Eight-year follow-up of a randomized clinical trial comparing ultrasound-guided foam sclerotherapy with surgical stripping of the great saphenous vein

BACKGROUND

This was an 8-year follow-up of an RCT comparing ultrasound-guided foam sclerotherapy (UGFS) with high ligation and surgical stripping (HL/S) of the great saphenous vein (GSV).

METHODS

Patients were randomized to UGFS or HL/S of the GSV. The primary outcome was the recurrence of symptomatic GSV reflux. Secondary outcomes were patterns of reflux according to recurrent varices after surgery, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification, Venous Clinical Severity Score (VCSS) and EuroQol Five Dimensions (EQ-5D™) quality-of-life scores.

RESULTS

Of 430 patients originally randomized (230 UGFS, 200 HL/S), 227 (52·8 per cent; 123 UGFS, 103 HL/S) were available for analysis after 8 years. The proportion of patients free from symptomatic GSV reflux at 8 years was lower after UGFS than HL/S (55·1 versus 72·1 per cent; P = 0·024). The rate of absence of GSV reflux, irrespective of venous symptoms, at 8 years was 33·1 and 49·7 per cent respectively (P = 0·009). More saphenofemoral junction (SFJ) failure (65·8 versus 41·7 per cent; P = 0·001) and recurrent reflux in the above-knee GSV (72·5 versus 20·4 per cent; P = 0·001) was evident in the UGFS group. The VCSS was worse than preoperative scores in both groups after 8 years; CEAP classification and EQ-5D® scores were similar in the two groups.

CONCLUSION

Surgical stripping had a technically better outcome in terms of recurrence of GSV and SFJ reflux than UGFS in the long term. Long-term follow-up suggests significant clinical progression of venous disease measured by VCSS in both groups, but less after surgery. Registration number: NCT02304146 (http://www.clinicaltrials.gov).

Mediating Mechanisms in Cognitive Behavioral Therapy for Childhood OCD: The Role of Dysfunctional Beliefs

Reframing cognitions is assumed to play an important role in treatment for obsessive-compulsive disorder (OCD). However, there hardly is any empirical support for this assumption, especially for children. The aim of this study was to examine if changing dysfunctional beliefs is a mediating mechanism of cognitive behavioral therapy (CBT) for childhood OCD. Fifty-eight children (8-18 years) with OCD received CBT. Dysfunctional beliefs (OBQ-CV) and OCD severity (CY-BOCS) were measured pre-treatment, mid-treatment, post-treatment, and at 16-week follow-up. Results showed that OCD severity and dysfunctional beliefs decreased during CBT. Changes in severity predicted changes in beliefs within the same time interval. Our results did not support the hypothesis that changing dysfunctional beliefs mediates treatment effect. Future studies are needed to replicate these findings and shed more light on the role of explicit and implicit cognitions in treatment for childhood OCD.

Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein

BACKGROUND

New minimally invasive treatment modalities, such as ultrasound-guided foam sclerotherapy (UGFS), are becoming more popular. In a multicentre randomized controlled non-inferiority trial, the effectiveness and costs of UGFS and surgery for treatment of the incompetent great saphenous vein (GSV) were compared.

METHODS

Patients with primary great saphenous varicose veins were assigned randomly to either UGFS or surgical stripping with high ligation. Recurrence, defined as reflux combined with venous symptoms, was determined on colour duplex scans at baseline, 3 months, 1 year and 2 years after initial treatment. Secondary outcomes were presence of recurrent reflux (irrespective of symptoms), reduction of symptoms, health-related quality of life (EQ-5D(™)), adverse events and direct hospital costs.

RESULTS

Two hundred and thirty patients were treated by UGFS and 200 underwent GSV stripping. The 2-year probability of recurrence was similar in the UGFS and surgery groups: 11·3 per cent (24 of 213) and 9·0 per cent (16 of 177) respectively (P = 0·407). At 2 years, reflux irrespective of venous symptoms was significantly more frequent in the UGFS group (35·0 per cent) than in the surgery group (21·0 per cent) (P = 0·003). Mean(s.d.) hospital costs per patient over 2 years were €774(344) per patient for UGFS and €1824(141) for stripping.

