A clinico-radiological review of chronic non-bacterial osteomyelitis in paediatrics, adolescents, and adults: demystifying a forgotten differential

Chronic non-bacterial osteomyelitis (CNO), also known as non-bacterial osteitis, is a chronic autoinflammatory disease of unknown aetiology that primarily occurs in the paediatric population, although rare cases of adult-onset disease also exist. CNO has non-specific clinical and radiological presentations, and the affected population often present with bone pain of insidious onset secondary to sterile bony inflammation that can be associated with swelling, focal tenderness, and warmth at the affected sites. The pattern of bony involvement appears to be dependent on the age of onset, with adults frequently having axial skeletal lesions and children and adolescents often being affected in the appendicular skeletal sites. CNO is a diagnosis of exclusion, and imaging is heavily relied on to identify and characterise the bony lesions in addition to exclude diseases that can mimic CNO. Magnetic resonance imaging is often the reference standard with biochemical and histopathological findings being complementary. Although combining imaging methods can be used to facilitate the diagnosis, a single technique could be adequate depending on the clinical picture. Given the relatively rare incidence of CNO, limited awareness of the disease among care providers, and its similarity in clinical and radiological presentation to various bony diseases, there are often long delays in diagnosis, with adults being unfavourably affected compared to paediatrics and adolescents. This review of CNO will describe the condition, overview its clinical presentation, highlight the radiological features, and emphasise clinical pearls that can aid in diagnosis and ruling out the mimics.

Loneliness in the workplace: a mixed-method systematic review and meta-analysis

BACKGROUND

Loneliness is a risk factor for a range of mental and physical health problems and has gained increasing interest from policy-makers and researchers in recent years. However, little attention has been paid to loneliness at work and its implications for workers and employers.

AIMS

Identify workplace, health and personal factors associated with workplace loneliness.

METHODS

We searched five databases (PubMed, MEDLINE, EMBASE, PsycINFO and EBSCO Business Source Complete) for relevant articles published from 1 January 2000 to 23 February 2023. Quantitative data were synthesized using narrative synthesis and random-effects meta-analysis of correlation coefficients. Qualitative data were synthesized using thematic synthesis. Evidence quality was appraised using the Mixed-Methods Appraisal Tool.

RESULTS

We identified 49 articles meeting the inclusion criteria. Pooled results indicate that workplace loneliness was associated with lower job performance (r = -0.35, 95% CI -0.49, -0.21), reduced job satisfaction (r = -0.34, 95% CI -0.44, -0.24), worse worker-manager relationship (r = -0.31, 95% CI -0.38, -0.24) and elevated burnout (r = 0.39, 95% CI 0.25, 0.51). Qualitative results suggest links between loneliness and inadequate workplace social interactions and mental health problems. As most studies used cross-sectional data and few adjusted for potential confounders, the direction and robustness of the associations remain untested.

CONCLUSIONS

Our results indicate that loneliness is associated with poor occupational functioning and well-being among workers. Results also show that loneliness is associated with modifiable aspects of the work environment, suggesting that the workplace may offer a fruitful avenue for interventions targeting loneliness.

My body, my decision: the lived experience of young people with a variation in sex characteristics in New Zealand

Background

Young people born with a variation in sex characteristics (VSC), or disorders of sex development (DSD) face numerous challenges in navigating issues relating to identity and to their lived and embodied experience. There is limited research amplifying the voices of young people with a VSC in the literature, especially in Aotearoa/New Zealand. There has been issues raised from a Humans Rights perspective which public health forums are yet to address.

Methods

This original qualitative study provides an up-to-date picture of the lived experiences of 10 young people with a VSC in Aotearoa/New Zealand using face to face interviews and thematic analysis. The research was conducted in collaboration with the advocacy group, Intersex Youth Aotearoa, and explored the level of support provided by health services, peers and advocacy groups in relation to the ways the participants viewed themselves and their bodies, and their health related decision-making.

Results

Our research reveals the pressure on young people with a VSC to conform to cultural and societal norms, specifically, heteronormative and traditional constructs of how male and female bodies should look prevalent within Aotearoa/NZ society. Such views, often held and perpetuated by health professionals and parents, contributed to the complexities surrounding identity, agency and acceptance of difference experienced by these young people. Young people wanted the right to bodily autonomy.

