Fatigue during acute systemic inflammation is associated with reduced mental effort expenditure while task accuracy is preserved

BACKGROUND

Earlier work within the physical domain showed that acute inflammation changes motivational prioritization and effort allocation rather than physical abilities. It is currently unclear whether a similar motivational framework accounts for the mental fatigue and cognitive symptoms of acute sickness. Accordingly, this study aimed to assess the relationship between fatigue, cytokines and mental effort-based decision making during acute systemic inflammation.

METHODS

Eighty-five participants (41 males; 18-30 years (M=23.0, SD=2.4)) performed a mental effort-based decision-making task before, 2 hours after, and 5 hours after intravenous administration of 1 ng/kg bacterial lipopolysaccharide (LPS) to induce systemic inflammation. Plasma concentrations of cytokines (interleukin (IL)-6, IL-8 and tumor necrosis factor (TNF)) and fatigue levels were assessed at similar timepoints. In the task, participants decided whether they wanted to perform (i.e., 'accepted') arithmetic calculations of varying difficulty (3 levels: easy, medium, hard) in order to obtain rewards (3 levels: 5, 6 or 7 points). Acceptance rates were analyzed using a binomial generalized estimated equation (GEE) approach with effort, reward and time as independent variables. Arithmetic performance was measured per effort level prior to the decisions and included as a covariate. Associations between acceptance rates, fatigue (self-reported) and cytokine concentrations levels were analyzed using partial correlation analyses.

RESULTS

Plasma cytokine concentrations and fatigue were increased at 2 hours post-LPS compared to baseline and 5 hours post-LPS administration. Acceptance rates decreased for medium, but not for easy or hard effort levels at 2 hours post-LPS versus baseline and 5 hours post-LPS administration, irrespective of reward level. This reduction in acceptance rates occurred despite improved accuracy on the arithmetic calculations itself. Reduced acceptance rates for medium effort were associated with increased fatigue, but not with increased cytokines.

CONCLUSION

Fatigue during acute systemic inflammation is associated with alterations in mental effort allocation, similarly as observed previously for physical effort-based choice. Specifically, willingness to exert mental effort depended on effort and not reward information, while task accuracy was preserved. These results extend the motivational account of inflammation to the mental domain and suggest that inflammation may not necessarily affect domain-specific mental abilities, but rather affects domain-general effort-allocation processes.

Lymphocele following lymph node dissection in cervical and endometrial cancer: A systematic review and meta-analysis

OBJECTIVES

The purpose of this systematic review and meta-analysis was to evaluate the proportion and risk factors of lymphoceles and symptomatic lymphoceles after PLND in early-stage cervical and early-stage high or high-intermediate risk endometrial cancer.

METHODS

Studies reporting on the proportion of lymphocele after PLND were conducted in PubMed, Embase and Cochrane Library. Retrieved studies were screened on title/abstract and full text by two reviewers independently. Quality assessment was conducted using the Newcastle Ottowa Scale and the Cochrane risk-of-bias tool. Proportion of lymphocele and possible risk factors were pooled through random-effects meta-analyses.

RESULTS

From the 233 studies retrieved, 24 studies were included. The pooled proportion of lymphocele was 14% and of symptomatic lymphocele was 3%. Routinely performing diagnostics was associated with a significantly higher proportion of lymphocele compared to diagnostics performed on indication (21% versus 4%, p < 0.01). Laparotomic surgical approach led to a significantly higher proportion of lymphoceles than laparoscopic surgical approach (18% versus 7%, p = 0.05). The proportion of lymphocele was significantly higher when >15% of the study population underwent additional paraaortic lymph node dissection (PAOLND) opposed to <15% (15% versus 3%, p < 0.01). A mean number of lymph nodes dissected of <21 resulted in a significantly higher pooled proportion of lymphoceles opposed to when the mean number was 21 or higher (19% versus 5%, p = 0.02). Other risk factors analysed were BMI, lymph node metastasis, adjuvant radiotherapy and follow up. There was no sufficient data to detect significant risk factors for the development of symptomatic lymphoceles.

CONCLUSION

The pooled proportion of lymphocele was 14% of which symptomatic lymphoceles occurred in 3%. Significant risk factors for the total proportion of lymphoceles were laparotomic approach, decreased number of lymph nodes dissected and additional PAOLND.

Interorganisational collaboration to improve accessibility of diagnostic evaluations for children

Background

Children with a suspected developmental disability need early diagnostic evaluations and support, to maximize developmental opportunities. Accessibility to diagnostic settings in Flanders, Belgium, is poor, with waiting periods up to two years. Interorganisational coordination of activities using a public health and needs of the population perspective is needed to strengthen the system. This study aims to evaluate current practices and opportunities for interorganisational collaboration of organisations active in the field of diagnostics.

Methods

It concerns a qualitative, policy-support research project. 6 homogeneous focus groups were organised for the 6 types of organisations subsidized by the government to perform diagnostic evaluations of children with a (suspected) developmental disorders. Data were thematically analysed and categorized in a process of researcher and data-triangulation. A member check validation was done.

Results

59 persons participated. We classified the hampering and facilitating factors for collaboration Current interorganisational collaboration is mostly limited to referral. Organisational differences in vision and goals, working processes and quality requirements, regulations and financial support criteria, a problem of accessibility and communication problems are hampering factors. Knowledge of mutual expertise and working processes, personal contacts and open communication are facilitating factors.

