A subgroup of light-driven sodium pumps with an additional Schiff base counterion

Light-driven sodium pumps (NaRs) are unique ion-transporting microbial rhodopsins. The major group of NaRs is characterized by an NDQ motif and has two aspartic acid residues in the central region essential for sodium transport. Here we identify a subgroup of the NDQ rhodopsins bearing an additional glutamic acid residue in the close vicinity to the retinal Schiff base. We thoroughly characterize a member of this subgroup, namely the protein ErNaR from Erythrobacter sp. HL-111 and show that the additional glutamic acid results in almost complete loss of pH sensitivity for sodium-pumping activity, which is in contrast to previously studied NaRs. ErNaR is capable of transporting sodium efficiently even at acidic pH levels. X-ray crystallography and single particle cryo-electron microscopy reveal that the additional glutamic acid residue mediates the connection between the other two Schiff base counterions and strongly interacts with the aspartic acid of the characteristic NDQ motif. Hence, it reduces its pKa. Our findings shed light on a subgroup of NaRs and might serve as a basis for their rational optimization for optogenetics.

The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders

BACKGROUND

The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression.

METHODS

A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires.

RESULTS

Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression.

CONCLUSIONS

These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Childhood maltreatment, dissociation and borderline personality disorder: Preliminary data on the mediational role of mentalizing in complex post-traumatic stress disorder

OBJECTIVES

Treatments for borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are less effective for patients with co-occurring symptoms of both disorders, who are considered to have complex PTSD (cPTSD), compared with patients with either condition alone. Evidence suggests that co-occurrence of symptoms indicates greater impairment in mentalizing. This study examines evidence for targeting mentalizing when treating individuals with co-occurring symptoms, irrespective of their exposure to developmental trauma and, for the first time, investigates the mediational role of mentalizing in the associations between BPD symptomatology and cPTSD.

DESIGN

We identified in a routine clinical service a group of patients with BPD, with or without co-occurring symptoms of PTSD. We hypothesized that patients with co-occurring symptoms and a history of childhood maltreatment will show more severe clinical profiles and greater mentalizing problems, which in turn lead to symptoms consistent with cPTSD.

METHOD

Clinical profiles of 72 patients with BPD (43 with and 29 without co-occurring symptoms of PTSD; mean age in both groups 28 years, 79% and 83% female, respectively) were identified using the Structured Clinical Interview for DSM-IV Axis II Disorders. Patients completed self-report measures of BPD and PTSD symptoms, well-being, dissociation and reflective functioning. Childhood trauma histories were evaluated.

RESULTS

Compared with patients with BPD-only, those with co-occurring BPD and PTSD showed greater severity in terms of BPD and dissociative symptoms, met a broader range of BPD diagnostic criteria, had a greater sense of personal worthlessness and self-evaluated their well-being as considerably diminished. This group was also more inclined to recall increased instances of childhood sexual abuse. In a mediation analysis, mentalizing acted as a partial mediator for the relationship between BPD severity and cPTSD, as well as between dissociative symptoms and cPTSD. Interestingly, mentalizing did not mediate the relationship between childhood sexual abuse and cPTSD.

CONCLUSIONS

Overall, the correlational findings are consistent with an intended focus on mentalizing to treat cPTSD symptoms in individuals who also meet criteria for a diagnosis of BPD.

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT)

INTRODUCTION

Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT.

OBJECTIVE

The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD.

METHODS

Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037.

RESULTS

Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056).

CONCLUSION

Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study

PURPOSE

Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia.

METHOD AND MATERIALS

In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending.

RESULTS

Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles.

CONCLUSIONS

Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder

OBJECTIVE

Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format.

METHODS

Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety.

RESULTS

The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning.

CONCLUSIONS

Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

Intraoperative radiotherapy for pancreatic cancer: implementation and initial experience

This article reports on the first series of patients to receive intraoperative radiotherapy for pancreatic cancer in the UK. The data suggest that this treatment modality is feasible and safe, laying a platform for collaborative multicentre trials to better assess efficacy.

Detailed statistical analysis plan for the short-term versus long-term mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder randomised clinical trial (MBT-RCT)

Background

Psychotherapy for borderline personality disorder is often extensive and resource-intensive. Mentalisation-based therapy is a psychodynamically oriented treatment option for borderline personality disorder, which includes a case formulation, psychoeducation, and group and individual therapy. The evidence on short-term compared with long-term mentalisation-based therapy is currently unknown.

Methods/design

The Short-Term MBT Project (MBT-RCT) is a single-centre, parallel-group, investigator-initiated, randomised clinical superiority trial in which short-term (20 weeks) will be compared with long-term (14 months) mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Outcome assessors, data managers, the data safety and monitoring committee, statisticians, and decision-makers will be blinded to treatment allocation. Participants will be assessed before randomisation and at 8, 16, and 24 months after randomisation. The primary outcome will be the severity of borderline symptomatology assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes will be functional impairment (Work and Social Adjustment Scale), quality of life (Short-Form Health Survey 36—mental component), global functioning (Global Assessment of Functioning), and proportion of participants with severe self-harm. In this paper, we present a detailed statistical analysis plan including a comprehensive explanation of the planned statistical analyses, methods to handle missing data, and assessments of the underlying statistical assumptions. Final statistical analyses will be conducted independently by two statisticians following the present plan.

