A randomized controlled trial of a multicomponent online stress reduction intervention in inflammatory bowel disease

BACKGROUND

Psychological stress negatively impacts inflammatory bowel disease (IBD) outcomes. Patients have prioritized access to online interventions; yet, the data on these have been limited by mixed in-person/online interventions, low adherence, and non-randomized controlled trial (RCT) design.

OBJECTIVES

We assessed the efficacy of and adherence to a 12-week online multicomponent stress reduction intervention in IBD.

DESIGN

This is a RCT.

METHODS

Adult participants on stable IBD medical therapy with elevated stress levels from four centers were randomized to intervention or control groups. Intervention participants received a 12-week online program including a weekly yoga, breathwork and meditation video (target 2-3 times/week), a weekly cognitive behavioral therapy/positive psychology informed video activity, and weekly 10-min check-ins by a study team member. Control participants received weekly motivational messages by email. All patients received standard of care IBD therapy. The primary outcome was Cohen's Perceived Stress Scale (PSS). Secondary outcomes evaluated mental health, resilience, health-related quality of life (HRQoL), symptom indices, acceptability, adherence, and inflammatory biomarkers. Analysis of covariance was used to determine between-group differences.

RESULTS

Of 150 screened patients, 101 were randomized to the intervention (n = 49) and control (n = 52) groups (mean age: 42.5 ± 14.1 years; M:F 1:3, 48% with ulcerative colitis and 52% with Crohn's disease). The between-group PSS improved by 22.4% (95% confidence interval, 10.5-34.3, p < 0.001). Significant improvements were seen in mental health, resilience, and HRQoL measures, with a median satisfaction score of 89/100 at the end of the 12 weeks. In the 44/49 patients who completed the intervention, 91% achieved program adherence targets.

CONCLUSION

This 12-week online intervention improved perceived stress, mental health, and HRQoL, but did not impact IBD symptom indices or inflammatory biomarkers. The program was readily adopted and adhered to by participants with high retention rates. After iterative refinement based on participant feedback, future studies will evaluate the impact of a longer/more intense intervention on disease course.

REGISTRATION

ClinicalTrials.gov Identifier NCT03831750.

PLAIN LANGUAGE SUMMARY

An online stress reduction intervention in inflammatory bowel disease patients improves stress, mental health, and quality of life People with inflammatory bowel disease (IBD) have high levels of stress, anxiety, and depression. Although IBD patients have expressed the need for online mental wellness interventions, the existing data to support these interventions in IBD are limited. In this trial, 101 IBD patients had the chance to participate in a 12-week online stress reduction intervention. In those patients randomly selected to participate in the online intervention, each week they received the following: a 20- to 30-min yoga, breathwork, and meditation video that they were asked to do 2-3 times a week, a 10- to 20-min mental wellness activity they were asked to do once during the week, and a 10-min telephone check-in with a study team member. Participants who were not selected to use the online intervention received a weekly motivational message by email. In all, 90 of the 101 participants (89%) completed the study with the mean age of participants being 43 years and the majority being females (75%). Ninety-one percent of participants who completed the intervention met the program target of doing the yoga, breathwork, and meditation video at least 2 times per week. Significant improvements were seen in perceived stress (by 22.4%), depression (by 29.5%), anxiety (by 23.7%), resilience (by 10.6%), and quality of life (by 8.9%). No changes were seen in IBD severity or in blood markers of inflammation. In conclusion, this study demonstrates evidence that a 12-week online stress reduction intervention had low dropout rates, high adherence and beneficial effects on stress, mental health, and quality of life measures. Continued feedback will be sought from study participants and our IBD patient partners to refine the intervention and assess the impact in future studies of patients with active IBD, as well as the impact of a longer/more intense intervention.

Prospective Investigation of Glutamate Levels and Percentage Gray Matter in the Medial Prefrontal Cortex in Females at Risk for Postpartum Depression

BACKGROUND

The substantial female hormone fluctuations associated with pregnancy and postpartum have been linked to a greater risk of developing depressive symptoms, particularly in high-risk women (HRW), i.e. those with histories of mood sensitivity to female hormone fluctuations. We have shown that glutamate (Glu) levels in the medial prefrontal cortex (MPFC) decrease during perimenopause, a period of increased risk of developing a major depressive episode. Our team has also demonstrated that percentage gray matter (%GM), another neural correlate of maternal brain health, decreases in the MPFC during pregnancy.

OBJECTIVE

To investigate MPFC Glu levels and %GM from late pregnancy up to 7 weeks postpartum in HRW and healthy pregnant women (HPW).

METHODS

Single-voxel spectra were acquired from the MPFC of 41 HPW and 22 HRW using 3- Tesla in vivo proton magnetic resonance spectroscopy at five different time points.

RESULTS

We observed a statistically significant interaction between time and group for the metabolite Glu, with Glu levels being lower for HRW during pregnancy and early postpartum (p<0.05). MPFC %GM was initially lower during pregnancy and then significantly increased over time in both groups (p<0.01).

