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Personality and all-cause mortality: individual-participant meta-analysis of 3,947 deaths in 76,150 adults.

Personality may influence the risk of death, but the evidence remains inconsistent. We examined associations between personality traits of the five-factor model (extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience) and the risk of death from all causes through individual-participant meta-analysis of 76,150 participants from 7 cohorts (the British Household Panel Survey, 2006-2009; the German Socio-Economic Panel Study, 2005-2010; the Household, Income and Labour Dynamics in Australia Survey, 2006-2010; the US Health and Retirement Study, 2006-2010; the Midlife in the United States Study, 1995-2004; and the Wisconsin Longitudinal Study's graduate and sibling samples, 1993-2009). During 444,770 person-years at risk, 3,947 participants (54.4% women) died (mean age at baseline = 50.9 years; mean follow-up = 5.9 years). Only low conscientiousness-reflecting low persistence, poor self-control, and lack of long-term planning-was associated with elevated mortality risk when taking into account age, sex, ethnicity/nationality, and all 5 personality traits. Individuals in the lowest tertile of conscientiousness had a 1.4 times higher risk of death (hazard ratio = 1.37, 95% confidence interval: 1.18, 1.58) compared with individuals in the top 2 tertiles. This association remained after further adjustment for health behaviors, marital status, and education. In conclusion, of the higher-order personality traits measured by the five-factor model, only conscientiousness appears to be related to mortality risk across populations.

American journal of epidemiology · meta-analysis · 171 citationsread the source →

Nilotinib Effects in Parkinson's disease and Dementia with Lewy bodies.

Background: We evaluated the effects of low doses of the tyrosine kinase Abelson (Abl) inhibitor Nilotinib, on safety and pharmacokinetics in Parkinson's disease dementia or dementia with Lewy bodies. Objectives: The primary outcomes of this study were safety and tolerability; pharmacokinetics and target engagement were secondary, while clinical outcomes were exploratory. Methods: Twelve subjects were randomized into 150 mg (n = 5) or 300 mg (n = 7) groups and received Nilotinib orally every day for 24 weeks. Results: This study shows that 150 mg and 300 mg doses of Nilotinib appear to be safe and tolerated in subjects with advanced Parkinson's disease. Nilotinib is detectable in the cerebrospinal fluid (CSF) and seems to engage the target Abl. Motor and cognitive outcomes suggest a possible beneficial effect on clinical outcomes. The CSF levels of homovanillic acid are significantly increased between baseline and 24 weeks of treatment. Exploratory CSF biomarkers were measured. Conclusions: This small proof-of-concept study lacks a placebo group and participants were not homogenous, resulting in baseline differences between and within groups. This limits the interpretations of the biomarker and clinical data, and any conclusions should be drawn cautiously. Nonetheless, the collective observations suggest that it is warranted to evaluate the safety and efficacy of Nilotinib in larger randomized, double-blind, placebo-controlled trials.

Journal of Parkinson's disease · randomised controlled trial · 186 citationsread the source →

Extended-release quetiapine fumarate (quetiapine XR): a once-daily monotherapy effective in generalized anxiety disorder. Data from a randomized, double-blind, placebo- and active-controlled study.

The efficacy and tolerability of extended-release quetiapine fumarate (quetiapine XR) once-daily monotherapy in generalized anxiety disorder (GAD) was assessed. This multicentre, double-blind, randomized, placebo- and active-controlled, phase III trial consisted of a 1- to 4-wk enrolment/wash-out period and a 10-wk (8-wk active treatment, 2-wk post-treatment drug-discontinuation) study period; 873 patients were randomized to 50 mg or 150 mg quetiapine XR, 20 mg paroxetine, or placebo. Primary endpoint was change from randomization at week 8 in Hamilton Rating Scale for Anxiety (HAMA) total score. At week 8, all active agents produced significant improvements in HAMA total and psychic subscale scores vs. placebo; HAMA somatic subscale scores were significantly reduced only by 150 mg quetiapine XR. Significant separation from placebo (-2.90) in HAMA total score was observed at day 4 for 50 mg quetiapine XR (-4.43, p<0.001) and 150 mg quetiapine XR (-3.86, p<0.05), but not for paroxetine (-2.69). Remission (HAMA total score 7) rates at week 8 were significantly higher for 150 mg quetiapine XR (42.6%, p<0.01) and paroxetine (38.8%, p<0.05) vs. placebo (27.2%). The most common adverse events (AEs) were dry mouth, somnolence, fatigue, dizziness, and headache, for quetiapine XR, and nausea, headache, dizziness for paroxetine. A lower proportion of patients reported sexual dysfunction with quetiapine XR [0.9% (50 mg), 1.8% (150 mg)] than with placebo (2.3%) or paroxetine (7.4%). The incidence of AEs potentially related to extrapyramidal symptoms was: quetiapine XR: 50 mg, 6.8%, 150 mg, 5.0%; placebo, 1.8%; and paroxetine, 8.4%. Once-daily quetiapine XR is an effective and generally well-tolerated treatment for patients with GAD, with symptom improvement seen as early as day 4.

The international journal of neuropsychopharmacology · randomised controlled trial · 85 citationsread the source →

The impact of Ramadan intermittent fasting on anthropometric measurements and body composition: Evidence from LORANS study and a meta-analysis.

Background: Although the effect of Ramadan intermittent fasting (RIF) on anthropometry and body composition has been questioned, none of the previous studies tried to explain the reported changes in these parameters. Also, systematic reviews that investigated the topic were limited to healthy individuals or a specific disease group. Methods: The London Ramadan Study (LORANS) is an observational study on health effects of RIF. We measured weight, waist circumference (WC), hip circumference (HC), body mass index (BMI), waist-to-hip ratio (WHR), basal metabolic rate (BMR), fat percentage (FP), free-fat mass (FFM), extremities predicted muscle mass, total body water (TBW), trunk FM, trunk FFM and trunk predicted muscle mass before and immediately after Ramadan. Using mixed-effects regression models, we investigated the effect of RIF with adjustment for potential confounders. We also conducted a meta-analysis of the results of LORANS with other studies that investigated the effect of RIF on anthropometry and body composition. The review protocol is registered with PROSPERO registry (CRD42020186532). Results: We recruited 146 participants (Mean ± SD age = 43.3 ± 15 years). Immediately after Ramadan, compared with before Ramadan, the mean difference was-1.6 kg (P<0.01) in weight,-1.95cm (P<0.01) in WC,-2.86cm (P <0.01) in HC, -0.60 kg/m2 (P < 0.01) in BMI and -1.24 kg (P < 0.01) in FM. In the systematic review and meta-analysis, after screening 2,150 titles and abstracts, 66 studies comprising 7,611 participants were included. In the general population, RIF was followed by a reduction of 1.12 Kg in body weight (-1.89- -0.36, I2 = 0), 0.74 kg/m2 reduction in BMI (-0.96- -0.53, I2 = 0), 1.54cm reduction in WC (-2.37- -0.71, I2 = 0) and 1.76cm reduction in HC (-2.69- -0.83, I2 = 0). The effect of fasting on anthropometric and body composition parameters starts to manifest in the second week of Ramadan and starts to diminish 3 weeks after Ramadan. Conclusion: RIF is associated with a reduction in body weight, BMI, WC, HC, FM, FP and TBW. Most of these reductions are partially attributed to reduced FM and TBW. The reductions in these parameters appear to reverse after Ramadan.

Frontiers in nutrition · review · 16 citationsread the source →

Exercise as adjunctive therapy for systemic lupus erythematosus.

Background: Systemic lupus erythematosus (SLE) is a rare, chronic autoimmune inflammatory disease with a prevalence varying from 4.3 to 150 people in 100,000, or approximately five million people worldwide. Systemic manifestations frequently include internal organ involvement, a characteristic malar rash on the face, pain in joints and muscles, and profound fatigue. Exercise is purported to be beneficial for people with SLE. For this review, we focused on studies that examined all types of structured exercise as an adjunctive therapy in the management of SLE. Objectives: To evaluate the benefits and harms of structured exercise as adjunctive therapy for adults with SLE compared with usual pharmacological care, usual pharmacological care plus placebo and usual pharmacological care plus non-pharmacological care. Search methods: We used standard, extensive Cochrane search methods. The latest search date was 30 March 2022. Selection criteria: We included randomised controlled trials (RCTs) of exercise as an adjunct to usual pharmacological treatment in SLE compared with placebo, usual pharmacological care alone and another non-pharmacological treatment. Major outcomes were fatigue, functional capacity, disease activity, quality of life, pain, serious adverse events, and withdrawals due to any reason, including any adverse events. Data collection and analysis: We used standard Cochrane methods. Our major outcomes were 1. fatigue, 2. functional capacity, 3. disease activity, 4. quality of life, 5. pain, 6. serious adverse events, and 7. withdrawals due to any reason. Our minor outcomes were 8. responder rate, 9. aerobic fitness, 10. depression, and 11. anxiety. We used GRADE to assess certainty of evidence. The primary comparison was exercise compared with placebo. Main results: We included 13 studies (540 participants) in this review. Studies compared exercise as an adjunct to usual pharmacological care (antimalarials, immunosuppressants, and oral glucocorticoids) with usual pharmacological care plus placebo (one study); usual pharmacological care (six studies); and another non-pharmacological treatment such as relaxation therapy (seven studies). Most studies had selection bias, and all studies had performance and detection bias. We downgraded the evidence for all comparisons because of a high risk of bias and imprecision. Exercise plus usual pharmacological care versus placebo plus usual pharmacological care Evidence from a single small study (17 participants) that compared whole body vibration exercise to whole body placebo vibration exercise (vibrations switched off) indicated that exercise may have little to no effect on fatigue, functional capacity, and pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). The study did not report disease activity, quality of life, and serious adverse events. The study measured fatigue using the self-reported Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue), scale 0 to 52; lower score means less fatigue. People who did not exercise rated their fatigue at 38 points and those who did exercise rated their fatigue at 33 points (mean difference (MD) 5 points lower, 95% confidence interval (CI) 13.29 lower to 3.29 higher). The study measured functional capacity using the self-reported 36-item Short Form health questionnaire (SF-36) Physical Function domain, scale 0 to 100; higher score means better function. People who did not exercise rated their functional capacity at 70 points and those who did exercise rated their functional capacity at 67.5 points (MD 2.5 points lower, 95% CI 23.78 lower to 18.78 higher). The study measured pain using the SF-36 Pain domain, scale 0 to 100; lower scores mean less pain. People who did not exercise rated their pain at 43 points and those who did exercise rated their pain at 34 points (MD 9 points lower, 95% CI 28.88 lower to 10.88 higher). More participants from the exercise group (3/11, 27%) withdrew from the study than the placebo group (1/10, 10%) (risk ratio (RR) 2.73, 95% CI 0.34 to 22.16). Exercise plus usual pharmacological care versus usual pharmacological care alone The addition of exercise to usual pharmacological care may have little to no effect on fatigue, functional capacity, and disease activity (low-certainty evidence). We are uncertain whether the addition of exercise improves pain (very low-certainty evidence), or results in fewer or more withdrawals (very low-certainty evidence). Serious adverse events and quality of life were not reported. Exercise plus usual care versus another non-pharmacological intervention such as receiving information about the disease or relaxation therapy Compared with education or relaxation therapy, exercise may reduce fatigue slightly (low-certainty evidence), may improve functional capacity (low-certainty evidence), probably results in little to no difference in disease activity (moderate-certainty evidence), and may result in little to no difference in pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). Quality of life and serious adverse events were not reported. Authors' conclusions: Due to low- to very low-certainty evidence, we are not confident on the benefits of exercise on fatigue, functional capacity, disease activity, and pain, compared with placebo, usual care, or advice and relaxation therapy. Harms data were not well reported.

The Cochrane database of systematic reviews · systematic review · 11 citationsread the source →

Emotional and behavioral problems among adolescent students: the role of immigrant, racial/ethnic congruence and belongingness in schools.

