The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial

Importance

Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments.

Objective

To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders.

Design, Setting, and Participants

From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat.

Interventions

The UP or SDPs.

Main Outcomes and Measures

Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs.

Results

Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, -0.93; 95% CI, -1.29 to -0.57) and SDPs (Cohen d, -1.08; 95% CI, -1.43 to -0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, -0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, -0.39 to 0.70) indicated statistical equivalence between the UP and SDPs.

Conclusions and Relevance

The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders.

Trial Registration

clinicaltrials.gov Identifier: NCT01243606.

Positron emission tomography study of voluntary saccadic eye movements and spatial working memory

1. The purpose of this study is to define the cortical regions that subserve voluntary saccadic eye movements and spatial working memory in humans. 2. Regional cerebral blood flow (rCBF) during performance of oculomotor tasks was measured with [15O]-H2O positron emission tomography (PET). Eleven well-trained, healthy young adults performed the following tasks: visual fixation, visually guided saccades, antisaccades (a task in which subjects made saccades away from rather than toward peripheral targets), and either an oculomotor delayed response (ODR, a task requiring memory-guided saccades after a delay period) or a conditional antisaccade task (a task in which the color of the peripheral target determined whether a saccade toward or away from the target was required). An additional six subjects performed a sequential hand movement task to compare localization of hand-related motor cortex and the frontal eye fields (FEFs) and of the hand- and eye-movement-related regions of the supplementary motor area (SMA). 3. Friston's statistical parametric mapping (SPM) method was used to identify significant changes in rCBF associated with task performance. Because SPM does not take advantage of the anatomic information available in magnetic resonance (MR) scans, each subject's PET scan was registered to that individual's MR scan, after which all PET and MR studies were transformed to conform to a standard reference MR image set. Subtraction images were visually inspected while overlayed on the reference MR scan to which PET images had been aligned, in order to confirm anatomic localization of significant rCBF changes. 4. Compared with visual fixation, performing visually guided saccades led to a significant bilateral activation in FEF, cerebellum, striate cortex, and posterior temporal cortex. Right posterior thalamus activation was also observed. 5. The visually guided saccade task served as the comparison task for the ODR, antisaccade, and conditional antisaccade tasks for identification of task-related changes in rCBF beyond those associated with saccade execution. Performance on the ODR task was associated with a bilateral increase of rCBF in FEFs, SMA, dorsolateral prefrontal cortex (DLPFC), and posterior parietal cortex. The cortical regions of increased regional blood flow during the ODR task also showed increased rCBF during the antisaccade task; however, FEF and SMA activations were significant only in the right hemisphere. These findings closely parallel those of single-cell recording studies with behaving monkeys in indicating that FEF, DLPFC, SMA, and posterior parietal cortex perform computational activity for voluntary purposive saccades. 6. Comparison of PET scans obtained during performance of eye movement and hand movement tasks indicated that peak activations in FEF were located approximately 2 cm lateral and 1 cm anterior to those of hand-related motor cortex. The oculomotor area of SMA, the supplementary eye field (SEF), was located approximately 7-8 mm anterior and superior to the hand-related area of SMA. 7. During performance of antisaccade and ODR tasks, rCBF was significantly lower in ventromedial prefrontal cortex (PFC), along the rectus gyrus, and in ventral anterior cingulate cortex than during the visually guided saccade and fixation tasks. During the antisaccade task, the ventral region of lower rCBF involved medial structures including left ventral striatum and bilateral medial temporal-limbic cortex. During the ODR task, the ventral aspect of the region of lower rCBF extended laterally, rather than medially, to include the temporal poles. The lower blood flow observed in ventromedial PFC during both the antisaccade and ODR tasks, relative to the visually guided saccade and fixation tasks, suggests that modulation of output from ventromedial PFC to limbic cortex and the striatum may play a role in the voluntary control of saccadic eye movements, possibly in the suppression of responses that would interrupt

Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial

This study further evaluates the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). A diagnostically heterogeneous clinical sample of 37 patients with a principal anxiety disorder diagnosis was enrolled in a randomized controlled trial (RCT) involving up to 18 sessions of treatment and a 6-month follow-up period. Patients were randomly assigned to receive either immediate treatment with the UP (n=26) or delayed treatment, following a 16-week wait-list control period (WLC; n=11). The UP resulted in significant improvement on measures of clinical severity, general symptoms of depression and anxiety, levels of negative and positive affect, and a measure of symptom interference in daily functioning across diagnoses. In comparison, participants in the WLC condition exhibited little to no change following the 16-week wait-list period. The effects of UP treatment were maintained over the 6-month follow-up period. Results from this RCT provide additional evidence for the efficacy of the UP in the treatment of anxiety and comorbid depressive disorders, and provide additional support for a transdiagnostic approach to the treatment of emotional disorders.

