Cognitive Remediation in Bipolar (CRiB2): study protocol for a randomised controlled trial assessing efficacy and mechanisms of cognitive remediation therapy compared to treatment as usual

BACKGROUND

A substantial proportion of people with bipolar disorder (BD) experience persistent cognitive difficulties associated with impairments in psychosocial functioning and a poorer disorder course. Emerging evidence suggests that cognitive remediation (CR), a psychological intervention with established efficacy in people with schizophrenia, can also benefit people with BD. Following a proof-of-concept trial showing that CR is feasible and potentially beneficial for people with BD, we are conducting an adequately powered trial in euthymic people with BD to 1) determine whether an individual, therapist-supported, computerised CR can reduce cognitive difficulties and improve functional outcomes; and 2) explore how CR exerts its effects.

METHODS

CRiB2 is a two-arm, assessor-blind, multi-site, randomised controlled trial (RCT) comparing CR to treatment-as-usual (TAU). Participants are people with a diagnosis of BD, aged between 18 and 65, with no neurological or current substance use disorder, and currently euthymic. 250 participants will be recruited through primary, secondary, tertiary care, and the community. Participants will be block-randomised (1:1 ratio, stratified by site) to continue with their usual care (TAU) or receive a 12-week course of therapy and usual care (CR + TAU). The intervention comprises one-on-one CR sessions with a therapist supplemented with independent cognitive training for 30-40 h in total. Outcomes will be assessed at 13- and 25-weeks post-randomisation. Efficacy will be examined by intention-to-treat analyses estimating between-group differences in primary (i.e., psychosocial functioning at week 25 measured with the Functional Assessment Short Test) and secondary outcomes (i.e., measures of cognition, mood, patient-defined goals, and quality of life). Global cognition, metacognitive skills, affect fluctuation, and salivary cortisol levels will be evaluated as putative mechanisms of CR through mediation models.

DISCUSSION

This study will provide a robust evaluation of efficacy of CR in people with BD and examine the putative mechanisms by which this therapy works. The findings will contribute to determining the clinical utility of CR and potential mechanisms of action.

TRIAL REGISTRATION

Cognitive Remediation in Bipolar 2 (CRiB2): ISRCTN registry: https://www.isrctn.com/ISRCTN10362331 . Registered 04 May 2022. Overall trial status: Ongoing; Recruitment status: Recruiting.

Reduced critical care demand with early CPAP and proning in COVID-19 at Bradford: A single-centre cohort

Background

Guidance in COVID-19 respiratory failure has favoured early intubation, with concerns over the use of CPAP. We adopted early CPAP and self-proning, and evaluated the safety and efficacy of this approach.

Methods

This retrospective observational study included all patients with a positive COVID-19 PCR, and others with high clinical suspicion. Our protocol advised early CPAP and self-proning for severe cases, aiming to prevent rather than respond to deterioration. CPAP was provided outside critical care by ward staff supported by physiotherapists and an intensive critical care outreach program. Data were analysed descriptively and compared against a large UK cohort (ISARIC).

Results

559 patients admitted before 1 May 2020 were included. 376 were discharged alive, and 183 died. 165 patients (29.5%) received CPAP, 40 (7.2%) were admitted to critical care and 28 (5.0%) were ventilated. Hospital mortality was 32.7%, and 50% for critical care. Following CPAP, 62% of patients with S:F or P:F ratios indicating moderate or severe ARDS, who were candidates for escalation, avoided intubation. Figures for critical care admission, intubation and hospital mortality are lower than ISARIC, whilst critical care mortality is similar. Following ISARIC proportions we would have admitted 92 patients to critical care and intubated 55. Using the described protocol, we intubated 28 patients from 40 admissions, and remained within our expanded critical care capacity.

Conclusion

Bradford's protocol produced good results despite our population having high levels of co-morbidity and ethnicities associated with poor outcomes. In particular we avoided overloading critical care capacity. We advocate this approach as both effective and safe.

Compassion Focused Group Therapy for People With a Diagnosis of Bipolar Affective Disorder: A Feasibility Study

Background

Compassion focused therapy (CFT) is an evolutionary informed, biopsychosocial approach to mental health problems and therapy. It suggests that evolved motives (e.g., for caring, cooperating, competing) are major sources for the organisation of psychophysiological processes which underpin mental health problems. Hence, evolved motives can be targets for psychotherapy. People with certain types of depression are psychophysiologically orientated towards social competition and concerned with social status and social rank. These can give rise to down rank-focused forms of social comparison, sense of inferiority, worthlessness, lowered confidence, submissive behaviour, shame proneness and self-criticism. People with bipolar disorders also experience elevated aspects of competitiveness and up rank status evaluation. These shift processing to a sense of superiority, elevated confidence, energised behaviour, positive affect and social dominance. This is the first study to explore the feasibility of a 12 module CFT group, tailored to helping people with a diagnosis of bipolar disorder understand the impact of evolved competitive, status-regulating motivation on their mental states and the value of cultivating caring and compassion motives and their psychophysiological regulators.

Methods

Six participants with a history of bipolar disorder took part in a CFT group consisting of 12 modules (over 25 sessions) as co-collaborators to explore their personal experiences of CFT and potential processes of change. Assessment of change was measured via self-report, heart rate variability (HRV) and focus groups over three time points.

Results

Although changes in self-report scales between participants and across time were uneven, four of the six participants consistently showed improvements across the majority of self-report measures. Heart rate variability measures revealed significant improvement over the course of the therapy. Qualitative data from three focus groups revealed participants found CFT gave them helpful insight into: how evolution has given rise to a number of difficult problems for emotion regulation (called tricky brain) which is not one's fault; an evolutionary understanding of the nature of bipolar disorders; development of a compassionate mind and practices of compassion focused visualisations, styles of thinking and behaviours; addressing issues of self-criticism; and building a sense of a compassionate identity as a means of coping with life difficulties. These impacted their emotional regulation and social relationships.

Conclusion

Although small, the study provides evidence of feasibility, acceptability and engagement with CFT. Focus group analysis revealed that participants were able to switch from competitive focused to compassion focused processing with consequent improvements in mental states and social behaviour. Participants indicated a journey over time from 'intellectually' understanding the process of building a compassionate mind to experiencing a more embodied sense of compassion that had significant impacts on their orientation to (and working with) the psychophysiological processes of bipolar disorder.

The Truthfulness of Nutrition Information in YouTube Cooking Channels

Objectives

To evaluate the truthfulness of nutrition, cooking, or food information in videos from Youtube cooking channels’ recipes/meal preparation demonstrations. Currently, no studies directly evaluate the truthfulness of nutrition information from cooking channels on YouTube, this research aims to fill this gap in knowledge.

Methods

Keywords (mealprep, healthy cooking, recipe, healthy dishes, meals) were selected; Google Trends was used to determine the use of each term. Each keyword was used to select 16 videos for a total of 80 videos. Each channel was evaluated to ensure it qualified as a cooking channel, then sorted into categories (professional chef, nonprofessional cook, home cook, or food media company; each category was sorted into health focused or nonhealth focused) for analysis. Both researchers abstracted content from all videos. Nutrition claims were scored for accuracy & specificity (how detailed the information was) using a tool modeled after the DISCERN tool. In addition, the following indicators of video popularity were collected: number of views, likes, dislikes, comments & subscribers. Truthfulness was assessed using the sum of accuracy and specificity scores of the videos’ nutrition content; higher scores reflect better accuracy, truthfulness, and specificity.

