Implementing a complex mental health intervention in occupational settings: process evaluation of the MENTUPP pilot study

BACKGROUND

According to the Medical Research Council (MRC) framework, the theorisation of how multilevel, multicomponent interventions work and the understanding of their interaction with their implementation context are necessary to be able to evaluate them beyond their complexity. More research is needed to provide good examples following this approach in order to produce evidence-based information on implementation practices.

OBJECTIVES

This article reports on the results of the process evaluation of a complex mental health intervention in small and medium enterprises (SMEs) tested through a pilot study. The overarching aim is to contribute to the evidence base related to the recruitment, engagement and implementation strategies of applied mental health interventions in the workplace.

METHOD

The Mental Health Promotion and Intervention in Occupational Settings (MENTUPP) intervention was pilot tested in 25 SMEs in three work sectors and nine countries. The evaluation strategy of the pilot test relied on a mixed-methods approach combining qualitative and quantitative research methods. The process evaluation was inspired by the RE-AIM framework and the taxonomy of implementation outcomes suggested by Proctor and colleagues and focused on seven dimensions: reach, adoption, implementation, acceptability, appropriateness, feasibility and maintenance.

RESULTS

Factors facilitating implementation included the variety of the provided materials, the support provided by the research officers (ROs) and the existence of a structured plan for implementation, among others. Main barriers to implementation were the difficulty of talking about mental health, familiarisation with technology, difficulty in fitting the intervention into the daily routine and restrictions caused by COVID-19.

CONCLUSIONS

The results will be used to optimise the MENTUPP intervention and the theoretical framework that we developed to evaluate the causal mechanisms underlying MENTUPP. Conducting this systematic and comprehensive process evaluation contributes to the enhancement of the evidence base related to mental health interventions in the workplace and it can be used as a guide to overcome their contextual complexity.

TRIAL REGISTRATION NUMBER

ISRCTN14582090.

Outcome assessment of a complex mental health intervention in the workplace. Results from the MENTUPP pilot study

OBJECTIVE

Multicomponent interventions are recommendable to achieve the greatest mental health benefits, but are difficult to evaluate due to their complexity. Defining long-term outcomes, arising from a Theory of Change (ToC) and testing them in a pilot phase, is a useful approach to plan a comprehensive and meaningful evaluation later on. This article reports on the pilot results of an outcome evaluation of a complex mental health intervention and examines whether appropriate evaluation measures and indicators have been selected ahead of a clustered randomised control trial (cRCT).

METHODS

The MENTUPP pilot is an evidence-based intervention for Small and Medium Enterprises (SMEs) active in three work sectors and nine countries. Based on our ToC, we selected the MENTUPP long-term outcomes, which are reported in this article, are measured with seven validated scales assessing mental wellbeing, burnout, depression, anxiety, stigma towards depression and anxiety, absenteeism and presenteeism. The pilot MENTUPP intervention assessment took place at baseline and at 6 months follow-up.

RESULTS

In total, 25 SMEs were recruited in the MENTUPP pilot and 346 participants completed the validated scales at baseline and 96 at follow-up. Three long-term outcomes significantly improved at follow-up (p < 0.05): mental wellbeing, symptoms of anxiety, and personal stigmatising attitudes towards depression and anxiety.

CONCLUSIONS

The results of this outcome evaluation suggest that MENTUPP has the potential to strengthen employees' wellbeing and decrease anxiety symptoms and stigmatising attitudes. Additionally, this study demonstrates the utility of conducting pilot workplace interventions to assess whether appropriate measures and indicators have been selected. Based on the results, the intervention and the evaluation strategy have been optimised.

Implementation and evaluation of a multi-level mental health promotion intervention for the workplace (MENTUPP): study protocol for a cluster randomised controlled trial

BACKGROUND

Well-organised and managed workplaces can be a source of wellbeing. The construction, healthcare and information and communication technology sectors are characterised by work-related stressors (e.g. high workloads, tight deadlines) which are associated with poorer mental health and wellbeing. The MENTUPP intervention is a flexibly delivered, multi-level approach to supporting small- and medium-sized enterprises (SMEs) in creating mentally healthy workplaces. The online intervention is tailored to each sector and designed to support employees and leaders dealing with mental health difficulties (e.g. stress), clinical level anxiety and depression, and combatting mental health-related stigma. This paper presents the protocol for the cluster randomised controlled trial (cRCT) of the MENTUPP intervention in eight European countries and Australia.