Discussion

We have developed this statistical analysis plan before unblinding of the trial results in line with the Declaration of Helsinki and the International Conference on Harmonization of Good Clinical Practice Guidelines, which should increase the validity of the MBT-RCT trial by mitigation of analysis bias.

Trial registration

ClinicalTrials.gov NCT03677037. Registered on 19 September 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05450-y.

Individual participant data systematic reviews with meta-analyses of psychotherapies for borderline personality disorder

INTRODUCTION

The heterogeneity in people with borderline personality disorder (BPD) and the range of specialised psychotherapies means that people with certain BPD characteristics might benefit more or less from different types of psychotherapy. Identifying moderating characteristics of individuals is a key to refine and tailor standard treatments so they match the specificities of the individual participant. The objective of this is to improve the quality of care and the individual outcomes. We will do so by performing three systematic reviews with meta-analyses of individual participant data (IPD). The aim of these reviews is to investigate potential predictors and moderating patient characteristics on treatment outcomes for patients with BPD.

METHODS AND ANALYSIS

We performed comprehensive searches in 22 databases and trial registries up to October 6th 2020. These will be updated with a top-up search up until June 2021. Our primary meta-analytic method will be the one-stage random-effects approach. To identify predictors, we will use the one-stage model that accounts for interaction between covariates and treatment allocation. Heterogeneity in case-mix will be assessed with a membership model based on a multinomial logistic regression where study membership is the outcome. A random-effects meta-analysis is chosen to account for expected levels of heterogeneity.

ETHICS AND DISSEMINATION

The statistical analyses will be conducted on anonymised data that have already been approved by the respective ethical committees that originally assessed the included trials. The three IPD reviews will be published in high-impact factor journals and their results will be presented at international conferences and national seminars.

PROSPERO REGISTRATION NUMBER

CRD42021210688.

A Phase II Study of Biodegradable Stents Plus Palliative Radiotherapy in Oesophageal Cancer

AIMS

Self-expanding metal stents provide rapid improvement of dysphagia in oesophageal cancer but are associated with complications. The aim of the present study was to test the effectiveness of an alternative treatment of combining biodegradable stents with radiotherapy.

MATERIALS AND METHODS

A Simon two-stage single-arm prospective phase II trial design was used to determine the efficacy of biodegradable stents plus radiotherapy in patients with dysphagia caused by oesophagus cancer who were unsuitable for radical treatment. Fourteen patients were recruited and data from 12 were included in the final analyses.

RESULTS

Five of 12 patients met the primary end point: one stent-related patient death; four further interventions for dysphagia within 16 weeks of stenting (41.7%, 95% confidence interval 15.2-72.3%). The median time to a 10-point deterioration of quality of life was 2.7 weeks. Nine patients died within 52 weeks of registration. The median time to death from any cause was 15.0 weeks (95% confidence interval 9.6-not reached).

CONCLUSION

The high re-intervention observed, which met the pre-defined early stopping criteria, meant that the suggested alternative treatment was not sufficiently effective to be considered for a larger scale trial design. Further work is needed to define the place of biodegradable stents in the management of malignant oesophageal strictures.

Rupture and Repair in Mentalization-Based Group Psychotherapy

The article explores ideas about the role of group mentalizing-the experience of joint attention and shared intentionality-as a process that can support the emergence of more collaborative and salutogenic social functioning. This is based on developmental and evolutionary thinking about the importance of joint attention in human social cognitive development and functioning. The importance of experiencing rupture and repair as part of the process of thinking together-while also working with the separate nature of our thoughts-is described, emphasizing that it is through an understanding of the complex and inevitably uneven and challenging nature of joint attention and social cooperation that such cooperation is itself made possible.

Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation

Background

Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD.

Methods

Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale – Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken.

Discussion

This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk.

Trial registration

ISRCTN 32309003. Registered on 8 April 2016.

Lighthouse Parenting Programme: Description and pilot evaluation of mentalization-based treatment to address child maltreatment

This article introduces an innovative mentalization-based treatment (MBT) parenting intervention for families where children are at risk of maltreatment. The Lighthouse MBT Parenting Programme aims to prevent child maltreatment by promoting sensitive caregiving in parents. The programme is designed to enhance parents' capacity for curiosity about their child's inner world, to help parents 'see' (understand) their children clearly, to make sense of misunderstandings in their relationship with their child and to help parents inhibit harmful responses in those moments of misunderstanding and to repair the relationship when harmed. The programme is an adaptation of MBT for borderline and antisocial personality disorders, with a particular focus on attachment and child development. Its strength is in engaging hard to reach parents, who typically do not benefit from parenting programmes. The findings of the pilot evaluation suggest that the programme may be effective in improving parenting confidence and sensitivity and that parents valued the programme and the changes it had helped them to bring about.