CONCLUSION

At 2-year follow-up, UGFS was not inferior to surgery when reflux associated with venous symptoms was the clinical outcome of interest. UGFS has the potential to be a cost-effective approach to a common health problem. Registration numbers: NCT01103258 (http://www.clinicaltrials.gov) and NTR654 (http://www.trialregister.nl).

Paediatric electrophysiologic studies: how and what with?

Catheter ablation of arrhythmias in children has become standard practice virtually worldwide. Successful and safe ablation has been made possible by a combination of factors. These include increased operator experience, a better understanding of the natural history of a wide variety of arrhythmias, advances in technology such as smaller catheters, the routine use of various three-dimensional mapping systems, and the development of alternative energy sources. It is also not uncommon to perform multiple catheter intervention procedures (ablation +/- intravascular stent implantation +/- device closure of residual shunts +/- elective pacemaker or device implantation) during a single session. It is important to bear in mind that arrhythmia recurrence is commoner in children in general, and that this is particularly the case with postoperative (scar-related arrhythmias). Despite acute success, long-term follow-up is mandated for this subgroup of patients.

Device therapy in children: current indications

The implantable cardioverter defibrillator has achieved increasing acceptance in paediatric cardiologic practice. Concurrent with technological advances which have made the devices more versatile, easier to implant and to program, there has been a fundamental breakthrough in our understanding of genetic and inherited arrhythmia syndromes in the last decade. This in turn has led to investigations into risk stratification, with the aim of choosing high risk candidates for timely device therapy. The second group of young patients with a risk of sudden death are those who have had a previous repair of a structural heart defect. Given that sudden arrhythmic death is the commonest cause of mortality in this population, it behoves the practising paediatric cardiologist to be aware of the current recommendations for device implantation in this population. In this manuscript, we summarise the current state of our understanding of the risk factors for sudden death, and identify possible candidates for ICD implantation.

Cognitions in children with OCD. A pilot study for age specific relations with severity

Cognitive theory, postulates that dysfunctional cognitions play a maintaining or even aetiological role in obsessive-compulsive disorder (OCD). In this study it was hypothesised that if distorted cognitions play a central role in OCD, there should be a relation between cognitive measures and the severity of the obsessive-compulsive symptoms in a childhood OCD sample. A group of 39 children and adolescents with a primary diagnosis OCD was measured on the CY-BOCS, and on the cognitive questionnaires the MTQ, and the CATS. The findings suggest no relation between the severity of the OCD and magical thinking. In the younger group aged 8-12 years (n = 18) no relations with any negative thoughts were found. In the older group, aged 13-18 years (n = 21), relations between the CY-BOCS Obsession scale and the CATS subscales Physical Threat, Social Threat and Personal Failure were found. Compared to a previously published community sample, the MTQ scores in the present sample are lower. The CATS scores for the OCD sample were found to be lower than most clinical comparison groups, which is especially true for the CATS Hostility subscale. Issues about criterion contamination and explanatory hypothesis about the age specific relation are addressed.

Predictors of course in obsessive-compulsive disorder: logistic regression versus Cox regression for recurrent events

OBJECTIVE

Two methods for predicting remissions in obsessive-compulsive disorder (OCD) treatment are evaluated. Y-BOCS measurements of 88 patients with a primary OCD (DSM-III-R) diagnosis were performed over a 16-week treatment period, and during three follow-ups.

METHOD

Remission at any measurement was defined as a Y-BOCS score lower than thirteen combined with a reduction of seven points when compared with baseline. Logistic regression models were compared with a Cox regression for recurrent events model.

RESULTS

Logistic regression yielded different models at different evaluation times. The recurrent events model remained stable when fewer measurements were used. Higher baseline levels of neuroticism and more severe OCD symptoms were associated with a lower chance of remission, early age of onset and more depressive symptoms with a higher chance.

CONCLUSION

Choice of outcome time affects logistic regression prediction models. Recurrent events analysis uses all information on remissions and relapses. Short- and long-term predictors for OCD remission show overlap.