As levels of immigration and ethnic diversity continue to rise in most Western societies, the social demography of schools is changing rapidly. Although schools represent a prominent developmental context, relatively little is known about the extent to which the racial/ethnic composition of schools influences mental health outcomes in students. The objective of the present study is to examine the association between immigrant and racial/ethnic congruence in school-the numerical representation of a student's immigrant generational status and race/ethnicity in the student body-and levels of emotional and behavioral problems. This study also examines the extent to which the association between congruence and emotional-behavioral problems differs across racial/ethnic immigrant sub-groups and is accounted for by individual perceptions of school belonging. Data come from the in-school survey of the Longitudinal Study of Adolescent Health (Add Health) conducted in the United States. The sample is nationally representative, and includes 128 schools and 77,150 adolescents in grades 7-12 (50 % female, M age = 14.9 years, SD = 1.78). After controlling for school and family socio-demographic characteristics, immigrant and racial/ethnic congruence in school exhibited a negative association with emotional and behavioral problems for most sub-groups examined. School belonging was associated negatively with emotional and behavioral problems, and partially accounted for the effects linked to congruence in schools. The immigrant and racial/ethnic composition of schools and perceptions of belonging have strong links with emotional and behavioral problems and may represent important targets for intervention.

Journal of youth and adolescence · 27 citationsread the source →

Associations between neighbourhood environmental characteristics and obesity and related behaviours among adult New Zealanders.

Background: The prevalence of adult obesity is escalating in most wealthy and middle income countries. Due to the magnitude of this issue, research and interventions at the individual-level abound. However, the limited success and high costs of such interventions has led to a growing recognition of the potential role of environmental factors in reducing obesity and promoting physical activity and healthy diets. Methods: This study utilised individual-level data from the 2006/7 New Zealand Health Survey on obesity, physical activity, diet and socio-economic variables linked to geographic information from other sources on potentially aetiologically-relevant environmental factors, based on the respondent's residential address. We fitted logistic regression models for eight binary measures of weight or weight-related behaviours: 1) overweight; 2) obesity; 3) overweight + obesity; 4) active at least 30 minutes a day for 5+ days per week; 5) active <30 minutes per week; 6) walk 150 minutes + per week; 7) walk <30 minutes per week; and 8) consumption of 5+ fruits and vegetables per day. We included a range of independent environmental characteristics of interest in separate models. Results: We found that increased neighbourhood deprivation and decreased access to neighbourhood greenspace were both significantly associated with increased odds of overweight and/or obesity. The results for weight-related behaviours indicate that meeting the recommended level of physical activity per week was associated with urban/rural status, with higher activity in the more rural areas and a surprising tendency for less activity among those living in areas with higher levels of active travel to work. Increased access to greenspace was associated with high levels of walking, while decreased access to greenspace was associated with low levels of walking. There was also a significant trend for low levels of walking to be positively associated with neighbourhood deprivation. Results for adequate fruit and vegetable consumption show a significant urban/rural gradient, with more people meeting recommended levels in the more rural compared to more urban areas. Conclusion: Similar to findings from other international studies, these results highlight greenspace as an amenable environmental factor associated with obesity/overweight and also indicate the potential benefit of targeted health promotion in both urban and deprived areas in New Zealand.

BMC public health · 32 citationsread the source →

Effectiveness of an Internet- and App-Based Intervention for College Students With Elevated Stress: Randomized Controlled Trial.

Background: Mental health problems are highly prevalent among college students. Most students with poor mental health, however, do not receive professional help. Internet-based self-help formats may increase the utilization of treatment. Objective: The aim of this randomized controlled trial was to evaluate the efficacy of an internet-based, app-supported stress management intervention for college students. Methods: College students (n=150) with elevated levels of stress (Perceived Stress Scale 4-item version, PSS-4 ≥8) were randomly assigned to either an internet- and mobile-based stress intervention group with feedback on demand or a waitlist control group. Self-report data were assessed at baseline, posttreatment (7 weeks), and 3-month follow-up. The primary outcome was perceived stress posttreatment (PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinically relevant symptoms of depression (Center for Epidemiological Studies' Depression Scale >17). Results: A total of 106 participants (76.8%) indicated that they were first-time help-seekers, and 77.3% (intervention group: 58/75; waitlist control group: 58/75) showed clinically relevant depressive symptoms at baseline. Findings indicated significant effects of the intervention compared with the waitlist control group for stress (d=0.69; 95% CI 0.36-1.02), anxiety (d=0.76; 95% CI 0.43-1.09), depression (d=0.63; 95% CI 0.30-0.96), college-related productivity (d=0.33; 95% CI 0.01-0.65), academic work impairment (d=0.34; 95% CI 0.01-0.66), and other outcomes after 7 weeks (posttreatment). Response rates for stress symptoms were significantly higher for the intervention group (69%, 52/75) compared with the waitlist control group (35%, 26/75, P<.001; number needed to treat=2.89, 95% CI 2.01-5.08) at posttest (7 weeks). Effects were sustained at 3-month follow-up, and similar findings emerged in students with symptoms of depression. Conclusions: Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress and might potentially attract students with clinically relevant depression who would not otherwise seek help. Trial registration: German Clinical Trial Register DRKS00010212; http://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010212 (Archived by WebCite at http://www.webcitation.org/6w55Ewhjd).

Journal of medical Internet research · randomised controlled trial · 129 citationsread the source →

An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial.

Background: There are few evidence-based interventions for long COVID; however, holistic approaches supporting recovery are advocated. We assessed whether an online breathing and wellbeing programme improves health related quality-of-life (HRQoL) in people with persisting breathlessness following COVID-19. Methods: We conducted a parallel-group, single-blind, randomised controlled trial in patients who had been referred from one of 51 UK-based collaborating long COVID clinics. Eligible participants were aged 18 years or older; were recovering from COVID-19 with ongoing breathlessness, with or without anxiety, at least 4 weeks after symptom onset; had internet access with an appropriate device; and were deemed clinically suitable for participation by one of the collaborating COVID-19 clinics. Following clinical assessment, potential participants were given a unique online portal code. Participants were randomly assigned (1:1) to either immediate participation in the English National Opera (ENO) Breathe programme or to usual care. Randomisation was done by the research team using computer-generated block randomisation lists, with block size 10. The researcher responsible for randomisation was masked to responses. Participants in the ENO Breathe group participated in a 6-week online breathing and wellbeing programme, developed for people with long COVID experiencing breathlessness, focusing on breathing retraining using singing techniques. Those in the deferred group received usual care until they exited the trial. The primary outcome, assessed in the intention-to-treat population, was change in HRQoL, assessed using the RAND 36-item short form survey instrument mental health composite (MHC) and physical health composite (PHC) scores. Secondary outcome measures were the chronic obstructive pulmonary disease assessment test score, visual analogue scales (VAS) for breathlessness, and scores on the dyspnoea-12, the generalised anxiety disorder 7-item scale, and the short form-6D. A thematic analysis exploring participant experience was also conducted using qualitative data from focus groups, survey responses, and email correspondence. This trial is registered with ClinicalTrials.gov, NCT04830033. Findings: Between April 22 and May 25, 2021, 158 participants were recruited and randomly assigned. Of these, eight (5%) individuals were excluded and 150 participants were allocated to a treatment group (74 in the ENO Breathe group and 76 in the usual care group). Compared with usual care, ENO Breathe was associated with an improvement in MHC score (regression coefficient 2·42 [95% CI 0·03 to 4·80]; p=0·047), but not PHC score (0·60 [-1·33 to 2·52]; p=0·54). VAS for breathlessness (running) favoured ENO Breathe participation (-10·48 [-17·23 to -3·73]; p=0·0026). No other statistically significant between-group differences in secondary outcomes were observed. One minor self-limiting adverse event was reported by a participant in the ENO Breathe group who felt dizzy using a computer for extended periods. Thematic analysis of ENO Breathe participant experience identified three key themes: (1) improvements in symptoms; (2) feeling that the programme was complementary to standard care; and (3) the particular suitability of singing and music to address their needs. Interpretation: Our findings suggest that an online breathing and wellbeing programme can improve the mental component of HRQoL and elements of breathlessness in people with persisting symptoms after COVID-19. Mind-body and music-based approaches, including practical, enjoyable, symptom-management techniques might have a role supporting recovery. Funding: Imperial College London.

The Lancet. Respiratory medicine · randomised controlled trial · 74 citationsread the source →

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

Importance: Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. Objective: To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. Design, setting, and participants: Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. Interventions: Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0). Main outcomes and measures: Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. Results: Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02). Conclusions and relevance: Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS. Trial registration: clinicaltrials.gov Identifier: NCT00976833.

JAMA · randomised controlled trial · 299 citationsread the source →

Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial.

Context: Depressive symptoms commonly follow coronary artery bypass graft (CABG) surgery and are associated with less positive clinical outcomes. Objective: To test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs usual physician care. Design, setting, and participants: Single-blind effectiveness trial at 7 university-based and community hospitals in or near Pittsburgh, Pennsylvania. Participants were 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression recruited between March 2004 and September 2007 and observed as outpatients until June 2008. Intervention: Eight months of telephone-delivered collaborative care provided by nurses working with patients' primary care physicians and supervised by a psychiatrist and primary care physician from this study. Main outcome measures: Mental health-related quality of life (HRQL) measured by the Short Form-36 Mental Component Summary (SF-36 MCS) at 8-month follow-up; secondary outcome measures included assessment of mood symptoms (Hamilton Rating Scale for Depression [HRS-D]), physical HRQL (SF-36 PCS), and functional status (Duke Activity Status Index [DASI]); and hospital readmissions. Results: The intervention patients reported greater improvements in mental HRQL (all P < or = .02) (SF-36 MCS: Delta, 3.2 points; 95% confidence interval [CI], 0.5-6.0), physical functioning (DASI: Delta, 4.6 points; 95% CI, 1.9-7.3), and mood symptoms (HRS-D: Delta, 3.1 points; 95% CI, 1.3-4.9); and were more likely to report a 50% or greater decline in HRS-D score from baseline (50.0% vs 29.6%; number needed to treat, 4.9 [95% CI, 3.2-10.4]) than usual care patients (P < .001). Men with depression were particularly likely to benefit from the intervention (SF-36 MCS: Delta, 5.7 points; 95% CI, 2.2-9.2; P = .001). However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group. Conclusion: Compared with usual care, telephone-delivered collaborative care for treatment of post-CABG depression resulted in improved HRQL, physical functioning, and mood symptoms at 8-month follow-up. Trial registration: clinicaltrials.gov Identifier: NCT00091962.

JAMA · randomised controlled trial · 230 citationsread the source →

Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial.

Objective: To assess the effectiveness of a primary care based programme of exercise on prescription among relatively inactive women over a two year period. Design: Randomised controlled trial. Setting: 17 primary care practices in Wellington, New Zealand Participants: 1089 women aged 40-74 not undertaking 30 minutes of moderate intensity physical activity on at least five days of the week Intervention: Brief physical activity intervention led by nurse with six month follow-up visit and monthly telephone support over nine months. Main outcome measure: Physical activity assessed at baseline and 12 and 24 months. Secondary outcomes were quality of life (SF-36), weight, waist circumference, blood pressure, concentrations of fasting serum lipids, glycated haemoglobin (HbA(1c)), glucose, insulin, and physical fitness. Results: Mean age was 58.9 (SD 7) years. Trial retention rates were 93% and 89% at 12 and 24 months, respectively. At baseline, 10% of intervention participants and 11% of control participants were achieving 150 minutes of at least moderate intensity physical activity a week. At 12 months rates increased to 43% and 30% and at 24 months to 39.3% and 32.8% (P<0.001), respectively. SF-36 physical functioning (P=0.03) and mental health (P<0.05) scores improved more in intervention compared with control participants, but role physical scores were significantly lower (P<0.01). There were no significant differences in clinical outcomes. More falls (P<0.001) and injuries (P=0.03) were recorded in the intervention group. Conclusions: This programme of exercise on prescription increased physical activity and quality of life over two years, although falls and injuries also increased. This finding supports the use of exercise on prescription programmes as part of population strategies to reduce physical inactivity. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTRN012605000490673.

