Mental health of help-seeking outpatients pre and post COVID-19: A real-world data, multicentre study

OBJECTIVE

A great deal of research addresses the mental health implications of the COVID-19 pandemic for the general population. Little is known about the implications for mental health of help-seeking outpatients and for the effectiveness of mental health services. The present study investigated the mental health and treatment response of help-seeking outpatients before and during the COVID-19 pandemic.

METHOD

Routine outcome monitoring data from 3706 clients in the United States and Northern Europe was analysed using multilevel modelling with global subjective well-being as the dependent variable.

RESULTS

As opposed to before the pandemic, during the pandemic, well-being scores were significantly higher at intake and improvement throughout treatment was significantly smaller in the US sample, while both were comparable in the EU sample.

CONCLUSION

Although there is also evidence of less effective treatments since the pandemic, no conclusive picture emerges that portrays the impact of the pandemic on mental health as uniform. More research is needed to elucidate the impact of the pandemic on the help-seeking population.

Tropical forests are approaching critical temperature thresholds

The critical temperature beyond which photosynthetic machinery in tropical trees begins to fail averages approximately 46.7 °C (Tcrit)1. However, it remains unclear whether leaf temperatures experienced by tropical vegetation approach this threshold or soon will under climate change. Here we found that pantropical canopy temperatures independently triangulated from individual leaf thermocouples, pyrgeometers and remote sensing (ECOSTRESS) have midday peak temperatures of approximately 34 °C during dry periods, with a long high-temperature tail that can exceed 40 °C. Leaf thermocouple data from multiple sites across the tropics suggest that even within pixels of moderate temperatures, upper canopy leaves exceed Tcrit 0.01% of the time. Furthermore, upper canopy leaf warming experiments (+2, 3 and 4 °C in Brazil, Puerto Rico and Australia, respectively) increased leaf temperatures non-linearly, with peak leaf temperatures exceeding Tcrit 1.3% of the time (11% for more than 43.5 °C, and 0.3% for more than 49.9 °C). Using an empirical model incorporating these dynamics (validated with warming experiment data), we found that tropical forests can withstand up to a 3.9 ± 0.5 °C increase in air temperatures before a potential tipping point in metabolic function, but remaining uncertainty in the plasticity and range of Tcrit in tropical trees and the effect of leaf death on tree death could drastically change this prediction. The 4.0 °C estimate is within the 'worst-case scenario' (representative concentration pathway (RCP) 8.5) of climate change predictions2 for tropical forests and therefore it is still within our power to decide (for example, by not taking the RCP 6.0 or 8.5 route) the fate of these critical realms of carbon, water and biodiversity3,4.

Measurement-based care professional practice guideline: Fine, but guidelines do not make good therapy

Boswell et al. (2022) persuasively make the case for and propose professional practice guidelines (PPG) for measurement-based care (MBC). Although the evidence for MBC is robust, implementing MBC effectively in practice requires skills and processes not discussed in the PPG. We discuss five problems with the PPG for MBC: The "what's in a name?" problem, lack of actionable actions problem, the stopwatch problem, the stock market problem, and looking for the keys under the light problem. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Spatial covariation in nutrient enrichment and fishing of herbivores in an oceanic coral reef ecosystem

Both natural and anthropogenic stressors are increasing on coral reefs, resulting in large-scale loss of coral and potential shifts from coral- to macroalgae-dominated community states. Two factors implicated in shifts to macroalgae are nutrient enrichment and fishing of reef herbivores. Although either of these factors alone could facilitate establishment of macroalgae, reefs may be particularly vulnerable to coral-to-algae phase shifts in which strong bottom-up forcing from nutrient enrichment is accompanied by a weakening of herbivore control of macroalgae via intense fishing. We explored spatial heterogeneity and covariance in these drivers on reefs in the lagoons of Moorea, French Polynesia, where the local fishery heavily targets herbivorous fishes and there are spatially variable inputs of nutrients from agricultural fertilizers and wastewater systems. Spatial patterns of fishing and nutrient enrichment were not correlated at the two landscape scales we examined: among the 11 interconnected lagoons around the island or among major habitats (fringing reef, mid-lagoon, back reef) within a lagoon. This decoupling at the landscape scale resulted from patterns of covariation between enrichment and fishing that differed qualitatively between cross-shore and long-shore directions. At the cross-shore scale, nutrient enrichment declined but fishing increased from shore to the crest of the barrier reef. By contrast, nutrient enrichment and fishing were positively correlated in the long-shore direction, with both increasing with proximity to a pass in the barrier reef. Contrary to widespread assumptions in the scientific literature that human coastal population density correlates with impact on marine ecosystems and that fishing effort declines linearly with distance from the shore, these local stressors produced a complex spatial mosaic of reef vulnerabilities. Our findings support spatially explicit management involving the control of anthropogenic nutrients and strategic reductions in fishing pressure on herbivores by highlighting specific areas to target for management actions.

