between groups, despite improvements in some maternal secondary outcomes in the intervention group, including reduced dietary glycaemic load, gestational weight gain, and maternal sum-of-skinfold thicknesses, and increased physical activity. Adverse events included neonatal death (two in the standard care group and three in the intervention group) and fetal death in utero (ten in the standard care group and six in the intervention group). No maternal deaths were reported. Incidence of miscarriage (2% in the standard care group vs 2% in the intervention group), major obstetric haemorrhage (1% vs 3%), and small-for-gestational-age infants (≤5th customised birthweight centile; 6% vs 5%) did not differ between groups. Interpretation: A behavioural intervention addressing diet and physical activity in women with obesity during pregnancy is not adequate to prevent gestational diabetes, or to reduce the incidence of large-for-gestational-age infants. Funding: National Institute for Health Research, Guys and St Thomas' Charity, Chief Scientist Office Scotland, Tommy's Charity.

The lancet. Diabetes & endocrinology · randomised controlled trial · 465 citationsread the source →

Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan

Importance: The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. Objective: To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. Design, Setting, and Participants: A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Interventions: Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. Main Outcomes and Measures: Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). Results: Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help (AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder (AMD, -3.41; 95% CI, -4.49 to -2.34). Conclusions and Relevance: Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. Trial Registration: anzctr.org.au Identifier: ANZCTR12614001235695.

JAMA · randomised controlled trial · 306 citationsread the source →

Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster randomised trial.

Background: Parenting interventions have been implemented to improve the compromised developmental potential among 39% of children younger than 5 years living in low-income and middle-income countries. Maternal wellbeing is important for child development, especially in children younger than 3 years who are vulnerable and dependent on their mothers for nutrition and stimulation. We assessed an integrated, community-based parenting intervention that targeted both child development and maternal wellbeing in rural Uganda. Methods: In this community-based, cluster randomised trial, we assessed the effectiveness of a manualised, parenting intervention in Lira, Uganda. We selected and randomly assigned 12 parishes (1:1) to either parenting intervention or control (inclusion on a waitlist with a brief message on nutrition) groups using a computer-generated list of random numbers. Within each parish, we selected two to three eligible communities that had a parish office or a primary school in which a preschool could be established, more than 75 households with children younger than 6 years, and at least 15 socially disadvantaged families (ie, maternal education of primary school level or lower) with at least one child younger than 36 months. Participants within communities were mother-child dyads, where the child was 12-36 months of age at enrollment, and the mother had low maternal education. In the parenting intervention group, participants attended 12 fortnightly peer-led group sessions focusing on child care and maternal wellbeing. The primary outcomes were cognitive and receptive language development, as measured with the Bayley Scales of Infant Development, 3rd edn. Secondary outcomes included self-reported maternal depressive symptoms, using the Center for Epidemiologic Studies Depression Scale, and child growth. Theoretically-relevant parenting practices, including the Home Observation for Measurement of the Environment inventory, and mother-care variables, such as perceived spousal support, were also assessed as potential mediators. Baseline assessments were done in January, 2013, and endline assessments were done in November, 2013, 3 months after completion of the programme. Ethics approval was received from Mbarara and McGill universities. This trial is registered with ClinicalTrials.gov, NCT01906606. Findings: Between December, 2012, and January, 2013, 13 communities (194 dyads) were randomly assigned to receive intervention, and 12 communities (154 dyads) were assigned to a waitlist control. 319 dyads completed baseline measures (171 in the intervention group and 148 in the control group), and 291 dyads completed endline measures (160 in the intervention group and 131 in the control group). At endline, children in the intervention group had significantly higher cognitive scores (58·90 vs 55·65, effect size 0·36, 95% CI 0·12-0·59) and receptive language scores (23·86 vs 22·40, 0·27, 0·03-0·50) than did children in the control group. Mothers in the intervention group reported significantly fewer depressive symptoms (15·36 vs 18·61, -0·391, 95% CI -0·62 to -0·16) than did mothers in the control group. However, no differences were found in child growth between groups. Interpretation: The 12 session integrated parenting intervention delivered by non-professional community members improved child development and maternal wellbeing in rural Uganda. Because this intervention was largely managed and implemented by a local organisation, using local community members and minimal resources, such a programme has the potential to be replicated and scaled up in other low-resource, village-based settings. Funding: Plan Uganda via Plan Finland (Ministry of Foreign Affairs) and Plan Australia (Australian Aid).

The Lancet. Global health · randomised controlled trial · 208 citationsread the source →

Effect of a Workplace Wellness Program on Employee Health and Economic Outcomes: A Randomized Clinical Trial.

Importance: Employers have increasingly invested in workplace wellness programs to improve employee health and decrease health care costs. However, there is little experimental evidence on the effects of these programs. Objective: To evaluate a multicomponent workplace wellness program resembling programs offered by US employers. Design, setting, and participants: This clustered randomized trial was implemented at 160 worksites from January 2015 through June 2016. Administrative claims and employment data were gathered continuously through June 30, 2016; data from surveys and biometrics were collected from July 1, 2016, through August 31, 2016. Interventions: There were 20 randomly selected treatment worksites (4037 employees) and 140 randomly selected control worksites (28 937 employees, including 20 primary control worksites [4106 employees]). Control worksites received no wellness programming. The program comprised 8 modules focused on nutrition, physical activity, stress reduction, and related topics implemented by registered dietitians at the treatment worksites. Main outcomes and measures: Four outcome domains were assessed. Self-reported health and behaviors via surveys (29 outcomes) and clinical measures of health via screenings (10 outcomes) were compared among 20 intervention and 20 primary control sites; health care spending and utilization (38 outcomes) and employment outcomes (3 outcomes) from administrative data were compared among 20 intervention and 140 control sites. Results: Among 32 974 employees (mean [SD] age, 38.6 [15.2] years; 15 272 [45.9%] women), the mean participation rate in surveys and screenings at intervention sites was 36.2% to 44.6% (n = 4037 employees) and at primary control sites was 34.4% to 43.0% (n = 4106 employees) (mean of 1.3 program modules completed). After 18 months, the rates for 2 self-reported outcomes were higher in the intervention group than in the control group: for engaging in regular exercise (69.8% vs 61.9%; adjusted difference, 8.3 percentage points [95% CI, 3.9-12.8]; adjusted P = .03) and for actively managing weight (69.2% vs 54.7%; adjusted difference, 13.6 percentage points [95% CI, 7.1-20.2]; adjusted P = .02). The program had no significant effects on other prespecified outcomes: 27 self-reported health outcomes and behaviors (including self-reported health, sleep quality, and food choices), 10 clinical markers of health (including cholesterol, blood pressure, and body mass index), 38 medical and pharmaceutical spending and utilization measures, and 3 employment outcomes (absenteeism, job tenure, and job performance). Conclusions and relevance: Among employees of a large US warehouse retail company, a workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months. Although limited by incomplete data on some outcomes, these findings may temper expectations about the financial return on investment that wellness programs can deliver in the short term. Trial registration: ClinicalTrials.gov Identifier: NCT03167658.

JAMA · randomised controlled trial · 170 citationsread the source →

Symptoms, complications and management of long COVID: a review.

Globally, there are now over 160 million confirmed cases of COVID-19 and more than 3 million deaths. While the majority of infected individuals recover, a significant proportion continue to experience symptoms and complications after their acute illness. Patients with 'long COVID' experience a wide range of physical and mental/psychological symptoms. Pooled prevalence data showed the 10 most prevalent reported symptoms were fatigue, shortness of breath, muscle pain, joint pain, headache, cough, chest pain, altered smell, altered taste and diarrhoea. Other common symptoms were cognitive impairment, memory loss, anxiety and sleep disorders. Beyond symptoms and complications, people with long COVID often reported impaired quality of life, mental health and employment issues. These individuals may require multidisciplinary care involving the long-term monitoring of symptoms, to identify potential complications, physical rehabilitation, mental health and social services support. Resilient healthcare systems are needed to ensure efficient and effective responses to future health challenges.

Journal of the Royal Society of Medicine · review · 621 citationsread the source →

The Adult Attachment Interview and self-reports of attachment style: an empirical rapprochement.

Although 10 studies have been published on the empirical overlap of the Adult Attachment Interview (AAI) and measures of self-reported attachment style, results in this literature have been inconsistently interpreted in narrative reviews. This report was designed as a rapprochement of the AAI and attachment style literatures and includes 3 studies. Study 1 (combined N = 961) is a meta-analytic review showing that by J. Cohen's (1992) criteria (mean r = .09), the association between AAI security and attachment style dimensions is trivial to small. Study 2 (N = 160) confirms meta-analytic results with state-of-the-art assessments of attachment security and also examines attachment dimensions in relation to the Big 5 personality traits. Finally, Study 3 is an investigation of 50 engaged couples that shows that developmental and social psychological measures of attachment security predict somewhat distinct--though theoretically anticipated--aspects of functioning in adult relationships.

