Acceptance and commitment therapy for people with acquired brain injury: Rationale and description of the BrainACT treatment.

BACKGROUND: The treatment of anxiety and depressive symptoms following acquired brain injury is complex and more evidence-based treatment options are needed. We are currently evaluating the BrainACT intervention; acceptance and commitment therapy for people with acquired brain injury. RATIONALE: This paper describes the theoretical underpinning, the development and content of BrainACT. Acceptance and commitment therapy focuses on the acceptance of feelings, thoughts and bodily sensations and on living a valued life, without fighting against what is lost. Since the thoughts that people with acquired brain injury can experience are often realistic or appropriate given their situation, this may be a suitable approach. THEORY INTO PRACTICE: Existing evidence-based protocols were adapted for the needs and potential cognitive deficits after brain injury. General alterations are the use of visual materials, summaries and repetition. Acceptance and commitment therapy-specific adaptions include the Bus of Life metaphor as a recurrent exercise, shorter mindfulness exercises, simplified explanations, a focus on experiential exercises and the monitoring of committed actions. The intervention consists of eight one-hour sessions with a psychologist, experienced in acceptance and commitment therapy and in working with people with acquired brain injury. The order of the sessions, metaphors and exercises can be tailored to the needs of the patients. DISCUSSION: Currently, the effectiveness and feasibility of the intervention is evaluated in a randomised controlled trial. The BrainACT intervention is expected to be a feasible and effective intervention for people with anxiety or depressive symptoms following acquired brain injury.

Is overhydration in peritoneal dialysis patients associated with cardiac mortality that might be reversible?

AIM: To study the relationship between overhydration (OH) in peritoneal dialysis (PD) patients and cardiac mortality. METHODS: OH, as measured by body composition monitor (BCM), is associated with increased mortality in dialysis patients. BCM has been used to guide treatment on the assumption that correcting OH will improve cardiac morbidity and mortality although data demonstrating causality that is reversible is limited. We wished to determine if OH in PD patients predicted cardiac mortality, and if there was a correlation between OH and cardiac troponin-T (cTnT) levels. Finally, we wished to determine if improving OH values would lead to a decrement in cTnT. All prevalent PD patients over the study period of 57 mo who had contemporaneous BCM and cTnT measurements were followed irrespective of transplantation or PD technique failure. We also studied a cohort of patients with who had severe OH (> +2L). The Fresenius Body Composition Monitor was used to obtain hydration parameters. cTnT levels were done as part of routine clinical care. Data was analysed using SPSS version 20.0. RESULTS: There were 48 deaths in the 336 patients. The patients that died from cardiac or non-cardiac causes were similar with respect to their age, incidence of diabetes mellitus, gender, ethnicity and cause of renal failure. However, the patients with cardiac causes of death had significantly shorter dialysis vintage (10.3 mo vs 37.0 mo, P < 0.0001) and were significantly more overhydrated by BCM measurement (2.95 L vs 1.35 L, P < 0.05). The mean (standard error of the means) hydration status of the 336 patients was +1.15 (0.12) L and the median [interquartile range (IQR)] cTnT level was 43.5 (20-90) ng/L. The cTnT results were not normally distributed and were therefore transformed logarithmically. There was a statistically significant correlation between Log (cTnT) with the OH value (Spearman r value 0.425, P < 0.0001). We identified a sub-group of patients that were severely overhydrated; median (IQR) hydration at baseline was +2.7 (2.3 to 3.7) L. They were followed up for a minimum of 6 mo. Reduction in OH values in these patients over 6 mo correlated with lowering of cTnT levels (Spearman r value 0.29, P < 0.02). CONCLUSION: Patients that were overhydrated had higher cTnT, and had deaths that were more likely to be cardiac related. Reduction in OH correlated with lowering of cTnT.

Can Bioimpedance Measurements of Lean and Fat Tissue Mass Replace Subjective Global Assessments in Peritoneal Dialysis Patients?