What is eating you? Stress and the drive to eat

Non-human animal studies demonstrate relationships between stress and selective intake of palatable food. In humans, exposure to laboratory stressors and self-reported stress are associated with greater food intake. Large studies have yet to examine chronic stress exposure and eating behavior. The current study assessed the relationship between stress (perceived and chronic), drive to eat, and reported food frequency intake (nutritious food vs. palatable non-nutritious food) in women ranging from normal weight to obese (N=457). Greater reported stress, both exposure and perception, was associated with indices of greater drive to eat-including feelings of disinhibited eating, binge eating, hunger, and more ineffective attempts to control eating (rigid restraint; r's from .11 to .36, p's<.05). These data suggest that stress exposure may lead to a stronger drive to eat and may be one factor promoting excessive weight gain. Relationships between stress and eating behavior are of importance to public health given the concurrent increase in reported stress and obesity rates.

Human smooth pursuit: stimulus-dependent responses

We studied pursuit eye movements in seven normal human subjects with the scleral search-coil technique. The initial eye movements in response to unpredictable changes in target motion were analyzed to determine the effect of target velocity and position on the latency and acceleration of the response. By restricting our analysis to the presaccadic portion of the response we were able to eliminate any saccadic interactions, and the randomized stimulus presentation minimized anticipatory responses. This approach has allowed us to characterize a part of the smooth-pursuit system that is dependent primarily on retinal image properties. The latency of the smooth-pursuit response was very consistent, with a mean of 100 +/- 5 ms to targets moving 5 degrees/s or faster. The responses were the same whether the velocity step was presented when the target was initially stationary or after tracking was established. The latency did increase for lower velocity targets; this increase was well described by a latency model requiring a minimum target movement of 0.028 degrees, in addition to a fixed processing time of 98 ms. The presaccadic accelerations were fairly low, and increased with target velocity until an acceleration of about 50 degrees/s2 was reached for target velocities of 10 degrees/s. Higher velocities produced only a slight increase in eye acceleration. When the target motion was adjusted so that the retinal image slip occurred at increasing distances from the fovea, the accelerations declined until no presaccadic response was measurable when the image slip started 15 degrees from the fovea. The smooth-pursuit response to a step of target position was a brief acceleration; this response occurred even when an oppositely directed velocity stimulus was present. The latency of the pursuit response to such a step was also approximately 100 ms. This result seems consistent with the idea that sensory pathways act as a low-pass spatiotemporal filter of the retinal input, effectively converting position steps into briefly moving stimuli. There was a large asymmetry in the responses to position steps: the accelerations were much greater when the position step of the target was away from the direction of tracking, compared with steps in the direction of tracking. The asymmetry may be due to the addition of a fixed slowing of the eyes whenever the target image disappears from the foveal region. When saccades were delayed by step-ramp stimuli, eye accelerations increased markedly approximately 200 ms after stimulus onset.(ABSTRACT TRUNCATED AT 400 WORDS)

Positive emotion regulation in emotional disorders: a theoretical review

Conceptualizations of emotion regulation have led to the identification of cognitive and behavioral regulatory abnormalities that contribute to the development and maintenance of emotional disorders. However, existing research on emotion regulation in anxiety and mood disorders has primarily focused on the regulation of negative emotions rather than positive emotions. Recent findings indicate that disturbances in positive emotion regulation occur across emotional disorders, and may be a generative target for treatment research. The aims of this paper are to: 1. Present a transdiagnostic model of positive emotion disturbances in emotional disorders; 2. Review evidence for disturbances in positive emotion regulation in emotional disorders across categories of emotion regulation; and 3. Propose treatment strategies that may address these disturbances.