Systemic neoadjuvant chemotherapy in modern pancreatic cancer treatment: a systematic review and meta-analysis

BACKGROUND

Pancreatic ductal adenocarcinoma remains a disease with a poor prognosis despite advances in surgery and systemic therapies. Neoadjuvant therapy strategies are a promising alternative to adjuvant chemotherapy. However, their role remains controversial. This meta-analysis aims to clarify the benefits of neoadjuvant therapy in resectable pancreatic ductal adenocarcinoma.

METHODS

Eligible studies were identified from MEDLINE, Embase, Web of Science and the Cochrane Library. Studies comparing neoadjuvant therapy with a surgery first approach (with or without adjuvant therapy) in resectable pancreatic ductal adenocarcinoma were included. The primary outcome assessed was overall survival. A random-effects meta-analysis was performed, together with pooling of unadjusted Kaplan-Meier curve data.

RESULTS

A total of 533 studies were identified that analysed the effect of neoadjuvant therapy in pancreatic ductal adenocarcinoma. Twenty-seven studies were included in the final data synthesis. Meta-analysis suggested beneficial effects of neoadjuvant therapy with prolonged survival compared with a surgery-first approach, (hazard ratio 0.72, 95% confidence interval 0.69-0.76). In addition, R0 resection rates were significantly higher in patients receiving neoadjuvant therapy (relative risk 0.51, 95% confidence interval 0.47-0.55). Individual patient data analysis suggested that overall survival was better for patients receiving neoadjuvant therapy (P = 0.008).

CONCLUSIONS

Current evidence suggests that neoadjuvant chemotherapy has a beneficial effect on overall survival in resectable pancreatic ductal adenocarcinoma in comparison with upfront surgery and adjuvant therapy. Further trials are needed to address the need for practice change.

European guidelines for personality disorders: past, present and future

Personality disorders (PD) are common and burdensome mental disorders. The treatment of individuals with PD represents one of the more challenging areas in the field of mental health and health care providers need evidence-based recommendations to best support patients with PDs. Clinical guidelines serve this purpose and are formulated by expert consensus and/or systematic reviews of the current evidence. In this review, European guidelines for the treatment of PDs are summarized and evaluated. To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement. Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general. After evaluating the methodological quality of the nine European guidelines from eight countries, results in the domains of diagnosis, psychotherapy and pharmacological treatment of PD are discussed. Our comparison of guidelines reveals important contradictions between recommendations in relation to diagnosis, length and setting of treatment, as well as the use of pharmacological treatment. All the guidelines recommend psychotherapy as the treatment of first choice. Future guidelines should rigorously follow internationally accepted methodology and should more systematically include the views of patients and users.

Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study

BACKGROUND

Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in some mental disorders such as Borderline Personality Disorder (BPD). Some studies have suggested that Eating Disorders (EDs) may also be associated with impairments in mentalizing, but studies have not always yielded consistent results. This is the first study to systematically investigate mentalizing impairments in patients with Bulimia Nervosa (BN) compared with controls. In addition, we investigated whether impairments in mentalizing were related to BPD features, rather than BN per se, given the high comorbidity between BPD and BN.

METHODS

Patients with BN (n = 53) and healthy controls (HCs; n = 87) completed a battery of measures assessing mentalizing including the Reflective Function Questionnaires (RFQ), the Object Relations Inventory (ORI; Differentiation-Relatedness Scales) and the Reading The Mind in The Eyes Test (RMET).

RESULTS

Patients with BN scored significantly lower than HCs on all tests of mentalizing, with moderate to large between-group effect sizes. These differences were partially accounted for by BPD features as assessed with the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and partially by bulimic symptoms measured with the Eating Disorder Examination Questionnaire (EDE-Q).

CONCLUSIONS

Patients with BN have significantly lower levels of mentalizing as assessed with a broad range of tests compared to HCs. These differences were related to both bulimic symptoms and BPD features. Although further research in larger samples is needed, if replicated, these findings suggest that poor mentalizing may be a significant factor in BN patients and should be addressed in treatment, regardless of the presence of BPD features.

Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial

Background

Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program.

Methods/design

This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change.

Discussion

This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder.

Trial registration

ClinicalTrials.gov, NCT03677037. Registered on September 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3306-7) contains supplementary material, which is available to authorized users.

Clinical audit research and evaluation of motor neuron disease (CARE-MND): a national electronic platform for prospective, longitudinal monitoring of MND in Scotland