BMJ (Clinical research ed.) · randomised controlled trial · 108 citationsread the source →

Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial.

Background: Health anxiety has been treated by therapists expert in cognitive behaviour therapy with some specific benefit in some patients referred to psychological services. Those in hospital care have been less often investigated. Following a pilot trial suggesting efficacy we carried out a randomised study in hospital medical clinics. Methods: We undertook a multicentre, randomised trial on health anxious patients attending cardiac, endocrine, gastroenterological, neurological, and respiratory medicine clinics in secondary care. We included those aged 16-75 years, who satisfied the criteria for excessive health anxiety, and were resident in the area covered by the hospital, were not under investigation for new pathology or too medically unwell to take part. We used a computer-generated random scheme to allocate eligible medical patients to an active treatment group of five-to-ten sessions of adapted cognitive behaviour therapy (CBT-HA group) delivered by hospital-based therapists or to standard care in the clinics. The primary outcome was change in health anxiety symptoms measured by the Health Anxiety Inventory at 1 year and the main secondary hypothesis was equivalence of total health and social care costs over 2 years, with an equivalence margin of £150. Analysis was by intention to treat. The study is registered with controlled-trials.com, ISRCTN14565822. Findings: Of 28,991 patients screened, 444 were randomly assigned to receive either adapted cognitive behaviour therapy (CBT-HA group, 219 participants) or standard care (standard care group, 225), with 205 participants in the CBT-HA group and 212 in the standard care group included in the analyses of the primary endpoints. At 1 year, improvement in health anxiety in the patients in the CBT-HA group was 2·98 points greater than in those in the standard care group (95% CI 1·64-4·33, p<0·0001), and twice as many patients receiving cognitive behaviour therapy achieved normal levels of health anxiety compared with those in the control group (13·9% vs 7·3%; odds ratio 2·15, 95% CI 1·09-4·23, p=0·0273). Similar differences were observed at 6 months and 2 years, and there were concomitant reductions in generalised anxiety and, to a lesser extent, depression. Of nine deaths, six were in the control group; all were due to pre-existing illness. Social functioning or health-related quality of life did not differ significantly between groups. Equivalence in total 2-year costs was not achieved, but the difference was not significant (adjusted mean difference £156, 95% CI -1446 to 1758, p=0·848). Interpretation: This form of adapted cognitive behaviour therapy for health anxiety led to sustained symptomatic benefit over 2 years, with no significant effect on total costs. It deserves wider application in medical care. Funding: National Institute for Health Research Health Technology Assessment Programme.

Lancet (London, England) · randomised controlled trial · 96 citationsread the source →

PACE-UP (Pedometer and consultation evaluation--UP)--a pedometer-based walking intervention with and without practice nurse support in primary care patients aged 45-75 years: study protocol for a randomised controlled trial.

Background: Most adults do not achieve the 150 minutes weekly of at least moderate intensity activity recommended for health. Adults' most common physical activity (PA) is walking, light intensity if strolling, moderate if brisker. Pedometers can increase walking; however, most trials have been short-term, have combined pedometer and support effects, and have not reported PA intensity. This trial will investigate whether pedometers, with or without nurse support, can help less active 45-75 year olds to increase their PA over 12 months. Methods/design: Design: Primary care-based 3-arm randomized controlled trial with 12-month follow-up and health economic and qualitative evaluations. Participants: Less active 45-75 year olds (n = 993) will be recruited by post from six South West London general practices, maximum of two per household and households randomised into three groups. Step-count and time spent at different PA intensities will be assessed for 7 days at baseline, 3 and 12 months by accelerometer. Questionnaires and anthropometric assessments will be completed. Intervention: The pedometer-alone group will be posted a pedometer (Yamax Digi-Walker SW-200), handbook and diary detailing a 12-week pedometer-based walking programme, using targets from their baseline assessment. The pedometer-plus-support group will additionally receive three practice nurse PA consultations. The handbook, diary and consultations include behaviour change techniques (e.g., self-monitoring, goal-setting, relapse prevention planning). The control group will receive usual care. Outcomes: Changes in average daily step-count (primary outcome), time spent sedentary and in at least moderate intensity PA weekly at 12 months, measured by accelerometry. Other outcomes include change in body mass index, body fat, self-reported PA, quality of life, mood and adverse events. Cost-effectiveness will be assessed by the incremental cost of the intervention to the National Health Service and incremental cost per change in step-count and per quality adjusted life year. Qualitative evaluations will explore reasons for trial non-participation and the interventions' acceptability. Discussion: The PACE-UP trial will determine the effectiveness and cost-effectiveness of a pedometer-based walking intervention delivered by post or practice nurse to less active primary care patients aged 45-75 years old. Approaches to minimise bias and challenges anticipated in delivery will be discussed. Trial registration: ISRCTN98538934.

Trials · randomised controlled trial · 22 citationsread the source →

The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock.

Purpose: This study was designed to identify factors associated with in-intensive care unit (ICU) death and develop a practical mortality risk score for venoarterial-extracorporeal membrane oxygenation (VA-ECMO)-treated acute myocardial infarction (AMI) patients. Long-term survivors' health-related quality of life (HRQOL), anxiety, depression, and post-traumatic stress disorder (PTSD) frequencies were also assessed. Methods: Data from 138 ECMO-treated AMI patients admitted to two French ICUs (2008-2013) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQOL, psychological and PTSD status. Results: Sixty-five patients (47%) survived to ICU discharge. On the basis of multivariable logistic regression analyses, the ENCOURAGE score was constructed with seven pre-ECMO parameters: age >60, female sex, body mass index >25 kg/m(2), Glasgow coma score <6, creatinine >150 μmol/L, lactate (<2, 2-8, or >8 mmol/L), and prothrombin activity <50%. Six months after ECMO, probabilities of survival were 80, 58, 25, 20, and 7% for ENCOURAGE score classes 0-12, 13-18, 19-22, 23-27, and ≥28, respectively. The ENCOURAGE score ROC AUC [0.84 (95% CI 0.77-0.91)] was significantly better than those of the SAVE, SAPS II, and SOFA scores. Survivors' HRQOL evaluated after median follow-up of 32 months revealed satisfactory mental health but persistent physical and emotional-related difficulties, with 34% (95% CI 20-49%) anxiety, 20% (95% CI 8-32%) depression, and 5% (95% CI 0-12%) PTSD symptoms reported. Conclusions: The ENCOURAGE score might be a useful tool to predict mortality of severe cardiogenic shock AMI patients who received VA-ECMO. However, it now needs prospective validation on other populations of AMI patients.

Intensive care medicine · cohort or longitudinal · 351 citationsread the source →

Going to scale: a nonrandomized nationwide trial of the KiVa antibullying program for grades 1-9.

Objective: The effects of school-based antibullying programs have typically been examined on small samples, with number of schools ranging from 1 to 78 (Farrington & Ttofi, 2009). This study investigated the effectiveness of the KiVa antibullying program in the beginning of its nationwide implementation in Finland. Method: At each time point, the participants included 888 schools with approximately 150,000 students in 11,200 classrooms in Grades 1-9 (8-16 years of age; 51% boys and 49% girls). Victims and bullies were identified with the global questions from the Revised Olweus Bully/Victim Questionnaire (Olweus, 1996), utilizing the criteria suggested by Solberg and Olweus (2003). The program effects were examined by calculating odds ratios based on a cohort-longitudinal design, correcting the standard errors for clustering. Results: During the first 9 months of implementation, the KiVa program reduced both victimization and bullying, with a control/intervention group odds ratio of 1.22 (95% CI [1.19, 1.24]) for victimization and 1.18 (95% CI [1.15, 1.21]) for bullying. Conclusions: Generalized to the Finnish population of 500,000 students, this would mean a reduction of approximately 7,500 bullies and 12,500 victims.

Journal of consulting and clinical psychology · clinical trial · 78 citationsread the source →

Pharmacokinetics of once-daily darunavir-ritonavir and atazanavir-ritonavir over 72 hours following drug cessation.

The object of this study was to investigate the pharmacokinetics of darunavir-ritonavir and atazanavir-ritonavir once-daily dosing over 72 h (h) following drug intake cessation. Volunteers received darunavir-ritonavir at 800 and 100 mg, respectively, once daily for 10 days, followed by a 7-day washout period, and atazanavir-ritonavir at 300 and 100 mg, respectively, once daily for 10 days. Full pharmacokinetic profiles were assessed for each phase for the 72 h following day 10. Pharmacokinetic parameters were determined over 24 h and to the last measurable concentration by noncompartmental methods. Seventeen subjects completed the study. The geometric mean (GM) terminal elimination half-life to 72 h of darunavir was 6.48 h, which was lower than the 0- to 24-h half-life (10.70 h). The terminal elimination half-life of atazanavir was 6.74 h, which was lower than the 0- to 24-h half-life (13.72 h). All subjects but one had darunavir concentrations higher than the target of 550 ng/ml for protease-resistant HIV isolates (equivalent to 10 times the protein-binding-corrected 50% inhibitory concentration [IC(50)] for wild-type virus) at 24 h postdose, and 14 out of 17 had concentrations higher than the target at 30 h postdose (GM of 1,088 and 851 ng/ml). All subjects had atazanavir concentrations above the suggested minimum effective concentration of 150 ng/ml (equivalent to 10 times the protein-binding-corrected IC(50) for wild-type virus) at 24 and 30 h postdose (GM of 693 and 392 ng/ml). Two of 17 and 5 of 17 subjects were above target at 48 h postdose while on darunavir-ritonavir and atazanavir-ritonavir. Ritonavir half-life to 72 h was 6.84 h with darunavir and 6.07 with atazanavir. This study investigated the pharmacokinetic forgiveness of two boosted protease inhibitors. Although the rates of decline of darunavir and atazanavir slightly increased as ritonavir concentrations declined, most individuals had concentrations 6 h after the end of the ideal dosing interval of 24 h which were above the cutoff used to define therapeutic concentrations.

Antimicrobial agents and chemotherapy · clinical trial · 31 citationsread the source →

Association between healthy lifestyle and memory decline in older adults: 10 year, population based, prospective cohort study.

Objective: To identify an optimal lifestyle profile to protect against memory loss in older individuals. Design: Population based, prospective cohort study. Setting: Participants from areas representative of the north, south, and west of China. Participants: Individuals aged 60 years or older who had normal cognition and underwent apolipoprotein E (APOE) genotyping at baseline in 2009. Main outcome measures: Participants were followed up until death, discontinuation, or 26 December 2019. Six healthy lifestyle factors were assessed: a healthy diet (adherence to the recommended intake of at least 7 of 12 eligible food items), regular physical exercise (≥150 min of moderate intensity or ≥75 min of vigorous intensity, per week), active social contact (≥twice per week), active cognitive activity (≥twice per week), never or previously smoked, and never drinking alcohol. Participants were categorised into the favourable group if they had four to six healthy lifestyle factors, into the average group for two to three factors, and into the unfavourable group for zero to one factor. Memory function was assessed using the World Health Organization/University of California-Los Angeles Auditory Verbal Learning Test, and global cognition was assessed via the Mini-Mental State Examination. Linear mixed models were used to explore the impact of lifestyle factors on memory in the study sample. Results: 29 072 participants were included (mean age of 72.23 years; 48.54% (n=14 113) were women; and 20.43% (n=5939) were APOE ε4 carriers). Over the 10 year follow-up period (2009-19), participants in the favourable group had slower memory decline than those in the unfavourable group (by 0.028 points/year, 95% confidence interval 0.023 to 0.032, P<0.001). APOE ε4 carriers with favourable (0.027, 95% confidence interval 0.023 to 0.031) and average (0.014, 0.010 to 0.019) lifestyles exhibited a slower memory decline than those with unfavourable lifestyles. Among people who were not carriers of APOE ε4, similar results were observed among participants in the favourable (0.029 points/year, 95% confidence interval 0.019 to 0.039) and average (0.019, 0.011 to 0.027) groups compared with those in the unfavourable group. APOE ε4 status and lifestyle profiles did not show a significant interaction effect on memory decline (P=0.52). Conclusion: A healthy lifestyle is associated with slower memory decline, even in the presence of the APOE ε4 allele. This study might offer important information to protect older adults against memory decline. Trial registration: ClinicalTrials.gov NCT03653156.

