A Systematic Quality Review of Single-Case Experimental Designs Using Acceptance and Commitment Therapy in Adult Clinical Populations.

Recent publications within Contextual Behavioral Science provided a rationale for the expansion of intervention efficacy research using methods that capture idiographic factors and processes. We conducted a systematic review of the use and quality of single-case experimental designs (SCED) within the Acceptance and Commitment Therapy (ACT) literature in adult clinical populations. The systematic review was conducted according to PRISMA guidelines and the databases CINAHL, MEDLINE, PsycINFO, PsycArticles and OpenGrey were searched for peer-reviewed articles. Further studies were sought through review of reference lists of all full text studies. Studies were assessed against What Works Clearinghouse (WWC) single-case design standards. Twenty-six studies met eligibility criteria and were conducted within research teams all implementing multiple-baseline designs. Twenty-four studies did not meet WWC standards with most failing to ensure a degree of concurrence across participants. The extent of randomisation methods was also captured. The review highlights the sparsity of SCEDs within ACT literature in clinical populations and current methodological practices. Limitations of the review and implications for future research are discussed.

Group psychological intervention for emotional distress in haematopoietic stem cell transplantation: A feasibility randomised clinical trial.

PURPOSE: Haematopoietic stem cell transplantation (HSCT) is an intensive procedure associated with elevated psychological distress, particularly during the initial stages. Based on self-regulatory theory, a prophylactic group intervention was developed to mitigate this distress by targeting perceptions of HSCT and coping. This study evaluated the feasibility of delivering the intervention and of conducting a randomised clinical trial to assess efficacy. METHODS: Adults from consecutive referrals at two transplant centres were randomised to the intervention or to treatment as usual at each site. Psychological distress (primary outcome), HSCT perceptions, and coping were assessed at baseline, on transplant day, and two and four weeks after transplantation. RESULTS: Of 99 eligible patients, 45 consented. Main barriers to consent were insufficient time prior to transplantation, competing priorities, being unwell, and travel distance. Of 21 participants randomised to the intervention, five attended. Main barriers to attendance included insufficient time prior to transplantation and having competing priorities. Groups could not be held sufficiently frequently to enable attendance prior to transplantation, as randomising participants to the control group limited accrual. Anxiety peaked two weeks following transplantation. Depression increased throughout the acute phase. Clinical levels of distress were observed in 42% of patients during HSCT. Intervention effects were small but sample sizes for a full trial appeared feasible. CONCLUSIONS: Multimodal prehabilitation is required but there are specific barriers to delivering a group-based intervention and conducting a trial. Group prehabilitation requires customisation and better integration with routine care, such as patient screening, personalisation, and options for remote delivery.

Mental health mobile application self-help for adolescents exhibiting psychological distress: A single case experimental design.

OBJECTIVES: The present demand for child and adolescent mental health services exceeds the capacity for service provision. Greater research is required to understand the utility of accessible self-help interventions, such as mobile apps. This study sought to investigate whether use of a mental health app, underpinned by CBT, led to changes in psychological distress amongst adolescents. Mechanisms of change were examined, specifically whether changes are attributable to cognitive strategies. DESIGN: This study utilised a multiple-baseline single-case experimental design, tracking variables across baseline and intervention phases. Surveys assessing participant experience were also administered. METHODS: Five participants with moderate-to-severe levels of psychological distress engaged with a CBT-based app over five weeks. Participants were recruited from both a well-being service and the general population. Supplementary weekly calls to participants offered clarification of app content. RESULTS: A small overall effect of the intervention of psychological distress was evident; however, outcomes were dependent on the analysis conducted. The intervention appeared to promote an increase in use of adaptive cognitive strategies but not negative thinking styles. The CBT app did not promote changes in participant well-being. Participant feedback highlighted practical challenges of utilising the app. CONCLUSIONS: The clinical benefits of app-based CBT were small, and a range of barriers to engagement were recognised. While further research is required, caution should be exercised in the interpretation of studies reporting on app effectiveness.