CONCLUSION

This investigation suggests that the vulnerability towards PPD is associated with unique fluctuations of MPFC Glu levels during pregnancy and early postpartum period. Our results also suggest that the decline in MPFC %GM associated with pregnancy seems to progressively recover over time. Further investigations are needed to determine the specific role that female hormones play on the physiological changes in %GM during pregnancy and postpartum.

Fostering Coexistence Between People and Large Carnivores in Africa: Using a Theory of Change to Identify Pathways to Impact and Their Underlying Assumptions

Coexistence with large carnivores poses challenges to human well-being, livelihoods, development, resource management, and policy. Even where people and carnivores have historically coexisted, traditional patterns of behavior toward large carnivores may be disrupted by wider processes of economic, social, political, and climate change. Conservation interventions have typically focused on changing behaviors of those living alongside large carnivores to promote sustainable practices. While these interventions remain important, their success is inextricably linked to broader socio-political contexts, including natural resource governance and equitable distribution of conservation-linked costs and benefits. In this context we propose a Theory of Change to identify logical pathways of action through which coexistence with large carnivores can be enhanced. We focus on Africa's dryland landscapes, known for their diverse guild of large carnivores that remain relatively widespread across the continent. We review the literature to understand coexistence and its challenges; explain our Theory of Change, including expected outcomes and pathways to impact; and discuss how our model could be implemented and operationalized. Our analysis draws on the experience of coauthors, who are scientists and practitioners, and on literature from conservation, political ecology, and anthropology to explore the challenges, local realities, and place-based conditions under which expected outcomes succeed or fail. Three pathways to impact were identified: (a) putting in place good governance harmonized across geographic scales; (b) addressing coexistence at the landscape level; and (c) reducing costs and increasing benefits of sharing a landscape with large carnivores. Coordinated conservation across the extensive, and potentially transboundary, landscapes needed by large carnivores requires harmonization of top-down approaches with bottom-up community-based conservation. We propose adaptive co-management approaches combined with processes for active community engagement and informed consent as useful dynamic mechanisms for navigating through this contested space, while enabling adaptation to climate change. Success depends on strengthening underlying enabling conditions, including governance, capacity, local empowerment, effective monitoring, and sustainable financial support. Implementing the Theory of Change requires ongoing monitoring and evaluation to inform adaptation and build confidence in the model. Overall, the model provides a flexible and practical framework that can be adapted to dynamic local socio-ecological contexts.

Assisted colonisation trials for the western swamp turtle show that juveniles can grow in cooler and wetter climates

Species with restricted ranges and long generation times are vulnerable to climate change due to limited opportunity to disperse or adapt. Australia’s rarest reptile, the western swamp turtle Pseudemydura umbrina, persists naturally in only one seasonal swamp that holds water in the Austral winter and spring. A marked reduction in winter rainfall in recent decades has shortened the swamp hydroperiod, restricting when turtles are able to feed, grow and reproduce. To mitigate possible future loss of reproductive capacity in the native habitat, assisted colonisation was trialled in 2016 using 35 captive-bred juveniles. Here, we report the outcomes of this 6 mo trial, which compared the growth of turtles released approximately 300 km south of the species’ indigenous range with growth of turtles released at an existing northern translocation site. We showed that growth rates comparable to those at warmer northern translocation sites can be achieved in the south, even in an atypically cool spring as occurred in 2016. Microclimates available to P. umbrina at 2 southern sites were suitable for foraging and growth in late spring and early summer, but juvenile growth at one southern site was significantly better than at the other, likely due to higher prey biomass when water temperatures were suitable for foraging. These early results suggest that introduction of P. umbrina to seasonal wetlands near the south coast of Western Australia could be considered in the immediate future, but further trials are recommended to assess growth and survivorship over longer periods.

Autism Spectrum Social Stories In Schools Trial 2 (ASSSIST2): study protocol for a randomised controlled trial analysing clinical and cost-effectiveness of Social Stories™ in primary schools

Background

Interventions designed to support children with a diagnosis of Autism Spectrum Conditions (ASC) can be time consuming, needing involvement of outside experts. Social Stories™ are a highly personalised intervention aiming to give children with ASC social information or describing an otherwise difficult situation or skill. This can be delivered daily by staff in education settings. Studies examining Social Story™ use have yielded mostly positive results but have largely been single case studies with a lack of randomised controlled trials (RCTs). Despite this numerous schools are utilising Social Stories™, and a fully powered RCT is timely.

Methods

A multi-site pragmatic cluster RCT comparing care as usual with Social Stories™ and care as usual. This study will recruit 278 participants (aged 4–11) with a clinical diagnosis of ASC, currently attending primary school in the North of England. Approximately 278 school based staff will be recruited to provide school based information about participating children with approximately 140 recruited to deliver the intervention. The study will be cluster randomised by school. Potential participants will be screened for eligibility prior to giving informed consent. Follow up data will be collected at 6 weeks and 6 months post randomisation and will assess changes in participants’ social responsiveness, goal based outcomes, social and emotional health. The primary outcome measure is the Social Responsiveness Scale Second Edition (SRS-2) completed by school based staff at 6 months. Approvals have been obtained from the University of York’s Research Governance Committee, Research Ethics Committee and the Health Research Authority. Study results will be submitted for publication in peer-reviewed journals and disseminated to participating families, educational staff, local authority representatives, community groups and Patient and Participant Involvement representatives. Suggestions will be made to NICE about treatment evidence dependent on findings.

