Partner symptom accommodation in generalized anxiety disorder: a preliminary examination of correlates with symptoms and cognitive behavioural therapy outcome.

BACKGROUND: Symptom accommodation is suggested to maintain anxiety pathology and interfere with treatment effectiveness for anxiety and related disorders. However, little is known about symptom accommodation in generalized anxiety disorder (GAD). AIM: This study investigated the associations between romantic partner symptom accommodation, GAD symptoms, intolerance of uncertainty (IU), relationship satisfaction, and cognitive behavioural therapy (CBT) outcomes from the perspective of the person with GAD. METHOD: One hundred and twelve people with GAD participated in group CBT and completed measures at pre- and post-treatment. RESULTS: All participants endorsed that their partner engaged in symptom accommodation to some extent, and the most commonly endorsed type was providing reassurance. Greater self-reported partner symptom accommodation was associated with greater GAD symptoms, chronic worry severity, IU, and relationship satisfaction at baseline. Partner symptom accommodation was found to significantly decrease over treatment; however, less improvement in symptom accommodation from pre- to post-treatment was associated with worse treatment outcomes. DISCUSSION: This study is the first to show that partner symptom accommodation is prevalent in adults with GAD and to elucidate the presentation and frequency of behaviours. The findings provide preliminary evidence that targeting partner symptom accommodation in treatment may improve CBT outcomes.

Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting.

BACKGROUND: Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings. AIM: This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic. METHOD: Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly. RESULTS: Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time. DISCUSSION: These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

Optimizing screening for depression, anxiety disorders, and post-traumatic stress disorder in inpatient addiction treatment: A preliminary investigation.

OBJECTIVE: Substance use disorders (SUD) are frequently comorbid with other psychiatric conditions, but a comprehensive diagnostic assessment is often not feasible clinically. Efficient psychometrically-validated screening tools exist for commonly comorbid conditions, but cutoff accuracies have typically not been evaluated in addiction treatment settings. This study examined the performance of several widely-used screening measures in relation to diagnostic status from a clinical interview to identify and validate cutoff scores in an inpatient SUD treatment setting. METHOD: Participants were 99 patients in a large residential SUD treatment program in Ontario, Canada. Participants completed a screening battery, including the Patient Health Questionnaire - 9 (PHQ-9), Generalized Anxiety Disorder - 7 (GAD-7), and Post-Traumatic Stress Disorder Checklist-5 (PCL-5), and underwent a semi-structured diagnostic clinical interview. Receiver operating characteristic curves were used to determine optimal cutoff scores on the screening tool against the interview-based diagnosis. RESULTS: Area under the curve (AUC) was statistically significant for all screens and were as follows: PHQ-9 = 0.70 (95% CI = 0.59-0.80), GAD-7 = 0.74 (95% CI = 0.63-0.84), and PCL-5 = 0.79 (95% CI = 0.66-0.91). The optimal accuracy cutoff scores based on sensitivity and specificity were: PHQ-9 ≥ 16, GAD-7 ≥ 9, the PCL-5 ≥ 42. CONCLUSIONS: In general, the candidate screeners performed acceptably in this population. However, the optimal cutoff scores were notably higher than existing guidelines for depression and PTSD, potentially due to the general elevations in negative affectivity among individuals initiating SUD treatment. Further validation of these cutoff values is warranted. PUBLIC HEALTH SIGNIFICANCE: This study provides modified screening cutoff scores for major depression, anxiety disorders, and post-traumatic stress disorder in addiction treatment settings.

Objective and subjective vasomotor symptom outcomes in the CBT-Meno randomized controlled trial.

Objective: Vasomotor symptoms (hot flashes, night sweats) are common during the menopausal transition. Pharmacotherapy is effective but is associated with health risks for some women. There is an increasing demand for non-pharmacological interventions. The CBT-Meno protocol is a psychological intervention targeting a range of common menopausal symptoms. We compared the impact of CBT-Meno vs. waitlist on objective and subjective measures of vasomotor symptoms and on the relationship between vasomotor symptoms and sleep difficulties.Materials: The participants were 36 perimenopausal or postmenopausal women with co-occurring depressive symptoms who participated in the CBT-Meno trial (clinicaltrials.gov NCT02480192). Subjective measures included the Hot Flash Related Daily Interference Scale, the Greene Climacteric Scale, and the Pittsburgh Sleep Quality Inventory. Objective (physiological) and 'in-the-moment' measures of vasomotor symptoms were assessed with sternal skin conductance.Results: Greater improvements in vasomotor 'bothersomeness' and 'interference' were observed in the CBT-Meno condition compared to the waitlist condition. No between-group differences were observed in vasomotor frequency (subjectively or objectively recorded) or severity ratings. Sleep disturbance was unrelated to objectively measured vasomotor symptom frequency.Conclusion: The CBT-Meno trial improved subjective but not objective (physiological) measures of vasomotor symptoms. Self-reported sleep difficulties were unrelated to subjective or objective vasomotor symptoms.