OBJECTIVE: Malnutrition and protein energy wasting (PEW) determined by Subjective Global Assessment (SGA) is associated with increased mortality. There is an inverse relationship between body mass and overhydration in dialysis patients. Is the predictive accuracy of SGA (for death) independent of hydration status? Can bioimpedance spectroscopy analysis of lean tissue index (LTI) and fat tissue index (FTI) accurately identify dialysis patients with protein energy wasting and increased mortality? METHODS: We report an observational study of 455 peritoneal dialysis (PD) patients. RESULTS: We found that 96 patients (21%) were malnourished (SGA score between 1 and 5), and 192 (42%) had LTI values below 10th centile (age, gender adjusted). FTI was significantly lower in the SGA-defined malnourished cohort. By contrast, there was an inverse relationship between LTI and FTI. Malnourished (by SGA) patients were significantly more overhydrated (P < .0001), but SGA remained highly predictive of survival in multivariate analysis that included hydration status (hazard ratio: 3.12, 95% confidence interval 1.86-5.23, P < .0001). Obesity (patients with the highest 20% FTI) predicted survival (hazard ratio of death was 0.47, 95% confidence interval 0.16-0.85, P < .02) on univariate but not multivariate analysis. CONCLUSIONS: We have confirmed that SGA is an accurate predictor of mortality in PD patients, and its predictive value is independent of the hydration status. Predictive power of SGA was not affected when LTI and FTI were included in multivariate analysis. Patients with low LTI were different from patients with low SGA (associated with high FTI). Sensitivity and specificity of Body Composition Monitor to diagnose patients with low SGA readings were poor (area under the curve for receiver operator characteristics analysis 0.66). The phenomenon of reverse epidemiology (high FTI predicting a survival advantage) was found in our PD cohort.

Comparing lung ultrasound with bioimpedance spectroscopy for evaluating hydration in peritoneal dialysis patients.

BACKGROUND: Bioimpedance spectroscopy (BIS), ultrasound lung comets (ULC) and serum biomarkers (N-terminal pro-brain natriuretic peptide, NT-proBNP) have all been used to assist clinicians to determine hydration status in dialysis patients. METHODS: We performed simultaneous BIS, ULC and NT-proBNP measurements in 27 peritoneal dialysis patients to determine the concordance of the three methods. RESULTS: Patients with evidence of increasing lung congestion (as determined by ultrasound) were more likely to be diabetic, have systolic hypertension and have higher NT-proBNP (r = 0.65, P < 0.0005). Although there was a trend for patients with high ULC to be overhydrated as determined by BIS, this did not reach statistical significance. Moreover, the correlation between BIS and NT-proBNP (though statistically significant at r = 0.47, P < 0.02) appeared to be weaker. CONCLUSION: BIS and ULC may be complementary, providing different information, whereas BIS may be more specific to hydration. ULC and NT-proBNP may indicate left ventricular failure coexisting with overhydration.

Clinical significance of multi-frequency bioimpedance spectroscopy in peritoneal dialysis patients: independent predictor of patient survival.

BACKGROUND: It is becoming increasingly evident that the accurate assessment of hydration status is critical to care of a dialysis patient. Using the Body Composition Monitor, different parameters (overhydration (OH), extra-cellular water/total body water (ECW/TBW) or OH/ECW) have been proposed to indicate hydration status. We wished to determine which parameter (if any) was most predictive of all-cause mortality, and if this was independent of nutritional indices. METHODS: We performed a single-centre retrospective analysis of prospectively collected data of all peritoneal dialysis (PD) patients between 1 January 2008 and 30 March 2012. Record review was undertaken to establish patient survival, clinical and demographic data. Follow-up was continued even after PD technique failure (transfer to haemodialysis) and transplantation. RESULTS: The study included 529 patients. OH index (OH and OH/ECW) was the independent predictor of mortality in multi-variate analysis. ECW/TBW as a continuous variable was not associated with increased risk of death. In contrast, patients that were severely overhydrated (highest 33%) had hazard ratios (HRs) that were statistically significant irrespective of the parameter used to define hydration. Using OH, severely overhydrated patients had an HR of 1.83 [95% confidence interval (CI) 1.19-2.82, P < 0.01], OH/ECW: 2.09 (95% CI 1.36-3.20, P < 0.001) and ECW/TBW: 2.05 (95% CI 1.31-3.22, P < 0.005). CONCLUSIONS: Our results also indicated that there was no influence of body mass index (BMI) on the hydration parameter OH/ECW. OH/ECW remained an independent predictor of mortality when the BMI and lean tissue index were included in multivariate model. However, it remains to be determined if correcting the OH status of a patient will lead to improvement in mortality.