Foraging ecology of critically endangered Eastern Pacific hawksbill sea turtles (Eretmochelys imbricata) in the Gulf of California, Mexico

The Eastern Pacific hawksbill sea turtle population is one of the most endangered of all sea turtle species. Here, we examine the foraging ecology of 47 hawksbill turtles (40.5-90.3 cm CCL, mean = 54.1 ± 10.1 cm) around Isla San José, Gulf of California, Mexico by integrating information from passive acoustic telemetry, behavior recordings, fecal analysis, and habitat surveys. Tagged hawkbill turtles exhibited high site fidelity over months and years (tracking duration 1-1490 days, mean = 255 ± 373 days) to the location and benthic habitat where individuals were initially caught. Diet was dominated by benthic invertebrates and algae including sponges, algae, tunicates, and mangrove roots. The mean percent cover of these benthic food items was significantly greater in the mangrove estuary than in adjacent rocky and sandy reef habitats. The Isla San José foraging ground is a high-use area for hawksbills and should be granted national protection status.

Use of Psychics for Stress and Emotional Problems: A Descriptive Survey Comparison with Conventional Providers and Informal Helpers

Conventional mental health treatments do not meet the needs of all who seek help: some consult informal and alternative providers. Researching the use and perceived benefits of these non-conventional sources of help may contribute to understanding help-seeking behavior and inform mental health policy. We explored the experiences of people consulting psychics (a type of alternative provider) for mental health needs, through comparisons with experiences of people consulting conventional and informal providers. An online survey sought feedback on help seeking for stress or emotional problems from 734 adults who had consulted a psychologist or counsellor; doctor or psychiatrist who prescribed medication; friend or family member; or psychic or similar alternative provider. Analyses included descriptive and inferential statistics and content analysis of textual responses. Problems were commonly described in symptom or disorder terminology with considerable overlap across groups. Content analysis of reasons for choice of helper identified four main categories-functional, reasoned, emotional, and passive-which differed significantly across groups (Cramer's V = 0.26), with consulting psychics predominantly a reasoned choice. Ratings of overall effectiveness of help by those consulting psychics were greater than for the three other groups (d = 0.31 to 0.42), with very few adverse outcomes in any group. Help seeking for stress or emotional problems includes consultations with psychics or similar alternative providers, with self-reported outcomes better than for conventional providers. Further research is warranted to establish whether psychic consultations may serve a useful public health function.

Spanish Versions of the Outcome Rating Scale and the Session Rating Scale: Normative Data, Reliability, and Validity

Routine outcome monitoring (ROM) uses standardized measures to both track and inform mental health service delivery. Use of ROM has been shown to improve the outcome of psychotherapy when applied to different types of patients. The present research was designed to determine the reliability and validity of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) in a sample of Spanish patients. After a controlled process of translation into the Spanish that is spoken and written in Spain (i.e., in Europe, as distinct from, e.g., Latin American Spanish), both measures were completed by patients of an outpatient mental health unit during eight sessions of psychotherapy. Sixty mental health patients filled out the ORS and 59 the SRS. In addition, the ORS was completed by 33 people who constituted the non-clinical sample. The cut-off of the ORS was 24.52 points, and the Reliable Change Index (RCI) was 9.15 points. ORS and SRS scores exhibited excellent internal consistency. The temporal stability of the SRS was adequate. The convergent and discriminant validity of the two measures were adequate. Regarding the factorial validity of the ORS and the SRS, in the third psychotherapy session, confirmatory factor analyses evidenced the existence of a unifactorial model. The predictive validity of SRS was acceptable. The ORS was sensitive to changes in patients’ symptoms. In conclusion, compared to the original English versions of the ORS and SRS measures, the Spanish versions of the measures are also reliable and valid.