BMJ (Clinical research ed.) · 157 citationsread the source →

Independent association between nocturnal intermittent hypoxemia and metabolic dyslipidemia.

Background: There is growing evidence from animal models that intermittent hypoxemia (IH) may induce dyslipidemia. Altered lipid metabolism may contribute to the increased cardiovascular risk observed in obstructive sleep apnea (OSA). In this multisite, cross-sectional study, we tested the hypothesis that there is an independent association between nocturnal IH and dyslipidemia in OSA. Methods: Fasting serum lipid levels were measured in 2,081 patients (638 women) undergoing nocturnal recording for clinical suspicion of OSA. Multivariate regression analyses were performed to evaluate the independent associations between oxygen desaturation index (ODI) and lipid profile after adjustment for potential confounders, including components of the metabolic syndrome (MS) or the MS itself. Adjusted OR for metabolic dyslipidemia (triglycerides [TG] ≥ 150 mg/dL and high-density lipoprotein cholesterol [HDL-C] ≤ 50 mg/dL for women and ≤ 40 mg/dL for men) according to quartiles of ODI were determined by logistic regression. Results: Total cholesterol and low-density lipoprotein cholesterol were not associated with ODI. In contrast, nocturnal IH and OSA severity were associated with higher TG levels and lower HDL-C levels after adjustment for confounding factors. The association between ODI and TG and HDL-C levels was independent of the MS. Adjusted OR (95% CIs) for metabolic dyslipidemia were 1 (reference), 1.56 (1.24-1.96), 1.72 (1.29-2.29), and 1.93 (1.55-2.41) for ODI ≤ 7, > 7 to ≤ 18, > 18 to ≤ 38, and > 38, respectively (P < .0001 for linear trend). Conclusions: Nocturnal IH is independently associated with metabolic dyslipidemia, which may predispose patients with OSA to a higher risk of cardiovascular disease.

Chest · cohort or longitudinal · 86 citationsread the source →

Nutritional Evaluation and Optimisation in Neonates (NEON) trial of amino acid regimen and intravenous lipid composition in preterm parenteral nutrition: a randomised double-blind controlled trial

Background: Parenteral nutrition (PN) is central to the care of very immature infants. Early intakes of higher amounts of amino acids and the use of lipid emulsions containing fish oils are recommended by current international recommendations. Objective: To confirm the safety and demonstrate efficacy of the immediate introduction of the recommended daily intake of amino acids (Imm-RDI) and soya bean oil, medium-chain triglycerides, olive oil and fish oil lipid in PN to increase non-adipose (lean) body mass and decrease intrahepatocellular lipid (IHCL) content. Design: Multicentre, double-blind, 2 × 2 factorial and randomised controlled trial (RCT). Setting: Neonatal units in London and south-east England, UK. Participants: Extremely preterm infants born before 31 weeks of gestation without major congenital or life-threatening abnormalities who could to be randomised to receive PN within 24 hours of birth. Interventions: Infants were randomised within 24 hours of birth to receive PN containing either high [RDI of amino acids (Imm-RDI)] or low [incremental amino acids (Inc-AA) control] levels of amino acids. In addition, infants were randomised to receive either 20% SMOFlipid® (Fresenius Kabi AG, Richmond Hill, ON, Canada) or 20% Intralipid® (Fresenius Kabi AG, Richmond Hill, ON, Canada) (control). This resulted in four groups: (1) Inc-AA/Intralipid, (2) Inc-AA/SMOFlipid, (3) Imm-RDI/Intralipid and (4) Imm-RDI/SMOFlipid. The intervention was continued until infants were receiving 150 ml/kg/day of enteral feeds for 24 hours. Primary outcome measure: For the amino acid intervention, this was non-adipose or lean body mass measured by magnetic resonance imaging. For the lipid composition intervention, this was IHCL content as measured by hepatic magnetic resonance spectroscopy. Primary outcomes were measured at term age equivalent, between 37 and 44 weeks postmenstrual age. Results: We randomised 168 infants born before 31 weeks of gestation. We evaluated outcomes, at term, in 133 infants. There were no significant differences in non-adipose mass between the Imm-RDI and Inc-AA groups [adjusted mean difference 1.0 g, 95% confidence interval (CI) –108 to 111 g] or in levels of IHCLs between the SMOFlipid and Intralipid groups (adjusted mean SMOFlipid to Intralipid ratio 1.1, 95% CI 0.8 to 1.6). Infants receiving the Imm-RDI were more likely than Inc-AA infants to have blood urea nitrogen levels > 7 mmol/l [75% vs. 49% (p < 0.01)] and > 10 mmol/l [49% vs. 18% (p < 0.01)]. Furthermore, head circumference at term was smaller in the Imm-RDI group (mean difference –0.8 cm, 95% CI –1.5 to –0.1 cm; p = 0.02). There were no significant differences in any prespecified secondary outcomes, including adiposity, liver function tests, weight, length and mortality. Limitations: Not all eligible babies were available for recruitment, as pharmacy staff trained in clinical trial procedures were unavailable at weekends in three of the four centres. We were able to assess brain volumes in only one-third of participants, as imaging was carried out while the participants were sleeping naturally and we measured primary outcomes first and continued to brain imaging only if the infant remained asleep. Conclusions: Immediate delivery of the recommended daily intake of parenteral amino acids does not benefit body composition or growth to term and may be harmful; SMOFlipid does not affect IHCL content. Future work: The long-term functional outcomes of early administration of RDI of amino acids and the use of SMOFlipid, including neurodevelopment, body composition and metabolic health, should be evaluated. Trial registration: Current Controlled Trials ISRCTN29665319 and EudraCT 2009-016731-34. Funding: This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership.

review · 2 citationsread the source →

Vagus nerve stimulation: from pre-clinical to clinical application: challenges and future directions.

Vagus nerve stimulation was performed experimentally for the first time more than 150 years ago. In the 1980s and 1990s, vagus nerve stimulation was shown, both in the anesthetized and in the conscious animal, to exert marked antiarrhythmic effects, particularly during acute myocardial ischemia. There is a strong rationale for a beneficial effect of augmented vagal activity in the setting of chronic heart failure. Studies in experimental models of heart failure showed that chronic vagus nerve stimulation exerts beneficial effects on left ventricular function and on survival. Vagus nerve stimulation is approved in man for refractory epilepsy and depression. The first-in-man study performed in 32 patients with chronic heart failure suggests that vagus nerve stimulation was safe and well tolerated. Six months of open-label treatment was associated with significant improvements (P < 0.001) in NYHA class, quality of life, 6-min walk test, LV ejection fraction (from 22 ± 7 to 29 ± 8%), and LV systolic volumes (P = 0.02). These improvements were maintained at 1 year. Mechanisms of action may include the following: heart rate, anti-adrenergic, anti-apoptotic, and anti-inflammatory effects as well as an increase in nitric oxide. Controlled clinical trials will start soon to assess whether vagus nerve stimulation can indeed represent a new non-pharmacological approach for the treatment of symptomatic heart failure.

Heart failure reviews · review · 123 citationsread the source →

Interventions for promoting habitual exercise in people living with and beyond cancer.

Background: The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important. Objectives: To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour? Search methods: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews. Selection criteria: We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis. Data collection and analysis: Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative. Main results: Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials. None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%). Authors' conclusions: Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.

The Cochrane database of systematic reviews · meta-analysis · 65 citationsread the source →