Validity of parentally reported febrile seizures: the generation R study.

The objective of this study was to examine the validity of the diagnosis of "febrile seizure" as reported by parents. The study was embedded in a population-based prospective cohort study. Information on paroxysmal events was obtained by screening questions at ages 1, 2, and 3 years. One of these questions was the following: "Did your child have a febrile seizure?" If a screen-positive result was found, an additional questionnaire was sent and the medical record was consulted. Based on this information, paroxysmal events were classified by a pediatric neurologist as febrile seizure or other event. The validity of a positive reply to the screening question on febrile seizures was assessed, taking this classification as reference standard. Analyses were based on participants who reported at least one paroxysmal event (n = 610). The sensitivity of the positive reply to the question, "Did your child have a febrile seizure?", for the diagnosis of febrile seizures was 92%, the specificity 72%, the positive predictive value 41%, and the negative predictive value 98%. In conclusion, the sensitivity of the question, "Did your child have a febrile seizure?", is high. The positive predictive value is only 41%. Although this question may be appropriate as a screening instrument for febrile seizures, a second stage of evaluation is necessary to identify true cases.

Febrile seizures and behavioural and cognitive outcomes in preschool children: the Generation R study.

AIM: General developmental outcome is known to be good in school-aged children who experienced febrile seizures. We examined cognitive and behavioural outcomes in preschool children with febrile seizures, including language and executive functioning outcomes. METHOD: This work was performed in the Generation R Study, a population-based cohort study in Rotterdam from early fetal life onwards. Information about the occurrence of febrile seizures was collected by questionnaires at the ages of 1, 2, and 3 years. At the age of 3 years, behaviour and emotion were assessed using the Child Behavior Checklist. Information on expressive language development was obtained by the Language Development Survey at the age of 2 years 6 months. To assess executive functioning, parents completed the Behaviour Rating Inventory of Executive Function - Preschool Version when their children were 4 years old. Final analyses were based on 3157 children. RESULTS: No associations were found between febrile seizures and the risk of behavioural problems or executive functioning. In contrast to single febrile seizures, recurrent febrile seizures were significantly associated with an increased risk of delayed vocabulary development (odds ratio 3.22, [95% confidence interval 1.30-7.94]). INTERPRETATION: Febrile seizures are not associated with problem behaviour or executive functioning in preschool children, but the results suggest that children with recurrent febrile seizures might be at risk for delayed language development.

Frequent fever episodes and the risk of febrile seizures: the Generation R study.