METHODS

Each intervention country will aim to recruit at least two SMEs in each of the three sectors. The design of the cRCT is based on the experiences of a pilot study and guided by a Theory of Change process that describes how the intervention is assumed to work. SMEs will be randomly assigned to the intervention or control conditions. The aim of the cRCT is to assess whether the MENTUPP intervention is effective in improving mental health and wellbeing (primary outcome) and reducing stigma, depression and suicidal behaviour (secondary outcome) in employees. The study will also involve a process and economic evaluation.

CONCLUSIONS

At present, there is no known multi-level, tailored, flexible and accessible workplace-based intervention for the prevention of non-clinical and clinical symptoms of depression, anxiety and burnout, and the promotion of mental wellbeing. The results of this study will provide a comprehensive overview of the implementation and effectiveness of such an intervention in a variety of contexts, languages and cultures leading to the overall goal of delivering an evidence-based intervention for mental health in the workplace.

TRIAL REGISTRATION

Please refer to Item 2a and registration ISRCTN14104664. Registered on 12th July 2022.

Promoting employee wellbeing and preventing non-clinical mental health problems in the workplace: a preparatory consultation survey

BACKGROUND

Small and medium-sized enterprises (SMEs) face major financial losses due to mental health issues affecting employees at all levels but seldom apply programs to promote wellbeing and prevent mental health issues among employees. To support the development of a multi-country workplace-based mental health intervention for SMEs (MENTUPP), a multinational consultation study was conducted. The study aimed to examine the experiences and needs of SMEs concerning the promotion of employee wellbeing, and the prevention and management of non-clinical mental health problems in workplaces.

METHODS

A survey consisting of open and closed questions was designed to assess key informants' opinion about the acceptability, the use, and the implementation of interventions to promote wellbeing and prevent mental health issues in the workplace. Academic experts and representatives of SME organisations, specific sector organisations, labour or advocacy groups, and occupational health organisations across the nine MENTUPP intervention countries (eight European countries and Australia) were invited to complete the survey. Data were collected via the online platform Qualtrics. Sixty-five of 146 informants responded, representing a 44.5% response rate. Descriptive statistics were used to analyse the quantitative data and qualitative data were analysed through thematic analysis.

RESULTS

Measures to create mentally healthy workplaces were most used in SMEs, while more specific mental health interventions, such as training staff on how to promote wellbeing, were hardly used. Managers lack resources to implement mental health interventions and are concerned about employees spending too much time on these interventions during working hours. Receiving information about the economic benefits of mental health interventions and hearing successful testimonials from other SMEs can persuade managers otherwise. Employees have concerns about confidentiality, discrimination and stigma, and career opportunities when using such interventions.

CONCLUSIONS

The study identifies a variety of challenges, needs and possibilities related to implementing mental health interventions in SMEs. Employers need to be convinced that investing in mental health in the workplace is worth their time and money. This requires more studies on the (cost-)effectiveness of mental health interventions. Once employers are engaged, their knowledge and competencies about how to implement such interventions should be increased and privacy concerns of employees to participate in them should be addressed.

Developing a framework for evaluation: a Theory of Change for complex workplace mental health interventions

BACKGROUND

There is a gap between the necessity of effective mental health interventions in the workplace and the availability of evidence-based information on how to evaluate them. The available evidence outlines that mental health interventions should follow integrated approaches combining multiple components related to different levels of change. However, there is a lack of robust studies on how to evaluate multicomponent workplace interventions which target a variety of outcomes at different levels taking into account the influence of different implementation contexts.