Hope for the Best, and Prepare for the Worst

Medical Writings4 March 2003Hope for the Best, and Prepare for the WorstAnthony L. Back, MD, Robert M. Arnold, MD, and Timothy E. Quill, MDAnthony L. Back, MDFrom Veterans Administration Puget Sound Health Care System, University of Washington, Seattle, Washington; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Rochester, Rochester, New York., Robert M. Arnold, MDFrom Veterans Administration Puget Sound Health Care System, University of Washington, Seattle, Washington; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Rochester, Rochester, New York., and Timothy E. Quill, MDFrom Veterans Administration Puget Sound Health Care System, University of Washington, Seattle, Washington; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Rochester, Rochester, New York. Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-138-5-200303040-00028 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Mr. J., a 40-year-old father of two young children, has metastatic non–small-cell lung cancer that has not responded to two different chemotherapy regimens. His physician, Dr. B., explains that the cancer is progressing. Mr. J. says, Isn't there something you can do? Please don't give up on me. Dr. B. pauses and says, Well, there is an experimental protocol we could try. When faced with life-threatening illness, patients and physicians often feel that they must choose between hoping for disease remission and preparing for death. Mr. J. wants to fight the cancer in hope of living longer, and his physician ...References1. Delvecchio Good MJ, Good BJ, Schaffer C, Lind SE. American oncology and the discourse on hope. Cult Med Psychiatry. 1990;14:59-79. 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On Dying and Denying: A Psychiatric Study of Terminality. New York: Behavioral Publications; 1972. Google Scholar9. McCormick TR, Conley BJ. Patients' perspectives on dying and on the care of dying patients. West J Med. 1995;163:236-43. [PMID: 7571586] MedlineGoogle Scholar10. Barnard D, Boston P, Towers AM, Lambrinidou Y. Crossing over: Narratives of Palliative Care. New York: Oxford Univ Pr; 2000. Google Scholar11. Kuhl D. What Dying People Want: Practical Wisdom for the End of Life. New York: PublicAffairs; 2002. Google Scholar12. Herth K. Fostering hope in terminally-ill people. J Adv Nurs. 1990;15:1250-9. [PMID: 2269747] CrossrefMedlineGoogle Scholar13. Quill TE, Cassel CK. Nonabandonment: a central obligation for physicians. Ann Intern Med. 1995;122:368-74. [PMID: 7847649] LinkGoogle Scholar14. Crawshaw R, Rogers DE, Pellegrino ED, Bulger RJ, Lundberg GD, Bristow LR, . Patient-physician covenant. JAMA. 1995;273:1553. [PMID: 7739086] CrossrefMedlineGoogle Scholar15. Maguire P. 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Palliative and end-of-life care in the African American community. JAMA. 2000;284:2518-21. [PMID: 11074786] CrossrefMedlineGoogle Scholar32. Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. [PMID: 2393317] CrossrefMedlineGoogle Scholar33. Remen RN. Recapturing the soul of medicine: physicians need to reclaim meaning in their working lives. West J Med. 2001;174:4-5. [PMID: 11154646] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Veterans Administration Puget Sound Health Care System, University of Washington, Seattle, Washington; University of Pittsburgh, Pittsburgh, Pennsylvania; University of Rochester, Rochester, New York. Acknowledgments: The authors thank Dr. Susan Block for her helpful suggestions about the role of ambivalence. Grant Support: Drs. Back and Arnold are Faculty Scholars of the Project on Death in America. Dr. Arnold was also supported by the Greenwall Foundation, Ladies Hospital Aid Society of Western Pennsylvania, and the LAS Trust Foundation. Corresponding Author: Anthony Back, MD, Veterans Administration Puget Sound Health Care System, 1660 South Columbian Way S111, Seattle, WA 98108; e-mail, [email protected]washington.edu. Current Author Addresses: Dr. Back: Veterans Administration Puget Sound Health Care System, 1660 South Columbian Way S111, Seattle, WA 98108.Dr. Arnold: Section of Palliative Care and Medical Ethics, MUH 200 Lothrop Street 932, Pittsburgh, PA 15213.Dr. Quill: Palliative Care Program, University of Rochester School of Medicine, Box 601, 601 Elmwood Avenue, Rochester, NY 14642. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoHope for the Best, and Prepare for the Worst James D. 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A Culturally Sensitive ModelUnd wenn der Krebs doch wiederkommt? – Palliative Situation und VerlustPrognostication in dementiaPalliative care and its own identity, through an autoethnography: do you recognize these patterns?Hopeful dying? The meanings and practice of hope in palliative care family meetingsAdvance care planning in adult congenital heart disease: Unique approaches for a unique population3. Practice and Benefits of Advance Care PlanningCommunication principles and practices for making shared decisions about renal replacement therapy: a review of the literatureDevelopment of the Oncolo-GIST ("Giving Information Strategically & Transparently") Intervention Manual for Oncologist Skills Training in Advanced Cancer Prognostic Information CommunicationHope-Colored Glasses: Perceptions of Prognosis Among Pediatric Oncology Patients and Their ParentsJCS/JHFS 2021 Statement on Palliative Care in Cardiovascular DiseasesThe experiences and needs of couples affected by prostate cancer aged 65 and under: a qualitative studyRoles and Responsibilities of Nurses in Advance Care Planning in Palliative Care in the Acute Care SettingAdvance Care Planning – Vorausschauende VersorgungsplanungIllness and prognostic understanding in patients with hematologic malignanciesModels of Palliative Care Delivery for Individuals with Cystic Fibrosis: Cystic Fibrosis Foundation Evidence-Informed Consensus GuidelinesNonbeneficial Intensive Care: Misalignments Between Provider Assessments of Benefit and Use of Invasive TreatmentsThe considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative studyEnd-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual modelHoping for the best, planning for the worst: Palliative care approach to Parkinson disease during the COVID-19 pandemicEnd-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005–2014Identifying Goals of CareChapitre 23. Soins palliatifs en cancérologiePalliative Care in Lung CancerPalliative Care in MCS Patients: Insights into Current Practice and OutcomesEnd of life care for patients with meningiomaDecision-Making about the Place of Death for Cancer Patients: A Concept AnalysisThirty Years Later: An Oncologist Reflects on Kübler-Ross's WorkReply to Hope, optimism, and the importance of caregivers in end‐of‐life careAdding a Wider Range and "Hope for the Best, and Prepare for the Worst" Statement: Preferences of Patients with Cancer for Prognostic CommunicationEmotions in the room: common emotional reactions to discussions of poor prognosis and tools to address themThe Use of Expectancy and Empathy When Communicating With Patients With Advanced Breast Cancer; an Observational Study of Clinician–Patient ConsultationsThe Effects of Adding Reassurance Statements: Cancer Patients' Preferences for Phrases in End-of-Life DiscussionsFinding Hope and Healing When Cure Is Not PossiblePalliative Care in the Intensive Care Unit (ICU)PrognosticationKommunikation, Partizipation, PatientenorientierungAdvance directives from haematology departments: the patient's freedom of choice and communication with families. A qualitative analysis of 35 written documentsQu'écrivent les personnes atteintes d'hémopathies malignes dans leurs directives anticipées ? Analyse qualitative de 35 écritsSupporting Family Decision-making for a Child Who Is Seriously Ill: Creating Synchrony and ConnectionHospice Use and Palliative Care for Patients With Heart FailureNICU Communication: The Many Disguises of OpportunityCommunication skills training for healthcare professionals working with people who have cancerKeeping Expectations in Check With Immune Checkpoint InhibitorsSources of parental hope in pediatric oncology"How Much Time Do I Have?": Communicating Prognosis in the Era of Exceptional RespondersWhen a Patient Is Reluctant To Talk About It: A Dual Framework To Focus on Living Well and Tolerate the Possibility of DyingDistress Due to Prognostic Uncertainty in Palliative Care: Frequency, Distribution, and Outcomes among Hospitalized Patients with Advanced CancerThree big things in neuropalliative care: Communication, personhood and uncertaintyAddressing a Patient's Hope for a MiraclePalliative Care in the Intensive Care Unit (ICU)Goals of Care and Difficult ConversationsPalliative Care for Geriatric Psychiatric Patients with Life-Limiting IllnessHope in the Context of Pain and Palliative CareSuffering, Hope, and HealingEnd of Life SupportPalliative and End-of-Life CareA Proposed Model for Perinatal Palliative CareHope and Uncertainty in the Age of MiraclesREMAP: A Framework for Goals of Care ConversationsQualitative Study on the Perceptions of Terminally Ill Cancer Patients and Their Family Members Regarding End-of-Life Experiences Focusing on Palliative SedationHow should realism and hope be combined in physician–patient communication at the end of life? An online focus-group study among participants with and without a Muslim backgroundPharmacological Management of People Living with End-Stage Chronic Obstructive Pulmonary DiseaseThe Liminal and the ParallaxIs There Hope? Is She There? How Families and Clinicians Experience Severe Acute Brain InjuryPalliative Care in Liver Transplantation: When to Consult a SpecialistEarly Palliative Care for Patients with Advanced CancerPalliative Care and End-of-Life Considerations in Patients with PAH–CHDCommunicationFamily discussions on life-sustaining interventions in neurocritical careA Singular Hope: How the Discussion Around Cancer Surgery Sometimes FailsCommunicating prognostic uncertainty in potential end-of-life contexts: experiences of family membersDirectives anticipées en dermato-oncologie : situation actuelle et perspectivesUsing a supportive care framework to understand and improve palliative care among cancer patients in AfricaInadequate Palliative Care in Chronic Lung Disease. An Issue of Health Care InequalityPalliative Care in Liver Transplantation, When to Consult a SpecialistPalliative Care and the Dying PatientDeeper Conversations Need Not Wait Until the EndPalliative CareAssessing Goals of CarePalliative Care for Patients with End-Stage Liver DiseaseCommunications by Professionals in Palliative CareCommunication with Older, Seriously Ill PatientsTeaching Colleagues How to Discuss Prognosis as Part of a Hospital-Wide Quality Improvement Project: The Positive Impact of a 90-Minute WorkshopParents' Faith and Hope during the Pediatric Palliative Phase and the Association with Long-Term Parental AdjustmentParental Hope for Children With Advanced CancerBreaking Bad News and Discussing Goals of Care in the Intensive Care UnitImproving End-of-Life Care Prognostic DiscussionsRespect des volontés en fin de vie : étude de faisabilité d'une information sur la personne de confiance et les directives anticipéesFrom hope to hope: The experience of older Chinese people with advanced cancerPreferences of Patients With Parkinson's Disease for Communication About Advanced Care PlanningPalliative Care and Hospice in Patients with Advanced Cardiovascular DiseasePalliative Care in Liver Transplantation, When to Consult a SpecialistEnd-of-Life Care and Treatment Preferences Among Adults with Congenital Heart DiseaseThe Changing Role of Palliative Care in the ICUCurrent State of the Art and Science of Patient-Clinician Communication in Progressive Disease: Patients' Need to Know and Need to Feel KnownA Communication Framework for Dialysis Decision-Making for Frail Elderly PatientsFamilies and the transition to specialist palliative careDying with Dignity in the Intensive Care UnitPalliative and End-of-Life Care in StrokeSoins palliatifs en cancérologieFactors influencing patients' hope in stroke and spinal cord injury: A narrative reviewMedicolegal aspects of treatment on the Intensive Care UnitCommunicating About Prognosis: Ethical Responsibilities of Pediatricians and ParentsCommunication Between Doctor and Cancer PatientManaging brain metastases patientswith and without radiotherapy: initial lessonsfrom a team-based consult service through a multidisciplinary integrated palliative oncology clinicParent perceptions of early prognostic encounters following children's severe traumatic brain injury: 'Locked up in this cage of absolute horror'Trajectory of parental hope when a child has difficult-to-treat cancer: a prospective qualitative study"In the Beginning . . . "'I don't want to burden my family': handling communication challenges in geriatric oncologyPalliative care for people with heart failure: Summary of current evidence and future directionEnd-of-Life Care Discussions in Patients With Advanced CancerPatient's expression of hope and illness narratives in three neurological conditions: a meta-ethnographyAcute Lung Injury and Acute Respiratory Distress Syndrome Requiring Tracheal Intubation and Mechanical Ventilation in the Intensive Care UnitCoping des patients atteints de cancer en phase palliative et communication médicaleThe Cultivation of Prognostic Awareness Through the Provision of Early Palliative Care in the Ambulatory Setting: A Communication GuideSurvival times of women with metastatic breast cancer starting first-line chemotherapy in routine clinical practice versus contemporary randomised trialsBreaking Bad News in Counseling: Applying the PEWTER Model in the School SettingLatent Classes of Prognosis Conversations in Palliative Care: A Mixed-Methods StudyImproving Oncology Nurses' Communication Skills for Difficult ConversationsBoth Maintaining Hope and Preparing for Death: Effects of Physicians' and Nurses' Behaviors From Bereaved Family Members' PerspectivesFamily involvement in the end-of-life decisions of competent intensive care patientsHope in the Context of Pain and Palliative CareSuffering, Hope, and HealingEthical Issues in Stroke PatientsBesonderheiten der pädiatrischen Palliativversorgung bei besonderen PatientengruppenWhat Is Known About Prognostication in Advanced Illness?What Special Considerations Are Needed for Treating Patients With Chronic Liver Disease?The meaning of cancer: implications for family finances and consequent impact on lifestyle, and Communication to hope is a Hope in the context of care Discussions for Patients With Life-Limiting Strategies for of the Kidney Disease by Elderly Patients and A Much a Family Meeting with an in with congenital heart disease: A for early of Patients with Ethical End-of-Life Issues in Patients with Lung Management and Palliative CareHope Is a and Decision The Need for a To Patient in Decision a need for pediatric palliative with Prognostic Disclosure of Families of Patients with Experiences of hope among cancer patients in palliative care planning in chronic disease: barriers and of about palliative care and end-of-life a of skills for care with heart a review and narrative Issues Among People Living With Advanced of Hope as a of Distress and Life in a of Cancer Hope and Prognostic Nurses' Perspectives on Their Role When Patients Life-Limiting and the of Hope in with Severe experience of the of in a When Discussing and Life with a A Is of qualitative study in neurological and hope: communication with in the for of and and Death: A of Dying Cancer Patients' Talk About care: on patient and family on and Practical to the Family a Decision in the in the practice of palliative of CarePalliative Care in Pediatric and Preparing for Death: Perspectives of Decision A. M. MD, MD, and B. MD, of in and Benefits of Early Phase Cancer What Do What Do Patients About Conversations at the End of Life Is the illness in the of of patients who in the intensive care Regarding Palliative and End-of-Life Care in Severe Chronic Obstructive Pulmonary Disease or Advanced by and for end-of-life care in the intensive care A by the American of Care der pädiatrischen Palliativversorgung bei besonderen and Prognostic in a A for to the Care in Advanced of Palliative Care of communication skills for oncology advanced practice about Lung Transplantation: of Patients and about lung needs of patients and support and Discussing Death in the A of Physician care and end-of-life decision in and palliative care Understanding the of With Ill Patients and care for patients with chronic About Prognosis Between and of Children With Preferences and the Impact of Prognostic Care and Intensive Care Unit Care: Care and Intensive Care Unit Care: Intensive Care Unit Care care: evaluation in clinical at of with and with Families in Palliative Care: Not for a to improve palliative care: Advanced heart Clinical and On a of Palliative Care: A for and on and en de la of Chinese Cancer Patients of the and by Their about Palliative Care for Patients with Chronic Obstructive Pulmonary or Not to Is the Pain When Pain and are family members with palliative care A qualitative and hope when the future with cancer patients and their Prognostic Communication With Advanced Cancer the End of the Relationship with Patients Who Are L. Back, MD, Robert M. Arnold, MD, James A. MD, MD, and A. Perceptions of and the of About the Communication Issues and issues to end‐of‐life careA conceptual framework for end-of-life care: A of influencing the of the about the of treatment and transition to palliative Years Later: An Oncologist Reflects on palliative and supportive care in advanced heart and Bad A Patient's for the Best, and Prepare for the D. Communication and Hope: Communication in Palliative Issues for the and Cancer and End-of-Life advanced care planning and of dying for people with of palliative care March Issue care March Issue March & by American of

Annals of Internal Medicine · case report · 366 citationsread the source →

Trauma exposure and PTSD prevalence among Yazidi, Christian and Muslim asylum seekers and refugees displaced to Iraqi Kurdistan.