Caribbean reefs of the Anthropocene: Variance in ecosystem metrics indicates bright spots on coral depauperate reefs

Dramatic coral loss has significantly altered many Caribbean reefs, with potentially important consequences for the ecological functions and ecosystem services provided by reef systems. Many studies examine coral loss and its causes-and often presume a universal decline of ecosystem services with coral loss-rather than evaluating the range of possible outcomes for a diversity of ecosystem functions and services at reefs varying in coral cover. We evaluate 10 key ecosystem metrics, relating to a variety of different reef ecosystem functions and services, on 328 Caribbean reefs varying in coral cover. We focus on the range and variability of these metrics rather than on mean responses. In contrast to a prevailing paradigm, we document high variability for a variety of metrics, and for many the range of outcomes is not related to coral cover. We find numerous "bright spots," where herbivorous fish biomass, density of large fishes, fishery value, and/or fish species richness are high, despite low coral cover. Although it remains critical to protect and restore corals, understanding variability in ecosystem metrics among low-coral reefs can facilitate the maintenance of reefs with sustained functions and services as we work to restore degraded systems. This framework can be applied to other ecosystems in the Anthropocene to better understand variance in ecosystem service outcomes and identify where and why bright spots exist.

The Child Outcome Rating Scale: validating a four-item measure of psychosocial functioning in community and clinic samples of children aged 10-15

Psychosocial functioning is considered an important and valued outcome in relation to young people's mental health as a construct distinct from psychiatric symptomology, especially in the light of an increasing focus on transdiagnostic approaches. Yet, the level of psychosocial functioning is rarely directly asked of young people themselves, despite the widespread recognition that the young person's perspective is valuable and is often at odds with those of other reporters, such as parents or professionals. One possible reason for this is that the field lacks a clear agreed tool to capture this information in a non-burdensome way. To begin to address this gap, this paper describes psychometric analysis of the Child Outcome Rating Scale (CORS), a brief and highly accessible self-report measure of young people's psychosocial functioning already used extensively by mental health professionals around the world but with only limited data on psychometric robustness. Using large community (n = 7822) and clinic (n = 2604) samples, we explore the factor structure, construct validity, internal consistency, differential item functioning, and sensitivity of the CORS. We found that the CORS stands up to psychometric scrutiny, having found satisfactory levels of reliability, validity, and sensitivity in this sample. We also found that the CORS is suitable for use with young people as old as 15 years old. That the CORS has been found to be psychometrically robust while being highly feasible (brief, simple, easy to administer) for use in busy clinical settings, combined with the fact that the CORS has already been widely adopted by clinicians and young people, suggests CORS may be an important tool for international use.

The FLUXNET2015 dataset and the ONEFlux processing pipeline for eddy covariance data

The FLUXNET2015 dataset provides ecosystem-scale data on CO₂, water, and energy exchange between the biosphere and the atmosphere, and other meteorological and biological measurements, from 212 sites around the globe (over 1500 site-years, up to and including year 2014). These sites, independently managed and operated, voluntarily contributed their data to create global datasets. Data were quality controlled and processed using uniform methods, to improve consistency and intercomparability across sites. The dataset is already being used in a number of applications, including ecophysiology studies, remote sensing studies, and development of ecosystem and Earth system models. FLUXNET2015 includes derived-data products, such as gap-filled time series, ecosystem respiration and photosynthetic uptake estimates, estimation of uncertainties, and metadata about the measurements, presented for the first time in this paper. In addition, 206 of these sites are for the first time distributed under a Creative Commons (CC-BY 4.0) license. This paper details this enhanced dataset and the processing methods, now made available as open-source codes, making the dataset more accessible, transparent, and reproducible.