METHOD

We use the MENTUPP project as a research context to develop a theory-driven approach to facilitate the evaluation of complex mental health interventions in occupational settings and to provide a comprehensive rationale of how these types of interventions are expected to achieve change. We used a participatory approach to develop a ToC involving a large number of the project team representing multiple academic backgrounds exploiting in tandem the knowledge from six systematic reviews and results from a survey among practitioners and academic experts in the field of mental health in SMEs.

RESULTS

The ToC revealed four long-term outcomes that we assume MENTUPP can achieve in the workplace: 1) improved mental wellbeing and reduced burnout, 2) reduced mental illness, 3) reduced mental illness-related stigma, and 4) reduced productivity losses. They are assumed to be reached through six proximate and four intermediate outcomes according to a specific chronological order. The intervention consists of 23 components that were chosen based on specific rationales to achieve change on four levels (employee, team, leader, and organization).

CONCLUSIONS

The ToC map provides a theory of how MENTUPP is expected to achieve its anticipated long-term outcomes through intermediate and proximate outcomes assessing alongside contextual factors which will facilitate the testing of hypotheses. Moreover, it allows for a structured approach to informing the future selection of outcomes and related evaluation measures in either subsequent iterations of complex interventions or other similarly structured programs. Hence, the resulting ToC can be employed by future research as an example for the development of a theoretical framework to evaluate complex mental health interventions in the workplace.

Workplace interventions to reduce depression and anxiety in small and medium-sized enterprises: A systematic review

BACKGROUND

Depression and anxiety are the most prevalent mental health difficulties in the workplace, costing the global economy $1 trillion each year. Evidence indicates that symptoms may be reduced by interventions in the workplace. This paper is the first to systematically review psychosocial interventions for depression, anxiety, and suicidal ideation and behaviours in small-to medium-size enterprises (SMEs).

METHODS

A systematic search following PRISMA guidelines, registered in PROSPERO (CRD42020156275), was conducted for psychosocial interventions targeting depression, anxiety, and suicidal ideation/behaviour in SMEs. The PubMed, PsycINFO, Scopus, and two specific occupational health databases were searched, as well as four databases for grey literature, without time limit until 2nd December 2019.

RESULTS

In total, 1283 records were identified, 70 were retained for full-text screening, and seven met the inclusion criteria: three randomised controlled trials (RCTs), three before and after designs and one non-randomised trial, comprising 5111 participants. Study quality was low to moderate according to the Quality Assessment Tool for Quantitative Studies. Five studies showed a reduction in depression and anxiety symptoms using techniques based on cognitive behavioural therapy (CBT), two reported no significant change.

LIMITATIONS

Low number and high heterogeneity of interventions and outcomes, high attrition and lack of rigorous RCTs.

CONCLUSIONS

Preliminary evidence indicates CBT-based interventions can be effective in targeting symptoms of depression and anxiety in SME employees. There may be unique challenges to implementing programmes in SMEs. Further research is needed in this important area.

Evidence for implementation of interventions to promote mental health in the workplace: a systematic scoping review protocol

BACKGROUND

Mental health problems are common in the working population and represent a growing concern internationally, with potential impacts on workers, organisations, workplace health and compensation authorities, labour markets and social policies. Workplace interventions that create workplaces supportive of mental health, promote mental health awareness, destigmatise mental illness and support those with mental disorders are likely to improve health and economical outcomes for employees and organisations. Identifying factors associated with successful implementation of these interventions can improve intervention quality and evaluation, and facilitate the uptake and expansion. Therefore, we aim to review research reporting on the implementation of mental health promotion interventions delivered in workplace settings, in order to increase understanding of factors influencing successful delivery.

METHODS AND ANALYSIS

A scoping review will be conducted incorporating a stepwise methodology to identify relevant literature reviews, primary research and grey literature. This review is registered with Research Registry (reviewregistry897). One reviewer will conduct the search to identify English language studies in the following electronic databases from 2008 through to July 1, 2020: Scopus, PROSPERO, Health Technology Assessments, PubMed, Campbell Collaboration, Joanna Briggs Library, PsycINFO, Web of Science Core Collection, CINAHL and Institute of Occupational Safety and Health (IOSH). Reference searching, Google Scholar, Grey Matters, IOSH and expert contacts will be used to identify grey literature. Two reviewers will screen title and abstracts, aiming for 95% agreement, and then independently screen full texts for inclusion. Two reviewers will assess methodological quality of included studies using the Mixed Methods Appraisal Tool and extract and synthesize data in line with the RE-AIM framework, Nielson and Randall's model of organisational-level interventions and Moore's sustainability criteria, if the data allows. We will recruit and consult with international experts in the field to ensure engagement, reach and relevance of the main findings.