Discussion

This study addresses a much used but currently under researched intervention and results will inform school based support for primary school children with a diagnosis of ASC.

Trial registration

The trial is registered on the ISRCTN registry (registration number: ISRCTN11634810). The trial was retrospectively registered on 23rd April 2019.

Engaging people with lived experience in the grant review process

People with lived experience are individuals who have first-hand experience of the medical condition(s) being considered. The value of including the viewpoints of people with lived experience in health policy, health care, and health care and systems research has been recognized at many levels, including by funding agencies. However, there is little guidance or established best practices on how to include non-academic reviewers in the grant review process. Here we describe our approach to the inclusion of people with lived experience in every stage of the grant review process. After a budget was created for a specific call, a steering committee was created. This group included researchers, people with lived experience, and health systems administrators. This group developed and issued the call. After receiving proposals, stage one was scientific review by researchers. Grants were ranked by this score and a short list then reviewed by people with lived experience as stage two. Finally, for stage three, the Steering Committee convened and achieved consensus based on information drawn from stages one and two. Our approach to engage people with lived experience in the grant review process was positively reviewed by everyone involved, as it allowed for patient perspectives to be truly integrated. However, it does lengthen the review process. The proposed model offers further practical insight into including people with lived experience in the review process.

The Role of Water in Fast Plant Movements

Plants moved onto land ∼450 million years ago and faced their biggest challenge: living in a dry environment. Over the millennia plants have become masters of regulating water flow and the toolkit they have developed has been co-opted to effect rapid movements. Since plants are rooted, these fast movements are used to disperse reproductive propagules including spores, pollen, and seeds. We compare five plants to demonstrate three ways, used alone or in combination, that water powers rapid movements: the direct capture of the kinetic energy of a falling raindrop propels gemmae from the splash cups of the liverwort, Marchantia; the loss of water powers the explosive dispersal of the spores of Sphagnum moss; the alternate loss and gain of water in the bilayer of the elaters of Equisetum drive the walk, jump, and glide of spores; the gain of water in the inner layer of the arils of Oxalis drive the eversion of the aril that jettisons seeds from the capsule; and the buildup of turgor pressure in the petals and stamens of bunchberry dogwood (Cornus canadensis) explosively propels pollen. Each method is accompanied by morphological features, which facilitate water movement as a power source. The urn shaped splash cups of Marchantia allow dispersal of gemmae by multiple splashes. The air gun design of Sphagnum capsules results in a symmetrical impulse creating a vortex ring of spores. The elaters of Equisetum can unfurl while they are dropping from the plant, so that they capture updrafts and glide to new sites. The arils of Oxalis are designed like miniature toy "poppers." Finally, in bunchberry, the softening of stamen filament tissue where it attaches to the anther allows them to function as miniature hinged catapults or trebuchets.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease

IMPORTANCE

A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed.

OBJECTIVE

To determine the association of mental health disorders with health care costs among people with chronic diseases.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018.

EXPOSURES

Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder).

MAIN OUTCOMES AND MEASURES

Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions.

RESULTS

Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.

Bridging the divide between scientists and decision-makers: how behavioural ecologists can increase the conservation impact of their research?

Effective conservation management is underpinned by science. Yet, there are often barriers against the incorporation of up-to-date scientific research into decision-making and policy. Here, we draw on experience from a multi-nation approach to conserve cheetah and African wild dogs across Africa, using relationships between scientists and managers established over more than a decade, to better understand scientific information needs of managers. While our analysis focuses on Africa, many of our findings are likely to be relevant to other regions. Managers view science as critical to their decision-making processes and strongly support scientific research, particularly when research directly addresses their information needs. However, managers reported problems in accessing final results and highlighted the need to access raw ecological data from research undertaken within protected areas. Fundamental to improving the management relevance of scientific research is the need for scientists to engage with managers through all steps of the research process, from project design and implementation through to scientific publication and end-of-project agreements. Effective engagement requires open and clear communication; including agreed processes for access to biodiversity data and submission of final results. In order to foster future scientific endeavours and collaborations, systems should be established to better facilitate information exchange, while also safeguarding the rights of scientists to publish their data and protect their academic freedom. Our analysis also calls for a greater awareness of the geo-political context under which science is undertaken, and for increased scientific participation through an inclusive approach that recognizes, and gives credit to, a wider diversity of scientific contributions and expertise. This article is part of the theme issue 'Linking behaviour to dynamics of populations and communities: application of novel approaches in behavioural ecology to conservation'.

Depression in cirrhosis - a prospective evaluation of the prevalence, predictors and development of a screening nomogram

BACKGROUND

Depression is associated with substantial morbidity and mortality in cirrhosis, but is underdiagnosed and undertreated.