Measurement(s)	net ecosystem exchange • carbon dioxide • water • energy
Technology Type(s)	eddy covariance • measurement device
Sample Characteristic - Environment	terrestrial biome • atmosphere
Sample Characteristic - Location	Earth (planet)

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.12295910

Transesophageal echocardiography guidance for atrial-caval thrombus removal with the AngioVac system

Thromboembolectomy is often guided with fluoroscopy. For intracardiac and great vessel thromboemboli, transesophageal echocardiography (TEE) can assess these thrombi, guide precise suction catheter placement, prevent intracardiac injury, and serve as a hemodynamic monitor. TEE can also be used to assess blood flow and thrombotic material reduction following embolectomy. TEE is a low-risk, high-value, real-time imaging modality that facilitates thromboembolectomy and increases patient safety.

Routine monitoring of therapeutic alliance to predict treatment engagement in a Veterans Affairs substance use disorders clinic

Measurement-based care (MBC) can improve mental health treatment outcomes and is a priority within the Department of Veterans Affairs (VA). However, to date, MBC efforts within the VA have focused on assessment of psychological symptoms to the exclusion of psychotherapy process variables such as the therapeutic alliance that may predict treatment response. This quality improvement project involved the implementation of routine monitoring of alliance within a VA substance use disorder (SUD) clinic predominantly serving veterans with serious mental illness. Alliance ratings were provided by 98 veterans following group therapy sessions. Low alliance ratings were used by the clinicians (n = 4) leading the groups (n = 9) as opportunities to discuss veterans' treatment experience and increase engagement. Using multilevel models that accounted for the nested nature of the data and veteran demographics, alliance ratings showed a small increase over time (B = 0.075, p < .001, f2 = 0.033). In addition, maximum alliance rating (i.e., patients' highest rating of alliance across all observations) was significantly but modestly associated with attendance at both MBC group sessions and all SUD-related visits in the 3 months following the initial alliance rating (Bs = 0.96 and 1.79; ps = .006 and .004; f2s = 0.079 and 0.088, respectively). Average alliance rating, however, was not associated with treatment attendance (ps > .050). Findings suggest that assessment of alliance is feasible within a VA SUD clinic and may provide information signaling risk for disengagement that could be used for increasing treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

OBJECTIVE

Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia).

METHOD

The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments.

RESULTS

When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies.

CONCLUSION

Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice

Recent evidence suggests that psychotherapists may not increase in effectiveness over accrued experience in naturalistic settings, even settings that provide access to patients' outcomes. The current study examined changes in psychotherapists' effectiveness within an agency making a concerted effort to improve outcomes through the use of routine outcome monitoring coupled with ongoing consultation and the planful application of feedback including the use of deliberate practice. Data were available for 7 years of implementation from 5,128 patients seen by 153 psychotherapists. Results indicate that outcomes indeed improved across time within the agency, with increases of d = 0.035 (p = .003) per year. In contrast with previous reports, psychotherapists in the current sample showed improvements within their own caseloads across time (d = 0.034, p = .042). It did not appear that the observed agency-level improvement was due to the agency simply hiring higher-performing psychotherapists or losing lower-performing psychotherapists. Implications of these findings are discussed in relation to routine outcome monitoring, expertise in psychotherapy, and quality improvement within mental health care. (PsycINFO Database Record

