Pragmatic randomised controlled trial of guided self-help versus individual cognitive behavioural therapy with a trauma focus for post-traumatic stress disorder (RAPID).

Background: Guided self-help has been shown to be effective for other mental conditions and, if effective for post-traumatic stress disorder, would offer a time-efficient and accessible treatment option, with the potential to reduce waiting times and costs. Objective: To determine if trauma-focused guided self-help is non-inferior to individual, face-to-face cognitive-behavioural therapy with a trauma focus for mild to moderate post-traumatic stress disorder to a single traumatic event. Design: Multicentre pragmatic randomised controlled non-inferiority trial with economic evaluation to determine cost-effectiveness and nested process evaluation to assess fidelity and adherence, dose and factors that influence outcome (including context, acceptability, facilitators and barriers, measured qualitatively). Participants were randomised in a 1 : 1 ratio. The primary analysis was intention to treat using multilevel analysis of covariance. Setting: Primary and secondary mental health settings across the United Kingdom's National Health Service. Participants: One hundred and ninety-six adults with a primary diagnosis of mild to moderate post-traumatic stress disorder were randomised with 82% retention at 16 weeks and 71% at 52 weeks. Nineteen participants and ten therapists were interviewed for the process evaluation. Interventions: Up to 12 face-to-face, manualised, individual cognitive-behavioural therapy with a trauma focus sessions, each lasting 60-90 minutes, or to guided self-help using Spring, an eight-step online guided self-help programme based on cognitive-behavioural therapy with a trauma focus, with up to five face-to-face meetings of up to 3 hours in total and four brief telephone calls or e-mail contacts between sessions. Main outcome measures: Primary outcome: the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, at 16 weeks post-randomisation. Secondary outcomes: included severity of post-traumatic stress disorder symptoms at 52 weeks, and functioning, symptoms of depression, symptoms of anxiety, alcohol use and perceived social support at both 16 and 52 weeks post-randomisation. Those assessing outcomes were blinded to group assignment. Results: Non-inferiority was demonstrated at the primary end point of 16 weeks on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [mean difference 1.01 (one-sided 95% CI -∞ to 3.90, non-inferiority p = 0.012)]. Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, score improvements of over 60% in both groups were maintained at 52 weeks but the non-inferiority results were inconclusive in favour of cognitive-behavioural therapy with a trauma focus at this timepoint [mean difference 3.20 (one-sided 95% confidence interval -∞ to 6.00, non-inferiority p = 0.15)]. Guided self-help using Spring was not shown to be more cost-effective than face-to-face cognitive-behavioural therapy with a trauma focus although there was no significant difference in accruing quality-adjusted life-years, incremental quality-adjusted life-years -0.04 (95% confidence interval -0.10 to 0.01) and guided self-help using Spring was significantly cheaper to deliver [£277 (95% confidence interval £253 to £301) vs. £729 (95% CI £671 to £788)]. Guided self-help using Spring appeared to be acceptable and well tolerated by participants. No important adverse events or side effects were identified. Limitations: The results are not generalisable to people with post-traumatic stress disorder to more than one traumatic event. Conclusions: Guided self-help using Spring for mild to moderate post-traumatic stress disorder to a single traumatic event appears to be non-inferior to individual face-to-face cognitive-behavioural therapy with a trauma focus and the results suggest it should be considered a first-line treatment for people with this condition. Future work: Work is now needed to determine how best to effectively disseminate and implement guided self-help using Spring at scale. Trial registration: This trial is registered as ISRCTN13697710. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/97) and is published in full in Health Technology Assessment; Vol. 27, No. 26. See the NIHR Funding and Awards website for further award information.

