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حَدَّثَنَا هَنَّادٌ، حَدَّثَنَا أَبُو مُعَاوِيَةَ، عَنِ الأَعْمَشِ، عَنْ ذَرٍّ، عَنْ يُسَيْعٍ الْكِنْدِيِّ، عَنِ النُّعْمَانِ بْنِ بَشِيرٍ، عَنِ النَّبِيِّ صلى الله عليه وسلم فِي قَوْلِهِ ‏:‏ ‏(‏وَقَالَ رَبُّكُمُ ادْعُونِي أَسْتَجِبْ لَكُمْ ‏)‏ قَالَ ‏"‏ الدُّعَاءُ هُوَ الْعِبَادَةُ ‏"‏ ‏.‏ وَقَرَأَ ‏:‏‏(‏ وَقَالَ رَبُّكُمُ ادْعُونِي أَسْتَجِبْ لَكُمْ ‏)‏ إِلَى قَوْلِهِ ‏(‏ دَاخِرِينَ ‏)‏ ‏.‏ قَالَ أَبُو عِيسَى هَذَا حَدِيثٌ حَسَنٌ صَحِيحٌ ‏.‏

Narrated An-Nu'man bin Bashir:from the Prophet (ﷺ) regarding Allah's saying: Your Lord said: Invoke Me, I shall respond to you (40:60, it appears that the author intended to apply it to Al-Baqarah 2:186). - he said: "The supplication is the worship." And he recited: 'Your Lord said: Invoke Me, I shall respond to you.' up to His saying: 'in humiliation

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Post-sleep inertia performance benefits of longer naps in simulated nightwork and extended operations.

Operational settings involving shiftwork or extended operations require periods of prolonged wakefulness, which in conjunction with sleep loss and circadian factors, can have a negative impact on performance, alertness, and workplace safety. Napping has been shown to improve performance and alertness after periods of prolonged wakefulness and sleep loss. Longer naps may not only result in longer-lasting benefits but also increase the risk of sleep inertia immediately upon waking. The time course of performance after naps of differing durations is thus an important consideration in weighing the benefits and risks of napping in workplace settings. The objective of this study was to evaluate the effectiveness of nap opportunities of 20, 40, or 60 min for maintaining alertness and performance 1.5-6 h post-nap in simulated nightwork (P1) or extended operations (P2). Each protocol included 12 participants in a within-subjects design in a controlled laboratory environment. After a baseline 8 h time-in-bed, healthy young males (P1 mean age 25.1 yr; P2 mean age 23.2 yr) underwent either ≈ 20 h (P1) or ≈ 30 h (P2) of sleep deprivation on four separate occasions, followed by nap opportunities of 0, 20, 40, and 60 min. Sleep on the baseline night and during the naps was recorded polysomnographically. During the nap opportunities, sleep onset latency was short and sleep efficiency was high. A greater proportion of slow-wave sleep (SWS) was obtained in nap opportunities of 40 and 60 min compared with 20 min. Rapid eye movement (REM) sleep occurred infrequently. A subjective sleepiness rating (Karolinska Sleepiness Scale, KSS), 2-Back Working Memory Task (WMT), and Psychomotor Vigilance Task (PVT) were completed 1.5, 2, 2.5, 3, 4, 5, and 6 h post-nap. The slowest 10% of PVT responses were significantly faster after 40 and 60 min naps compared with a 20 min (P1) or no (P2) nap. There were significantly fewer PVT lapses after 40 and 60 min naps compared with no nap (P2), and after 60 min naps compared with 20 min naps (P1). Participants felt significantly less sleepy and made more correct responses and fewer omissions on the WMT after 60 min naps compared with no nap (P2). Subjective sleepiness and WMT performance were not related to the amount of nap-time spent in SWS. However, PVT response speed was significantly slower when time in SWS was <10 min compared with 20-29.9 min. In conclusion, in operationally relevant scenarios, nap opportunities of 40 and 60 min show more prolonged benefits 1.5-6 h post-nap, than a 20 min or no nap opportunity. Benefits were more apparent when the homeostatic pressure for sleep was high and post-nap performance testing occurred across the afternoon (P2). For sustained improvement in cognitive performance, naps of 40-60 min are recommended.

Chronobiology international · clinical trial · 28 citationsread the source →

Exercise and circulating cortisol levels: the intensity threshold effect.

This study examined the influence of exercise intensity upon the cortisol response of the hypothalamic-pituitary-adrenal (HPA) axis. Specifically, we examined exercise at intensities of 40, 60, and 80% maximal oxygen uptake (VO2max) in an attempt to determine the intensity necessary to provoke an increase in circulating cortisol. Twelve active moderately trained men performed 30 min of exercise at intensities of 40, 60, and 80% of their VO2max, as well as a 30-min resting-control session involving no exercise on separate days. Confounding factors such as time of day--circadian rhythms, prior diet--activity patterns, psychological stress, and levels of exercise training were controlled. Cortisol and ACTH were assessed in blood collected immediately before (pre-) and after (post-) each experimental session. Statistical analysis involved repeated measures analysis of variance and Tukey post-hoc testing. The percent change in cortisol from pre- to post-sampling at each session was: resting-control, 40, 60, and 80% sessions (mean+/-SD) =-6.6+/-3.5%, +5.7+/-11.0%, +39.9+/-11.8%, and +83.1+/-18.5%, respectively. The 60% and 80% intensity magnitude of change was significantly greater than in the other sessions, as well as from one to another. The ACTH responses mirrored those of cortisol, but only the 80% exercise provoked a significant (p<0.05) increase pre- to post-exercise. The calculated changes in plasma volume for the resting-control, 40%, 60%, and 80% sessions were: +2.2+/-3.0%, -9.9+/-5.0%, -15.6+/-3.5%, and -17.2+/-3.3%, respectively. Collectively, the cortisol findings support the view that moderate to high intensity exercise provokes increases in circulating cortisol levels. These increases seem due to a combination of hemoconcentration and HPA axis stimulus (ACTH). In contrast, low intensity exercise (40%) does not result in significant increases in cortisol levels, but, once corrections for plasma volume reduction occurred and circadian factors were examined, low intensity exercise actually resulted in a reduction in circulating cortisol levels.

Journal of endocrinological investigation · 367 citationsread the source →

The prevalence of loneliness across 113 countries: systematic review and meta-analysis.

Objectives: To identify data availability, gaps, and patterns for population level prevalence of loneliness globally, to summarise prevalence estimates within World Health Organization regions when feasible through meta-analysis, and to examine temporal trends of loneliness in countries where data exist. Design: Systematic review and meta-analysis. Data sources: Embase, Medline, PsycINFO, and Scopus for peer reviewed literature, and Google Scholar and Open Grey for grey literature, supplemented by backward reference searching (to 1 September 2021) ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Observational studies based on nationally representative samples (n≥292), validated instruments, and prevalence data for 2000-19. Two researchers independently extracted data and assessed the risk of bias using the Joanna Briggs Institute checklist. Random effects meta-analysis was conducted in the subset of studies with relatively homogeneous research methods by measurement instrument, age group, and WHO region. Results: Prevalence data were available for 113 countries or territories, according to official WHO nomenclature for regions, from 57 studies. Data were available for adolescents (12-17 years) in 77 countries or territories, young adults (18-29 years) in 30 countries, middle aged adults (30-59 years) in 32 countries, and older adults (≥60 years) in 40 countries. Data for all age groups except adolescents were lacking outside of Europe. Overall, 212 estimates for 106 countries from 24 studies were included in meta-analyses. The pooled prevalence of loneliness for adolescents ranged from 9.2% (95% confidence interval 6.8% to 12.4%) in South-East Asia to 14.4% (12.2% to 17.1%) in the Eastern Mediterranean region. For adults, meta-analysis was conducted for the European region only, and a consistent geographical pattern was shown for all adult age groups. The lowest prevalence of loneliness was consistently observed in northern European countries (2.9%, 1.8% to 4.5% for young adults; 2.7%, 2.4% to 3.0% for middle aged adults; and 5.2%, 4.2% to 6.5% for older adults) and the highest in eastern European countries (7.5%, 5.9% to 9.4% for young adults; 9.6%, 7.7% to 12.0% for middle aged adults; and 21.3%, 18.7% to 24.2% for older adults). Conclusion: Problematic levels of loneliness are experienced by a substantial proportion of the population in many countries. The substantial difference in data coverage between high income countries (particularly Europe) and low and middle income countries raised an important equity issue. Evidence on the temporal trends of loneliness is insufficient. The findings of this meta-analysis are limited by data scarcity and methodological heterogeneity. Loneliness should be incorporated into general health surveillance with broader geographical and age coverage, using standardised and validated measurement tools. Systematic review registration: PROSPERO CRD42019131448.

BMJ (Clinical research ed.) · meta-analysis · 397 citationsread the source →

Beyond the Trial: Systematic Review of Real-World Uptake and Engagement With Digital Self-Help Interventions for Depression, Low Mood, or Anxiety.

Background: Digital self-help interventions (including online or computerized programs and apps) for common mental health issues have been shown to be appealing, engaging, and efficacious in randomized controlled trials. They show potential for improving access to therapy and improving population mental health. However, their use in the real world, ie, as implemented (disseminated) outside of research settings, may differ from that reported in trials, and implementation data are seldom reported. Objective: This study aimed to review peer-reviewed articles reporting user uptake and/or ongoing use, retention, or completion data (hereafter usage data or, for brevity, engagement) from implemented pure self-help (unguided) digital interventions for depression, anxiety, or the enhancement of mood. Methods: We conducted a systematic search of the Scopus, Embase, MEDLINE, and PsychINFO databases for studies reporting user uptake and/or usage data from implemented digital self-help interventions for the treatment or prevention of depression or anxiety, or the enhancement of mood, from 2002 to 2017. Additionally, we screened the reference lists of included articles, citations of these articles, and the titles of articles published in Internet Interventions, Journal of Medical Internet Research (JMIR), and JMIR Mental Health since their inception. We extracted data indicating the number of registrations or downloads and usage of interventions. Results: After the removal of duplicates, 970 papers were identified, of which 10 met the inclusion criteria. Hand searching identified 1 additional article. The included articles reported on 7 publicly available interventions. There was little consistency in the measures reported. The number of registrants or downloads ranged widely, from 8 to over 40,000 per month. From 21% to 88% of users engaged in at least minimal use (eg, used the intervention at least once or completed one module or assessment), whereas 7-42% engaged in moderate use (completing between 40% and 60% of modular fixed-length programs or continuing to use apps after 4 weeks). Indications of completion or sustained use (completion of all modules or the last assessment or continuing to use apps after six weeks or more) varied from 0.5% to 28.6%. Conclusions: Available data suggest that uptake and engagement vary widely among the handful of implemented digital self-help apps and programs that have reported this, and that usage may vary from that reported in trials. Implementation data should be routinely gathered and reported to facilitate improved uptake and engagement, arguably among the major challenges in digital health.

Journal of medical Internet research · systematic review · 420 citationsread the source →

Self-management intervention for head and neck cancer couples: Results of a randomized pilot trial.

Background: Patients with head and neck cancer (HNC) experience significant physical and psychological morbidity during radiotherapy (RT) that contributes to treatment interruptions and a poor quality of life. Although spouses/partners can help by encouraging patient self-management (eg, self-care) during RT, they often experience high psychological distress rates, lack basic health care knowledge and skills, and report increased marital conflict regarding patient self-management. The current pilot study examined the feasibility and acceptability of a 6-session telephone-based intervention called Spouses coping with the Head And neck Radiation Experience (SHARE), which teaches self-management, communication, and coping skills to patients with HNC and their spouses. The treatment effects of SHARE compared with usual medical care (UMC) in controlling patient physical symptoms and improving patient/spouse psychological and marital functioning also were examined. Methods: Thirty patients who initiated RT and their spouses (60 participants; 40% of whom were racial/ethnic minorities) were randomized to SHARE or UMC, and preintervention and postintervention assessments were completed. Results: Solid recruitment (70%) and low attrition rates (7%) demonstrated feasibility. Strong program evaluations and homework completion rates (72%) supported acceptability. Significant treatment effects (medium in magnitude) were observed for SHARE compared with UMC with regard to HNC-specific physical symptom burden (Cohen's d, -0.89) and symptom interference (Cohen's d, -0.86). Medium to large effects favoring SHARE also were found for patient and spouse depressive symptoms (Cohen's d, -0.84) and cancer-specific distress (Cohen's d, -1.05). Conclusions: The findings of the current study support the feasibility, acceptability, and preliminary efficacy of SHARE. They also suggest that programs that empower HNC couples with the necessary skills to coordinate care and manage the challenges of RT together hold great promise for controlling a patient's physical symptoms and improving the psychological functioning of both partners.

Cancer · randomised controlled trial · 48 citationsread the source →

Extended-Release Mixed Amphetamine Salts vs Placebo for Comorbid Adult Attention-Deficit/Hyperactivity Disorder and Cocaine Use Disorder: A Randomized Clinical Trial.

Importance: Adult attention-deficit/hyperactivity disorder (ADHD) is prevalent but often unrecognized, in part because it tends to co-occur with other disorders such as substance use disorders. Cocaine use disorder is one such disorder with high co-occurrence of ADHD. Objective: To examine whether treatment of co-occurring ADHD and cocaine use disorder with extended-release mixed amphetamine salts is effective at both improving ADHD symptoms and reducing cocaine use. Design, setting, and participants: Thirteen-week, randomized, double-blind, 3-arm, placebo-controlled trial of participants meeting DSM-IV-TR criteria for both ADHD and cocaine use disorder conducted between December 1, 2007, and April 15, 2013, at 2 academic health center substance abuse treatment research sites. One hundred twenty-six adults diagnosed as having comorbid ADHD and cocaine use disorder were randomized to extended-release mixed amphetamine salts or placebo. Analysis was by intent-to-treat population. Interventions: Participants received extended-release mixed amphetamine salts (60 or 80 mg) or placebo daily for 13 weeks and participated in weekly individual cognitive behavioral therapy. Main outcomes and measures: For ADHD, percentage of participants achieving at least a 30% reduction in ADHD symptom severity, measured by the Adult ADHD Investigator Symptom Rating Scale; for cocaine use, cocaine-negative weeks (by self-report of no cocaine use and weekly benzoylecgonine urine screens) during maintenance medication (weeks 2-13) and percentage of participants achieving abstinence for the last 3 weeks. Results: More patients achieved at least a 30% reduction in ADHD symptom severity in the medication groups (60 mg: 30 of 40 participants [75.0%]; odds ratio [OR] = 5.23; 95% CI, 1.98-13.85; P < .001; and 80 mg: 25 of 43 participants [58.1%]; OR = 2.27; 95% CI, 0.94-5.49; P = .07) compared with placebo (17 of 43 participants [39.5%]). The odds of a cocaine-negative week were higher in the 80-mg group (OR = 5.46; 95% CI, 2.25-13.27; P < .001) and 60-mg group (OR = 2.92; 95% CI, 1.15-7.42; P = .02) compared with placebo. Rates of continuous abstinence in the last 3 weeks were greater for the medication groups than the placebo group: 30.2% for the 80-mg group (OR = 11.87; 95% CI, 2.25-62.62; P = .004) and 17.5% for the 60-mg group (OR = 5.85; 95% CI, 1.04-33.04; P = .04) vs 7.0% for placebo. Conclusions and relevance: Extended-release mixed amphetamine salts in robust doses along with cognitive behavioral therapy are effective for treatment of co-occurring ADHD and cocaine use disorder, both improving ADHD symptoms and reducing cocaine use. The data suggest the importance of screening and treatment of ADHD in adults presenting with cocaine use disorder. Trial registration: clinicaltrials.gov Identifier:NCT00553319.

JAMA psychiatry · randomised controlled trial · 104 citationsread the source →

Strength training at high versus low external resistance in older adults: effects on muscle volume, muscle strength, and force-velocity characteristics.

Muscle adaptations can be induced by high-resistance exercise. Despite being potentially more suitable for older adults, low-resistance exercise protocols have been less investigated. We compared the effects of high- and low-resistance training on muscle volume, muscle strength, and force-velocity characteristics. Fifty-six older adults were randomly assigned to 12 weeks of leg press and leg extension training at either HIGH (2×10-15 repetitions at 80% of one repetition maximum (1RM)), LOW (1×80-100 repetitions at 20% of 1RM), or LOW+ (1×60 repetitions at 20% of 1RM, followed by 1×10-20 repetitions at 40% of 1RM). All protocols ended with muscle failure. Leg press and leg extension of 1RM were measured at baseline and post intervention and before the first training session in weeks 5 and 9. At baseline and post intervention, muscle volume (MV) was measured by CT-scan. A Biodex dynamometer evaluated knee extensor static peak torque in different knee angles (PT(stat90°), PT(stat120°), PT(stat150°)), dynamic peak torque at different speeds (PT(dyn60°s)(-1), PT(dyn180°s)(-1), PT(dyn240°s)(-1)), and speed of movement at 20% (S20), 40% (S40), and 60% (S60) of PTstat90°. HIGH and LOW+ resulted in greater improvements in 1RM strength than LOW (p<0.05). These differences were already apparent after week 5. Similar gains were found between groups in MV, PT(stat), PT(dyn60°s)(-1), and PT(dyn180°s)(-1). No changes were reported in speed of movement. HIGH tended to improve PT(dyn240°s)(-1) more than LOW or LOW+ (p=0.064). In conclusion, high- and low-resistance exercises ending with muscle failure may be similarly effective for hypertrophy. High-resistance training led to a higher increase in 1RM strength than low-resistance training (20% of 1RM), but this difference disappeared when using a mixed low-resistance protocol in which the resistance was intensified within a single exercise set (40% of 1RM). Our findings support the need for more research on low-resistance programs in older age, in particular long-term training studies and studies focusing on residual effects after training cessation.