As good as it gets? Therapy outcomes of trainees over time

There is a paucity of empirical studies that demonstrate psychotherapy trainees improve at assisting their clients' therapy outcomes over time. We examined whether trainees (i.e., practicum, predoctoral interns, and postdoctoral fellows) improved in their clients' therapy outcomes over time. We examined 114 trainees (i.e., who were trainees for the first client in the database) and had over 12 months of client outcome data (M = 45.31 months). At the start of their time in our database, about half of the participants (48.2%) were predoctoral interns, 42.1% were practicum students, and 9.6% were postdoctoral fellows. Collectively, they treated 2,991 clients (M = 26 clients per trainee). Clients completed the Behavioral Health Measure, which assesses general psychological functioning (i.e., well-being, symptom distress, and life functioning), as a measure of therapy outcomes. Trainees demonstrated small-sized growth in their clients' outcomes over time (d = 0.04 per year); however, this growth was moderated by client severity. That is, trainees demonstrated growth over time in working with clients who were less distressed (d = -0.13 to 0.10 over time), but there was no change over time for trainees when working with more distressed clients (d = 0.67 to .65 over time). The results were consistent across trainee level (i.e., practicum, predoctoral intern, postdoctoral fellow), yet trainees varied in their patterns of growth. Psychotherapy training has a small, but positive, effect on trainees' ability to foster positive outcomes with their clients over time. (PsycINFO Database Record

Effect size calculations for the clinician: methods and comparability

OBJECTIVE

The measurement of clinical change via single-group pre-post effect size has become increasingly common in psychotherapy settings that collect practice-based evidence and engage in feedback-informed treatment. Different methods of calculating effect size for the same sample of clients and the same measure can lead to wide-ranging results, reducing interpretability.

METHOD

Effect sizes from therapists-including those drawn from a large web-based database of practicing clinicians-were calculated using nine different methods.

RESULTS

The resulting effect sizes varied significantly depending on the method employed. Differences between measurement methods routinely exceeded 0.40 for individual therapists.

CONCLUSIONS

Three methods for calculating effect sizes are recommended for moderating these differences, including two equations that show promise as valid and practical methods for use by clinicians in professional practice.

The outcome of psychotherapy: yesterday, today, and tomorrow

In 1963, the first issue of the journal Psychotherapy appeared. Responding to findings reported in a previous publication by Eysenck (1952), Strupp wrote of the "staggering research problems" (p. 2) confronting the field and the necessity of conducting "properly planned an executed experimental studies" to resolve questions about the process and outcome of psychotherapy. Today, both the efficacy and effectiveness of psychotherapy has been well established. Despite the consistent findings substantiating the field's worth, a significant question remains the subject of debate: how does psychotherapy work? On this subject, debate continues to divide the profession. In this paper, a "way out" is proposed informed by research on the therapist's contribution to treatment outcome and findings from studies on the acquisition of expertise.

Iron and CF-related anemia: expanding clinical and biochemical relationships

INTRODUCTION

This cross-sectional study was conducted to assess the relationship between iron levels in the plasma and sputum of cystic fibrosis (CF) patients.

METHODS

Demographic, clinical, and iron-related laboratory data were prospectively obtained from 25 patients with stable clinical features and 14 patients with worsened clinical features since their most recent evaluations.

RESULTS

Compared to patients with stable clinical features, those who experienced clinical deterioration demonstrated significantly worse lung function and were more frequently malnourished and diabetic. Members of the latter group were also significantly more hypoferremic and had higher sputum iron content than patients with stable clinical features. No significant correlation was found between plasma and sputum iron levels when the groups were analyzed together and separately.

CONCLUSIONS

Sputum iron content does not correlate with iron-related hematologic tests. Hypoferremia is common in CF and correlates with poor lung function and overall health.

99th Dahlem conference on infection, inflammation and chronic inflammatory disorders: triggering of autoimmune diseases by infections

Human autoimmune diseases, such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis and systemic lupus erythematosus (SLE), are linked genetically to distinct major histocompatibility complex (MHC) class II molecules and other immune modulators. However, genetic predisposition is only one risk factor for the development of these diseases, and low concordance rates in monozygotic twins as well as geographical distribution of disease risk suggest a critical role for environmental factors in the triggering of these autoimmune diseases. Among potential environmental factors, infections have been implicated in the onset and/or promotion of autoimmunity. This review will discuss human autoimmune diseases with a potential viral cause, and outline potential mechanisms by which pathogens can trigger autoimmune disease as discerned from various animal models of infection-induced autoimmune disease.