DISCUSSION

This will be the first systematic scoping review to identify and synthesise evidence of barriers and facilitators to implementing mental health promotion interventions in workplace settings. Our results will inform future evaluation studies and randomised controlled trials and highlight gaps in the evidence base.

SYSTEMATIC REVIEW REGISTRATION

Research Registry ( reviewregistry897 ).

A rare presentation of small diaphragmatic epidermoid cyst with extremely elevated serum CA19-9 level

Epidermoid cysts are rare lesions that can occur anywhere in the body. They are associated with elevated serum levels of CA 19-9. The spleen represents the most common site of intra-abdominal localisation. Only two cases of diaphragmatic epidermoid cyst are reported in the literature. We present the case of a 61-year-old woman with a small suprasplenic subdiaphragmatic cyst discovered during the investigation of left flank pain. The establishment of an adequate diagnosis was challenging due to the difficulty in specifying the exact localisation of the cyst, the extremely elevated CA 19-9 level of 19,000 and the high uptake on 18-fluoro-2-deoxy-D-glucose positron emission tomography. The definitive diagnosis followed complete surgical excision. Intra-abdominal epidermoid cysts are usually discovered incidentally on imaging for another reason. The cyst is lined by squamous epithelium responsible for the secretion of CA 19-9. The elevation of serum CA 19-9 is due to small rupture or increased intraluminal pressure followed by diffusion to the bloodstream. Surgery with en-bloc resection represents the optimal treatment to avoid any risk of recurrence. The definitive diagnosis is established by demonstrating positive immunohistopathological staining of epithelial cell to CA 19.9.

Effectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression

BACKGROUND

General Practitioners (GPs) are well placed as gatekeepers for managing depression and suicidal ideation but not always well prepared. Capacity building has therefore been recommended as a useful strategy for suicide prevention. This study aimed to examine whether GPs' knowledge and attitudes towards and confidence to deal with depression and suicide improve after following a training program.

METHODS

As part of the OSPI-Europe multilevel intervention, a standardized training on depression and suicide was provided to 208 GPs in three European countries. Core outcomes were assessed using the Depression Attitude Questionnaire, the Attitude towards Suicide Prevention Scale, and the Morriss Confidence Scale. Data were collected before and after training, and at three to six months follow-up.

RESULTS

At baseline, GPs demonstrated various stigmatizing attitudes towards depression and low optimism about the therapeutic treatment of depression. They showed moderately positive attitudes towards suicide prevention but felt little confident in dealing with depression and suicide in daily practice. The training resulted in improved knowledge, attitudes and confidence regarding depression and suicide and their prevention and treatment. At follow-up, only the increase in confidence to deal with depression and suicide was sustained.

LIMITATIONS

The Depression Attitude Questionnaire has rather weak psychometric properties. Other external factors may have contributed to the observed training effects as the study included no control group.

CONCLUSIONS

The OSPI-Europe training program was able to improve the GPs' attitudes towards suicide prevention, several attitudes towards depression and its treatment as well as the GPs' confidence to deal with depression and suicide in everyday practice. At follow, only the GPs' confidence to deal with depression and suicide was preserved.

[Evaluation of stone size before flexible ureteroscopy: Which measurement is best?]

PURPOSE

To retrospectively assess the clinical utility in ureteroscopy (URS) planning of radiological parameters as predictor of stone-free status after a single flexible ureteroscopy.

MATERIAL

Sixty-seven patients with renal stones treated by flexible URS were retrospectively evaluated. To assess the clinical utility of radiological parameters, relationships between stone-free (SF) status and stone burden (maximal diameter, calculated area, calculated volume, cumulative diameter, and tridimentionnal volume [V3D]) were analyzed using the area under the receiver operating characteristics curve and logistic regression.

