Psychotherapeutic benefits of compassion-focused therapy: an early systematic review.

BACKGROUND: Compassion-focused therapy (CFT) is a relatively novel form of psychotherapy that was developed for people who have mental health problems primarily linked to high shame and self-criticism. The aim of this early systematic review was to draw together the current research evidence of the effectiveness of CFT as a psychotherapeutic intervention, and to provide recommendations that may inform the development of further trials. METHOD: A comprehensive search of electronic databases was undertaken to systematically identify literature relating to the effectiveness of CFT as a psychotherapeutic intervention. Reference lists of key journals were hand searched and contact with experts in the field was made to identify unpublished data. RESULTS: Fourteen studies were included in the review, including three randomized controlled studies. The findings from the included studies were, in the most part, favourable to CFT, and in particular seemed to be effective for people who were high in self-criticism. CONCLUSIONS: CFT shows promise as an intervention for mood disorders, particularly those high in self-criticism. However, more large-scale, high-quality trials are needed before it can be considered evidence-based practice. The review highlights issues from the current evidence that may be used to inform such trials.

Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia.

BACKGROUND: Hypocalcaemia is common after thyroidectomy. Accurate prediction and appropriate management may help reduce morbidity and hospital stay. The aim of this study was to perform a systematic literature review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. METHODS: A systematic search of PubMed, EMBASE and the Cochrane Library databases was undertaken, and the quality of manuscripts assessed using a modified Newcastle-Ottawa Scale. RESULTS: Some 115 observational studies were included. The median (i.q.r.) incidence of transient and permanent hypocalcaemia was 27 (19-38) and 1 (0-3) per cent respectively. Independent predictors of transient hypocalcaemia included levels of preoperative calcium, perioperative parathyroid hormone (PTH), preoperative 25-hydroxyvitamin D and postoperative magnesium. Clinical predictors included surgery for recurrent goitre and reoperation for bleeding. A calcium level lower than 1·88 mmol/l at 24 h after surgery, identification of fewer than two parathyroid glands (PTGs) at surgery, reoperation for bleeding, Graves' disease and heavier thyroid specimens were identified as independent predictors of permanent hypocalcaemia in multivariable analysis. Factors associated with transient hypocalcaemia in meta-analyses were inadvertent PTG excision (odds ratio (OR) 1·90, 95 per cent confidence interval 1·31 to 2·74), PTG autotransplantation (OR 2·03, 1·44 to 2·86), Graves' disease (OR 1·75, 1·34 to 2·28) and female sex (OR 2·28, 1·53 to 3·40). CONCLUSION: Perioperative PTH, preoperative vitamin D and postoperative changes in calcium are biochemical predictors of post-thyroidectomy hypocalcaemia. Clinical predictors include female sex, Graves' disease, need for parathyroid autotransplantation and inadvertent excision of PTGs.

Colistimethate sodium powder and tobramycin powder for inhalation for the treatment of chronic Pseudomonas aeruginosa lung infection in cystic fibrosis: systematic review and economic model.