AIMS

Using the Mini International Neuropsychiatric Interview (MINI) as a gold-standard, to determine prevalence, predictors, and outcomes of depression, and to develop a screening nomogram for use in cirrhosis patients.

METHODS

Cirrhotic outpatients 18-80 years of age, not on anti-depressants, were consecutively recruited from liver clinics at three tertiary care hospitals. Baseline health-related quality of life (HRQoL) and frailty were determined by the chronic liver disease questionnaire, EQ-VAS, Clinical Frailty Scale and Fried Frailty Criteria. Depression was identified using the MINI and participants were followed up to 6 months to determine unplanned hospitalization/death.

RESULTS

Of 305 patients, 62% were male; mean age 55(10) years; mean MELD 12.5(5), 61% Child Pugh B/C. Prevalence of depression 18% by MINI. Patients with depression had lower baseline HRQoL and higher frailty scores. Five independently predictive factors were used to develop a clinical nomogram for the diagnosis of clinical depression. These included three Hospital Anxiety and Depression Screening tool variables: "I have lost interest in my appearance" (adjusted odds ratio [aOR] 2.2, P = 0.006), "I look forward with enjoyment to things" (aOR 2.0, P = 0.02), "I feel cheerful" (aOR 2.8, P = 0.002), and two demographic variables: younger age (aOR 0.92, P = 0.001) and not being married or in a common-law relationship (aOR 0.30, P = 0.008).

CONCLUSIONS

Depression is common in patients with cirrhosis. It has a significant impact on HRQoL and functional status. The developed clinical nomogram is promising for the rapid screening of depression in patients with cirrhosis.

Diagnostic accuracy of the Geriatric Depression Scale-30, Geriatric Depression Scale-15, Geriatric Depression Scale-5 and Geriatric Depression Scale-4 for detecting major depression: protocol for a systematic review and individual participant data meta-analysis

INTRODUCTION

The 30-item Geriatric Depression Scale (GDS-30) and the shorter GDS-15, GDS-5 and GDS-4 are recommended as depression screening tools for elderly individuals. Existing meta-analyses on the diagnostic accuracy of the GDS have not been able to conduct subgroup analyses, have included patients already identified as depressed who would not be screened in practice and have not accounted for possible bias due to selective reporting of results from only better-performing cut-offs in primary studies. Individual participant data meta-analysis (IPDMA), which involves a standard systematic review, then a synthesis of individual participant data, rather than summary results, could address these limitations. The objective of our IPDMA is to generate accuracy estimates to detect major depression for all possible cut-offs of each version of the GDS among studies using different reference standards, separately and among participant subgroups based on age, sex, dementia diagnosis and care settings. In addition, we will use a modelling approach to generate individual participant probabilities for major depression based on GDS scores (rather than a dichotomous cut-off) and participant characteristics (eg, sex, age, dementia status, care setting).

METHODS AND ANALYSIS

Individual participant data comparing GDS scores to a major depression diagnosis based on a validated structured or semistructured diagnostic interview will be sought via a systematic review. Data sources will include Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO and Web of Science. Bivariate random-effects models will be used to estimate diagnostic accuracy parameters for each cut-off of the different versions of the GDS. Prespecified subgroup analyses will be conducted. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

ETHICS AND DISSEMINATION

The findings of this study will be of interest to stakeholders involved in research, clinical practice and policy.

PROSPERO REGISTRATION NUMBER

CRD42018104329.

Centralization of Services: Standard Setting and Outcomes

Objective

To test specific standards set in the newly established cleft lip and palate service in three regions of the U.K. The standards relate to record collection and outcomes.

Design

Retrospective analysis.

Patients

Records of 31 children, 5 years of age, who were born in 1997 with complete unilateral clefts of lip and palate and were treated by surgeons in three regions.

Main outcome measures

Record collection standards were measured by collecting dental study models. Outcomes were measured with the 5-Year-Old Index.

Results

Of the 31 subjects, 52% had excellent and good outcomes. The 31 cases represented 62% of the total records collected.

Conclusions

The three regions examined fell short of the standards set, but the outcomes were improved compared with previous national outcomes. The failings in record collection need to be rectified. This study provides baseline data for further development of cleft services within three regions.

mSOAR: an effective bedside stroke prognosis tool

The modified-SOAR (mSOAR) score is composed of the stroke subtype, Oxfordshire Community Stroke Project classification, age, pre-stroke modified Rankin score (mRS) and the National Institutes of Health Stroke Scale score. It has previously been shown to be a reliable predictor of mortality and length of -hospital stay. This study sought to identify whether the mSOAR can also be used to predict patient disability on discharge. A post-hoc calculation of mSOAR using Sentinel Stroke National Audit Programme (SSNAP) data and electronic discharge -summaries was performed on all stroke admissions to Bridgend Hospital over an 11-month period. This study included 230 patients, of which 88% had suffered infarcts and 23% had experienced a previous cerebrovascular episode or transient ischaemic attack; 52% were female. The mortality rate was 13% and 57% had slight disability or less (mRS≤2) on discharge. Each increase in mSOAR score was associated with significantly worse discharge disability (p<0.05). We conclude that the mSOAR score is an excellent tool for predicting both discharge disability and mortality. As such, it's useful for admission prognosis discussions with patients, their relatives and the multidisciplinary team and for early supported discharge decision making.