Abnormally increased semantic priming in children with symptomatic HIV-1 disease: evidence for impaired development of semantics?

Language deficits are a major characteristic of neurobehavioral dysfunction in pediatric HIV disease. An object decision task, which assessed reaction time facilitation following a semantic or identical prime in comparison to an unrelated prime, was used to investigate whether semantic processing abnormalities could be responsible, in part, for these deficits. Thirty children with vertically acquired HIV infection (M age 9.0 years; range 6-13) participated. Either a picture of the same object (repetition prime), a semantically related object (semantic prime), a semantically unrelated object, or a nonsense object preceded a target picture, which in 50% of the cases was a real object. Brain scans of children were rated and used together with neurobehavioral functioning to classify children as having HIV-related CNS abnormalities (n = 13) or not (n = 17). Increased semantic priming but not repetition priming was associated with a greater degree of cortical atrophy. Furthermore, CNS compromised children had significantly faster reaction times following a semantic prime compared to an unrelated prime than non-compromised patients. This facilitation following semantic priming for the CNS compromised patients (13.3%) almost equaled the facilitation following repetition priming (15.3%) while for the non-compromised patients facilitation following semantic priming (7.9%) was clearly smaller than following repetition priming (14.6%). These data suggest that HIV infection in children may result in a reduced neural network leading to impoverished semantic representations characterized by poor differentiation between closely related objects.

Conscious and preconscious selective attention to social threat: different neuroendocrine response patterns

This study was designed to investigate the relationship between selective attention to social threat and neuroendocrine activity. Selective attention to social threat was measured using a supraliminal (unmasked) and a subliminal (masked) version of a pictorial emotional Stroop task, comparing color-naming latencies of neutral and angry faces. Neuroendocrine activity was assessed as (pre-task to post-task) increases in salivary cortisol and testosterone. Forty subjects were randomly assigned to the unmasked or masked version of the task. Analyses for the unmasked task revealed that post-task cortisol levels were significantly increased in subjects showing selective attention to angry faces. Results for the masked task indicated that post-task cortisol and testosterone levels were significantly increased in subjects showing preconscious selective attention to angry faces. The difference in neuroendocrine activity between tasks is suggested to depend on cortical (i.e. prefrontal) control in the unmasked task. Thus, psychological affective regulatory processes were involved in the unmasked task, whereas the neuroendocrine response patterns in the masked task indicates a biologically prepared mechanism.

Correlations among salivary testosterone, mood, and selective attention to threat in humans

An experiment was designed to investigate the relation among salivary testosterone, mood, and selective attention to threat. The participant group consisted of 32 nonclinical subjects (16 men and 16 women). Individuals completed the Profile Of Mood States (POMS) and performed a pictorial emotional Stroop task measuring selective attention to angry faces. Anticipating a time lag between testosterone (as measured in saliva) and cognitive emotional behavior, multiple time-coursed saliva samples were taken preceding the assessment of questionnaire and task for every subject. In both sexes, salivary testosterone was significantly related to mood (i.e., anger and tension) and selective attention to angry faces when saliva samples were taken 6 h before questionnaire and task assessment. Research on the relation between testosterone and human behavior might benefit by taking into account time lags between the behavioral manifestations and the continuously changing levels of testosterone.

Collaborative study to improve the quality control of rare earth element determinations in environmental matrices

In order to control the quality of rare earth determinations in environmental matrices, the Standards, Measurements and Testing Programme (formerly Community Bureau of Reference, BCR) of the European Commission has started a project, the final aim of which is to certify four types of matrices (tuna muscle, mussel tissue, aquatic plant and estuarine sediment) for their contents of a range of rare earth elements (Sc, Y and the lanthanides: La, Ce, Pr, Nd, Sm, Eu, Gd, Tb, Dy, Ho, Er, Tm, Yb and Lu). The elements U and Th were added to the study. The first part of this project consisted of an interlaboratory study which aimed to test the feasibility of preparation of environmental reference materials and to detect and remove most of the pitfalls observed in rare earth determinations. This paper presents the preparation of the four matrices for the intercomparison study and for the candidate reference material. The main results are presented of the interlaboratory study that was carried out prior to the certification campaign. This collaborative trial is the first attempt ever carried out at this scale to evaluate the state-of-the-art of rare earth determinations in the environment. Its impact on the improvement of chemical measurements will have positive effects on the comparability of data necessary for environmental monitoring.