BACKGROUND: Cystic fibrosis (CF) is an inherited condition characterised by the abnormal transport of chloride ions across transporting epithelia. This leads to the production of thick sticky mucus in the lungs, pancreas, liver, intestine and reproductive tract, and an increase in the salt content in sweat. Among other problems, people with CF experience recurrent respiratory infections and have difficulties digesting food. CF affects over 9000 individuals in the UK. CF shortens life expectancy and adversely affects quality of life. In 2010, CF was recorded as the cause of 103 deaths in England and Wales. OBJECTIVE: To evaluate the clinical effectiveness and cost-effectiveness of colistimethate sodium dry powder for inhalation (DPI) (Colobreathe(®), Forest Laboratories) and tobramycin DPI (TOBI Podhaler(®), Novartis Pharmaceuticals) for the treatment of Pseudomonas aeruginosa lung infection in CF. DATA SOURCES: Electronic databases were searched in February and March 2011 [MEDLINE, MEDLINE In-Process & Other Non-Indexed citations, EMBASE, The Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Conference Proceedings Citation Index (CPCI) and Bioscience Information Service (BIOSIS) Previews]. Relevant databases were searched for ongoing and unpublished studies, and bibliographies of relevant systematic reviews and the manufacturers' submissions were also hand-searched. REVIEW METHODS: A systematic review of the clinical effectiveness and cost-effectiveness of colistimethate sodium DPI and tobramycin DPI for the treatment of chronic P. aeruginosa lung infection in CF was conducted. Existing economic evidence within the literature was reviewed and a de novo health economic model was also developed. RESULTS: Three randomised controlled trials (RCTs) were included in the clinical effectiveness review. Both colistimethate sodium DPI and tobramycin DPI were reported to be non-inferior to nebulised tobramycin for the outcome forced expiratory volume in first second percentage predicted (FEV1%). It was not possible to draw any firm conclusions as to the relative efficacy of colistimethate sodium DPI compared with tobramycin DPI. The economic analysis suggests that colistimethate sodium DPI produces fewer quality-adjusted life-years (QALYs) than nebulised tobramycin. Given the incremental discounted lifetime cost of tobramycin DPI compared with nebulised tobramycin, it highly unlikely that tobramycin DPI has an incremental cost-effectiveness ratio that is better than £30,000 per QALY gained. LIMITATION: The uncertainty surrounding the short-term evidence base inevitably results in uncertainty surrounding the long-term clinical effectiveness and cost-effectiveness of colistimethate sodium DPI. CONCLUSIONS: Both DPI formulations have been shown to be non-inferior to nebulised tobramycin as measured by FEV1%. The results of these trials should be interpreted with caution owing to the means by which the results were analysed, the length of follow-up, and concerns about the ability of FEV1% to accurately represent changes in lung health. Although the increase in QALYs is expected to be lower with colistimethate sodium DPI than with nebulised tobramycin, a price for this intervention had not been agreed at the time of the assessment. Depending on the price of colistimethate sodium DPI, this results either in a situation whereby colistimethate sodium DPI is dominated by nebulised tobramycin or in one whereby the incremental cost-effectiveness of nebulised tobramycin compared with colistimethate sodium DPI is in the range of £24,000-277,000 per QALY gained. The economic analysis also suggests that, given its price, it is unlikely that tobramycin DPI has a cost-effectiveness ratio of < £30,000 per QALY gained when compared with nebulised tobramycin. A RCT to assess the longer-term (≥ 12 months) efficacy of colistimethate sodium DPI and tobramycin DPI in comparison with nebulised treatments would be beneficial. Such a study should include the direct assessment of HRQoL using a relevant preference-based instrument. Future studies should ensure that the European Medicines Agency guidelines are adhered to. In addition, high-quality research concerning the relationship between forced expiratory volume in first second % (FEV1%) predicted or other measures of lung function and survival/health-related quality of life (HRQoL) would be useful. STUDY REGISTRATION: PROSPERO CRD42011001350. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Natural history of Staphylococcus aureus nasal carriage and its relationship to exit-site infection.

OBJECTIVE: To study the natural history of nasal carriage of Staphylococcus aureus (SA) and its impact on exit-site infection (ESI). SETTING: A teaching hospital single-center study. DESIGN: A prospective cohort study in prevalent continuous ambulatory peritoneal dialysis (CAPD) patients. PATIENTS: 153 patients (76 male, 77 female; mean age 46 years) with a mean duration of CAPD of 2.4 years. METHODS: Nasal swabs were taken at approximately 2-month intervals over the mean period of follow-up of 22.6 months and cultured for SA. RESULTS: An average of 69% of patients received systemic antibiotics for therapy of ESI, peritonitis, and other infections during the period of the study, but none received local nasal antibiotics. Four groups of patients were identified according to their nasal carriage history: chronic, intermittent, occasional, and noncarriers. The intermittent and chronic carriers had significantly higher SA ESI than the occasional and noncarrier groups. The intermittent group also had the highest percentage of non-SA ES infections. CONCLUSION: Although this study shows that only half of our CAPD patients with nasal carriage were at risk of developing ESI, we recommend that patients with a positive nasal swab at the start of CAPD therapy should be treated with nasal antibiotics or local antibiotics at the exit site.