Journal of personality and social psychology · meta-analysis · 217 citationsread the source →

Use of standardised outcome measures in adult mental health services: randomised controlled trial.

Background: Routine use of standardised outcome measures is not universal. Aims: To evaluate the effectiveness of standardised outcome assessment. Method: A randomised controlled trial, involving 160 representative adult mental health patients and paired staff (ISRCTN16971059). The intervention group (n=101) (a) completed monthly postal questionnaires assessing needs, quality of life, mental health problem severity and therapeutic alliance, and (b) received 3-monthly feedback. The control group (n=59) received treatment as usual. Results: The intervention did not improve primary outcomes of patient-rated unmet need and of quality of life. Other subjective secondary outcome measures were also not improved. The intervention reduced psychiatric inpatient days (3.5 v.16.4 mean days, bootstrapped 95% CI1.6-25.7), and hence service use costs were 2586 UK pounds (95% CI 102-5391) less for intervention-group patients. Net benefit analysis indicated that the intervention was cost-effective. Conclusions: Routine use of outcome measures as implemented in this study did not improve subjective outcomes, but was associated with reduced psychiatric inpatient admissions.

The British journal of psychiatry : the journal of mental science · randomised controlled trial · 63 citationsread the source →

Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: the Scandinavian Prostate Cancer Group-4 randomised trial.

Background: For men with localised prostate cancer, surgery provides a survival benefit compared with watchful waiting. Treatments are associated with morbidity. Results for functional outcome and quality of life are rarely reported beyond 10 years and are lacking from randomised settings. We report results for quality of life for men in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) after a median follow-up of more than 12 years. Methods: All living Swedish and Finnish men (400 of 695) randomly assigned to radical prostatectomy or watchful waiting in SPCG-4 from 1989 to 1999 were included in our analysis. An additional 281 men were included in a population-based control group matched for region and age. Physical symptoms, symptom-induced stress, and self-assessed quality of life were evaluated with a study-specific questionnaire. Longitudinal data were available for 166 Swedish men who had answered quality-of-life questionnaires at an earlier timepoint. Findings: 182 (88%) of 208 men in the radical prostatectomy group, 167 (87%) of 192 men in the watchful-waiting group, and 214 (76%) of 281 men in the population-based control group answered the questionnaire. Men in SPCG-4 had a median follow-up of 12·2 years (range 7-17) and a median age of 77·0 years (range 61-88). High self-assessed quality of life was reported by 62 (35%) of 179 men allocated radical prostatectomy, 55 (34%) of 160 men assigned to watchful waiting, and 93 (45%) of 208 men in the control group. Anxiety was higher in the SPCG-4 groups (77 [43%] of 178 and 69 [43%] of 161 men) than in the control group (68 [33%] of 208 men; relative risk 1·42, 95% CI 1·07-1·88). Prevalence of erectile dysfunction was 84% (146 of 173 men) in the radical prostatectomy group, 80% (122 of 153) in the watchful-waiting group, and 46% (95 of 208) in the control group and prevalence of urinary leakage was 41% (71 of 173), 11% (18 of 164), and 3% (six of 209), respectively. Distress caused by these symptoms was reported significantly more often by men allocated radical prostatectomy than by men assigned to watchful waiting. In a longitudinal analysis of men in SPCG-4 who provided information at two follow-up points 9 years apart, 38 (45%) of 85 men allocated radical prostatectomy and 48 (60%) of 80 men allocated watchful waiting reported an increase in number of physical symptoms; 50 (61%) of 82 and 47 (64%) of 74 men, respectively, reported a reduction in quality of life. Interpretation: For men in SPCG-4, negative side-effects were common and added more stress than was reported in the control population. In the radical prostatectomy group, erectile dysfunction and urinary leakage were often consequences of surgery. In the watchful-waiting group, side-effects can be caused by tumour progression. The number and severity of side-effects changes over time at a higher rate than is caused by normal ageing and a loss of sexual ability is a persistent psychological problem for both interventions. An understanding of the patterns of side-effects and time dimension of their occurrence for each treatment is important for full patient information. Funding: US National Institutes of Health; Swedish Cancer Society; Foundation in Memory of Johanna Hagstrand and Sigfrid Linnér.

The Lancet. Oncology · randomised controlled trial · 277 citationsread the source →

Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study.

Background: Dying in the complex, efficiency-driven environment of the intensive care unit can be dehumanizing for the patient and have profound, long-lasting consequences for all persons attendant to that death. Objective: To bring peace to the final days of a patient's life and to ease the grieving process. Design: Mixed-methods study. Setting: 21-bed medical-surgical intensive care unit. Participants: Dying patients and their families and clinicians. Intervention: To honor each patient, a set of wishes was generated by patients, family members, or clinicians. The wishes were implemented before or after death by patients, families, clinicians (6 of whom were project team members), or the project team. Measurements: Quantitative data included demographic characteristics, processes of care, and scores on the Quality of End-of-Life Care-10 instrument. Semistructured interviews of family members and clinicians were transcribed verbatim, and qualitative description was used to analyze them. Results: Participants included 40 decedents, at least 1 family member per patient, and 3 clinicians per patient. The 159 wishes were implemented and classified into 5 categories: humanizing the environment, tributes, family reconnections, observances, and "paying it forward." Scores on the Quality of End-of-Life Care-10 instrument were high. The central theme from 160 interviews of 170 persons was how the 3 Wishes Project personalized the dying process. For patients, eliciting and customizing the wishes honored them by celebrating their lives and dignifying their deaths. For families, it created positive memories and individualized end-of-life care for their loved ones. For clinicians, it promoted interprofessional care and humanism in practice. Limitation: Impaired consciousness limited understanding of patients' viewpoints. Conclusion: The 3 Wishes Project facilitated personalization of the dying process through explicit integration of palliative and spiritual care into critical care practice. Primary funding source: Hamilton Academy of Health Science Research Organization, Canadian Intensive Care Foundation.

Annals of internal medicine · 64 citationsread the source →

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY.