Conclusions

A population public health based organisation of the field of multidisciplinary diagnostic evaluations for children with a developmental disorder, with interorganisational collaboration and coordination of activities in mandated networks, sharing experience and knowledge, would increase the accessibility for all children and strenghten the health system. The implementation of interorganisational networks would benefit from a functional and institutional analysis of organisations.

Key messages

• Coordination of activities and interorganisational collaboration in mandated networks, could potentially improve the accessibility of diagnostic evaluations for children with a developmental disorder.

• Implementation of interorganisational networks would benefit from a functional and institutional analysis of organisations.

Establishment of the Namibian National Public Health Institute: laboratory systems strengthening

 

In 2020, the Namibian Ministry of Health and Social Services (MoHSS) and the Robert Koch Institute (RKI) started a twinning project with the long-term goal of establishing a Namibia Institute of Public Health (NIPH). A fundamental pillar of an NIPH is a fully operational Public Health laboratory system. Due to the COVID-19 pandemic, the need for strengthening the existing Namibian Laboratory system became eminent. Following the Intra-Action Review (IAR) of the COVID-19 response in Namibia in 2020, three regional diagnostic laboratories, at points of entry, were assessed. The major issues identified were long delays between sampling of both suspected cases and COVID-19 patients and receiving test results due to extended sample transport times to the central laboratory in Windhoek and the overload of the central capacities due to overwhelming numbers of samples during peak times. This led to the establishment of three SARS-CoV-2 PCR diagnostic laboratories through procurement and installation of equipment, provision of consumables/reagents, and on-site training of laboratory technicians with continued virtual technical support. Consequently, an important reduction of the diagnosis turnaround time was achieved. Of great value was the technical support given by the staff at the central laboratory during the trainings allowing for immediate validation of the newly established laboratories and to strengthen the communication between regional laboratories and the central laboratory. The Namibian molecular diagnostic capacities have increased in important regions in Namibia and will provide data to support the health policies of the future NIPH. New diagnostic protocols will be developed to foster the sustainability of the established laboratories and could support the implementation of genomic surveillance capacities. Finally, stronger relationships were built through these joint activities, which will support and the next steps of the establishment of the NIPH.

Key messages

• Supporting and Strengthening the Namibian Public Health Laboratory system.

• Long-term goal of establishing a Namibia Institute of Public Health (NIPH).

New Constraint on the Local Relic Neutrino Background Overdensity with the First KATRIN Data Runs

We report on the direct search for cosmic relic neutrinos using data acquired during the first two science campaigns of the KATRIN experiment in 2019. Beta-decay electrons from a high-purity molecular tritium gas source are analyzed by a high-resolution MAC-E filter around the end point at 18.57 keV. The analysis is sensitive to a local relic neutrino overdensity ratio of η<9.7×10^{10}/α (1.1×10^{11}/α) at a 90% (95%) confidence level with α=1 (0.5) for Majorana (Dirac) neutrinos. A fit of the integrated electron spectrum over a narrow interval around the end point accounting for relic neutrino captures in the tritium source reveals no significant overdensity. This work improves the results obtained by the previous neutrino mass experiments at Los Alamos and Troitsk. We furthermore update the projected final sensitivity of the KATRIN experiment to η<1×10^{10}/α at 90% confidence level, by relying on updated operational conditions.

SARS-CoV-2 prevalence and immunity: a hospital-based study from Malawi

Background

COVID-19 transmission and disease dynamics in sub-Saharan Africa are not well understood. Our study aims to provide insight into COVID-19 epidemiology in Malawi by estimating SARS-CoV-2 prevalence and immunity after SARS-CoV-2 infection in a hospital-based setting.

Methods

We conducted a hospital-based, convenience sampling, cross-sectional survey for SARS-CoV-2 in Lilongwe, Malawi. Participants answered a questionnaire and were tested for SARS-CoV-2 by enzyme-linked immunosorbent assay and real-time reverse-transcription polymerase chain reaction (RT-PCR). A surrogate virus neutralization test (sVNT) was performed in seropositive samples to estimate immunity. Poisson regression was used to assess SARS-CoV-2 point prevalence association with demographic and behavioral variables.

Findings

The study included 930 participants. We found a combined point prevalence of 10.1%. Separately analyzed, RT-PCR positivity was 2.0%, and seropositivity was 9.3%. Of tested seropositive samples, 90.1% were sVNT positive. We found a high rate (45.7%) of asymptomatic SARS-CoV-2 infection. SARS-CoV-2 point prevalence was significantly associated with being a healthcare worker.

Interpretation

Our study suggests that official data underestimate COVID-19 transmission. Using sVNTs to estimate immunity in Malawi is feasible and revealed considerable post-infection immunity in our cohort. Subclinical infection and transmission are probably a game-changer in surveillance, mitigation and vaccination strategies.