Conclusions

Implications of these findings are: better public education of VSC, development of resources for parents and young people and advocacy for psychological and peer support systems for young people.

A mixed methods pilot and feasibility open trial of internet-delivered cognitive behaviour therapy (iCanADAPT Advanced) for people with advanced cancer with depression and/or anxiety

PURPOSE

Evaluate the feasibility, acceptability and potential efficacy of a form of online therapy for clinical depression and/or anxiety in people living with advanced cancer.

METHODS

A single-arm open trial of a six-lesson clinician-supervised, internet-delivered cognitive behavioural therapy (iCBT) transdiagnostic intervention (iCanADAPT Advanced) was undertaken. Qualitative (semi-structured telephone interview conducted at 3-months) and quantitative data (questionnaires collected at pre-, post-, and 3-month follow-up) were analysed.

RESULTS

27 participants partook (26 women, 56% breast cancer, mean age 56yo; average number of mental health diagnoses 1.8, with majority (81%) meeting criteria for generalised anxiety disorder). Feasibility - Unanticipated numbers (48%) of participants had physical health deterioration (cancer progression or death). iCBT had high adherence overall (completion rates: 37% did 6 lessons; 70% did 4 lessons) but adherence was higher for those whose cancer remained stable (completion rates: 43% did 6 lessons; 85% did 4 lessons). Acceptability - the intervention was acceptable to the majority of participants, with high treatment satisfaction. Advisory data was achieved regarding future versions. Potential efficacy - regardless of physical health status, participants who completed the iCBT showed a significant decrease over time in anxiety and depression symptoms.

CONCLUSIONS

Online therapies may be useful in assisting those living with advanced cancer dealing with clinical depression and anxiety disorders. The specific modality of clinician supervised iCBT has significant potential to be a suitable modality of online therapy.

A real-world estimate of the value of one metabolic equivalent in a population of patients planning major surgery

BACKGROUND

One metabolic equivalent (MET) is equal to resting oxygen consumption. The average value for one MET in humans is widely quoted as 3.5ml/kg/min. However this value was derived from a single male participant at the end of the nineteenth century and has become canonical. Several small studies have identified varied estimates of one MET from widely varying populations. The ability of a patient to complete 4 METS (or 14mls/kg/min) is considered an indicator of their fitness to proceed to surgery.

AIMS

The study aimed to define a typical value of one MET from a real-world patient population, as well as determine factors that influenced the value.

METHODS

A database of cardiopulmonary exercise tests (CPET) tests was interrogated to find total of 1847 adult patients who had undergone CPET testing in the previous 10 years. From this database, estimates of oxygen consumption (VO₂ ) at rest and at the anaerobic threshold and a number of other variables were obtained. The influence of age, body mass index (BMI), sex and the use of beta blockers was tested.

RESULTS

The median resting VO₂ at rest was 3.6ml/kg/min (IQR 3.0-4.2). Neither sex nor age greater than 65 years nor the use of beta blockers produced a significant difference in resting VO₂ , while those with a BMI greater than 25 had a significantly lower VO₂ at rest (3.4ml/kg/min vs 4.0ml/kg/min, p <0.001).

CONCLUSIONS

The estimate of 3.6ml/kg/min for resting VO₂ presented here is consistent with the previous literature, despite this being the first large study of its kind. This estimate can be safely used for pre-operative risk stratification. This article is protected by copyright. All rights reserved.

Randomised controlled trial of internet-delivered cognitive behaviour therapy for clinical depression and/or anxiety in cancer survivors (iCanADAPT Early)

PURPOSE

To evaluate internet-delivered cognitive behavioural therapy (iCBT) on clinical depression and/or anxiety, distress, fear of cancer recurrence, and quality of life in cancer survivors.

METHODS

Random assignation of 114 participants to iCBT or treatment-as-usual (TAU). The clinician-supervised iCBT program (iCanADAPT Early) consisted of eight lessons over 16 weeks. Self-report questionnaires occurred at baseline, midpoint, and posttreatment for both groups with 3-month follow-up for iCBT participants. A mixed modelling approach to compare groups occurred.