Objective: Development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and the American College of Endocrinology (ACE) Board of Trustees and adheres to published AACE protocols for the standardized production of clinical practice guidelines (CPGs). Methods: Recommendations are based on diligent review of clinical evidence with transparent incorporation of subjective factors. Results: There are 9 broad clinical questions with 123 recommendation numbers that include 160 specific statements (85 [53.1%] strong [Grade A]; 48 [30.0%] intermediate [Grade B], and 11 [6.9%] weak [Grade C], with 16 [10.0%] based on expert opinion [Grade D]) that build a comprehensive medical care plan for obesity. There were 133 (83.1%) statements based on strong (best evidence level [BEL] 1 = 79 [49.4%]) or intermediate (BEL 2 = 54 [33.7%]) levels of scientific substantiation. There were 34 (23.6%) evidence-based recommendation grades (Grades A-C = 144) that were adjusted based on subjective factors. Among the 1,790 reference citations used in this CPG, 524 (29.3%) were based on strong (evidence level [EL] 1), 605 (33.8%) were based on intermediate (EL 2), and 308 (17.2%) were based on weak (EL 3) scientific studies, with 353 (19.7%) based on reviews and opinions (EL 4). Conclusion: The final recommendations recognize that obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. The detailed evidence-based recommendations allow for nuanced clinical decision-making that addresses real-world medical care of patients with obesity, including screening, diagnosis, evaluation, selection of therapy, treatment goals, and individualization of care. The goal is to facilitate high-quality care of patients with obesity and provide a rational, scientific approach to management that optimizes health outcomes and safety. Abbreviations: A1C = hemoglobin A1c AACE = American Association of Clinical Endocrinologists ACE = American College of Endocrinology ACSM = American College of Sports Medicine ADA = American Diabetes Association ADAPT = Arthritis, Diet, and Activity Promotion Trial ADHD = attention-deficit hyperactivity disorder AHA = American Heart Association AHEAD = Action for Health in Diabetes AHI = apnea-hypopnea index ALT = alanine aminotransferase AMA = American Medical Association ARB = angiotensin receptor blocker ART = assisted reproductive technology AUC = area under the curve BDI = Beck Depression Inventory BED = binge eating disorder BEL = best evidence level BLOOM = Behavioral Modification and Lorcaserin for Overweight and Obesity Management BLOSSOM = Behavioral Modification and Lorcaserin Second Study for Obesity Management BMI = body mass index BP = blood pressure C-SSRS = Columbia Suicidality Severity Rating Scale CAD = coronary artery disease CARDIA = Coronary Artery Risk Development in Young Adults CBT = cognitive behavioral therapy CCO = Consensus Conference on Obesity CHF = congestive heart failure CHO = carbohydrate CI = confidence interval COR-I = Contrave Obesity Research I CPG = clinical practice guideline CV = cardiovascular CVD = cardiovascular disease DASH = Dietary Approaches to Stop Hypertension DBP = diastolic blood pressure DEXA = dual-energy X-ray absorptiometry DPP = Diabetes Prevention Program DSE = diabetes support and education EL = evidence level ED = erectile dysfunction ER = extended release EWL = excess weight loss FDA = Food and Drug Administration FDG = 18F-fluorodeoxyglucose GABA = gamma-aminobutyric acid GERD = gastroesophageal reflux disease GI = gastrointestinal GLP-1 = glucagon-like peptide 1 HADS = Hospital Anxiety and Depression Scale HDL-c = high-density lipoprotein cholesterol HR = hazard ratio HTN = hypertension HUNT = Nord-Trøndelag Health Study ICSI = intracytoplasmic sperm injection IFG = impaired fasting glucose IGT = impaired glucose tolerance ILI = intensive lifestyle intervention IVF = in vitro fertilization LAGB = laparoscopic adjustable gastric banding LDL-c = low-density lipoprotein cholesterol LES = lower esophageal sphincter LSG = laparoscopic sleeve gastrectomy LV = left ventricle LVH = left ventricular hypertrophy LVBG = laparoscopic vertical banded gastroplasty MACE = major adverse cardiovascular events MAOI = monoamine oxidase inhibitor MI = myocardial infarction MNRCT = meta-analysis of non-randomized prospective or case-controlled trials MRI = magnetic resonance imaging MUFA = monounsaturated fatty acid NAFLD = nonalcoholic fatty liver disease NASH = nonalcoholic steatohepatitis NES = night eating syndrome NHANES = National Health and Nutrition Examination Surveys NHLBI = National Heart, Lung, and Blood Institute NHS = Nurses' Health Study NICE = National Institute for Health and Care Excellence OA = osteoarthritis OGTT = oral glucose tolerance test OR = odds ratio OSA = obstructive sleep apnea PHQ-9 = Patient Health Questionnaire PCOS = polycystic ovary syndrome PCP = primary care physician POMC = pro-opiomelanocortin POWER = Practice-Based Opportunities for Weight Reduction PPI = proton pump inhibitor PRIDE = Program to Reduce Incontinence by Diet and Exercise PSA = prostate specific antigen QOL = quality of life RA = receptor agonist RCT = randomized controlled trial ROC = receiver operator characteristic RR = relative risk RYGB = Roux-en-Y gastric bypass SAD = sagittal abdominal diameter SBP = systolic blood pressure SCOUT = Sibutramine Cardiovascular Outcome Trial SG = sleeve gastrectomy SHBG = sex hormonebinding globulin SIEDY = Structured Interview on Erectile Dysfunction SNRI = serotonin-norepinephrine reuptake inhibitors SOS = Swedish Obese Subjects SS = surveillance study SSRI = selective serotonin reuptake inhibitors STORM = Sibutramine Trial on Obesity Reduction and Maintenance TCA = tricyclic antidepressant TONE = Trial of Nonpharmacologic Intervention in the Elderly TOS = The Obesity Society T2DM = type 2 diabetes mellitus UKPDS = United Kingdom Prospective Diabetes Study U.S = United States VAT = visceral adipose tissue VLDL = very low-density lipoprotein WC = waist circumference WHO = World Health Organization WHR = waist-hip ratio WHtR = waist-to-height ratio WMD = weighted mean difference WOMAC = Western Ontario and McMaster Universities osteoarthritis index XENDOS = XEnical in the Prevention of Diabetes in Obese Subjects.

Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists · guideline · 1258 citationsread the source →

Reduction of leucocyte telomere length in radiographic hand osteoarthritis: a population-based study.

Background: Although age is the strongest predictor of osteoarthritis, the exact mechanism underlying this disorder remains elusive. Objective: To examine the association between leucocyte telomere length (LTL), a bio-indicator of ageing, and radiographic hand osteoarthritis. Methods: An unselected, predominantly female sample from the TwinsUK Adult Twin Registry (Twin Research and Genetic Epidemiology Unit, St Thomas Hospital, London, UK) was studied. Radiographs of both hands were obtained with a standard posteroanterior view and assessed for radiographic osteoarthritis according to the Kellgren/Lawrence (K/L) score. Individual radiographic features including osteophytes and joint space narrowing (JSN) were also assessed on a four-point scale using a standard atlas. Hand osteoarthritis was defined radiographically as having >or=3 osteoarthritis-affected joints of both hands (K/L score>or=2). Severity of hand osteoarthritis was indicated semiquantitatively by total K/L scores, osteophytes, JSN scores and proportion of joints affected. Mean LTL was measured by the terminal restriction fragment length using the Southern blot. Results: A total of 1086 Caucasian subjects (mean (SD) age 55 (8.0) years) were studied. LTL was 6.95 (0.64) kb and was inversely correlated with age. After adjustment for age, sex, body mass index and smoking, LTL was significantly shorter by 178 bp in subjects with hand osteoarthritis (n = 160) than in those without (n = 926; p = 0.04). LTL was also significantly associated with semicontinuous measures of osteoarthritis (eg, total K/L score, JSN score, osteophyte score and proportion of joints affected) after adjustment (all p<or=0.02) in a dose-response fashion. Conclusion: Shorter LTL equivalent to around 11 years of annual loss in normal people is associated with radiographic hand osteoarthritis and disease severity, suggesting potential shared mechanisms between osteoarthritis and ageing, and implicating oxidative stress and low-level chronic inflammation in both conditions.

Annals of the rheumatic diseases · cohort or longitudinal · 57 citationsread the source →

Subjective wellbeing, health, and ageing.

Subjective wellbeing and health are closely linked to age. Three aspects of subjective wellbeing can be distinguished-evaluative wellbeing (or life satisfaction), hedonic wellbeing (feelings of happiness, sadness, anger, stress, and pain), and eudemonic wellbeing (sense of purpose and meaning in life). We review recent advances in the specialty of psychological wellbeing, and present new analyses about the pattern of wellbeing across ages and the association between wellbeing and survival at older ages. The Gallup World Poll, a continuing survey in more than 160 countries, shows a U-shaped relation between evaluative wellbeing and age in high-income, English speaking countries, with the lowest levels of wellbeing in ages 45-54 years. But this pattern is not universal. For example, respondents from the former Soviet Union and eastern Europe show a large progressive reduction in wellbeing with age, respondents from Latin America also shows decreased wellbeing with age, whereas wellbeing in sub-Saharan Africa shows little change with age. The relation between physical health and subjective wellbeing is bidirectional. Older people with illnesses such as coronary heart disease, arthritis, and chronic lung disease show both increased levels of depressed mood and impaired hedonic and eudemonic wellbeing. Wellbeing might also have a protective role in health maintenance. In an analysis of the English Longitudinal Study of Ageing, we identify that eudemonic wellbeing is associated with increased survival; 29·3% of people in the lowest wellbeing quartile died during the average follow-up period of 8·5 years compared with 9·3% of those in the highest quartile. Associations were independent of age, sex, demographic factors, and baseline mental and physical health. We conclude that the wellbeing of elderly people is an important objective for both economic and health policy. Present psychological and economic theories do not adequately account for the variations in patterns of wellbeing with age across different parts of the world. The apparent association between wellbeing and survival is consistent with a protective role of high wellbeing, but alternative explanations cannot be ruled out at this stage.

Lancet (London, England) · review · 1109 citationsread the source →

The Diagnosis and Treatment of Prostate Cancer: A Review.

Importance: Prostate cancer is the most common cancer diagnosis made in men with more than 160 000 new cases each year in the United States. Although it often has an indolent course, prostate cancer remains the third-leading cause of cancer death in men. Observations: When prostate cancer is suspected, tissue biopsy remains the standard of care for diagnosis. However, the identification and characterization of the disease have become increasingly precise through improved risk stratification and advances in magnetic resonance and functional imaging, as well as from the emergence of biomarkers. Multiple management options now exist for men diagnosed with prostate cancer. Active surveillance (the serial monitoring for disease progression with the intent to cure) appears to be safe and has become the preferred approach for men with less-aggressive prostate cancer, particularly those with a prostate-specific antigen level of less than 10 ng/mL and Gleason score 3 + 3 tumors. Surgery and radiation continue to be curative treatments for localized disease but have adverse effects such as urinary symptoms and sexual dysfunction that can negatively affect quality of life. For metastatic disease, chemotherapy as initial treatment now appears to extend survival compared with androgen deprivation therapy alone. New vaccines, hormonal therapeutics, and bone-targeting agents have demonstrated efficacy in men with metastatic prostate cancer resistant to traditional hormonal therapy. Conclusions and relevance: Advances in the diagnosis and treatment of prostate cancer have improved the ability to stratify patients by risk and allowed clinicians to recommend therapy based on cancer prognosis and patient preference. Initial treatment with chemotherapy can improve survival compared with androgen deprivation therapy. Abiraterone, enzalutamide, and other agents can improve outcomes in men with metastatic prostate cancer resistant to traditional hormonal therapy.