Bound on 3+1 Active-Sterile Neutrino Mixing from the First Four-Week Science Run of KATRIN

We report on the light sterile neutrino search from the first four-week science run of the KATRIN experiment in 2019. Beta-decay electrons from a high-purity gaseous molecular tritium source are analyzed by a high-resolution MAC-E filter down to 40 eV below the endpoint at 18.57 keV. We consider the framework with three active neutrinos and one sterile neutrino. The analysis is sensitive to the mass, m_{4}, of the fourth mass state for m_{4}^{2}≲1000  eV^{2} and to active-to-sterile neutrino mixing down to |U_{e4}|^{2}≳2×10^{-2}. No significant spectral distortion is observed and exclusion bounds on the sterile mass and mixing are reported. These new limits supersede the Mainz results for m_{4}^{2}≲1000  eV^{2} and improve the Troitsk bound for m_{4}^{2}<30  eV^{2}. The reactor and gallium anomalies are constrained for 100<Δm_{41}^{2}<1000  eV^{2}.

Saliva oxytocin, cortisol, and testosterone levels in adolescent boys with autism spectrum disorder, oppositional defiant disorder/conduct disorder and typically developing individuals

The aim of the current study was to compare levels of oxytocin, cortisol, and testosterone in adolescents with either autism spectrum disorder (ASD), or oppositional defiant disorder (ODD)/conduct disorder (CD), and in typically developing individuals (TDI), and relate hormone levels to severity and subtype of aggression and callous-unemotional (CU) traits. Saliva concentrations of oxytocin, cortisol, and testosterone were assessed in 114 male participants (N = 49 ASD, N = 37 ODD/CD, N = 28 TDI,) aged 12-19 years (M = 15.4 years, SD = 1.9). The ASD and the ODD/CD groups had significantly lower levels of oxytocin than the TDI group, and the ODD/CD group had significantly higher levels of testosterone than the ASD group. There were no group effects on cortisol levels. Group differences remained for oxytocin after correcting for the influence of CU traits, but were not significant after controlling for aggression. Results for testosterone became non-significant after correction for either CU traits or aggression. Across groups, higher levels of CU traits were related to higher levels of cortisol and testosterone, however, proactive and reactive aggression were unrelated to all three hormonal levels. The current findings show that, regardless of cognitive ability or comorbid disorders, the diagnostic groups (ASD, ODD/CD) differ from each other by their hormonal levels, with the ASD group characterized by relative low level of oxytocin, and the ODD/CD group by a relative low level of oxytocin and high level of testosterone. These group effects were partly driven by differences in CU traits between the groups.

Improved Upper Limit on the Neutrino Mass from a Direct Kinematic Method by KATRIN

We report on the neutrino mass measurement result from the first four-week science run of the Karlsruhe Tritium Neutrino experiment KATRIN in spring 2019. Beta-decay electrons from a high-purity gaseous molecular tritium source are energy analyzed by a high-resolution MAC-E filter. A fit of the integrated electron spectrum over a narrow interval around the kinematic end point at 18.57 keV gives an effective neutrino mass square value of (-1.0_{-1.1}^{+0.9})  eV^{2}. From this, we derive an upper limit of 1.1 eV (90% confidence level) on the absolute mass scale of neutrinos. This value coincides with the KATRIN sensitivity. It improves upon previous mass limits from kinematic measurements by almost a factor of 2 and provides model-independent input to cosmological studies of structure formation.

Allegiance Bias and Treatment Quality as Moderators of the Effectiveness of Humanistic Psychotherapy: Protocol for a Systematic Review and Meta-Analysis

Background

In many countries, humanistic psychotherapy (HPT) is viewed as a broad psychotherapeutic approach and is accepted in health care systems. To qualify for reimbursement by health insurance in Germany, psychotherapy approaches have to be evaluated positively by the German Scientific Board of Psychotherapy (GSBP). The GSBP examined HPT and its subapproaches based on an application by a number of professional organizations affiliated with HPT (Work Group Humanistic Psychotherapy, WGHPT). The GSBP came to the decision that none of the HPT subapproaches provided sufficient evidence to be evaluated as evidence based. Potential reasons for the discrepancy between international recognition of HPT and GSBP’s decision will be explored: researchers’ allegiance may have led to a risk of bias disadvantaging HPT. Furthermore, the evaluation criteria of the GSBP did not systematically consider whether HPT was conceptualized bona fide and implemented with sufficient treatment integrity in the studies.

Objective

This systematic review will re-examine the studies included in the review of the GSBP. Within 2 comparisons (HPT vs control and HPT vs other psychotherapeutic interventions), we will examine moderating effects of treatment quality (bona fide and treatment integrity) and allegiance on the effectiveness of HPT.

Methods

This review is based on the prior systematic review by the GSBP. The GSBP examined randomized controlled trials (RCTs) and studies with non-RCTs of HPT interventions for individuals with mental disorders. All studies suggested by the WGHPT were included; moreover, the GSBP conducted searches in standard electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, and PSYNDEX) and handsearches in relevant systematic reviews and contacted experts. A total of 2 independent GSBP reviewers performed study screening using a structured form. On the basis of the prior work of the GSBP, all studies that were positively screened by the GSBP will be included in this review. Data will be extracted independently by 4 authors. Standardized mean difference will be calculated, and possible publication bias will be tested using funnel plots and Egger test. A priori defined subgroup or meta-regression analyses will be performed for treatment quality, allegiance, type of nonactive control, study quality, type of subapproach, and target population (children and adolescents or adults).

Results

The GSBP identified 115 eligible studies that will be reanalyzed in this systematic review.