Background: There is unreliable, and negligible information on the mental health and trauma-exposure of asylum-seekers and displaced refugees in the Iraqi Kurdistan region. Objectives: To evaluate how responsible the ethno-religious origins are, for the prevalence of trauma exposure and post-traumatic stress disorder (PTSD) in displaced Iraqi asylum-seekers and refugees residing in the Iraqi Kurdistan region. Methods: Structured interviews with a cross-sectional sample of 150 individuals, comprised of three self-identified ethno-religious groups (50 participants in each): Christians, Muslims, and Yazidis. Results: 100% prevalence of trauma exposure and 48.7% of current PTSD among refugees, 70% PTSD rate of Yazidi participants, which is significantly higher (p < 0.01) compared to 44% of Muslim participants and 32% of Christian participants. These findings were corroborated using the self-rated PTSD, DSM-5 Checklist, with more severe PTSD symptom scores (p < 0.001) obtained among Yazidis (43.1; 19.7), compared to Muslims (31.3; 20.1) and Christians (29.3; 17.8). Self-rated depressive symptoms (Patient Health Questionnaire-9) were also higher (p < 0.007) among Yazidis (12.3; 8.2) and Muslims (11.7; 5.9), compared to Christians (8.1; 7).

PloS one · 15 citationsread the source →

Promoting sexual well-being

INTRODUCTION The fundamental drive behind most feelings, thoughts, and behavior is sexuality. Sexuality influences the way an individual projects himself psychologically and socially, and it is determined by genetic, anatomical, physiological, and other biological characteristics, as well as sociocultural factors. Interpersonal relationships and developmental experiences also shape individual sexuality in a significant way. Sexuality includes the gender identity of a person, internal sexual representations including private thoughts and fantasies as well as manifest behavior with self and others. Our sense of humor, way of dressing, and way of talking are all influenced by sexuality. Neuropsychologist Karl Pribram described four drives that motivate us to accomplish our goals. These drives included feeding, fighting, fleeing, and sex. Physical and psychological health essentially needs these drives. Hence, sex is a crucial aspect of life and sexual health is an important component of overall health. This has been realized by scholars in every field and texts and traditions of ancient origin in almost all cultures attempted to understand, explain, and value sexual knowledge in health and disease. However, sex and sexuality are still relatively less understood and less studied drives.[1] The history of human sexuality is as ancient as human history. Artifacts from some of the ancient cultures are thought to be fertility totems. A Hindu epic Kama Sutra (400 BC–200 BC) describes love, pleasure, and desire. Torah, Quran, and Bible also have rules, advice, and stories about sex. Scientific studies on sexuality started only 150 years ago. Henry Havelock Ellis, a British physician, used case study methods to study sexuality scientifically.[2] He emphasized sexuality of homosexuals is different from transgenders. He also advocated equal sexual rights for women. Sigmund Freud, the father of Psychiatry, linked sex to healthy development and recognized sexuality throughout life. Alfred Kinsey who is recognized as the father of modern sexuality research believed that most sexual knowledge is guesswork and unbiased scientific literature about sexuality is scarce.[3,4] Although a lot of research studies have been conducted and attention has been given to sexuality in recent years, scientific information is still insufficient in several domains. SEXUAL HEALTH The term sex is used in several different ways in different contexts. Sex describes the means of biological reproduction. Sex also describes sexual organs both internal and external defining an individual as male or female. World Health Organisation[5] has defined sexual health as “a state of physical, emotional, mental, and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Human sexuality emerges in the body, but, like other human phenomena, it simultaneously unfolds in mental landscapes, social relations, and cultural spheres. Sexuality is closely linked to personal integrity, identity, body image, bonding, and social curiosity. Physiological and psychosocial determinants contribute significantly to sexual health.” The mere absence of sexual dysfunction is not considered sexual health. The sexual health is often reflected as normal sexual behavior. The normal sexual behavior is defined as having experiences that are pleasurable for oneself and one's partner and may or may not involve sexual intercourse. The behavior is also free from guilt, compulsion, or distress. The concept of normal sexual behavior is also significantly influenced by social and cultural factors. Sexual health like any other health is multifactorial and contextual.[6] The core concepts related to sexual health are defined in Table 1, and Figure 1 elucidates the component of sexual well-being. Figure 1: Components of sexual well-beingTable 1: Core concepts related to sexual wellnessGENDER AND SEXUAL ORIENTATION Gender represents the sociological and psychological representation of biological sex, which includes gender roles and gender identity. Although sex and gender are important aspects of a person's identity, it does not convey anything about orientation. Orientation refers to a person's sexual attraction to others. A person's capacity to have a sexual interest in others refers to sexual attraction. An individual must be comfortable with their sex role and chosen gender and accept themselves without guilt, shame, or fear and should be able to maintain good relationships with both sexes, regardless of whether they are intimate or platonic.[7] Gender equality includes concepts related to equal access to resources including material resources, such as money, clothes, books, etc., and non-material resources, such as love, care, and attention, as well as opportunities in education, occupation, economic pursuits, social acceptance, and decision making for their life. Gender sensitization is about providing information and strategy teaching in behavior modification regarding the adoption of gender equality in speech, behavior, and conduct. Provisions of appropriate information, sensitization, training of relevant stakeholders, and creating an enabling environment that is supportive of freedom of expression about one's orientation and gender identity are important aspects in improving sexual health promotion efforts. ATTITUDE TOWARD SEX Sexuality and general health are associated in diverse and intricate ways, and they can interact both in positive and negative ways. Culture plays a significant role in determining individuals' attitudes toward sexuality. Beliefs about normal and deviant sexual behavior are majorly influenced by culture. Concepts related to sexuality and gender are changing rapidly across the globe owing to rapid globalization and information technology advances, resulting in enhanced dissemination of information and ideas. Traditionally, cultures has been broadly classified as sex-negative and sex-positive cultures. India and the Asian subcontinent were considered sex-negative culture where sex was considered majorly for procreation. Western countries which were considered sex-positive culture considered sex beyond procreation.[8] The contemporary world is much more globalized and homogeneous, and previous concepts are only partially correct. However, consideration of sex as a taboo subject and the unavailability of sex education are still having much influence on the attitudes of people related to sexuality, especially in India. MYTHS ABOUT SEXUALITY A lot of myths and misconceptions prevail about sexuality. In women, myths, like sex is dirty, sex is sweat only during the second decade, having sex during menstruation is harmful, better sex with bigger breasts, women “no” always convey “yes,” orgasm is a must in all encounters, only vaginal and clitoral sex leads to orgasm, women never masturbate, and sexual desire decreases dramatically after menopause, are common and prevalent. Some of the common myths about male sexuality include erectile dysfunction is incurable, if a man does not get an erection by the mere sight of his partner implies that he is unable to perform, masturbation and nocturnal emission leads to impotence, and semen is a special type of cargo.[9] These myths and misconceptions do play an important role in influencing the sexual well-being of a large section of the population. This leads to sexual dissatisfaction, insecurities, and poor sexual interpersonal relationships in couples as well as impacts the presentation, symptomatology, course, and outcome of subjects with sexual dysfunctions. Hence, the provision of age-appropriate sex education addressing common myths and misconceptions can play an important role in handling sexual well-being at public health levels. Inappropriate depiction of optimal sexuality in popular media and movies, like sex is instant, easy, and leading to amazing gratification, can create unrealistic expectations. Advertisement strategies for several products and services related to sexuality often disseminate wrong and exaggerated expectations of sexuality. Such advertisements are often promoted by individuals or corporations that benefit from the promotion of a sense of sexual inadequacy in public. The unregulated advertisement and inadequate modern medicine health service sector in sexual medicine are responsible for the continuation of several sexual myths and misconceptions in society. PROMOTION OF SEXUAL WELL-BEING ACROSS AGES Children and adolescents Children and adolescents have unique needs for sexual health owing to their physical maturity, cognitive capabilities, and sociocultural factors. To become healthy adults with appropriate sexual functioning, children and adolescents would ideally need comprehensive education related to sexual and reproductive matters, freedom from any sexual coercion, and avoidance of inappropriate and premature exposure to sexual content. Aims of sexual well-being in children and adolescents include enabling them to make developmentally appropriate sexual choices, responsible sexual behavior at individual and community levels, and morally and socioculturally appropriate attitudes and outlook toward sexuality. Hence, policymakers and health professionals have always considered comprehensive sex education (CSE) as an important tool not only to promote sexual health and well-being but also the social, emotional health, and academic output of young individuals. Studies have reported that implementation of CSE in school settings helps to improve understanding of gender and gender norms, more considerate attitude toward sexual diversity including LGBTQA (lesbian, gay, bisexual, transgender, queer, and asexual) population, improves knowledge and skills to handle healthy relationships, including reduction in interpersonal violence and dating, as well as having awareness and strategies to prevent child sexual abuse.[10] Older people Although it is widely believed that sex and sexuality are no longer important for older adults, several research studies reported contrary findings. Sexuality continues to be an important aspect of quality of life even in older adults. However, there is a wide variety of inter-individual diversity in the amount of importance given to sexuality in later life. Clinicians need to be aware of and acknowledge this variability along with offering advice, help, and treatment to those who are seeking help with sexual difficulties. The expression of sexuality in older adults is influenced by age-related limitations imposed by bodily functioning, medical factors, and sociocultural concepts of sexuality norms about older adults. Active sexual life has also been useful in helping with better mental and physical health, improving life span, strengthening relationships, and reducing stress and tension. Several strategies to promote healthy aging are also helpful in the promotion of sexuality in this population. Following are the important approaches that can be helpful in having better sexual health in older adults. Accepting and acknowledging age-related changes: Changes in sexual abilities in later life are inevitable. However, it does not necessarily lead to a reduction of and in this older adults can to sex in later life at a or even that with aging is is of the most important of sexual in both However, acknowledging and age-related helps in skills to it and do An enhanced on and physical is the of sexual from to or sex can be if not better physical health, having better and a healthy are other helpful is useful to older adults to medical help for related to sexuality influenced by medical and SEXUAL WELL-BEING Gender rights Sexual health also includes aspects of reproductive health, such as fertility of and of sexual and having pleasurable sexual experiences free from The of sexual well-being is closely associated with human rights like the to the to and to be free from violence and coercion, and the to education and information regarding sexual health have been to gender which include the human rights the on the to the of health, others. the related to sexuality with human rights helps in sexual health. However, have a negative on human for the access of to sexual health services can lead to of and to sexual health is an of sexual sexual health is related to the private of and decision making is adolescents may not help in case is from or to access sexual health to information and education regarding sexual well-being has been by human rights The to one's gender and without any is an important of health and sexual violence does have a negative on health and An important aspect of related to sexual health is the of by and related to individuals need to be to the human rights of Human rights Sexual health is linked to the given to the human rights of individuals. Sexual rights include human of which are a of and human rights The of human rights to sexuality and sexual health sexual The of human rights to sexuality and sexual health sexual which have been in Table Human rights important to sexual ABOUT are can have from the which they have a negative on sexual sexual health, and reproductive health of individuals. people years from is linked with to to in as a of or in behavior to prevent is a and can a positive in individuals. of public of training and related to a to and seeking health services for and treatment of often to inadequate resources and poor quality of The of with the of includes sex and (lesbian, gay, bisexual, transgender, and and and do not have access to health services are leading to inadequate resources, and the of health sector strategy on and has as in Table health sector strategy on and all countries and related to a healthy environment where individuals can and and of services with and health for in and HEALTH SEXUAL WELL-BEING Sexual well-being is important as a public health However, there would be some to sexual health as a public health more in and be resources to to the sexual health of individuals. to sexual well-being as of public health is to make more In countries like the a to sexual health is which the of sexual sexual well-being is relevant to contemporary public health are in Table of sexual well-being to contemporary public well-being is a from sexual health and of both is for addressing sexual The of sexual well-being is to sexual health and and and of sexual of sexual well-being in sexual health is much but would an and SEXUAL WELL-BEING Sexual well-being in a is of the aspects of a physical and sexuality in the and the are several strategies for healthy couples to their sexual life The strategies are in Table Components of strategies for of optimal sexuality in of sexual skills are in relationships is an important aspect of good couples it to about sex without on may be influenced by shame, guilt, and of or in or both the of the about sexuality can be useful in this quality with helps in about and intimate of positive feelings, such as love, and often and helps in an appropriate for other an appropriate for related to sexuality is and responsible for or difficulties. and is A and is the of the good sexual well-being of the and resources in improving is to the to quality making to and or the of partner if it is not having a of and helping other in can be strategy to more and some to the like without an important with partner of or of making and to other are some of the strategies that can be considered to on oneself and one's Sexual well-being is closely related to physical health and physical especially is of sexual in both and has been reported to improve erectile dysfunction in a large physical has been reported to improve sexual in women, in that women by and women who have Several and cognitive strategies have in the of sexual in both are also that and the of these strategies can have a on sexual improves sexual in both and women. general and other can sexual and general health. Hence, it is not to healthy with of and a is of sexual health. and The it or also to sexual Hence, sexual is useful for couples as a healthy aging sexual and some and in sexual by couples can sexual and interest the of sexual of sexual if both and are comfortable with and can an of to sexual and can be helpful in the of sexual some and like the of or sexual if the has not used them etc., can be if both are to the of intimate partner violence is an important to sexual health. A of physical and sexual is reported in and in to and In the an important public health In women violence have reported and and Physical sexual psychological etc., are common of by is a significant for health in general and sexual health in have more and sexual health, as well as in to at the and handling of by are important public health strategies for several health including sexual health. SEXUAL WELL-BEING health In from such as or to a the of sexual dysfunction is often sexual In mental such as sexual can as a of the and also to In such as the reported of sexual dysfunction is has an with the sexual and contribute to sexual in also have sexual dysfunctions. is more in from such as social are also associated with sexual and sexual Sexual dysfunction is more common in such as the of the and used all the of the sexual The in different cultures can be of years and the good for that sexual The of sexual and is believed to be an can as a leading some people to be more This helps in the that can sexuality. can with and The of sexual dysfunction is related to the of and by the a can erectile dysfunction more has a history of it has a but on on sexuality is In the of some an in sexual of and of women of their sexual to have on sexuality to and The of can desire and but orgasm be and of has a significant negative on sexual like have a for sexual desire and have been that in sexual that they not they were is a and sexual behavior. is believed to be a people an in sexual and of have also been In the case of there is a of and and also an of with which in and also in they can be and may In the recent and scientific has awareness of the of and in the of is a of and with it and making the an is about the and sexual behavior. Some studies that sexual behavior was general with others an the of and and sexuality An older which was on the without any that of the was in sexual reported that they still sexual are regarding the sexuality and cognitive A study women not any sexual and cognitive An study subjects who sexual interest or better cognitive study that the of cognitive in the of that only of individuals sexual to of the healthy cognitive This study cognitive and significantly sexual The that to the sexual in these individuals include and medical include a in sex and erectile include and role from to the medical include and The of such as and can and of the studies the importance of in sexual relationships in individuals. Sexual is reported in of the Sexual in the gender identity was as a of or In the recent gender identity is as a where or is of a of gay, transgender, and individuals have more body and negative body to individuals. have more and sexual desire to their treatment decreases sexual desire and the is In sexual desire after the of of are to maintain in with an In with a and vaginal and vaginal to is is A large of with but with masturbation with partner sex. to orgasm is more and do with orgasm the is not are less in with from to both in and of the is common after which may lead to tension. may during which in may lead to sexual who were the even after treatment has been to improve with a and have the of sexual development and is an of with are more influenced by sociocultural and social with are able to positive sexual and be aware of their sexual studies have a where these individuals themselves and toward their sexuality. they are by as from sex and they are on the other they are as is always an internal the as they are to on their are from sexuality as a means of which them and Sexual orientation in this is as by is that in of and orientation are in the of with have knowledge about sexuality, and reproductive of their concepts of sexuality are by myths and sex is and Physical and developmental impacts sexual which in leads to to about their sexual and reproductive individuals less sexual knowledge and in sexual The of individuals with a desire to be in intimate in a them and and also a sense of individuals and but do not in in sex The sex and are and The and lead to limitations in the access of the for sex to fear of for care, and sex access to health services do not the information and inadequate and The sex sexual health influences sexual health of and other in society. of better access to education, and other help in sexual not only sex but also other in the OF SEXUAL HEALTH are crucial in health human and the and provision of sexual health information and also help in and of people on sexuality and are to social on sexuality and to and A of is beyond the of the An has been Sexual sexual is a and is a significant for the promotion of health, in and sexual in of individuals in society. sexual sexual sexual sexual and others. In to medical and social in the in physical and mental if the environment is not to a that has a and healthy developmental environment that is free from sexual is for the healthy development of children and Hence, the of Children from Sexual was in India. sexual violence sexual sexual and are the important sexual violence and of such are in the sexual well-being of the people in the Several related are in India to to sexual The relevant related to this Sexual people have several in having sexual owing to of access to education, and access to health The relevant are in Table provision in to sexual well-being in SEXUAL Sex education is defined as a that to a for sexual health by information and and about one's identity, relationships, and CSE is in the development and promotion of sexual of The sexual and reproductive health needs of children and adolescents are in India. are several cultural in the wide and dissemination of sex education as sex is considered a taboo subject in India. has been that the provision of CSE in to the including of sexual a reduction in and and their associated of sexual of education and later to and the of and a of the of including Health services for people in sexual The of good quality and health services is an important aspect of sexual health The health services related to a sexual can be in different of health like and include and treatment of sexual and services for and The provision of services should be and for a wide of service including people from sexual information and sexuality Sex and sexuality are a significant of the of information and the Sexuality and these other in ways. Although people of all are by information and depiction of sexuality in these and adolescents are most influenced by A lot of information related to sexuality and sex is from media owing to the unavailability of information from other Hence, there is a need to study the influences of these on in to sexual should be to inappropriate and exposure to media and in to sexuality on especially in children and strategies to with to inappropriate exposure to media should also be and sexual well-being strategies at and Human rights related to sexual health and are important aspects of these the who are to and are important A of appropriate and sex-positive health sector can help in and these strategies Table the for this for promotion of sexual well-being in and relevant and of interest are no of