The global decline of cheetah Acinonyx jubatus and what it means for conservation

Establishing and maintaining protected areas (PAs) are key tools for biodiversity conservation. However, this approach is insufficient for many species, particularly those that are wide-ranging and sparse. The cheetah Acinonyx jubatus exemplifies such a species and faces extreme challenges to its survival. Here, we show that the global population is estimated at ∼7,100 individuals and confined to 9% of its historical distributional range. However, the majority of current range (77%) occurs outside of PAs, where the species faces multiple threats. Scenario modeling shows that, where growth rates are suppressed outside PAs, extinction rates increase rapidly as the proportion of population protected declines. Sensitivity analysis shows that growth rates within PAs have to be high if they are to compensate for declines outside. Susceptibility of cheetah to rapid decline is evidenced by recent rapid contraction in range, supporting an uplisting of the International Union for the Conservation of Nature (IUCN) Red List threat assessment to endangered. Our results are applicable to other protection-reliant species, which may be subject to systematic underestimation of threat when there is insufficient information outside PAs. Ultimately, conserving many of these species necessitates a paradigm shift in conservation toward a holistic approach that incentivizes protection and promotes sustainable human-wildlife coexistence across large multiple-use landscapes.

Detailed thermodynamic analysis of the activation parameters for the simple hydrolysis of acetic anhydride in the acetonitrile/water cosolvent system

A plot ofvs. Tfor the acetonitrile/water system. Terms such as this one are crucial for a thermodynamic analysis of Eyring activation parameters.

Depression and Survival in Patients With Head and Neck Cancer: A Systematic Review

IMPORTANCE

The incidence of depression in patients with head and neck cancer (HNC) is estimated to be as high as 40%. Previous studies have demonstrated an effect of depression on rehabilitation and survival in the posttreatment period.

OBJECTIVE

To systematically review the relationship between depression and survival in patients with HNC undergoing curative treatment.

EVIDENCE REVIEW

A search of electronic databases as well as gray literature was undertaken from January 1, 1974, to August 20, 2014, including MEDLINE (via Ovid), EMBASE (via Ovid), CINAHL, EBSCO, PsycINFO (via Ovid), Elsevier Scopus, and Institute for Scientific Information Web of Science Core Collection, using controlled vocabulary and medical subject headings representing HNC, depression, and survival. Articles in these databases were reviewed for inclusion by 2 independent reviewers according to predetermined eligibility criteria and were adjudicated by a third reviewer. The articles were then quantitatively scored using the GRACE (Good Research for Comparative Effectiveness) tool, a validated instrument for assessing the quality of observational studies. Qualitative assessment of each article was then undertaken.

FINDINGS

A total of 654 references were retrieved across all databases. A review of the abstracts and full texts identified 3 articles, each describing a distinct, single study, including a total of 431 patients, that were eligible for analysis. Scores for the articles as assessed with the GRACE tool ranged from 9 to 11. In each of the 3 studies used in the analysis, the comparison groups were depressed and nondepressed patients as established by a standardized psychiatric assessment tool. Two of the 3 studies demonstrated a statistically significant difference in survival for patients with HNC and depression; however, a sensitivity analysis was not possible due to the incompatible statistical analyses performed in each study.

CONCLUSIONS AND RELEVANCE

An association between depression and survival in patients with HNC is apparent; however, the strength and etiology of this association is not yet clear. Further directed and multi-institutional study is required to investigate this association and determine appropriate screening and management strategies.

Diagnostic accuracy of the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses

INTRODUCTION

The Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) has been recommended for depression screening in medically ill patients. Many existing HADS-D studies have used exploratory methods to select optimal cut-offs. Often, these studies report results from a small range of cut-off thresholds; cut-offs with more favourable accuracy results are more likely to be reported than others with worse accuracy estimates. When published data are combined in meta-analyses, selective reporting may generate biased summary estimates. Individual patient data (IPD) meta-analyses can address this problem by estimating accuracy with data from all studies for all relevant cut-off scores. In addition, a predictive algorithm can be generated to estimate the probability that a patient has depression based on a HADS-D score and clinical characteristics rather than dichotomous screening classification alone. The primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the HADS-D to detect major depression among adults across all potentially relevant cut-off scores and to generate a predictive algorithm for individual patients. We are already aware of over 100 eligible studies, and more may be identified with our comprehensive search.

METHODS AND ANALYSIS

Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO and Web of Science. Eligible studies will have datasets where patients are assessed for major depression based on a validated structured or semistructured clinical interview and complete the HADS-D within 2 weeks (before or after). Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values, and a predictive algorithm for individual patients will be generated.

ETHICS AND DISSEMINATION

The findings of this study will be of interest to stakeholders involved in research, clinical practice and policy.