Peritoneal dialysate IgG/C3 levels do not predict susceptibility to peritonitis.

OBJECTIVE: To investigate the usefulness of dialysate IgG and C3 concentrations in predicting likelihood of developing peritonitis. DESIGN: Prospective, longitudinal, and comparative study. SETTING: Single university teaching hospital dialysis unit and outpatient clinic. PATIENTS: Thirty-four uremic patients were studied (20 males, 14 females: mean age 47.2, range 20-73 years). Monthly serum and overnight dialysate (eight- to eleven-hour dwell) samples were obtained for IgG and C3 estimations over the first six months of the study, and trimonthly samples were obtained thereafter. All patients performed exchanges using standard transfer sets (Baxter system II, Baxter Healthcare Ltd., Thetford, Norfolk, U.K.), used no hypertonic fluid (3.86%) for overnight exchanges, and were followed up for a minimum of 18 months. OUTCOME MEASURES: Dialysate and serum levels of IgG and C3; peritonitis episodes. RESULTS: Forty-five episodes of peritonitis occurred in 24 patients during the study period. We examined opsonin levels in the group as a whole, and then in two subgroups of patients: those who remained peritonitis-free throughout the study, and those who did not. There were no significant differences between IgG and C3 levels in the two groups at any time point, and large interpatient and intrapatient variation in levels were seen. CONCLUSION: Dialysate levels of IgG and C3 from the overnight dwell are not helpful in predicting the risk of developing continuous ambulatory peritoneal dialysis peritonitis in individual patients. No correlation was found between opsonin levels and onset of clinical peritonitis.

Limitations of the peritoneal equilibration test in prescribing and monitoring dialysis therapy.

Based on correlation analysis with 24-h dialysis collections the peritoneal equilibration test (PET) has been promoted as an aid to prescribe and monitor dialysis dose. However correlation is an incorrect statistical technique to demonstrate the similarity of one measure to another. The closeness (or limits) of agreement should be measured using the technique of Bland and Altman. One hundred and nineteen patients underwent a 24-h dialysate collection and a PET. D/P ratios for urea and creatinine, dialysate volume, urea and creatinine clearance and KT/V (urea) were calculated using both methods and compared using correlation analysis. In addition the limits of agreement, reflecting the potential margins of difference between the two methods, were determined. When used to calculate a daily dialysate volume required to achieve adequacy targets, the PET was found to result in a prescription error range of -0.6 to +1.51/day for creatinine clearance and -0.9 to +0.61/day for urea clearance. The tendency of the PET to exaggerate clearance resulted in 14% of patients incorrectly achieving a target creatinine clearance of 50 1/week and 17% incorrectly reaching a target KT/V of 1.7. The PET cannot be used in place of 24-h dialysis collections to prescribe or monitor dialysis therapy.

The normalized protein catabolic rate is a flawed marker of nutrition in CAPD patients.