Conclusions

Results about moderator effects of treatment quality and allegiance will provide important information about their impact on the evaluation of HPT and other psychotherapy approaches and can be used for further evaluation methods.

Trial Registration

PROSPERO CRD42019128983; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=128983

International Registered Report Identifier (IRRID)

PRR1-10.2196/15140

High Treatment Uptake in Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients After Unrestricted Access to Direct-Acting Antivirals in the Netherlands

Background

The Netherlands has provided unrestricted access to direct-acting antivirals (DAAs) since November 2015. We analyzed the nationwide hepatitis C virus (HCV) treatment uptake among patients coinfected with human immunodeficiency virus (HIV) and HCV.

Methods

Data were obtained from the ATHENA HIV observational cohort in which >98% of HIV-infected patients ever registered since 1998 are included. Patients were included if they ever had 1 positive HCV RNA result, did not have spontaneous clearance, and were known to still be in care. Treatment uptake and outcome were assessed. When patients were treated more than once, data were included from only the most recent treatment episode. Data were updated until February 2017. In addition, each treatment center was queried in April 2017 for a data update on DAA treatment and achieved sustained virological response.

Results

Of 23574 HIV-infected patients ever linked to care, 1471 HCV-coinfected patients (69% men who have sex with men, 15% persons who [formerly] injected drugs, and 15% with another HIV transmission route) fulfilled the inclusion criteria. Of these, 87% (1284 of 1471) had ever initiated HCV treatment between 2000 and 2017, 76% (1124 of 1471) had their HCV infection cured; DAA treatment results were pending in 6% (92 of 1471). Among men who have sex with men, 83% (844 of 1022) had their HCV infection cured, and DAA treatment results were pending in 6% (66 of 1022). Overall, 187 patients had never initiated treatment, DAAs had failed in 14, and a pegylated interferon-alfa-based regimen had failed in 54.

Conclusions

Fifteen months after unrestricted DAA availability the majority of HIV/HCV-coinfected patients in the Netherlands have their HCV infection cured (76%) or are awaiting DAA treatment results (6%). This rapid treatment scale-up may contribute to future HCV elimination among these patients.

[What rheumatologists can learn from ophthalmologists]

Intraocular inflammation with the imprecise and broad umbrella term "uveitis" is a diagnostic and therapeutic challenge in ophthalmology. Uveitis is one of the most common causes of blindness worldwide and due to the associated costs is comparable to diabetic retinopathy. Patients can be affected by uveitis at any age. Any part of the eye may be affected. The symptoms range from complete absence of symptoms, through all types of vision deterioration up to a red and even very painful eye. Uveitis can be strictly unilateral (also alternating from the left to the right eye) or bilateral with a relapsing or chronic course. The transitions are smooth and the differential diagnoses are very broad. In addition to infectious forms and ocular syndromes restricted to the eye, it also includes those with extraocular systemic diseases, such as ankylosing spondylitis or sarcoidosis. All commonly administered immunosuppressive treatment strategies in rheumatology can be used for non-infectious forms in addition to local and regional forms of treatment. The diagnostic and therapeutic impulses of this interdisciplinary interface between rheumatology and ophthalmology is discussed in more detail in this article.

Food craving in daily life: comparison of overweight and normal-weight participants with ecological momentary assessment

Background

The present study examined food cravings in daily life by comparing overweight and normal‐weight participants right before eating events and at non‐eating moments. It was hypothesised that overweight participants would have (i) more frequent, (ii) stronger and (iii) a greater variety of high‐caloric palatable food cravings, and also would (iv) consume more high‐caloric palatable foods, than normal‐weight participants.

Methods

Ecological momentary assessment (EMA) was used to assess food craving strength and frequency, variety of specific food cravings, and food intake. Fifty‐seven overweight and 43 normal‐weight adult participants were assessed at eating events and at an average of eight random non‐eating moments per day for 2 weeks. Foods were categorised as: high‐caloric high palatable foods (HCHP), fruits and salads, staple food dishes and sandwiches, and soups and yoghurts.

Results

Overweight participants reported more frequent HCHP food cravings specifically at non‐eating moments than did normal‐weight participants. Normal‐weight participants reported more food cravings for staple foods, specifically at eating events. Moreover, overweight participants craved a greater variety of HCHP foods than normal‐weight participants at both eating events and random non‐eating moments. No other significant between‐group differences were found.

Conclusions

The results highlight the importance for obesity interventions (i) to specifically target high‐caloric palatable food cravings that are experienced during the day and are not tied to eating moments and (ii) to aim for a reduction in the variety of high‐caloric palatable food cravings. It might be fruitful to deliver treatment aimed at reducing cravings via mobile devices because this allows for easy individual tailoring and timing of interventions.

Comparative effectiveness of continuation and maintenance treatments for persistent depressive disorder in adults

BACKGROUND

Persistent depressive disorder (PDD) is defined as a depressive disorder with a minimum illness duration of two years, including four diagnostic subgroups (dysthymia, chronic major depression, recurrent major depression with incomplete remission between episodes, and double depression). Persistent forms of depression represent a substantial proportion of depressive disorders, with a lifetime prevalence ranging from 3% to 6% in the Western world. Growing evidence indicates that PDD responds well to several acute interventions, such as combined psychological and pharmacological treatments. Yet, given the high rates of relapse and recurrences of depression following response to acute treatment, long-term continuation and maintenance therapy are of great importance. To date, there has been no evidence synthesis available on continuation and maintenance treatments of PDDs.