JAMA · review · 1051 citationsread the source →

The use of a vodcast to support eating and reduce anxiety in people with eating disorder: A case series.

Individuals with eating disorders have difficulty controlling obsessive intrusions and ritualistic behaviours relating to food and exercise. An imagery-based intervention using a vodcast (small video file played on a mobile phone or portable media device), with visual and aural components, was designed to target eating related psychopathology in a consecutive series of four patients. The vodcast was used to support consumption of a smoothie, both as a behavioural experiment and at home, in naturalistic circumstances. More of the smoothie was drunk in a shorter time when the smoothie was offered with the vodcast (mean of 218 g, SD = 64) than in the comparison condition (mean of 160 g, SD = 71). The vodcast condition was associated with reduced anxiety in three out of four patients. Three out of four patients used the vodcasts at home and found they provided them with support and motivation. All patients' weight increased after 3 months. Using a vodcast to support patients during meal times may be a useful addition to treatment for anorexia nervosa.

European eating disorders review : the journal of the Eating Disorders Association · case report · 22 citationsread the source →

Engaging mothers with substance use issues and their children in early intervention: Understanding use of service and outcomes.

Mothers who use substances need integrated, multi-sectoral intervention services to support substance use discontinuation. We explored mothers' service use at Breaking the Cycle, an early intervention and prevention program for pregnant and parenting women and their young children in Toronto, Canada. We conducted retrospective analyses of families' service records and client charts (N = 160). Aims were to 1) describe women's use of service, 2) examine how early engagement of pregnant women related to postnatal service use, and 3) examine the circumstances in which women ended their service relationship with Breaking the Cycle. Specifically, we examined circumstances at service ending relating to women's service goals; custody status with children; and global substance-use, parent-child relationship, and child development outcomes. We found that these vulnerable women were actively engaged in many services and for a long duration, early engagement was associated with greater service use, and greater service use was associated with more positive circumstances upon ending service. Results provide support for a relational approach to service that promotes not only the relationship between mother and child, and mother and service provider, but also highlights relationships among staff, between staff and management, and between community partners as integral to effective service delivery. Integrating positive relationships at all levels is critical to support vulnerable families with complex needs.

Child abuse & neglect · 30 citationsread the source →

Fear-focused Self-compassion Therapy for young breast cancer patients' fear of cancer recurrence: Study protocol of a randomized controlled trial.

Background: In China, there are a growing number of young women being diagnosed with breast cancer. Fear of Cancer Recurrence (FCR) has become one of the major psychological concerns reported by young breast cancer patients. Yet, there is a lack of psychological intervention tailored for reducing FCR for Chinese young breast cancer patients. In the current study, the Fear-focused Self-compassion Therapy is developed to help Chinese young breast cancer patients to manage FCR. The therapy was developed based on FCR development theories and self-compassion related therapy. The primary objective is to evaluate the short-term and long-term effectiveness of Fear-focused Self-compassion Therapy. The secondary objective is to examine the underlying mechanisms of therapy in reducing FCR in young breast cancer patients. Methods: The Fear-focused Self-compassion Therapy consists of 8-week face to face group sessions. This study will be a randomized controlled trial with 160 Chinese young female breast cancer patients with severe FCR. Participants will be randomized to the therapy group or a usual care control group (1:1). Measurements will be completed at baseline, immediately completing intervention, 3, 6, and 12 months later. Primary outcomes are FCR severity, and secondary outcomes include symptoms of depression and anxiety, satisfaction with therapy, and cost-effectiveness of the therapy. Discussion: If successful, this study will provide an effective psychological intervention to treat FCR for young breast cancer patients in China, and illuminate the underlying mechanisms of the Fear-focused Self-compassion Therapy in reducing FCR. Clinical trial registration: ClinicalTrials.gov: NCT04965428. Registered 23rd July 2021, https://clinicaltrials.gov/ct2/show/NCT04965428?cond=fear+of+cancer+recurrence&draw=2&rank=1.

Frontiers in psychiatry · 3 citationsread the source →

The role of family and individual factors in going through adolescence having a disabled sibling - analysis of a healthy child's functioning. A case-control study protocol.

Background: Having a disabled sibling can be a source of extremely important and enriching experiences that foster the development of social and emotional competences, as well as broadening the child's perspective and knowledge. On the other hand, it also poses many challenges for the siblings, especially in adolescence. Thus, the aim of the proposed project is to investigate the specificity of the growing up process in young people with disabled siblings. Participants and procedure: A total of 160 dyads (320 participants) - an adolescent and one of his/her parents - will take part in this cross-sectional case-control study. Participants will be assigned to four groups, having a sibling with: 1) intellectual disability, 2) motor disability, 3) chronic somatic disease, and 4) the control group - having a sibling without any disability. Both the healthy adolescent and one of the parents will fill out a set of questionnaires regarding the study variables: Questionnaire of Relationships with Siblings, Parental Attitude Scale-2, KidScreen-27, Parentification Questionnaire for Youth, Teenage Rebellion Questionnaire, Child Behavior Checklist 6-18. Results: The primary outcomes include investigating the healthy adolescent functioning in three environments: family, peers and school. The proposed research model focuses both on the difficulties associated with having a disabled sibling (e.g. possible occurrence of disorders) and resources (e.g. higher quality of relationships in the family, especially in the sibling subsystem). Conclusions: The proposed comprehensive approach to the issue of disability in the family from the perspective of a healthy child will allow for a better understanding of the mechanisms underlying the process of growing up with disabled siblings.

Health psychology report · 1 citationsread the source →

Trajectories of marital, parent-child, and sibling conflict during pediatric cancer treatment.

Objective: The stress of having a child with cancer can impact the quality of relationships within the family. The current study describes the longitudinal trajectory of marital, parent-child, and sibling conflict beginning around the time of diagnosis through the first year of treatment. We examined the average level of marital, parent-child, and sibling conflict at each monthly time point in the first year of treatment; the proportion of families that fall into the distressed range of marital, parent-child, and sibling conflict at each time point; the typical trajectory of conflict during the first year of treatment and whether there are differences in trajectories across families. Method: A total of 160 families of children newly diagnosed with cancer (Mage = 5.6 years; range = 2-18 years) participated in a short-term prospective longitudinal study. Primary caregivers provided monthly reports of marital, parent-child, and sibling conflict. Results: Using multilevel modeling (MLM), most families showed stability in quality of family relationships, although considerable between-family variability was observed. For married couples, 25-36% of couples were in the distressed range at one time point over the first year of treatment. For married couples, more distress occurred at earlier months, particularly month 3. For parent-child and sibling dyads, the most difficult time periods were during later months. Conclusion: Implications for development of interventions that target at-risk family relationships are discussed. Identifying processes that predict between-family variability in trajectories of family relationships is an important next step, particularly for the marital relationship. (PsycINFO Database Record

Health psychology : official journal of the Division of Health Psychology, American Psychological Association · 16 citationsread the source →

Effectiveness of an 8-Week Web-Based Mindfulness Virtual Community Intervention for University Students on Symptoms of Stress, Anxiety, and Depression: Randomized Controlled Trial