Baseline salivary cortisol levels and preconscious selective attention for threat. A pilot study

This study was conducted to examine the relationship between baseline salivary cortisol (CORT) levels and selective attention for displays of angry faces. Selective attention was investigated using a pictorial emotional Stroop task, comparing colournaming-speed of angry and neutral faces. The task was assessed in supraliminal (unmasked) and subliminal (masked) conditions to 28 non-clinical subjects (14 male and 14 female). Repeated measures analysis of variance revealed a significant interaction between median split CORT levels (low vs. high) and masked face valence (angry vs. neutral). The latter effect was mainly due to significant facilitation in the high CORT subject-group; these subjects seemed to allocate their attention away from the masked angry face. A relation between baseline CORT levels and fast withdrawal behavior is suggested.

Behavior therapy versus clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents

OBJECTIVE

To compare, via a pilot study, the effectiveness of behavior therapy and of drug treatment in children and adolescents with obsessive-compulsive disorder.

METHOD

Twenty-two children aged between 8 and 18 years were randomly assigned to behavior therapy (n = 12) or open clomipramine (n = 10) in a parallel design lasting 12 weeks. Behavior therapy included exposure and response prevention administered in weekly sessions. The mean dosage of clomipramine was 2.5 mg/kg (range = 1.4-3.3 mg/kg). The main outcome variables were the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Leyton Obsessional Inventory-Child Version (LOI-CV).

RESULTS

Significant improvement was obtained in both treatment conditions. Behavior therapy produced stronger therapeutic changes than clomipramine on the CY-BOCS (p < .05), whereas on the LOI-CV no significant differences between the results of the two treatments were found. Five of the nine initial nonresponders showed significant changes after extension of treatment for another 12 weeks.

CONCLUSION

Behavior therapy is shown to be a good alternative for drug treatment and deserves further study in larger samples of children with obsessive-compulsive disorder.

Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive compulsive disorder

The purpose of this treatment package design study was to investigate the differential efficacy of cognitive therapy or exposure in vivo with response prevention for obsessive compulsive disorder (OCD) versus the sequential combination with fluvoxamine. Patients with OCD (N = 117) were randomized to one of the following five conditions: a) cognitive therapy for weeks 1 to 16, b) exposure in vivo with response prevention for weeks 1 to 16, c) fluvoxamine for weeks 1 to 16 plus cognitive therapy in weeks 9 to 16, d) fluvoxamine for weeks 1 to 16 plus exposure in vivo with response prevention in weeks 9 to 16, or e) waiting list control condition for weeks 1 to 8 only. Assessments took place before treatment (pretest) and after 8 (midtest), and 16 weeks (posttest). In the first 8 weeks, six treatment sessions were delivered. During weeks 9 to 16, another 10 sessions were given. Thirty-one patients dropped out. Outcome was assessed by patient-, therapist- and assessor-ratings of the Anxiety Discomfort Scale, the Yale-Brown Obsessive Compulsive Scale, and the Padua Inventory-Revised. In contrast with the four treatments, after 8 weeks the waiting list control condition did not result in a significant decrease of symptoms. After 16 weeks of treatment, all four treatment packages were effective on these OCD ratings, but they did not differ among each other in effectiveness. In OCD, the sequential combination of fluvoxamine with cognitive therapy or exposure in vivo with response prevention is not superior to either cognitive therapy or exposure in vivo alone.