The Origins of Neuroticism

In this article, we provide a fresh perspective on the developmental origins of neuroticism—a dimension of temperament marked by elevated stress reactivity resulting in the frequent experience of negative emotions. This negative affectivity is accompanied by a pervasive perception that the world is a dangerous and threatening place, along with beliefs about one’s inability to manage or cope with challenging events. Historically, neuroticism has been viewed as a stable, genetically based trait. However, recent understanding of ongoing gene–environment interactions that occur throughout the life span suggests there may be a more complex and dynamic etiology. Thus, the purpose of this article is to offer a theory for understanding the development of neuroticism that integrates genetic, neurobiological, and environmental contributions to this trait. Given the strong correlation between neuroticism and the development of negative health outcomes—most notably, the full range of anxiety and mood disorders—an enhanced understanding of how neuroticism originates has implications for the treatment and prevention of a broad range of pathologies and, perhaps, even for the prevention of neuroticism itself.

Short latency ocular-following responses in man

The ocular-following responses elicited by brief unexpected movements of the visual scene were studied in human subjects. Response latencies varied with the type of stimulus and decreased systematically with increasing stimulus speed but, unlike those of monkeys, were not solely determined by the temporal frequency generated by sine-wave stimuli. Minimum latencies (70-75 ms) were considerably shorter than those reported for other visually driven eye movements. The magnitude of the responses to sine-wave stimuli changed markedly with stimulus speed and only slightly with spatial frequency over the ranges used. When normalized with respect to spatial frequency, all responses shared the same dependence on temporal frequency (band-pass characteristics with a peak at 16 Hz), indicating that temporal frequency, rather than speed per se, was the limiting factor over the entire range examined. This suggests that the underlying motion detectors respond to the local changes in luminance associated with the motion of the scene. Movements of the scene in the immediate wake of a saccadic eye movement were on average twice as effective as movements 600 ms later: post-saccadic enhancement. Less enhancement was seen in the wake of saccade-like shifts of the scene, which themselves elicited weak ocular following, something not seen in the wake of real saccades. We suggest that there are central mechanisms that, on the one hand, prevent the ocular-following system from tracking the visual disturbances created by saccades but, on the other, promote tracking of any subsequent disturbance and thereby help to suppress post-saccadic drift. Partitioning the visual scene into central and peripheral regions revealed that motion in the periphery can exert a weak modulatory influence on ocular-following responses resulting from motion at the center. We suggest that this may help the moving observer to stabilize his/her eyes on nearby stationary objects.

The Björk-Shiley aortic prosthesis: flow characteristics, thrombus formation and tissue overgrowth

Thrombus formation and tissue overgrowth were observed in nine Björk-Shiley aortic prostheses recovered six months or longer after implantation. These pathologic findings may be attributed to the flow characteristics of the prosthesis. The open disc of the valve separates the flow into two unequal regions. Varying degrees of thrombus formation were observed in the minor outflow region, including the depression in the aortic face of the disc and the metal strut bridging this area. Tissue overgrowth was noted along the perimeter of the prosthesis adjacent to the minor outflow region. That overgrowth further reduced the available cross section for flow in this already constrained area. In vitro velocity measurements with a laser-Doppler anemometer identified a zone of stagnation about 20 mm wide near the aortic face of the disc. The average velocities in the major and minor outflow regions were around 100 and 25 cm/sec, respectively, and the corresponding peak-shear stresses were approximately 700 and 150 dynes/cm2. There is reason, then, to attribute the thrombus formation and tissue overgrowth to the stagnation zone and the low shear in the minor outflow region.

Neurological disease in xeroderma pigmentosum. Documentation of a late onset type of the juvenile onset form

Xeroderma pigmentosum (XP) is an autosomal recessive, neurocutaneous disorder characterized by sunlight-induced skin cancers and defective DNA repair. Many XP children develop a primary neuronal degeneration. We describe 2 unusual XP patients who had a delayed onset of XP neurological disease. Somatic cell genetic studies indicated that they have the same defective DNA repair gene and are both in XP complementation group A. These 2 patients, together with a group A patient previously reported from London, establish as a distinct clinical entity the late onset type of the juvenile onset form of XP neurological disease. The functional capacity of these patients' cultured fibroblast strains to survive after treatment with ultraviolet radiation indicates that their DNA repair defect is less severe than that of typical group A patients who have a more severe neurodegeneration with an earlier symptomatic onset. The premature death of nerve cells in XP patients (which is presumably due to their inherited defects in DNA repair mechanisms) suggests that normal repair of damaged DNA in neurons is required to maintain integrity of the human nervous system.