OBJECTIVES

To assess the effects of pharmacological and psychological (either alone or combined) continuation and maintenance treatments for persistent depressive disorder, in comparison with each other, placebo (drug/attention placebo/non-specific treatment control), and treatment as usual (TAU). Continuation treatments are defined as treatments given to currently remitted people (remission is defined as depressive symptoms dropping below case level) or to people who previously responded to an antidepressant treatment. Maintenance therapy is given during recovery (which is defined as remission lasting longer than six months).

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 28 September 2018. An earlier search of these databases was also conducted for RCTs via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 Dec 2015). In addition we searched grey literature resources as well as the international trial registers ClinicalTrials.gov and ICTRP to 28 September 2018. We screened reference lists of included studies and contacted the first author of all included studies.

SELECTION CRITERIA

We included randomized (RCTs) and non-randomized controlled trials (NRCTs) in adults with formally diagnosed PDD, receiving pharmacological, psychological, or combined continuation and maintenance interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted and analyzed data. The primary efficacy outcome was relapse/recurrence rate of depression. The primary acceptance outcome was dropout due to any reason other than relapse/recurrence. We performed random-effects meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 10 studies (seven RCTs, three NRCTs) involving 840 participants in this review, from which five studies investigated continuation treatments and five studies investigated maintenance treatments. Overall, the included studies were at low-to-moderate risk of bias. For the three NRCTs, the most common source of risk of bias was selection of reported results. For the seven RCTs, the most common sources of risk of bias was non-blinding of outcome assessment and other bias (especially conflict of interest due to pharmaceutical sponsoring).Pharmacological continuation and maintenance therapiesThe most common comparison was antidepressant medication versus tablet placebo (five studies). Participants taking antidepressant medication were probably less likely to relapse or to experience a recurrent episode compared to participants in the placebo group at the end of the intervention (13.9% versus 33.8%, RR 0.41, 95% CI 0.21 to 0.79; participants = 383; studies = 4; I² = 54%, moderate quality evidence). Overall dropout rates may be similar between participants in the medication and placebo group (23.0% versus 25.5%, RR 0.90, 95% CI 0.39 to 2.11; RCTs = 4; participants = 386; I² = 64%, low quality evidence). However, sensitivity analyses showed that the primary outcome (rate of relapse/recurrence) showed no evidence of a difference between groups when only including studies with low risk of bias.None of the studies compared pharmacological or psychological treatments versus TAU.Psychological continuation and maintenance therapiesOne study compared psychological therapies versus attention placebo/non-specific control. One study compared psychotherapy with medication. The results of the studies including psychotherapy might indicate that continued or maintained psychotherapy could be a useful intervention compared to no treatment or antidepressant medication. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusions.Combined psychological and pharmacological continuation and maintenance therapiesThree studies compared combined psychological and pharmacological therapies with pharmacological therapies alone. One study compared combined psychological and pharmacological therapies with psychotherapeutic therapies alone. However, the body of evidence for these comparisons was too small and uncertain to draw any high quality conclusionsComparison of different antidepressant medications Two studies reported data on the direct comparison of two antidepressants. However, the body of evidence for this comparison was too small and uncertain to draw any high quality conclusions.

AUTHORS' CONCLUSIONS

Currently, it is uncertain whether continued or maintained pharmacotherapy (or both) with the reviewed antidepressant agents is a robust treatment for preventing relapse and recurrence in people with PDD, due to moderate or high risk of bias as well as clinical heterogeneity in the analyzed studies.For all other comparisons, the body of evidence was too small to draw any final conclusions, although continued or maintained psychotherapy might be effective compared to no treatment. There is need for more high quality trials of psychological interventions. Further studies should address health-related quality of life and adverse events more precisely, as well as assessing follow-up data.

Fernbehandlung aus psychotherapeutischer Sicht

Es steht mittlerweile eine Vielzahl von digitalen Anwendungen zur Verfügung, die die psychotherapeutische Behandlung ergänzen und die Versorgung psychisch kranker Menschen verbessern können, sie können sie jedoch nicht ersetzen. Dazu gehören beispielsweise digitale Anwendungen zur Videokommunikation, die Psychotherapeuten und Patienten die Möglichkeit bieten, auch über Entfernung miteinander zu kommunizieren. Zudem stehen internetbasierte Interventionen wie Internet(behandlungs-)programme und Gesundheits-Apps für die Prävention und Behandlung psychischer Erkrankungen zur Verfügung. Aufgezeigt wird im Folgenden, welche Chancen und Risiken mit dem Einsatz digitaler Anwendungen bei psychischen Erkrankungen verbunden sein können. Damit digitale Anwendungen zu einer Verbesserung der psychotherapeutischen Versorgung beitragen können, müssen sie genauso sorgfältig durchgeführt werden wie eine Behandlung im unmittelbaren Kontakt. Dazu gehört, dass Diagnose, Indikationsstellung und Aufklärung grundsätzlich in unmittelbarem Kontakt zwischen Psychotherapeut und Patient erfolgen müssen. Dargestellt ist außerdem, welche gesetzlichen Rahmenbedingungen aktuell den Einsatz digitaler Anwendungen in der psychotherapeutischen Versorgung regeln.