Experimental gerontology · randomised controlled trial · 119 citationsread the source →

Feasibility of Exercise Training for the Short-Term Treatment of Generalized Anxiety Disorder: A Randomized Controlled Trial

BACKGROUND: Exercise training may be especially helpful for patients with generalized anxiety disorder (GAD). We conducted a randomized controlled trial to quantify the effects of 6 weeks of resistance (RET) or aerobic exercise training (AET) on remission and worry symptoms among sedentary patients with GAD. METHODS: Thirty sedentary women aged 18-37 years, diagnosed by clinicians blinded to treatment allocation with a primary DSM-IV diagnosis of GAD and not engaged in any treatment other than pharmacotherapy, were randomly allocated to RET, AET, or a wait list (WL). RET involved 2 weekly sessions of lower-body weightlifting. AET involved 2 weekly sessions of leg cycling matched with RET for body region, positive work, time actively engaged in exercise, and load progression. Remission was measured by the number needed to treat (NNT). Worry symptoms were measured by the Penn State Worry Questionnaire. RESULTS: There were no adverse events. Remission rates were 60%, 40%, and 30% for RET, AET, and WL, respectively. The NNT was 3 (95% CI 2 to 56) for RET and 10 (95% CI -7 to 3) for AET. A significant condition-by-time interaction was found for worry symptoms. A follow-up contrast showed significant reductions in worry symptoms for combined exercise conditions versus the WL. CONCLUSIONS: Exercise training, including RET, is a feasible, low-risk treatment that can potentially reduce worry symptoms among GAD patients and may be an effective adjuvant, short-term treatment or augmentation for GAD. Preliminary findings warrant further investigation.

Psychotherapy and Psychosomatics · randomised controlled trial · 200 citationsread the source →

IMPACT: Evaluation of a Controlled Organizational Intervention Using Influential Peers to Promote Professional Fulfillment.

Objective: To determine the effects of a popular opinion leader (POL)-led organizational intervention targeting all physicians and advanced practice providers (APPs) working within clinic groups on professional fulfillment (primary outcome), gratitude, burnout, self-valuation, and turnover intent. Patients and methods: All 20 Stanford University HealthCare Alliance clinics with ≥5 physicians-APPs were matched by size and baseline gratitude scores and randomly assigned to immediate or delayed intervention (control). Between July 10, 2018, and March 15, 2019, trained POLs and a physician-PhD study investigator facilitated 4 interactive breakfast or lunch workshops at intervention clinics, where colleagues were invited to discuss and experience one evidence-based practice (gratitude, mindfulness, cognitive, and behavioral strategies). Participants in both groups completed incentivized annual assessments of professional fulfillment, workplace gratitude, burnout, self-valuation, and intent to leave as part of ongoing organizational program evaluation. Results: Eighty-four (75%) physicians-APPs at intervention clinics attended at least 1 workshop. Of all physicians-APPs, 236 of 251 (94%) completed assessments in 2018 and 254 of 263 (97%) in 2019. Of 264 physicians-APPs with 2018 or 2019 assessment data, 222 (84%) had completed 2017 assessments. Modal characteristics were 60% female, 46% White, 49% aged 40 to 59 years, 44% practicing family-internal medicine, 78% living with partners, and 53% with children. Change in professional fulfillment by 2019 relative to average 2017 to 2018 levels was more favorable (0.63 points; effect size = 0.35; P=.001) as were changes in gratitude and intent to leave among clinicians practicing at intervention clinics. Conclusion: Interventions led by respected physicians-APPs can achieve high participation rates and have potential to promote well-being among their colleagues.

Mayo Clinic proceedings · randomised controlled trial · 9 citationsread the source →

Web-based self-help for problem drinkers: a pragmatic randomized trial.

Aims: Self-help interventions for adult problem drinkers in the general population have proved effective. The question is whether this also holds for self-help interventions delivered over the internet. Design: We conducted a pragmatic randomized trial with two parallel groups, using block randomization stratified for gender and with follow-up at 6 months. Setting: The intervention and trial were conducted online in the Netherlands in 2003-2004. Participants: We selected 261 adult problem drinkers from the general population with a weekly alcohol consumption above 210 g of ethanol for men or 140 g for women, or consuming at least 60 g (men) or 40 g (women) at least 1 day a week over the past 3 months. Participants were randomized to either the experimental drinking less (DL) condition or to the control condition (PBA). Intervention: DL is a web-based, multi-component, interactive self-help intervention for problem drinkers without therapist guidance. The recommended treatment period is 6 weeks. The intervention is based on cognitive-behavioural and self-control principles. The control group received access to an online psychoeducational brochure on alcohol use (PBA). Outcome measures: We assessed the following outcome measures at 6-month follow-up: (i) the percentage of participants who had reduced their drinking levels to within the normative limits of the Dutch guideline for low-risk drinking; and (ii) the reduction in mean weekly alcohol consumption. Findings: At follow-up, 17.2% of the intervention group participants had reduced their drinking successfully to within the guideline norms; in the control group this was 5.4% [odds ratio (OR) = 3.66; 95% confidence interval (CI) 1.3-10.8; P = 0.006; number needed to treat (NNT) = 8.5]. The intervention subjects decreased their mean weekly alcohol consumption significantly more than control subjects, with a difference of 12.0 standardized units (95% CI 5.9-18.1; P < 0.001; standardized mean difference 0.40). Conclusions: To our knowledge this is one of the first randomized controlled trials on a web-based self-help intervention without therapist guidance for self-referred problem drinkers among the adult general population. The intervention showed itself to be effective in reducing problem drinking in the community.

Addiction (Abingdon, England) · randomised controlled trial · 188 citationsread the source →

What Predicts Stable Mental Health in the 18⁻29 Age Group Compared to Older Age Groups? Results from the Stockholm Public Health Cohort 2002⁻2014.

Mental health has decreased in young people since the 1990s, and mental health promotion is an urgent matter. A first step is to identify which social determinants could be of importance for intervention. We used the Stockholm Public Health Cohort, a longitudinal population-based health survey, completed by 31,000 inhabitants in the Stockholm County. We focused on the 18⁻29 age group, n = 3373 (60% females, 40% males) and aimed at assessing which social determinants predict stable mental health, measured as scoring <3 points on the General Health Questionnaire 12 at all time points: 2002, 2007, 2010, and 2014. Forty-six percent of males and 36% of females reported stable mental health. Among the 17 predictors on sociodemographics, socioeconomics, social capital, health behavior, and victimization, six predicted stable mental health in the following order: occupation and especially employment, emotional support, male gender, being born in Sweden, absence of financial strain, and consumption of fruit and berries. In the 30⁻84 age group, 66% males and 55% females reported stable mental health. Nine determinants in the following rank predicted stable mental health: absence of financial strain, occupation and especially being self-employed, emotional support, male gender, physical activity, instrumental support, interpersonal trust, community trust, and absence of hazardous alcohol consumption. Interaction analysis showed significant difference between the younger and older group regarding physical activity and absence of financial strain with importance being higher for the older group. Our findings indicate that the determinants of health differ across the life-course with fewer predictors related to social capital and health behavior in the younger group compared to the older. We conclude that health-promoting interventions should be lifespan-sensitive.

International journal of environmental research and public health · cohort or longitudinal · 13 citationsread the source →

Burn size determines the inflammatory and hypermetabolic response.

Background: Increased burn size leads to increased mortality of burned patients. Whether mortality is due to inflammation, hypermetabolism or other pathophysiologic contributing factors is not entirely determined. The purpose of the present study was to determine in a large prospective clinical trial whether different burn sizes are associated with differences in inflammation, body composition, protein synthesis, or organ function. Methods: Pediatric burned patients were divided into four burn size groups: <40% total body surface area (TBSA) burn, 40-59% TBSA burn, 60-79% TBSA burn, and >80% TBSA burn. Demographic and clinical data, hypermetabolism, the inflammatory response, body composition, the muscle protein net balance, serum and urine hormones and proteins, and cardiac function and changes in liver size were determined. Results: One hundred and eighty-nine pediatric patients of similar age and gender distribution were included in the study (<40% TBSA burn, n = 43; 40-59% TBSA burn, n = 79; 60-79% TBSA burn, n = 46; >80% TBSA burn, n = 21). Patients with larger burns had more operations, a greater incidence of infections and sepsis, and higher mortality rates compared with the other groups (P < 0.05). The percentage predicted resting energy expenditure was highest in the >80% TBSA group, followed by the 60-79% TBSA burn group (P < 0.05). Children with >80% burns lost the most body weight, lean body mass, muscle protein and bone mineral content (P < 0.05). The urine cortisol concentration was highest in the 80-99% and 60-79% TBSA burn groups, associated with significant myocardial depression and increased change in liver size (P < 0.05). The cytokine profile showed distinct differences in expression of IL-8, TNF, IL-6, IL-12p70, monocyte chemoattractant protein-1 and granulocyte-macrophage colony-stimulating factor (P < 0.05). Conclusion: Morbidity and mortality in burned patients is burn size dependent, starts at a 60% TBSA burn and is due to an increased hypermetabolic and inflammatory reaction, along with impaired cardiac function.

Critical care (London, England) · 208 citationsread the source →

Reducing dementia risk by targeting modifiable risk factors in mid-life: study protocol for the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) randomised controlled feasibility trial.

Background: Dementia prevalence is increasing as populations live longer, with no cure and the costs of caring exceeding many other conditions. There is increasing evidence for modifiable risk factors which, if addressed in mid-life, can reduce the risk of developing dementia in later life. These include physical inactivity, low cognitive activity, mid-life obesity, high blood pressure, and high cholesterol. This study aims to assess the acceptability and feasibility and impact of giving those in mid-life, aged between 40 and 60 years, an individualised dementia risk modification score and profile and access to personalised on-line health information and goal setting in order to support the behaviour change required to reduce such dementia risk. A secondary aim is to understand participants' and practitioners' views of dementia prevention and explore the acceptability and integration of the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) intervention into daily life and routine practice. Methods/design: In-MINDD is a multi-centre, primary care-based, single-blinded randomised controlled feasibility trial currently being conducted in four European countries (France, Ireland, the Netherlands and the UK). Participants are being recruited from participating general practices. Inclusion criteria will include age between 40 and 60 years; at least one modifiable risk factor for dementia risk (including diabetes, hypertension, obesity, renal dysfunction, current smoker, raised cholesterol, coronary heart disease, current or previous history of depression, self-reported sedentary lifestyle, and self-reported low cognitive activity) access to the Internet. Primary outcome measure will be a change in dementia risk modification score over the timescale of the trial (6 months). A qualitative process evaluation will interview a sample of participants and practitioners about their views on the acceptability and feasibility of the trial and the links between modifiable risk factors and dementia prevention. This work will be underpinned by Normalisation Process Theory. Discussion: This study will explore the feasibility and acceptability of a risk profiler and on-line support environment to help individuals in mid-life assess their risk of developing dementia in later life and to take steps to alleviate that risk by tackling health-related behaviour change. Testing the intervention in a robust and theoretically informed manner will inform the development of a future, full-scale randomised controlled trial. Trial registration: ISRCTN Registry: ISRCTN 98553005 (DOI: 10.1186/ISRCTN98553005).

Pilot and feasibility studies · 21 citationsread the source →

Adaptive crossover designs for assessment of symptomatic treatments targeting behaviour in neurodegenerative disease: a phase 2 clinical trial of intranasal oxytocin for frontotemporal dementia (FOXY).

Background: There are currently no treatments for empathy deficits in neuropsychiatric disorders. Acute administration of the hormone oxytocin has been associated with symptomatic improvements across animal models and several neuropsychiatric disorders, but results of the majority of oxytocin randomised controlled trials (RCTs) of longer duration have been negative or inconclusive. This lack of efficacy of may be due to rapid habituation to oxytocin with chronic dosing. The objective of the present study is to describe the design of a phase 2 adaptive randomised controlled crossover trial of intranasal oxytocin in frontotemporal dementia (FOXY) as an efficient model for future investigations of symptomatic treatments in neuropsychiatric and neurodegenerative disorders. Methods: Stage 1 will identify which of three dose schedules is most promising based on change in the primary outcome measure, the Neuropsychiatric Inventory apathy/indifference domain score, over 6 weeks of treatment. In stage 2, additional patients are enrolled at the most promising dose for preliminary efficacy analysis when combined with stage 1 to determine if a phase 3 trial is warranted. Objective measures include facial expression recognition, cerebrospinal fluid (CSF) oxytocin levels, and behavioural ratings of videotaped interactions. Results: A total of 20 patients per arm will be entered into stage 1 for a total of 60 patients. In stage 2, an additional 40 patients will be enrolled in the most promising dose arm. Conclusions: The use of adaptive, crossover designs and inclusion of objective measures of change in CSF oxytocin levels and social behaviour will improve the efficiency and conclusiveness of RCTs of oxytocin and other symptomatic treatments in neuropsychiatric disorders. Trial registration: ClinicalTrials.gov, NCT03260920 . Registered on August 24, 2017.

Alzheimer's research & therapy · randomised controlled trial · 27 citationsread the source →

A Brief Exposure-Based Treatment vs Cognitive Processing Therapy for Posttraumatic Stress Disorder: A Randomized Noninferiority Clinical Trial

Importance: Written exposure therapy (WET), a 5-session intervention, has been shown to efficaciously treat posttraumatic stress disorder (PTSD). However, this treatment has not yet been directly compared with a first-line PTSD treatment such as cognitive processing therapy (CPT). Objective: To determine if WET is noninferior to CPT in patients with PTSD. Design, Setting, and Participants: In this randomized clinical trial conducted at a Veterans Affairs medical facility between February 28, 2013, and November 6, 2016, 126 veteran and nonveteran adults were randomized to either WET or CPT. Inclusion criteria were a primary diagnosis of PTSD and stable medication therapy. Exclusion criteria included current psychotherapy for PTSD, high risk of suicide, diagnosis of psychosis, and unstable bipolar illness. Analysis was performed on an intent-to-treat basis. Interventions: Participants assigned to CPT (n = 63) received 12 sessions and participants assigned to WET (n = 63) received 5 sessions. The CPT protocol that includes written accounts was delivered individually in 60-minute weekly sessions. The first WET session requires 60 minutes while the remaining 4 sessions require 40 minutes. Main Outcomes and Measures: The primary outcome was the total score on the Clinician-Administered PTSD Scale for DSM-5; noninferiority was defined by a score of 10 points. Blinded evaluations were conducted at baseline and 6, 12, 24, and 36 weeks after the first treatment session. Treatment dropout was also examined. Results: For the 126 participants (66 men and 60 women; mean [SD] age, 43.9 [14.6] years), improvements in PTSD symptoms in the WET condition were noninferior to improvements in the CPT condition at each of the assessment periods. The largest difference between treatments was observed at the 24-week assessment (mean difference, 4.31 points; 95% CI, -1.37 to 9.99). There were significantly fewer dropouts in the WET vs CPT condition (4 [6.4%] vs 25 [39.7%]; χ21 = 12.84, Cramer V = 0.40). Conclusions and Relevance: Although WET involves fewer sessions, it was noninferior to CPT in reducing symptoms of PTSD. The findings suggest that WET is an efficacious and efficient PTSD treatment that may reduce attrition and transcend previously observed barriers to PTSD treatment for both patients and providers. Trial Registration: clinicaltrials.gov Identifier: NCT01800773.

JAMA Psychiatry · randomised controlled trial · 233 citationsread the source →

The distribution of ''sense of coherence'' among Swedish adults: a quantitative cross-sectional population study.

Background: Antonovsky's concept of ''sense of coherence'' (SOC) has been shown to be related to health. The aim of this study was to describe the distribution of SOC scores and their components in an adult Swedish population aged 20-80 years. Methods: A random sample of 910 individuals from Jönköping, Sweden, aged 20, 30, 40, 50, 60, 70 and 80 years, of which 589 agreed to participate in an oral health examination. The participants answered Antonovsky's 13-item version of ''the life orientation questionnaire scale''. The response to the items and the distribution of the three components of comprehensibility, manageability and meaningfulness were analyzed for different age groups and genders using mean values and standard deviations, Student's t-test and ANOVA. Results: A total of 526 individuals, 263 men and 263 women, answered all 13 questions and constituted the final material for the study (response rate 89%). The individual SOC score increased with age. The 20 year olds had a statistically significantly lower SOC score compared with the other age groups and 55% of them had a low SOC (< or = 66 points) compared with 17% of the 80 year olds. Men in the 60 and 70 year age groups had a statistically significantly higher SOC score compared with women of the same age. Conclusions: The individual distribution of SOC varied with age and gender. Twenty year olds had a significantly lower SOC score compared with elderly age groups. Elderly men had a statistically significantly higher SOC score compared with women of the same age.

Scandinavian journal of public health · cohort or longitudinal · 60 citationsread the source →

X-Linked Intellectual Developmental Disorder-93 Caused by BRWD3 Mutation in Females: A Case Report and Literature Review.

Objective: To report the clinical manifestations and genetic diagnosis of a female patient with X-linked intellectual developmental disorder-93 (XLID93, OMIM#300659) caused by a BRWD3 gene mutation. Systematically summarize the clinical and genetic characteristics of reported female cases and analyze the genotype-phenotype correlation. Methods: A case of XLID93 in a 1-year-and-3-month-old girl was reported. Perform whole-exome sequencing, qPCR copy number verification, X-chromosome inactivation analysis, and three-dimensional protein structure prediction for the child in this case; systematically search relevant databases, and summarize and analyze the phenotypes and genotypes of 5 female patients with BRWD3 mutations reported in the literature to date. Results: The patient was a 1-year-and-3-month-old female presenting with delayed gross motor development, unable to stand or walk independently; poor fine motor skills; high muscle tone in the upper limbs and low muscle tone in the lower limbs. Her head circumference was 48.2 cm (95th-97th). She had slightly wide eye spacing, a low nasal bridge, a prominent forehead, a short neck, and a low posterior hairline. There was a heterozygous deletion variation of exon (loss1, EXON 21-30) in the BRWD3 gene of the patient. First-generation verification showed that both parents of the proband were wild-type; this mutation is a de novo mutation, and it is currently impossible to determine whether it is located on the paternal or maternal X chromosome. Protein structure prediction shows that this deletion results in the complete loss of a bromodomain, which may significantly affect the protein function. Through X-chromosome inactivation testing, the inactivation ratio of the maternally derived X-chromosome of the proband was about 89%, indicating non-random inactivation. In summary, the analysis of the clinical and genetic characteristics of five female patients with XLID93 syndrome caused by BRWD3 gene mutations shows that their core clinical phenotypes have obvious commonalities, mainly manifested as: developmental delay (60%), neurological manifestations (60%), head circumference greater than the 95th percentile (60%), and special facial features (40%), with the overall clinical manifestations being milder than those in the male population. Notably, all three female patients who underwent X chromosome inactivation (XCI) testing exhibited skewed XCI, and the severity of the clinical phenotype was closely related to the direction and degree of XCI skewing: patients with preferential inactivation of the mutant X chromosome had milder clinical manifestations (patient 1 had mild cognitive impairment in early childhood); in contrast, patients with preferential inactivation of the normal X chromosome and active expression of the mutant X chromosome had more severe phenotypes (patient 4 had macrocephaly, special facial features, and developmental delay). This further clarifies the important significance of XCI testing in the genotype-phenotype correlation analysis of female patients with MRX93 syndrome. Conclusion: Clinicians should recommend early genetic testing for children with intellectual disability, language development delay, macrocephaly, or epilepsy. For female patients, X-chromosome inactivation testing should also be completed. Early diagnosis can improve long-term outcomes and prevent the birth of severely affected male children in the same family.