Microwave catheter design

A microwave antenna system for transcatheter ablation of cardiac tissue is investigated. A numerical model based on the finite-difference time-domain method incorporating a Gaussian pulse excitation has been constructed and frequency domain electric and magnetic fields are obtained through Fourier transformation. Results are presented for a coaxial line fed monopole catheter which is modified by the successive inclusion of a Teflon sheath outer coating, a terminating disk at the tip of the antenna, a sleeve choke, and a high dielectric constant cylinder surrounding the monopole antenna. The effects of these design features are characterized in terms of specific absorption rate (SAR) and return loss (RL). Numerical calculations are confirmed by comparing with the RL measurement of a Teflon-coated monopole containing a disk and choke.

Eye tracking abnormalities in schizophrenia: evidence for dysfunction in the frontal eye fields

BACKGROUND

Eye tracking deficits are robust abnormalities in schizophrenia, but the neurobiological disturbance underlying these deficits is not known.

METHODS

To clarify the pathophysiology of eye tracking disturbances in schizophrenia, we tested 12 first-episode treatment-naive schizophrenic patients and 10 matched healthy individuals on foveofugal and foveopetal step-ramp pursuit tasks.

RESULTS

On foveopetal tasks, the initiation of pursuit eye movements was delayed in schizophrenic patients, and their steady-state pursuit gain was reduced particularly at slower target speeds (8 and 16 deg/sec). In foveofugal step-ramp tasks, their primary catch-up saccades were normal in latency and accuracy, but their postsaccadic pursuit in the first 100 msec after the primary catch-up saccade was significantly reduced even relative to their slow steady-state pursuit, especially during and immediately after an acute episode of illness.

CONCLUSIONS

These observations indicate that motion-sensitive areas in posterior temporal cortex provide sufficiently intact information about moving targets to guide accurate catch-up saccades, but that the sensory processing of motion information is not being used effectively for pursuit eye movements. Low-gain pursuit after the early stage of pursuit initiation suggests that the use of extraretinal signals about target motion (e.g., anticipatory prediction) only partially compensates for this deficit. The pattern of low-gain pursuit, impaired pursuit initiation, and intact processing of motion information for catch-up saccades but not pursuit eye movements, was consistent in the schizophrenic patients tested at five time points over a 2-year follow-up period, and implicates the frontal eye fields or their efferent or afferent pathways in the pathophysiology of eye tracking abnormalities in schizophrenia.

Axillary sampling and the risk of erroneous staging of breast cancer. An analysis of 960 consecutive patients

Axillary nodal status was analysed in 960 consecutive cases of primary invasive breast cancer operated in two Danish hospitals. After stratification according to the number of nodes removed, the rate of node positivity in each subgroup was calculated. We found that the probability of finding at least one metastatic node increased continuously up to about 10 removed nodes. In lymph node negative patients, who did not receive any adjuvant treatment, there was a significant association between the recurrence-free survival and the number of nodes removed, provided that less than 8-10 nodes had been collected. The percentage of node positivity in each subgroup seemed to level off above 10 nodes at about 64%, suggesting that this represents the true rate of node positivity at the time of primary surgery. We conclude that about 10 axillary nodes should be removed in order to minimize the risk of erroneous classification of the axilla.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated promising results among patients with heterogeneous anxiety and comorbid depressive disorders when delivered on an individual basis, but greater efficiencies may be achieved with group-based applications. The aim of the present study was to provide a preliminary exploration of the UP when delivered in a group format. Among diagnostically diverse patients ( N = 11), the UP group treatment resulted in moderate to strong effects on anxiety and depressive symptoms, functional impairment, quality of life, and emotion regulation skills, as well as good acceptability and overall satisfaction ratings from patients. Three clinical cases are presented in detail to illustrate the group-based UP delivery, followed by a critical discussion of associated challenges and proposed guidelines for group administration, as well as directions for future research.