Patient coping and expectations predict recovery after major orthopaedic trauma.

BACKGROUND: Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. METHODS: We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 yr. RESULTS: Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high (≥74) SPOC scores [odds ratio: 5.63; 99% confidence interval (CI): 3.59-8.84; absolute risk increase 40.6%; 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06; 99% CI: 3.97-9.25; absolute risk increase: 18.3%; 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. CONCLUSIONS: Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr. CLINICAL TRIAL REGISTRATION: NCT00788398.

Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials.

BACKGROUND: Persistent post-surgical pain affects 10-80% of individuals after common operations, and is more common among patients with psychological factors such as depression, anxiety, or catastrophising. METHODS: We conducted a systematic review and meta-analysis of randomised, controlled trials to evaluate the efficacy of perioperative psychotherapy for persistent post-surgical pain and physical impairment. Paired independent reviewers identified studies, extracted data, and assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluation system was used to assess the quality of evidence. RESULTS: Our search of five electronic databases, up to September 1, 2016, found 15 trials (2220 patients) that were eligible for review. For both persistent post-surgical pain and physical impairment, perioperative education was ineffective, while active psychotherapy suggested a benefit (test of interaction P=0.01 for both outcomes). Moderate quality evidence showed that active perioperative psychotherapy (cognitive-behaviour therapy, relaxation therapy, or both) significantly reduced persistent post-surgical pain [weighted mean difference (WMD) -1.06 cm on a 10 cm visual analogue scale for pain, 95% confidence interval (CI) -1.56 to -0.55 cm; risk difference (RD) for achieving no more than mild pain (≤3 cm) 14%, 95% CI 8-21%] and physical impairment [WMD -9.87% on the 0-100% Oswestry Disability Index, 95% CI -13.42 to -6.32%, RD for achieving no more than mild disability (≤20%) 21%, 95% CI 13-29%]. CONCLUSIONS: Perioperative cognitive behavioural therapy and relaxation therapy are effective for reducing persistent pain and physical impairment after surgery. Future studies should explore targeted psychotherapy for surgical patients at higher risk for poor outcome. CLINICAL TRIAL REGISTRATION: PROSPERO CRD42016047335.

Effect of distraction and coping style on in vivo exposure for specific phobia of spiders.

Recent studies have generated mixed findings regarding the effects of distraction on exposure-based treatments. Results have also been inconsistent regarding the effects of monitoring and blunting coping styles on outcome. The present study attempted to integrate these two areas of research. We hypothesized that the effect of distraction on treatment outcome might depend on coping style. Specifically, we predicted that for blunters (i.e.. individuals who tend to avoid threat-related information), distraction would interfere with the effects of exposure. However, we predicted that distraction might benefit monitors (i.e., individuals who tend to seek out threat-related information). Sixty individuals with a specific phobia of spiders underwent a single, two-hour session of exposure treatment. During the first hour, half of the participants were distracted by listening to an audiotape and the other half underwent exposure without distraction. In the second hour, all participants underwent focused exposure. Based on measures of heart rate, subjective fear, and behavioral testing, participants improved after one hour of treatment, and improved further during the second hour. However, neither distraction, coping style, nor their interaction had a significant effect on outcome. The present study provides support for the benefits of behavioral treatment for specific phobias. However, our hypotheses regarding distraction and coping style were not confirmed.

Enhancement of human osteoblast proliferation and phenotypic expression when cultured in human serum.