Diagnostic accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for detecting major depression in pregnant and postnatal women: protocol for a systematic review and individual patient data meta-analyses

INTRODUCTION

Studies of the diagnostic accuracy of depression screening tools often used data-driven methods to select optimal cut-offs. Typically, these studies report results from a small range of cut-off points around whatever cut-off score is identified as most accurate. When published data are combined in meta-analyses, estimates of accuracy for different cut-off points may be based on data from different studies, rather than data from all studies for each cut-off point. Thus, traditional meta-analyses may exaggerate accuracy estimates. Individual patient data (IPD) meta-analyses synthesise data from all studies for each cut-off score to obtain accuracy estimates. The 10-item Edinburgh Postnatal Depression Scale (EPDS) is commonly recommended for depression screening in the perinatal period. The primary objective of this IPD meta-analysis is to determine the diagnostic accuracy of the EPDS to detect major depression among women during pregnancy and in the postpartum period across all potentially relevant cut-off scores, accounting for patient factors that may influence accuracy (age, pregnancy vs postpartum).

METHODS AND ANALYSIS

Data sources will include Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. Studies that include a diagnosis of major depression based on a validated structured or semistructured clinical interview administered within 2 weeks of (before or after) the administration of the EPDS will be included. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values. Analyses will evaluate data from pregnancy and the postpartum period separately, as well as combining data from all women in a single model.

ETHICS AND DISSEMINATION

This study does not require ethics approval. Dissemination will include journal articles and presentations to policymakers, healthcare providers and researchers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2015:CRD42015024785.

Depression as a predictor of postoperative functional performance status (PFPS) and treatment adherence in head and neck cancer patients: a prospective study

Background

Head and neck cancer (HNC) is a debilitating disease due in part to its effects on function, including speech, swallowing, and cosmesis. Previous studies regarding depression in HNC have focused on demographic predictors, incidence, and quality of life studies. There is, however, a paucity of studies that objectively address depressive symptoms in HNC patients and the resultant effects on post-treatment functional performance status. The aim of this study was to assess the relationship between preoperative depressive symptoms (PDS) and postoperative functional performance status (PFPS), in addition to other predictors of rehabilitation and survival.

Methods

A prospective cohort study was undertaken at the University of Alberta, including all new adult HNC patients undergoing surgery as primary therapy for HNC from May 2013 to January 2014. Baseline depressive symptoms were measured on the Quick Inventory of Depressive Symptoms (QIDS) questionnaire 2 weeks preoperatively and PFPS was assessed 12 months postoperatively on the Functional Assessment of Cancer Therapy-Head & Neck (FACT-HN) scale. Secondary outcomes included completion of adjuvant therapy, narcotic dependence, return to detrimental habits, loss of follow-up, and length of hospital stay (LOHS). Differences between the Normal-Mild and Moderate-Severe QIDS groups were assessed using Mann–Whitney and Fischer Exact statistical analyses.

Results

Seventy-one patients were included in the study. Mild and Moderate-Severe PDS were 35.2 % and 18.3 %, respectively. Significantly lower FACT-HN scores were noted in the Moderate-Severe group at 12 months (p = 0.03). The risk ratio (RR) for FACT-HN score < 50 % at 12 months in the Moderate-Severe group was 5.66. In addition, significantly lower completion of adjuvant treatment (p = 0.03), significantly higher incidence of narcotic dependence (p = 0.004), and significantly higher LOHS (24 days vs. 18 days; p = 0.02) was observed in the Moderate-Severe group. There was no significant difference in loss of follow-up between the 2 groups (p = 0.64).

Conclusions

The incidence and severity of PDS in HNC patients treated with surgery is high (53.5 %). Patients with Moderate-Severe PDS have significantly decreased PFPS, increased narcotic use, decreased completion of adjuvant therapy, and a longer LOHS. HNC patients should be monitored closely for depressive symptoms.

Consensus recommendations on training and competing in the heat

Exercising in the heat induces thermoregulatory and other physiological strain that can lead to impairments in endurance exercise capacity. The purpose of this consensus statement is to provide up-to-date recommendations to optimise performance during sporting activities undertaken in hot ambient conditions. The most important intervention one can adopt to reduce physiological strain and optimise performance is to heat acclimatise. Heat acclimatisation should comprise repeated exercise-heat exposures over 1–2 weeks. In addition, athletes should initiate competition and training in a euhydrated state and minimise dehydration during exercise. Following the development of commercial cooling systems (eg, cooling-vest), athletes can implement cooling strategies to facilitate heat loss or increase heat storage capacity before training or competing in the heat. Moreover, event organisers should plan for large shaded areas, along with cooling and rehydration facilities, and schedule events in accordance with minimising the health risks of athletes, especially in mass participation events and during the first hot days of the year. Following the recent examples of the 2008 Olympics and the 2014 FIFA World Cup, sport governing bodies should consider allowing additional (or longer) recovery periods between and during events, for hydration and body cooling opportunities, when competitions are held in the heat.

First-in-human trial of the safety, pharmacokinetics and immunogenicity of a PEGylated anti-CD40L antibody fragment (CDP7657) in healthy individuals and patients with systemic lupus erythematosus

OBJECTIVE

The objective of this paper is to investigate the safety, pharmacokinetics (PK) and immunogenicity of CDP7657, a PEGylated anti-CD40L antibody fragment, in healthy individuals and patients with systemic lupus erythematosus (SLE).