Molecular genetics & genomic medicine · reviewread the source →

Maintenance treatment with varenicline for smoking cessation in patients with schizophrenia and bipolar disorder: a randomized clinical trial.

Importance: It is estimated that more than half of those with serious mental illness smoke tobacco regularly. Standard courses of pharmacotherapeutic cessation aids improve short-term abstinence, but most who attain abstinence relapse rapidly after discontinuation of pharmacotherapy. Objective: To determine whether smokers diagnosed with schizophrenia and bipolar disease have higher rates of prolonged tobacco abstinence with maintenance pharmacotherapy than with standard treatment. Design, setting, and participants: Randomized, double-blind, placebo-controlled, parallel-group, relapse-prevention clinical trial conducted in 10 community mental-health centers. Of 247 smokers with schizophrenia or bipolar disease recruited from March 2008-April 2012, 203 received 12-weeks' open-label varenicline and cognitive behavioral therapy and 87 met abstinence criteria to enter the relapse prevention intervention. Interventions: Participants who had 2 weeks or more of continuous abstinence at week 12 of open treatment were randomly assigned to receive cognitive behavioral therapy and double-blind varenicline (1 mg, 2 per day) or placebo from weeks 12 to 52. Participants then discontinued study treatment and were followed up to week 76. Main outcomes and measures: Seven-day rate of continuous abstinence at study week 52, the end of the relapse-prevention phase, confirmed by exhaled carbon monoxide. Secondary outcomes were continuous abstinence rates for weeks 12 through 64 based on biochemically verified abstinence and weeks 12 through 76, based on self-reported smoking behavior. Results: Sixty-one participants completed the relapse-prevention phase; 26 discontinued participation (7 varenicline, 19 placebo) and were considered to have relapsed for the analyses; 18 of these had relapsed prior to dropout. At week 52, point-prevalence abstinence rates were 60% in the varenicline group (24 of 40) vs 19% (9 of 47) in the placebo group (odds ratio [OR], 6.2; 95% CI, 2.2-19.2; P < .001). From weeks 12 through 64, 45% (18 of 40) among those in the varenicline group vs 15% (7 of 47) in the placebo group were continuously abstinent (OR, 4.6; 95% CI, 1.5-15.7; P = .004), and from weeks 12 through 76, 30% (12 of 40) in the varenicline group vs 11% (5 of 47) in the placebo group were continuously abstinent (OR, 3.4; 95% CI, 1.02-13.6; P = .03). There were no significant treatment effects on psychiatric symptom ratings or psychiatric adverse events. Conclusions and relevance: Among smokers with serious mental illness who attained initial abstinence with standard treatment, maintenance pharmacotherapy with varenicline and cognitive behavioral therapy improved prolonged tobacco abstinence rates compared with cognitive behavioral therapy alone after 1 year of treatment and at 6 months after treatment discontinuation. Trial registration: clinicaltrials.gov Identifier: NCT00621777.

JAMA · randomised controlled trial · 157 citationsread the source →

Nurse and physician barriers to spiritual care provision at the end of life.

Context: Spiritual care (SC) from medical practitioners is infrequent at the end of life (EOL) despite national standards. Objectives: The study aimed to describe nurses' and physicians' desire to provide SC to terminally ill patients and assess 11 potential SC barriers. Methods: This was a survey-based, multisite study conducted from October 2008 through January 2009. All eligible oncology nurses and physicians at four Boston academic centers were approached for study participation; 339 nurses and physicians participated (response rate=63%). Results: Most nurses and physicians desire to provide SC within the setting of terminal illness (74% vs. 60%, respectively; P=0.002); however, 40% of nurses/physicians provide SC less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians, but neither was associated with actual SC provision. Barriers that predicted less frequent SC for all medical professionals included inadequate training (nurses: odds ratio [OR]=0.28, 95% confidence interval [CI]=0.12-0.73, P=0.01; physicians: OR=0.49, 95% CI=0.25-0.95, P=0.04), "not my professional role" (nurses: OR=0.21, 95% CI=0.07-0.61, P=0.004; physicians: OR=0.35, 95% CI=0.17-0.72, P=0.004), and "power inequity with patient" (nurses: OR=0.33, 95% CI=0.12-0.87, P=0.03; physicians: OR=0.41, 95% CI=0.21-0.78, P=0.007). A minority of nurses and physicians (21% and 49%, P=0.003, respectively) did not desire SC training. Those less likely to desire SC training reported lower self-ratings of spirituality (nurses: OR=5.00, 95% CI=1.82-12.50, P=0.002; physicians: OR=3.33, 95% CI=1.82-5.88, P<0.001) and male gender (physicians: OR=3.03, 95% CI=1.67-5.56, P<0.001). Conclusion: SC training is suggested to be critical to the provision of SC in accordance with national care quality standards.

Journal of pain and symptom management · cohort or longitudinal · 160 citationsread the source →

Air quality during the COVID-19: PM2.5 analysis in the 50 most polluted capital cities in the world.

On December 31, 2019, the Chinese authorities reported to the World Health Organization (WHO) the outbreak of a new strain of coronavirus that causes a serious disease in the city of Wuhan, China. This outbreak was classified as SARS-CoV2 and is the cause of the COVID-19 disease. On March 11, 2020, the WHO declares it a Pandemic and today it is considered the greatest challenge in global health that humanity has faced since World War II and it is estimated that between 40 and 60% of the population worldwide will catch the virus. This has caused enormous challenges in countries around the world in social, economic, environmental and obviously health issues. These challenges are mainly due to the effects of the established quarantines in almost all capitals and major cities around the world, from Asia, Europe to America. However, these lockdown which began worldwide from January 23, have had a significant impact on the environment and on the air quality of cities as recently reported by NASA (National Aeronautics and Space Administration) and ESA (European Space Agency), with reductions according to them of up to 30% in some of the epicenters such as the case of Wuhan. Knowing that air pollution causes approximately 29% of lung cancer deaths, 43% of COPD deaths, and 25% of ischemic heart disease deaths, it is important to know the effects of quarantines in cities regarding air quality to take measures that favor populations and urban ecosystems when the emergency ends. Therefore, this paper describes the behavior of PM2.5 emissions particulate matter from the 50 most polluted capital cities in the world according to the WHO, measured before-after the start of the quarantine. Likewise, the impact at the local and global level of this emissions behavior, which averaged 12% of PM2.5 decrease in these cities.

Environmental pollution (Barking, Essex : 1987) · review · 144 citationsread the source →

Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association.

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

Circulation. Cardiovascular quality and outcomes · review · 72 citationsread the source →

Interventions targeting social isolation in older people: a systematic review.

Background: Targeting social isolation in older people is a growing public health concern. The proportion of older people in society has increased in recent decades, and it is estimated that approximately 25% of the population will be aged 60 or above within the next 20 to 40 years. Social isolation is prevalent amongst older people and evidence indicates the detrimental effect that it can have on health and wellbeing. The aim of this review was to assess the effectiveness of interventions designed to alleviate social isolation and loneliness in older people. Methods: Relevant electronic databases (MEDLINE, EMBASE, ASSIA, IBSS, PsycINFO, PubMed, DARE, Social Care Online, the Cochrane Library and CINAHL) were systematically searched using an extensive search strategy, for randomised controlled trials and quasi-experimental studies published in English before May 2009. Additional articles were identified through citation tracking. Studies were included if they related to older people, if the intervention aimed to alleviate social isolation and loneliness, if intervention participants were compared against inactive controls and, if treatment effects were reported. Two independent reviewers extracted data using a standardised form. Narrative synthesis and vote-counting methods were used to summarise and interpret study data. Results: Thirty two studies were included in the review. There was evidence of substantial heterogeneity in the interventions delivered and the overall quality of included studies indicated a medium to high risk of bias. Across the three domains of social, mental and physical health, 79% of group-based interventions and 55% of one-to-one interventions reported at least one improved participant outcome. Over 80% of participatory interventions produced beneficial effects across the same domains, compared with 44% of those categorised as non-participatory. Of interventions categorised as having a theoretical basis, 87% reported beneficial effects across the three domains compared with 59% of interventions with no evident theoretical foundation. Regarding intervention type, 86% of those providing activities and 80% of those providing support resulted in improved participant outcomes, compared with 60% of home visiting and 25% of internet training interventions. Fifty eight percent of interventions that explicitly targeted socially isolated or lonely older people reported positive outcomes, compared with 80% of studies with no explicit targeting. Conclusions: More, well-conducted studies of the effectiveness of social interventions for alleviating social isolation are needed to improve the evidence base. However, it appeared that common characteristics of effective interventions were those developed within the context of a theoretical basis, and those offering social activity and/or support within a group format. Interventions in which older people are active participants also appeared more likely to be effective. Future interventions incorporating all of these characteristics may therefore be more successful in targeting social isolation in older people.

BMC public health · systematic review · 395 citationsread the source →

Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review.

WHAT IS KNOWN ON THE SUBJECT?: In many countries, the majority of psychiatric care is being delivered in an outpatient setting and the proportion of outpatients is increasing on a global level. Nurses are the largest workforce in psychiatric care, but their role has been said to be difficult to define. According to our knowledge, there are no previous reviews focusing on nurse-delivered interventions in the adult psychiatric outpatient setting. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review summarizes nurse-delivered interventions identified in the research literature and describes these systematically. Analysing all the identified interventions using the Nursing Interventions Classification, we conclude that the emphasis of nurse-delivered interventions in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from those presented in a review on inpatient psychiatric nursing. There are several clinical trials describing nurse-delivered evidence-based treatments, such as psychoeducation for patients and their family members in the case of patients diagnosed with schizophrenia and bipolar disorder. The quality of randomized controlled trials was higher than in earlier reviews describing psychiatric nursing interventions in general or in connection with a specific patient group. Further clinical trials are needed to describe the role of nurses in the care of patients diagnosed with depression and in the use of web-based interventions. Additionally, it would be important to study what supports, and on the other hand hinders, the role of nurses in delivering evidence-based treatments at the clinical level. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses can play a central role in responding to the growing demand for evidence-based practices in adult outpatient psychiatry, by delivering treatments for patients and family members. It is important that both nursing education and clinical practices recognize and support this role. Abstract Introduction According to our knowledge, there are no previous reviews on nurse-delivered interventions in the adult psychiatric outpatient setting. Aim To identify and systematically describe and analyse nurse-delivered interventions based on research literature. Method An integrative review. Results This review included 60 studies, of which 46 were intervention studies, including 40 clinical trials. The most common patient groups were patients diagnosed with schizophrenia and bipolar disorder. The nursing interventions described in the studies resembled a total of 68 interventions from the Nursing Interventions Classification. The treatment delivery methods varied and treatments often lacked a clear theoretical background. Implications for practice The core of nurse-delivered interventions identified in research literature in psychiatric outpatient care is on interventions aiming at improving the functioning of both patients and their family members by building on their own strengths. These findings differ from the interventions identified in a review describing nursing in the inpatient setting. There are high-quality clinical trials describing nurse-delivered treatments for patients diagnosed with schizophrenia and bipolar disorder. These include evidence-based treatments such as psychoeducation. Understanding of how these treatments are transferred in clinical practice is missing. Clinical trials describing nurse-delivered web-based interventions and interventions for patients diagnosed with depression are needed.

Journal of psychiatric and mental health nursing · systematic review · 14 citationsread the source →