Traditionally, culture medium is supplemented with foetal bovine serum (FBS). However, in cultures of osteoblasts intended for human re-implantation, such serum presents potential risks of foreign protein contamination and transmission of viral or prion-related material, if used. We cultured human osteoblasts from 16 patients in 10% autologous human serum, 10% pooled human serum, 10% FBS or 2% Ultroser G. Non-synthetic sera were tested in both heat-treated and non-heat-treated forms. We determined cell growth and osteoblast phenotype. Cell proliferation in all types of human serum was significantly greater than in FBS. This was most marked in heat-treated autologous human serum. Cells cultured in Ultroser G had less proliferation than all other groups. The phenotypic tests showed that cells cultured in human and foetal bovine serum displayed an osteoblast phenotype, with greater protein expression in cells cultured in human serum. We conclude that culture of human osteoblasts in autologous human serum enhances cell proliferation, while maintaining an osteoblast phenotype. These findings have implications for the use of cultured osteoblasts in self-cell therapy. Human osteoblast growth is supported by autologous human serum, which allows re-implantation of cultured cells, while avoiding the risk of foreign protein carry-over with enhancement of cell proliferation.

Weight-related and shape-related self-evaluation in eating-disordered and non-eating-disordered women.

OBJECTIVE: Weight- and shape-related self-evaluation refers to the process whereby an individual determines her self-worth based on an evaluation of her body weight and shape. This is a hallmark feature of both anorexia and bulimia nervosa, as specified in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. The purpose of this study was to further our understanding of weight-related self-evaluation in eating-disordered women. METHOD: Eating-disordered patients, restrained eaters, and unrestrained eaters completed an experimenter-designed questionnaire that examines different dimensions of weight-related self-evaluation (i.e., the Multidimensional Weight-Related Self-Evaluation Inventory). RESULTS: Results revealed that weight-related self-evaluation is a feature shared, to some extent, by both eating-disordered patients and restrained eaters. However, eating-disordered patients extend weight-related self-evaluation to include more domains of self-esteem than did restrained eaters. DISCUSSION: These findings support a multidimensional approach to weight-related self-evaluation and further our understanding of the process of weight-related self-evaluation in eating-disordered patients.

Eating disorders, dieting, and the accuracy of self-reported weight.

OBJECTIVE: This study investigated the accuracy of self-reported weight and height in individuals with an eating disorder (i.e., anorexia nervosa [AN] and bulimia nervosa [BN]) and in individuals without an eating disorder (i.e., dieters and nondieters). METHOD: Self-reported and measured weights and heights were obtained from the eating disorder sample (n = 81) and the college student sample (n = 163) and were compared within and between the groups. RESULTS: Eating disorder patients were extremely accurate at self-reporting their weight. However, there was a significant difference in accuracy between AN and BN patients. AN patients slightly overreported their weight, whereas BN patients slightly underreported their weight. Both dieters and nondieters significantly underreported their weight. However, dieters significantly underreported their weight to a greater degree than did the nondieters. DISCUSSION: The implications of these subgroup differences and their specificity to weight reporting are discussed with reference to the accuracy of self-reported height.

Randomized comparison trial of teicoplanin i.v., teicoplanin i.m., and cefazolin therapy for skin and soft tissue infections caused by gram-positive bacteria.

Teicoplanin, a glycopeptide antibiotic chemically related to the vancomycin-ristocetin group of antibiotics, has potent activity against aerobic and anaerobic gram-positive bacteria. In this study, we examined the efficacy and safety of teicoplanin for parenteral treatment of skin and soft tissue infections caused by gram-positive bacteria. Ninety-six hospitalized adults with moderate to severe skin and soft tissue infections were randomized to receive either teicoplanin intravenously (i.v.) once a day, teicoplanin intramuscularly (i.m.) once a day, or cefazolin i.v. every 8 hours. We evaluated patients' clinical and microbiologic status and assessed clinical and laboratory adverse events. Of 76 clinically assessable patients, 26 of 26 (100%) given teicoplanin i.v., 21 of 22 (95%) given teicoplanin i.m., and 26 of 28 (93%) given cefazolin showed improvement or cure. Of 60 microbiologically assessable patients, 22 of 22 (100%) given teicoplanin i.v., 16 of 18 (89%) given teicoplanin i.m, and 18 of 20 (90%) given cefazolin were cured. Of 96 patients assessable for adverse events, 7 of 34 (21%) given teicoplanin i.v., 4 of 31 (13%) give teicoplanin i.m., and 1 of 31 (3%) given cefazolin had adverse events. In this study, once daily teicoplanin appeared to be safe and effective therapy for skin and soft tissue infections.

Molecular typing of ampicillin-resistant, non-beta-lactamase-producing Enterococcus faecium isolates from diverse geographic areas.