AIM: To examine the association between the number of fever episodes and the risk of febrile seizures. METHODS: This study was embedded in a population-based prospective cohort study from early foetal life onwards. Information about the occurrence of febrile seizures and fever episodes was collected by questionnaires at the ages of 12, 24 and 36 months. Analyses were based on 3033 subjects. The risk of febrile seizures was compared between children with frequent fever episodes (>2 per year), and children with only 1 or 2 fever episodes per year. RESULTS: The frequency of fever episodes was not associated with the risk of febrile seizures in the age range of 6-12 months. In the second and third year of life, having more than 2 fever episodes was associated with an increased risk of febrile seizures (odds ratios 2.02 [95% confidence interval 1.13-3.62] and 2.29 [95% confidence interval 1.00-5.24], respectively). In the age range between 6 and 36 months, we observed a significant trend between the frequency of fever episodes (<2, 3-4 or >4 per year) and the risk of febrile seizures (p-value for trend < 0.001). The association between the number of fever episodes and the occurrence of febrile seizures was stronger for children with recurrent febrile seizures. CONCLUSION: Frequent fever episodes are associated with an increased risk of febrile seizures in the second and third years of life. Further studies are needed to identify the mechanisms underlying this association.

Fetal growth retardation and risk of febrile seizures.

OBJECTIVE: The goal was to examine the associations between fetal growth characteristics in different trimesters of pregnancy and the occurrence of febrile seizures in early childhood. METHODS: This study was embedded in a population-based, prospective, cohort study from early fetal life onward. Fetal growth characteristics (femur length, abdominal circumference, estimated fetal weight, head circumference, biparietal diameter, and transverse cerebellar diameter [TCD]) were measured with ultrasonography in the second and third trimesters of pregnancy. Information on the occurrence of febrile seizures was collected with questionnaires at the ages of 12 and 24 months. Analyses were based on data for 3372 subjects. RESULTS: In the second trimester, children in the lowest tertile of TCDs were at increased risk of developing febrile seizures, compared with children in the highest tertile (odds ratio 2.87 [95% confidence interval: 1.31-6.28]). In the third trimester, children in the lowest tertile of all general growth characteristics (femur length, abdominal circumference, and estimated fetal weight) were at increased risk of developing febrile seizures. This association was strongest for children in the lowest tertile of estimated fetal weight (odds ratio: 2.57 [95% confidence interval: 1.34-4.96]). Children in the lowest tertile of biparietal diameter in the third trimester also were at increased risk of febrile seizures. Similar but not statistically significant tendencies were observed for head circumference and TCD. CONCLUSIONS: Fetal growth retardation is associated with increased risk of febrile seizures in the first 2 years of life. Adverse environmental and genetic factors during pregnancy may be important in the development of febrile seizures.

Paroxysmal disorders in infancy and their risk factors in a population-based cohort: the Generation R Study.

AIM: To examine the incidence of paroxysmal epileptic and non-epileptic disorders and the associated prenatal and perinatal factors that might predict them in the first year of life in a population-based cohort. METHOD: This study was embedded in the Generation R Study, a population-based prospective cohort study from early fetal life onwards. Information about the occurrence of paroxysmal events, defined as suddenly occurring episodes with an altered consciousness, altered behaviour, involuntary movements, altered muscle tone, and/or a changed breathing pattern, was collected by questionnaires at the ages of 2, 6, and 12 months. Information on possible prenatal and perinatal determinants was obtained by measurements and questionnaires during pregnancy and after birth. RESULTS: Information about paroxysmal events in the first year of life was available in 2860 participants (1410 males, 1450 females). We found an incidence of paroxysmal disorders of 8.9% (n=255) in the first year of life. Of these participants, 17 were diagnosed with febrile seizures and two with epilepsy. Non-epileptic events included physiological events, apnoeic spells, loss of consciousness by causes other than epileptic seizures or apnoeic spells, parasomnias, and other events. Preterm birth (p<0.001) and low Apgar score at 1 minute (p<0.05) were significantly associated with paroxysmal disorders in the first year of life. Continued maternal smoking during pregnancy and preterm birth were significantly associated with febrile seizures in the first year of life (p<0.05). INTERPRETATION: Paroxysmal disorders are frequent in infancy. They are associated with preterm birth and a low Apgar score. Epileptic seizures only form a minority of the paroxysmal events in infancy. In this study, children whose mothers continued smoking during pregnancy had a higher reported incidence of febrile seizures in the first year of life. These findings may generate various hypotheses for further investigations.