The incidence of cutaneous squamous cell carcinoma in patients receiving voriconazole therapy for chronic pulmonary aspergillosis.

Voriconazole has been associated with cutaneous squamous cell carcinoma (cSCC) in transplant patients but less is known about the risk in less severely immunosuppressed patients. Our aim was to estimate the incidence of cSCC after voriconazole exposure in patients with chronic pulmonary aspergillosis on a background of chronic lung disease. The notes of patients seen at a tertiary referral centre from 2009 to 2019 with chronic pulmonary aspergillosis were reviewed for the diagnosis of cSCC and voriconazole use documented. Among 1111 patients, 668 (60.1%) received voriconazole for longer than 28 days. Twelve patients received a diagnosis of cSCC; nine had used voriconazole. Mean duration of voriconazole use was 36.7 months. The crude incidence rate was 4.88 in 1000 person/years in those who had voriconazole and 2.79 in 1000 patient/years in those who did not receive voriconazole for longer than 28 days. On Cox regression, age (HR 1.09, 95% CI 1.02-1.16, p = 0.01) and male gender (HR 3.97, 95% CI 0.84-18.90, p = 0.082) were associated with cSCC. Voriconazole use was associated with a slightly increased risk, which was not significant (HR 1.35, 95% CI 0.35-5.20, p = 0.659). Voriconazole use beyond 28 days did not lead to a significantly increased risk of cSCC in a large cohort of patients with chronic pulmonary aspergillosis.

Burden of hereditary cancer susceptibility in unselected patients with pancreatic ductal adenocarcinoma referred for germline screening.

BACKGROUND: Recent guidelines recommend consideration of germline testing for all newly diagnosed pancreatic ductal adenocarcinoma (PDAC). The primary aim of this study was to determine the burden of hereditary cancer susceptibility in PDAC. A secondary aim was to compare genetic testing uptake rates across different modes of genetic counselling. PATIENTS AND METHODS: All patients diagnosed with PDAC in the province of British Columbia, Canada referred to a population-based hereditary cancer program were eligible for multi-gene panel testing, irrespective of cancer family history. Any healthcare provider or patients themselves could refer. RESULTS: A total of 305 patients with PDAC were referred between July 2016 and January 2019. Two hundred thirty-five patients attended a consultation and 177 completed index germline genetic testing. 25/177 (14.1%) of unrelated patients had a pathogenic variant (PV); 19/25 PV were in known PDAC susceptibility genes with cancer screening or risk-reduction implications. PDAC was significantly associated with PV in ATM (OR, 7.73; 95% CI, 3.10 to 19.33, P = 6.14E-05) when comparing age and gender and ethnicity-matched controls tested on the same platform. The overall uptake rate for index testing was 59.2% and was significantly higher with 1-on-1 consultations and group consultations compared to telehealth consultations (88.9% vs 82.9% vs 61.8%, P < .001). CONCLUSION: In a prospective clinic-based cohort of patients with PDAC referred for testing irrespective of family history, germline PV were detected in 14.1%. PV in ATM accounted for half of all PVs and were significantly associated with PDAC. These findings support recent guidelines and will guide future service planning in this population.

Help from home for depression: A randomised controlled trial comparing internet-delivered cognitive behaviour therapy with bibliotherapy for depression.