Results

43 of the videos (53.8%) discussed nutrition information. Mean accuracy, specificity, & truthfulness scores were 4.16 of 5, 2.65 of 5, & 6.18 out of 10, respectively. Both truthfulness and specificity were positively (p < 0.05) associated with the number of nutrition concepts noted (r = 0.309; r = 0.375). No associations were found between truthfulness scores and measures of popularity, except for number of subscribers and specificity (r = −0.366; p = 0.05). Upload source was significantly associated with accuracy (p = 0.009) but not truthfulness or specificity. Nonhealth focused professional chefs had a significantly higher mean accuracy than nonhealth focused non-professional cooks (p = 0.036). Nonhealth focused food media companies had a significantly higher mean accuracy score than nonhealth focused non-professional cooks (p = 0.014).

Conclusions

YouTube cooking channels could be reasonable sources for factual nutrition information, but truthfulness can vary based on certain factors.

Funding Sources

Simmons University.

The effect of pre-analytical variables on downstream application and data analysis of human endometrial biopsies

STUDY QUESTION

What are the effects of pre-analytical variables on the downstream analysis of patient-derived endometrial biopsies?

SUMMARY ANSWER

There are distinct differences in the protein levels of the master regulator of oxygen homeostasis, hypoxia-inducible factor-1-alpha (HIF1α), and the protein and mRNA levels of three related genes, carbonic anhydrase 9 (CA9), vascular endothelial growth factor A (VEGFA) and progesterone receptor (PR) in human endometrial biopsies, depending on the pre-analytical variables: disease status (cancer vs benign), timing of biopsy (pre- vs post-hysterectomy) and type of biopsy (pipelle vs full-thickness).

WHAT IS KNOWN ALREADY

Patient-derived biopsies are vital to endometrial research, but pre-analytical variables relating to their collection may affect downstream analysis, as is evident in other tissues.

STUDY DESIGN SIZE DURATION

A prospective observational study including patients undergoing hysterectomy for endometrial cancer (EC) or benign indications was conducted at a large tertiary gynaecological unit in the UK. Endometrial biopsies were obtained at different time points (pre- or post-hysterectomy) using either a pipelle endometrial sampler or as a full-thickness wedge biopsy.

PARTICIPANTS/MATERIALS SETTING METHODS

The changes in HIF1α, CA9, VEGFA and PR protein levels were measured by semi-quantitative analysis of immunostaining, and the expression levels of three genes (CA9, VEGFA and PR) were investigated by quantitative real-time PCR, in endometrial biopsies from 43 patients undergoing hysterectomy for EC (n = 22) or benign gynaecological indications (n = 21).

MAIN RESULTS AND THE ROLE OF CHANCE

An increase in HIF1α immunostaining was observed in EC versus benign endometrium (functionalis glands) obtained pre-hysterectomy (P < 0.001). An increase in CA9 immunostaining was observed in EC versus benign endometrial functionalis glands at both pre- and post-hysterectomy time points (P = 0.03 and P = 0.003, respectively). Compared with benign endometrial pipelle samples, EC samples demonstrated increased mRNA expression of CA9 (pre-hysterectomy P < 0.001, post-hysterectomy P = 0.008) and VEGFA (pre-hysterectomy P = 0.004, post-hysterectomy P = 0.002). In benign uteri, HIF1α immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.009), VEGFA immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.01) and VEGFA mRNA levels (P = 0.008) were increased in matched post-hysterectomy versus pre-hysterectomy samples. Similarly, in EC, an increase in VEGFA immunoscores (epithelial and stromal) and VEGFA mRNA expression was observed in the matched post-hysterectomy versus pre-hysterectomy biopsies (P = 0.008, P = 0.004 and P = 0.018, respectively). Full-thickness benign post-hysterectomy endometrial biopsies displayed increased VEGFA (P = 0.011) and PR (P = 0.006) mRNA expression compared with time-matched pipelle biopsies.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

This descriptive study explores the effect of pre-analytical variables on the expression of four proteins and three hypoxia-related genes in a limited number of endometrial biopsies from patients with EC and benign controls. Due to the small number, it was not possible to investigate other potential variables such as menstrual cycle phase, region-specific differences within the endometrium, grade and stage of cancer, and surgical technicalities.

WIDER IMPLICATIONS OF THE FINDINGS

Careful consideration of the effects of these pre-analytical variables is essential when interpreting data relating to human endometrial biopsies. A standardized approach to endometrial tissue collection is essential to ensure accurate and clinically transferrable data.

STUDY FUNDING/COMPETING INTERESTS

The authors have no conflicts of interest to declare. The work included in this manuscript was funded by Wellbeing of Women project grants RG1073 and RG2137 (D.K.H.), Wellbeing of Women Entry-Level Scholarship ELS706 and Medical Research Council MR/V007238/1 (A.M./D.K.H.), Liverpool Women's Hospital Cancer Charity (M.A.) and University of Liverpool (L.B., L.R. and E.N.).

Patient Satisfaction With Telehealth in Rural Settings: A Systematic Review

Date Presented 04/21/21

This systematic review analyzes patient satisfaction with telehealth rehabilitation (OT, physical therapy, speech-language pathology) in global rural communities. Telehealth services should be used to deliver therapy to patients in rural settings for greater outreach. Patients report high satisfaction related to ease of travel, quality of care, safety, and reduced costs. This study has implications for telehealth program development within OT practice.

Primary Author and Speaker: Angela Patterson

Additional Authors and Speakers: Stephanie C. DeLuca, Hoàng Khánh Chi

Contributing Authors: Lê Tường Giao Lê Tường, Đang Nguyễn Thị, and Thi Bich Ngoc Nguyen

Chiari I malformation with craniosynostosis and persistent falcine sinus draining into the straight sinus

Owing to the interconnected nature of the brain, anatomical variations in one area often coincide with, or are caused by, abnormalities in another. During dissection of a specimen with both Chiari I malformation and craniosynostosis, a persistent falcine sinus was observed to drain into the straight sinus. Such a variant should be noted by physicians as it could alter treatment plans and require more detailed imaging procedures prior to surgical correction. Herein, we report the case and discuss the possible embryological origins and clinical significance of the variant.

Pharmacokinetics of the Monoclonal Antibody MHAA4549A Administered in Combination With Oseltamivir in Patients Hospitalized With Severe Influenza A Infection

MHAA4549A is a human anti‐influenza A monoclonal antibody developed to treat influenza A. We report MHAA4549A serum, nasopharyngeal, and tracheal aspirate pharmacokinetics from a phase 2b study in hospitalized patients with severe influenza A. Patients were randomized 1:1:1 into 3 groups receiving single intravenous doses of 3600 mg (n = 55) or 8400 mg (n = 47) MHAA4549A or placebo (n = 56). Patients also received oral oseltamivir twice daily for ≥5 days. Serum, nasopharyngeal, and tracheal aspirate pharmacokinetic samples were collected on days 1‐60 from MHAA4549A‐treated groups. Day 5 plasma samples from all groups were collected for assessing the pharmacokinetics of oseltamivir and its active metabolite, oseltamivir carboxylate. Noncompartmental pharmacokinetic analysis was performed using Phoenix WinNonlin. Data were collected during a preplanned interim analysis that became final when the trial terminated because of a lack of efficacy. Serum MHAA4549A concentrations were dose‐proportional and biphasic. Mean MHAA4549A clearance was 288‐350 mL/day, and mean half‐life was 17.8‐19.0 days. Nasopharyngeal MHAA4549A concentrations were non‐dose‐proportional. We detected MHAA4549A in tracheal aspirate samples, but intersubject variability was high. MHAA4549A serum and nasopharyngeal exposures were confirmed in all MHAA4549A‐treated patients. Serum MHAA4549A had faster clearance and a shorter half‐life in influenza A‐infected patients compared with healthy subjects. MHAA4549A detection in tracheal aspirate samples indicated exposure in the lower respiratory tract. Oseltamivir and oseltamivir carboxylate exposures were similar between MHAA4549A‐treated and placebo groups, suggesting a lack of MHAA4549A interference with oseltamivir pharmacokinetics.

Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study

Background

All NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.

Aims

To identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.

Design

The study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.

Setting

The study was conducted in 57 NHS providers of inpatient mental health care in England.

Participants

In work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.

Results

The patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.

Limitations

The study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.

Conclusions

Patient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and interpretation of patient experience data is needed, particularly to ways of triangulating these with outcomes and safety data.

Future work

Further evaluative research is needed to develop and evaluate a locally adapted intervention based on the 18 rules for best practice.

Study registration

The systematic review (work package 1) is registered as PROSPERO CRD42016033556.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 21. See the NIHR Journals Library website for further project information.

What are the critical incidents that affect how people cope with being detained under Section 136 of the Mental Health Act (1983, 2007)?

Purpose: Section 136 (S136) of the Mental Health Act (1983, 2007) provides legislative powers for police officers to detain those suspected of being 'mentally disordered' for a mental health assessment. Despite its increasing use, there is currently little qualitative research exploring detainee's experiences. Methodology: Participants recruited from NHS places of safety participated in a semi-structured interview. The novel application of Critical Incident Technique (CIT) within this study enabled the specific identification of critical incidents which mental health service users thought had either helped with, or worsened the S136 detention experience. A wish list of absent factors was also gathered. Findings: Six categories of helpful critical incidents, seven categories of unhelpful critical incidents and five categories of wish-list items were identified. The importance of authentic relationships underpinned many categories, as well as challenging stigma, considering previous detentions; and receiving practical support. Originality/value: The outlined study is the first of its kind to utilise CIT methodology to specifically identify critical incidents related to the process of S136 detention. These findings provide specific ways to improve the experience of detention informed directly by those who have been directly subjected to S136. Key points Take time to invest in meaningful relationships with those who are detained; asking about the individual's life experience and their perception of its relationship to their current presenting difficulties. Identify the service user's values -what's important to them, and what gives meaning to their life - and discuss this in relation to what their worries, concerns or wishes may be for treatment. Discuss previous experiences of involuntary admission- this can support all parties involved to consider the impact of detention upon the individual, and services. Use problem-free discussions to normalise and help de-stigmatise mental health difficulties and support rapport building. Provide practical support, such as food, drink and routinely allow those who are detained to gather personal belongings such as a change of clothes or a book. Ensure advocacy services are always available and accessible for those who are detained under S136. Where possible, avoid the use of restrictive or stigmatising practices in front of the public where possible (e.g. use of handcuffs, police vehicles as transport) to minimise risk of increasing mental health stigma.

Experiences of in-patient mental health services: systematic review

BACKGROUND

In-patients in crisis report poor experiences of mental healthcare not conducive to recovery. Concerns include coercion by staff, fear of assault from other patients, lack of therapeutic opportunities and limited support. There is little high-quality evidence on what is important to patients to inform recovery-focused care.AimsTo conduct a systematic review of published literature, identifying key themes for improving experiences of in-patient mental healthcare.

METHOD

A systematic search of online databases (MEDLINE, PsycINFO and CINAHL) for primary research published between January 2000 and January 2016. All study designs from all countries were eligible. A qualitative analysis was undertaken and study quality was appraised. A patient and public reference group contributed to the review.

RESULTS

Studies (72) from 16 countries found four dimensions were consistently related to significantly influencing in-patients' experiences of crisis and recovery-focused care: the importance of high-quality relationships; averting negative experiences of coercion; a healthy, safe and enabling physical and social environment; and authentic experiences of patient-centred care. Critical elements for patients were trust, respect, safe wards, information and explanation about clinical decisions, therapeutic activities, and family inclusion in care.

CONCLUSIONS

A number of experiences hinder recovery-focused care and must be addressed with the involvement of staff to provide high-quality in-patient services. Future evaluations of service quality and development of practice guidance should embed these four dimensions.Declaration of interestK.B. is editor of British Journal of Psychiatry and leads a national programme (Synergi Collaborative Centre) on patient experiences driving change in services and inequalities.

Reflection of near-infrared light confers thermal protection in birds

Biologists have focused their attention on the optical functions of light reflected at ultraviolet and human-visible wavelengths. However, most radiant energy in sunlight occurs in 'unseen' near-infrared (NIR) wavelengths. The capacity to reflect solar radiation at NIR wavelengths may enable animals to control heat gain and remain within their critical thermal limits. Here, using a continent-wide phylogenetic analysis of Australian birds, we show that species occupying hot, arid environments reflect more radiant energy in NIR wavelengths than species in thermally benign environments, even when controlling for variation in visible colour. Biophysical models confirm that smaller species gain a greater advantage from high NIR reflectivity in hot, arid environments, reducing water loss from compensatory evaporative cooling by up to 2% body mass per hour. These results highlight the importance of NIR reflectivity for thermal protection, which may become increasingly critical as the frequency of extreme climatic events increases.

The microstructure of white feathers predicts their visible and near-infrared reflectance properties

Research on the optical properties of animal integuments, including fur, feather, skin and cuticle, has focussed almost exclusively on animal-visible wavelengths within the narrow range of 300-700 nm. By contrast, the near-infrared (NIR) portion of direct sunlight, spanning 700-2600 nm, has been largely ignored despite its potentially important thermal consequences. We quantified variation in visible and NIR reflectance and transmission for white body contour feathers of 50 bird species, and examined how well they are predicted by feather macro- and micro-structural morphology. Both visible and NIR reflectance of the feathers varied substantially across species. Larger, thicker, and sparser feathers that are characteristic of larger species, and feathers with rounder barbs and more closely spaced barbules, had high average reflectance, particularly within avian-visible wavelengths (300-700 nm). Feathers with rounder barbs and more closely situated barbules also had high average reflectance, particularly for NIR wavelengths. Barb roundness and barbule density were the only predictors of NIR reflectance after accounting for variation in visible reflectance and body size. Our results highlight the potential for adaptive variation in NIR reflectance mediated by feather structure, which may inform the design of functional materials to control light and heat.