Motion processing for saccadic eye movements in humans

1. We studied the latencies and amplitudes of saccades to moving targets in normal human subjects. Targets underwent ramp or step-ramp motions. The goal was to determine how the saccadic system uses information about target velocity. 2. For simple ramp motion saccadic latency decreased as target speed increased. A threshold distance model, which assumes that the target has to move a minimum distance before saccadic processing starts, provided a good fit to the responses of all four subjects and explains discrepancies between previously published findings. 3. A double step experiment showed that target position may have some effect on saccadic amplitude when sampled approximately 70 ms before saccade onset, but it must be sampled at least 140 ms before onset for an accurate saccade to occur. 4. Saccades to simple ramp targets approximated the target position 55 ms before saccade onset. Based on our double step results, this is more compensation than possible by a simple position estimate and implies extrapolation of target motion by the saccadic system. The lack of complete compensation may be due to an underestimate of the target speed and/or of the saccadic latency. 5. A delayed-saccade paradigm resulted in saccades with a longer, constant latency and allowed longer viewing of target motion. These saccades accounted for all but approximately 20 ms of target motion, suggesting that with more processing time of target motion a better extrapolation may be generated. 6. In a step-ramp paradigm the target stepped in one direction, then moved smoothly in the opposite direction. Saccades in this paradigm could be made in either the direction of the step or in the direction of target motion: the direction and latency were determined solely by the time at which the target crossed the fixation point. This time must be calculated from target speed and position, implying that the saccadic system must use speed information to adjust latency or to cancel unnecessary saccades.

Human ocular responses to translation of the observer and of the scene: dependence on viewing distance

Recent experiments on monkeys have indicated that the eye movements induced by brief translation of either the observer or the visual scene are a linear function of the inverse of the viewing distance. For the movements of the observer, the room was dark and responses were attributed to a translational vestibulo-ocular reflex (TVOR) that senses the motion through the otolith organs; for the movements of the scene, which elicit ocular following, the scene was projected and adjusted in size and speed so that the retinal stimulation was the same at all distances. The shared dependence on viewing distance was consistent with the hypothesis that the TVOR and ocular following are synergistic and share central pathways. The present experiments looked for such dependencies on viewing distance in human subjects. When briefly accelerated along the interaural axis in the dark, human subjects generated compensatory eye movements that were also a linear function of the inverse of the viewing distance to a previously fixated target. These responses, which were attributed to the TVOR, were somewhat weaker than those previously recorded from monkeys using similar methods. When human subjects faced a tangent screen onto which patterned images were projected, brief motion of those images evoked ocular following responses that showed statistically significant dependence on viewing distance only with low-speed stimuli (10 degrees/s). This dependence was at best weak and in the reverse direction of that seen with the TVOR, i.e., responses increased as viewing distance increased. We suggest that in generating an internal estimate of viewing distance subjects may have used a confounding cue in the ocular-following paradigm--the size of the projected scene--which was varied directly with the viewing distance in these experiments (in order to preserve the size of the retinal image). When movements of the subject were randomly interleaved with the movements of the scene--to encourage the expectation of ego-motion--the dependence of ocular following on viewing distance altered significantly: with higher speed stimuli (40 degrees/s) many responses (63%) now increased significantly as viewing distance decreased, though less vigorously than the TVOR. We suggest that the expectation of motion results in the subject placing greater weight on cues such as vergence and accommodation that provide veridical distance information in our experimental situation: cue selection is context specific.

Abduction nystagmus in internuclear ophthalmoplegia

We tested the hypothesis that abnormalities of the abducting eye in internuclear ophthalmoplegia reflect an adaptive process that helps overcome the adduction weakness of the opposite eye. This response operates under the constraints of Hering's law of equal innervation: any attempt to increase the innervation to a weak muscle in one eye must be accompanied by a commensurate increase in innervation to the yoke muscle in the other eye. In 4 patients with internuclear ophthalmoplegia, we patched one eye for 1 to 5 days to allow time for the central nervous system to optimize innervation for the habitually viewing eye. We predicted that there would be a conjugate adjustment of innervation that would diminish the abduction overshoot and backward postsaccadic drift made by the habitually viewing eye. This was the case in 3 of our 4 patients. Our findings show that the abduction nystagmus is a manifestation of a normal adaptive response in some patients with INO.