Major Depressive Disorder (MDD) is a leading cause of the Global Burden of Disease. Cognitive Behavioural Therapy (CBT) is an effective treatment for MDD, but access can be impaired due to numerous barriers. Internet-delivered CBT (iCBT) can be utilised to overcome treatment barriers and is an effective treatment for depression, but has never been compared to bibliotherapy. This Randomised Controlled Trial (RCT) included participants meeting diagnostic criteria for MDD (n = 270) being randomised to either: iCBT (n = 61), a CBT self-help book (bCBT) (n = 77), a meditation self-help book (bMED) (n = 64) or wait-list control (WLC) (n = 68). The primary outcome was the Patient Health Questionnaire 9-item scale (PHQ-9) at 12-weeks (post-treatment). All three active interventions were significantly more effective than WLC in reducing depression at post-treatment, but there were no significant differences between the groups. All three interventions led to large within-group reductions in PHQ-9 scores at post-treatment (g = 0.88-1.69), which were maintained at 3-month follow-up, although there was some evidence of relapse in the bMED group (within-group g [post to follow-up] = 0.09-1.04). Self-help based interventions could be beneficial in treating depression, however vigilance needs to be applied when selecting from the range of materials available. Replication of this study with a larger sample is required.

Do Demographic Factors Influence Uveitis Patients' Understanding of Uveitis?

PURPOSE: To establish how much uveitis patients know about their own condition and to investigate the contribution of demographic factors to that knowledge. METHODS: A self-designed questionnaire, comprising 20 questions about uveitis, was distributed to 200 consecutive patients attending a uveitis clinic. The questionnaire requested demographic details and required responses to uveitis-specific knowledge questions. Postcode was used to determine level of social deprivation using Index of Multiple Deprivation 2007. Univariate analyses with the Mann-Whitney test and Kruskal-Wallis test were utilized. Multivariable logistic regression was performed to simultaneously measure the independent influence of demographic variables on the level of patients' understanding of their condition. RESULTS: Of the respondents, 62% were female, 71% aged >40 years and 67% of white ethnic origin, with 41% having been under the care of a uveitis specialist for >10 years and 72% attending ≥3 clinic appointments in the preceding 12 months. Median questionnaire score (out of 60) was 27 (interquartile range, IQR 15). Females scored significantly higher than males (30 vs 24; p = 0.001), but there was no difference according to age, ethnicity, or social deprivation quintile, nor the duration patients had been under ophthalmic review or number of clinic attendances in the preceding 12 months. Multivariable analyses determined no independent influence of any of the factors on the uveitis questionnaire score. CONCLUSIONS: Uveitis patients' understanding of their condition is poor. This has relevance for adherence to treatment, follow-up clinic attendance, and eventual outcomes in these patients.

Internet cognitive-behavioural treatment for panic disorder: randomised controlled trial and evidence of effectiveness in primary care.

BACKGROUND: Internet cognitive-behavioural therapy (iCBT) for panic disorder of up to 10 lessons is well established. The utility of briefer programmes is unknown. AIMS: To determine the efficacy and effectiveness of a five-lesson iCBT programme for panic disorder. METHOD: Study 1 (efficacy): Randomised controlled trial comparing active iCBT (n=27) and waiting list control participants (n=36) on measures of panic severity and comorbid symptoms. Study 2 (effectiveness): 330 primary care patients completed the iCBT programme under the supervision of primary care practitioners. RESULTS: iCBT was significantly more effective than waiting list control in reducing panic (g=0.97, 95% CI 0.34 to 1.61), distress (g=0.92, 95% CI 0.28 to 1.55), disability (g=0.81, 95% CI 0.19 to 1.44) and depression (g=0.79, 95% CI 0.17 to 1.41), and gains were maintained at 3 months post-treatment (iCBT group). iCBT remained effective in primary care, but lower completion rates were found (56.1% in study 2 v. 63% in study 1). Adherence appeared to be related to therapist contact. CONCLUSIONS: The five-lesson Panic Program has utility for treating panic disorder, which translates to primary care. Adherence may be enhanced with therapist contact. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Internet cognitive behavioural treatment for obsessive compulsive disorder: A randomised controlled trial.