RESULTS

Maximal diameter (AUC=0.75), calculated area (AUC 0.79), calculated volume (AUC=0.79), cumulative diameter (AUC=0.80) and tridimensional volume (AUC=0.82) revealed ability to predict SF status after URS.

CONCLUSION

Stone burden evaluation is critical in predicting SF status after a single URS. Planar and volumetric measurements showed equal ability to predict SF status. V3D is more accurate but diameter measurement remains easier in clinical practice.

LEVEL OF EVIDENCE

4.

Prevalence and impact of childhood adversities and post-traumatic stress disorder in women with fibromyalgia and chronic widespread pain

OBJECTIVE

This study investigates the prevalence of different types of childhood adversities (CA) and posttraumatic stress disorder (PTSD) in female patients with Fibromyalgia or Chronic Widespread Pain (FM/CWP) compared to patients with Functional Dyspepsia (FD) and achalasia. In FM/CWP, we also investigated the association between CA and PTSD on the one hand and pain severity on the other.

METHODS

Patient samples consisted of 154 female FM/CWP, 83 female FD and 53 female achalasia patients consecutively recruited from a tertiary care hospital. Well-validated self-report questionnaires were used to investigate CA and PTSD.

RESULTS

Forty-nine per cent of FM/CWP patients reported at least 1 type of CA, compared to 39.7% of FD patients and 23.4% of achalasia patients (p < 0.01). The prevalence of CA did not differ significantly between FM/CWP and FD, but both groups had a higher prevalence of CA compared to both achalasia and healthy controls (p < 0.01). FM/CWP patients were six times more likely to report PTSD than both FD (p < 0.001) and achalasia (p < 0.001) patients.

CONCLUSION

In FM/CWP, PTSD comorbidity, but not CA, was associated with self-reported pain severity and PTSD severity mediated the relationship between CA and pain severity. In summary, the prevalence of CA is higher in FM/CWP compared to achalasia, but similar to FD. However, PTSD is more prevalent in FM/CWP compared to FD and associated with higher pain intensity in FM/CWP.

SIGNIFICANCE

As expected and has been shown in other functional disorders, we found elevated levels of childhood adversity in FM/CWP patients. Results of this study however suggest that the impact of childhood adversity (i.e. whether such events have led to the development of PTSD symptoms), rather than the mere presence of such adversity, is of crucial importance in FM/CWP patients. Screening for PTSD symptoms should be an essential part of the assessment process in patients suffering from FM/CWP, and both prevention and intervention efforts should take into account PTSD symptoms and their impact on pain severity and general functioning.

Effectiveness of community facilitator training in improving knowledge, attitudes, and confidence in relation to depression and suicidal behavior: results of the OSPI-Europe intervention in four European countries

BACKGROUND

Community facilitators (CFs), such as teachers, nurses and social workers, are well placed as gatekeepers for depression and suicidal behavior, but not properly prepared to provide preventive and supportive services. The current study aimed: (1) to improve CFs' attitudes toward depression, knowledge on suicide, and confidence to detect suicidal behavior in four European countries and (2) to identify specific training needs across regions and CF groups.

METHODS

A standardized training program was provided to 1276 CFs in Germany, Hungary, Ireland, and Portugal. Attitudes toward depression, knowledge about suicide, and confidence in identifying suicidal persons were assessed before training, after training, and at three to six months follow-up. Additionally, several participants' characteristics were registered.

RESULTS

At baseline, CFs showed relatively favorable attitudes toward depression, but limited knowledge on suicide, and little confidence to identify suicidal behavior. Basic skills strongly differed across CF groups and countries. For example, in Germany, carers for the elderly, nurses, teachers, and managers were most in need of training, while in Portugal pharmacists and the clergy appeared to be important target groups. Most importantly, the training program improved the competencies of CF groups across countries and these improvements were sustained after three to six months. CFs with low basic skills benefited most of the training.

LIMITATIONS

The observed training effects could be influenced by other external factors as our results are based upon a pre-post comparison with no control group.