RESULTS

iCBT was superior to TAU on all outcome measures at posttreatment. Compared with TAU, the iCBT group showed a significant decrease over time in anxiety and depression symptoms (primary outcome, Hospital Anxiety and Depression Scale, Hedges g = 1.51). Additionally the iCBT group had significantly lower general distress (Kessler-10, g = 1.56), fear of cancer recurrence (Fear of Cancer Recurrence Inventory, g = 0.39), and significantly higher quality of life (Functional Assessment of Cancer Therapy-General, g = 0.74) at posttreatment compared with the TAU group. High adherence and satisfaction were found for iCBT with low clinician time.

CONCLUSION

Clinician-supervised iCBT has significant benefits for cancer survivors with clinical depression and anxiety disorders.

C-49 Externalizing Behavior Differences Between FASD and ACC: 11-13 Year Olds

Objective

Investigate the externalizing behaviors of rule breaking and aggression among children ages 11-13 years with partial (pACC), full Agenesis of the Corpus Collosum (ACC) or Fetal Alcohol Spectrum Disorders (FASD) in order to broaden our understanding of the behaviors found in pre- and young adolescents with these diagnoses.

Method

This sample was taken from two data sets; one with individuals with ACC, the other individuals with FASD. The data for both ACC and FASD studies were gathered using mailing lists. Packets included informed consent, the Child Behavior Checklist (CBCL), the FAS BeST with additional developmental questions, and a demographic questionnaire. Of the 511 ACC packets returned, 47 were analyzed. Of the nearly 50 FASD packets returned, 7 were analyzed (n = 54).

Results

A multivariate analysis of variance (MANOVA) of the 54 participant’s external behaviors of rule breaking and aggression were analyzed. Participants with diagnoses of FASD present with higher rates of externalizing behaviors than those with pACC and ACC. Aggressive behaviors have a small effect size (n2 = .151) and rule breaking behaviors present with a large effect size (n2 = .441).

Conclusions

Treatment plans for those with FAS and ACC differ greatly from the commonly provided misdiagnoses of Autism, Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder and Conduct Disorder, which can leave clients with FAS and ACC misunderstood and improperly treated. By examining the common and differing external behavioral traits of FAS and ACC, clinicians can have stronger evidence when considering differential diagnoses and treatment plans.

B-76 Benefits of Solution Focused Therapy for Collegiate Athletes

Objective

Collegiate athletes experience competition anxiety as their greatest impedance to optimal performance. Competition anxiety encompasses both somatic and cognitive symptoms (Smith, Smoll, Cumming, & Grossbard, 2006). Somatic symptoms are more likely to impact performance (Mabweazara, Leach, & Andrews, 2017). Solution-Focused Therapy is an effective intervention used to decrease competition anxiety (Bell, Skinner, & Halbrook, 2011). This study sought to discover if Solution-Focused Therapy decreases anxiety levels in team sports athletes compared to individual sports.

Method

The study consisted of college athletes (7 women, 10 men) who volunteered to participate. Anxiety was measured through self-report questionnaires (General Anxiety Disorder Scale and the Sports Anxiety Scale) measured both pre and posttest. Solution-Focused Therapy was administered through 5 hour-long sessions by Masters level clinicians-in-training. The independent variable was sport (team or individual). The dependent variables included level of anxiety, worry, and concentration disruption.

Results

A MANOVA was used to analyze the data. A main effect for time occurred for anxiety scores (p = .006, n2 = .422). A main effect for time was found for worry (p = .027, n2 = .302) and a significant interaction occurred between type of sport and time (p = .044, n2 = .260). Those in individual sports had larger decreases in worry. There were no significant differences in concentration difficulties (p = .770).

Conclusion

Participation in Solution-Focused Therapy decreased anxiety overall for athletes in both team and individual sports. Athletes in individual sports appear to benefit from Solution-Focused Therapy to decrease worry more than those in team sports. Solution-Focused therapy is beneficial for managing anxiety in collegiate athletes.

C-46 Assessing Global Delays in Corpus Callosum Agenesis: Infants and Toddlers

Objective

Corpus callosum agenesis (ACC) is a congenital birth defect in which the corpus callosum fails to fully form (Badaruddin, et al., 2007). The partial or complete absence of a corpus callosum affects specific functioning (Brown, Jeeves, Dietrich, & Burnison, 1999) resulting in behavioral, social, and cognitive difficulties (Badaruddin, et al., 2007). We evaluated the development of infants and toddlers with ACC in cognition, language, and motor functioning.