Effectiveness of metacognitive interventions for mental disorders in adults: a systematic review protocol (METACOG)

INTRODUCTION

Whereas the efficacy of cognitive-behavioural therapy has been demonstrated for a variety of mental disorders, there is still need for improvement, especially regarding less prevalent or more severe disorders. Recently, metacognitive interventions have been developed and are now available for a variety of diagnoses. Still, a systematic review investigating the effectiveness of different metacognitive interventions for various mental disorders is missing.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs), cross-over and cluster RCTs and non-randomised controlled trials on metacognitive interventions (ie, metacognitive therapy, metacognitive training, others) in adults with any mental disorder will be included. As comparators, another psychological or pharmacological treatment, a combined psychological and pharmacological treatment, treatment as usual or no active treatment are eligible. Outcomes refer to efficacy and acceptability of metacognitive interventions.

ETHICS AND DISSEMINATION

In light of the popularity of metacognitive interventions, the systematic review will provide researchers, clinicians and patients with substantial information on the intervention's effectiveness across different mental disorders. Results will be published in peer-reviewed journals and disseminated through a patient workshop.

Placebo and nocebo reactions in randomized trials of pharmacological treatments for persistent depressive disorder. A meta-regression analysis

BACKGROUND

We aimed to investigate placebo and nocebo reactions in randomized controlled trials (RCT) of pharmacological treatments for persistent depressive disorder (PDD).

METHODS

We conducted a systematic electronic search and included RCTs investigating antidepressants for the treatment of PDD. Outcomes were the number of patients experiencing response and remission in placebo arms (=placebo reaction). Additional outcomes were the incidence of patients experiencing adverse events and related discontinuations in placebo arms (=nocebo reaction). A priori defined effect modifiers were analyzed using a series of meta-regression analyses.

RESULTS

Twenty-three trials were included in the analyses. We found a pooled placebo response rate of 31% and a placebo remission rate of 22%. The pooled adverse event rate and related discontinuations were 57% and 4%, respectively. All placebo arm outcomes were positively associated with the corresponding medication arm outcomes. Placebo response rate was associated with a greater proportion of patients with early onset depression, a smaller chance to receive placebo and a larger sample size. The adverse event rate in placebo arms was associated with a greater proportion of patients with early onset depression, a smaller proportion of females and a more recent publication.

CONCLUSIONS

Pooled placebo and nocebo reaction rates in PDD were comparable to those in episodic depression. The identified effect modifiers should be considered to assess unbiased effects in RCTs, to influence placebo and nocebo reactions in practice.

LIMITATIONS

Limitations result from the methodology applied, the fact that we conducted only univariate analyses, and the number and quality of included trials.

Clinical instruments and methods for assessing physical oral health: A systematic review

OBJECTIVE

This study aimed at exploring available clinical instruments and methods for assessing physical oral health, and at identifying those with sufficient diagnostic performance.

METHODS

A systematic literature search was conducted in Embase and MEDLINE. Identified instruments and methods were critically appraised, and quality of diagnostic performance was rated by two independent reviewers as A (sufficient diagnostic performance), B (either sufficient reliability or validity) or C (insufficient quality, or empirical results unsatisfactory and/or inconsistent). For all A-rated instruments and methods, an in-depth literature search was conducted to supplement and verify their effectiveness and accuracy.

RESULTS

A total of 141 instruments and methods were identified. Only 12 methods with sufficient diagnostic performance could be rated as A, 72 were rated as B, and 34 received a C-rating. Further 23 instruments and methods could not be rated due to lack of available information on diagnostic performance. Of all A-rated instruments, six were designed for tooth structure, two for periodontium, one for endodontium and three for temporomandibular joints and muscles.

CONCLUSION

Even though some instruments and methods exhibited good to excellent reliability and validity and can be recommended for research and clinical practice, they do not allow assessing all components of physical oral health. There is a need to identify and define standard instruments, and for components of physical oral health where methods with sufficient diagnostic performance are lacking, further research is required.

Infertility in the Global South: Raising awareness and generating insights for policy and practice

Infertility is a highly prevalent reproductive health condition in the global South, which often has a devastating impact on the people concerned. Yet, thus far it hardly received any attention from policy makers, Non-Governmental Organizations (NGOs) or donors working in the field of Sexual and Reproductive Health and Rights (SRHR). For this reason we have set up a project to increase knowledge and awareness about infertility and childlessness among those stakeholders and organizations and to generate insight into (possible) interventions in this field. The project received a grant by Share-Net International (the Knowledge Platform in the field of SRHR, funded by the Dutch Ministry of Foreign Affairs) and is a unique collaboration between universities, fertility clinics, fertility support groups and the Walking Egg Foundation. The project consists of multimethods studies in Ghana and Kenya as well as dissemination workshops and meetings in these countries and the Netherlands. The first workshops in Kenya have already taken place with successful feedback from stakeholders. In this commentary we provide insight into the project and the main points and recommendations discussed in the Workshops in Kenya.