Indian Journal of Psychiatry · 16 citationsread the source →

Adherence to physical activity guidelines in older adults, using objectively measured physical activity in a population-based study.

Background: Physical activity (PA) levels in older adults decline with age. The prevalence and correlates of adherence to current UK PA guidelines in older adults has not been studied using objectively measured PA, which can examine precisely whether PA is carried out in bouts of specified length and intensity. Methods: Free living men and women aged 70-93 years from 25 towns in the United Kingdom, participating in parallel on-going population based cohort studies were invited (by post) to wear a GT3x accelerometer over the hip for one week in 2010-12. Adherence to UK PA guidelines was defined as ≥150 minutes/week of moderate or vigorous PA (MVPA) in bouts of ≥10 minutes; the effect of different intensities and durations were examined. Results: 1593 men and 857 women participated (responses 51% and 29% respectively). 15% men and 10% women achieved ≥150 minutes/week of MVPA (defined as >1040 cpm) in bouts lasting ≥10 minutes. With MVPA defined as >1952 cpm, prevalences were 7% and 3% respectively. Those adhering to guidelines were younger, had fewer chronic health conditions, less depression, less severe mobility limitations, but higher exercise self-efficacy and exercise outcomes expectations. They rated their local environment more highly for social activities and leisure facilities, having somewhere nice to go for a walk and feeling safe after dark, They left the house on more days per week, were more likely to use active transport (cycle or walk) and to walk a dog regularly. Conclusions: Few older adults attain current PA guidelines. Health promotion to extend the duration of moderate-intensity activity episodes to 10 minutes or more could yield important health gains among older adults. However future studies will need to clarify whether attaining guideline amounts of PA in spells lasting 10 minutes or more is critical for reducing chronic disease risks as well as improving cardiometabolic risk factors.