BACKGROUND: A student mental health crisis is increasingly acknowledged and will only intensify with the COVID-19 crisis. Given accessibility of methods with demonstrated efficacy in reducing depression and anxiety (eg, mindfulness meditation and cognitive behavioral therapy [CBT]) and limitations imposed by geographic obstructions and localized expertise, web-based alternatives have become vehicles for scaled-up delivery of benefits at modest cost. Mindfulness Virtual Community (MVC), a web-based program informed by CBT constructs and featuring online videos, discussion forums, and videoconferencing, was developed to target depression, anxiety, and experiences of excess stress among university students. OBJECTIVE: The aim of this study was to assess the effectiveness of an 8-week web-based mindfulness and CBT program in reducing symptoms of depression, anxiety, and stress (primary outcomes) and increasing mindfulness (secondary outcome) within a randomized controlled trial (RCT) with undergraduate students at a large Canadian university. METHODS: An RCT was designed to assess undergraduate students (n=160) who were randomly allocated to a web-based guided mindfulness-CBT condition (n=80) or to a waitlist control (WLC) condition (n=80). The 8-week intervention consisted of a web-based platform comprising (1) 12 video-based modules with psychoeducation on students' preidentified life challenges and applied mindfulness practice; (2) anonymous peer-to-peer discussion forums; and (3) anonymous, group-based, professionally guided 20-minute live videoconferences. The outcomes (depression, anxiety, stress, and mindfulness) were measured via an online survey at baseline and at 8 weeks postintervention using the Patient Health Questionnaire-9 (PHQ9), the Beck Anxiety Inventory (BAI), the Perceived Stress Scale (PSS), and the Five Facets Mindfulness Questionnaire Short Form (FFMQ-SF). Analyses employed generalized estimation equation methods with AR(1) covariance structures and were adjusted for possible covariates (gender, age, country of birth, ethnicity, English as first language, paid work, unpaid work, relationship status, physical exercise, self-rated health, and access to private mental health counseling). RESULTS: Of the 159 students who provided T1 data, 32 were males and 125 were females with a mean age of 22.55 years. Participants in the MVC (n=79) and WLC (n=80) groups were similar in sociodemographic characteristics at T1 with the exception of gender and weekly hours of unpaid volunteer work. At postintervention follow-up, according to the adjusted comparisons, there were statistically significant between-group reductions in depression scores (β=-2.21, P=.01) and anxiety scores (β=-4.82, P=.006), and a significant increase in mindfulness scores (β=4.84, P=.02) compared with the WLC group. There were no statistically significant differences in perceived stress for MVC (β=.64, P=.48) compared with WLC. CONCLUSIONS: With the MVC intervention, there were significantly reduced depression and anxiety symptoms but no significant effect on perceived stress. Online mindfulness interventions can be effective in addressing common mental health conditions among postsecondary populations on a large scale, simultaneously reducing the current burden on traditional counseling services. TRIAL REGISTRATION: ISRCTN Registry ISRCTN12249616; http://www.isrctn.com/ISRCTN12249616.

JMIR Mental Health · 144 citationsread the source →

Religious coping strategies in patients diagnosed with breast cancer in the UK.

Objectives: The use of religious/spiritual coping strategies may be particularly prevalent when dealing with the stress of a cancer diagnosis. There has, however, been very little research conducted on this topic outside the USA. Existing measures of coping largely ignore the complexity of religious/spiritual coping and its potential to be adaptive as well as maladaptive. The aim of this study was to examine the prevalence of various religious coping strategies in a UK cancer sample. Method: A longitudinal design assessed religious coping strategies in patients newly diagnosed with breast cancer at the time of surgery and at 3 and 12 months post surgery. We recruited 202 patients of which, at 12 months, 160 remained. A non-religious coping measure was included for comparison. Results: The use of religious coping strategies was overall common; up to 73% of patients used positive religious coping to some degree at surgery and up to 53% experienced various religious/spiritual struggles. The use of some religious coping strategies showed differing patterns of change across time while others remained stable. Conclusion: Using religious/spiritual resources in the coping process during the early stages of breast cancer appears common in the UK. Patients may benefit from having their spiritual needs addressed as experiencing some form of religious/spiritual struggle may serve as a barrier to illness adjustment. Health-care professionals should also be aware that some religious coping strategies may be more prevalent at different times during the first year of illness.

Psycho-oncology · 37 citationsread the source →

Conducting a needs assessment for women and girls using a gender analysis framework: the Philadelphia Ujima Coalition for a Healthier Community experience.

Introduction: Despite a century of work toward gender equality, sex and gender disparities in health remain. Morbidity and mortality rates as well as quality of care received differ between men and women. The Philadelphia Ujima Coalition for a Healthier Community is composed of 23 academic, social service, wellness, faith-based, governmental, and healthcare organizations. The coalition, funded by the U.S. Department of Health and Human Services, Office on Women's Health, used a community participatory framework to conduct a gender-informed needs assessment of priority areas for women's health. Methods: A four-tiered approach was used: 1) Coalition members identified priority areas; 2) we analyzed data from the Southeastern Pennsylvania 2010 Household Health Survey to identify gender differences in health; 3) using a gender analysis framework, we conducted interviews with "key informant" stakeholders; and 4) we conducted a community health assessment including 160 women. We used a participatory process to rank priority areas. Results: Sex and gender disparities in health outcomes and behaviors were observed. Data were used to identify gender barriers and norms that influence health practices and behaviors, defining priority areas for the health of women and girls. Effective health promotion strategies were also identified. Conclusions: A gender-integrated needs assessment of girls and women can reveal priority areas and gender-related objectives that should be included in health promotion programming for girls and women.

Women's health issues : official publication of the Jacobs Institute of Women's Health · 2 citationsread the source →

Impact of left atrial volume on clinical outcome in organic mitral regurgitation.

Objectives: The purpose of this paper was to assess the link between left atrial (LA) volume at diagnosis and outcome of patients with mitral regurgitation (MR). Background: Left atrial enlargement is a consequence of organic MR, but its association with clinical outcome independently of MR severity is uncertain. Methods: We prospectively enrolled 492 patients (age 63 +/- 15 years, 60% men) in sinus rhythm with organic MR (regurgitant volume 68 +/- 42 ml/beat) and performed at baseline triple echocardiographic quantitation (MR severity, LA volume, and left ventricular characteristics). Outcome with medical and surgical management was analyzed. Results: Left atrial volume indexed to body surface area (LA index) was 55 +/- 26 ml/m(2) (<40 ml/m(2) in 158 patients, 40 to 59 ml/m(2) in 160 patients, and > or =60 ml/m(2) in 174 patients). Under medical management, 5-year survival was 80 +/- 2.9% and cardiac events 28 +/- 3%. Adjusting for established predictors of outcome, LA index was independently associated with survival after diagnosis (hazard ratio [HR]: 1.3 [95% confidence interval (CI): 1.1 to 1.5] per 10 ml/m(2) increment, p = 0.001). Patients with LA index > or =60 ml/m(2) had lower 5-year survival than those with no or mild LA enlargement (p < 0.0001) and than the rates of survival expected in the U.S. population (53 +/- 8.6% vs. 76%, p = 0.017). Compared with patients with LA index <40 ml/m(2), those with LA index > or =60 ml/m(2) had increased mortality (HR: 2.8 [95% CI: 1.2 to 6.5], p = 0.016) and cardiac events (HR: 5.2 [95% CI: 2.6 to 10.9], p < 0.0001) with medical management. Mitral surgery was associated with decreased mortality (HR: 0.46 [95% CI: 0.26 to 0.84], p = 0.01) and cardiac events (HR: 0.38 [95% CI: 0.23 to 0.62], p = 0.0001) and after surgery patients with LA index > or =60 ml/m(2) versus <60 ml/m(2) did not incur excess mortality or cardiac events (both p > 0.30). Conclusions: In organic MR, LA index at diagnosis predicts long-term outcome, incrementally to known predictors of outcome. This marker of risk is particularly important because mitral surgery in these patients markedly improves outcome and restores life expectancy. LA index should be measured in routine clinical practice for risk-stratification and for clinical decision making in patients with organic MR.

Journal of the American College of Cardiology · 169 citationsread the source →

Predictors of depressive symptoms in patients with stroke - a three-month follow-up.

Background and purpose: Depression is one of the most common post-stroke complications, which could impair rehabilitation outcome and quality of life, and could also increase mortality after stroke. The aim of the present study was to assess the association between demographic, socioeconomic and clinical (stroke risk factors, type of stroke, location of vascular lesion, cognitive functions) factors on the presence and severity of post-stroke depressive symptoms in patients after first ever stroke as well as on their social functioning. Material and methods: A prospective, cohort study with a three-month observation period was performed in seven centres. Severity of depressive symptoms was assessed with the help of a short, 15-item version of the Geriatric Depression Scale (GDS), 3 months after stroke onset. Results: On the basis of GDS (GDS Ł 5 points or > 5 points) patients were allocated to a group without (n = 160) or with symptoms suggestive of depression (n = 82). The study groups did not differ with respect to age, sex or place of residence. Univariate logistic regression analysis showed that independent predictors for the presence of symptoms suggestive of depression at 3 months after stroke were: low level of education, low income, greater severity of stroke, worse functional status, self-reported problems with daily-living activities and need of help in daily living activities. More than 60% of patients with depressive symptoms limited their social contacts. Patients with depressive symptoms were unsatisfied with their relations with life partners and friends. Conclusions: Our study showed a complex aetiology of post-stroke depressive symptoms with an important role of socioeconomic factors. Depressive symptoms after stroke worsen existing health, social and economic problems, and cause social isolation of patients.

Neurologia i neurochirurgia polska · 30 citationsread the source →

Broiler chicken thigh and breast muscle responses to cold stress during simulated transport before slaughter.