Clinical Presentation of Left Atrial Cardiac Myxoma

Introduction Cardiac myxoma is the most frequent “benign” tumor of the heart and presents an important diagnostic challenge (4,43,47). Myxomas may resemble many cardiovascular or systemic diseases, and can arise in any of the cardiac chambers, although 75% occur in the left atrium. Most cases of atrial myxomas are now diagnosed in living patients, allowing successful surgical extirpation (1,3,30,44,53). Before the introduction of angiocardiography in 1951, cardiac myxoma diagnosis was made only at autopsy (22). The first successful surgical removal of an atrial myxoma was performed in 1954 (35,47). In 1959, the first M-mode echocardiogram of a left atrial myxoma was reported (16). Indeed, the introduction of echocardiography has provided an important noninvasive means of diagnosis for cardiac myxomas (55). Thus, the diagnosis of small myxomas (less than 5 cm in size and asymptomatic) is becoming easier. We report here the experience of a French cardiovascular center in the clinical presentation of left atrial myxomas. The large number of patients in this series allowed us to perform an analytic, clinicopathologic study. Patients and Methods We reviewed the 112 cases of left atrial myxoma seen at 1 institution (Hôpital Louis Pradel, Lyons, France) over a 40-year period (1959–1998). In all cases the diagnosis was established before surgical removal. The patients’ medical records were reviewed, and data concerning clinical presentation, diagnostic methods, and postoperative course were collected. Histopathologic slides were reviewed for all cases by the same pathologist (RL). Other locations where cardiac myxoma occurred during that time period were the right atrium (15 cases), left ventricle (2 cases), and right ventricle (1 case). Follow-up information was obtained by contacting either the patients or the attending physicians, and a standardized questionnaire was completed for each case. Statistical analysis A chi-square test, or the Fisher exact test when required, was performed for all qualitative variables, and odds ratios (OR) with 95% confidence intervals (95% CI) were computed. For ordinal variables a Wilcoxon rank sum test was used. Data analysis was performed using SAS (Statistical Analysis System, SAS Institute Inc., Cary, NC). The variables studied in the statistical analysis were 1) sex and age, period of diagnosis (before or after echocardiography was available), delay to diagnosis (delay between the first symptoms and diagnosis), possible systematic (serendipitous) discovery; 2) size of the tumor (> or < 5 cm), tumor surface appearance (smooth or villous); 3) the main symptoms: cardiac (cardiac failure, malaise or syncope, chest pain or palpitations), embolic (cerebral, coronary, or peripheral artery), systemic (fever, weight loss, or pseudo-connective tissue disease signs), or neurologic (stroke, vertigo, epilepsy, coma, or other signs); 4) cardiac auscultation modifications (pseudo-mitral signs, “tumor plop”, nonspecific other signs); 5) possible chest X-ray abnormalities (left cardiac failure signs, cardiomegaly, pleural effusion, left atrium enlargement, visible myxoma when calcified), electrocardiogram (ECG) alterations (arrhythmias or conduction disturbances, ST-segment and T-wave shifts, left atrial hypertrophy, and nonspecific signs), or serologic test abnormalities (elevated erythrocyte sedimentation rate [ESR], anemia). Results Patient characteristics The study group included 72 women, (64% of the whole sample; median age, 53 yr; range, 23–84 yr) and 40 men (36% of the sample; median age, 58 yr, range, 5–77 yr). Forty-six patients (41% of the sample, 31 women, 15 men) were less than 50 years old, 47 (42%, 31 women, 16 men) were between 50 and 70 years, and 19 (17%, 10 women, 9 men) were older than 70. Age distribution was homogenous in men, but most female patients were between 40 and 60 years old (Figure 1).Fig. 1: Age distribution of 112 patients with left atrial myxoma. The clinical and laboratory features of left atrial myxoma in our series are presented in Table 1. The different frequencies of clinical and laboratory signs according to sex and age are detailed in Table 2. Male patients were more at risk than females for embolic complications and for neurologic symptoms; females were more at risk than males to develop systemic symptoms such as fever; younger patients (age <50 yr) had more neurologic symptoms and cardiac auscultation abnormalities than older patients (age >50 yr).TABLE 1: Clinical and laboratory features of left atrial myxoma (112 cases)TABLE 2: Frequencies of clinical and laboratory signs by sex and age*We divided the patients into 2 groups according to the pre-and post-echocardiography periods: 1) between 1959 and 1977, when the only diagnostic methods were angiocardiography and cardiac cathe-terization, only 14 patients (12.5%) underwent surgery; 2) since 1977, with 2-dimensional echocardiography use (transthoracic, then transesophageal), about 5 patients per year have undergone surgery for left atrial myxoma (98 patients, 87.5%). The sex ratio and age ranges are similar in these 2 patient groups, but other differences can be identified (Table 3). Before 1977, most patients were diagnosed on the basis of serologic or blood test abnormalities (particularly elevated ESR) and radiologic abnormalities; chest X-ray evidence of cardiac failure or left atrium enlargement was particularly prevalent in patients diagnosed before 1977 compared with those diagnosed after 1977 (p = 0.006 and p = 0.02, respectively).TABLE 3: Symptoms by year of diagnosis*Delay before surgery In our series, the time interval between symptoms onset and diagnosis (surgical removal) varied from 0 to 126 months (median, 4 mo). The median delay before surgery was 5.5 months before 1977, and 3 months after 1977; the difference is not significant. The median delay to diagnosis increased significantly when cardiac symptoms were present; there was no significant difference for the other symptoms (Table 4).TABLE 4: Delay to diagnosis by year and by principal clinical symptoms*Initial symptoms ( Figure 2) For 11 patients, the left atrial myxoma diagnosis was a mere chance, or serendipitous, discovery (“systematic findings” in Figure 2). Among these patients, in 9 cases echocardiography (8 cases) or computed tomography (CT) (1 case) was performed for another indication and allowed a diagnosis of myxoma. For 2 patients, echocardiography had been systematically performed during follow-up for surgery on a right atrial myxoma. Fig. 2: Initial symptoms of left atrial myxoma (112 cases).The most common initial symptoms of left atrial myxoma in our series were related to mitral valve obstruction: dizziness and occasionally syncope, palpitations, dyspnea, cough, pulmonary edema, or congestive heart failure were observed in 58 patients. Eight patients showed atypical paroxysmal clinical manifestations: chest pain, hemoptysis, limb claudication, thoracic noise, shortness of breath, or syncope when reclining. Embolic manifestations suggested myxoma in 18 patients. Constitutional or general systemic signs appeared as initial manifestations for 17 patients: myalgia, muscle weakness, arthralgia, fever, weight loss, fatigue, and Raynaud syndrome. Clinical features at diagnosis All patients presented with at least 1 or more symptoms of the classic triad: 1) obstructive cardiac signs; 2) embolic signs; and 3) constitutional or systemic manifestations (See Table 1). 1) Intracardiac obstruction signs occurred in 75 patients. Pulmonary edema or progressive congestive cardiac failure (dyspnea, orthopnea) were the most common symptoms (n = 48). Malaise or syncope occurred in 16 cases. Two patients experienced cardiac arrest before surgery and fully recovered after resuscitation. Other nonspecific cardiac symptoms were present in 34 patients: cough, thoracic pain, palpi-tations, myocardial infarction due to coronary embolism. Malaise, palpitations, or thoracic pain could vary with body postural changes. 2) Signs of embolism were present in 33 patients, either with 1 (n = 25) or several (n = 8) locations. Embolic locations were the central nervous system (n = 24), in 1 case in the retinal artery, the upper and lower extremities (n = 15), and the coronary arteries (n = 4). 3) Thirty-eight patients presented with systemic or constitutional symptoms. These symptoms were obviously nonspecific, including fever (n = 22), weight loss or fatigue (n = 20), and immunologic diseases mimicking symptoms such as myalgia, muscle weakness, arthralgia, or Raynaud syndrome (n = 6). 4) Other clinical presentations 4.1) Twenty-nine patients had neurologic symptoms, particularly transient or permanent motor or sensory neurologic deficiencies (n = 23), when cerebral emboli were present (stroke). Three of these patients developed multiple cerebral aneurysms, induced by cerebral emboli. Three patients had epileptic fits, or multilocular sclerosis mimicking symptoms. Six patients also suffered from other neurologic manifestations, such as vertigo or coma. One patient with streptococcal meningitis underwent surgery for a supposed antibiotic-resistant endocarditis suggested by echocardiographic findings, but surgery uncovered an incidental noninfected myxoma. 4.2) One patient had fever and positive blood cultures for Streptococcus viridans. 4.3) Three patients were investigated for liver abnormalities connected in fact with right cardiac failure. 4.4) For 3 patients, the main symptoms were abdominal pain or hemoptysis. Physical examination (cardiac auscultation) On cardiac auscultation 72 patients (64%) had abnormal findings, 18 (16%) of them with postural changes or with time examination modifications. These murmurs looked like significant mitral stenosis findings: apical diastolic or presystolic murmur (n = 60, 53%). A tumor plop was heard in 17 patients (15%), all before 1989. Other auscultatory features were changes in preexisting murmurs, gallops, or modification of the first (split) or second heart sound (n = 12, 11%). A significant was observed between cardiac auscultation abnormalities and 1) systemic symptoms (fever, weight loss or and 2) cardiac symptoms and signs (cardiac failure, (Table no between auscultatory signs and embolic or neurologic symptoms was between clinical The most frequent laboratory was in patients Table 1). in men, in was observed in 15 patients. blood or was present in patients. The between these serologic abnormalities and systemic manifestations was significant Table there was no significant between serologic signs and or neurologic symptoms. abnormalities of the patients (n = had abnormal Table 1). atrial was the most frequent (n = or or conduction were Other were ST-segment abnormalities (n = or nonspecific abnormalities (n = hypertrophy, The of abnormalities with systemic manifestations and cardiac signs was significant Table was no significant with embolic or neurologic symptoms. were abnormal in patients Table 1). included pulmonary or congestive heart failure signs (n = and nonspecific (n = atrial enlargement (n = that made the tumor visible (n = and pleural were (n = The of radiologic abnormalities with systemic and cardiac manifestations was significant Table X-ray abnormalities were significantly less frequent in patients with embolic or neurologic methods Before 1977, all cases were diagnosed by angiocardiography with left heart (n = 1977, echocardiography was the diagnostic (n = only M-mode echocardiography was (Figure 3). 2-dimensional and particularly echocardiography the methods in many cases. For 2 patients the diagnosis was established by or 3: A myxoma is seen in the left The diagnosis of myxoma was obtained after surgical tumor for all cases. On the tumor from 1 cm to 15 The size was for was than 5 cm in and in cases had been during The weight of the from 15 to In our series of the myxomas were with a cm), and were the left atrial myxomas in our series, the and from the left atrial with only a other left and small mitral valve The myxoma surface was studied in was or in of these (n = and (Figure 4) in the other cases (n = The less common or (Figure 5) myxomas had a surface that of multiple or and with a to (Figure 4: left atrial myxoma after left atrial were on the of myxoma in an of an The myxoma had a or an and a were the The surface of the tumor was by a of was observed in of the cases. We with a myxoma from with a and or different of 1) (Figure with or by then by 2) (Figure with many or in the of the cases were left atrial of them with and with were myxomas with All were observed in patients with myxoma and atrial myxoma with with myxoma in atrial myxoma with or myxoma in significant could be between myxoma size or 5 and diagnosis or or of or serologic symptoms or signs (Table 6). a myxoma size cm was significantly with cardiac symptoms, auscultatory signs, and and chest X-ray of myxomas appeared to be more and the delay to diagnosis was for small than for large Table of clinical features to myxoma size was significantly with neurologic symptoms, embolic and cardiac auscultation there was no significant between and or X-ray signs or symptoms; discovery; or delay in diagnosis (Table of clinical features to myxoma surface course All patients had patients during the 1 patient in during a second surgical for a of myxoma years after the first surgical a on in with cardiac and on the second postoperative from a in from mitral by a mitral and a in from meningitis with the the incidental tumor had been 1 patient a mitral valve endocarditis was with the myxoma. The most frequent postoperative was transient or atrial in patients A permanent cardiac for was for only 2 patients. Follow-up the postoperative patients were to patients to and not our Among the other patients, 4 and were during the follow-up Patients presented with peripheral fully The follow-up for patients with multiple cerebral is 14 years a In the present series, were for a median of 3 years 1 yr). Six patients had a of myxoma. Three patients with myxoma in the left and 17 years Three other patients had One of them suffered 2 in the left 16 and months The other 2 patients with had an initial myxoma in the right for 1 of them the was in the left atrium 3 years and for the other the were multiple in the left atrium and years and then in the right atrium years We report here the series of patients with left atrial myxoma diagnosed in a to our The patients presented over a 40-year ratio is with other in this ratio from to Myxomas can occur in all but are most frequent between the and of occur in although there is no for this female due in to In our series, younger age is significantly with neurologic signs or cardiac auscultation and is with neurologic or embolic symptoms in men and systemic symptoms in Clinical features The clinical features of these are by and there are no signs and symptoms that the of a myxoma In a of there are no symptoms at all in our there is no significant between the size of the tumor or 5 and the of discovery or atrial myxomas when the mitral or systemic 1) symptoms occur in of patients in our cases as mitral valve in mitral atrial and of fever are only of patients had in our study. Cardiac obstruction can be by progressive congestive cardiac failure on or or by syncope, or to mitral valve obstruction by the myxoma or coronary arteries The of obstruction may vary with body and these postural changes are particularly of myxoma (35,47). Cardiac failure the most frequent in our In our the of cardiac signs increased the diagnosis to that clinical symptoms are by another more common disease due to 2) emboli are the second of the classic in of myxoma patients in our study. than of emboli to the central nervous system in our but any may be to a of symptoms and cases emboli in the upper and lower coronary and more emboli may to aneurysms, as of cardiac myxomas as in 3 patients in our was 12, yr, We that the of an or surface is significantly with cerebral and peripheral 3) Constitutional signs are the of the classic these symptoms are may occur in to of cases The is lower in our series studied a at a cardiovascular These signs and symptoms myalgia, muscle weakness, arthralgia, fever, weight loss, and are obviously nonspecific and may occur in a of or or immunologic diseases tissue manifestations have also been reported in myxoma patients Cardiac auscultation Cardiac auscultatory may vary between and may on body presystolic or diastolic murmurs, significant mitral may be heard in more than of the patients in our The auscultatory of myxoma is “tumor is a heart sound of heard after the second heart sound may be with a heart sound or a mitral The tumor plop is in only of patients in our We established a significant between cardiac auscultation abnormalities and cardiac or systemic symptoms. and are abnormal in only of the patients those with systemic symptoms significant was in our The main but nonspecific laboratory abnormalities are and elevated or is or may occur by on the has also been common are and that the and of a by the tumor may be for systemic and manifestations has been with of in patients with myxoma that to after surgical removal A between the size of the tumor and the of has also been suggested have also been in myxoma tissue myxoma tissue in cases by and are nonspecific but observed in our atrial in of patients, the alterations by the is (less than of cases) in to the in mitral valve We observed a significant between signs and the of cardiac or systemic symptoms. also nonspecific features in the patients and are not for when the tumor is in our a left atrium enlargement and signs of pulmonary may be In our series, chest X-ray abnormalities were significantly with cardiac or systemic symptoms, but there were radiologic signs when the myxoma was by embolic or neurologic In cardiac signs or symptoms are more prevalent with large and may that embolic becoming are diagnosed before the the size 5 that to cardiac and radiologic data a positive between small tumor size and embolic Table 6). methods is the and diagnostic of is and not any risk of tumor and and cardiac examination may be by the echocardiography is less with an to but echocardiography the for surgery is only on echocardiographic evidence of the in our series angiocardiography has not been since coronary in patients over 40 years old is in to coronary disease Other diagnostic methods and The of and over echocardiography is that of and thoracic are also more in tumor and tumor and size data that most left atrial myxomas arise from the atrial or the on the of and on the appearance is or with a or or is and the surface is either or and in our myxomas with constitutional symptoms, or In the such as and surface are seen in older that In our series, there was no significant between and The size and weight of myxomas but in our the of symptoms was in patients with on could or myxomas and or myxomas according to the of the that all occurred in patients with and myxomas. the of cardiac myxomas have been The of most is that myxomas are of is no that myxomas are myxomas may have a of that at first may be the of multiple surface or is not with or any of presentation, and is important not to an on the basis of these atypical are cardiac not be with myxomas The to the tumor are to be and analysis has that myxoma as tumor = and are and may be for and cases with is as is the showed that was by is also a for the that myxomas arise from the to A study that myxomas with a between tumor size and the of this a in Myxomas may to the but these not have any The myxoma tissue emboli may may the and may or may but any cerebral tissue years the may to Three patients in our series had embolic that into the with of multiple aneurysms, any or during and follow-up The of for myxomas is surgical removal the diagnosis is of the tumor is Embolic complications or are in patients: of patients in the time of our series, not due to cardiac but 2 patients had cardiac arrest in the before surgery with successful resuscitation. surgery is a as most are can be The may according to In our series, was 3 patients during the postoperative period before and another patient in of meningitis not to myxoma. The most frequent postoperative was transient or with an of Cardiac myxomas occur but or cases have been The reported rate ranges from to in the in our are reported from as as a months to as as years after of the myxoma in our The of is not but risk or of tumor of the a of tumor in the In most cases of of the to be the of Patients with abnormalities are at risk of and from 2 or more of the cardiac and myxomas or of the with and are as or The risk of for and myxomas is about and is only for In our series, 3 cases the cardiac myxoma the time of myxoma patients are younger than myxoma patients. myxomas of the 2 patient groups are not A to has been identified The is In the the rate is and after of myxomas ranges from 0 to in our may surgical removal in our A patients may permanent cardiac for conduction 2 patients in our In of the of a tumor that with mitral valve to in heart failure, the mitral valve is In our only 1 patient mitral valve for endocarditis with left atrial myxoma. the myxoma patients to be and cases. echocardiogram is over the period at diagnosis The mitral valve other and heart more common than and occur in patients with myocardial infarction or systemic symptoms are present (fever, weight loss, the diagnosis heart and tissue disease or The of embolic and constitutional symptoms is due more to but may also myxoma. The of or syndrome to the 2 diseases, as these are in myxoma. myxomas are occasionally the clinical of myxoma and endocarditis more of cardiac myxomas reported 40 cases with a presentation similar to is no clinical between and noninfected myxoma cardiac symptoms and the rate of systemic or cerebral constitutional symptoms significantly in patients with myxoma (fever, elevated and men are more than series of 112 cases of left atrial myxoma clinical that this tumor may a of clinical symptoms not only such as cardiac but also or neurologic is made only on clinical there are no signs or symptoms. but or cases have been that and of the by the tumor may be for or including the is the of for diagnosis and follow-up of this myxomas are be in the diagnosis of mitral valve disease and congestive heart failure, in patients with is also for any patient with embolic embolic in in the of signs or symptoms of endocarditis or to a of myxoma as the embolic The obtained by be are to the clinical features of in in myxoma or be studied for embolic myxomas with of could be performed to for the ratio and age We a series of 112 cases of left atrial myxoma diagnosed in a French and 40 age range, yr) over 40 years, from 1959 to Symptoms of mitral valve the first of the classic of myxoma presentation, were present in 75 patients with cardiac failure or Symptoms of the second frequent presentation in the classic were observed in 33 cases with 1 or several cerebral emboli with are at risk than females of embolic The of the classic of constitutional symptoms with fever, weight loss, or symptoms tissue due to and patients have more neurologic symptoms, and female patients have more systemic symptoms. patients (64%) had cardiac auscultation valve disease and more the tumor plop The most frequent was left atrial were The number of myxoma patients diagnosed after 1977 the introduction of echocardiography as a noninvasive diagnostic there was no significant in the time from onset of symptoms to between patients seen in the before and after The tumor from 1 to 15 cm with a weight of between 15 and The myxoma surface was or in of the and in the other cases. Myxomas in patients with embolism have a those in patients with cardiac symptoms, auscultation signs, tumor and electrocardiogram or radiologic signs of left atrium and are significantly the The is and only 4 occurred our 112 cases over a median follow-up of 3 The rate is but follow-up and echocardiography are for patients. The surgical were performed during the 40-year period by We are to for the

Medicine · review · 878 citationsread the source →

The genetics of eating disorders.

Over the past decade, considerable advances have been made in understanding genetic influences on eating pathology. Eating disorders aggregate in families, and twin studies reveal that additive genetic factors account for approximately 40% to 60% of liability to anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Molecular genetics studies have been undertaken to identify alterations in deoxyribonucleic acid sequence and/or gene expression that may be involved in the pathogenesis of disordered eating behaviors, symptoms, and related disorders and to uncover potential genetic variants that may contribute to variability of treatment response. This article provides an in-depth review of the scientific literature on the genetics of AN, BN, and BED including extant studies, emerging hypotheses, future directions, and clinical implications.

Annual review of clinical psychology · review · 115 citationsread the source →

Health-related quality of life among adults who experienced maltreatment during childhood.

Objectives: We sought to assess the difference in a preference-based measure of health among adults reporting maltreatment as a child versus those reporting no maltreatment. Methods: Using data from a study of adults who reported adverse childhood experiences and current health status, we matched adults who reported childhood maltreatment (n = 2812) to those who reported no childhood maltreatment (n = 3356). Propensity score methods were used to compare the 2 groups. Health-related quality-of-life data (or "utilities") were imputed from the Medical Outcomes Study 36-Item Short Form Health Survey using the Short Form-6D preference-based scoring algorithm. Results: The combined strata-level effects of maltreatment on Short Form-6D utility was a reduction of 0.028 per year (95% confidence interval=0.022, 0.034; P<.001). All utility losses for the childhood-maltreatment versus no-childhood-maltreatment groups by age group were significantly different: 18-39 years, 0.042; 40-49 years, 0.038; 50-59 years, 0.023; 60-69 years, 0.016; 70 or more years, 0.025. Conclusions: Persons who experienced childhood maltreatment had significant and sustained losses in health-related quality of life in adulthood relative to persons who did not experience maltreatment. These data are useful for assessing the cost-effectiveness of interventions designed to prevent child maltreatment in terms of cost per quality-adjusted life years saved.

American journal of public health · cohort or longitudinal · 186 citationsread the source →

The efficacy and safety of transcutaneous auricular vagus nerve stimulation in patients with mild cognitive impairment: A double blinded randomized clinical trial.