Objectives: Launched in 1989, the Scottish Motor Neuron Disease Register (SMNDR) has provided a resource for prospective clinical data collection. However, in 2015 we aimed to evolve a system to allow: i) A patient-centered approach to care based on recognized standards, ii) Harmonized data sharing between Scottish health professionals in "real-time", iii) Regular audit of care to facilitate timely improvements in service delivery, and iv) Patient participation in a diverse range of observational and interventional research studies including clinical trials. Methods: We developed a standardized national electronic data platform-Clinical Audit Research and Evaluation of MND (CARE-MND) which integrates clinical audit and research data fields. Data completion pre- and post-CARE-MND were compared, guided by recently published National Institute for Clinical Excellence (NICE) recommendations. Statistical difference in data capture between time periods was assessed using Z-test of proportions. Results: Data field completion for the historical 2011-2014 period ranged from 4 to 95%; median 50%. CARE-MND capture ranged from 32 to 98%; median 87%. 15/17 fields were significantly more complete post-CARE-MND (p < 0.001). All MND nurse/allied health specialists in Scotland use the CARE-MND platform. Management of MND in Scotland is now coordinated through a standardized template. Conclusions: Through CARE-MND, national audits of MND care and interventions have been possible, leading to protocols for harmonized service provision. Stratification of the MND population is facilitating participation in observational and interventional studies. CARE-MND can act as a template for other neurological disorders.

Treatment of Borderline Personality Disorder

Findings from randomized controlled trials and meta-analyses suggest that there are several efficacious treatments for borderline personality disorder, including those based on cognitive behavior theories and psychodynamic theories. In addition, there are generalist and adjunctive approaches. These treatments and the corresponding evidence associated with each are described. It is concluded randomized controlled trials and meta-analyses suggest little to no difference between any active specialty treatments for borderline personality disorder; there are no differences between dialectical behavior therapy and non-dialectical behavior therapy treatments or between cognitive behavior-based and psychodynamic theory-based treatments. Thus, clinicians are justified in using any of these efficacious treatments.

Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study

PURPOSE

Reliable biomarkers for predicting subsequent sepsis among patients with suspected acute infection are lacking. In patients presenting to emergency departments (EDs) with suspected acute infection, we aimed to evaluate the reliability and discriminant ability of 47 leukocyte biomarkers as predictors of sepsis (Sequential Organ Failure Assessment score ≥ 2 at 24 h and/or 72 h following ED presentation).

METHODS

In a multi-centre cohort study in four EDs and intensive care units (ICUs), we standardised flow-cytometric leukocyte biomarker measurement and compared patients with suspected acute infection (cohort-1) with two comparator cohorts: ICU patients with established sepsis (cohort-2), and ED patients without infection or systemic inflammation but requiring hospitalization (cohort-3).

RESULTS

Between January 2014 and February 2016, we recruited 272, 59 and 75 patients to cohorts 1, 2, and 3, respectively. Of 47 leukocyte biomarkers, 14 were non-reliable, and 17 did not discriminate between the three cohorts. Discriminant analyses for predicting sepsis within cohort-1 were undertaken for eight neutrophil (cluster of differentiation antigens (CD) CD15; CD24; CD35; CD64; CD312; CD11b; CD274; CD279), seven monocyte (CD35; CD64; CD312; CD11b; HLA-DR; CD274; CD279) and a CD8 T-lymphocyte biomarker (CD279). Individually, only higher neutrophil CD279 [OR 1.78 (95% CI 1.23-2.57); P = 0.002], higher monocyte CD279 [1.32 (1.03-1.70); P = 0.03], and lower monocyte HLA-DR [0.73 (0.55-0.97); P = 0.03] expression were associated with subsequent sepsis. With logistic regression the optimum biomarker combination was increased neutrophil CD24 and neutrophil CD279, and reduced monocyte HLA-DR expression, but no combination had clinically relevant predictive validity.

CONCLUSIONS

From a large panel of leukocyte biomarkers, immunosuppression biomarkers were associated with subsequent sepsis in ED patients with suspected acute infection.

CLINICAL TRIAL REGISTRATION

NCT02188992.

A randomized controlled trial of a mentalization-based intervention (MBT-FACTS) for families of people with borderline personality disorder

This article reports a delayed-treatment randomized controlled trial of a mentalization-based intervention for families or significant others living with or supporting a person with borderline personality disorder (BPD). In all, 56 family members/significant others living with/supporting people with a diagnosis of BPD were randomized either to immediate mentalization-based Families and Carers Training and Support, a supportive and skills-based program consisting of five 1.5- to 2-hr evening meetings, delivered by trained family members, or to delayed intervention. The primary outcome was adverse incidents reported by the family member in relation to the person with BPD. Secondary outcomes included self-reported family well-being, empowerment, burden, and levels of anxiety and depression. Family members randomized to immediate intervention showed a significant reduction in reported adverse incidents between themselves and the identified patient in the second phase of treatment compared with those randomized to delayed intervention. Analysis of the rate of change indicated a significantly steeper decline for the immediate-treatment group compared with the delayed-intervention group (β = -1.07, 95% confidence interval [-1.40, -0.74], z = -6.3, p < .000). Secondary outcome measures showed family functioning and well-being improved more in the immediate-treatment group; changes were maintained at follow-up. There were no differences in depression, total anxiety, and total burden; both groups showed improvement on all these measures. Findings show that the mentalization-based Families and Carers Training and Support program delivered by families to families supporting a person with BPD reduces reported adverse incidents within the family. Further studies are needed to show whether this reduction improves outcomes for the individual with BPD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cell-surface signatures of immune dysfunction risk-stratify critically ill patients: INFECT study

PURPOSE

Cellular immune dysfunctions, which are common in intensive care patients, predict a number of significant complications. In order to effectively target treatments, clinically applicable measures need to be developed to detect dysfunction. The objective was to confirm the ability of cellular markers associated with immune dysfunction to stratify risk of secondary infection in critically ill patients.