Methods

Boys (n = 6) and girls (n = 4) ages 3 to 41 months were assessed utilizing the Bayley Scales of Infant and Toddler Development-Third Edition, a test designed to assess the developmental functioning in 5 domains: motor, social-emotional, adaptive behavior, cognitive, and language (Bayley, 2006). Volunteers were assessed during ACC conferences.

Results

Cognitive, language and motor index scores were significantly correlated but not age. Moderate to large effect sizes (Cohens d) were found. Girls had lower Cognitive Index scores and were below average; boys mean score was within the average range. Large effect sizes for receptive and expressive language. Boys scored within the low average range; girls below average for receptive language. For expressive language, girls fell in the borderline range, boys were low average. Gross motor was very low compared to age norms. Girls showed deficits in fine motor skill development; boys within the average range.

Conclusions

Global developmental deficits and gender differences occurred for infants and toddlers with ACC. Girls show more delays than boys. Outcomes suggest that delays can be measured well before entering school and supports early intervention services.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

iCanADAPT Early protocol: randomised controlled trial (RCT) of clinician supervised transdiagnostic internet-delivered cognitive behaviour therapy (iCBT) for depression and/or anxiety in early stage cancer survivors -vs- treatment as usual

BACKGROUND

This RCT with two parallel arms will evaluate the efficacy of an internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for the treatment of clinical depression and/or anxiety in early stage cancer survivors.

METHODS/DESIGN

Early stage cancer survivors will be recruited via the research arm of a not-for-profit clinical research unit and randomised to an intervention (iCBT) group or a 'treatment as usual' (TAU) control group. The minimum sample size for each group is 45 people (assuming effect size > 0.6, power of 80%, and alpha at .05), but 10% more will be recruited to account for attrition. A solitary or cumulative diagnosis(es) of Major Depressive Episode (current), Generalised Anxiety Disorder, Illness Anxiety Disorder, Panic Disorder, Agoraphobia, and/or Adjustment disorder will be determined using modules from the Anxiety Disorders Interview Schedule for DSM-5. Depression and anxiety levels with be measured via the total score of the Hospital Anxiety and Depression scale (HADS-T), the primary outcome measure. Secondary measures will include the Kessler 10 to measure general distress, the Fear of Cancer Recurrence Inventory (FCRI) to measure the specific fear of cancer recurrence and the Functional Assessment of Cancer Therapy, General Version 4 (FACT-G) for self-report of physical, social, emotional and functional well-being. iCBT participants will complete the measures before lessons 1 and 5, at post-treatment and at 3-month follow-up. The TAU group will complete similar measures at weeks 1, 8 and 16 of the waiting period. Program efficacy will be determined using intent-to-treat mixed models. Maintenance of gains will be assessed at 3-month follow-up. Mediation analyses using PROCESS will be used to examine the association between change in depressive and anxious symptoms over time and changes in FCRI and FACT-G QOL in separate analysis.

DISCUSSION

This is the first RCT looking at iCBT specifically for clinical depression and/or anxiety in a cancer population. Findings will help to direct the role of iCBT in streamlined psycho-social care pathways.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12616000231448, registered 19th February 2016 ( www.anzctr.org.au ). This trial protocol is in compliance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.

Does Internet-based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trials

BACKGROUND

Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.

METHOD

Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.

RESULTS

A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29-0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.

CONCLUSIONS

Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.

Classification of anxiety and depressive disorders: problems and solutions

The American Psychiatric Association and the World Health Organization have begun to revise their classifications of mental disorders. Four issues related to these revisions are discussed in this study: the structure of the classifications, the relationship between categories and dimensions, the sensitivity of categorical thresholds to definitions, and maximizing the utility and validity of the diagnostic process. There is now sufficient evidence to consider replacing the present groupings of disorders with an empirically based structure that reflects the actual similarities among disorders. For example, perhaps the present depression and anxiety disorders would be best grouped as internalizing disorders. Most mental disorders exist on a severity dimension. The reliability and validity of the classification might be improved if we accepted the dimensional nature of disorders while retaining the use of categorical diagnoses to enhance clinical utility. Definitions of the thresholds that define categories are very susceptible to detail. In International Classification of Diseases-11(ICD-11) and Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), disorders about which there is agreement should be identically defined, and disorders in which there is disagreement should be defined differently, so that research can identify which definition is more valid. The present diagnostic criteria are too complex to have acceptable clinical utility. We propose a reduced criterion set that can be remembered by clinicians and an enhanced criterion set for use with decision support tools.