Background: There are 9.9 million new cases of dementia in the world every year. Short-term conversion rate from mild cognitive impairment (MCI) to dementia is between 20% and 40%, but long-term in 5-10 years ranges from 60% to 100%. It is particularly important to prevent or prolong the development of MCI into dementia. Both auriculotherapy and vagus nerve stimulation are effective on improving cognitive functions. However, there is no double blinded randomized clinical trial to support the effectiveness of transcutaneous electrical stimulation of auricular acupoints in patients with MCI. Methods: This randomized controlled trial involved patients with MCI, aged from 55 to 75 years old. Patients were randomly allocated to transcutaneous auricular vagus nerve stimulation (taVNS) group or sham taVNS group. In the taVNS group, two auricular acupoints were stimulated, including heart (concha, CO15) and kidney (CO10), which are in the distribution of vagus nerve. While in the sham taVNS group, two other auricular acupoints were stimulated, including elbow (scaphoid fossa, SF3) and shoulder (SF4,5), which are out of the distribution of vagus nerve. The primary outcome was the Montreal cognitive assessment-basic, MOCA-B. The secondary outcomes included auditory verbal learning test-HuaShan version (AVLT-H), shape trails test A&B (STT-A&B), animal fluence test (AFT), Boston naming test (BNT), Pittsburgh sleep quality index (PSQI), rapid eye movement sleep behavior disorder screening questionnaire (RBDSQ), Epworth sleepiness scale (ESS) and functional activities questionnaire (FAQ). These outcome measures were taken at baseline, 24 weeks later. Results: After 24 weeks of intervention, the data of 52 patients were intended for analysis. After intervention, there was significant difference in the overall scores of MoCA-B between taVNS group and sham taVNS group (p = 0.033 < 0.05). In taVNS group, compared with before intervention, the overall scores of MOCA-B increased significantly after intervention (p < 0.001). As for N5 and N7, the two sub-indicators of AVLT-H, in taVNS group, compared with before intervention, both N5 and N7 increased significantly after intervention (both ps < 0.001). As for STTB, in taVNS group, compared with before intervention, STTB was significantly reduced after intervention (p = 0.016). For BNT, in taVNS group, compared with before intervention, BNT increased significantly after intervention (p < 0.001). In taVNS group, compared with before intervention, PSQI, RBDSQ, ESS and FAQ decreased significantly after intervention (p = 0.002, 0.025, <0.001, 0.006 respectively). 1 patient with a history of tympanic membrane perforation in taVNS group was reported with mild adverse reactions which disappeared a week after termination of taVNS. The intervention of taVNS is effective on increasing the overall scores of MoCA-B, N5 and N7. Conclusion: The clinical trial demonstrated that taVNS can improve cognitive performance in patients with MCI. This inexpensive, effective and innovative method can be recommended as a therapy for more patients with MCI in the prevention or prolonging of its development into dementia, but it is still required to be further investigated. Trial registration: http://www.chictr.org.cn. (ID: ChiCTR2000038868).

Brain stimulation · randomised controlled trial · 109 citationsread the source →

Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence.

We review the general amount and patterns of exposure to solar ultraviolet (UV) radiation that children and teenagers experience and the spectrum of UV-related skin damage that can occur as a result. Data about the amount of solar UV received by children and teenagers are relatively few but suggest that around 40-50% of total UV to age 60 occurs before age 20. Among white children, those with the palest complexions suffer the most damage. Comparisons of prevalence and incidence of outcomes in children and teenagers sharing common ancestry, but living at different latitudes, show that prevalence rates of photoaging and melanocytic naevi are higher in Australian compared with British children, and similarly for melanoma. Genetic risk for the majority of the melanomas in teens is a function of genes controlling naevus propensity and pigmentation in the skin. High numbers of naevi and freckles, red hair, blue eyes, inability to tan, as well as a family history are the primary determinants of melanoma among adolescents. Beyond the signs of skin damage seen in children are the latent effects observed later in adulthood. Childhood is believed to be a susceptible window for long-term harmful effects of UV, as evidenced by clear differences in skin cancer risk between child and adult migrants from high to low latitudes. Effective UV radiation protection from childhood is necessary to control both immediate and long-term harmful effects on children's skin.

Progress in biophysics and molecular biology · review · 144 citationsread the source →

Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation

INTRODUCTION In the last few decades, psychoeducation has come up as a useful and effective mode of psychotherapy for persons with mental illness. It has been found to be fruitful in both clinical and community settings. Psychoeducation has its roots in the “Mental Hygiene Movement” of the early 20th century and “Deinstitutionalization Movement” of the 1950s and 1960s. Subsequently, studies on the role of “Expressed Emotions” in schizophrenia provided further impetus to the growth of psychoeducation. Psychoeducation combines the elements of cognitive-behavior therapy, group therapy, and education. The basic aim is to provide the patient and families knowledge about various facets of the illness and its treatment so that they can work together with mental health professionals for a better overall outcome. WHAT IS PSYCHOEDUCATION? Anderson et al. used the term for the first time in 1980 for the family treatment of patients with schizophrenia. They mentioned four essential elements of psychoeducation [Table 1]. They suggested that the relatives of the patients were also to be included in the sessions. Table 1: Essential elements of psychoeducationBarker, in the Social Work Dictionary, defined psychoeducation as the “process of teaching clients with mental illness and their family members about the nature of the illness, including its etiology, progression, consequences, prognosis, treatment, and alternatives.” GOALS OF PSYCHOEDUCATION To ensure basic knowledge and competence of patients and their relatives about the illness To provide insight into the illness To promote relapse prevention Engaging in crisis management and suicide prevention. BASIC COMPONENTS OF PSYCHOEDUCATION Psychoeducation usually includes certain basic components of information, which are to be imparted to patients and their family members regarding a particular mental disorder. The modules may be modified to suit the needs of the patients, family members, clinicians, or vary according to a particular disorder. Thus, the number and timing of the sessions may vary along with alterations in the overall content. However, it is desirable to cover the essential components, as shown in Table 2.Table 2: Essential components of psychoeducation sessionsVARIOUS TYPES OF PSYCHOEDUCATION According to the target population, psychoeducation can be individual, family, group, or community based. According to the predominant focus of psychoeducation, it can be compliance/adherence focused, illness focused, treatment focused, and rehabilitation focused. Active psychoeducation involves the active involvement of the therapist with the patient/family during the process, leading to interaction and clarification. In passive psychoeducation, materials are provided to patients/family members in the form of pamphlets, audio/video material that they are supposed to read and assimilate on their own. In a busy clinic with limited available time, a clinician may take resort to passive psychoeducation by distributing leaflets or educative materials about the illness written in a simple language, which the patient and guardians can easily understand and assimilate. GROUP PSYCHOEDUCATION This usually comprises patients having similar kinds of illness. Thus, groups may consist of patients with bipolar disorder, schizophrenia, substance abuse, etc. It is not desirable to form a group with members having different kinds of illness. Groups usually have 4–12 members, with the optimum number being 8. The number of sessions usually varies from 5 to 24, with the optimum number of sessions being determined by research and practice. Often, the availability of resources in terms of available time and workforce may lead to modifications in the number of sessions, though the broad areas to be covered for each disorder remain the same. The sessions usually last 40–60 min and are mostly held at weekly intervals. The optimal time and frequency of sessions help in the better assimilation of the information, which has been shared and discussed. It may be useful to hand over printed material after each session, which highlights in simple language the salient features of the topics discussed in that particular session. FAMILY PSYCHOEDUCATION Family psychoeducation can be carried in the setting of single families or in a group with more than one family having similar kinds of illness in their patients (multifamily groups). Family-based psychoeducation models can be quite useful in the Indian context as most of the Indian patients stay with their families unlike their Western counterparts. Family-based psychoeducation models have been found to be effective in schizophrenia and bipolar disorder. Family psychoeducation becomes especially important in dealing with severe mental illnesses when in symptomatic phases, patients lack insight and may be reluctant to take medicines. It is also helpful to make them aware of early signs of relapse so that they can identify and seek help accordingly. The number and frequency of sessions are variable, though the average number is between 6 and 12 sessions held at weekly intervals. Follow-up sessions may be conducted at monthly intervals following the discharge of the patient. MODELS OF PSYCHOEDUCATION Information model The focus is on providing families knowledge about psychiatric illness and their management. Skill training model The skill training model focusses on developing certain skills so that the family members can manage the illness more effectively. Supportive model The supportive model mainly involves taking help of support groups for engaging the family members of the patients in sharing their feelings. Comprehensive model The comprehensive model uses a combination of the previous three models. HOW EFFECTIVE IS PSYCHOEDUCATION Zhao et al. in a systematic review of 20 studies concluded that psychoeducation appears to reduce relapse and promote adherence in severe mental illnesses such as schizophrenia. Most studies have evaluated family psychoeducation for schizophrenia or schizoaffective disorder only. However, the results of several controlled studies support the benefits of psychoeducational family interventions for other psychiatric disorders, including bipolar disorder, major depression, obsessive-compulsive disorder, substance abuse, and borderline personality disorder. PSYCHOEDUCATION IN VARIOUS PSYCHIATRIC DISORDERS Psychoeducation for schizophrenia Initial discussions should start by encouraging the patients to come out with their understanding of the disorder. Once this area has been clarified, a common denominator between layman's knowledge of illness and scientific textbook knowledge of illness is gradually developed. The basic message should be that schizophrenia is caused by biological factors in combination with psychological stress. Hence, both medications and psychosocial interventions are essential for management. Apart from the essential components mentioned before, other information specific to the illness which needs to be shared includes Meaning of the term “Schizophrenia” Positive and negative symptoms Neurobiological origin of symptoms Stress-vulnerability-coping model Various medicines and their side effects Psychosocial measures Psychotherapeutic interventions and suicide prevention Early warning signs and relapse prevention Long-term course and outcome, including remission and recovery. PSYCHOEDUCATION FOR BIPOLAR DISORDER The working group on psychoeducation in bipolar disorder defines psychoeducation as information-based behavioral training aimed at adjusting lifestyle to cope with bipolar disorder. The components include increasing the awareness of illness, treatment adherence, early detection of relapse, and avoidance of potential triggers such as illegal drugs and sleep deprivation. Illness awareness Most of the patients of bipolar disorder have poor insight into their condition. If the patient does not gain insight into his condition, he would be unlikely to take interest in the subsequent sessions of psychoeducation. Emphasizing the medical model of the illness helps in reducing stigma related to the illness. It is also taught that the illness has a biological origin, though triggering factors may be either biological or psychological. The issues addressed cover the following areas: Introduction What is Bipolar Disorder? Etiologies and triggering factors Symptoms of mania and hypomania Symptoms of depression and mixed episode Course and outcome of bipolar disorder. Treatment adherence Almost half of the patients with bipolar disorder discontinue treatment abruptly and without supervision sometime in their lives. Almost all patients of bipolar disorder think of discontinuing medications at some point of time during the course of illness. This occurs quite commonly during the euthymic phase or in those with comorbid substance abuse or personality disorder. The areas that need to be covered while targeting better treatment adherence are as follows: Mood stabilizers Antimanic agents Antidepressants Serum levels of lithium, carbamazepine, and valproate Pregnancy and genetic counseling Psychopharmacology versus alternative therapies Risks associated with treatment withdrawal. A detailed discussion about the side effects of the commonly used medications and the ways of handling them is essential for getting rid of several myths among the patients in relation to medications. Fears of becoming “dependent for life” on these medications or “losing sharpness of mind” are some of the well-publicized misconceptions regarding psychotropics which force patients to discontinue medicines abruptly. Such myths must be gradually dispelled by careful discussion. Avoiding substance misuse More than half of bipolar disorder patients have comorbid substance abuse. Alcohol is the most frequently misused drug among bipolar patients. This is associated with more depressive episodes, greater problems with adherence, and poor recovery. Sometimes, substance use can trigger a full-blown affective episode. Psychoeducation must involve knowledge about alcohol and other drugs and their harmful effects on patients with bipolar disorder. DETECTING EARLY WARNING SIGNS Detecting early warning signs is a very important step for preventing a full-blown episode. It is very important to emphasize that a hypomanic episode needs to be identified and acted upon very quickly as it may quickly escalate to a manic state. It also needs to be addressed that many patients enjoy the initial mood elevation of the hypomanic episode and hence have a tendency not to report the symptoms to family members or psychiatrists. It is also important to give the patient and family members an emergency plan of what is to be done in case of a relapse. Regularity of lifestyle Regular habits, including proper sleep habits and structuring of activities, are emphasized. The necessity of 7–9 h of night-time sleep is emphasized with avoidance of daytime naps is taught. The role of sleep deprivation in triggering manic episodes is also highlighted. The patients are also taught the necessity of regular physical exercise. Stress management techniques are also taught followed by simple problem-solving skills which may be of use in a day-to-day life. PSYCHOEDUCATION FOR ANXIETY AND DEPRESSIVE DISORDERS Psychoeducation has become an important step in the management of anxiety and depressive disorders. After the diagnosis of anxiety and depressive disorder and performing necessary assessments, the mental health professionals should provide detailed information to the patient regarding the symptoms, causes, various treatment options, side effects of medications, need for adherence, and overall course and outcome of the disorder. Apart from medications, the role of nonpharmacological measures such as activity scheduling and regular physical exercise is emphasized. Passive psychoeducation is very popular in patients with anxiety disorders. This involves passing on to the patients’ various resources such as books, pamphlets, or videos which explain clearly various aspects of anxiety disorders. Unlike active psychoeducation, here the therapist does not interact actively with the patient while imparting education about the illness. PSYCHOEDUCATION FOR SUBSTANCE USE DISORDER Group psychoeducation is one of the cornerstones of psychosocial management of patients with substance use disorder. Such groups educate patients about substance misuse and its consequences. Such groups usually deal with individuals in precontemplation and contemplation phase of change and help in increasing their motivation to abstain. Typical group psychoeducation for substance abuse must highlight certain points which are as follows:. Medical complications Detailed discussion of physical and psychological complications is carried out. Many times, patients have wrong conceptions about physical illness, for example, they think that they are alright as long as they do not have obvious physical symptoms. Such misconceptions are cleared. Family issues Various aspects of family problems in patients with alcohol dependence are discussed. This includes family conflicts and the role of family in maintaining substance-related behavior. How the family can help in promoting relapse prevention is also discussed. Social and professional aspects This includes the role of peer group in initiating and maintaining substance dependence. The role of friends in promoting relapse prevention and avoiding critical comments is also discussed. Treatment process and recovery The different phases of treatment from detoxification to relapse prevention are discussed. The role of various drugs and their side effects is discussed. Craving and relapse In this session, the role of craving in causing relapse is discussed. This also includes the role of various triggering factors and how to avoid them. The methods of controlling craving are also discussed. Utilizing free time The importance of finding alternate sources of pleasure is discussed along with the need to “decondition” the concept of substance with “good times” and “enjoyment.” Adaptation to a new life The patient is taught to adopt and gradually accept the new role of a “substance-free individual.” PSYCHOEDUCATION FOR PERSONALITY DISORDERS The primary objective of the psychoeducation program is to make the patients aware of personality disorders in general, and the particular personality disorder with which he has been diagnosed. Initially, a baseline idea regarding the patient's knowledge about his own diagnosis is obtained and what according to him would help him. The concepts of personality and personality disorder are discussed. How personality disorders can cause problems to affected individuals is highlighted. The particular personality disorder which affects the individual is discussed in detail. The patient is also encouraged to point out those features that are present in him from a written checklist consisting of various maladaptive personality traits. As psychoeducation progresses, the attempt is gradually made to make the patient aware of his maladaptive traits. Once the patient develops some insight, detailed psychoeducation of the biological and psychological factors, leading to his current maladaptive traits is carried out. However, in cases with severe personality disorders, one has to gradually work through the areas where the patient takes recourse to denial. PSYCHOEDUCATION FOR DUAL DIAGNOSIS Dual diagnosis refers to patients having a psychiatric disorder along with comorbid substance abuse or dependence. About one-third of patients with serious mental illness has a comorbid substance use disorder. The dominant models of care for these groups of patients include parallel and sequential models. In the parallel model, separate specialists treat the comorbid disorders separately. In the sequential model, the primary condition is treated first followed by the comorbid condition. The group psychoeducation model for patients with dual diagnosis relies on an integrated holistic approach where the same team deals with the treatment of both the conditions. The main advantage of the integrated approach is that both the conditions can be given due attention in the same sitting by the same team. The individual or group psychoeducation programs for dual diagnosis patients must highlight the following points: Stages of motivation and how to overcome the barriers to change Various aspects of substance misuse and its effects on mood and behavior How substance abuse adversely affects mental health and negatively alters the course and outcome of mental disorders Techniques of relapse prevention and skills training Ways to cope with emotional problems and symptoms of mental illness Skills training and lifestyle change. CONCLUSION Over the years, psychoeducation has emerged as an effective adjunctive psychotherapeutic tool for patients and their families with various types of psychiatric disorders. Its efficacy in promoting adherence and preventing relapse has been well established by trials in schizophrenia and bipolar disorder. Studies are also being carried out in other psychiatric disorders to firmly establish its efficacy. It remains a simple and cost-effective treatment modality, which goes a long way in empowering the patients and their family members with the knowledge of their illness, which helps them cope better with the condition and manage it more effectively. Although studies on psychoeducation are relatively scarce in India, the overwhelming family support available to most of the psychiatric patients makes this treatment modality an ideal tool for implementation in our settings. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Indian Journal of Psychiatry · 179 citationsread the source →

Lower breathing frequencies in personalized slow-paced breathing enhance relaxation and reduce arousal.

Among all vital functions, breathing is uniquely under both autonomic and volitional control. This dual control enables conscious recognition and regulation of arousal. While breathwork affects arousal and relaxation, research rarely investigates the impact of specific parameters or individual differences. In a randomized crossover trial (N = 42), university students practiced three 5-min, personalized slow-paced breathing protocols at 40%, 60%, and 80% of their spontaneous breathing frequency. Lower frequencies enhanced subjective relaxation and reduced physiological arousal, as indicated by decreased heart rate, increased heart rate variability, and increased peripheral skin temperature. Lower frequencies also induced a greater shift in prefrontal neurophysiological arousal, with decreased relative delta power and increased relative alpha and beta power. In addition, prior experience with relaxation techniques strengthened subjective benefits, whereas higher anxious-depressive symptoms were associated with greater perceived stress after slow-paced breathing. Personalization and parameter-based optimization of breathing protocols may enhance relaxation during practice and strengthen self-regulatory capacity.

iScienceread the source →

Neighborhood Socioeconomic Status and Health Care Costs: A Population-Wide Study in the Netherlands.

Objectives. To identify disparities in several types of insured health care costs in the Netherlands across neighborhoods with different socioeconomic statuses and to assess the room for improvement. Methods. We used 2015 Dutch whole-population registry data to estimate the age- and gender-specific cost structure by neighborhood for total, specialist, pharmaceutical, and mental health care. Classifying neighborhoods by the quintile of their neighborhood socioeconomic status (NSES), we determined differences in observed and expected health care costs for several scenarios of NSES improvement. Results. From low to high NSES, we found a clear downward gradient in health care costs. Total health care costs would drop by 7.3% if each neighborhood's cost structure was equal to that of the most affluent neighborhoods. The potential for cost reduction appeared highest for females, for age groups between 40 and 60 years, and for pharmaceutical care. Conclusions. Low NSES is associated with relatively high health care costs, and represents considerable potential for cost savings in health care. Public Health Implications. Our research suggests that policies aimed at improving the socioeconomic determinants of health locally may be pivotal in containing health care costs.