Mental Health Recovery Using the Individual Recovery Outcomes Counter (I.ROC) in a Community Rehabilitation Team: A Service Evaluation.

There are many definitions of recovery in mental health. Community Rehabilitation Teams (CRTs) aim to support the mental health recovery of people. The Individual Recovery Outcomes Counter (I.ROC) is a way to measure recovery. To determine if being supported by a CRT helps mental health recovery for people transitioning from an inpatient service to the community. Individual reliable and clinically meaningful change indices were calculated for a total of 31 people. Two I.ROC questionnaires were completed by 31 people. Of these 31 people, 14 people had three completed I.ROC questionnaires. Of the 31 people, 17 showed a positive reliable change and three people made a clinically meaningful change. Of the 14 people, one had a positive reliable change, two had a negative reliable change, and no-one had a clinically meaningful change. The I.ROC shows the CRT to successfully support recovery in people with mental health difficulties.

Strengthening Mental Abilities with Relational Training (SMART) in multiple sclerosis (MS): study protocol for a feasibility randomised controlled trial.

BACKGROUND: Multiple sclerosis (MS) is a chronic condition of the central nervous system, affecting around 1 in every 600 people in the UK, with 130 new diagnoses every week. Cognitive difficulties are common amongst people with MS, with up to 70% experiencing deficits in higher-level brain functions-such as planning and problem-solving, attention, and memory. Cognitive deficits make it difficult for people with MS to complete everyday tasks and limit their abilities to work, socialise, and live independently. There is a clear need-and recognised research priority-for treatments that can improve cognitive functioning in people with MS. The absence of effective cognitive interventions exacerbates burdens on the services accessed by people with MS-requiring these services to manage sequelae of untreated cognitive deficits, including reduced quality of life, greater disability and dependence, and poorer adherence to disease-modifying treatments. Our planned research will fill the evidence gap through developing-and examining the feasibility of trialling-a novel online cognitive rehabilitation programme for people with MS (SMART). The SMART programme directly trains relational skills (the ability to flexibly relate concepts to one another) based on theory that these skills are critical to broader cognitive functioning. METHODS: The primary objective of this study aims to conduct a feasibility study to inform the development of a definitive trial of SMART for improving cognitive functioning in people with MS. The secondary objective is to develop the framework for a cost-effectiveness analysis alongside a definitive trial, and the exploratory objective is to assess the signal of efficacy. DISCUSSION: As a feasibility trial, outcomes are unlikely to immediately effect changes to NHS practice. However, this is a necessary step towards developing a definitive trial-and will give us a signal of efficacy, a prerequisite for progression to a definitive trial. If found to be clinically and cost-effective, the latter trial could create a step-change in MS cognitive rehabilitation-improving service delivery and optimising support with limited additional resources. TRIAL REGISTRATION: Registration ID: ClnicalTrials.gov: NCT04975685-registered on July 23rd, 2021. PROTOCOL VERSION: 2.0, 25 November 2021.

Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

Usability and acceptability of a cognitive training intervention (SMART) for people with multiple sclerosis (MS): A prefeasibility formative evaluation.