Post-traumatic stress disorder is a common, disabling condition that can occur following major traumatic events. Typical symptoms include distressing reliving, avoidance of reminders and feeling a current sense of threat. First-choice treatments for post-traumatic stress disorder are individual, face-to-face talking treatments, of 12­16 hours duration, including cognitive behavioural therapy with a trauma focus. If equally effective treatments could be developed that take less time and can be largely undertaken in a flexible manner at home, this would improve accessibility, reduce waiting times and hence the burden of disease. RAPID was a randomised controlled trial using a web-based programme called Spring. The aim was to determine if trauma-focused guided self-help provided a faster and cheaper treatment for post-traumatic stress disorder than first-choice face-to-face therapy, while being equally effective. Guided self-help using Spring is delivered through eight steps. A therapist provides a 1-hour introductory meeting followed by four further, fortnightly sessions of 30 minutes each and four brief (around 5 minutes) telephone calls or e-mail contacts between sessions. At each session, the therapist reviews progress and guides the client through the programme, offering continued support, monitoring, motivation and problem-solving. One hundred and ninety-six people with post-traumatic stress disorder to a single traumatic event took part in the study. Guided self-help using Spring was found to be equally effective to first-choice face-to-face therapy at reducing post-traumatic stress disorder symptoms at 16 weeks. Very noticeable improvements were maintained at 52 weeks post-randomisation in both groups, when most results were inconclusive but in favour of face-to-face therapy. Guided self-help using Spring was significantly cheaper to deliver and appeared to be well-tolerated. It is noteworthy that not everyone benefitted from guided self-help using Spring, highlighting the importance of considering it on a person-by-person basis, and personalising interventions. But, the RAPID trial has demonstrated that guided self-help using Spring provides a low-intensity treatment option for people with post-traumatic stress disorder that is ready to be implemented in the National Health Service.

Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID).

OBJECTIVE: To determine if guided internet based cognitive behavioural therapy with a trauma focus (CBT-TF) is non-inferior to individual face-to-face CBT-TF for mild to moderate post-traumatic stress disorder (PTSD) to one traumatic event. DESIGN: Pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID). SETTING: Primary and secondary mental health settings across the UK's NHS. PARTICIPANTS: 196 adults with a primary diagnosis of mild to moderate PTSD were randomised in a 1:1 ratio to one of two interventions, with 82% retention at 16 weeks and 71% retention at 52 weeks. 19 participants and 10 therapists were purposively sampled and interviewed for evaluation of the process. INTERVENTIONS: Up to 12 face-to-face, manual based, individual CBT-TF sessions, each lasting 60-90 minutes; or guided internet based CBT-TF with an eight step online programme, with up to three hours of contact with a therapist and four brief telephone calls or email contacts between sessions. MAIN OUTCOME MEASURES: Primary outcome was the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at 16 weeks after randomisation (diagnosis of PTSD based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, DSM-5). Secondary outcomes included severity of PTSD symptoms at 52 weeks, and functioning, symptoms of depression and anxiety, use of alcohol, and perceived social support at 16 and 52 weeks after randomisation. RESULTS: Non-inferiority was found at the primary endpoint of 16 weeks on the CAPS-5 (mean difference 1.01, one sided 95% confidence interval -∞ to 3.90, non-inferiority P=0.012). Improvements in CAPS-5 score of more than 60% in the two groups were maintained at 52 weeks, but the non-inferiority results were inconclusive in favour of face-to-face CBT-TF at this time point (3.20, -∞ to 6.00, P=0.15). Guided internet based CBT-TF was significantly (P<0.001) cheaper than face-to-face CBT-TF and seemed to be acceptable and well tolerated by participants. The main themes of the qualitative analysis were facilitators and barriers to engagement with guided internet based CBT-TF, treatment outcomes, and considerations for its future implementation. CONCLUSIONS: Guided internet based CBT-TF for mild to moderate PTSD to one traumatic event was non-inferior to individual face-to-face CBT-TF and should be considered a first line treatment for people with this condition. TRIAL REGISTRATION: ISRCTN13697710.

Muscular Strength, Power, and Endurance Adaptations after Two Different University Fitness Classes.

Physical activity (PA) classes help college students add weekly PA, which can help improve health and maintain body weight. Traditional weight training (TWT) can improve strength and aerobic capacity. High-intensity functional training such as CrossFit® (CF) provides time-efficient workouts with both muscle strengthening and aerobic exercises. Limited research has compared these classes for college students. We examined changes in muscular strength, power, and endurance as well as body composition. Participants were 85 healthy college students enrolled in TWT (n = 36, age 22.6 ± 4.1 years, 72.2% male) or CF (n = 49, age 21.8 ± 3.2 years, 55.1% male) classes meeting twice/wk for 8 weeks between October 2017 and May 2018. Baseline and posttest measurements included a vertical jump, grip strength, a 2 min push-up test, a 1 min squat test, height, weight, and a bioelectrical impedance analysis. Although no significant group × time interactions were found, there was a significant main effect of time for push-ups and squats (both p < 0.001). Participants enjoyed the classes and most planned to continue. Both classes improved muscular endurance although no significant differences were found between them. Activity classes provide college students with an option for increasing their weekly PA and help maintain body composition. Future research should examine the benefits from longer or more frequent classes.