Realist Evaluation of the Use of Patient Experience Data to Improve the Quality of Inpatient Mental Health Care (EURIPIDES) in England: study protocol

INTRODUCTION

Inpatient mental healthcare continues to be an area of high risk and where patients report negative experiences. To ensure the patient voice is heard, National Health Service (NHS) Trusts are required to collect feedback from patients routinely. We do not know what kinds of feedback are most important or what management processes are needed to translate this into effective action plans. Further, we do not know if this makes any difference to the patients themselves. This study seeks to explore which of the many different approaches to collecting and using patient experience data are the most useful for supporting improvements in inpatient mental healthcare. The overarching aim of the study is to arrive at recommendations for best practice in the collection and use of patient experience data in NHS England adult inpatient mental health settings. We present the protocol for Realist Evaluation of the Use of Patient Experience Data to Improve the Quality of Inpatient Mental Health Care study (EURIPIDES).

METHODS AND ANALYSIS

The study is composed of five work packages (WPs), including a systematic review of patient experiences (WP1); a telephone survey to assist the selection of case sites (WP2); six indepth case studies involving interviews with service users, carers and staff to enable a realist evaluation of the use of patient experience to improve quality in adult inpatient mental health services (WP3); an economic evaluation of patient experience feedback activity (WP5); and a consensus conference (WP4). We discuss the methodological rationale for the five WPs.

ETHICS AND DISSEMINATION

This study has received approval from West Midlands/South Birmingham NHS Research Ethics Committee. The outcome of the consensus conference meeting (WP4) will form the basis of the outputs to be disseminated to NHS providers. Dissemination will also take place through publications and presentations at relevant conferences.

Thermal consequences of colour and near-infrared reflectance

The importance of colour for temperature regulation in animals remains controversial. Colour can affect an animal's temperature because all else being equal, dark surfaces absorb more solar energy than do light surfaces, and that energy is converted into heat. However, in reality, the relationship between colour and thermoregulation is complex and varied because it depends on environmental conditions and the physical properties, behaviour and physiology of the animal. Furthermore, the thermal effects of colour depend as much on absorptance of near-infrared ((NIR), 700-2500 nm) as visible (300-700 nm) wavelengths of direct sunlight; yet the NIR is very rarely considered or measured. The few available data on NIR reflectance in animals indicate that the visible reflectance is often a poor predictor of NIR reflectance. Adaptive variation in animal coloration (visible reflectance) reflects a compromise between multiple competing functions such as camouflage, signalling and thermoregulation. By contrast, adaptive variation in NIR reflectance should primarily reflect thermoregulatory requirements because animal visual systems are generally insensitive to NIR wavelengths. Here, we assess evidence and identify key research questions regarding the thermoregulatory function of animal coloration, and specifically consider evidence for adaptive variation in NIR reflectance.This article is part of the themed issue 'Animal coloration: production, perception, function and application'.

If psychosis were cancer: a speculative comparison

Recently, health policy in the UK has begun to engage with the concept of 'parity of esteem' between physical and mental healthcare. This has led one recent initiative to improve service provision for first episode psychosis, which aims to bring it into line with some of the principles underpinning good practice in cancer care. In this paper, we consider some of the metaphorical consequences of likening psychosis to cancer. While we find the comparison unhelpful for clinical purposes, we argue that it can be a helpful lens through which to examine service provision for psychosis in young people. Through this lens, specialist community-based services would appear to compare reasonably well. Inpatient care for young people with psychosis, on the other hand, suffers very badly by comparison with inpatient facilities for teenage cancer care. We note some of the many positive features of inpatient cancer care for young adults, and-drawing upon previous research on inpatient psychiatric care-observe that many of these are usually absent from mental health facilities. We conclude that this metaphor may be a helpful rhetorical device for communicating the lack of 'parity of esteem' between mental and physical healthcare. This inequity must be made visible in health policy, in commissioning, and in service provision.

Factors underlying metastatic breast cancer patients' perceptions of symptom importance: a qualitative analysis

The symptom literature in cancer has primarily examined symptom severity, frequency and distress. Assessing cancer patients' perceptions of symptom importance-how important it is for them to see improvement in a symptom following an intervention-and factors influencing these judgments would also inform patient-centred care, but this analysis has not been undertaken. This qualitative study aimed to identify factors underlying perceptions of symptom importance among 25 symptomatic metastatic breast cancer (MBC) patients. Participants were recruited from a cancer centre in the Midwestern USA. Semi-structured interviews focused on patients' rationale for considering common symptoms (i.e., anxiety, sadness, sleep problems, pain or fatigue) to be important. Thematic analyses revealed five interrelated factors underlying MBC patients' perceptions of symptom importance: activity restriction, concentration difficulties, exacerbation of other physical symptoms, symptom-related long-term health concerns and negative impact on their relationships with others. Patients most frequently stated that a physical or psychological symptom was important because of the resulting activity restriction. Additionally, some patients considered pain to be important because it signalled potential long-term health concerns, such as worsening metastatic disease. Findings suggest that clinicians should take into account MBC patients' perceptions of symptom importance and factors underlying these judgments when making shared treatment decisions.

An outcomes analysis of anterior epistaxis management in the emergency department

Background

Many treatment options exist for the management of anterior epistaxis. However, little is known about treatment outcomes. The objective was to identify the currently utilised methods of management and outcomes for patients with anterior epistaxis presenting to the emergency department (ED) at a Canadian tertiary care center.

Methods

A retrospective review of ED visits from January 2012-May 2014 for adult patients with a diagnosis of anterior epistaxis was performed. Patient demographic data, comorbidities, and treatment methods were documented. The effectiveness of different treatment modalities was determined.

Results

Three hundred fifty-three primary anterior epistaxis cases were included. Mean patient age was 70 years and 49 % of patients were female. Comorbidities included hypertension (56 %), diabetes (19 %), CAD (28 %), and atrial fibrillation (27 %). A large proportion of the cohort (61 %) was on at least one anticoagulant or antiplatelet therapy. The most common utilised treatment modalities were silver nitrate cauterization, Merocel®, petroleum gauze packing, nasal clip and 15 % were simply observed. Initial treatment success was achieved in 74 % of cases. Of patients receiving specific treatment modalities, silver nitrate cauterization had the highest success rate at 80 %. 26 % of patients returned to the ED for recurrence of epistaxis with highest rates occurring in the nasal clip (59 %), Merocel® (26 %), and petroleum gauze packing (42 %) groups.

Conclusions

The differences in recurrence rate among the different treatment modalities observed may be due to true differences in effectiveness or differences in treatment selection by the ED physicians based on severity of epistaxis. Cauterization with silver nitrate, however, offers the added benefit of no need for follow up. Further study is needed to elucidate the most efficacious treatment modality based on epistaxis severity.

The experiential impact of hospitalisation: Parents' accounts of caring for young people with early psychosis

This research examines the experiential impact of hospitalisation on the parents of young people with early psychosis. In-depth interviews were conducted with a small sample of parents, and the resulting transcripts were analysed using Interpretative Phenomenological Analysis. Five themes emerged from the data: Accepting and blaming, Feeling out of control, Hospitalisation as temporary containment, Feeling let down by services and Stigma. Aspects of the hospitalisation process were characterised by parents as generally negative, but a number of positive affirmations were also offered regarding the containing, supportive and crucial role of services. Parents' perceptions of hospitalisation as a difficult, and sometimes distressing, experience are exacerbated by the complexity of being the carer of a young person. Negotiating services and boundaries within the context of this relationship contributes to feelings of exclusion and disregard by professionals and services. The implications of this study resonate with the current government mental health strategy with regard to how services can engage and include carers in the mental health system, and equip and enable them to support their relatives with early psychosis.