An examination of generalized anxiety disorder and dysthymic disorder by latent class analysis

BACKGROUND

The nosological status of generalized anxiety disorder (GAD) versus dysthymic disorder (DD) has been questioned. The aim of this study was to examine qualitative differences within (co-morbid) GAD and DD symptomatology.

METHOD

Latent class analysis was applied to anxious and depressive symptomatology of respondents from three population-based studies (2007 Australian National Survey of Mental Health and Wellbeing; National Comorbidity Survey Replication; and Netherlands Mental Health Survey and Incidence Study-2; together known as the Triple study) and respondents from a multi-site naturalistic cohort [Netherlands Study of Depression and Anxiety (NESDA)]. Sociodemographics and clinical characteristics of each class were examined.

RESULTS

A three-class (Triple study) and two-class (NESDA) model best fitted the data, reflecting mainly different levels of severity of symptoms. In the Triple study, no division into a predominantly GAD or DD co-morbidity subtype emerged. Likewise, in spite of the presence of pure GAD and DD cases in the NESDA sample, latent class analysis did not identify specific anxiety or depressive profiles in the NESDA study. Next, sociodemographics and clinical characteristics of each class were examined. Classes only differed in levels of severity.

CONCLUSIONS

The absence of qualitative differences in anxious or depressive symptomatology in empirically derived classes questions the differentiation between GAD and DD.

Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) have the highest co-morbidity rates within the internalizing disorders cluster, yet no Internet-based cognitive behavioural therapy (iCBT) programme exists for their combined treatment.

METHOD

We designed a six-lesson therapist-assisted iCBT programme for mixed anxiety and depression. Study 1 was a randomized controlled trial (RCT) comparing the iCBT programme (n = 46) versus wait-list control (WLC; n = 53) for patients diagnosed by structured clinical interview with MDD, GAD or co-morbid GAD/MDD. Primary outcome measures were the Patient Health Questionnaire nine-item scale (depression), Generalized Anxiety Disorder seven-item scale (generalized anxiety), Kessler 10-item Psychological Distress scale (distress) and 12-item World Health Organization Disability Assessment Schedule II (disability). The iCBT group was followed up at 3 months post-treatment. In study 2, we investigated the adherence to, and efficacy of the same programme in a primary care setting, where patients (n = 136) completed the programme under the supervision of primary care clinicians.

RESULTS

The RCT showed that the iCBT programme was more effective than WLC, with large within- and between-groups effect sizes found (>0.8). Adherence was also high (89%), and gains were maintained at 3-month follow-up. In study 2 in primary care, adherence to the iCBT programme was low (41%), yet effect sizes were large (>0.8). Of the non-completers, 30% experienced benefit.

CONCLUSIONS

Together, the results show that iCBT is effective and adherence is high in research settings, but there is a problem of adherence when translated into the 'real world'. Future efforts need to be placed on developing improved adherence to iCBT in primary care settings.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

An analysis of a token economy in stuttering therapy

A stuttering therapy program in which adult stutterers were hospitalized and treated in small groups (n = 4) under token economy conditions is described. The Token System reinforced reductions and penalized increases in stuttering during conversation. The therapy program was divided into three stages. Initially, subjects were treated by the token system, which was then integrated with a delayed auditory feedback schedule designed to instate and shape a prolonged speech pattern into normal fluent speech. Finally, subjects passed through a speech situation hierarchy while under token control conditions. Experiments conducted in the first two stages of treatment are described. The first-stage experiments examined the design of the token system; the second-stage experiment assessed the effect of a contingent punishment schedule integrated with the delayed auditory feedback procedure in order to shape rate of speaking as well as fluency.