METHODS

This randomized, double-blind, single-dose, dose-escalation phase I study consisted of two parts. In part 1, 28 healthy individuals received CDP7657 IV (0.004-5 mg/kg) or placebo. In part 2, 17 patients with SLE received CDP7657 IV (5-60 mg/kg) or placebo. The CDP7657:placebo ratio was 3:1.

RESULTS

Adverse events (AEs) were reported by 76% of healthy individuals and 100% of patients with SLE treated with CDP7657; most were mild or moderate in intensity. Two healthy individuals reported serious AEs (SAEs), one of which was considered treatment related (infusion-related reaction; 5 mg/kg cohort). One patient with SLE (60 mg/kg cohort) experienced three SAEs, one of which was considered treatment related (herpes zoster infection). No thromboembolic events were reported. CPD7657 exposure increased in a dose-proportional manner. Low anti-CDP7657 antibody titres were detected in the majority of CDP7657-treated participants with no apparent impact on the PK of CDP7657.

CONCLUSION

Single doses of CDP7657 showed predictable PK in healthy individuals and patients with SLE and were well tolerated, with no safety signals of concern. These findings support further investigation of CDP7657 as a therapy for SLE.

Optimal Interventions for Depression after Diagnosis of Head and Neck Cancer: A Systematic Review

Objectives:

Depression in head and neck cancer (HNC) patients is undertreated and under-recognized, yet has been shown to be present in up to 40% of patients. The objective in this study was to perform a systematic review of the literature regarding the optimal psychologic intervention for HNC patients with depressive symptomatology.

Methods:

A systematic review. PubMed, Medline, and ENCASE were searched in December 2013 for studies examining psychologic interventions in head and neck cancer patients. Results were screened by 2 independent reviewers. The level of evidence for each study and intervention were evaluated using criteria put forth by the Agency for Healthcare Research and Quality US Preventative Services Task Force. Subsequent analysis was then planned according to the criteria in the Cochrane Handbook for Systematic Reviews.

Results:

Eleven studies met inclusion criteria. Three studies were rated “good” for internal validity and 6 for external validity. Psychologic education and cognitive behavior therapy were evaluated by 8 studies, and antidepressant use was examined by 2 studies. Support group therapy was examined by 1 study. Meta-analysis was precluded by significant heterogeneity. Strongest evidence for successful treatment of depression was demonstrated by psycho-education.

Conclusions:

Evidence for the optimal psychologic intervention for depression in HNC patients is limited by the small number of studies examining treatment types, lack of high level of evidence in research methodology, and poor comparability of studies. Future studies should target a standardized assessment and diagnosis as well as evaluation of treatment type.

A review of the behaviour of U-238 series radionuclides in soils and plants

The U-238 series of radionuclides is of relevance in a variety of environmental contexts ranging from the remediation of former uranium mining and milling facilities to the deep geological disposal of solid radioactive wastes. Herein, we review what is known concerning the behaviour of radionuclides from the U-238 decay chain in soils and plants. This review is intended to provide a single comprehensive source of information to anyone involved in undertaking environmental impact assessment studies relating to this decay chain. Conclusions are drawn relating to values and ranges of distribution coefficients appropriate to uranium, thorium, radium, lead and polonium in different soil types and under various environmental conditions. Similarly, conclusions are drawn relating to plant:soil concentration ratios for these elements for different plant and soil types, and consideration is given to the distribution of these elements within plants following both root uptake and foliar application.

Sonic hedgehog regulates presynaptic terminal size, ultrastructure and function in hippocampal neurons

Sonic hedgehog (Shh) signaling is essential to the patterning of the embryonic neural tube, but its presence and function in the postmitotic differentiated neurons in the brain remain largely uncharacterized. We recently showed that Shh and its signaling components, Patched and Smoothened, are expressed in postnatal and adult hippocampal neurons. We have now examined whether Shh signaling has a function in these neurons. Using cultured hippocampal neurons as a model system, we found that presynaptic terminals become significantly larger in response to the application of Shh. Ultrastructural examination confirmed the enlarged presynaptic profiles and also revealed variable increases in the size of synaptic vesicles, with a resulting loss of uniformity. Furthermore, electrophysiological analyses showed significant increases in the frequency, but not the amplitude, of spontaneous miniature excitatory postsynaptic currents (mEPSCs) in response to Shh, providing functional evidence of the selective role of Shh in presynaptic terminals. Thus, we conclude that Shh signaling regulates the structure and functional properties of presynaptic terminals of hippocampal neurons.