Predicting echo thresholds from speech onset characteristics

Echo threshold variability has previously been examined using stimuli that are carefully controlled and artificial (e.g., clicks and noise bursts), while studies using speech stimuli have only reported average thresholds. To begin to understand how echo thresholds might vary among speech sounds, four syllables were selected in pairs that contrasted abruptness vs gradualness of onset envelopes. Fusion and discrimination suppression thresholds, two echo thresholds commonly used to study the precedence effect, differed among syllables. Results were used to evaluate two predictive heuristics adapted from perceptual center (p-center) models.

The role of infections in autoimmune disease

Autoimmunity occurs when the immune system recognizes and attacks host tissue. In addition to genetic factors, environmental triggers (in particular viruses, bacteria and other infectious pathogens) are thought to play a major role in the development of autoimmune diseases. In this review, we (i) describe the ways in which an infectious agent can initiate or exacerbate autoimmunity; (ii) discuss the evidence linking certain infectious agents to autoimmune diseases in humans; and (iii) describe the animal models used to study the link between infection and autoimmunity.

Distinctions without a difference: direct comparisons of psychotherapies for alcohol use disorders

To estimate the relative efficacy of alcohol use disorder treatments, the authors meta-analyzed studies that directly compared 2 bona fide psychological treatments. The authors accommodated problems with the inclusion of multiple treatment comparisons by randomly assigning a positive/negative sign to the effect size derived from each comparison and then estimating the extent to which effect sizes were heterogeneous. The authors' primary hypothesis was that the variability in effect sizes of bona fide psychological treatments for alcohol use disorders that were directly compared would be zero. For both alcohol measures and measures of abstinence, analyses indicate that effects were homogenously distributed about zero (I(2) = 10.61, 0.00, respectively), indicating that different treatment comparisons yielded a common effect size that was not significantly different from zero. Analyses also indicate that allegiance accounted for a significant portion of variability in differences between treatments. Implications for the treatment of alcohol use disorders as well as research on the mechanisms responsible for the benefit of treatment are discussed.

Effect of hematopoietic growth factors on severity of experimental autoimmune encephalomyelitis

We have investigated the influence of different hematopoietic growth factors, including granulocyte colony-stimulating factor (G-CSF), stem cell factor (SCF), Flt-3 ligand (Flt-3L) and thrombopoietin (TPO), on the course of relapsing experimental autoimmune encephalomyelitis, a mouse model of multiple sclerosis. Disease course and central nervous system histology were evaluated in all groups. When given after immunization but before either disease onset or during remission, Flt-3L, SCF and G-CSF exacerbated disease severity whereas TPO had no effect compared to non-cytokine-treated controls. When compared to controls, TPO did not exacerbate disease. We conclude that autoimmune disease severity may be affected by hematopoietic growth factors currently being employed in hematopoietic stem cell transplantation of patients with autoimmune disease. The mechanism of their effects remains unknown: it may be related to both T helper (Th) 1/Th2 skewing and/or homing of inflammatory cells to the disease-affected organ.

A virus-induced molecular mimicry model of multiple sclerosis

Multiple sclerosis1 (MS) is an immune-mediated autoimmune demyelinating disease in humans. The initiating event in MS is unknown, but epidemiological evidence suggests that virus infections may be important and one possible mechanism for induction of infection-induced autoimmune disease is molecular mimicry. To test the ability of a virus encoding a self myelin mimic epitope to induce an autoimmune response, we have developed a mouse model wherein the immunodominant myelin epitope PLP139-151, or mimics of this epitope, were inserted into a nonpathogenic variant of Theiler's murine encephalomyelitis virus (TMEV). SJL mice infected with TMEV containing PLP139-151 or a mimic of PLP139-151 expressed by the protease IV protein of Haemophilus influenzae, sharing only 6/13 amino acids with the native epitope, developed an early-onset demyelinating disease associated with activation of CD4+ T cells reactive with PLP139-151. We have used this molecular mimicry model to further address the requirements for mimic epitope processing and presentation during infection and the requirements for TCR recognition and MHC binding of mimic epitopes. We have also investigated whether molecular mimicry may require multiple infections, with either the mimic-encoding virus or an unrelated virus, to initiate autoimmune disease. Finally, we have asked whether a virus encoding a molecular mimic has to directly infect the target organ to induce autoimmune disease. Overall, this virus-induced molecular mimicry model has provided critical information regarding the mechanisms by which infection-induced molecular mimicry can induce autoimmune diseases.