On the Brink of Genuinely Collaborative Care: Experience-Based Co-Design in Mental Health

Inpatient mental health services in the United Kingdom are currently dissatisfactory for service-users and staff. For young people with psychosis, being hospitalized is often distressing, and can lead to disengagement with mental health services. This article describes how we took three qualitative research studies about hospitalization in early psychosis (exploring the perspectives of service-users, parents, and staff) and translated them into service improvements developed in collaboration with a range of stakeholders, including service-users, carers, community and inpatient staff, and management. We used an adapted form of experience-based co-design (EBCD), a participatory action-research method for collaboratively improving health care services. The use of EBCD is still relatively novel in mental health settings, and we discuss how we adapted the methodology, and some of the implications of using EBCD with vulnerable populations in complex services. We reflect on both the disappointments and successes and give some recommendations for future research and methodological development.

The experiential impact of hospitalisation in early psychosis: service-user accounts of inpatient environments

Early Intervention in Psychosis services aim to keep young people out of hospital, but this is not always possible. This research used in-depth interviews to explore the experience of hospitalisation amongst young people with psychosis. Findings describe fear and confusion at admission, conflicting experiences of the inpatient unit as both safe and containing, and unsafe and chaotic, and the difficult process of maintaining identity in light of the admission. We discuss the need to move from construing psychiatric hospitals as places for 'passive seclusion', to developing more permeable and welcoming environments that can play an active role in recovery.

Depression, antidepressants, and falls among community-dwelling elderly people: the MOBILIZE Boston study

BACKGROUND

The mechanisms linking falls and depression are still unknown. The aim of the study is to examine the association between depression and antidepressants, with indoor and outdoor falls, and to investigate how antidepressants mediate this relationship.

METHODS

The study included 763 men and women aged 70 and older with baseline measures for depression and antidepressant use are captured with prospective data on falls from the "Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly" (MOBILIZE) Boston study, which is a population-based longitudinal study (from 2005 to 2009).

RESULTS

Overall, the rate of falls was 26 falls/100 person-years. Seventeen percent of participants had clinically significant depressive symptoms (CSDS), and 12% used antidepressants. CSDS increased the risk of indoor and outdoor falls (incidence rate ratio [IRR] = 1.6, 95% confidence interval [CI] = 1.2-2.3, p < .01; IRR = 1.6, 95% CI = 1.2-2.2, p < .01). Antidepressant use increased the risk of outdoor falls by 70% and partially mediated the association between CSDS and outdoor falls (IRR = 1.7, 95% CI = 1.2-2.5, p < .05). There was no relationship between antidepressant use and indoor falls. Similar results were observed when depression was considered as a continuous variable.

CONCLUSIONS

Depression increased the risk of indoor and outdoor falls. Antidepressant use among older adults with CSDS increased the risk of outdoor, but not indoor falls. Clinicians should carefully consider the role of antidepressants among older adults with CSDS and their potential increase for the risk of outdoor falls.

Use of a Novel Two-layer Bandage in the Treatment of Chronic Venous Hypertension

Since the development of Unna boot therapies, there has been development in newer technologies for venous compression syndromes and chronic venous hypertension. Chronic lower extremity venous insufficiency results in venous stasis, edema and hypercongestion of the lower extremities. Given the breadth of potential uses, the goal of this study was to retrospectively compile and analyze the clinical application and effectiveness of a 2-layer zinc-impregnated foam Unna boot bandage (Andover Healthcare, Salisbury, MA) in patients with lower extremity swelling with or without wounds treated by a single physician and monitored for 12 weeks post-application in the outpatient setting. In patients with complex comorbidities, the use of this new foam-impregnated multi-layer compression Unna boot shows efficacy in reduction of edema and wound size within 12 weeks. This newer therapy shows extensive promise in the ability to keep patients adherent to treatment regimens with higher rates of success.

Haemophilus influenzae serotype B (Hib) seroprevalence in England and Wales in 2009

A national seroprevalence study was performed to determine the prevalence of Haemophilus influenzae type b (Hib) antibodies in England and Wales in 2009, when Hib disease incidence was the lowest ever recorded. A total of 2,693 anonymised residual sera from routine diagnostic testing submitted by participating National Health Service hospital laboratories were tested for Hib anti-polyribosyl-ribitol phosphate (PRP) IgG antibodies using a fluorescent bead assay. Median anti-PRP IgG concentrations were highest in toddlers aged 1–4 years (2.65 μg/ml), followed by children aged 5–9 years (1.95 μg/ml). Antibody concentrations were significantly lower after this age, but were still significantly higher among 10–19 year-olds (0.54 μg/ml) compared with adults aged >20 years (0.16 μg/ ml; p<0.0001). Half of the adults (51%) did not have Hib antibody concentrations ≥0.15 μg/ml, the level considered to confer short-term protection. Thus, the current excellent Hib control appears to be the result of high anti-PRP antibody concentrations in children aged up to 10 years, achieved through the various childhood vaccination campaigns offering booster immunisation. The lack of seroprotection in adults emphasises the importance of maintaining control of the disease and, most probably carriage, in children, therefore raising the question as to whether long-term routine boosting of either pre-school children or adolescents may be required.

The relationship between brain volume and walking outcomes in older adults with and without diabetic peripheral neuropathy

OBJECTIVE

Diabetic peripheral neuropathy (DPN) alters walking. Yet, the compensatory role of central locomotor circuits remains unclear. We hypothesized that walking outcomes would be more closely related to regional gray matter volumes in older adults with DPN as compared with nonneuropathic diabetic patients and nondiabetic control subjects.

RESEARCH DESIGN AND METHODS

Clinically important outcomes of walking (i.e., speed, stride duration variability, and double support time) were measured in 29 patients with DPN (type 2 diabetes with foot-sole somatosensory impairment), 68 diabetic (DM) patients (type 2 diabetes with intact foot-sole sensation), and 89 control subjects. Global and regional gray matter volumes were calculated from 3 Tesla magnetic resonance imaging.

RESULTS

DPN subjects walked more slowly (P = 0.005) with greater stride duration variability (P < 0.001) and longer double support (P < 0.001) as compared with DM and control subjects. Diabetes was associated with less cerebellar gray matter volume (P < 0.001), but global gray matter volume was similar between groups. DPN subjects with lower gray matter volume globally (P < 0.004) and regionally (i.e., cerebellum, right-hemisphere dorsolateral prefrontal cortex, basal ganglia, P < 0.005) walked more slowly with greater stride duration variability and/or longer double support. Each relationship was stronger in DPN than DM subjects. In control subjects, brain volumes did not relate to walking patterns.

CONCLUSIONS

Strong relationships between brain volumes and walking outcomes were observed in the DPN group and to a lesser extent the DM group, but not in control subjects. Individuals with DPN may be more dependent upon supraspinal elements of the motor control system to regulate several walking outcomes linked to poor health in elderly adults.

Retinal microvascular signs and disability in the Cardiovascular Health Study

OBJECTIVE

To study the associations of retinal microvascular changes, which are associated with systemic conditions and cognitive decline, with disability in performing activities of daily living (ADL).