CONCLUSIONS

Gatekeeper trainings in community settings are successful in improving knowledge, reshaping attitudes, and boosting the confidence of gatekeepers. The most effective strategy to achieve the preferred objectives is to target those CF groups that are most in need of training and to tailor the content of the training program to the individual needs of the target group.

Fear conditioning following a unilateral anterior temporal lobectomy: reduced autonomic responding and stimulus contingency knowledge

Animal research demonstrated that during fear conditioning the amygdala plays a central role in forming an association between the conditioned stimulus (CS) and the unconditioned stimulus (US). Lesion studies conducted in patients who underwent a unilateral anterior temporal lobe resection, however; yielded contradictory findings. To date, it remains unclear whether amygdala damage only affects fear-conditioned startle responding or impairs both the latter and fear-conditioned skin conductance responding (SCR). Moreover inconsistency exists regarding the preservation of contingency knowledge in amygdala-damaged patients. In the current study, a differential fear conditioning task was presented to a unilaterally amygdala-damaged patient group and a healthy control group, recording fear-potentiated startle responses along with SCRs. Retrospectively, the valence of the CSs and contingency awareness was assessed. Unlike the control group, unilaterally amygdala-damaged patients showed neither in their SCRs nor in their valence ratings an effect of fear conditioning. The startle data, however, yielded in none of the two test groups fear-conditioned responding. Finally, considerably fewer patients (37.5%) than controls (95%) acquired correct memory of the presented contingency. Based on these findings we concluded that the fear conditioning impairment in amygdala-damaged patients was not restricted to SCRs, but also affected valence ratings and memory of the presented contingency. A broader theory of the amygdala as relevance detector is proposed in order to account for the diverse neurological findings obtained so far.

Classically conditioned fear responses are preserved following unilateral temporal lobectomy in humans when concurrent US-expectancy ratings are used

Previous lesion studies demonstrate that patients who underwent a unilateral temporal lobe resection show impaired skin conductance responding (SCR) to aversively conditioned stimuli. The aim of the current lesion study was to examine whether the amygdala is also critically involved in differential SCR during a more explicit form of fear learning. A simple discrimination task was presented to a unilaterally amygdala-damaged patient group and a control group, in which one neutral stimulus was always followed by an electric shock (CS+), whereas a second stimulus always appeared alone (CS-). To direct attention towards the stimulus contingencies, participants were asked to predict the occurrence of the shock continuously throughout the whole task. The results revealed that patients and controls rapidly acquired contingency knowledge as measured by the online US-expectancy ratings. Crucially, both test groups showed differential SCRs during CS+ and CS- trials. Thus, contrary to earlier findings, robust conditioned SCRs can be obtained in patients with unilateral temporal lobe resection as long as they are able to acquire explicit stimulus contingency knowledge. The two-level account of Ohman and Mineka [Ohman, A., & Mineka, S. (2001). Fears, phobias, and preparedness: Toward an evolved module of fear and fear learning. Psychological Review, 108, 483-522] is proposed in order to explain the diverse lesion data obtained so far.

Automatic affective stimulus processing is intact after unilateral resection of the anterior temporal lobe in humans

Only hundreds of milliseconds after an incoming stimulus is perceived, we make an evaluation of whether it is good or bad. This evaluation seems to occur automatically and can significantly influence behavior. According to several functional imaging studies, the amygdala, which is localized in the temporal lobes of the brain, is an important structure for the automatic processing of affective stimuli. To investigate how critical a role the amygdala plays in this process, we had 20 participants with unilateral resection of the temporal lobe and 20 controls perform an affective priming task. Both controls and patients demonstrated shorter response latencies on trials where prime and target had the same valence than on trials where prime and target had the opposite valence. This finding is generally known as the affective priming effect and is considered to reflect automatic stimulus evaluation. More specifically, it is assumed that the valence of the prime stimulus is activated automatically and exerts an influence on the speed by which the target stimulus is evaluated. Given that the affective priming effect is equally large in both groups, our results suggest that the automatic processing of stimulus valence is intact in participants who sustained unilateral resection of the temporal lobe.