American journal of public health · 33 citationsread the source →

Non-Linear Relationships of Loneliness with Age in People Living with Schizophrenia and Non-Psychiatric Comparison Participants: Relations non linéaires entre la solitude et l'âge chez les personnes atteintes de schizophrénie et les personnes n'ayant aucun antécédent de maladie psychiatrique.

Objective: Loneliness - distress that arises from discrepancies between perceived and desired relationships - is increasingly prevalent and recognized as a major public health concern due to the association with negative health outcomes. People living with schizophrenia (PLWS) experience higher rates of loneliness than the general population and may be particularly vulnerable to these adverse outcomes. In the general population, loneliness fluctuates throughout the lifespan, but the relationship between loneliness and age in PLWS is not well understood. Method: 271 adults, 141 adults with a diagnosis of schizophrenia or schizoaffective disorder (PLWS)and 130 adults with no history of major psychiatric illness (NCs) aged 27-69 completed clinical interviews and self-report measures assessing loneliness, perceived social support, and mental and physical health. Participants also completed blood draws for biomarkers of inflammation and hyperglycaemia. Locally Weighted Scatterplot Smoothing (LOWESS) regression modelling was used to examine potential non-linear relationships between loneliness and age for both groups and to select the polynomial that best fit the observed relationship. Results: We observed an age by diagnostic group interaction (log estimate = -0.005, SE = 0.003) such that PLWS reported higher loneliness scores compared to NCs of similar age. Patterns of loneliness differed with age between diagnostic groups such that loneliness remained relatively stable and high for PLWS while for NCs loneliness increased from age 40 to age 60. In both groups, loneliness was associated with worse self-reported physical health, depression, and, among PLWS, positive symptoms. Conclusion: Results suggest different patterns of loneliness across adulthood for PLWS and NC, reflecting the different social milestones for NCs during this age period that are not as commonly experienced by PLWS, such as marriage, empty nesting and retirement. Loneliness is linked with poor physical and mental health outcomes among PLWS and may be an important target for improving morbidity and mortality for PLWS.Plain Language Summary TitleLoneliness and Aging in Schizophrenia.

Canadian journal of psychiatry. Revue canadienne de psychiatrie · 1 citationsread the source →

Frequent callers to crisis helplines: who are they and why do they call?

Objective: Frequent callers present a challenge for crisis helplines, which strive to achieve optimal outcomes for all callers within finite resources. This study aimed to describe frequent callers to Lifeline (the largest crisis helpline in Australia) and compare them with non-frequent callers, with a view to furthering knowledge about models of service delivery that might meet the needs of frequent callers. Method: Lifeline provided an anonymous dataset on calls made between December 2011 and May 2013. We assumed calls from the same (encrypted) phone number were made by the same person, and aggregated call level data up to the person level. Individuals who made 0.667 calls per day in any period from 1 week to the full 549 days for which we had data (i.e. 4.7 calls in 7 days, 20 calls in 30 days, 40 calls in 60 days, etc.) were regarded as frequent callers. Results: Our analysis dataset included 411,725 calls made by 98,174 individuals, 2594 (2.6%) of whom met our definition of frequent callers. We identified a number of predictors of being a frequent caller, including being male or transgender, and never having been married. The odds increased with age until 55-64 years, and then declined. Suicidality, self-harm, mental health issues, crime, child protection and domestic violence issues all predicted being a frequent caller. Conclusions: Collectively, frequent callers have a significant impact on crisis lines, and solutions need to be found for responding to them that are in everybody's best interests (i.e. the frequent callers themselves, other callers, telephone crisis supporters who staff crisis lines, and those who manage crisis lines). In striking this balance, the complex and multiple needs of frequent callers must be taken into account.

The Australian and New Zealand journal of psychiatry · 40 citationsread the source →

Anxiety, depression, stress, fear and social support during COVID-19 pandemic among Jordanian healthcare workers.

The emergence of Coronavirus disease 2019 (COVID-19) has affected health-care workers' psychological and mental health. Few studies have been conducted examining the psychological effect of COVID-19 on health-care worker psychological health in Jordan. Therefore, the present study aims to assess the respective levels of fear, anxiety, depression, stress, social support, and the associated factors, experienced by Jordanian health-care workers during the COVID-19 Pandemic. This study adopted a cross-sectional, correlational design to collect data from 365 health-care workers in Amman, Jordan, from August 16th to 23rd, 2020. Along with collecting sociodemographic characteristics, the Fear of COVID-19 Scale, the Depression, Anxiety, Stress Scale, and the Multidimensional Scale of Perceived Social Support electronically administered to participants. The majority of the participants (69.3%) were registered nurses. The mean overall score for the Fear of COVID-19 scale was 23.64 (SD + 6.85) which again exceeded the mid-point for the total score range (21), indicating elevated level fear of the COVID-19 pandemic. Participants had displayed extremely severe depression 40%, extremely severe anxiety 60%, and 35% severely distressed. Scores for depression (21.30 ± 10.86), anxiety (20.37 ± 10.80), stress (23.33 ± 10.87) were also high. Factors determined to be associated with psychological distress were being male, married, aged 40 years and older, and having more clinical experience. Assessment of social support indicated moderate-to-high levels of perceived support for all dimensions (significant other: 5.17 ± 1.28, family: 5.03 ± 1.30, friends: 5.05 ± 1.30). Weak significant correlations were found between social support and the other study variables (r < 0.22), indicating a weak association with fear, depression, anxiety, and stress, respectively. Overall, Jordanian health-care workers sample reported fear, depression, anxiety, and stress. The associated factors were being male, married, aged 40 years and older, and having more clinical experience. Regarding social support, participants primarily relied on support from their families, followed by support from friends.

PloS one · 207 citationsread the source →

Does life get better after middle age? Cultural comparisons of trends and key predictors of life satisfaction across the lifespan.

Background: This study investigated 1) whether there are differences in the trajectory of life satisfaction (LS) across the lifespan between British and Indonesian adults, and 2) which factors are associated with LS overall, and according to culture and age. Methods: 1355 participants aged 18 to 91 were included: 649 British and 706 Indonesian. Participants completed an online questionnaire examining LS, quality of life (which included physical health, psychological wellbeing, social relationships, and environment), depression, anxiety, and religiosity. Data were examined looking at all participants within each culture and then by further separating each cultural group into three age groups (Young adults/YA (18-39), middle-aged/MA (40-59), older adults/OA (60+). Results: The trajectory of LS across the lifespan was U-shaped in British participants but followed an inverted U-shaped pattern in Indonesian participants. Regression analyses on Indonesian and British participants (when all ages were grouped together) revealed that psychological well-being, social relationships, and environment were significantly associated with LS in both cultures, but LS was further impacted by other distinct factors in each group, such as anxiety and religiosity in Indonesian participants and depression in British participants. On analysing the age groups separately some of these predictors of LS were no longer significant, or were only applicable to specific age group(s) and/or one country. Discussion: Psychological well-being, social relationships, and environment are important variables which should be incorporated into LS interventions for both cultures. Addressing the distinct needs of different cultures and age groups may further help when tailoring LS interventions for these different groups.

Archives of gerontology and geriatrics · 1 citationsread the source →

The Relationships Between Self-Compassion, Attachment and Interpersonal Problems in Clinical Patients with Mixed Anxiety and Depression and Emotional Distress.

Self-compassion has been consistently linked to psychological well-being. The ability to be self-compassionate may be shaped by early attachment experiences and associated with interpersonal difficulties. However, evidence has yet to be extended to clinical populations. This study examined the role of self-compassion and its relationship with attachment and interpersonal problems in clinical patients with anxiety and depression. Participants (N = 74; 60% female, mean age 40 years) were recruited from a primary care psychological therapies service in Scotland, UK. Participants completed four self-report questionnaires assessing self-compassion, attachment, interpersonal problems and emotional distress (including depression and anxiety). Low self-compassion, attachment-related avoidance (but not attachment-related anxiety) and high interpersonal problems were all associated with higher levels of emotional distress and anxiety. Low self-compassion and high interpersonal problems were predicted by attachment-related avoidance. Self-compassion mediated the relationship between attachment-related avoidance and emotional distress and anxiety. This was a cross-sectional design and therefore a definitive conclusion cannot be drawn regarding causal relationships between these variables. Self-reported questionnaires were subject to response bias. This study has extended the evidence base regarding the role of self-compassion in patients with clinical levels of depression and anxiety. Notably, our findings indicated that self-compassion may be a particularly important construct, both theoretically and clinically, in understanding psychological distress amongst those with higher levels of attachment avoidance. This study supports the development and practice of psychotherapeutic approaches, such as compassion-focused therapy for which there is a growing evidence base.

Mindfulness · 23 citationsread the source →

Relationship between sense of community belonging and self-rated health across life stages.

Background: Health interventions aimed at facilitating connectedness among seniors have recently gained traction, seeing as social connectedness is increasingly being recognized as an important determinant of health. However, research examining the association between connectedness and health across all age groups is limited, and few studies have focused on community belonging as a tangible aspect of social connectedness. Using a population-based Canadian cohort, this study aims to investigate (1) the associations between community belonging with self-rated general health and self-rated mental health, and (2) how these associations differ across life stages. Methods: Data from six cycles of a national population health survey (Canadian Community Health Survey) from 2003 to 2014 were combined. Multinomial logistic regressions were run for both outcomes on the overall study sample, as well as within three age strata: (1) 18-39, (2) 40-59, and (3) ≥ 60 years old. Results: Weaker community belonging exhibited an association with both poorer general and mental health, though a stronger association was observed with mental health. These associations were observed across all three age strata. In the fully adjusted model, among those reporting a very weak sense of community belonging, the odds of reporting the poorest versus best level of health were 3.21 (95% CI: 3.11, 3.31) times higher for general health, and 4.95 (95% CI: 4.75, 5.16) times higher for mental health, compared to those reporting a very strong sense of community belonging. The largest effects among those reporting very weak community belonging were observed among those aged between 40 and 59 years old. Conclusion: This study contributed to the evidence base supporting life stage differences in the relationship between community belonging and self-perceived health. This is a starting point to identifying how age-graded differences in unmet social needs relate to population health interventions.

SSM - population health · 68 citationsread the source →

Transforming Connections: A Trauma-Informed and Attachment-Based Program to Promote Sensitive Parenting of Trans and Gender Non-conforming Youth

Gender non-conforming and trans youth experience high rates of bullying and victimization, placing them at risk for serious mental health challenges. Parent support is one of the most significant protective factors in this population, and yet few programs are specifically developed to promote parenting sensitivity, understanding, and acceptance. Connect , a trauma-informed and attachment-based group program for caregivers of at-risk adolescents, has been shown to reduce parent stress and depressed mood, increase parents' sense of efficacy and satisfaction, and reduce parent-teen conflict. Teens benefit from increased attachment security and improved mental health and well-being. Treatment effects have been documented to continue for up to 2 years post-treatment. This paper describes the adaptation of the Connect program to create a new program, Transforming Connections , for caregivers of transgender and gender non-conforming youth. Participants in the first three groups were 20 parents of 16 gender non-conforming youth (ages 12–18). Common themes in group discussions related to gender included: coming out, connecting with peers, affirming pronouns/names, medical transition, parental reactions (e.g., confusion, isolation, grief, acceptance), and concerns about safety and mental health. All parents completed the full program, attending on average 9 of 10 sessions. Caregivers reported feeling respected, safe, and welcomed in the program and indicated that learning about attachment enhanced their understanding of their teen and their gender journey as well as themselves as a parent. Additionally, all parents reported applying the ideas discussed in the group frequently (60%) or somewhat frequently (40%). The majority indicated that their relationship with their teen had improved somewhat (65%) or a great deal (20%). Findings provide positive preliminary evidence of the fit and value of Transforming Connections for these families.

Frontiers in Psychology · 20 citationsread the source →

The Prevalence and Burden of Non-AIDS Comorbidities Among Women Living With or at Risk for Human Immunodeficiency Virus Infection in the United States.

Background: The prevalence and burden of age-related non-AIDS comorbidities (NACMs) are poorly characterized among women living with HIV (WLWH). Methods: Virologically suppressed WLWH and HIV-seronegative participants followed in the Women's Interagency HIV Study (WIHS) through at least 2009 (when >80% of WLWH used antiretroviral therapy) were included, with outcomes measured through 31 March 2018. Covariates, NACM number, and prevalence were summarized at most recent WIHS visit. We used linear regression models to determine NACM burden by HIV serostatus and age. Results: Among 3232 women (2309 WLWH, 923 HIV-seronegative) with median observation of 15.3 years, median age and body mass index (BMI) were 50 years and 30 kg/m2, respectively; 65% were black; 70% ever used cigarettes. WLWH had a higher mean NACM number than HIV-seronegative women (3.6 vs 3.0, P < .0001) and higher prevalence of psychiatric illness, dyslipidemia, non-AIDS cancer, kidney, liver, and bone disease (all P < .01). Prevalent hypertension, diabetes, and cardiovascular and lung disease did not differ by HIV serostatus. Estimated NACM burden was higher among WLWH versus HIV-seronegative women in those aged 40-49 (P < .0001) and ≥60 years (P = .0009) (HIV × age interaction, P = .0978). In adjusted analyses, NACM burden was associated with HIV, age, race, income, BMI, alcohol abstinence, cigarette, and crack/cocaine use; in WLWH, additional HIV-specific indices were not associated, aside from recent abacavir use. Conclusions: Overall, NACM burden was high in the cohort, but higher in WLWH and in certain age groups. Non-HIV traditional risk factors were significantly associated with NACM burden in WLWH and should be prioritized in clinical guidelines for screening and intervention to mitigate comorbidity burden in this high-risk population.

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America · 58 citationsread the source →

Mental health consequences of COVID-19: a nationally representative cross-sectional study of pandemic-related stressors and anxiety disorders in the USA.

Objective: To document the prevalence of anxiety disorders in the USA during the COVID-19 pandemic. Design: A cross-sectional analysis. Setting: A nationally representative sample in the USA between 31 March and 13 April 2020. Participants: 1450 English-speaking adult participants in the AmeriSpeak Panel. AmeriSpeak is a probability-based panel designed to be representative of households in the USA. Main outcome measures: Prevalence of probable generalised anxiety disorder (GAD) using the GAD-7 and post-traumatic stress symptoms (PTSS) using the four-item PTSD (post-traumatic stress disorder) checklist. Both outcomes were stratified by demographics and COVID-19-related stressors. Results: The majority of participants were female (51.8%), non-Hispanic white (62.9%) and reported a household saving of $5000 or more. Those between 18 and 29 years old were the largest age group (38.1%) compared with 40-59 years (32.0%) and 60 years or more (29.9%). The prevalence of probable GAD was 10.9% (95% CI 9.1% to 13.2%) and the prevalence of PTSS was 21.7% (95% CI 19.1% to 24.6%). Among participants reporting five or more COVID-19-related stressors, the prevalence of probable GAD was 20.5% (95% CI 16.1% to 25.8%) and the prevalence of PTSS was 35.7% (95% CI 30.2% to 41.6%). Experiencing five or more COVID-19-related stressors was a predictor of both probable GAD (OR=4.5, 95% CI 2.3 to 8.8) and PTSS (OR=3.3, 95% CI 2.1 to 5.1). Conclusions: The prevalence of probable anxiety disorders in the USA, as the COVID-19 pandemic and policies implemented to tackle it unfolded, is higher than estimates reported prior to the pandemic and estimates reported following other mass traumatic events. Exposure to COVID-19-related stressors is associated with higher prevalence of both probable GAD and PTSS, highlighting the role these stressors play in increasing the risk of developing anxiety disorders in the USA. Mitigation and recovery policies should take into account the mental health toll the pandemic had on the USA population.

BMJ open · 46 citationsread the source →

Psychological therapies for treatment-resistant depression in adults.

Background: Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date. Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group. Objectives: To assess the effectiveness of psychotherapies for adults with TRD. Search methods: We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions. Selection criteria: We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone. Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability). Data collection and analysis: We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs). Main results: We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term. With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years. Authors' conclusions: Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone. Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

The Cochrane database of systematic reviews · meta-analysis · 76 citationsread the source →

Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis.

Background: Bipolar disorder affects up to one in 25 individuals and identification of early risk indicators of negative outcomes could facilitate early detection of patients with greatest clinical needs and risk. We aimed to investigate the association between childhood maltreatment and key negative outcomes in patients with bipolar disorder. Methods: For this systematic review and meta-analysis we searched MEDLINE, PsycINFO, and Embase to identify articles published before Jan 1, 2015, examining the association of maltreatment (physical, sexual, or emotional abuse, neglect, or family conflict) before age 18 years with clinical features and course of illness in bipolar disorder. Data were extracted from published reports and any missing information was requested from investigators. We did 12 independent random-effects meta-analyses to quantify the associations between childhood maltreatment and course of illness or clinical features. Findings: We initially identified 527 records and after unsuitable studies were removed, our search yielded 148 publications of which 30 were used in the meta-analysis. Patients with bipolar disorder and history of childhood maltreatment had greater mania severity (six studies, 780 participants; odds ratio [OR] 2·02, 95% CI 1·21-3·39, p=0·008), greater depression severity (eight studies, 1007 participants; 1·57, 1·25-1·99, p=0·0001), greater psychosis severity (seven studies, 1494 participants; 1·49, 1·10-2·04, p=0·011), higher risk of comorbidity with post-traumatic stress disorder (eight studies, 2494 participants; 3·60, 2·45-5·30, p<0·0001), anxiety disorders (seven studies, 5091 participants; 1·90, 1·39-2·61, p<0·0001), substance misuse disorders (11 studies, 5469 participants; 1·84, 1·41-2·39, p<0·0001), alcohol misuse disorder (eight studies, 5040 participants; 1·44, 1·13-1·83, p=0·003), earlier age of bipolar disorder onset (14 studies, 5733 participants; 1·85, 1·43-2·40, p<0·0001), higher risk of rapid cycling (eight studies, 3010 participants; 1·89, 1·45-2·48, p<0·0001), greater number of manic episodes (seven studies, 3909 participants; 1·26, 1·09-1·47, p=0·003), greater number of depressive episodes (eight studies, 4025 participants; 1·38, 1·07-1·79, p=0·013), and higher risk of suicide attempt (13 studies, 3422 participants; 2·25, 1·88-2·70, p<0·0001) compared with those with bipolar disorder without childhood maltreatment. Overall, these associations were not explained by publication bias, undue effects of individual studies, or variation in study quality. Interpretation: Childhood maltreatment predicts unfavourable clinical features and course of illness in patients with bipolar disorder. Funding: None.