Molecular typing methods were compared by using 66 ampicillin-resistant, non-beta-lactamase-producing Enterococcus faecium clinical isolates from diverse geographic areas. Whole-plasmid analysis, restriction enzyme analysis of plasmid DNA with EcoRI and HindIII, and contour-clamped homogeneous electric field electrophoresis with digestion by SmaI and ApaI were performed on all isolates. Whole-plasmid analysis identified 47 different groups. Restriction enzyme analysis of plasmid DNA identified 50 groups when EcoRI was used and 51 groups when HindIII was used. Results with EcoRI and HindIII differed in 9 of 66 isolates. Grouping results with whole-plasmid analysis differed from results of restriction enzyme analysis of plasmid DNA (combining EcoRI and HindIII) in 20 of 66 isolates. Contour-clamped homogeneous electric field electrophoresis identified 46 groups when SmaI was used and 44 groups when ApaI was used. Results with SmaI and ApaI differed in 3 of 66 isolates. Grouping results with contour-clamped homogeneous electric field electrophoresis (combining SmaI and ApaI) differed from results of restriction enzyme analysis of plasmid DNA (combining EcoRI and HindIII) in 17 of 66 isolates. The combined use of whole-plasmid analysis, restriction enzyme analysis of plasmid DNA with two enzymes, and contour-clamped homogeneous electric field electrophoresis with two restriction enzymes should be considered when E. faecium is typed for epidemiologic investigation.

Nosocomial acquisition of beta-lactamase--negative, ampicillin-resistant enterococcus.

BACKGROUND: A recent prospective study at the Department of Veterans Affairs Medical Center, Martinez, Calif, revealed that 9% of enterococcal clinical isolates were ampicillin resistant. We prospectively studied 100 patients hospitalized in one general medicine ward and in the medical intensive care unit to study determinants of acquisition of ampicillin-resistant enterococcus. METHODS: Rectal swabs and urine cultures were obtained from patients within 72 hours of admission to the study ward and twice weekly until discharge from the ward or the intensive care unit. Cultures were obtained from the hands of personnel and from environmental surfaces in the general medical ward and the intensive care unit. Ampicillin-resistant enterococcal isolates were examined for molecular relatedness by plasmid DNA analysis. RESULTS: The cultures from 23 patients yielded ampicillin-resistant enterococci. The rectal swabs yielded ampicillin-resistant enterococci before the urine cultures did except in one patient whose urine and rectal cultures were both positive on the same day. Acquisition of ampicillin-resistant enterococci was significantly associated with previous antimicrobial agents, Foley catheterization, and being bedridden. Resistant enterococci were not isolated from hospital personnel or environmental surfaces. Plasmid analysis by gel electrophoresis demonstrated nine strains, two of which predominated. Rectal and urine isolates from the same patient had identical plasmid electrophoresis patterns. CONCLUSIONS: We conclude that ampicillin-resistant enterococci are common in the rectal flora, can spread to the urinary system, are associated with patient characteristics that predipose to nosocomial infection, and may become an emerging clinical problem.

Endovascular infections caused by enterococci highly resistant to ampicillin.

Enterococci frequently cause endocarditis and are the most common gram-positive isolates in polymicrobial bacteremia. We report three cases of polymicrobial endovascular infections at a single institution during a 12-month period; the enterococcal isolates were highly resistant to penicillins. These cases comprised 18% of all enterococcal endovascular isolates during the same 12-month period. Previous use of antibiotics, presence of endovascular catheters, and nosocomial acquisition of the organism occurred in all three cases. Clinicians should be aware of enterococcal resistance to penicillins and should exercise care in designing appropriate regimens for serious enterococcal infections.

Ampicillin-resistant Enterococcus raffinosus in an acute-care hospital: case-control study and antimicrobial susceptibilities.

A prospective study identified 9 (32%) of 28 ampicillin-resistant (MIC greater than or equal to 16 micrograms/ml) enterococcus isolates as Enterococcus raffinosus. A case-control study found no significant differences with respect to underlying diseases, catheterization, or surgery between patients with ampicillin-resistant E. raffinosus and those with ampicillin-susceptible Enterococcus spp. Prior treatment with antibiotics and prolonged hospitalization were more frequent among patients with ampicillin-resistant E. raffinosus. Patients with the same strain (determined by plasmid analysis) were frequently hospitalized concurrently.

Ceftibuten versus cefaclor for the treatment of bronchitis.