The effect of acute cold exposure was assessed on broiler physiology, breast and thigh muscle metabolites, and meat quality. In total, 160 male birds at ages of 5 and 6 wk were exposed to temperatures of -9 to -15°C (cold stressed) and +20°C (control) in a simulated transport chamber for 3 h before slaughter followed by 0 or 2 h of lairage. Bird physiology parameters, including core body temperature, live shrink, blood glucose, and muscle temperature, were assessed. Core body temperature was monitored every minute using i-Button data loggers, and live shrink and blood glucose were assessed. Total glucose and lactate concentrations at 30 h postmortem, as well as ultimate pH (pH(u)), color, and water-holding attributes were evaluated on pectoralis major muscle of breast and iliotibialis muscle of thigh. Birds were grouped based on their microclimate temperature to control and cold-stressed groups (0 to -8, -8 to -11, and -11 to -14°C). Significant (P < 0.05) decreases in core body temperature and breast and thigh muscle temperatures were observed at simulated transport temperatures below 0°C. In addition, higher (P < 0.05) live shrink and lower blood glucose values were observed as a result of 3-h exposure to temperatures below 0°C, exacerbated as temperature decreased further below -8°C. Thigh muscle was almost depleted of glycogen reserve compared with a significant but small reduction in breast muscle glycogen when exposure temperature was below -8°C. Similarly, much greater effects were observed on thigh pH(u) and quality attributes compared with breast. In addition, 84% incidence of the dark, firm, dry quality defect was observed in thigh meat (pH(u) > 6.4, L* < 44) compared with 42% incidence of dark, firm, dry in breast meat (pH(u) > 6.1, L* < 46) when transportation temperature was below 0°C. Results of this study showed that thigh muscle was affected more severely than breast muscle by exposure to cold temperatures before slaughter.

Poultry science · 28 citationsread the source →

Binge eating in overweight treatment-seeking adolescents.

Objective: To examine the frequency and recency of binge eating in relation to psychopathology in overweight, treatment-seeking adolescents. Methods: We investigated psychological correlates of the frequency and recency of reported loss of control (LOC) eating episodes in 160 overweight (body mass index [BMI]: 40.7 +/- 8.8 kg/m(2)) adolescents. On the basis of the responses to the eating disorder examination (EDE), participants were categorized into one of four groups: full-syndrome binge eating disorder (BED); recent but infrequent binge eating (episodes within the 3 months before interview; RECENT-BINGE); remote and infrequent LOC eating (episodes occurring >3 months before assessment; PAST-LOC), or no history of LOC episodes (NE). Results: The BED group reported higher EDE scores (global, p < .01), and more negative mood and anxiety than all other groups (p's < .01). Compared with NE, RECENT-BINGE also reported more anxiety and higher EDE scores (p's < .01). Conclusions: Overweight, treatment-seeking adolescents with BED are clearly distinguishable from teens without the disorder on measures of eating-related psychopathology, mood, and anxiety. RECENT-BINGE, but not PAST-LOC, is also associated with significantly greater eating-related and general psychopathology.

Journal of pediatric psychology · 149 citationsread the source →

Ranolazine improves abnormal repolarization and contraction in left ventricular myocytes of dogs with heart failure by inhibiting late sodium current.

Background: Ventricular repolarization and contractile function are frequently abnormal in ventricular myocytes from human failing hearts as well as canine hearts with experimentally induced heart failure (HF). These abnormalities have been attributed to dysfunction involving various steps of the excitation-contraction coupling process, leading to impaired intracellular sodium and calcium homeostasis. We previously reported that the slow inactivating component of the Na(+) current (late I(Na)) is augmented in myocytes from failing hearts, and this appears to play a significant role in abnormal ventricular myocytes repolarization and function. We tested the effect of ranolazine, a novel drug being developed to treat angina, on (1) action potential duration (APD), (2) peak transient and late I(Na) (I(NaT) and I(NaL), respectively), (3) early afterdepolarizations (EADs), and (4) twitch contraction (TC), including after contractions and contracture. Methods: Myocytes were isolated from the left ventricle of normal dogs and of dogs with chronic HF caused by multiple sequential intracoronary micro-embolizations. I(NaT) and I(NaL) were recorded using conventional whole-cell patch-clamp techniques. APs were recorded using the beta-escin perforated patch-clamp configuration at frequencies of 0.25 and 0.5 Hz. TCs were recorded using an edge movement detector at stimulation frequencies ranging from 0.5 to 2.0 Hz. Results: Ranolazine significantly (P<0.05) and reversibly shortened the APD of myocytes stimulated at either 0.5 or 0.25 Hz in a concentration-dependent manner. At a stimulation frequency of 0.5 Hz, 5, 10, and 20 microM ranolazine shortened the APD(90) (APD measured at 90% repolarization) from 516+/-51 to 304+/-22, 212+/-34 and 160+/-11 ms, respectively, and markedly decreased beat-to-beat variability of APD(90), EADs, and dispersion of APDs. Ranolazine preferentially blocked I(NaL) relative to I(NaT) in a state-dependent manner, with a approximately 38-fold greater potency against I(NaL) to produce tonic block (IC(50)=6.5 microM) than I(NaT) (IC(50)=294 microM). When we evaluated inactivated state blockade of I(NaL) from the steady-state inactivation mid-potential shift using a theoretical model, ranolazine was found to bind more tightly to the inactivated state than the resting state of the sodium channel underlying I(NaL), with apparent dissociation constants K(dr)=7.47 microM and K(di)=1.71 microM, respectively. TCs of myocytes stimulated at 0.5 Hz were characterized by an initial spike followed by a dome-like after contraction, which was observed in 75% of myocytes from failing hearts and coincided with the long AP plateau and EADs. Ranolazine at 5 and 10 microM reversibly shortened the duration of TCs and abolished the after contraction. When the rate of myocyte stimulation was increased from 1.0 to 2.0 Hz, there was a progressive increase in diastolic "tension," that is, contracture. Ranolazine at 5 and 10 microM reversibly prevented this frequency-dependent contracture.