For both hemodialysis and CAPD patients nutrition has been linked to mortality. Protein calorie malnutrition is present in 20 to 40% of CAPD patients. The normalized protein catabolic rate (NPCR), has been proposed as a useful measure of dietary protein intake and ultimately nutrition. However, the NPCR value has not been consistently predictive of outcome in CAPD patients. We have performed a cross sectional study on 147 clinically stable CAPD patients, who had a mean dialysis duration 22 months, to evaluate the relationship between the NPCR and conventional markers of nutrition. The NPCR was significantly correlated with normalized models of dialysis adequacy including KT/V (urea), total weekly creatinine clearance and the dialysis index. A significant negative correlation was found between individual anthropometric measures and the NPCR. Using a composite nutritional index to nutritionally categorize our population we found a significantly higher NPCR value in the severely malnourished group. The unadjusted protein catabolic rate (PCR) was significantly correlated with individual nutritional measures and was significantly greater in the well-nourished group. The NPCR, obtained by dividing the PCR by body weight (itself a nutritional measure), is lowest in well-nourished or obese patients, and thus as a marker of nutrition may be flawed. The PCR has nutritional relevance, however, adjusting its value to take into account patient size will require prospective evaluation of the influence of small solute removal on body composition.

Limitations of kinetic models as predictors of nutritional and dialysis adequacy in continuous ambulatory peritoneal dialysis patients.

Nutrition has been shown to predict clinical outcome in continuous ambulatory peritoneal dialysis (CAPD) patients. However, despite the positive relationship between KT/V (urea) and the normalised protein catabolic rate, the ability of urea kinetic modelling to predict clinical outcome or nutrition remains inconclusive. We have evaluated the relationship between nutrition and achieved dialysis in a cross-sectional study of 147 stable CAPD patients on dialysis for a mean period of 22 months. Protein-energy malnutrition was present in 22-32% of the study population. 39 and 41% of the population failed to achieve suggested adequacy targets of 50 liters/week for total creatinine clearance and a weekly KT/V (urea) of 1.7, respectively. Severely malnourished patients had significantly greater normalised clearance and adequacy values than well-nourished patients. Intrinsic actual peritoneal clearance bore no relation to patient size. The subsequent normalisation of this value by a component of patient mass results in a mathematical bias against well-nourished or obese patients. This may explain the failure of such adequacy values to reflect outcome and argues against accepting such values as measures of dialysis well-being.

Imipenem versus netilmicin and vancomycin in the treatment of CAPD peritonitis.

Imipenem/cilastatin is a new thienamycin antibiotic with a broad bactericidal spectrum. We undertook a prospective randomised study to compare the safety and efficacy of intraperitoneal (IP) imipenem/cilastatin (2 gm daily) [group A; 21 patients, mean age 49.2 years] with a combination of IP netilmicin and vancomycin (500 and 60-100 mg daily resp.) [group B; 20 patients, mean age 55.2 years] in CAPD peritonitis. Each patient underwent 4 daily CAPD exchanges with antibiotics in alternate exchanges. The causative organisms were similar in both the groups as was the duration of therapy (gr.A: 6.8 +/- 0.27 days; gr.B: 7.2 +/- 0.51 days; p = NS). Complete cure was marginally better with imipenem/cilastatin (gr.A; 94.1%, gr.B: 83.3%) with less relapses (gr.A: 1 episode; gr.B: 3 episodes). One episode in gr.A (S. aureus) and 2 in gr.B (Yeast & Proteus) failed to resolve and required catheter removal. Two gr. A patients developed generalised convulsions which settled after discontinuation of the drug. Whilst the results show no significant difference in the outcome in the two groups, the use of IP imipenem would offer a possible advantage as a single antibiotic. Larger experience is needed before imipenem can be recommended as a 'blind' first line agent for CAPD peritonitis.

Does catheter immobilization reduce exit-site infections in CAPD patients?

This study was undertaken to ascertain the effectiveness of an immobilization device in reducing exit site infections (ESI) in CAPD patients, and whether immuno-suppressive therapy, diabetes, disconnect system and Staphylococcus aureus nasal carriage had any bearing on the incidence of ESI. Sixty-six patients having a Tenckhoff catheter placement were randomly allocated into one of three groups; immobilizer, tape and non-immobilized group. The groups were monitored for the incidence of ESI over a total period of 347 patient months. The results show no significant difference in infection rates between the three groups, nor do the factors mentioned have any bearing on ESI rate. Whilst immobilization is important, the ineffectiveness of this device was probably related to its design problem.