BMC public health · 185 citationsread the source →

Problematic Internet use: an overview

The “global village”, a metaphor used to describe how the Internet has shortened distances and facilitated the flow of information, has grown to over one billion users 1. Statistics from across the world highlight its reach and penetrance: 90% of South Korean households connect to high-speed, inexpensive broadband 2; Londoners spend an average of 45 days a year online, more than they spend watching TV 3; and the rate of increase in the number of Internet users in Africa and the Middle East exceeded 1,300% between 2000 and 2009 4. For the majority of Internet users, the World Wide Web represents a tremendous wellspring of opportunity that enhances well-being. For others, however, it can lead to a state that appears to meet the DSM definition of a mental disorder, described as a “clinically significant behavioral or psychological syndrome…that is associated with present distress… or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” 5. Scientific understanding of that state has lagged behind media attention 6, in part because of inconsistency in defining the problem 7, disagreement about its very existence 8, and the variable research methodology used in studying it. Still, a body of data by scientists from the East and West (with the East increasingly leading the way) tells a cautionary tale about the Internet's potential to bring about psychological harm. In 1996, the psychologist K. Young became the first to publish a detailed case report of problematic Internet use 9. Her “patient zero” was a non-technologically oriented 43-year-old homemaker with a “content home life and no prior addiction or psychiatric history”, who, within three months of discovering chat rooms, was spending up to 60 hours per week online. She reported feeling excited in front of the computer, and depressed, anxious, and irritable when she would log off. She described having an addiction to the medium “like one would to alcohol”. Within one year of purchasing her home computer, she was ignoring household chores, had quit social activities she used to enjoy, and had become estranged from her two teenage daughters and her husband of 17 years. Based on this and other patients she interviewed, Young proposed the first set of diagnostic criteria for what she termed “Internet addiction”. She modeled them on the DSM-IV definition for substance dependence because of similarities she observed with the states of tolerance (needing more of the substance to achieve the same effect) and withdrawal (psychological and physical discomfort upon reducing or stopping the substance) 9. Others conceptualized problematic Internet use as a behavioral addiction not involving an intoxicant 10, and Young subsequently updated her definition, adapting the DSM-IV criteria for pathological gambling, an impulse control disorder often described as a behavioral addiction, into her Diagnostic Questionnaire 11 (Table 1). The questionnaire, which required at least five of the eight criteria be met for the Internet addiction diagnosis, has not received adequate psychometric testing. Shapira et al 12 proposed five years later a more inclusive diagnostic schema in the general style of the impulse control disorders. They argued that definitions based solely on substance dependence or pathological gambling were too narrow to capture the population of problematic Internet users and could lead to premature conclusions about the new disorder and the patients. They eschewed the “Internet addiction” label for lack of scientific proof for true addiction and favored the less controversial “problematic Internet use”, defining it as: a) maladaptive preoccupation with Internet use, experienced as irresistible use for periods of time longer than intended; b) significant distress or impairment resulting from the behavior; and c) the absence of other Axis I pathology that might explain the behavior, such as mania or hypomania. To date, only two studies have attempted to develop diagnostic criteria empirically by testing them against the diagnosis made on the basis of a systematic psychiatric interview. Ko et al 13 tested a set of criteria in 468 Taiwanese high school students. Starting with 13 candidate criteria, they eliminated those with low diagnostic accuracy, and determined that a cutoff of six out of the nine remaining criteria had the best diagnostic accuracy while maintaining high specificity (97.1%) and acceptable sensitivity (87.5%). The criterion for functional impairment was listed separately as criterion B and was required for the diagnosis (Table 2). In a second study, Ko et al 14 confirmed the diagnostic accuracy of their criteria in an older cohort of 216 Taiwanese college students. However, the relatively small size of both studies and the non-representative nature of the groups studied limit the applicability of the proposed criteria to the general population. Several assessment scales have been proposed to screen for, and help diagnose, problematic Internet use. As a group, these instruments show no consensus on the underlying dimensions that constitute the condition 6,15. In addition to Young's Diagnostic Questionnaire, two are in relatively common use in research and/or clinical settings: Young's Internet Addiction Test 16 and the Chen Internet Addiction Scale 17. Young's Internet Addiction Test 16 consists of 20 “how-often” questions, each rated on a scale of 1 to 5 (1=rarely; 2=occasionally; 3=frequently; 4=often; 5=always.) A score of 80 or above is consistent with problematic use (Table 3). The psychometric properties of the instrument were studied in 86 subjects 18. Six factors were extracted from the questionnaire: salience, excessive use, neglect of work, anticipation, lack of control, and neglect of social life. These factors showed good concurrent validity and internal consistency. Salience explained most of the variance and was also found to be the most reliable as indicated by its Cronbach's alpha. However, the selection bias introduced by online recruitment and the small size of the study limit its value. The Chen Internet Addiction Scale 17 is a self-report instrument composed of 26 items rated on a 4-point Likert scale (adapted in Table 4). It assesses five domains of Internet-related problems: compulsive use, withdrawal, tolerance, interpersonal and health consequences, and time management difficulties. Scores range from 26 to 104. In a study of 454 Taiwanese adolescents who completed the scale and received a structured diagnostic interview, a cutoff of 64 was shown to have high diagnostic accuracy and specificity (88% and 92.6%, respectively) 19. The internal reliability of the scale and subscales in the original study ranged from 0.79 to 0.93 17. Due to the lack of consensus on diagnostic criteria and the dearth of large epidemiological studies, the prevalence of problematic Internet use in the general population has not been established. Overall, prevalence surveys conducted in various countries fall into two main categories, online vs. offline studies, with the former typically yielding higher rates, most likely because of inherent selection bias 20. Only two epidemiological studies exploring the prevalence of problematic Internet use in the general population have been published. One was conducted in the US, the other in Norway 20,21. The US study used random-digit telephone dialing (cellular phone numbers were not included) to interview 2,513 adults taken from all 50 states in a manner proportional to the population in each state 20. More than half of the people reached agreed to be interviewed. Participants’ average age was 48, and 51% fell in the middle class socioeconomic stratum. 68.9% were regular Internet users. The authors’ diagnostic definition, based on published criteria and on similarities with impulse control disorders, substance dependence and obsessive-compulsive disorder, required: a) Internet use that interferes in personal relationships; b) preoccupation with the Internet when offline; c) unsuccessful attempts at quitting or cutting down; and d) staying online longer than intended. This definition yielded a point prevalence of 0.7%. Less stringent definitions yielded higher prevalence rates, and individual features consistent with problematic Internet use were endorsed by as many as 13.7% (respondents who found it hard to stay offline for days in a row). In the second study, Bakken et al 21 mailed Young's Diagnostic Questionnaire to 10,000 inhabitants of Norway, randomly selected from a database of the entire population. 3,399 completed questionnaires were returned (a somewhat lower response rate than the US study). Recipients of the mailed questionnaire also had the option of completing it online. Among respondents, 87% were Internet users. The prevalence of “addicted Internet use” (≥5 questions answered “yes”) was calculated to be 1%, whereas the prevalence of “at risk” Internet use (3–4 questions answered “yes”) was 5.2%. Multivariate analysis showed young age, male gender, higher educational achievement, and financial stress to be positively associated with “problematic Internet use” (defined by the authors to include both “Internet addicts” and “at risk” respondents). Prevalence rates among adolescents have been researched more extensively, perhaps because the so-called “digital natives” grew up incorporating the Internet in many aspects of life and as a result are perceived to be at higher risk. However, even when online-based surveys are excluded, the results can vary widely and are difficult to compare, due to differences in Internet access, recruitment methodology, the exact age bracket studied, and the definitions utilized. Considering only relatively large and offline studies, research from China 22, South Korea 23,24, Greece 25, Norway 26, and Iran 27 has yielded prevalence estimates ranging between 2% and 11%. Problematic Internet use has not been incorporated into large-scale epidemiological studies aimed at estimating the relative prevalence of mental disorders. Still, a review of published studies reveals that the presence of other psychiatric conditions in patients with problematic Internet use is the rule rather than the exception 6. The studies, however, were not designed or statistically powered to detect the nature of the association (cause, effect, or independent). In Bakken's general-population study 21, based on subjects’ self-report, 41.4% of Internet “addicts” reported feelings of depression in the 12-month period prior to the study, compared to 15.8% of non-problematic users. Sleep disturbances, anxious feelings, and alcohol and substance abuse were also more common (38.6% vs. 26.4%, 36.4% vs. 5%, and 13.6% vs. 1.1%, respectively). However, the questions used to assess co-occurring psychological impairment were not based on established criteria for mood, sleep, anxiety, or substance use disorders. Two US case series involved face-to-face interviews of adult patients with problematic Internet use. Black et al 28 assessed 21 subjects with the Diagnostic Interview Schedule and found the lifetime prevalence of mood disorders and major depression to be 33% and 15%, respectively. Further, 38% had a lifetime substance use disorder and 19% had a lifetime diagnosis of anxiety disorder. In a case series that included 20 patients, Shapira et al 29 found a very high (70%) lifetime prevalence for bipolar affective disorder, type I or II, compared with 15% for major depression. Fifty-five percent had a lifetime prevalence of substance abuse, and 45% met criteria for social anxiety disorder. Fifty percent of subjects had a lifetime diagnosis of an impulse control disorder. The authors highlight their observation that patients’ Internet-related symptoms were more impulsive and egosyntonic than compulsive and egodystonic, concluding that problematic Internet use resembles the DSM-IV definition of an impulse control disorder more closely than that of obsessive-compulsive disorder. Our clinical experience supports this conclusion. As a group, surveys conducted among high school and college students show similarly high comorbidity rates with mood and anxiety disorders, but a link between attention-deficit/hyperactivity disorder (ADHD) and problematic Internet use seems more obvious than among adults. One study in 752 South Korean elementary students found that 33% of those with ADHD also met criteria for problematic Internet use 30. Another study in 216 Taiwanese college students showed that 32% subjects with problematic Internet use also had ADHD compared to only 8% of regular Internet users 31. Whether Web-based activities appeal to the short attention span of ADHD sufferers or whether excessive Internet use may cause inattention remains to be elucidated. The clinical evaluation of the patient with problematic Internet use should include a careful assessment of the comorbid conditions frequently present. Those should then be treated according to established treatment guidelines. To the extent that the Internet-related problem may stem from another diagnosis (e.g., a patient with severe social anxiety who starts leading a “virtual” life at the expense of offline interactions), it might improve as the primary condition is addressed. Pharmacotherapeutic and psychotherapeutic interventions specific to problematic Internet use have not yet received adequate testing in large, rigorous studies. Pharmacotherapy often begins with selective serotonin reuptake inhibitors (SSRIs). However, while effective in treating obsessive-compulsive disorder, SSRIs have shown mixed results in impulse control disorders 32,33,34,35–36. In light of the greater similarity between problematic Internet use and impulse control disorders compared to obsessive-compulsive disorder 29, it is unclear whether SSRIs will ultimately prove beneficial, and no double-blind placebo-controlled studies have been published so far. One discontinuation study tested escitalopram, 20 mg/day, in 19 subjects with problematic Internet use 37. During the 10-week open-label phase, subjects showed significant decreases in weekly hours spent online (from a mean of 36.8 hours to 16.5 hours) and improvement in global functioning. At the end of the 10 weeks, subjects were blindly randomized to either continued escitalopram treatment or to placebo. Beyond that, they were followed for 9 weeks. No significant difference was seen between the two groups at the end of the second phase, as gains achieved at week 10 were maintained in both treatment groups. The authors speculate that nine weeks may have not been sufficient for the effect to be lost in the placebo group or for additional gains to be made in the escitalopram group, but do not rule out the possibility that the improvement seen in the open-label phase may have been a placebo response. One case study reported successful treatment with naltrexone 38, a drug that has shown benefit in other impulse control disorders 39,40. The patient was a 31 year old male with compulsive cybersexual behavior who had failed antidepressants, group and individual psychotherapy, Sexual Addicts Anonymous, and pastoral counseling. Naltrexone (150 mg/day), gradually added to a stable dose of sertraline which on its own had been ineffective in treating his problematic Internet use, helped induce a three-year remission. The authors hypothesize that, by blocking the capacity of endogenous opioids to trigger dopamine release in response to reward, naltrexone may block the reinforcing nature of compulsive Internet sexual activity. Another case study reported the successful use of an atypical antipsychotic, quetiapine, 200 mg/day, gradually added to citalopram, in a 23 year old subject with problematic Internet use 41. The improvement was maintained at four-month follow-up. More recently, a study tested methylphenidate in 62 children with ADHD who were Internet video game players 42. Participants’ average age was around 9. After 8 weeks of treatment (average dose 30.5 mg/day), Internet usage decreased significantly and correlated with reduction in ADHD symptoms. The authors cautiously suggest that methylphenidate might be beneficial as a treatment for problematic Internet use, especially when co-occurring with ADHD. Of the psychotherapy approaches used, cognitive behavioral therapy (CBT) has received the most empiric investigation. The largest study enrolled 114 adult subjects and employed CBT interventions including: keeping a daily log of Internet activity, teaching time management skills, and confronting cognitive distortions and rationalizations frequently used by patients to justify continued Internet usage, such as “just a few more minutes won't hurt” 43. Most subjects were able to control their symptoms by the eighth session, and improvement was sustained over a 6-month follow-up. For children and adolescents, family-based interventions that improve communication and teach family monitoring of Internet use can be helpful 44. However, the intensive (and typically very expensive) residential treatment options that have received much media attention have undergone little empiric investigation to warrant a strong recommendation 2,45. The same applies to online treatment websites that encourage the person with problematic Internet use to “click here if you are addicted to the Internet”. For a medium that has so radically changed the way we conduct our lives, the Internet's effects on our psychological health remain understudied. Simply stating that similar fears were raised when the radio, movies and early video games were introduced is not sufficient: the immersive and interactive qualities of the virtual world, and its sheer penetrance, make it potentially more serious. Also deserving of exploration are the more subtle psychological changes that occur in the virtual world, such as online disinhibition and increased risk-taking 46. Those changes are not necessarily evidence of “Internet addiction”, and may not be pathological, but, as important features of the new virtual psychology, should also be studied. As our field continues to debate whether their condition belongs in the next edition of the DSM 47, patients continue to present with symptoms born out of the digital age, and their symptoms are changing as the technology evolves from browsers, to “crackberries”, to “smart phones” that combine texting, talking, video games, and browsing in one device that to many is like a new appendage. Even the “problematic Internet use” designation now seems outdated, which is why some have wisely opted for “pathological use of electronic media”, instead 47. Technology, like media outlets, remains far ahead of scientific investigation. Given the dramatic changes that our society is undergoing as a result of the Internet revolution, it behooves us to try to bridge the gap.

World Psychiatry · 340 citationsread the source →