Journal of cardiovascular electrophysiology · 189 citationsread the source →

Personality and psychopathology

Personality and psychopathology can relate to one another in three different ways 1. Personality and psychopathology can influence the presentation or appearance of one another, commonly referred to as a pathoplastic relationship. They can share a common, underlying etiology, referred to as a spectrum relationship. And, finally, they can have a causal role in the development or etiology of one another. Each of these relationships has significant theoretical and clinical implications, and each will be considered in turn. The influence of personality and psychopathology on the presentation, appearance, or expression of one another is typically characterized as a pathoplastic relationship. This relationship is bidirectional, as psychopathology can vary in its appearance depending upon a person's premorbid personality traits, and the appearance of personality can similarly be affected by the presence of a comorbid psychopathology. Personality is the characteristic manner in which one thinks, feels, behaves, and relates to others. Mental disorders are clinically significant impairments in one or more areas of psychological functioning. It would be surprising for the presentation, course, or treatment of a dysfunction in thinking or feeling not to be significantly affected by a person's a priori characteristic manner of thinking and feeling. For example, anorexia and bulimia tend to emerge during adolescence (driven in part perhaps by high levels of neuroticism). Persons with a preoccupation with weight loss who go on to develop anorexia are most likely characterized in part by high premorbid conscientiousness, one of the fundamental individual differences included within the well validated five-factor model (FFM) of general personality structure 2. Persons high in conscientiousness have high levels of self-discipline, competence, and achievement-striving, precisely the attributes that would be necessary to be so successful in weight loss. In contrast, persons low in conscientiousness would be prone to the impulsive dyscontrol characteristic of binge eating and bulimia. Empirical support for this hypothesis is provided by studies indicating the presence of perfectionistic and compulsive personality traits in persons with anorexia, particularly the restrained subtype, as well as personality traits of impulsivity with bulimic symptomatology 3. One of the most well-documented relationships between personality and psychopathology is the pathoplastic effect of psychopathology on the appearance, presentation, or perception of personality 4,5. Clinicians (and at times researchers) will typically assess a patient's personality during an initial intake procedure, yet this is perhaps the worst time to do so 6. Persons who are very anxious, depressed, angry, or distraught will often fail to provide an accurate description of their usual way of thinking, feeling, behaving, and relating to others. Once their mood, anxiety, or other mental disorder is successfully treated, their self-description changes accordingly. Consider, for example, temporal stability findings reported in the highly published, multi-site Collaborative Longitudinal Study of Personality Disorders (CLPS). Twenty-three of 160 persons (14%) who met diagnostic criteria for borderline personality disorder (BPD) at baseline had no more than two diagnostic criteria just six months later 7. Eighteen sustained this reduction from six months to one year. For five of the 18 cases, a “remission of the Axis I disorder was judged to be the most likely cause for the sudden BPD improvement” 7. For eight cases, “the changes involved gaining relief from severely stressful situations they were in at or before the baseline assessment” 7. For one of the participants, the “personality disorder” symptoms were even secondary to the use of a stimulant for weight reduction during the year prior to the beginning of the study: “the most dramatic improvement following a treatment intervention occurred when a subject discontinued a psychostimulant she had used the year prior to baseline for purposes of weight loss. Discontinuation was followed by a dramatic reduction of her depression, panic, abandonment fears, and self-destructiveness” 7. Nevertheless, all 18 cases have been considered to be true cases of remission from a personality disorder 7. An alternative view is that the initial assessments of personality disorder were inaccurate due to the presence of emotional distress at baseline. Costa et al 8 though argue that change in self-description secondary to a mood disorder can represent an actual change in personality. One of the fundamental traits of personality is neuroticism, which is a disposition to experience and express negative affects 3. Persons high in neuroticism will respond to stress with clinically significant levels of depression, and this depression could then be understood as a direct expression of the neuroticism. “Rather than regard these depression-caused changes in assessed personality trait levels as a distortion, we interpret them as accurate reflections of the current [personality] of the individual” 8. On the other hand, to the extent that one considers self-report levels of neuroticism secondary to a mood disorder to reflect actual personality functioning, it becomes difficult to conduct research on the etiological contribution of these same personality traits to the mood disorder. They are no longer distinguished constructs. One should at least not attempt to infer premorbid personality traits on the basis of an assessment when the person is suffering from a mood disorder (or other comparable disorder or condition). The identification of pathoplastic (and etiological) relationships of personality and psychopathology is complicated by the possibility that personality and psychopathology may themselves fail in some instances to be distinct entities. They may instead exist along a common spectrum of functioning. All personality disorders may in fact be maladaptive variants of general personality traits, and some personality disorders could be early onset, chronic, and pervasive variants of other mental disorders. These two possibilities will be discussed in turn. There is a considerable body of research on how general personality traits (e.g., neuroticism and low conscientiousness) can contribute to the etiology of anxiety, mood, substance, and other mental disorders 1, but little to no research on how these traits could contribute to the etiology of personality disorders. This may reflect an implicit acceptance that personality and personality disorders lie along a common spectrum of functioning. In fact, there is now a considerable body of research to indicate that personality disorders are readily understood as maladaptive and/or extreme variants of the FFM personality structure 9,10. For example, obsessive-compulsive personality disorder (OCPD, 11) can be understood as largely a maladaptive variant of FFM conscientiousness. FFM conscientiousness includes such facets as order (i.e., OCPD preoccupation with details, rules, lists, and order), achievement striving (i.e., OCPD excessive devotion to work and productivity), dutifulness (i.e., OCPD overconscientiousness and scrupulousness about matters of ethics and morality), competence (i.e., OCPD perfectionism), and deliberation (i.e., OCPD rumination). Empirical support for this conceptualization is extensive 12,13,14. The fifth edition of the American Psychiatric Association (APA)'s diagnostic nomenclature is likely to include a dimensional classification that will serve as an ancillary supplement to the traditional categorical diagnoses 15. The proposal for this model currently consists of six domains: negative emotionality (aligning with FFM neuroticism), introversion (FFM introversion), antagonism (FFM antagonism), compulsivity (FFM conscientiousness), disinhibition (low FFM conscientiousness), and schizotypy (low FFM openness). The authors of this model, however, argue that compulsivity is not in fact a maladaptive variant of conscientiousness and schizotypyal is not a maladaptive variant of openness 15. No normal variants for the dimensions of compulsivity and schizotypy are in fact proposed, suggesting that these maladaptive personality traits are somehow qualitatively distinct from general personality structure. A spectrum relationship may also exist for personality disorders with other mental disorders. In fact, a proposal for DSM-5 has been to abandon the classification of personality disorder altogether, subsuming personality disorders within other mental disorder diagnoses 16. Schizotypal personality disorder is already classified as a variant of schizophrenia rather than as a personality disorder in the ICD-10 17. Support for this alternative classification is that schizotypal personality disorder is genetically related to schizophrenia, many of its neurobiological risk factors and psychophysiological correlates are shared with schizophrenia (e.g., eye tracking, orienting, startle blink, and neurodevelopmental abnormalities), and the treatments that are effective in ameliorating schizotypal symptoms overlap with treatments used for persons with schizophrenia 18. One can similarly convert avoidant personality disorder into generalized social phobia, OCPD into an early onset, pervasive, and chronic variant of obsessive-compulsive disorder, antisocial into an adult variant of disruptive behavior disorder, and borderline into a mood dysregulation disorder 1. The narcissistic, histrionic, and dependent personality disorders are not well integrated into any existing mental disorder, but it might be no coincidence that these diagnoses are slated for deletion in DSM-5 14. A concern with reformulating personality disorders as early onset and chronic Axis I disorders, beyond the fundamental consideration that the diagnostic manual would no longer recognize the existence of maladaptive personality functioning, is that it might create more problems than it solves. Persons have constellations of maladaptive personality traits that are not well described by just one or even multiple personality disorder diagnoses 19. These constellations of maladaptive personality traits would be even less well described by a collection of anxiety, mood, disruptive behavior, and schizophrenic diagnoses. In addition, simply because a personality disorder (or trait) shares some genetic foundation with another mental disorder does not then indicate that it is a form of that disorder. For example, inconsistent with the ICD-10 classification of schizotypal personality disorder as a form of schizophrenia is that this disorder is far more comorbid with other personality disorders than it is with psychotic disorders. Furthermore, persons with schizotypal personality disorder almost never go on to develop schizophrenia, and schizotypal symptomatology is seen in quite a number of persons who appear to lack a genetic association with schizophrenia and would not be at all well described as being schizophrenic 18. Of primary concern to many personality, personality disorder, and psychopathology researchers is the etiological relationship between personality and psychopathology. This causal relationship is again bidirectional, as one's characteristic way of thinking, feeling, behaving, and relating to others can at times result in or contribute to the development of a mental disorder, just as a severe or chronic mental disorder can itself contribute to fundamental changes to personality. Psychopathology can fundamentally alter personality, for the better or for the worse. For example, it is conceivable that the experience of having suffered from a severe mental disorder, such as a psychosis or a major depression, might have a lasting effect on one's characteristic manner of thinking, feeling, and relating to others. This alteration to personality functioning, often referred to as a “scar” of a mental disorder, need not represent simply a continuing subthreshold manifestation of the psychopathology (e.g., a residual phase of schizophrenia appearing to be schizotypal personality traits) but may even represent the development of new personality traits due to the occurrence or experience of the psychopathology (e.g., dependent personality traits resulting from an experience of recurrent panic attacks or psychotic episodes). The ICD-10 does include a diagnosis for personality change secondary to a mental disorder, as well as secondary to catastrophic experience 17. The APA nomenclature though provides no recognition to either possibility 11. An example of the latter condition would be “complex post-traumatic stress disorder” (complex PTSD), a reaction to severe (often sustained) interpersonal stress (e.g., abuse, battering, or torture), that includes “impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual's previous personality characteristics” 11. Complex PTSD could be conceptualized as an adult-onset borderline personality disorder. However, most advocates for the inclusion of this diagnosis in a future edition of the diagnostic manual prefer that it be classified as an anxiety disorder rather than as a disorder of personality change 20. Much of the vast literature on the relationship of personality or personality disorder with psychopathology is concerned with the contribution of personality to the onset or etiology of mental disorder. Premorbid personality traits can provide a vulnerability (or a resilience) to stress, helping to explain why some people collapse under life stresses while others remain unscathed by severely traumatic circumstances. Neuroticism is a particularly robust predictor of future psychopathology in response to life stress 21,22, including mood, eating, substance use, anxiety, and other forms of psychopathology 23. Neuroticism can contribute both diathesis and stress, providing a vulnerability through both reactive and evocative person-environment interactions. Persons high in neuroticism react to events with high levels of distress, anxiety, and worry, providing an explicit risk for various forms of psychopathology, particularly mood and anxiety disorders (which perhaps can also be understood then as a spectrum rather than a causal relationship). The evocative interaction occurs when one's frequent expressions of upset, worry, and vulnerability produce negative reactions from others or contribute to poor decision-making, thus reinforcing and increasing the original distress (i.e., personality as causing stress). The contribution of neuroticism to the development of physical health problems, financial difficulties, and dissolution of relationships and other negative life outcomes 21 will result in a considerable amount of stress, with which persons high in neuroticism would have an inherent difficulty emotionally surmounting. Dependent personality traits have also been shown to have an important role in the etiology of depression. Multiple prospective, longitudinal studies have confirmed that dependent cognitions and behaviors result in increased feelings of depression in reaction to interpersonal loss or rejection 24. This relationship can again be both reactive and evocative. Dependent persons will react to interpersonal loss and rejection with intense feelings of despair, hopelessness, and sadness. The dependent traits of neediness, clinging, preoccupation with fears of loss, and excessive reassurance-seeking can also evoke a disengagement and rejection by others 25. However, despite the importance of dependent traits for the development of psychopathology, dependent personality disorder is slated for deletion in DSM-5 26. One basic observation of the research on the relationship of personality and psychopathology is its vibrancy. All aspects of the various relationships between personality and psychopathology (pathoplastic, spectrum, and causal) are the focus of a number of highly productive, sophisticated, and informed research programs. Disentangling the forms of relationship from one another, however, is a formidable task. However, it will be through the dismantling of this complexity that continued progress will be made in understanding the relationship of personality and psychopathology.