Internet-based cognitive behaviour therapy (iCBT) is becoming increasing accepted as an efficacious and effective treatment for the anxiety and depressive disorders. However few studies have examined the efficacy of iCBT for obsessive compulsive disorder (OCD). This randomised controlled trial compared technician-administered iCBT (n = 32) to a treatment as usual (TAU) control group (n = 35) in patients with OCD. The primary outcome measures were the Dimensional Obsessive-Compulsive Scale (DOCS) and the Obsessional Beliefs Questionnaire (OBQ-20) administered at pre- and post-treatment (or matched time points). The iCBT group was followed-up at 3-months post-treatment when diagnostic status was assessed at clinical interview. The iCBT program was more efficacious than TAU in reducing maladaptive OC beliefs as well as symptoms of OCD, distress, and depression, with large within- and between-groups effect sizes found (>.78). Adherence was high (75%) and gains were maintained at 3 month-follow-up with 54% of treatment completers no longer meeting diagnostic criteria for OCD at follow-up. These results are comparable to outcomes obtained by clinician-administered face-to-face and internet-based programs and suggest that iCBT for OCD is efficacious when administered by a clinically-supervised technician. Future research is now needed to evaluate how effective iCBT for OCD is in routine clinical settings.

Occupational impact of internet-delivered cognitive behaviour therapy for depression and anxiety: reanalysis of data from five Australian randomised controlled trials.

OBJECTIVE: To determine whether internet-delivered cognitive behaviour therapy (iCBT) for depression and anxiety reduces self-reported absenteeism in employed individuals. DESIGN, PARTICIPANTS AND SETTING: We reanalysed data from five randomised controlled trials of iCBT: two for depression (conducted from September 2008 to February 2009 and from June 2009 to January 2010), two for generalised anxiety disorder (conducted from March 2009 to June 2009 and from July 2009 to January 2010) and one for social phobia (conducted from May 2008 to July 2008). Participants across Australia were recruited via a website. The inclusion criteria were: (i) meets criteria for the disorder of interest; (ii) aged 18 years or over; (iii) no previous history of a psychotic disorder or drug or alcohol misuse; (iv) not actively suicidal. The iCBT courses each consisted of six online lessons (to be completed within 11 weeks), homework assignments, automatic emails and resource documents. MAIN OUTCOME MEASURE: The number of days absent (self-reported absenteeism) in the previous week. RESULTS: We included 284 participants in our analysis. When data for the three disorders were combined, participants who received iCBT had significant reductions in self-reported absenteeism compared with those in the control groups (who were on a waitlist) (P = 0.03). When data for the three disorders were analysed separately, reductions in self-reported absenteeism for participants who received iCBT were not significantly different to those for participants in the control groups. CONCLUSION: Using data from five RCTs, we showed that iCBT was associated with reductions in self-reported absenteeism. Future research should focus on replicating these findings in other contexts, such as other disorders and other iCBT courses.

Combining imagination and reason in the treatment of depression: a randomized controlled trial of internet-based cognitive-bias modification and internet-CBT for depression.

OBJECTIVE: Computerized cognitive-bias modification (CBM) protocols are rapidly evolving in experimental medicine yet might best be combined with Internet-based cognitive behavioral therapy (iCBT). No research to date has evaluated the combined approach in depression. The current randomized controlled trial aimed to evaluate both the independent effects of a CBM protocol targeting imagery and interpretation bias (CBM-I) and the combined effects of CBM-I followed by iCBT. METHOD: Patients diagnosed with a major depressive episode were randomized to an 11-week intervention (1 week/CBM-I + 10 weeks/iCBT; n = 38) that was delivered via the Internet with no face-to-face patient contact or to a wait-list control (WLC; n = 31). RESULTS: Intent-to-treat marginal models using restricted maximum likelihood estimation demonstrated significant reductions in primary measures of depressive symptoms and distress corresponding to medium-large effect sizes (Cohen's d = 0.62-2.40) following CBM-I and the combined (CBM-I + iCBT) intervention. Analyses demonstrated that the change in interpretation bias at least partially mediated the reduction in depression symptoms following CBM-I. Treatment superiority over the WLC was also evident on all outcome measures at both time points (Hedges gs = .59-.98). Significant reductions were also observed following the combined intervention on secondary measures associated with depression: disability, anxiety, and repetitive negative thinking (Cohen's d = 1.51-2.23). Twenty-seven percent of patients evidenced clinically significant change following CBM-I, and this proportion increased to 65% following the combined intervention. CONCLUSIONS: The current study provides encouraging results of the integration of Internet-based technologies into an efficacious and acceptable form of treatment delivery. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

CBT for depression: a pilot RCT comparing mobile phone vs. computer.