METHODS

Multi-centre, prospective observational cohort study of critically ill patients in four UK intensive care units. Serial blood samples were taken, and three cell surface markers associated with immune cell dysfunction [neutrophil CD88, monocyte human leucocyte antigen-DR (HLA-DR) and percentage of regulatory T cells (Tregs)] were assayed on-site using standardized flow cytometric measures. Patients were followed up for the development of secondary infections.

RESULTS

A total of 148 patients were recruited, with data available from 138. Reduced neutrophil CD88, reduced monocyte HLA-DR and elevated proportions of Tregs were all associated with subsequent development of infection with odds ratios (95% CI) of 2.18 (1.00-4.74), 3.44 (1.58-7.47) and 2.41 (1.14-5.11), respectively. Burden of immune dysfunction predicted a progressive increase in risk of infection, from 14% for patients with no dysfunction to 59% for patients with dysfunction of all three markers. The tests failed to risk stratify patients shortly after ICU admission but were effective between days 3 and 9.

CONCLUSIONS

This study confirms our previous findings that three cell surface markers can predict risk of subsequent secondary infection, demonstrates the feasibility of standardized multisite flow cytometry and presents a tool which can be used to target future immunomodulatory therapies.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (NCT02186522).

Building a strong European alliance for personality disorder research and intervention

People with personality disorders frequently face stigma, ignorance and pessimism regarding the treatability of their disorders. This is despite substantial progress that has been made in developing a number of effective evidence based psychotherapeutic treatments. However, expertise in how to systematically deliver these treatments in a sustainable way throughout Europe is largely lacking. To bridge the gap between evidence based treatments and their implementation in health services, the European Society for the Study of Personality Disorders is currently building a new alliance of experts to promote personality disorder scholarship, and to support the development of clinical expertise and systematic treatment implementation throughout Europe. The aim of this paper is to describe how the Society is currently using its interdisciplinary and international roster of experts to address the specific treatment and research needs of the European personality disorder field, particularly to countries in which expertise in the field is less developed.

A mentalization-based approach to common factors in the treatment of borderline personality disorder

In this paper we conceptualize borderline personality disorder as a disorder of mentalizing, social cognition, and loss of resilience. Several treatment approaches are effective, and meta-analyses suggest that there are few substantive differences in effectiveness between them and between specialized and non-specialized approaches. We propose that these findings arise because of shared mechanisms of change, congruent with current thinking both about the existence of a general 'p' factor of psychopathology and a reconceptualization of personality disorders as involving a lack of resilience resulting from problems with epistemic trust and salutogenesis, the capacity to derive benefit from the social environment. Effective treatments share the characteristics of consistency, coherence and continuity, qualities particularly relevant to borderline personality disorder. They create the conditions for the reopening of epistemic trust, an essential component in therapeutic change, as it enables the individual to use the experience of being mentalized, to learn mentalizing of others, and then apply and develop these experiences in day-to-day life, which is the basis for meaningful therapeutic change.

Mentalizing, Attachment, and Epistemic Trust in Group Therapy

This article sets out the relevance of recent theoretical developments in the areas of mentalizing, attachment and epistemic trust in relation to group therapy. It begins with an account of the role of mentalizing in the attachment context in the development of epistemic trust-defined as trust in the authenticity and personal relevance of interpersonally transmitted knowledge about how the social environment works. It then explains the particular way in which this emphasis on social communication is pertinent to group therapy and its function as a training ground for mentalizing and the initial experimentation with the opening of epistemic trust in a social context. The article finishes with an account of how mentalization-based group work is undertaken.

Conjugal amyotrophic lateral sclerosis: a case report from Scotland

Background

Conjugal amyotrophic lateral sclerosis is rare, with significant effects on psychological and care needs. We report a case of conjugal amyotrophic lateral sclerosis disease from central Scotland. This case is particularly unusual as both patients were diagnosed within an 18-month period and experienced the disease simultaneously, with similar symptomatology and progression.

Case presentation

Patient A was a 71-year-old man who presented with unilateral arm weakness and wasting. Patient B was a 68-year-old woman who presented with unilateral shoulder and elbow weakness. Diagnosis of amyotrophic lateral sclerosis was made within a few months of presentation in both cases, based on typical clinical symptomatology together with supportive neurophysiological testing. Interventions included enteral feeding and non-invasive ventilation. The time period between symptom onset and death was 5 years for Patient A and 3.5 years for Patient B.

Conclusion

This case illustrates two main points: the care issues surrounding cases of conjugal neurological disease, and the psychological issues in these patients.