Marine phytoplankton responses to oil and dispersant exposures: Knowledge gained since the Deepwater Horizon oil spill.

The Deepwater Horizon oil spill of 2010 brought the ecology and health of the Gulf of Mexico to the forefront of the public's and scientific community's attention. Not only did we need a better understanding of how this oil spill impacted the Gulf of Mexico ecosystem, but we also needed to apply this knowledge to help assess impacts from perturbations in the region and guide future response actions. Phytoplankton represent the base of the food web in oceanic systems. As such, alterations of the phytoplankton community propagate to upper trophic levels. This review brings together new insights into the influence of oil and dispersant on phytoplankton. We bring together laboratory, mesocosm and field experiments, including insights into novel observations of harmful algal bloom (HAB) forming species and zooplankton as well as bacteria-phytoplankton interactions. We finish by addressing knowledge gaps and highlighting key topics for research in novel areas.

Multiple Fitness Improvements Found after 6-Months of High Intensity Functional Training.

While short-term high intensity functional training (HIFT) effects have been established, fitness improvements from program participation exceeding 16 weeks are unknown. This study examined the effectiveness of participation in HIFT through CrossFit. During 2013-2014, fitness performance testing was incorporated into an ongoing university CrossFit program. Participants included 45 adults (23 women, 22 men) with 0-27 months of HIFT experience (grouped into 0-6 months and 7+ months). Participants completed three separate days of assessments across 10 fitness domains before and after participating in the program for six months. For each sex, 2 (Time) × 2 (Group) RANOVA were used for each fitness test. For women, significant Time effects were found for four fitness domains (i.e., flexibility, power, muscular endurance, and strength), and a Group × Time interaction for cardiorespiratory endurance, with the 0-6-month group improving more. For men, significant Time effects were found for flexibility, muscular endurance, and strength. These data provide evidence for multiple fitness improvements after six months of CrossFit participation with greater 1.5 mile run time improvement among women with less experience.

Oil Spills and Dispersants Can Cause the Initiation of Potentially Harmful Dinoflagellate Blooms ("Red Tides").

After oil spills and dispersant applications the formation of red tides or harmful algal blooms (HABs) has been observed, which can cause additional negative impacts in areas affected by oil spills. However, the link between oil spills and HABs is still unknown. Here, we present experimental evidence that demonstrates a connection between oil spills and HABs. We determined the effects of oil, dispersant-treated oil, and dispersant alone on the structure of natural plankton assemblages in the Northern Gulf of Mexico. In coastal waters, large tintinnids and oligotrich ciliates, major grazers of phytoplankton, were negatively affected by the exposure to oil and dispersant, whereas bloom-forming dinoflagellates ( Prorocentrum texanum, P. triestinum, and Scrippsiella trochoidea) notably increased their concentration. The removal of key grazers due to oil and dispersant disrupts the predator-prey controls ("top-down controls") that normally function in plankton food webs. This disruption of grazing pressure opens a "loophole" that allows certain dinoflagellates with higher tolerance to oil and dispersants than their grazers to grow and form blooms when there are no growth limiting factors (e.g., nutrients). Therefore, oil spills and dispersants can act as disrupters of predator-prey controls in plankton food webs and as indirect inducers of potentially harmful dinoflagellate blooms.

Pragmatic RAndomised controlled trial of a trauma-focused guided self-help Programme versus InDividual trauma-focused cognitive Behavioural therapy for post-traumatic stress disorder (RAPID): trial protocol.