World Psychiatry · 819 citationsread the source →

Relationships among spirituality, religious practices, personality factors, and health for five different faith traditions.

To determine: (1) differences in spirituality, religiosity, personality, and health for different faith traditions; and (2) the relative degree to which demographic, spiritual, religious, and personality variables simultaneously predict health outcomes for different faith traditions. Cross-sectional analysis of 160 individuals from five different faith traditions including Buddhists (40), Catholics (41), Jews (22), Muslims (26), and Protestants (31). Brief multidimensional measure of religiousness/spirituality (BMMRS; Fetzer in Multidimensional measurement of religiousness/spirituality for use in health research, Fetzer Institute, Kalamazoo, 1999); NEO-five factor inventory (NEO-FFI; in Revised NEO personality inventory (NEO PI-R) and the NEO-five factor inventory (NEO-FFI) professional manual, Psychological Assessment Resources, Odessa, Costa and McCrae 1992); Medical outcomes scale-short form (SF-36; in SF-36 physical and mental health summary scores: A user's manual, The Health Institute, New England Medical Center, Boston, Ware et al. 1994). (1) ANOVAs indicated that there were no significant group differences in health status, but that there were group differences in spirituality and religiosity. (2) Pearson's correlations for the entire sample indicated that better mental health is significantly related to increased spirituality, increased positive personality traits (i.e., extraversion) and decreased personality traits (i.e., neuroticism and conscientiousness). In addition, spirituality is positively correlated with positive personality traits (i.e., extraversion) and negatively with negative personality traits (i.e., neuroticism). (3) Hierarchical regressions indicated that personality predicted a greater proportion of unique variance in health outcomes than spiritual variables. Different faith traditions have similar health status, but differ in terms of spiritual, religious, and personality factors. For all faith traditions, the presence of positive and absence of negative personality traits are primary predictors of positive health (and primarily mental health). Spiritual variables, other than forgiveness, add little to the prediction of unique variance in physical or mental health after considering personality. Spirituality can be conceptualized as a characterological aspect of personality or a distinct construct, but spiritual interventions should continue to be used in clinical practice and investigated in health research.

Journal of religion and health · 31 citationsread the source →

“Let Me See If I Have This Right …”: Words That Help Build Empathy

Medical Writings7 August 2001"Let Me See If I Have This Right …": Words That Help Build EmpathyJohn L. Coulehan, MD, Frederic W. Platt, MD, Barry Egener, MD, Richard Frankel, PhD, Chen-Tan Lin, MD, Beth Lown, MD, and William H. Salazar, MDJohn L. Coulehan, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Frederic W. Platt, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Barry Egener, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Richard Frankel, PhDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Chen-Tan Lin, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, Beth Lown, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902, and William H. Salazar, MDDr. Coulehan: State University of New York at Stony Brook; Stony Brook, NY 11794-8036Dr. Platt: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Egener: American Academy on Physician and Patient; Portland, OR 97210Dr. Frankel: Highland Hospital; Rochester, NY 14620Dr. Lin: University of Colorado Health Sciences Center; Denver, CO 80222Dr. Lown: Mount Auburn Hospital; Cambridge, MA 02238Dr. Salazar: Medical College of Georgia; Augusta, GA 30902Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-3-200108070-00022 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Consider these two physician–patient dialogues:1. Patient: You know, when you discover a lump in your breast, you kind of feel—well, kind of—(her speech tapers off; she looks down; tears form in her eyes).Dr. A: When did you actually discover the lump?Patient: (absently) I don't know. It's been a while.2. Patient: (same as above)Dr. B: That sounds frightening. Patient: Well, yeah, sort of. Dr. B: Sort of frightening?Patient: Yeah … and I guess I'm feeling like my life is over. Dr. B: I see. Worried and sad too. Patient: That's it, Doctor. Dr. A's patient ...References1. Konrad TR, Williams ES, Linzer M, McMurray J, Pathman DE, Gerrity M, et al . Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Med Care. 1999;37:1174-82. [PMID: 10549620] CrossrefMedlineGoogle Scholar2. Donelan K, Blendon RJ, Lundberg GD, Calkins DR, Newhouse JP, Leape LL, et al . The new medical marketplace: physicians' views. Health Aff Millwood. 1997;16:139-48. [PMID: 9314685] CrossrefMedlineGoogle Scholar3. Bates AS, Harris LE, Tierney WM, Wolinsky FD. Dimensions and correlates of physician work satisfaction in a midwestern city. Med Care. 1998;36:610-7. 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Coulehan, MD, Department of Preventive Medicine, HSC L3-086, State University of New York at Stony Brook, Stony Brook, NY 11794-8036; e-mail, [email protected]sunysb.edu. Current Author Addresses: Dr. Coulehan: Department of Preventive Medicine, HSC L3-086, State University of New York at Stony Brook, Stony Brook, NY 11794-8036.Drs. Platt and Lin: University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80222.Dr. Egener: American Academy on Physician and Patient, Legacy Clinic Northwest, 1130 NW 22nd Avenue, Suite 220, Portland, OR 97210.Dr. Frankel: Highland Hospital, 1000 South Avenue, Rochester, NY 14620.Dr. Lown: Mount Auburn Hospital, 300 Mt. Auburn Street, Cambridge, MA 02238.Dr. Salazar: Medical College of Georgia, 1120 15th Street, HS2010, Augusta, GA 30902. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByHow does narrative medicine impact medical trainees' learning of professionalism? 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PhD, M. MD, and and role in education about care in Competencies in Care for and Communication in patients with in the Care of Cancer in of and of Empathic during When Being Not empathy learning for be and for effective the role of care in with and in the of the medicine and outcomes of physician empathy in A structural focus study of and perceptions of the of of Medical Student role of empathy in in the a new and in the a of the An or Do You to to Patients Do Not or with Challenges and a of of the of a for children with Care. A to in care: The role of perceptions in Older in Clinical during Health and H. or Not to Is That the Right empathy and sympathy: responses to troubles on a health care with to make the patient the Communication and With Patients in Your as a of The of Medicine, and How to and A Patient-Centered Communication Illness Using to Communication Care and Social in the office approach to the Words That in to and MD, M. MD, and Frederic Platt, I Student August August August by American College of

Annals of Internal Medicine · 322 citationsread the source →

Transforming growth factor-β, macrophage colony-stimulating factor and C-reactive protein levels correlate with CD14(high)CD16+ monocyte induction and activation in trauma patients.

Severe injury remains a leading cause of death and morbidity in patients under 40, with the number of annual trauma-related deaths approaching 160,000 in the United States. Patients who survive the initial trauma and post-traumatic resuscitation are at risk for immune dysregulation, which contributes to late mortality and accounts for approximately 20% of deaths after traumatic injury. This post-traumatic immunosuppressed state has been attributed to over-expression of anti-inflammatory mediators in an effort to restore host homeostasis. We measured a panel of monocyte markers and cytokines in 50 severely injured trauma patients for 3 days following admission. We made the novel observation that the subpopulation of monocytes expressing high levels of CD14 and CD16 was expanded in the majority of patients. These cells also expressed CD163 consistent with differentiation into alternatively activated macrophages with potential regulatory or wound-healing activity. We examined factors in trauma plasma that may contribute to the generation and activation of these cells. The percentage of CD14(high)CD16(+) monocytes after trauma correlated strongly with plasma C-reactive protein (CRP) transforming growth factor-β (TGF-β), and macrophage colony-stimulating factor (M-CSF) levels. We demonstrate a role for TGF-β and M-CSF, but not CRP in generating these cells using monocytes from healthy volunteers incubated with plasma from trauma patients. CD16 is a receptor for CRP and IgG, and we showed that monocytes differentiated to the CD14(high)CD16(+) phenotype produced anti-inflammatory cytokines in response to acute phase concentrations of CRP. The role of these cells in immunosuppression following trauma is an area of ongoing investigation.

PloS one · 30 citationsread the source →