There are significant care issues arising when co-habiting couples both develop severe functionally limiting neurological diseases at the same time. The more slowly progressive nature of Patient A’s disease may be at least partially explained by the support he was able to receive from Patient B before she developed symptoms. Secondly, there are important psychological effects of living with someone with the same – but more advanced – progressive and incurable neurological disease. Thus, Patient B was reluctant to have certain interventions that she had observed being given to her husband. Lastly, no plausible shared environmental risk factors were identified, implying that the co-occurrence of ALS in this couple was a random association.

The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder

Background

In this multi-centre randomized controlled trial (RCT) we compared modified mentalisation-based treatment (MBT-ED) to specialist supportive clinical management (SSCM-ED) in patients with eating disorders (EDs) and borderline personality disorder symptoms (BPD). This group of patients presents complex challenges to clinical services, and a treatment which addresses their multiple problems has the potential to improve outcome. MBT has been shown to be effective in improving outcome in patients with BPD, but its use has not been reported in ED.

Methods

Sixty-eight eligible participants were randomised to MBT-ED or SSCM-ED. The primary outcome measure was the global score on the Eating Disorder Examination. Secondary outcomes included measures of BPD symptoms (the Zanarini Rating Scale for Borderline Personality Disorder), general psychiatric state, quality of life and service utilisation. Participants were assessed at baseline and at 6, 12 and 18 months after randomisation. Analysis was performed using linear mixed models.

Results

Only 15 participants (22 %) completed the 18 month follow-up. Early drop-out occurred significantly more in the SSCM-ED group. Drop-out did not vary with treatment model later in therapy and was sometimes attributed to participants moving away. There was higher drop--out amongst smokers and those with higher neuroticism scores. 47.1 % of participants in the MBT-ED arm and 37.1 % in the SSCM-ED arm attended at least 50 % of therapy sessions offered.

Amongst those remaining in the trial, at 12 and 18 months MBT-ED was associated with a greater reduction in Shape Concern and Weight Concern in the Eating Disorder Examination compared to SSCM-ED. At 6, 12 and 18 months there was a decline of ED and BPD symptoms in both groups combined.

Ten participants were reported as having had adverse events during the trial, mostly self-harm, and there was one death, attributed as ’unexplained’ by the coroner.

Conclusions

The high drop-out rate made interpretation of the results difficult. Greater involvement of research staff in clinical management might have improved compliance with both therapy and research assessment. MBT-ED may have had an impact on core body image psychopathology.

Trial registration

Current Controlled Trials: ISRCTN51304415. Registered on 19 April 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1606-8) contains supplementary material, which is available to authorized users.

A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder

BACKGROUND

Antisocial personality disorder (ASPD) is an under-researched mental disorder. Systematic reviews and policy documents identify ASPD as a priority area for further treatment research because of the scarcity of available evidence to guide clinicians and policymakers; no intervention has been established as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment which specifically targets the ability to recognise and understand the mental states of oneself and others, an ability shown to be compromised in people with ASPD. The aim of the study discussed in this paper is to investigate whether MBT can be an effective treatment for alleviating symptoms of ASPD.

METHODS

This paper reports on a sub-sample of patients from a randomised controlled trial of individuals recruited for treatment of suicidality, self-harm, and borderline personality disorder. The study investigates whether outpatients with comorbid borderline personality disorder and ASPD receiving MBT were more likely to show improvements in symptoms related to aggression than those offered a structured protocol of similar intensity but excluding MBT components.

RESULTS

The study found benefits from MBT for ASPD-associated behaviours in patients with comorbid BPD and ASPD, including the reduction of anger, hostility, paranoia, and frequency of self-harm and suicide attempts, as well as the improvement of negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment.

CONCLUSIONS

MBT appears to be a potential treatment of consideration for ASPD in terms of relatively high level of acceptability and promising treatment effects.

TRIAL REGISTRATION

ISRCTN ISRCTN27660668 , Retrospectively registered 21 October 2008.

Translation: Mentalizing as treatment target in borderline personality disorder

The role of mentalizing in relation to borderline personality disorder (BPD) is examined with a view to achieving improved levels of mentalizing in BPD patients as a therapeutic target. The article seeks to explain why mentalizing works as a treatment target for BPD, and suggests that a mentalizing approach to BPD may be at the core of any successful intervention.

Group-Analytic Therapy of Borderline Patients in a Day Hospital Setting

The authors discuss the treatment of borderline patients in a slow open group within a psychodynamically-informed Day Hospital. The patients formed an `anti-group', a pathological organization, thereby seeking to avoid paranoid-schizoid and depressive anxiety. Containment of staff in such a setting is essential if they in turn are to maintain their own containing function.

Mentalization-based treatment for psychotic disorder: protocol of a randomized controlled trial

BACKGROUND

Many patients with a non-affective psychotic disorder suffer from impairments in social functioning and social cognition. To target these impairments, mentalization-based treatment for psychotic disorder, a psychodynamic treatment rooted in attachment theory, has been developed. It is expected to improve social cognition, and thereby to improve social functioning. The treatment is further expected to increase quality of life and the awareness of having a mental disorder, and to reduce substance abuse, social stress reactivity, positive symptoms, negative, anxious and depressive symptoms.