Neurocognitive disorders: cluster 1 of the proposed meta-structure for DSM-V and ICD-11

BACKGROUND

In an effort to group mental disorders on the basis of aetiology, five clusters have been proposed. In this paper, we consider the validity of the first cluster, neurocognitive disorders, within this proposal. These disorders are categorized as 'Dementia, Delirium, and Amnestic and Other Cognitive Disorders' in DSM-IV and 'Organic, including Symptomatic Mental Disorders' in ICD-10.

METHOD

We reviewed the literature in relation to 11 validating criteria proposed by a Study Group of the DSM-V Task Force as applied to the cluster of neurocognitive disorders.

RESULTS

'Neurocognitive' replaces the previous terms 'cognitive' and 'organic' used in DSM-IV and ICD-10 respectively as the descriptor for disorders in this cluster. Although cognitive/organic problems are present in other disorders, this cluster distinguishes itself by the demonstrable neural substrate abnormalities and the salience of cognitive symptoms and deficits. Shared biomarkers, co-morbidity and course offer less persuasive evidence for a valid cluster of neurocognitive disorders. The occurrence of these disorders subsequent to normal brain development sets this cluster apart from neurodevelopmental disorders. The aetiology of the disorders is varied, but the neurobiological underpinnings are better understood than for mental disorders in any other cluster.

CONCLUSIONS

Neurocognitive disorders meet some of the salient criteria proposed by the Study Group of the DSM-V Task Force to suggest a classification cluster. Further developments in the aetiopathogenesis of these disorders will enhance the clinical utility of this cluster.

Emotional disorders: cluster 4 of the proposed meta-structure for DSM-V and ICD-11

BACKGROUND

The extant major psychiatric classifications DSM-IV, and ICD-10, are atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis would be greatly enhanced by an understanding of risk factors and clinical manifestations. In an effort to group mental disorders on the basis of aetiology, five clusters have been proposed. This paper considers the validity of the fourth cluster, emotional disorders, within that proposal.

METHOD

We reviewed the literature in relation to 11 validating criteria proposed by a Study Group of the DSM-V Task Force, as applied to the cluster of emotional disorders.

RESULTS

An emotional cluster of disorders identified using the 11 validators is feasible. Negative affectivity is the defining feature of the emotional cluster. Although there are differences between disorders in the remaining validating criteria, there are similarities that support the feasibility of an emotional cluster. Strong intra-cluster co-morbidity may reflect the action of common risk factors and also shared higher-order symptom dimensions in these emotional disorders.

CONCLUSION

Emotional disorders meet many of the salient criteria proposed by the Study Group of the DSM-V Task Force to suggest a classification cluster.

Where should bipolar disorder appear in the meta-structure?

BACKGROUND

The extant major psychiatric classifications, DSM-IV and ICD-10, are purportedly atheoretical and largely descriptive. Although this achieves good reliability, the validity of a medical diagnosis is greatly enhanced by an understanding of both risk factors and clinical history. In an effort to group mental disorders on the basis of risk factors and clinical manifestations, five clusters have been proposed. The purpose of this paper is to consider the position of bipolar disorder (BPD), which could be either with the psychoses, or with emotional disorders, or in a separate cluster.

METHOD

We reviewed the literature on BPD, unipolar depression (UPD) and schizophrenia in relation to 11 validating criteria proposed by the DSM-V Task Force Study Group, and then summarized similarities and differences between BPD and schizophrenia on the one hand, and UPD on the other.

RESULTS

There are differences, often substantial and never trivial, for 10 of the 11 validators between BPD and UPD. There are also important differences between BPD and schizophrenia.

CONCLUSION

BPD has previously been classified together with UPD, but this is the least justifiable place for it. If it is to be recruited to a 'psychotic cluster', there are several important respects in which it differs from schizophrenia, so the cluster would have a division within it. The alternative would be to allow it to be in an intermediate position in a cluster of its own.

Exploring the feasibility of a meta-structure for DSM-V and ICD-11: could it improve utility and validity?

BACKGROUND

The organization of mental disorders into 16 DSM-IV and 10 ICD-10 chapters is complex and based on clinical presentation. We explored the feasibility of a more parsimonious meta-structure based on both risk factors and clinical factors.