Comparison of Colchicine, Dapsone, Triamcinolone, and Diphenhydramine Therapy for the Treatment of Brown Recluse Spider Envenomation

OBJECTIVE

To compare the efficacy of dapsone, diphenhydramine, colchicine, and intralesional triamcinolone in the treatment of brown spider bites. We used a purified venom that reproducibly produces a large eschar. To mimic real-life circumstances, all agents were administered following a 2-hour delay after envenomation. The animals were evaluated for the presence of coagulopathy to determine if the incidence of systemic findings correlated with the type of treatment.

DESIGN AND SETTING

In a research laboratory, 60 New Zealand white rabbits each received an intradermal injection of 20 microg of purified Loxosceles reclusa venom. The rabbits were divided into 5 groups of 12; a control group and 4 groups treated with a drug (either colchicine, triamcinolone, diphenhydramine, or dapsone). Measured end points included maximum eschar size as well as histologic grading of depth, inflammation, and thrombosis.

INTERVENTIONS

Treatment with colchicine, triamcinolone, diphenhydramine, or dapsone.

MAIN OUTCOME MEASURES

Maximum eschar size as well as histologic grading of depth, inflammation, and thrombosis.

RESULTS

There was no significant difference with respect to eschar size (1-way analysis of variance, P = .003). There was no significant difference between any treatment with respect to presence or absence of ulcer, necrosis, large vessel vasculitis, or small vessel vasculitis. The only outcome of significance was that triamcinolone offered protection from thrombosis (chi2 likelihood ratio, P = .04). We also noted evidence of coagulopathy in all of the envenomated animals. The rabbits had grossly elevated activated partial thromboplastin time results, which were corrected with 1:1 mixing with normal rabbit plasma, suggesting an acquired factor deficiency. We did not detect an individual factor deficiency or a lupus anticoagulant.

CONCLUSIONS

In a rabbit model, none of the agents tested (dapsone, diphenhydramine, colchicine, and intralesional triamcinolone) had an effect on eschar size. Triamcinolone appeared to offer some protection against histologic evidence of thrombosis, but this protection did not translate into a difference in clinical outcome. All animals developed evidence of coagulopathy, regardless of treatment. The coagulopathy could be corrected by fresh rabbit plasma, suggesting an acquired factor deficiency.

The partners for change outcome management system

A number of systems provide feedback regarding client progress and experience of the therapeutic alliance to clinicians. Available evidence indicates that access to such data improves retention and outcome for clients most at risk for treatment failure. Over the last several years, the team at the Institute for the Study of Therapeutic Change has worked to develop an outcome management system that not only provides valid and reliable feedback, but also is as user-friendly as possible for therapists and consumers. In this article, we describe the system and summarize current research findings.

Leishmaniasis acquired in the Iraqi Theater of Operations: lessons learned

Between August 2002 and February 2004, the Department of Defense identified 522 cases of cutaneous leishmaniasis in military personnel. This commentary examines reasons why there were so many cases of leishmaniasis during this conflict as compared with Operation Desert Storm. Lessons learned can be applied to reduce the risk to US personnel during future conflicts. Among the factors to be considered are environment, exposure, vector control, and the failure to deliver insect repellent to deployed US personnel.

Carbon in Amazon forests: unexpected seasonal fluxes and disturbance-induced losses

The net ecosystem exchange of carbon dioxide was measured by eddy covariance methods for 3 years in two old-growth forest sites near Santarém, Brazil. Carbon was lost in the wet season and gained in the dry season, which was opposite to the seasonal cycles of both tree growth and model predictions. The 3-year average carbon loss was 1.3 (confidence interval: 0.0 to 2.0) megagrams of carbon per hectare per year. Biometric observations confirmed the net loss but imply that it is a transient effect of recent disturbance superimposed on long-term balance. Given that episodic disturbances are characteristic of old-growth forests, it is likely that carbon sequestration is lower than has been inferred from recent eddy covariance studies at undisturbed sites.