Subjective craving and event-related brain response to olfactory and visual chocolate cues in binge-eating and healthy individuals

High-sugar/high-fat foods are related to binge-eating behaviour and especially people with low inhibitory control may encounter elevated difficulties to resist their intake. Incentive sensitization to food-related cues might lead to increased motivated attention towards these stimuli and to cue-induced craving. To investigate the combined influence of olfactory and visual stimuli on craving, inhibitory control and motivated attention, 20 healthy controls and 19 individuals with binge-eating viewed chocolate and neutral pictures, primed by chocolate or neutral odours. Subjective craving and electroencephalogram activity were recorded during the task. N2 and Late Positive Potential (LPP) amplitudes were analysed. Patients reported higher craving than controls. Subjective craving, N2 and LPP amplitudes were higher for chocolate versus neutral pictures. Patients showed a higher relative increase in N2 amplitudes to chocolate versus neutral pictures than controls. Chocolate images induced significant increases in craving, motivated attention and measures of cognitive control. Chocolate odour might potentiate the craving response to visual stimuli, especially in patients with binge-eating.

cAMP and cGMP do not mediate the vasorelaxation induced by iodinated radiographic contrast media in isolated swine renal arteries

Purpose: Vasodilatation is a frequent side effect of radiographic contrast media, partially due to a direct effect on vascular smooth muscles. Our purpose was therefore to examine any possible implication of the cyclic adenosine monophospate (cAMP) and cyclic guanosine monophosphate (cGMP) pathways in contrast media induced vasorelaxation.

Material and Methods: Isolated segments of swine renal arteries were precontracted with 10 μM phenylephrine and relaxed with iomeprol before and after blockade of the cAMP and cGMP pathways.

Results: 80 mM and 160 mM of iomeprol significantly relaxed about 52% and 68% of the precontracted arterial rings, respectively. 10 μm of IBMX, a phosphodiesterase inhibitor, did not increase the relaxant effect of 80 mM iomeprol but increased the relaxations induced by 400 nM forskolin by about 1.9 times (which stimulates the production of cAMP), and by 1 μm sodium nitroprusside (which stimulates the production of cGMP). 1 μm of H89 (an inhibitor of the cAMP-dependent protein kinase), was able to reduce the relaxation induced by 4 μM forskolin by about 2.5 times but had no significant effect on the relaxation induced by 160 mM iomeprol. 10 μM of ODQ (an inhibitor of the soluble guanylate cyclase), could reduce the relaxation induced by 10 μM of SNP but not the one induced by 160 mM iomeprol. Moreover, the absence of endothelial cells did not alter the relaxation induced by iomeprol.

Conclusion: The activation of the cAMP and cGMP pathways are not involved in the in vitro relaxation induced by iomeprol in swine renal arteries.

Oxytocin receptor polymorphism and childhood social experiences shape adult personality, brain structure and neural correlates of mentalizing

INTRODUCTION

The oxytocin system is involved in human social behavior and social cognition such as attachment, emotion recognition and mentalizing (i.e. the ability to represent mental states of oneself and others). It is shaped by social experiences in early life, especially by parent-infant interactions. The single nucleotid polymorphism rs53576 in the oxytocin receptor (OXTR) gene has been linked to social behavioral phenotypes.

METHOD

In 195 adult healthy subjects we investigated the interaction of OXTR rs53576 and childhood attachment security (CAS) on the personality traits "adult attachment style" and "alexithymia" (i.e. emotional self-awareness), on brain structure (voxel-based morphometry) and neural activation (fMRI) during an interactive mentalizing paradigm (prisoner's dilemma game; subgroup: n=163).

RESULTS

We found that in GG-homozygotes, but not in A-allele carriers, insecure childhood attachment is - in adulthood - associated with a) higher attachment-related anxiety and alexithymia, b) higher brain gray matter volume of left amygdala and lower volumes in right superior parietal lobule (SPL), left temporal pole (TP), and bilateral frontal regions, and c) higher mentalizing-related neural activity in bilateral TP and precunei, and right middle and superior frontal gyri. Interaction effects of genotype and CAS on brain volume and/or function were associated with individual differences in alexithymia and attachment-related anxiety. Interactive effects were in part sexually dimorphic.

CONCLUSION

The interaction of OXTR genotype and CAS modulates adult personality as well as brain structure and function of areas implicated in salience processing and mentalizing. Rs53576 GG-homozygotes are partially more susceptible to childhood attachment experiences than A-allele carriers.

Neural pathways of embarrassment and their modulation by social anxiety

While being in the center of attention and exposed to other's evaluations humans are prone to experience embarrassment. To characterize the neural underpinnings of such aversive moments, we induced genuine experiences of embarrassment during person-group interactions in a functional neuroimaging study. Using a mock-up scenario with three confederates, we examined how the presence of an audience affected physiological and neural responses and the reported emotional experiences of failures and achievements. The results indicated that publicity induced activations in mentalizing areas and failures led to activations in arousal processing systems. Mentalizing activity as well as attention towards the audience were increased in socially anxious participants. The converging integration of information from mentalizing areas and arousal processing systems within the ventral anterior insula and amygdala forms the neural pathways of embarrassment. Targeting these neural markers of embarrassment in the (para-)limbic system provides new perspectives for developing treatment strategies for social anxiety disorders.

Picky eating and child weight status development: a longitudinal study

BACKGROUND

Children's picky eating behaviour has been linked both to being overweight and underweight. However, the role of parenting practices in this relationship has rarely been investigated. The present study aimed to clarify the direction of the association between picky eating and weight status and to examine the moderating role of food parenting practices.