The lancet. Psychiatry · meta-analysis · 278 citationsread the source →

Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.

Background: Before the COVID-19 pandemic, coronaviruses caused two noteworthy outbreaks: severe acute respiratory syndrome (SARS), starting in 2002, and Middle East respiratory syndrome (MERS), starting in 2012. We aimed to assess the psychiatric and neuropsychiatric presentations of SARS, MERS, and COVID-19. Methods: In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases (from their inception until March 18, 2020), and medRxiv, bioRxiv, and PsyArXiv (between Jan 1, 2020, and April 10, 2020) were searched by two independent researchers for all English-language studies or preprints reporting data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection (SARS coronavirus, MERS coronavirus, or SARS coronavirus 2). We excluded studies limited to neurological complications without specified neuropsychiatric presentations and those investigating the indirect effects of coronavirus infections on the mental health of people who are not infected, such as those mediated through physical distancing measures such as self-isolation or quarantine. Outcomes were psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment. Both the systematic review and the meta-analysis stratified outcomes across illness stages (acute vs post-illness) for SARS and MERS. We used a random-effects model for the meta-analysis, and the meta-analytical effect size was prevalence for relevant outcomes, I2 statistics, and assessment of study quality. Findings: 1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria. The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and the mean age of participants in studies ranged from 12·2 years (SD 4·1) to 68·0 years (single case report). Studies were from China, Hong Kong, South Korea, Canada, Saudi Arabia, France, Japan, Singapore, the UK, and the USA. Follow-up time for the post-illness studies varied between 60 days and 12 years. The systematic review revealed that during the acute illness, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27·9%; 95% CI 20·5-36·0] of 129 patients), depressed mood (42 [32·6%; 24·7-40·9] of 129), anxiety (46 [35·7%; 27·6-44·2] of 129), impaired memory (44 [34·1%; 26·2-42·5] of 129), and insomnia (54 [41·9%; 22·5-50·5] of 129). Steroid-induced mania and psychosis were reported in 13 (0·7%) of 1744 patients with SARS in the acute stage in one study. In the post-illness stage, depressed mood (35 [10·5%; 95% CI 7·5-14·1] of 332 patients), insomnia (34 [12·1%; 8·6-16·3] of 280), anxiety (21 [12·3%; 7·7-17·7] of 171), irritability (28 [12·8%; 8·7-17·6] of 218), memory impairment (44 [18·9%; 14·1-24·2] of 233), fatigue (61 [19·3%; 15·1-23·9] of 316), and in one study traumatic memories (55 [30·4%; 23·9-37·3] of 181) and sleep disorder (14 [100·0%; 88·0-100·0] of 14) were frequently reported. The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32·2% (95% CI 23·7-42·0; 121 of 402 cases from four studies), that of depression was 14·9% (12·1-18·2; 77 of 517 cases from five studies), and that of anxiety disorders was 14·8% (11·1-19·4; 42 of 284 cases from three studies). 446 (76·9%; 95% CI 68·1-84·6) of 580 patients from six studies had returned to work at a mean follow-up time of 35·3 months (SD 40·1). When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study). At discharge, 15 (33%) of 45 patients with COVID-19 who were assessed had a dysexecutive syndrome in one study. At the time of writing, there were two reports of hypoxic encephalopathy and one report of encephalitis. 68 (94%) of the 72 studies were of either low or medium quality. Interpretation: If infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness. SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage. Clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term. Funding: Wellcome Trust, UK National Institute for Health Research (NIHR), UK Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London.

The lancet. Psychiatry · meta-analysis · 1531 citationsread the source →

Sucrose for analgesia in newborn infants undergoing painful procedures.

Background: Administration of oral sucrose with and without non-nutritive sucking is the most frequently studied non-pharmacological intervention for procedural pain relief in neonates. Objectives: To determine the efficacy, effect of dose, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin - TcpO2, TcpCO2), near infrared spectroscopy (NIRS), electroencephalogram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long-term neurodevelopmental outcomes. Search methods: We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016). We did not impose language restrictions. Selection criteria: RCTs in which term or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age), or both, received sucrose for procedural pain. Control interventions included no treatment, water, glucose, breast milk, breastfeeding, local anaesthetic, pacifier, positioning/containing or acupuncture. Data collection and analysis: Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I(2) test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system. Main results: Seventy-four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta-analyses and for most analyses the GRADE assessments indicated low- or moderate-quality evidence. There was high-quality evidence for the beneficial effect of sucrose (24%) with non-nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD -1.70 (95% CI -2.13 to -1.26; I(2) = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD -2.14 (95% CI -3.34 to -0.94; I(2) = 0% (no heterogeneity; 2 studies, n = 164). There was high-quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD -2.79 (95% CI -3.76 to -1.83; I(2) = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD -1.05 (95% CI -1.98 to -0.12; I(2) = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan-analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long-term neurodevelopmental outcomes are unknown. Authors' conclusions: Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate-quality evidence that sucrose in combination with other non-pharmacological interventions such as non-nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.

The Cochrane database of systematic reviews · meta-analysis · 183 citationsread the source →

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

Background: Metastatic extradural spinal cord compression (MESCC) is treated with radiotherapy, corticosteroids, and surgery, but there is uncertainty regarding their comparative effects. This is an updated version of the original Cochrane review published in theCochrane Database of Systematic Reviews (Issue 4, 2008). Objectives: To determine the efficacy and safety of radiotherapy, surgery and corticosteroids in MESCC. Search methods: In March 2015, we updated previous searches (July 2008 and December 2013) of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, CANCERLIT, clinical trials registries, conference proceedings, and references, without language restrictions. We also contacted experts for relevant published, unpublished and ongoing trials. Selection criteria: Randomised controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. Data collection and analysis: Three authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. Where possible, we pooled relative risks with their 95% confidence intervals, using a random effects model if heterogeneity was significant. We assessed overall evidence-quality using the GRADE approach. Main results: This update includes seven trials involving 876 (723 evaluable) adult participants (19 to 87 years) in high-income countries. Most were free of the risk of bias. Different radiotherapy doses and schedulesTwo equivalence trials in people with MESCC and a poor prognosis evaluated different radiotherapy doses and schedules. In one, a single dose (8 Gray (Gy)) of radiotherapy (RT) was as effective as short-course RT (16 Gy in two fractions over one week) in enhancing ambulation in the short term (65% versus 69%; risk ratio (RR) was 0.93, (95% confidence interval (CI) 0.82 to 1.04); 303 participants; moderate quality evidence). The regimens were also equally effective in reducing analgesic and narcotic use (34% versus 40%; RR 0.85, 95% CI 0.62 to 1.16; 271 participants), and in maintaining urinary continence (90% versus 87%; RR 1.03, 95% CI 0.96 to 1.1; 303 participants) in the short term (moderate quality evidence). In the other trial, split-course RT (30 Gy in eight fractions over two weeks) was no different from short-course RT in enhancing ambulation (70% versus 68%; RR 1.02, 95% CI 0.9 to 1.15; 276 participants); reducing analgesic and narcotic use (49% versus 38%; RR 1.27, 95% CI 0.96 to 1.67; 262 participants); and in maintaining urinary continence (87% versus 90%; RR 0.97, 0.93 to 1.02; 275 participants) in the short term (moderate quality evidence). Median survival was similar with the three RT regimens (four months). Local tumour recurrence may be more common with single-dose compared to short-course RT (6% versus 3%; RR 2.21, 95% CI 0.69 to 7.01; 303 participants) and with short-course compared to split-course RT (4% versus 0%; RR 0.1, 95% CI 0.01 to 1.72; 276 participants), but these differences were not statistically significant (low quality evidence). Gastrointestinal adverse effects were infrequent with the three RT regimens (moderate quality evidence), and serious adverse events or post-radiotherapy myelopathy were not noted. We did not find trials comparing radiotherapy schedules in people with MESCC and a good prognosis. Surgery plus radiotherapy compared to radiotherapyLaminectomy plus RT offered no advantage over RT in one small trial with 29 participants (very low quality evidence). In another trial that was stopped early for apparent benefit, decompressive surgery plus RT resulted in better ambulatory rates (84% versus 57%; RR 1.48, 95% CI 1.16 to 1.90; 101 participants, low quality evidence). Narcotic use may also be lower, and bladder control may also be maintained longer than with than RT in selected patients (low quality evidence). Median survival was longer after surgery (126 days versus 100 days), but the proportions surviving at one month (94% versus 86%; RR 1.09, 95% CI 0.96 to 1.24; 101 participants) did not differ significantly (low quality evidence). Serious adverse events were not noted. Significant benefits with surgery occurred only in people younger than 65 years. High dose corticosteroids compared to moderate dose or no corticosteroidsData from three small trials suggest that high-dose steroids may not differ from moderate-dose or no corticosteroids in enhancing ambulation (60% versus 55%; RR 1.08, 95% CI 0.81 to 1.45; 3 RCTs, 105 participants); survival over two years (11% versus 10%; RR 1.11, 95% CI 0.24 to 5.05; 1 RCT, 57 participants); pain reduction (78% versus 91%; RR 0.86, 95% CI 0.62 to 1.20; 1 RCT, 25 participants); or urinary continence (63% versus 53%; RR 1.18, 95% CI 0.66 to 2.13; 1 RCT, 34 participants; low quality evidence). Serious adverse effects were more frequent with high-dose corticosteroids (17% versus 0%; RR 8.02, 95% CI 1.03 to 62.37; 2 RCTs, 77 participants; moderate quality evidence).None of the trials reported satisfaction with care or quality of life in participants. Authors' conclusions: Based on current evidence, ambulant adults with MESCC with stable spines and predicted survival of less than six months will probably benefit as much from one dose of radiation (8 Gy) as from two doses (16 Gy) or eight doses (30 Gy). We are unsure if a single dose is as effective as two or more doses in preventing local tumour recurrence. Laminectomy preceding radiotherapy may offer no benefits over radiotherapy alone. Decompressive surgery followed by radiotherapy may benefit ambulant and non-ambulant adults younger than 65 years of age, with poor prognostic factors for radiotherapy, a single area of compression, paraplegia for less than 48 hours, and a predicted survival of more than six months. We are uncertain whether high doses of corticosteroids offer any benefits over moderate doses or indeed no corticosteroids; but high-dose steroids probably significantly increases the risk of serious adverse effects. Early detection; and treatment based on neurological status, age and estimated survival, are crucial with all treatment modalities. Most of the evidence was of low quality. High-quality evidence from more trials is needed to clarify current uncertainties, and some studies are in progress.

The Cochrane database of systematic reviews · meta-analysis · 39 citationsread the source →

High-performance liquid chromatography quantification of principal antioxidants in black seed (Nigella sativa L.) phytopharmaceuticals.

A new, simple, sensitive, rapid, and accurate isocratic RP-HPLC method was developed and validated for simultaneous analysis of the principal antioxidants of Nigella sativa, i.e., thymoquinone (TQ), carvacrol (CR), and its isomer thymol (THY), in different phytopharmaceuticals. The mobile phase was water-methanol (40 + 60, v/v) at a flow rate of 1.5 mL/min. Quantification was achieved with UV detection at 254 nm, based on peak area. The method was validated for linearity, accuracy, precision, selectivity, and robustness. The proposed method is stability-indicating for determination of TQ in the presence of its degradants. The LOD and LOQ (microg/mL) were, respectively, 0.006 and 0.021 for TQ, 0.002 and 0.006 for CR, and 0.027 and 0.090 for THY. The mean recoveries measured at three concentrations were higher than 99%, with RSD <2%. This analytical method is suitable for quality control of the marker substances in this widely used natural protective and curative remedy.

Journal of AOAC International · 18 citationsread the source →

Non-invasive measurement of stress in dairy cows using infrared thermography.

The possibility that changes in eye temperature, measured using infrared thermography (IRT), can detect stress in dairy cattle was examined by six different stimulations of the stress axis. Six cows were given six treatments in a random Latin-square design: 1) Control (saline) 2) ACTH (0.05 mg Synacthen) 3) bCRH (20 mug) 4) bCRH (40 mug) 5) epinephrine (1.4 mug /kg liveweight) and 6) social isolation. Treatments were administered at time 0 and blood samples were taken at -30, -15, 0, 5, 10, 15, 20, 30, 40, 50, 60, 75, 90, 120, 180 and 240 min except for epinephrine which was sampled at -30, -15, -10, -5, 0, 2, 5, 10, 15, 20, 30, 45, 60, 90 and 120 min. Core body temperature was recorded every 10 min and eye images collected every 2 min. Eye temperature and cortisol increased following catheterization (P<0.05). ACTH increased following bCRH, cortisol increased following ACTH and bCRH (P<0.001) and NEFA increased following epinephrine (P<0.001). Core body temperature was unaffected by treatments. Eye temperature was unaffected by CRH and epinephrine but was higher 30 and 60 min following control and ACTH (P<0.001). Our results provide evidence that exogenous HPA stimulation does not increase eye temperature. The increases in eye temperature following catheterization however raise the possibility that a cognitive component may be required for an eye temperature response to occur.

Physiology & behavior · 137 citationsread the source →

Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators.

Background: There is robust epidemiological and clinical evidence that a greater number of women than men experience depression and anxiety. This study investigated a number of socio-demographic, health and lifestyle, psychological and social factors as possible mediators for the gender difference in depression and anxiety in three cohorts (20-24, 40-44, 60-64). Methods: Responses were from a representative, community based survey (n = 7,485) conducted in Canberra and Queanbeyan (NSW), in Australia. Depression and anxiety were measured using the self-report Goldberg Anxiety and Depression Scales. The analyses initially identified gender differences in the potential mediators, followed by univariate and multivariate mediation models. Results: The results indicated several shared mediators for depression and anxiety across the three age groups including: childhood adversity, mastery, behavioural inhibition, ruminative style, neuroticism, physical health, physical activity, and perceived interpersonal and employment problems. There was a decrease in the number of social mediators as age increased. The multivariate models accounted for gender differences in both conditions for all age groups, except for anxiety in the 20-24 years old. This suggests further important unmeasured mediators for this age group. Conclusions: These findings add to the literature surrounding gender differences in depression and anxiety, and provide a basis for future research exploring variation in these gender disparities over the adult lifespan.

Social psychiatry and psychiatric epidemiology · 239 citationsread the source →

Sense of coherence and its relationship with oral health-related behaviour and knowledge of and attitudes towards oral health.

Objective: To investigate the relationship between sense of coherence (SOC), oral health-related behaviour, knowledge of and attitudes towards oral health in an adult Swedish population. Methods: A cross-sectional design with a stratified random sample of 910 individuals aged 20, 30, 40, 50, 60, 70 and 80 years were invited to the study, from Jönköping, Sweden. The investigation used the Swedish short version of the SOC questionnaire comprising 13 items and self-reported questions about oral health habits and knowledge of and attitudes towards oral health. In addition, a self-report questionnaire to elicit demographic information was included. Results: A total of 525 individuals, 261 men and 264 women, answered all the 13-item SOC questions, which constituted the final number of the participants. After adjustment for all the sociodemographic factors included in the analysis, individuals with a stronger SOC had twice as high a chance of having healthier behaviour, including a lower frequency of snacks and drinks between meals, as well as a more positive attitude, such as the importance of having one's own teeth as one gets older, satisfaction with their own teeth, perceiving their teeth as good and no feeling of dental fear, compared with individuals with a poorer SOC. Moreover, SOC and a good knowledge of caries were significantly associated after adjustment for age and gender. Conclusions: SOC was significantly associated with several oral health-related behaviours, attitudes towards oral health and knowledge of dental caries. When working with oral health promotion, SOC could be a way for promoting a better understanding of the behaviour and attitudes of individuals and for enabling dental personals to use that knowledge for the guidance of the individual.

Community dentistry and oral epidemiology · 45 citationsread the source →

When "don't worry" communicates fear: Children's perceptions of parental reassurance and distraction during a painful medical procedure.

Children's distress during painful medical procedures is strongly influenced by adult behavior. Adult reassurance (e.g., "it's okay") is associated with increased child distress whereas distraction is associated with increased child coping. It is unknown why reassurance shows this counterintuitive relationship with child distress. The present research investigated whether children perceive their parents as fearful when they reassure using complementary observational and experimental methodologies. One hundred children (40 boys, 60 girls) 5-10years old (M=8.02, SD=1.69) and their parents (86 mothers, 14 fathers) participated. First, spontaneous parent-child interactions during pediatric venipuncture were captured and used for a video-mediated recall task in which the children viewed instances of parental reassurance and distraction and rated their parents' fear and happiness. Second, the children were asked to rate the intensity of parental fear and happiness for 12 video vignettes showing an actor posing as a parent during venipuncture. To determine whether the children's perceptions varied with the qualities of the behavior, the vignettes manipulated: facial expression (happy vs. fearful), vocal tone (rising vs. falling), and content (informative reassurance vs. uninformative reassurance vs. distraction). For both tasks, the children provided higher ratings of fear during reassurance than distraction. In response to the vignettes, the children gave higher ratings of parental fear for a fearful facial expression, but the influence of vocal tone differed with the verbal content of the utterance. The results provide insight into the complexity of adult reassurance and highlight the important role of parental facial expression, tone, and verbal content during painful medical procedures.