Therapeutic targeting of the endoplasmic reticulum in Alzheimer's disease

The extensive prevalence of Alzheimer's disease (AD) places a tremendous burden physiologically, socially and economically upon those directly suffering and those caring for sufferers themselves. Considering the steady increases in numbers of patients diagnosed with Alzheimer's, the number of effective pharmacotherapeutic strategies to tackle the disease is still relatively few. As with many other neurodegenerative mechanisms, AD, is characterized by the continued presence and accumulation of cytotoxic protein aggregates, i.e. of beta-amyloid and the microtubule associated protein, tau. Therefore, one novel therapeutic avenue for the treatment of AD may be the actual targeting of factors that control protein synthesis, packaging and degradation. One of the prime cellular targets that, if effectively modulated, could accomplish this is the endoplasmic reticulum (ER). The ER can not only control cellular protein synthesis, trafficking and degradation but it is also closely associated with cytoprotective mechanisms, including calcium ion regulation and unfolded protein responses. This review will delineate some of the most important functional physiological features of the ER that, if effectively modulated, could result in beneficial amelioration or remediation of the negative cellular aspects of AD initiation and progression. While not a classical drug target, even with minimal levels of beneficial modulation, its multifactorial efficacy may amplify small effects resulting in significant therapeutic efficacy.

Characterization and Safety of Uniform Particle Size NovaSil Clay as a Potential Aflatoxin Enterosorbent

NovaSil (NS) clay, a common anti-caking agent in animal feeds, has been shown to adsorb aflatoxins and diminish their bioavailability in multiple animal models. The safety of long-term dietary exposure to NS has also been demonstrated in a 6-month sub-chronic study in rats and in a 3-month intervention in humans highly exposed to aflatoxins. Uniform particle size NovaSil (UPSN) is a refined material derived from parent NS; it contains lower levels of dioxins/furans, and has been selected for a more consistent uniform particle size. Nevertheless, the efficacy and potential safety/toxicity of UPSN for long term-use has not yet been determined. In this research, 4-week-old male and female Sprague Dawley rats were fed rations free of clay (control) and containing UPSN at low dose (0.25%) and high dose (2%) for 13 weeks. AFB(1) sorption characteristics remained the same for both clays. When compared to the control, total body weight gain was unaffected in either sex at the doses tested. No UPSN-dependent differences in relative organ weights or gross appearance were observed. Isolated differences between UPSN groups and the control were observed for some biochemical parameters and selected vitamins and minerals. None of these differences were dose-dependent, and all parameters fell between ranges reported as normal for rats less than 6 month old. The Na/K ratio, Na and vitamin E concentrations were the only parameters that were increased in both males and females in the low dose and high dose UPSN groups. Serum Zn levels in males from the 2% UPSN treatment were lower compared to the control. Serum K levels were lower in the males of UPSN groups than in the control. However, neither Na/K ratio, K, nor Zn values were dose dependent and fell outside ranges reported as normal. These results suggest that dietary inclusion of UPSN at levels as high as 2% (w/w) does not result in overt toxicity. Nevertheless, further research on the effects of clays on Na, Zn, K and vitamin E is warranted.

Minimal peroxide exposure of neuronal cells induces multifaceted adaptive responses

Oxidative exposure of cells occurs naturally and may be associated with cellular damage and dysfunction. Protracted low level oxidative exposure can induce accumulated cell disruption, affecting multiple cellular functions. Accumulated oxidative exposure has also been proposed as one of the potential hallmarks of the physiological/pathophysiological aging process. We investigated the multifactorial effects of long-term minimal peroxide exposure upon SH-SY5Y neural cells to understand how they respond to the continued presence of oxidative stressors. We show that minimal protracted oxidative stresses induce complex molecular and physiological alterations in cell functionality. Upon chronic exposure to minimal doses of hydrogen peroxide, SH-SY5Y cells displayed a multifactorial response to the stressor. To fully appreciate the peroxide-mediated cellular effects, we assessed these adaptive effects at the genomic, proteomic and cellular signal processing level. Combined analyses of these multiple levels of investigation revealed a complex cellular adaptive response to the protracted peroxide exposure. This adaptive response involved changes in cytoskeletal structure, energy metabolic shifts towards glycolysis and selective alterations in transmembrane receptor activity. Our analyses of the global responses to chronic stressor exposure, at multiple biological levels, revealed a viable neural phenotype in-part reminiscent of aged or damaged neural tissue. Our paradigm indicates how cellular physiology can subtly change in different contexts and potentially aid the appreciation of stress response adaptations.

Presence of plasmid-mediated quinolone resistance in Klebsiella pneumoniae and Escherichia coli isolates possessing blaVIM-1 in Greece

Amongst nalidixic acid-resistant, ciprofloxacin-susceptible Escherichia coli and Klebsiella pneumoniae clinical isolates recovered over a 5-month period from inpatients and outpatients of Attikon University General Hospital (Athens, Greece), only one E. coli was positive for qnrB2 and one K. pneumoniae was positive for qnrA1. Both isolates were extended-spectrum beta-lactamase-negative, metallo-beta-lactamase-positive and carried the bla(VIM-1) gene. Neither of the isolates had mutations in gyrA and parC or carried aac(6')-Ib-cr or qepA. The K. pneumoniae isolate also harboured bla(CMY-13) on the same transferable plasmid with qnrA1. This is the first report of a qnrA1-positive K. pneumoniae and qnrB2-positive E. coli harbouring a concurrent bla(VIM-1) gene.