Background: Multiple sclerosis (MS) is a chronic autoimmune, inflammatory neurological disease of the central nervous system (CNS), increasing in incidence and prevalence across both developed and developing countries. Cognitive difficulties are common in MS sufferers with 70% experiencing difficulties in higher-level brain functioning such as planning, attention, problem solving, and memory. Computerised cognitive training programmes may hold promise as a treatment option for improving cognitive function in people with MS, subject to exploring and addressing potential barriers to usability and acceptability. Methods: This study aimed to test the usability and acceptability of a computerised cognitive training intervention-Strengthening Mental Abilities Through Relational Training (SMART) -for people with MS, through a mostly qualitative prefeasibility design ( n= 12). There were two phases of testing: (1) initial usability testing via a think-aloud protocol ( n= 6) and (2) alpha-testing to assess experienced acceptability over a four-week period of engagement ( n= 6). Data from the two phases were subjected to Framework Analysis, wherein we deductively applied the Health IT Usability Evaluation Model and Theoretical Framework of Acceptability to assess usability and acceptability, respectively. Results: Results show SMART to have satisfactory usability with participants reacting positively to the formatting, visuality, and process of the interface. Minor suggestions were made on how best to adapt SMART for people with MS, but the programme and facilitative support were generally perceived to be acceptable, with participants expressing positive feelings about taking part in the intervention, despite associated burdens. Conclusions: This prefeasibility study provides preliminary evidence of the usability and acceptability of SMART as a computerised cognitive training programme for people with MS. We conclude that we can now move forward with a feasibility trial of SMART, with the intention of proceeding to a definitive trial with cost-effectiveness analysis.

AIMS: We are developing a new 'brain training' treatment to help people with multiple sclerosis (MS) who have problems with thinking skills ( e.g., problem-solving, attention, and memory). This study aimed to test whether the training (called 'Strengthening Mental Abilities Through Relational Training' ['SMART']) is suitable for people with MS. Specifically, we assessed whether SMART was easy to use and acceptable for use in their everyday lives. BACKGROUND: MS is a long-term condition that affects the nervous system, with the number of cases increasing in both developed and developing countries. MS affects an individual's thinking skills, which can affect their ability to go about their everyday lives. Brain training has potential for improving thinking skills in people with MS, provided ease of use and factors impacting willingness to use the training are explored. Design and methods used: This study used a mix of methods, such as scores from objective tests and verbal feedback, to explore whether SMART is easy to use and acceptable for people with MS. The study had two phases: think-aloud interviews (participants provided feedback on whether the training interface and guidance were easy to use) and then the alpha-testing phase (participants tested the training over time, and then gave feedback on acceptability). Common and salient themes were identified in both phases. RESULTS: Participants found SMART to be suitably easy to use and acceptable for use by people with MS. Participants thought that the interface was visually appealing, and easy to operate and navigate. Participants made minor suggestions for improving the intervention, but feedback was generally positive, despite demands on time and energy. DISCUSSION: SMART appears to be suitable for people with MS. We conclude that we can go ahead with the next phase of testing SMART, as a possible treatment for improving thinking skills in people with MS.

ACTing towards better living during COVID-19: The effects of Acceptance and Commitment therapy for individuals affected by COVID-19.

The widespread effects of COVID-19 have dramatically increased the prevalence of mental health difficulties, meaning it is vital to explore psychotherapy options. Acceptance and Commitment therapy (ACT) helps individuals engage in meaningful activities despite difficult and unchangeable circumstances. Recent literature suggests that psychological flexibility, the underlying process of ACT, may moderate COVID-related distress - making ACT a promising psychotherapy candidate. This study therefore aimed to explore the effects of an ACT-based, guided self-help intervention on wellbeing, psychological flexibility, COVID-related distress, and general psychological distress within the general population. 48 participants (recruited via social media) engaged in a three-week, non-concurrent baseline phase, then received six, weekly, digital modules and weekly webinars to address module queries. 20 participants completed all modules and provided post-intervention feedback via an online qualitative survey. Multilevel modelling analysis found significant improvements in: wellbeing; overall psychological flexibility (including subscales behavioural awareness and valued action); and general psychological distress (including depression, anxiety and stress). No significant changes were found for COVID-related distress. Findings were sustained at one- and two-months follow-up - suggesting lasting change. Qualitative findings provide further insights about the experience of the intervention: participants reported improved wellbeing, still experiencing COVID-related distress, but felt more able to cope with general psychological distress (such as anxiety). No change in COVID-related distress scores may be due to methodological and measurement issues. This study is one of the first to explore ACT as a psychotherapeutic intervention for COVID-related distress and adds to the growing body of literature highlighting psychological flexibility as a key process for mitigating COVID-related distress.