Prediction of outcome and early vs. late improvement in OCD patients treated with cognitive behaviour therapy and pharmacotherapy

In this study, follow-up results of cognitive-behaviour therapy and of a combination of cognitive-behaviour therapy with a serotonergic antidepressant were determined. The study also examined factors that can predict this treatment effect, both in the long term and in the short term. In addition, it investigated whether differential prediction is possible for cognitive-behaviour therapy vs. a combination of cognitive-behaviour therapy with a serotonergic antidepressant. A total of 99 patients were included in the study. Treatment lasted 16 weeks, and a naturalistic follow-up measurement was made 6 months later. Of the 70 patients who completed the treatment, follow-up information was available for 61 subjects. Significant time effects were found on all outcome measures at both post-treatment measurement and follow-up. No differences in efficacy were found between the treatment conditions. Effectiveness at post-treatment measurement appears to predict success at follow-up. However, 17 of the 45 non-responders at the post-treatment measurement had become responders by the follow-up. The severity of symptoms, motivation for treatment and the dimensional score on the PDQ-R for cluster A personality disorder appear to predict treatment outcome. No predictors were found that related specifically to cognitive-behaviour therapy or combined treatment. These results indicate that the effectiveness of cognitive-behaviour therapy or a combination of cognitive-behaviour therapy and fluvoxamine at the post-treatment measurement is maintained at follow-up. However, non-response at post-treatment does not always imply non-response at follow-up. Patients with more severe symptoms need a longer period of therapy to become responders. Although predictors for treatment success were found, no evidence was found to determine the choice of one of the treatment modalities.

Dissociating face processing skills: decision about lip-read speech, expression, and identity

The separability of different subcomponents of face processing has been regularly affirmed, but not always so clearly demonstrated. In particular, the ability to extract speech from faces (lip-reading) has been shown to dissociate doubly from face identification in neurological but not in other populations. In this series of experiments with undergraduates, the classification of speech sound (lip-reading) from personally familiar and unfamiliar face photographs was explored using speeded manual responses. The independence of lip-reading from identity-based processing was confirmed. Furthermore, the established pattern of independence of expression-matching from, and dependence of identity-matching on, face familiarity was extended to personally familiar faces and "difficult"-emotion decisions. The implications of these findings are discussed.

Nonspatial visual attention explained by spatial attention plus limited storage

The use of nonspatial attentional mechanisms in search tasks was investigated by presenting observers with stimuli that contained 4-12 elements located on a circle around the fixation point. The elements differed in one of six nonspatial 'dimensions', namely orientation, contrast, scale, number of cycles, 'shape', and place in the alphabet. The target element of the search task differed from trial to trial but was always presented to the observer as a nonspatial, visual cue. This cue was displayed either before the stimulus (precue) or after the stimulus (postcue). Whereas a precue creates optimal conditions for the use of nonspatial attentional mechanisms, a postcue precludes benefits from their use. The fact that performance was better in the case of precued stimuli than in the case of postcued stimuli indicates that observers employed nonspatial attentional mechanisms. In the final analysis, however, the effect of nonspatial attention reduces to spatial attention in combination with limited storage capacity.

Discrepancies between genital responses and subjective sexual function during testosterone substitution in women with hypothalamic amenorrhea

Psychosexual dysfunction is often suggested the cause of the disturbed eating habits associated with hypothalamic secondary amenorrhea. In contrast, we explored the possibility that impaired sexual function may result from reduced levels of testosterone in amenorrheic subjects as a consequence of particular lifestyles. We studied the effects of erotic stimuli in two experiments, one comparing amenorrheic women to normal controls, the other comparing testosterone substitution to a placebo treatment. The amenorrheic women had a higher incidence of lifestyle and bodily conditions identified as risk factors for amenorrhea (i.e., weight loss before the onset of amenorrhea, low body weight, strenuous exercise, and vegetarianism), lower levels of testosterone, and impaired sexual function compared with normally menstruating women. In an experimental session in which amenorrheic women were asked to produce erotic fantasies, they demonstrated a reduced capacity for sexual fantasizing, less subjective sexual excitement, and less vaginal vasocongestion (vaginal pulse amplitude). However, when exposed to the stronger of two erotic film excerpts, the degree of vaginal response of the amenorrheic women was comparable to that of normally menstruating women. Subsequently, we showed that treatment with testosterone increased vaginal vasocongestion in the same amenorrheic women during exposure to the most potent visual stimulus but had no effect on subjective sexual experience. Testosterone substitution influenced physiological aspects of sexual function, but the psychological level remained unaffected.

Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder

The present study is the first controlled study that evaluates the effects of cognitive therapy along the lines of Beck (1976) [Cognitive therapy and the emotional disorder. New York: International University Press] and Salkovskis (1985) [Behaviour Research and Therapy, 23, 571-583] in obsessive compulsive disorder (OCD) and compares these effects with those of self-controlled exposure in vivo with response prevention. Seventy-one patients were randomly assigned to either cognitive therapy or exposure in vivo. In each treatment condition seven patients dropped out. Both treatments consisted of 16 sessions. Cognitive therapy as well as exposure in vivo led to statistically significant improvement. Multivariate significant differences suggesting a superior efficacy of cognitive therapy in comparison to exposure in vivo on the obsessive compulsive measures and on the measures for associated psychopathology. However, no univariate differences were found. Further, in both treatment conditions a considerable percentage of the patients was rated as "recovered". Significantly more patients were rated as "recovered" in the cognitive therapy. The results show that this form of cognitive therapy is an effective treatment for OCD and suggest that cognitive therapy may be even more effective than exposure in vivo.

Do patients suffering from obsessions alone differ from other obsessive-compulsives?

The aim of this study was to determine whether a group of 48 patients with obsessions and compulsions differed from a group of 26 patients with obsessions alone, on the basis of demographic variables, variables relating to obsessive-compulsive neurosis, psychological variables and treatment outcome. It was found that they differed significantly in the following areas: marital status, level of education, age at onset of complaints, psychoactive medication taken when admitted for treatment, severity of obsessive-compulsive complaints, depression and intelligence. No difference was found as far as treatment outcome was concerned. Patients suffering from obsessions alone, would appear to form a distinct sub-group within the group of obsessive-compulsive patients as a whole.

Do drop-outs differ from successfully treated obsessive-compulsives?

The most common reasons given by patients for dropping out of treatment are: environmental constraints, dissatisfaction with services and that they no longer need help. In this study two groups of patients suffering from obsessive-compulsive disorders are compared. The drop-outs' reasons for terminating treatment are compared with the comments of patients who completed the therapy successfully. Drop-outs differ from successfully treated OCD's in five respects: they appear to be less obsessive-compulsive; they have more discongruent treatment expectations; they are more critical of the therapist; they experience less anxiety in carrying out homework assignments; they less frequently come under pressure from people close to them.

Marital adjustment and obsessive-compulsive disorder

Fifty obsessive-compulsives were treated by behavioural therapy (self-exposure in vivo and response prevention) either with their partner directly involved in all aspects of treatment or without their partner. The two treatment formats were equally effective. Although a substantial number of obsessive-compulsives were found to have marital problems, behavioural treatment directed at the obsessive-compulsive disorder resulted in improvement irrespective of marital quality and partner involvement in the therapy. The effects of treatment led neither to a deterioration of the marriage nor to adjustment problems in the partner.

The significance of the patient-therapist relationship in the treatment of obsessive-compulsive neurosis

Results are presented of two studies into the predictive value of the therapeutic relationship in the treatment of 60 and 25 obsessive-compulsive patients. A relationship was found between the therapist's score on the Barret-Lennard Relationship Inventory, assessed after the second and 10th sessions. As far as the patients' scores were concerned, however, a significant correlation with outcome was found only after the 10th session.

Severity and duration of obsessive-compulsive complaints. Results of treatment

There is no clear indication of how the severity and duration of obsessive-compulsive complaints can affect treatment results. Various studies seem to indicate that success or failure of treatment cannot be attributed to severity and duration of complaints. In this article, a bi-variant model is postulated, representing severity in combination with duration, and treatment results. Relatively short duration and relatively less severe complaints might, taken together, have predictive significance.

A search for high molecular impurities in penicillin G

A search for high molecular residues in penicillin G was carried out using several recently described methods. By the membrane filtration method the protein content of a large number of batches of penicillin G, 6-APA (chemically prepared), and ampicillin was determined. Significantly lower protein values were found for these compounds than for microbiologically produced 6-APA and the ampicillin made from it. Purified macromolecular complexes of penicillin gave protein values in the membrane filter method. Our results indicate that the protein content of most commercially available benzylpenicillins is negligible.