BACKGROUND: There is good evidence that trauma-focused therapies for Post-Traumatic Stress Disorder are effective. However, they are not always feasible to deliver due a shortage of trained therapists and demands on the patient. An online trauma-focused Guided Self-Help (GSH) programme which could overcome these barriers has shown promise in a pilot study. This study will be the first to evaluate GSH against standard face-to-face therapy to assess its suitability for use in the NHS. METHODS: The study is a large-scale multi-centre pragmatic randomised controlled non-inferiority trial, with assessors masked to treatment allocation. One hundred and ninety-two participants will be randomly allocated to receive either face-to-face trauma-focused cognitive behaviour therapy (TFCBT) or trauma-focused online guided self-help (GSH). The primary outcome will be the severity of symptoms of PTSD over the previous week as measured by the Clinician Administered PTSD Scale for DSM5 (CAPS-5) at 16 weeks post-randomisation. Secondary outcome measures include PTSD symptoms over the previous month as measured by the CAPS-5 at 52 weeks plus the Impact of Event Scale - revised (IES-R), Work and Social Adjustment Scale (WSAS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Test (AUDIT-O), Multidimensional Scale for Perceived Social Support (MSPSS), short Post-Traumatic Cognitions Inventory (PTCI), Insomnia Severity Index (ISI) and General Self Efficacy Scale (GSES) measured at 16 and 52 weeks post-randomisation. Changes in health-related quality of life will be measured by the EQ-5D and the level of healthcare resource utilisation for health economic analysis will be determined by an amended version of the Client Socio-Demographic and Service Receipt Inventory European Version. The Client Satisfaction Questionnaire (CSQ) will be collected at 16 weeks post-randomisation to evaluate treatment satisfaction. DISCUSSION: This study will be the first to compare online GSH with usual face-to-face therapy for PTSD. The strengths are that it will test a rigorously developed intervention in a real world setting to inform NHS commissioning. The potential challenges of delivering such a pragmatic study may include participant recruitment, retention and adherence, therapist retention, and fidelity of intervention delivery. TRIAL REGISTRATION: ISRCTN13697710 registered on 20/12/2016.

Mapping Coaches' Views of Participation in CrossFit to the Integrated Theory of Health Behavior Change and Sense of Community.

Group-based training through CrossFit has recently exploded in popularity. Anecdotally, participants often make lifestyle changes and experience improved fitness. Participation factors were mapped to the Integrated Theory of Health Behavior Change and "sense of community" constructs. Key informant interviews were conducted with 6 CrossFit gym owners/coaches. Data were thematically coded with NVivo 10. Results revealed key factors that both facilitated and restricted participation in CrossFit. Findings provide implications for future theory application and highlight how to improve initiation and adherence by capitalizing on community building and taking steps to reduce intimidation and cost, facilitate realistic goals, and ensure social support.

The influence of bloom intensity on the encystment rate and persistence of Alexandrium minutum in Cork Harbor, Ireland.

Toxic Alexandrium minutum blooms recur annually in Cork Harbor, Ireland where they initiate in an inlet known as the North Channel. The dynamics of these blooms have been studied since 2003, and a high degree of inter-annual variability in the cell densities has been observed. Two intense blooms, with maximum cell densities >500,000cellsL-1, were observed in the summers of 2004 and 2011. Annual cyst surveys during winter found that cyst densities decreased after the 2004 bloom, and by 2010 an average of ca. 40 cystsg dry wt sediment-1 was recorded. The intensity of blooms was found to be independent of the cyst density measured the previous winter. The cyst input to the sediment during both intense and low density blooms was measured directly through the deployment of sediment traps in the North Channel. The data allowed an estimate of the proportion of the A. minutum vegetative cells that underwent successful encystment, which averaged at 2.5% across a range of cell densities spanning three orders of magnitude. Maturation times of fresh cysts were determined at 5, 10 and 15°C. The maturation time at 15°C was found to be approximately 5 months, a value which increased by two months for a 5° decrease in temperature. A cyst dynamics model was constructed based on the field data to simulate the temporal variation of A. minutum cysts in the oxic layer of sediment. It revealed that a degree of resuspension is required to prevent cyst stocks from becoming exhausted in the thin oxic layer at the surface of the sediment. The model also demonstrated that the cysts supplied by periodic intense blooms, which occur with a frequency of every 7-8 years, are not in themselves enough to allow the population to persist over long time scales (decades). The cyst input from interim blooms of lower density is however enough to ensure the annual inoculation of the water column with A. minutum cells.