DESIGN

Prospective cohort study of 1487 community-dwelling participants in the Cardiovascular Health Study (mean age, 78 years) who were free of ADL disability and had available data on retinal signs and carotid intima-media thickness at the 1998-1999 visit. Main outcome measures were incident ADL disability, defined as self-reported difficulty in performing any ADL, by the presence of retinal signs and advanced carotid atherosclerosis, defined by carotid intima-media thickness in the 80th percentile or more or 25% or more stenosis, and potential mediation by cerebral microvascular disease on brain imaging or by executive dysfunction, slow gait, and depressive mood, which are symptoms of frontal subcortical dysfunction.

RESULTS

During the median follow-up of 3.1 years (maximum, 7.8 years), participants with 2 or more retinal signs had a higher rate of disability than those with fewer than 2 retinal signs (10.1% vs 7.1%; adjusted hazard ratio, 1.45; 95% confidence interval, 1.24-1.69; P < .001). There was no evidence of interaction by advanced carotid atherosclerosis (P > .10). The association seemed to be partially mediated by executive dysfunction, slow gait, and depressive symptoms but not by cerebral microvascular disease on brain imaging.

CONCLUSIONS

These results provide further support for the pathophysiologic and prognostic significance of microvascular disease in age-related disability. However, it remains to be determined how to best use retinal photography in clinical risk prediction.

Neurovascular coupling is impaired in slow walkers: the MOBILIZE Boston Study

OBJECTIVE

Neurovascular coupling may be involved in compensatory mechanisms responsible for preservation of gait speed in elderly people with cerebrovascular disease. Our study examines the association between neurovascular coupling in the middle cerebral artery and gait speed in elderly individuals with impaired cerebral vasoreactivity.

METHODS

Twenty-two fast and 20 slow walkers in the lowest quartile of cerebral vasoreactivity were recruited from the MOBILIZE Boston Study. Neurovascular coupling was assessed in bilateral middle cerebral arteries by measuring cerebral blood flow during the N-Back task. Cerebral white matter hyperintensities were measured for each group using magnetic resonance imaging.

RESULTS

Neurovascular coupling was attenuated in slow compared to fast walkers (2.8%; 95% confidence interval [CI], -0.9 to 6.6 vs 8.2%; 95% CI, 4.7-11.8; p = 0.02). The odds ratio of being a slow walker was 6.4 (95% CI, 1.7-24.9; p = 0.007) if there was a high burden of white matter hyperintensity; however, this risk increased to 14.5 (95% CI, 2.3-91.1; p = 0.004) if neurovascular coupling was also attenuated.

INTERPRETATION

Our results suggest that intact neurovascular coupling may help preserve mobility in elderly people with cerebral microvascular disease.

Retinal microvascular signs and functional loss in older persons: the cardiovascular health study

BACKGROUND AND PURPOSE

We hypothesized that retinal microvascular signs are associated with executive dysfunction, slow gait, and depressive mood, which are characteristic features of microvascular disease affecting frontal subcortical regions of the brain.

METHODS

In the Cardiovascular Health Study, 1744 participants (mean age, 78) free of stroke had retinal photographs and carotid ultrasound during the 1997 to 1998 visit. We examined the cross-sectional association of retinal signs with the digit-symbol substitution test (DSST) score, gait speed, the Center for Epidemiologic Studies-Depression score, and depressive mood, defined as Center for Epidemiologic Studies-Depression score >9 or antidepressant use.

RESULTS

After adjusting for potential confounders, retinal signs were associated with lower DSST score (generalized arteriolar narrowing and arteriovenous nicking), slower gait (retinopathy), and depressive mood (generalized arteriolar narrowing). A higher number of retinal signs was associated with lower DSST score (-0.76 and -2.79 points for 1 sign and ≥2 signs versus none; P<0.001) and slower gait (-0.009 and -0.083 m/s; P=0.047), but not with the square root of Center for Epidemiologic Studies-Depression score (0.079 and -0.208; P=0.072). In addition, coexistence of retinal signs (generalized arteriolar narrowing and arteriovenous nicking) and carotid atherosclerosis was associated with lower DSST score compared with either process alone (P for interaction <0.01). Notably, further adjustment for ventricular size, white matter disease, and infarcts on MRI did not attenuate the association.

CONCLUSIONS

Retinal signs are associated with executive dysfunction and slow gait, and possibly with depressive mood, suggesting a common process involving small vessels.

Physiological complexity and system adaptability: evidence from postural control dynamics of older adults

The degree of multiscale complexity in human behavioral regulation, such as that required for postural control, appears to decrease with advanced aging or disease. To help delineate causes and functional consequences of complexity loss, we examined the effects of visual and somatosensory impairment on the complexity of postural sway during quiet standing and its relationship to postural adaptation to cognitive dual tasking. Participants of the MOBILIZE Boston Study were classified into mutually exclusive groups: controls [intact vision and foot somatosensation, n = 299, 76 ± 5 (SD) yr old], visual impairment only (<20/40 vision, n = 81, 77 ± 4 yr old), somatosensory impairment only (inability to perceive 5.07 monofilament on plantar halluxes, n = 48, 80 ± 5 yr old), and combined impairments (n = 25, 80 ± 4 yr old). Postural sway (i.e., center-of-pressure) dynamics were assessed during quiet standing and cognitive dual tasking, and a complexity index was quantified using multiscale entropy analysis. Postural sway speed and area, which did not correlate with complexity, were also computed. During quiet standing, the complexity index (mean ± SD) was highest in controls (9.5 ± 1.2) and successively lower in the visual (9.1 ± 1.1), somatosensory (8.6 ± 1.6), and combined (7.8 ± 1.3) impairment groups (P = 0.001). Dual tasking resulted in increased sway speed and area but reduced complexity (P < 0.01). Lower complexity during quiet standing correlated with greater absolute (R = -0.34, P = 0.002) and percent (R = -0.45, P < 0.001) increases in postural sway speed from quiet standing to dual-tasking conditions. Sensory impairments contributed to decreased postural sway complexity, which reflected reduced adaptive capacity of the postural control system. Relatively low baseline complexity may, therefore, indicate control systems that are more vulnerable to cognitive and other stressors.

rNAPc2 inhibits colorectal cancer in mice through tissue factor

PURPOSE

Recombinant nematode anticoagulant protein c2 (rNAPc2) is a specific inhibitor of tissue factor (TF)/factor VIIa complex with novel antithrombotic activity. TF is highly expressed in human colorectal tumors, and levels are positively correlated with disease progression.

EXPERIMENTAL DESIGN

To explore the therapeutic potential and mechanism of action of rNAPc2 during tumor growth and metastasis, we tested rNAPc2 in several experimental colorectal cancer models in mice.

RESULTS

Administration of rNAPc2 inhibited pulmonary metastasis in mice systemically disseminated with CT26 murine colon carcinoma cells in a dose-dependent fashion. Combining rNAPc2 with the cytotoxic agent 5-fluorouracil or bevacizumab (humanized anti-vascular endothelial growth factor monoclonal antibody) resulted in additive growth inhibition and simultaneous reduction of microvessel density in HCT116 human colorectal tumor xenografts in nude mice. Furthermore, rNAPc2 potentiated CPT-11 in inhibiting hepatic metastasis in nude mice with portal vein injection of HCT116 tumor cells. Long-term administration of rNAPc2 significantly suppressed spontaneous formation of intestinal tumors in Apc(Min/+) mice. Using a RNA interference approach, we showed that TF expression is necessary for rNAPc2-mediated inhibition of HCT116 human colorectal tumor xenograft growth in nude mice, indicating that the antitumor effect of rNAPc2 may be transduced through TF that is expressed on tumor cells.