Phytochemicals as Therapeutic Interventions in Peripheral Artery Disease.

Peripheral artery disease (PAD) affects over 200 million people worldwide, resulting in significant morbidity and mortality, yet treatment options remain limited. Among the manifestations of PAD is a severe functional disability and decline, which is thought to be the result of different pathophysiological mechanisms including oxidative stress, skeletal muscle pathology, and reduced nitric oxide bioavailability. Thus, compounds that target these mechanisms may have a therapeutic effect on walking performance in PAD patients. Phytochemicals produced by plants have been widely studied for their potential health effects and role in various diseases including cardiovascular disease and cancer. In this review, we focus on PAD and discuss the evidence related to the clinical utility of different phytochemicals. We discuss phytochemical research in preclinical models of PAD, and we highlight the results of the available clinical trials that have assessed the effects of these compounds on PAD patient functional outcomes.

COVID-19: Psychological flexibility, coping, mental health, and wellbeing in the UK during the pandemic.

The COVID-19 pandemic has profoundly altered the daily lives of many people across the globe, both through the direct interpersonal cost of the disease, and the governmental restrictions imposed to mitigate its spread and impact. The UK has been particularly affected and has one of the highest mortality rates in Europe. In this paper, we examine the impact of COVID-19 on psychological health and well-being in the UK during a period of 'lockdown' (15th-21st May 2020) and the specific role of Psychological Flexibility as a potential mitigating process. We observed clinically high levels of distress in our sample (N = 555). However, psychological flexibility was significantly and positively associated with greater wellbeing, and inversely related to anxiety, depression, and COVID-19-related distress. Avoidant coping behaviour was positively associated with all indices of distress and negatively associated with wellbeing, while engagement in approach coping only demonstrated weaker associations with outcomes of interest. No relationship between adherence to government guidelines and psychological flexibility was found. In planned regression models, psychological flexibility demonstrated incremental predictive validity for all distress and wellbeing outcomes (over and above both demographic characteristics and COVID-19-specific coping responses). Furthermore, psychological flexibility and COVID-19 outcomes were only part-mediated by coping responses to COVID-19, supporting the position that psychological flexibility can be understood as an overarching response style that is distinct from established conceptualisations of coping. We conclude that psychological flexibility represents a promising candidate process for understanding and predicting how an individual may be affected by, and cope with, both the acute and longer-term challenges of the pandemic.

Educational resources for vascular laboratory education in vascular surgery residencies and fellowships: Survey of Vascular Surgery Program Directors.

OBJECTIVE: The Registered Physician in Vascular Interpretation (RPVI) credential is a prerequisite for certification by the Vascular Surgery Board of the American Board of Surgery. Of concern, as more current trainees and recent program graduates take the Physician Vascular Interpretation (PVI) examination, vascular surgery trainee pass rates have decreased. Residents and fellows have a lower PVI examination pass rates than practicing vascular surgeons. The purpose of this study was to assess current vascular laboratory (VL) training for vascular surgery residents and fellows and to identify gaps that residency and fellowship programs might address. METHODS: Program directors (PDs) of Accreditation Council for Graduate Medical Education-accredited vascular surgery programs (107 fellowships, 53 integrated residency programs) were surveyed using a web-based tool. Responses were submitted anonymously. Data collected included information about the program, the PD, accreditation status of the VL, and the curriculum used to meet the PVI prerequisites. Concurrent data (June 2017) on the credentials of all PDs were obtained from the Alliance for Physician Certification and Advancement (APCA). RESULTS: Sixty-one of 117 PDs participated in the survey (52% response rate). Of these, 44 individuals (72% of responders) reported they held the RPVI and/or Registered Vascular Technologist credential. Records from APCA indicated that 51 of 117 PDs of accredited vascular surgery residencies and fellowships (44%) had an RPVI/Registered Vascular Technologist credential. Ninety-four percent reported that their VL was accredited. Practical VL experience for trainees was reported to be 20 hours or less by 62% of respondents. The use of a structured curriculum for practical experience was reported by only 15 programs. Programs with fellowships established for more than 10 years were more likely to have a structured program for didactic instruction (P = .03). Only 23 programs reported a dedicated VL rotation. Didactic instruction provided was 20 hours or less for 75% of the cohort. CONCLUSIONS: In the absence of a standardized VL curriculum, there is variation in the VL instruction provided to trainees. Fellowship programs with longer histories have more structured instruction, but time allocated to VL education is substantially less than the 30 hours of didactic and 40 hours of practical experience recommended by the APCA. Programs and learners may benefit from the development of VL training guidelines and curriculum resources.

The effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for psychogenic nonepileptic seizures.

This study utilized a nonconcurrent case-series design to examine the effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for people with psychogenic nonepileptic seizures. A key aim of the study was to investigate the relationship between psychological flexibility (a key process within ACT), psychological health, quality of life, and seizure frequency. Six participants completed the study, with reliable and clinically significant changes in psychological flexibility, quality of life, and psychological health observed in the majority of participants. Notable reductions in self-reported seizure frequency were also observed. The implications of these findings for clinical practice are discussed and recommendations for future research suggested.

Up-and-Over Technique for Implantation of Iliac Branch Devices After Prior Aortic Endograft Repair.

PURPOSE: To describe a modified up-and-over access technique for treatment of iliac artery aneurysms in patients with prior bifurcated stent-grafts for endovascular aneurysm repair (EVAR). TECHNIQUE: This technique uses a coaxial 12-F flexible sheath that is docked with a through-and-through wire into a 7-F sheath advanced from the contralateral femoral approach. This maneuver allows both sheaths to be moved as a unit while maintaining position of the apex of the system as it loops over the flow divider, avoiding damage to or displacing the extant endograft. Once the 12-F sheath is positioned in the iliac limb of the aortic stent-graft and secured in place with the through-and-through wire, the repair is extended into the internal iliac artery using a bridging stent-graft or covered stent introduced via a coaxial sheath. CONCLUSION: The up-and-over technique with a flexible 12-F sheath mated with a 7-F sheath from the opposite side allows bilateral femoral access to be used for iliac branch device placement after prior aortic endograft procedures that create a higher, acutely angled bifurcation. Use of a through-and-through wire and a coaxial sheath for stent delivery creates a very stable platform for intervention.

Reclaiming Autologous Amputated Tissue for Limb Salvage of a Diabetic Foot Burn with Underlying Critical Limb Ischemia.

BACKGROUND: Diabetes mellitus is a worldwide pandemic that impacts more than 387 million people, with 29 million individuals affected in the United States alone. Diabetic patients have a 25% lifetime risk of developing a diabetic foot ulcer (DFU). Having a DFU is associated with a risk of recurrence approaching 70%. In addition, 1 in 6 patients with DFU will have a lower-limb amputation, with an associated increase in mortality ranging from 47% to 70%. Therefore, limb salvage is critical in patients with DFU. CASE STUDY: This article describes the case of a 70-year-old man with diabetes mellitus, end-stage renal disease, and peripheral arterial occlusive disease who presented with a 1.5% total-body-surface-area, third-degree burn to the left hallux with dry gangrene extending to the midfoot. Ankle brachial indexes were 0.66 on the left and 0.64 on the right. Toe pressures on the left were absent because of extensive dry gangrene. His right foot had a prior transmetatarsal amputation. Using a retrograde pedal approach, a chronic total occlusion of the left posterior tibial artery was recanalized with balloon angioplasty. He then underwent a transmetatarsal amputation with closure, except that the plantar medial side could not be closed without tension. Therefore, an autologous full-thickness skin graft, from the amputation specimen, was used to bridge the defect. DISCUSSION: At 32-week follow-up, the wound was healed, the graft had fully incorporated, and the patient was ambulating well using custom orthotic footwear. The creative use of amputated tissue to assist with wound coverage has not been well described in the literature.