METHODS/DESIGN

The study is a rater-blinded randomized controlled trial. Patients are offered 18 months of therapy and are randomly allocated to mentalization-based treatment for psychotic disorders or treatment as usual. Patients are recruited from outpatient departments of the Rivierduinen mental health institute, the Netherlands, and are aged 18 to 55 years and have been diagnosed with a non-affective psychotic disorder. Social functioning, the primary outcome variable, is measured with the social functioning scale. The administration of all tests and questionnaires takes approximately 22 hours. Mentalization-based treatment for psychotic disorders adds a total of 60 hours of group therapy and 15 hours of individual therapy to treatment as usual. No known health risks are involved in the study, though it is known that group dynamics can have adverse effects on a psychiatric disorder.

DISCUSSION

If Mentalization-based treatment for psychotic disorders proves to be effective, it could be a useful addition to treatment.

TRIAL REGISTRATION

Dutch Trial Register. NTR4747 . Trial registration date 08-19-2014.

Borderline Personality Disorder and Mood Disorders: Mentalizing as a Framework for Integrated Treatment

Borderline personality disorder (BPD) frequently co-occurs with mood disorders and each influences the course and response to treatment of the other, potentially reducing beneficial outcome. Mentalizing, the ability to infer one's own and others' mental states, is a key factor in both disorders, being a major component of affect regulation and self-identity as well as a central aspect of interpersonal relationships and social function. In this article, we suggest that using mentalization-based treatment may lead to better outcome by addressing the mentalizing problems arising from the dual pathway that leads from depressed mood and BPD to disruption of mentalizing. Some clinical interventions are described to address the mentalizing problems associated with depression and BPD.

Mentalization-based therapy (MBT): an overview

OBJECTIVE

This paper provides an overview of mentalization-based therapy (MBT). Multiple strands of research evidence converge to suggest that affect dysregulation, impulsivity and unstable interpersonal relationships are core features of borderline personality disorder (BPD). The MBT approach to BPD attempts to provide a theoretically consistent way of conceptualising the inter-relationship of these features.

METHODS

MBT makes mentalizing a core focus of therapy and was initially developed for the treatment of BPD in routine clinical services, delivered in group and individual modalities. This article provides a brief overview of mentalizing and its relevance to BPD, provides an overview of MBT and notes a number of current trends in MBT.

RESULTS

MBT provides clinicians with an empirically supported approach to BPD and its treatment.

CONCLUSIONS

Whilst mentalizing is viewed as an integrative framework for therapy, more knowledge is needed as to which of the therapies are of most benefit for individual patients.

Study Protocol for a randomized controlled trial of mentalization based therapy against specialist supportive clinical management in patients with both eating disorders and symptoms of borderline personality disorder

BACKGROUND

The NOURISHED study: Nice OUtcomes for Referrals with Impulsivity, Self Harm and Eating Disorders.Eating Disorders (ED) and Borderline Personality Disorder (BPD) are both difficult to treat and the combination presents particular challenges. Both are associated with vulnerability to loss of mentalization (awareness of one's own and others' emotional state). In BPD, Mentalization Based therapy (MBT) has been found effective in reducing symptoms. In this trial we investigate the effectiveness and cost-effectiveness of MBT adapted for Eating disorders (Mentalization Based Therapy for Eating Disorders (MBT-ED)) compared to a standard comparison treatment, Specialist Supportive Clinical Management (SSCM-ED) in patients with a combination of an Eating Disorder and either a diagnosis of BPD or a history of self-harm and impulsivity in the previous 12 months.

METHODS/DESIGN

We will complete a multi-site single-blind randomized controlled trial (RCT) of MBT-ED vs SSCM-ED. Participants will be recruited from three Eating Disorder Services and two Borderline Personality Disorder Services in London. Participants allocated to MBT-ED will receive one year of weekly group and individual therapy and participants allocated to SSCM-ED will receive 20 sessions of individual therapy over 1 year. In addition, participants in both groups will have access to up to 5 hours of dietetic advice. The primary outcome measure is the global score on the Eating Disorders Examination. Secondary outcome measures include total score on the Zanarini BPD scale, the Object Relations Inventory, the Depression Anxiety Stress Scales, quality of life and cost-effectiveness. Measures are taken at recruitment and at 6 month intervals up to 18 months.

DISCUSSION

This is the first Randomised Controlled Trial of MBT-ED in patients with eating disorders and symptoms of BPD and will provide evidence to inform therapy decisions in this group of patients. During MBT-ED mentalization is encouraged, while in SSCM-ED it is not overtly addressed. This study will help elucidate mechanisms of change in the two therapies and analysis of therapy and interview transcripts will provide qualitative information about the conduct of therapy and changes in mentalization and object relations.

TRIAL REGISTRATION

ISRCTN51304415.