CONCLUSIONS

rNAPc2 is a potent anticancer agent when used in combination with chemotherapy or antiangiogenic therapy in mouse models of colorectal cancer, and TF positivity appears to be required for its activity.

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth.

METHODS

This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at </= 32 weeks of gestation. The trial was analyzed using an intent-to-treat strategy.

RESULTS

Baseline characteristics were similar in the two treatment groups. Progesterone did not decrease the frequency of preterm birth at </= 32 weeks. There was no difference between the groups with respect to the mean gestational age at delivery, infant morbidity or mortality or other maternal or neonatal outcome measures. Adverse events during the course of treatment were similar for the two groups.

CONCLUSION

Prophylactic treatment with vaginal progesterone did not reduce the frequency of recurrent preterm birth (</= 32 weeks) in women with a history of spontaneous preterm birth. The effect of progesterone administration in patients at high risk for preterm delivery as determined by methods other than history alone (e.g. sonographic cervical length) requires further investigation.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester.

METHODS

This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at </= 32 weeks.

RESULTS

A cervical length < 28 mm was identified in 46 randomized women: 19 of 313 who received progesterone and 27 of 307 who received the placebo. Baseline characteristics of the two groups were similar. In women with a cervical length < 28 mm, the rate of preterm birth at </= 32 weeks was significantly lower for those receiving progesterone than it was for those receiving the placebo (0% vs. 29.6%, P = 0.014). With progesterone, there were fewer admissions into the neonatal intensive care unit (NICU; 15.8% vs. 51.9%, P = 0.016) and shorter NICU stays (1.1 vs. 16.5 days, P = 0.013). There was also a trend toward a decreased rate of neonatal respiratory distress syndrome (5.3% vs. 29.6%, P = 0.060).

CONCLUSION

Vaginal progesterone may reduce the rate of early preterm birth and improve neonatal outcome in women with a short sonographic cervical length.

Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial

BACKGROUND

Schizophrenia with an onset in adolescence is known to be associated with a poorer outcome and cognitive difficulties. These impairments have an impact on quality of life and represent treatment targets. Cognitive remediation therapy (CRT) attempts to improve cognitive deficits by teaching information processing strategies through guided mental exercises. The objective of this study is to evaluate the efficacy of CRT in alleviating cognitive deficits compared to treatment as usual and explore the mediating and moderating effects of cognitive improvement.

METHOD

Single-blind randomized controlled trial with two groups, one receiving CRT (N21) and the other standard care (N19) assessed at baseline, 3 months (post therapy) and follow-up (3 months post therapy). Participants were recruited from specialist inpatient and community mental health services and were young patients with recent onset schizophrenia (average age of 18) and evidence of cognitive and social behavioural difficulties. The intervention was individual cognitive remediation therapy delivered over a period of 3 months with at least three sessions per week. The main outcome measures were cognition (memory, cognitive flexibility and planning) and secondary outcomes (symptoms, social contacts and self-esteem).

RESULTS

Compared to standard care, CRT produced significant additional improvements in cognitive flexibility as measured by the Wisconsin Card Sort Test (WCST). Therapy moderated the effects of improved planning ability on symptoms such that improvements only had a beneficial effect when they were achieved in the context of CRT. Improvements in cognition in all domains had a direct effect on social functioning and improvements in WCST had a direct effect on overall symptom improvement.

CONCLUSIONS

Cognitive remediation therapy can contribute to the improvement in WCST even in adolescents. The changes in cognitive outcomes also contributed to improvements in functioning either directly or solely in the context of CRT. Evidence of the mediator and moderator effects of cognitive changes should lead to more effective therapy development.

More than just a place to talk: young people's experiences of group psychological therapy as an early intervention for auditory hallucinations

OBJECTIVES

Auditory hallucinations are extremely distressing, particularly when occurring during adolescence. They may be most responsive to psychological intervention during a three-year critical period following symptom-onset, but as yet no studies have investigated voices groups for young participants with adolescent-onset psychosis. The aim of the current study is to explore the experience of group-CBT amongst a group of young people experiencing distressing auditory hallucinations.

DESIGN

This project was planned and conducted in the tradition of idiographic, qualitative psychology. A small purposive sample was selected, and in-depth, open-ended interviews were conducted, in order to generate and explore rich, experiential accounts which are clearly situated and contextualized.

METHODS

Eight participants who had completed a cognitive behavioural group intervention were interviewed using a semi-structured interview schedule. The transcribed data were analysed according to the principles of Interpretative Phenomenological Analysis (IPA; Smith, Osborn, & Jarman, 1999).

RESULTS

Two superordinate themes emerged. The first describes experiential features of the respondents' accounts of group therapy. The second theme posits a cyclical relationship between four key factors: the content of the hallucinated voices, the participants' explanations for, and reactions to these voices, and thus, their ability to cope with them.

CONCLUSIONS

'Voices groups' are appreciated by young people with auditory hallucinations, as sources of therapy, information, and support. These results suggest a number of testable hypotheses about the efficacy of group treatment and its future development.

Estimating correlation with multiply censored data arising from the adjustment of singly censored data

Environmental data frequently are left censored due to detection limits of laboratory assay procedures. Left censored means that some of the observations are known only to fall below a censoring point (detection limit). This presents difficulties in statistical analysis of the data. In this paper, we examine methods for estimating the correlation between variables each of which is censored at multiple points. Multiple censoring frequently arises due to adjustment of singly censored laboratory results for physical sample size. We discuss maximum likelihood (ML) estimation of the correlation and introduce a new method (cp.mle2) that, instead of using the multiply censored data directly, relies on ML estimates of the covariance of the singly censored laboratory data. We compare the ML methods with Kendall's tau-b (ck.taub) which is a modification Kendall's tau adjusted for ties, and several commonly used simple substitution methods: correlations estimated with nondetects set to the detection limit divided by 2 and correlations based on detects only (cs.det) with nondetects setto missing. The methods are compared based on simulations and real data. In the simulations, censoring levels are varied from 0 to 90%, p from -0.8 to 0.8, and v (variance of physical sample size) is set to 0 and 0.5, for a total of 550 parameter combinations with 1000 replications at each combination. We find that with increasing levels of censoring most of the correlation methods are highly biased. The simple substitution methods in general tend toward zero if singly censored and one if multiply censored. ck.taub tends toward zero. Least biased is cp.mle2, however, it has higher variance than some of the other estimators. Overall, cs.det performs the worst and cp.mle2 the best.

In vivo protective performance of N95 respirator and surgical facemask

BACKGROUND

The SARS outbreak in 2003 has spawned a major controversy concerning protective performance facemasks for healthcare workers. This study reports a study on in-vivo protective performance of surgical masks and N95 respirators.

METHODS

Typical surgical masks and N95 respirators used in Hong Kong hospitals were tested in comparison with those treated with nano-functional materials (called nano-masks) on various physical properties and in-vivo wear filtration efficiency, as well as usability test in hospitals for surgical masks.

RESULTS

Tests on physical properties showed that N95 respirators had significantly lower air permeability and water vapor permeability than surgical masks. The in-vivo filtration tests illustrated that N95 respirators filtered out 97% of potassium chloride (KCl) solution, while surgical masks filtered out 95% of KCl solution. Nano-masks show stronger water repellency and antibacterial activities, but no difference in usability, comparing with normal N95 and surgical masks.