Pyocolpos in an elderly woman

BACKGROUND

Pyocolpos, an uncommon accumulation of pus in the vagina, has not been previously reported in an elderly woman.

CASE

A 76-year-old woman was hospitalised with post-menopausal bleeding and fever. Pelvic examination revealed an obstructed vagina. A gadolinium MRI showed pyocolpos. After surgical drainage, the patient rapidly recovered.

CONCLUSION

Pyocolpos in elderly woman may appear spontaneously without any history of gynaecologic cancer or trauma.

Evaluative conditioning is intact after unilateral resection of the anterior temporal lobe in humans

Several lesion and functional imaging studies conducted in animals and humans suggest that structures within the amygdaloid nuclear complex (ANC) are important for the occurrence of fear conditioning. Whether this brain structure is also critical for evaluative conditioning, has been investigated less frequently. In the current experiment, a group of participants with unilateral resection of the anterior temporal lobe and a control group received a differential evaluative flavor-taste conditioning task. In the pre-acquisition phase, two fruit flavors (the conditioned stimuli (CSs)) were presented and participants were instructed to evaluate both. In the subsequent acquisition phase, one of these fruit flavors (CS+) was presented together with a bad tasting substance Tween20 (polysorbate 20, the US), while the other flavor (CS-) was never paired with Tween20. Finally, in the post-acquisition phase, the two flavors were presented again without Tween20 and participants were asked to evaluate both of them for a last time. The control group as well as the lesion group rated the CS+ in the post-acquisition phase less favorable than in the pre-acquisition phase, while the ratings of the CS- remained the same in both phases. We clearly demonstrated evaluative conditioning in both test groups. Because the lesion group had still one intact ANC it would be premature, however, to conclude that the ANC is not involved in evaluative conditioning. We conclude that despite evidence for impaired fear conditioning, unilateral damage to the ANC does not impair evaluative conditioning.

Pancréatites chroniques et inflammatoires : apport des techniques d’imagerie en coupe

The role of diagnostic imaging in chronic and inflammatory pancreatitis is to detect structural changes of the ducts and pancreatic parenchyma, to assess the functional integrity of the gland, to detect associated complications, and to assist in management. These goals may be achieved using helical CT and MR imaging with secretin stimulation. In this review, the advantages of each technique are discussed and illustrated.

The role of PET scan in the preoperative management of oesophageal cancer

AIM

The aim of this study was to evaluate the role of the 18F-FDG-PET in the preoperative evaluation of patients with oesophageal or gastro-oesophageal junction (GEJ) cancer and to define its impact on therapeutic management.

PATIENTS AND METHODS

This study included 58 patients with biopsy proven oesophageal or GEJ cancer who underwent PET in addition to the conventional diagnostic work-up. The sensitivity, specificity and accuracy of CT and PET were calculated for detection of tumour and distant metastases.

RESULTS

The sensitivity, specificity and accuracy of tumour detection were, respectively, 84, 100 and 84% for CT and 87, 100 and 87% for PET (p=ns). PET permitted detection of distant metastases, which were not seen on CT in seven patients. In two patients, a second primary tumour was detected on PET.

CONCLUSIONS

The sensitivity of PET for loco regional lymph nodes detection is low. The major clinical impact is the detection of distant metastases.

Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter

BACKGROUND

We investigated the feasibility, safety, and efficacy of laparoscopic antireflux surgery (LARS) after failure of Enteryx injection in the lower esophageal sphincter for the treatment of gastroesophageal reflux disease (GERD).

METHODS

Four patients underwent LARS after failure of Enteryx injection. Particular care was taken during the procedure to identify unusual material or fibrosis.

RESULTS

All patients underwent LARS successfully. In three patients, tight adhesions with fibrous tissues and black foreign material were observed around the esophagus. No complications occurred during the procedures. The postoperative period was uneventful and functional results were excellent.

CONCLUSION

LARS following Enteryx injection is feasible. Careful dissection is mandatory to avoid operative complications. Both techniques may be considered as options for treating GERD.