Mentalization-Based Treatment

The concept of mentalizing has captured the interest and imagination of an astonishing range of people—from psychoanalysts to neuroscientists, from child development researchers to geneticists, from existential philosophers to phenomenologists—all of whom seem to have found it useful. According to the Thompson Reuter maintained Web of Science, the use of the term in titles and abstracts of scientific papers increased from 10 to 2,750 between 1991 and 2011. Clinicians in particular have enthusiastically embraced the idea, and have put it to innovative use in their practices. Mentalization-based treatment (MBT)—making mentalizing a core focus of therapy—was initially developed for the treatment of borderline personality disorder (BPD) in routine clinical services delivered in group and individual modalities. Therapy with mentalizing as a central component is currently being developed for treatment of numerous groups, including people with antisocial personality disorder, substance abuse, eating disorders, and at-risk mothers with infants and children (A. Bateman & Fonagy, 2011). It is also being used with families and adolescents, in schools, and in managing social groups (Asen & Fonagy, 2011; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a, 2005b). In this article, we focus on MBT in the treatment of BPD.

Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder

BACKGROUND

Evidence of remission from borderline personality disorder (BPD) without specialised treatment is accumulating.

AIMS

To establish whether specialised treatments are indicated for patients with clinically severe disorder.

METHOD

The impact of clinical severity on outcomes of a randomised controlled trial of mentalisation-based treatment (MBT) was contrasted with structured clinical management (SCM). Severity indicators were defined as severity of comorbid psychiatric syndromes, severity of BPD, severity of personality disturbance and severity of symptom distress. Logistic regressions were used to predict the likelihood of recovery at 18 months, and mixed-effects regression analysis was applied to examine the association of severity and rates of improvement across time in the two treatment groups.

RESULTS

None of the severity criteria predicted outcome at the end of treatment on logistic regression. However, testing the significance of distribution of cases of recovery v. non-recovery suggested that multiple Axis II diagnoses and symptom distress influenced outcomes.

CONCLUSIONS

Borderline personality disorder with significant Axis II comorbidity is a possible but uncertain indicator for specialist treatment. Patients whose only personality disorder diagnosis is BPD do equally well with SCM. Prospective studies are needed.

Oesophageal Chemoradiotherapy in the UK--current practice and future directions

The SCOPE 1 trial closed to recruitment in early 2012 and has demonstrably improved the quality of UK radiotherapy. It has also shown that there is an enthusiastic upper gastrointestinal clinical oncology community that can successfully complete trials and deliver high-quality radiotherapy. Following on from SCOPE 1, this paper, authored by a consensus of leading UK upper gastrointestinal radiotherapy specialists, attempts to define current best practice and the questions to be answered by future clinical studies. The two main roles for chemoradiotherapy (CRT) in the management of potentially curable oesophageal cancer are definitive (dCRT) and neoadjuvant (naCRT). The rates of local failure after dCRT are consistently high, showing the need to evaluate more effective treatments, both in terms of optimal local and systemic therapeutic components. This will be the primary objective of the next planned UK dCRT trial and here we discuss the role of dose escalation and systemic therapeutic options that will form the basis of that trial. The publication of the Dutch 'CROSS' trial of naCRT has shown that this pre-operative approach can both be given safely and offer a significant survival benefit over surgery alone. This has led to the development of the UK NeoSCOPE trial, due to open in 2013. There will be a translational substudy to this trial and currently available data on the role of biomarkers in predicting response to therapy are discussed. Postoperative reporting of the pathology specimen is discussed, with recommendations for the NeoSCOPE trial. Both of these CRT approaches may benefit from recent developments, such as positron emission tomography/computed tomography and four-dimensional computed tomography for target volume delineation, planning techniques such as intensity-modulated radiotherapy and 'type b' algorithms and new treatment verification methods, such as cone-beam computed tomography. These are discussed here and recommendations made for their use.

Comparing virtual with conventional microscopy for the consensus diagnosis of Barrett's neoplasia in the AspECT Barrett's chemoprevention trial pathology audit

AIMS

To compare the diagnostic accuracy of conventional versus virtual microscopy for the diagnosis of Barrett's neoplasia.

METHODS AND RESULTS

Sixty-one biopsies from 35 ASPirin Esomeprazole ChemopreventionTrial (AspECT) trial patients were given a Barrett's neoplasia score (1-5) by a panel of five pathologists using conventional microscopy. Thirty-three biopsies positive for neoplasia were digitized and rescored blindly by virtual microscopy. Diagnostic reliability was compared between conventional and virtual microscopy using Fleiss' kappa. There was substantial reliability of diagnostic agreement (κ = 0.712) scoring the 61 biopsies and moderate agreement scoring the subgroup of 33 'positive' biopsies with both conventional microscopy (κ = 0.598) and virtual microscopy (κ = 0.436). Inter-observer diagnostic agreement between two pathologists by virtual microscopy was substantial (κ = 0.76). Comparison of panel consensus neoplasia scores between conventional and virtual microscopy was almost perfect (κ = 0.8769). However, with virtual microscopy there was lowering of the consensus neoplasia score in nine biopsies.

CONCLUSIONS

Diagnostic agreement with virtual microscopy compares favourably with conventional microscopy in what is recognized to be a challenging area of diagnostic practice. However, this study highlights possible limitations for this method in the primary diagnostic setting.