CONCLUSIONS

Surgical masks can provide in-vivo filtration protection of 95% filtration efficiency. N95 respirators provide higher in-vivo filtration efficiency of 97% with significant reduction of air permeability and water vapor permeability. Compared to normal surgical masks/respirators, the nano-masks can provide additional protective functions in stopping capillary diffusion and antibacterial activities.

Docetaxel and capecitabine for previously treated metastatic colorectal cancer

13579

Background: Docetaxel (D) induces human colon cancer cell lines to upregulate thymidine phosphorylase, an enzyme which activates capecitabine (C) to its cytotoxic form. This provided rationale for adding low dose D to C in patients with colorectal cancer (CRC). Although this combination has been established in metastatic breast cancer, it has not been evaluated in CRC. Because of concerns of toxicity in a pretreated population, we performed a phase I trial in patients with previously treated CRC. Methods: Eligibility: At least 1 prior treatment for metastatic disease; ECOG PS 0–1; adequate organ function. Design: Phase I, dose escalation. D, IV, days 1 & 8, and C, PO BID days 5–18, repeated q21days. Dose Level 1: D=15mg/m2, C=1000mg/m2; Level 2: D= 15 mg/m2, C= 1100 mg/m2; Level 3: D= 20 mg/m2, C= 1100 mg/m2; Level 4: D=20mg/m2, C=1250mg/m2. Results: 13 patients have thus far been treated. 11 are evaluable for toxicity and 10 for response (1 at dose level 4 was taken off study due to non-compliance before completion of cycle 1; another died of progressive cancer before completing cycle 1 at dose level 4; another is evaluable for toxicity but not yet for response). 9 with colon, 4 with rectal primary sites. Median follow-up= 5 mo (1–19 mo). Med age= 59 (30–75); #prior regimens for met disease 1–2, all of which were 5-FU based. Toxicities No dose limiting toxicities (DLT) until Dose Level 4. Dose Level 1: 1/3 developed grade 2 diarrhea and hand-foot syndrome and delayed grade 3 hand-foot; Dose Level 2: 2/3 developed grade 2 toxicities (hand-foot in one and diarrhea in the other); Dose Level 3: 1/3 developed delayed grade 2 hand-foot; Dose Level 4: 1 patient with delayed grade 2 hand-foot and grade 1 eye tearing; another developed DLT (grade 4 stomatitis/dehydration). Response 6/10 patients progressed after 2 cycles; 2 pts had stable disease, one lasting 4.6 mo; 2 patients had a partial response, one of which lasted 9 mo. The latter case had refractory disease to FOLFOX 4 but a 78% reduction in her liver metastases to D+C. Conclusions: The combination of low dose docetaxel, used as chemosensitizing agent, with capecitabine in this pretreated group of patients with metastatic CRC appears to be well tolerated, with no DLTs seen until Dose Level 4, and has modest activity. MTD determination awaits further accrual.

No significant financial relationships to disclose.

Antimicrobial effect of surgical masks coated with nanoparticles

This study assessed the antimicrobial activity of nanoparticles (consisting of a mixture of silver nitrate and titanium dioxide) and nanoparticle-coated facemasks to protect against infectious agents. The minimum inhibitory concentrations of the nanoparticles against Escherichia coli and Staphylococcus aureus were 1/128 and 1/512, respectively. The antibacterial activity of nanoparticle-coated masks was quantified according to the procedures of AATCC 100-1999. A 100% reduction in viable E. coli and S. aureus was observed in the coated mask materials after 48 h of incubation. Skin irritation was not observed in any of the volunteers who wore the facemasks. Nanoparticles show promise when applied as a coating to the surface of protective clothing in reducing the risk of transmission of infectious agents.

Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations

Aim: The study was aimed at investigating the effects of wearing N95 and surgical facemasks with and without nano-functional treatments on thermophysiological responses and the subjective perception of discomfort. Method: Five healthy male and five healthy female participants performed intermittent exercise on a treadmill while wearing the protective facemasks in a climate chamber controlled at an air temperature of 25°C and a relative humidity of 70%. Four types of facemasks, including N95 (3M 8210) and surgical facemasks, which were treated with nano-functional materials, were used in the study. Results: (1) The subjects had significantly lower average heart rates when wearing nano-treated and untreated surgical facemasks than when wearing nano-treated and untreated N95 facemasks. (2) The outer surface temperature of both surgical facemasks was significantly higher than that of both N95 facemasks. On the other hand, the microclimate and skin temperatures inside the facemask were significantly lower than those in both N95 facemasks. (3) Both surgical facemasks had significantly higher absolute humidity outside the surface than both N95 facemasks. The absolute humidity inside the surgical facemask was significantly lower than that inside both N95 facemasks. (4) Both surgical facemasks were rated significantly lower for perception of humidity, heat, breath resistance and overall discomfort than both N95 facemasks. The ratings for other sensations, including feeling unfit, tight, itchy, fatigued, odorous and salty, that were obtained while the subjects were wearing the surgical facemasks were significantly lower than when the subjects were wearing the N95 facemasks. (5) Subjective preference for the nano-treated surgical facemasks was the highest. There was significant differences in preference between the nano-treated and untreated surgical facemasks and between the surgical and N95 facemasks. Discussion: We discuss how N95 and surgical facemasks induce significantly different temperature and humidity in the microclimates of the facemasks, which have profound influences on heart rate and thermal stress and subjective perception of discomfort.

Early psychological intervention for auditory hallucinations: an exploratory study of young people's voices groups

Twenty to fifty percent of people with a diagnosis of schizophrenia continue to hear voices despite taking neuroleptic medication. Trials of group cognitive behavioral therapy for adults with auditory hallucinations have shown promising results. Auditory hallucinations may be most amenable to psychological intervention during a 3-year critical period after symptom onset. This study evaluates the effectiveness of group cognitive behavioral therapy (CBT) for young people with recent-onset auditory hallucinations (N = 22), using a waiting list control. Outcome measures were administered at four separate time points. Significant reductions in auditory hallucinations occurred over the total treatment phase, but not over the waiting period. Further investigations in the form of randomized controlled trials are warranted.

Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program

This study examined the link between executive function and functional outcome in schizophrenia to identify useful psychological intervention targets and explore how executive function changes affect social functioning and symptoms. Participants from two randomized controlled trials (n = 63) with poor social functioning, positive and negative symptoms, and cognitive impairment completed seven measures of executive function. Three cognitive factors were extracted: verbal working memory, response inhibition speed, and stimulus-driven responding. Participants received individual cognitive remediation therapy (CRT) (n = 18), a control therapy (occupational therapy activities) (n = 14), or treatment as usual (n = 19). Only the CRT group improved on verbal working memory. No group improved on the other factors. Although verbal working memory was significantly associated with social functioning and symptom severity 3 months after baseline, change in this factor did not predict change in either functional outcome. There was a significant interaction between group and the stimulus-driven responding factor, and for the CRT group only, a change to a more externally focused responding style was associated with reduced social problems and symptoms. Regardless of treatment type, increased response inhibition speed was associated with reduced negative symptoms. Stimulus-driven responding and response inhibition speed may therefore make useful targets for intervention.