METHOD

Most DSM-IV disorders were allocated to one of five clusters as a starting premise. Teams of experts then reviewed the literature to determine within-cluster similarities on 11 predetermined validating criteria. Disorders were included and excluded as determined by the available data. These data are intended to inform the grouping of disorders in the DSM-V and ICD-11 processes.

RESULTS

The final clusters were neurocognitive (identified principally by neural substrate abnormalities), neurodevelopmental (identified principally by early and continuing cognitive deficits), psychosis (identified principally by clinical features and biomarkers for information processing deficits), emotional (identified principally by the temperamental antecedent of negative emotionality), and externalizing (identified principally by the temperamental antecedent of disinhibition).

CONCLUSIONS

Large groups of disorders were found to share risk factors and also clinical picture. There could be advantages for clinical practice, public administration and research from the adoption of such an organizing principle.

Neurodevelopmental disorders: cluster 2 of the proposed meta-structure for DSM-V and ICD-11

BACKGROUND

DSM-IV and ICD-10 are atheoretical and largely descriptive. Although this achieves good reliability, the validity of diagnoses can be increased by an understanding of risk factors and other clinical features. In an effort to group mental disorders on this basis, five clusters have been proposed. We now consider the second cluster, namely neurodevelopmental disorders.

METHOD

We reviewed the literature in relation to 11 validating criteria proposed by a DSM-V Task Force Study Group.

RESULTS

This cluster reflects disorders of neurodevelopment rather than a 'childhood' disorders cluster. It comprises disorders subcategorized in DSM-IV and ICD-10 as Mental Retardation; Learning, Motor, and Communication Disorders; and Pervasive Developmental Disorders. Although these disorders seem to be heterogeneous, they share similarities on some risk and clinical factors. There is evidence of a neurodevelopmental genetic phenotype, the disorders have an early emerging and continuing course, and all have salient cognitive symptoms. Within-cluster co-morbidity also supports grouping these disorders together. Other childhood disorders currently listed in DSM-IV share similarities with the Externalizing and Emotional clusters. These include Conduct Disorder, Attention Deficit Hyperactivity Disorder and Separation Anxiety Disorder. The Tic, Eating/Feeding and Elimination disorders, and Selective Mutisms were allocated to the 'Not Yet Assigned' group.

CONCLUSION

Neurodevelopmental disorders meet some of the salient criteria proposed by the American Psychiatric Association (APA) to suggest a classification cluster.

Hydronephrosis and urine retention in estrogen-implanted athymic nude mice

Subcutaneous estrogen pellet implantation is commonly practiced to induce tumor promotion in nude (Nu-FOXn1(nu)) mice for xenograft tumor modeling. Twelve of 23, 18-week-old nude mice developed dysuria after estrogen pellet implantation. Physical examination revealed variably distended abdomens with palpable distended bladders. All mice were euthanatized and postmortem examinations were made. Blood samples of the mice were collected, and serum estrogen concentration was measured. Postmortem examination revealed variable dilation of the urinary bladder and unilateral or bilateral dilations of ureters and kidneys. Microscopically, 12 of 23 mice and 13 of 23 mice showed dilated urinary bladder and hydronephrosis, respectively.

MR shoulder arthrography in patients younger than 40 years of age: Frequency of rotator cuff tear versus labroligamentous pathology

The purpose of this study was to compare the frequency of rotator cuff pathology versus labroligamentous pathology in patients younger than 40 years and to determine whether routine MR arthrography is justified in all patients in this age group, regardless of the clinical symptoms. The MR arthrography was carried out on 332 patients 40 years of age and younger. Two hundred and forty-three patients had clinical history of instability and possible labroligamentous pathology. Eighty-nine patients had no history or physical signs of instability and were referred for reasons other than instability, such as assessment for rotator cuff tear. In the 243 patients younger than 40 years with clinical history of potential labral pathology, 39% (95/243) showed a labral tear and 2.1% (5/243) had a full-thickness rotator cuff tendon tear. In the 89 patients with no history suggesting labral pathology, 19% (17/89) showed an unsuspected labral tear and 4.5% (4/89) had a full-thickness rotator cuff tear. These findings suggest that, regardless of the clinical indication for referral, patients aged 40 and less referred for shoulder MRI should be imaged using MR arthrography because of the significant risk that symptoms are related to unsuspected labral pathology.