Assessment of ileal function by abdominal counting of the retention of a gamma emitting bile acid analogue

In eight patients without gastrointestinal complaints and 30 patients with various gastrointestinal disorders ileal bile acid conservation was assessed by oral administration of 75Se 23-selena-25-homocholic acid (SeHCAT) followed by abdominal gamma counting (SeHCAT-test). The results of the test correlated fairly well with the clinical features and with the [1-14C]-cholylglycine breath test including faecal 14C measurements (breath test). Of the two bile acid absorption tests the new is perhaps the more sensitive and is the one most easily performed.

The Sleep Condition Indicator: reference values derived from a sample of 200 000 adults

The Sleep Condition Indicator (SCI) is an eight-item rating scale that was developed to screen for insomnia disorder based on DSM-5 criteria. It has been shown previously to have good psychometric properties among several language translations. We developed age- and sex-referenced values for the SCI to assist the evaluation of insomnia in everyday clinical practice. A random sample of 200 000 individuals (58% women, mean age: 31 ± 13 years) was selected from those who had completed the SCI via several internet platforms. Descriptive and inferential methods were applied to generate reference data and indices of reliable change for the SCI for men and women across the age deciles 16-25, 26-35, 36-45, 46-55, 56-65 and 66-75 years. The mean SCI score for the full sample was 14.97 ± 5.93. Overall, women scored worse than men (14.29 ± 5.83 versus 15.90 ± 5.94; mean difference: -1.60, η²  = 0.018, Cohen's d = 0.272) and those of older age scored worse than those younger (-0.057 points per year, 95% confidence interval (CI): -0.059 to -0.055) relative to age 16-25 years. The Reliable Change Index was established at seven scale points. In conclusion, the SCI is a useful instrument for clinicians and researchers that can help them to screen for insomnia, compare completers to individuals of similar age and sex and establish whether a reliable change was achieved following treatment.

Pediatric all-terrain vehicle trauma: a 5-year statewide experience

BACKGROUND/PURPOSE

This is a retrospective review of the pediatric all-terrain vehicle trauma victims who presented to the five major trauma centers serving the state of West Virginia during the 5-year period from January 1991 to December 1995. The purpose of this research is to characterize the nature of the injuries and the individuals injured to better appreciate the magnitude of the problem of ATV-related injuries in the pediatric population.

METHODS

This study is a retrospective review of these 218 consecutive pediatric patients from trauma registry data and their medical records.

RESULTS

Two hundred eighteen patients between the ages of 2 years and 16 years presented during the study period. Boys outnumbered girls three to one. The average Injury Severity Score (ISS) was 8.76, the average Glasgow Coma Score (GCS) was 14.4, and the average Trauma Score (TS) was 15.2. The most common injuries were orthopedic followed by head and facial injuries. The majority of the children did not wear helmets, and their injuries resulted in an average hospital length of stay of 4.3 days. Thirty-eight percent of the children required surgery. There were a total of four deaths for a mortality rate of 1.8%. The estimated total hospitalization cost for the 218 patients was $1,918,400.00.

CONCLUSIONS

All-terrain vehicle-related trauma remains an ongoing safety concern facing society today. Every physician who cares for children should address this important issue when talking to children and parents about safety issues and injury prevention.

A preliminary investigation of the effects of the unified protocol on temperament

Previous research has shown that two dimensions of temperament referred to as neuroticism/behavioral inhibition (N/BI) and extraversion/behavioral activation (E/BA) are key risk factors in the development and maintenance of anxiety and mood disorders (Brown & Barlow, 2009). Given such findings, these temperamental dimensions may represent promising treatment targets for individuals with emotional disorders; however, to date, few studies have investigated the effects of psychological treatments on temperamental constructs generally assumed to be "stable, inflexible, and pervasive" (American Psychiatric Association, 2000). The present study addresses this gap in the literature by examining the effects of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2011), a cognitive-behavioral therapy designed to target core processes of N/BI and E/BA temperaments, in a sample of adults with principal anxiety disorders and a range of comorbid conditions. Results revealed small effects of the UP on N/BI and E/BA compared with a waitlist control group at post-treatment. Additionally, decreases in N/BI and increases in E/BA during treatment were associated with improvements in symptoms, functioning, and quality of life. Findings provide preliminary support for the notion that the UP treatment facilitates beneficial changes in dimensions of temperament.