Ceftibuten is an oral third generation cephalosporin with potent antimicrobial activity against Enterobacteriaceae, beta-lactamase positive Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitidis, Neisseria gonorrheae, penicillin-susceptible pneumococci, and beta-hemolytic streptococci. To study the efficacy and safety of ceftibuten for treatment of bronchitis, 58 patients were randomized to therapy with either ceftibuten 400 mg once a day or cefaclor 250 mg every 8 h at a ratio of two to one. Of 45 clinically evaluable patients, 28 (87.5%) of the 32 ceftibuten patients and 12 (92.3%) of the 13 cefaclor patients were clinically improved or cured. Of 33 microbiologically evaluable patients, 21 (87.5%) of the 24 ceftibuten patients and eight (80%) of the ten cefaclor patients were cured. Of 56 patients evaluable for adverse effects, three (7.9%) of the 38 ceftibuten patients and one (5.6%) of the 18 cefaclor patients had adverse reactions. In this small study, once-daily ceftibuten appeared as safe and as effective as cefaclor for the treatment of bronchitis.

Intravenous or intramuscular teicoplanin once daily for skin and soft-tissue infections.

Teicoplanin is a new glycopeptide antibiotic with potent activity against gram-positive bacteria and pharmacokinetics that allow once daily administration. To study the efficacy and safety of teicoplanin for skin and soft-tissue infections, 75 patients received teicoplanin intravenously (38) or intramuscularly (37, of which 16 were outpatients). Of 62 clinically evaluable patients, 97 percent of teicoplanin iv and 93 percent of teicoplanin im patients were cured or improved. All teicoplanin iv patients and 64 percent of teicoplanin im patients were cured microbiologically at 24-48 hours posttherapy. Persistence of organisms frequently was associated with skin ulcers or abscess cavities and usually had no bearing on clinical outcome. Possible adverse clinical and laboratory reactions caused by teicoplanin occurred in 4 of 38 teicoplanin iv patients (11 percent) and in 8 of 37 teicoplanin im patients (22 percent). Reactions were mild and resolved with discontinuation of teicoplanin in most cases. In this study, teicoplanin appeared to be safe, efficacious, and convenient for both hospital staff and patients, and potentially cost-effective for the treatment of skin and soft-tissue infections. In particular, teicoplanin appears to be appropriate for outpatient parenteral therapy.

Endogenous interferon-gamma, macrophage activation, and murine host defense against acute infection with Trypanosoma cruzi.

Parenteral interferon-gamma (IFN-gamma) activates murine macrophages to inhibit Trypanosoma cruzi multiplication and diminishes parasitemia and mortality in acute infection. To investigate the role of endogenous IFN-gamma in acute infection, monoclonal antibody to IFN-gamma was injected intraperitoneally into mice. The 6250 neutralizing units given 24 and 96 h after infection reproducibly increased mortality (P less than .05). Histology sections showed markedly more nests of T. cruzi in treated mice. BALB/c, Swiss Webster, C57Bl/6, and C3H/HEN mice were susceptible to the effects of anti-IFN-gamma. Peritoneal macrophages from mice 4 days after infection and a single dose of 6250 units of anti-IFN-gamma had significantly reduced ability to inhibit T. cruzi multiplication. Multiple doses of anti-IFN-gamma delayed but did not prevent macrophage activation. These results indicate the critical role of endogenous IFN-gamma for macrophage activation and host defense against acute T. cruzi infection in mice.

In vitro model of attachment of Giardia intestinalis trophozoites to IEC-6 cells, an intestinal cell line.

Attachment of giardias to intestinal cells has been difficult to study because of a lack of a convenient in vitro model. We developed an assay for attachment of radiolabeled trophozoites to IEC-6 cells that can be done in microtiter trays. Attachment was confirmed by scanning and transmission electron microscopy. Trophozoites remained attached to the IEC-6 cells for 24 h with little evidence of damage to the IEC-6 cells. Preincubation of trophozoites with cytochalasins A, B, and D reduced attachment to approximately 20% of that of controls, whereas colchicine had no effect. Chelation of divalent cations with EDTA and EGTA [ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid] reduced attachment to 24 and 26% of control values, respectively, and incubation at 4 degrees C reduced attachment to 7% of the value for controls incubated at 37 degrees C. Glutaraldehyde fixation of trophozoites or IEC-6 cells resulted in significantly diminished attachment to the live substrate (17 and 40% of control values, respectively). Coincubation of IEC-6 cells and trophozoites on a rotary shaker resulted in detachment of 40% of trophozoites, but EDTA, EGTA, glutaraldehyde fixation of trophozoites, and low temperature diminished attachment markedly and significantly. Similar results were obtained in selected experiments with three strains of giardia.