Biliary pleural fistula as a complication of radiofrequency ablation for liver metastasis

Radiofrequency ablation (RFA) recently emerged as an efficient and safe local ablative method to treat unresecable liver tumours. Currently however, the full spectrum of potential complications of RFA remains undetermined. We report a case of severe biliary complication, associating main bile duct stricture and biliary pleural fistula, arising after extensive RFA for unresectable liver metastasis of central location. Treatment consisted of external drainage of the pleural effusion and internal endoscopic drainage via a biliary stenting. This description of a life-threatening complication emphazises the need to better knowledge of the contraindications of RFA, particularly for the treatment of large tumours at proximity of main bile ducts.

Laparoscopic adjustable silicone gastric banding: radiological appearances of a new surgical treatment for morbid obesity

BACKGROUND

The purpose of this report is to describe the radiologic appearances of laparoscopic adjustable silicone gastric banding (LASGB), a new surgical treatment for morbid obesity. In this procedure, a silicone band is fastened around the fundus, delimitating a small proximal gastric pouch and stoma. The inner surface of the band is inflatable and connected by a thin silicone tube to an access port. This allows postoperative stoma size adjustment by puncturing the port and injecting or withdrawing saline solution.

METHODS

One hundred eighty patients underwent LASGB. A radiologic study protocol was established and performed in all patients, including preoperative double-contrast upper gastrointestinal (GI) series and single-contrast upper GI series on the first postoperative day and 1 month after surgery. Radiologic evaluation was also performed at each band adjustment and in case of persistent vomiting or inadequate weight loss.

RESULTS

Postoperative stoma adjustment was performed in all patients. The optimal volume of saline was 1-4.5 mL. Percutaneous puncture of the port was impossible in three patients because of an inverted port. We observed 15 cases of pouch dilatation with stomal obstruction requiring reoperation. There were also nine cases of spontaneous band deflation caused by leaking reservoir in five cases and by disconnection between the connecting tube and the port in the other four cases.

CONCLUSIONS

Because radiologic evaluation is necessary after surgery and for band adjustments, radiologists are involved in the postoperative follow-up and may be asked to perform those adjustments themselves.

Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research

OBJECTIVE

A randomised, controlled clinical trial was performed to study the long-term effect of gradual withdrawal from benzodiazepines on the daily functioning of residents of homes for the elderly. The planned sample size was not achieved due to recruitment and follow-up problems.

RESULTS

The results in this small sample nevertheless suggest that gradual withdrawal from benzodiazepines is possible in residents of homes for the elderly, and that it can have a positive effect on their daily functioning. No major withdrawal symptoms were observed, although there was a decrease in sleep quality during withdrawal.

CONCLUSION

The findings are promising for further research, but researchers should anticipate the problems inherent in executing a trial with institutionalised elderly subjects.

Generation of a monoclonal antibody to the carboxy-terminal domain of tau by immunization with the amino-terminal domain of the amyloid precursor protein

A fusion protein between beta-galactosidase and the amino-terminal domain of amyloid precursor protein (APP) was used as an immunogen for the production of monoclonal antibodies. One of these antibodies, the 5D12 monoclonal antibody, labeled the neurofibrillary tangles (NFT) by immunohistochemistry, as well as isolated paired helical filaments (PHF) in electron microscopy. In immunoassay, the ascitic fluid produced by the 5D12 clone was demonstrated to contain a high titer of antibodies to heat-stable microtubule associated proteins (MAPs). By immunoblotting, the proteins recognized in heat-stable MAPs were found to correspond to tau proteins. The 5D12 antibody recognized normal tau isolated from rat and human brain homogenates, and PHF-tau isolated from the brain of patients with Alzheimer's disease (AD). By immunoblotting, the 5D12 antibody also recognized the full-length recombinant tau protein but not the fusion protein used as an immunogen. The immunoreactivity of the 5D12 antibody with tau was completely abolished when the half-carboxy domain of tau, containing the tubulin-binding repeats, was removed. This study demonstrates that the use of the amino-terminal domain of APP as an immunogen led to the generation of a monoclonal antibody to the half-carboxy domain of tau.