BACKGROUND: This paper reports the results of a pilot randomized controlled trial comparing the delivery modality (mobile phone/tablet or fixed computer) of a cognitive behavioural therapy intervention for the treatment of depression. The aim was to establish whether a previously validated computerized program (The Sadness Program) remained efficacious when delivered via a mobile application. METHOD: 35 participants were recruited with Major Depression (80% female) and randomly allocated to access the program using a mobile app (on either a mobile phone or iPad) or a computer. Participants completed 6 lessons, weekly homework assignments, and received weekly email contact from a clinical psychologist or psychiatrist until completion of lesson 2. After lesson 2 email contact was only provided in response to participant request, or in response to a deterioration in psychological distress scores. The primary outcome measure was the Patient Health Questionnaire 9 (PHQ-9). Of the 35 participants recruited, 68.6% completed 6 lessons and 65.7% completed the 3-months follow up. Attrition was handled using mixed-model repeated-measures ANOVA. RESULTS: Both the Mobile and Computer Groups were associated with statistically significantly benefits in the PHQ-9 at post-test. At 3 months follow up, the reduction seen for both groups remained significant. CONCLUSIONS: These results provide evidence to indicate that delivering a CBT program using a mobile application, can result in clinically significant improvements in outcomes for patients with depression. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN 12611001257954.

Personal maternal care reflections of general practice physicians.

BACKGROUND: As the number of female GPs increases, the need to understand delivery of maternity care to this group becomes increasingly important. Previous literature suggests doctors face additional barriers in utilizing health care compared to other patients, but little is known about GPs' maternal health care experiences and whether their occupation facilitates or compromises care. OBJECTIVE: To explore female GPs' personal experiences of maternal health care and how occupation affects care received. METHODS: Female GPs with children aged 6 months to 5 years were recruited from South Birmingham Primary Care Trust with subsequent snowballing. Data were obtained using semi-structured interviews and constant comparison analysis was applied to develop themes and categories. RESULTS: Fourteen GPs participated and no new themes emerged after interview 10 suggesting data saturation was achieved. Overall, GPs felt they received better care due to their occupation and where established relationships between the GP and the health care professional existed, communication and care satisfaction was enhanced. However, assumptions about knowledge led to reduced information provision and some problems in care provision, especially during labour and early motherhood when women were most vulnerable and unable to rely on work skills to address information deficits. CONCLUSION: This research supports the growing body of evidence that there are unique problems facing doctor-patients and clinicians treating them. However, contrary to expectations derived from anecdotal evidence, GPs indicated that care was enhanced due to their occupation. This study raises awareness of areas for consideration when female GPs approach pregnancy and health care professionals deliver maternal health care.

Reach Out! Innovation in service delivery.

With 75% of mental illness beginning before 25 years of age, it is essential that we improve young people's capacity to manage adversity and increase their opportunities for accessing professional help. With its unique ability to connect people to information and to other people, the Internet offers opportunities to engage the 70% of young people with mental health problems who currently are not seeking professional help. Reach Out! is a national Internet-based mental health service for young people. It has been accessed by over 6 million users since its launch in 1998. Reach Out! plays a role in the prevention of mental health problems by: facilitating help-seeking and connecting young people with services, such as general practitioners, and allied and mental health professionals in their local communities; and providing opportunities for all young people to develop the skills and capacity to better understand mental health difficulties and manage adversity, thereby complementing traditional support.