Insomnia as a mediating therapeutic target for depressive symptoms: A sub-analysis of participant data from two large randomized controlled trials of a digital sleep intervention

Insomnia predicts the onset of depression, commonly co-presents with depression and often persists following depression remission. However, these conditions can be challenging to treat concurrently using depression-specific therapies. Cognitive behavioural therapy for insomnia may be an appropriate treatment to improve both insomnia and depressive symptoms. We examined the effects of a fully-automated digital cognitive behavioural therapy intervention for insomnia (Sleepio) on insomnia and depressive symptoms, and the mediating role of sleep improvement on depressive symptoms in participants from two randomized controlled trials of digital cognitive behavioural therapy for insomnia. We also explored potential moderators of intervention effects. All participants met criteria for probable insomnia disorder and had clinically significant depressive symptomatology (PHQ-9 ≥ 10; n = 3,352). Individuals allocated to treatment in both trials were provided access to digital cognitive behavioural therapy. Digital cognitive behavioural therapy significantly improved insomnia (p < .001; g = 0.76) and depressive symptoms (p < .001; g = 0.48) at post-intervention (weeks 8-10), and increased the odds (OR = 2.9; 95% CI = 2.34, 3.65) of clinically significant improvement in depressive symptoms (PHQ-9 < 10). Improvements in insomnia symptoms at mid-intervention mediated 87% of the effects on depressive symptoms at post-intervention. No variables moderated effectiveness outcomes, suggesting generalizability of these findings. Our results suggest that effects of digital cognitive behavioural therapy for insomnia extend to depressive symptoms in those with clinically significant depressive symptomatology. Insomnia may, therefore, be an important therapeutic target to assist management of depressive symptoms.

A simpler, less expensive technique for delayed primary closure of fasciotomies

A variety of techniques have recently been advanced for delayed primary closure of wounds following emergent fasciotomy for compartment syndrome. We introduce a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips (3M Surgical Products, St. Paul, Minnesota). This method allows final closure of fasciotomy wounds with simple suture in 5-8 days without scar contractures, marginal necrosis, infection, or significant pain. Moreover, because it requires no specialized equipment and can be applied in skilled nursing centers or at home by trained nurses, this technique could reduce the cost of caring for fasciotomy patients.

Efficacy of digital cognitive behavioral therapy for moderate-to-severe symptoms of generalized anxiety disorder: A randomized controlled trial

BACKGROUND

Cognitive behavioral therapy (CBT) is an efficacious intervention for generalized anxiety disorder (GAD). Digital CBT may provide a scalable means of delivering CBT at a population level. We investigated the efficacy of a novel digital CBT program in those with GAD for outcomes of anxiety, worry, depressive symptoms, sleep difficulty, wellbeing, and participant-specific quality of life.

METHODS

This online, two-arm parallel-group superiority randomized controlled trial compared digital CBT with waitlist control in 256 participants with moderate-to-severe symptoms of GAD. Digital CBT (Daylight), was delivered using participants' own smartphones. Online assessments took place at baseline (Week 0; immediately preceding randomization), mid-intervention (Week 3; from randomization), post-intervention (Week 6; primary endpoint), and follow-up (Week 10).

RESULTS

Overall, 256 participants were randomized and intention-to-treat analysis found Daylight reduced symptoms of anxiety compared with waitlist control at post-intervention, reflecting a large effect size (adjusted difference [95% CI]: 3.22 [2.14, 4.31], d = 1.08). Significant improvements were found for measures of worry; depressive symptoms, sleep difficulty, wellbeing, and participant-specific quality of life.

CONCLUSION

Digital CBT (Daylight) appears to be safe and efficacious for symptoms of anxiety, worry, and further measures of mental health compared with waitlist control in individuals with GAD.