METHODS

The present study comprised a longitudinal study on the effects of picky eating on child weight status within the KOALA Birth Cohort Study, the Netherlands. Mothers and their children were included in the analyses. Children's picky eating behaviour and food parenting practices were assessed at baseline (child age 5 years). Their weight status was assessed repeatedly until age 9 years. Mixed effects linear and logistic regressions were used to compare picky eaters (n = 403) and non-picky eaters (n = 621) on changes in weight status over the years.

RESULTS

At baseline of age 5 years, picky eaters were slightly shorter, more often underweight and less often overweight than non-picky eaters, whereas energy intake in relation to body weight (kJ kg(-1)) was similar. Picky eaters with a normal weight at baseline had no increased risk of becoming underweight during follow-up until age 9 years, and were less likely to become overweight compared to non-picky eaters. There were no interactions with food parenting practices. The parents of picky eaters more often reported pressuring their child to eat and restrict unhealthy food intake compared to parents of non-picky eaters.

CONCLUSIONS

The association between picky eating and child weight status was not influenced by parenting practices.

The functional -1019C/G HTR1A polymorphism and mechanisms of fear

Serotonin receptor 1A gene (HTR1A) knockout mice show pronounced defensive behaviour and increased fear conditioning to ambiguous conditioned stimuli. Such behaviour is a hallmark of pathological human anxiety, as observed in panic disorder with agoraphobia (PD/AG). Thus, variations in HTR1A might contribute to neurophysiological differences within subgroups of PD/AG patients. Here, we tested this hypothesis by combining genetic with behavioural techniques and neuroimaging. In a clinical multicentre trial, patients with PD/AG received 12 sessions of manualized cognitive-behavioural therapy (CBT) and were genotyped for HTR1A rs6295. In four subsamples of this multicentre trial, exposure behaviour (n=185), defensive reactivity measured using a behavioural avoidance test (BAT; before CBT: n=245; after CBT: n=171) and functional magnetic resonance imaging (fMRI) data during fear conditioning were acquired before and after CBT (n=39). HTR1A risk genotype (GG) carriers more often escaped during the BAT before treatment. Exploratory fMRI results suggest increased activation of the amygdala in response to threat as well as safety cues before and after treatment in GG carriers. Furthermore, GG carriers demonstrated reduced effects of CBT on differential conditioning in regions including the bilateral insulae and the anterior cingulate cortex. Finally, risk genotype carriers demonstrated reduced self-initiated exposure behaviour to aversive situations. This study demonstrates the effect of HTR1A variation on defensive behaviour, amygdala activity, CBT-induced neural plasticity and normalization of defence behaviour in PD/AG. Our results, therefore, translate evidence from animal studies to humans and suggest a central role for HTR1A in differentiating subgroups of patients with anxiety disorders.

Altered top-down and bottom-up processing of fear conditioning in panic disorder with agoraphobia

BACKGROUND

Although several neurophysiological models have been proposed for panic disorder with agoraphobia (PD/AG), there is limited evidence from functional magnetic resonance imaging (fMRI) studies on key neural networks in PD/AG. Fear conditioning has been proposed to represent a central pathway for the development and maintenance of this disorder; however, its neural substrates remain elusive. The present study aimed to investigate the neural correlates of fear conditioning in PD/AG patients.

METHOD

The blood oxygen level-dependent (BOLD) response was measured using fMRI during a fear conditioning task. Indicators of differential conditioning, simple conditioning and safety signal processing were investigated in 60 PD/AG patients and 60 matched healthy controls.

RESULTS

Differential conditioning was associated with enhanced activation of the bilateral dorsal inferior frontal gyrus (IFG) whereas simple conditioning and safety signal processing were related to increased midbrain activation in PD/AG patients versus controls. Anxiety sensitivity was associated positively with the magnitude of midbrain activation.

CONCLUSIONS

The results suggest changes in top-down and bottom-up processes during fear conditioning in PD/AG that can be interpreted within a neural framework of defensive reactions mediating threat through distal (forebrain) versus proximal (midbrain) brain structures. Evidence is accumulating that this network plays a key role in the aetiopathogenesis of panic disorder.

Ethics of mandatory vaccination for healthcare workers

Healthcare workers (HCWs) are at increased risk of contracting infections at work and further transmitting them to colleagues and patients. Immune HCWs would be protected themselves and act as a barrier against the spread of infections and maintain healthcare delivery during outbreaks, but vaccine uptake rates in HCWs have often been low. In order to achieve adequate immunisation rates in HCWs, mandatory vaccination policies are occasionally implemented by healthcare authorities, but such policies have raised considerable controversy. Here we review the background of this debate, analyse arguments for and against mandatory vaccination policies, and consider the principles and virtues of clinical, professional, institutional and public health ethics. We conclude that there is a moral imperative for HCWs to be immune and for healthcare institutions to ensure HCW vaccination, in particular for those working in settings with high-risk groups of patients. If voluntary uptake of vaccination by HCWs is not optimal, patients’ welfare, public health and also the HCW’s own health interests should outweigh concerns about individual autonomy: fair mandatory vaccination policies for HCWs might be acceptable. Differences in diseases, patient and HCW groups at risk and available vaccines should be taken into consideration when adopting the optimal policy.