Pain · 90 citationsread the source →

Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae.

Unlabelled: Exposure network analysis and molecular epidemiologic methods were used to analyze the emergence and regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae over a 1-year period. Although 40 patients and 26 health care facilities were affected, 1 long-term acute care hospital played a critical role in the convergence of patients at high risk, amplification by cross-infection, and dissemination of these multidrug-resistant bacteria. Background: Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are an emerging antibiotic resistance threat with demonstrated epidemic potential. Methods: We conducted an outbreak investigation of KPC-producing Enterobacteriaceae among patients of acute and long-term acute care hospitals (LTACHs) in 4 adjacent counties in Indiana and Illinois from 1 January 2008 through 31 December 2008 (cases). The study used traditional and molecular epidemiologic methods and an adaptation of social network analysis ("exposure network analysis"). Results: Clinical records for 40 (95%) of 42 patients were available. Patients were mostly older with multiple comorbid conditions. Eleven patients (27.5%) died during the index hospitalization or were discharged to hospice; 23 (57.5%) were discharged to a nursing home, and 4 (10.0%) were discharged to home. One LTACH (LTACH-A) was central to the regional outbreak: 24 (60%) of 40 cases were linked to LTACH-A, and at least 10 patients (25%) acquired KPC there. Of 16 cases not linked to LTACH-A, 12 (75%) were linked to 3 nursing homes. Only 4 patients (10%) definitely acquired KPC during an acute care hospital stay. Molecular typing revealed the 31 available KPC-positive K. pneumoniae isolates to be similar and to cluster with epidemic multilocus sequence type 258; 2 KPC-positive Escherichia coli isolates were unique. Conclusions: We observed extensive transfer of KPC-positive patients throughout the exposure network of 14 acute care hospitals, 2 LTACHs, and 10 nursing homes. Although few cases were identified at most institutions, many facilities were affected. Successful control of KPC-producing Enterobacteriaceae will require a coordinated, regional effort among acute and long-term health care facilities and public health departments.

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America · 176 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 →

Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review.

Importance: Evidence supports palliative care effectiveness. Given workforce constraints and the costs of new services, payers and providers need help to prioritize their investments. They need to know which patients to target, which personnel to hire, and which services best improve outcomes. Objective: To inform how payers and providers should identify patients with "advanced illness" and the specific interventions they should implement, we reviewed the evidence to identify (1) individuals appropriate for palliative care and (2) elements of health service interventions (personnel involved, use of multidisciplinary teams, and settings of care) effective in achieving better outcomes for patients, caregivers, and the healthcare system. Evidence review: Systematic searches of MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Database of Systematic Reviews databases (1/1/2001-1/8/2015). Results: Randomized controlled trials (124) met inclusion criteria. The majority of studies in cancer (49%, 38 of 77 studies) demonstrated statistically significant patient or caregiver outcomes (e.g., p < 0.05), as did those in congestive heart failure (CHF) (62%, 13 of 21), chronic obstructive pulmonary disease (COPD; 58%, 11 of 19), and dementia (60%, 15 of 25). Most prognostic criteria used clinicians' judgment (73%, 22 of 30). Most interventions included a nurse (70%, 69 of 98), and many were nurse-only (39%, 27 of 69). Social workers were well represented, and home-based approaches were common (56%, 70 of 124). Home interventions with visits were more effective than those without (64%, 28 of 44; vs. 46%, 12 of 26). Interventions improved communication and care planning (70%, 12 of 18), psychosocial health (36%, 12 of 33, for depressive symptoms; 41%, 9 of 22, for anxiety), and patient (40%, 8 of 20) and caregiver experiences (63%, 5 of 8). Many interventions reduced hospital use (65%, 11 of 17), but most other economic outcomes, including costs, were poorly characterized. Palliative care teams did not reliably lower healthcare costs (20%, 2 of 10). Conclusions: Palliative care improves cancer, CHF, COPD, and dementia outcomes. Effective models include nurses, social workers, and home-based components, and a focus on communication, psychosocial support, and the patient or caregiver experience. High-quality research on intervention costs and cost outcomes in palliative care is limited.

Journal of palliative medicine · systematic review · 135 citationsread the source →

Tumour necrosis factor-α inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis: a systematic review and economic evaluation.

Background: Tumour necrosis factor (TNF)-α inhibitors (anti-TNFs) are typically used when the inflammatory rheumatologic diseases ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-AxSpA) have not responded adequately to conventional therapy. Current National Institute for Health and Care Excellence (NICE) guidance recommends treatment with adalimumab, etanercept and golimumab in adults with active (severe) AS only if certain criteria are fulfilled but it does not recommend infliximab for AS. Anti-TNFs for patients with nr-AxSpA have not previously been appraised by NICE. Objective: To determine the clinical effectiveness, safety and cost-effectiveness within the NHS of adalimumab, certolizumab pegol, etanercept, golimumab and infliximab, within their licensed indications, for the treatment of severe active AS or severe nr-AxSpA (but with objective signs of inflammation). Design: Systematic review and economic model. Data sources: Fifteen databases were searched for relevant studies in July 2014. Review methods: Clinical effectiveness data from randomised controlled trials (RCTs) were synthesised using Bayesian network meta-analysis methods. Results from other studies were summarised narratively. Only full economic evaluations that compared two or more options and considered both costs and consequences were included in the systematic review of cost-effectiveness studies. The differences in the approaches and assumptions used across the studies, and also those in the manufacturer's submissions, were examined in order to explain any discrepancies in the findings and to identify key areas of uncertainty. A de novo decision model was developed with a generalised framework for evidence synthesis that pooled change in disease activity (BASDAI and BASDAI 50) and simultaneously synthesised information on function (BASFI) to determine the long-term quality-adjusted life-year and cost burden of the disease in the economic model. The decision model was developed in accordance with the NICE reference case. The model has a lifetime horizon (60 years) and considers costs from the perspective of the NHS and personal social services. Health effects were expressed in terms of quality-adjusted life-years. Results: In total, 28 eligible RCTs were identified and 26 were placebo controlled (mostly up to 12 weeks); 17 extended into open-label active treatment-only phases. Most RCTs were judged to have a low risk of bias overall. In both AS and nr-AxSpA populations, anti-TNFs produced clinically important benefits to patients in terms of improving function and reducing disease activity; for AS, the relative risks for ASAS 40 ranged from 2.53 to 3.42. The efficacy estimates were consistently slightly smaller for nr-AxSpA than for AS. Statistical (and clinical) heterogeneity was more apparent in the nr-AxSpA analyses than in the AS analyses; both the reliability of the nr-AxSpA meta-analysis results and their true relevance to patients seen in clinical practice are questionable. In AS, anti-TNFs are approximately equally effective. Effectiveness appears to be maintained over time, with around 50% of patients still responding at 2 years. Evidence for an effect of anti-TNFs delaying disease progression was limited; results from ongoing long-term studies should help to clarify this issue. Sequential treatment with anti-TNFs can be worthwhile but the drug survival response rates and benefits are reduced with second and third anti-TNFs. The de novo model, which addressed many of the issues of earlier evaluations, generated incremental cost-effectiveness ratios ranging from £19,240 to £66,529 depending on anti-TNF and modelling assumptions. Conclusions: In both AS and nr-AxSpA populations anti-TNFs are clinically effective, although more so in AS than in nr-AxSpA. Anti-TNFs may be an effective use of NHS resources depending on which assumptions are considered appropriate. Future work recommendations: Randomised trials are needed to identify the nr-AxSpA population who will benefit the most from anti-TNFs. Study registration: This study is registered as PROSPERO CRD42014010182. Funding: The National Institute for Health Research Health Technology Assessment programme.

Health technology assessment (Winchester, England) · systematic review · 61 citationsread the source →

Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis.

Background: Several interventions are available for management of obsessive-compulsive disorder in adults, but few studies have compared their relative efficacy in a single analysis. We aimed to simultaneously compare all available treatments using both direct and indirect data. Methods: In this systematic review and network meta-analysis, we searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group for trials published up to Feb 16, 2016. We selected randomised controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with obsessive-compulsive disorder. We allowed all comorbidities except for schizophrenia or bipolar disorder. We excluded studies that focused exclusively on treatment-resistant patient populations defined within the same study. We extracted data from published reports. The primary outcome was symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. We report mean differences with 95% credible intervals compared with placebo. This study is registered with PROSPERO, number CRD42012002441. Findings: We identified 1480 articles in our search and included 53 articles (54 trials; 6652 participants) in the network meta-analysis. Behavioural therapy (mean difference -14·48 [95% credible interval -18·61 to -10·23]; 11 trials and 287 patients), cognitive therapy (-13·36 [-18·40 to -8·21]; six trials and 172 patients), behavioural therapy and clomipramine (-12·97 [-19·18 to -6·74]; one trial and 31 patients), cognitive behavioural therapy and fluvoxamine (-7·50 [-13·89 to -1·17]; one trial and six patients), cognitive behavioural therapy (-5·37 [-9·10 to -1·63]; nine trials and 231 patients), clomipramine (-4·72 [-6·85 to -2·60]; 13 trials and 831 patients), and all SSRIs (class effect -3·49 [95% credible interval -5·12 to -1·81]; 37 trials and 3158 patients) had greater effects than did drug placebo. Clomipramine was not better than were SSRIs (-1·23 [-3·41 to 0·94]). Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants). Interpretation: A range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder. Funding: National Institute for Health Research.

The lancet. Psychiatry · systematic review · 236 citationsread the source →

Myocardial T1 and T2 mapping at 3 T: reference values, influencing factors and implications.

Background: Myocardial T1 and T2 mapping using cardiovascular magnetic resonance (CMR) are promising to improve tissue characterization and early disease detection. This study aimed at analyzing the feasibility of T1 and T2 mapping at 3 T and providing reference values. Methods: Sixty healthy volunteers (30 males/females, each 20 from 20-39 years, 40-59 years, 60-80 years) underwent left-ventricular T1 and T2 mapping in 3 short-axis slices at 3 T. For T2 mapping, 3 single-shot steady-state free precession (SSFP) images with different T2 preparation times were acquired. For T1 mapping, modified Look-Locker inversion recovery technique with 11 single shot SSFP images was used before and after injection of gadolinium contrast. T1 and T2 relaxation times were quantified for each slice and each myocardial segment. Results: Mean T2 and T1 (pre-/post-contrast) times were: 44.1 ms/1157.1 ms/427.3 ms (base), 45.1 ms/1158.7 ms/411.2 ms (middle), 46.9 ms/1180.6 ms/399.7 ms (apex). T2 and pre-contrast T1 increased from base to apex, post-contrast T1 decreased. Relevant inter-subject variability was apparent (scatter factor 1.08/1.05/1.11 for T2/pre-contrast T1/post-contrast T1). T2 and post-contrast T1 were influenced by heart rate (p < 0.0001, p = 0.0020), pre-contrast T1 by age (p < 0.0001). Inter- and intra-observer agreement of T2 (r = 0.95; r = 0.95) and T1 (r = 0.91; r = 0.93) were high. T2 maps: 97.7% of all segments were diagnostic and 2.3% were excluded (susceptibility artifact). T1 maps (pre-/post-contrast): 91.6%/93.9% were diagnostic, 8.4%/6.1% were excluded (predominantly susceptibility artifact 7.7%/3.2%). Conclusions: Myocardial T2 and T1 reference values for the specific CMR setting are provided. The diagnostic impact of the high inter-subject variability of T2 and T1 relaxation times requires further investigation.

Journal of cardiovascular magnetic resonance : official journal of the Society for Cardiovascular Magnetic Resonance · 174 citationsread the source →

Childhood adversity and adult personality.

Objectives: To explore how recalled childhood adversity affects trait measures of personality in three age cohorts of an Australian adult population and to examine the effects of particular adversities on adult personality traits. Method: A total of 7485 randomly selected subjects in the age bands of 20-24, 40-44 and 60-64 years were interviewed at the outset of a longitudinal community study of psychological health in the Canberra region of Australia. In the initial interview, subjects answered 17 questions about domestic adversity and three questions on positive aspects of upbringing to age 16 years. Personality traits were measured by Eysenck Personality Questionnaire, Behavioural Activation and Inhibition Scales, Positive and Negative Affect Scales and a measure of dissocial behaviours. Results: Higher levels of childhood adversity substantially increase the risk of high neuroticism (OR = 2.6) and negative affect (OR = 2.6), less for behavioural inhibition (OR = 1.7) and for dissocial behaviour (OR = 1.7). No significant effect is seen for extraversion, psychoticism or behavioural activation. Age and gender had little effect on the pattern of risk. Maternal depression has significant and substantial independent effects on measures of neuroticism and negative affect as well as most other measures of personality. Conclusion: Childhood domestic adversity has substantial associations with clinically important aspects of personality: neuroticism and negative affect. Only small effects are seen on behavioural inhibition and dissocial behaviour, and no significant effect on extraversion and behavioural activation. These unexpected findings contradict clinical belief. Maternal psychological ill-health is pre-eminent among adversities predicting later disadvantageous traits, even for those traits that had only the slightest association with childhood adversity. Consequences of childhood adversity prevail throughout the lifespan in men and women equally. The study underlines the importance of childhood domestic adversity and especially maternal psychological ill-health as a target for preventive intervention for psychological difficulties at all ages.

The Australian and New Zealand journal of psychiatry · 37 citationsread the source →

Microemboli may link spreading depression, migraine aura, and patent foramen ovale.

Objective: Patent foramen ovale and pulmonary arteriovenous shunts are associated with serious complications such as cerebral emboli, stroke, and migraine with aura. The pathophysiological mechanisms that link these conditions are unknown. We aimed to establish a mechanism linking microembolization to migraine aura in an experimental animal model. Methods: We introduced particulate or air microemboli into the carotid circulation in mice to determine whether transient microvascular occlusion, insufficient to cause infarcts, triggered cortical spreading depression (CSD), a propagating slow depolarization that underlies migraine aura. Results: Air microemboli reliably triggered CSD without causing infarction. Polystyrene microspheres (10 microm) or cholesterol crystals (<70 microm) triggered CSD in 16 of 28 mice, with 60% of the mice (40% of those with CSD) showing no infarcts or inflammation on detailed histological analysis of serial brain sections. No evidence of injury was detected on magnetic resonance imaging examination (9.4T; T2 weighted) in 14 of 15 selected animals. The occurrence of CSD appeared to be related to the magnitude and duration of flow reduction, with a triggering mechanism that depended on decreased brain perfusion but not sustained tissue damage. Interpretation: In a mouse model, microemboli triggered CSD, often without causing microinfarction. Paradoxical embolization then may link cardiac and extracardiac right-to-left shunts to migraine aura. If translatable to humans, a subset of migraine auras may belong to a spectrum of hypoperfusion disorders along with transient ischemic attacks and silent infarcts.

Annals of neurology · 245 citationsread the source →

Frequency of complementary and alternative medicine utilization in hypertensive patients attending an urban tertiary care centre in Nigeria.

Background: To study the frequency and pattern of use of complementary and alternative medicine (CAM) in patients with essential hypertension attending a tertiary hypertension clinic. Methods: Two hundred and twenty-five consecutive hypertensive patients attending the hypertension clinic of the Lagos University Teaching Hospital over a 3-month period were interviewed. Socio-demographic data, duration of hypertension, clinic attendance, current blood pressure, and compliance to conventional medications was documented. CAM utilization was explored using both structured and open-ended questions. Results: There were 90 (40%) male and 135 (60%) female patients with mean age +/- SD overall was 55.1 +/- 12.4 years. 88 (39.1%) of the respondents used CAM. Herbal products were the most commonly used CAM type. Amongst the CAM users, the most common herbal product used was garlic (69.3%). Others were native herbs (25%), ginger (23.9%), bitter leaf (Vernonia amygdalina) (9.1%), and aloe vera (4.5%). 2.5% used spiritual therapy. There was no difference in the clinical characteristics, socio-economic status, and blood pressure control of CAM users and non-users. Patients who utilized CAM had higher BMI compared with those who did not, but the difference was not statistically significant (mean BMI +/- SD of 29.1 +/- 5.6 vs 27.1 +/- 5.9 kg/m2; P = 0.05). Conclusion: A significant proportion of hypertensive patients attending our tertiary facility and receiving conventional treatment also use CAM therapies. Clinicians need to be aware of this practice, understand the rationale for this health-seeking behaviour, proactively enquire about their use, and counsel patients regarding the potential of some of the therapies for adverse reactions and drug interactions.

BMC complementary and alternative medicine · 69 citationsread the source →

Evaluation of an Online Gottman's Psychoeducational Intervention to Improve Marital Communication among Iranian Couples.

Amounting evidence indicates that insufficient knowledge of marital communication skills leads to destructive interactions and poor marital adjustments in couples, especially during stressful situations. Despite the high effectiveness of Gottman's psychoeducational intervention, there is a lack of study on the online Gottman's psychoeducation intervention (O-GPI) to improve marital communication and dyadic adjustments. The aim of this study was to evaluate the effectiveness of O-GPI on the improvement of marital communication patterns among Iranian couples. Method: The study followed a single-blind parallel group in a randomized controlled trial using an experimental longitudinal design, comprising 72 heterosexual couples living in Shiraz, Iran, with a 1-7-year marital age and no severe marital problems. The experimental group received eight consecutive O-GPIs via the Zoom platform, while the control group received information related to parenting skills via email. The outcome measures were the three patterns of communication: (i) constructive communication; (ii) demand-withdraw communication; and (iii) mutual avoidance communication-the screening measure was the dyadic adjustment scale. Results: The findings indicated that O-GPI could improve couples' constructive communication significantly (45% for husbands and 40% wives) and decrease their total demand-withdrawal (51% for husbands and 65% wives) and mutual avoidance communication (60% for husbands and 62% wives). Limitations: Due to the homogenous nature of the sample, generalizations should be made with caution. Conclusions: This study demonstrates the feasibility and effectiveness of the online Gottman's psychoeducational intervention to improve couples' communication patterns.

International journal of environmental research and public health · randomised controlled trial · 3 citationsread the source →