A25 MEASURING THE OBSERVER (HAWTHORNE) EFFECT ON ADENOMA DETECTION RATES: A CASE-CONTROL RETROSPECTIVE STUDY

Background

The effectiveness of colonoscopy screening to prevent colorectal cancer (CRC) is directly linked to its procedural quality. An independent observer (Hawthorne effect) can improve colonoscopy procedural quality metrics, including adenoma detection rate (ADR). However, the results of studies are limited or controversial.

Purpose

We aimed to evaluate the colonoscopy quality metrics in a group of patients undergoing screening or diagnostic colonoscopies under stringent observer conditions.

Method

In a single-center, case–control study, consecutive patients undergoing routine screening or diagnostic colonoscopy were prospectively enrolled. In the case group, all procedural steps and quality metrics were observed and documented, and the procedure was video recorded by an independent research assistant. In the control group, colonoscopies were performed without independent observation. Colonoscopy quality metrics such as polyp, adenoma, serrated lesions, and advanced adenoma detection rates (PDR, ADR, SLDR, AADR), the mean number of adenomas detected per patient (MAP), and the mean number of adenomas and serrated lesions detected per patient (MASP) were compared. The probabilities of increased quality metrics were evaluated through regression analyses weighted by the inversed probability of observation during the procedure.

Result(s)

We included a total of 687 patients (327 cases and 360 controls) in the final analyses. The case group had significantly higher PDRs (62.4% vs. 53.1%) and ADRs (39.4% vs. 28.3%) compared with the control group. The SLDR was also higher in the case group than in the control group, but the difference was not significant (7.3% vs. 4.4%; P = 0.14). The AADR was not significantly increased. After adjusting for potential confounders, the ADR and SLDR were 50% (odds ratio [OR] 1.51; 95%CI 1.05–2.17) and more than twofold (OR 2.17; 95%CI 1.05–4.47) more likely to be higher in the case group than in the control group. The MAP and MASP were significantly increased in the case group compared with the control group (P < 0.001). The regression analyses for both metrics demonstrated the direct and significant association between the Hawthorne effect and elevated MAP/MASP.

Conclusion(s)

The presence of an independent observer documenting colonoscopy quality metrics and video recording the colonoscopy resulted in a significant increase in ADR and other quality metrics. The Hawthorne effect should be considered an alternative strategy to advanced devices to improve colonoscopy quality in routine practice.

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None

Disclosure of Interest

M. Taghiakbari: None Declared, D. Coman: None Declared, M. Takla: None Declared, A. N. Barkun: None Declared, M. Frija-Gruman: None Declared, M. Bouin: None Declared, S. Bouchard: None Declared, E. Deslandres: None Declared, S. Sidani: None Declared, D. von Renteln Grant / Research support from: ERBE, Ventage, Pendopharm, and Pentax, Consultant of: Boston Scientific and Pendopharm

A108 AUTOMATED DETECTION OF ILEOCECAL VALVE, APPENDICEAL ORIFICE, AND POLYP DURING COLONOSCOPY USING A DEEP LEARNING MODEL

Background

Identification and photo-documentation of the ileocecal valve (ICV) and appendiceal orifice (AO) confirm completeness of colonoscopy examinations. We hypothesized that an artificial intelligence (AI)-empowered solution could help us automatically differentiate anatomical landmarks such as AO and ICV from polyps and normal colon mucosa.

Purpose

We aimed to develop and test a deep convolutional neural network (DCNN) model that can automatically identify ICV and AO, and differentiate these landmarks from normal mucosa and colorectal polyps.

Method

We prospectively collected annotated full-length colonoscopy videos of 318 patients undergoing outpatient colonoscopies. We created three non-overlapping training, validation, and test datasets with 25,444 unaltered frames extracted from the colonoscopy videos showing four landmarks/image classes (AO, ICV, normal mucosa, and polyps). For each landmark, we extracted an average of 30 frames for each time of its appearance. All the extracted frames were reviewed and annotated by a team of three clinicians. Using a quality assessment tool, the clinicians examined a total of 86,754 frames (7982 AO, 8374 ICV, 32,971 polyps, and 37,427 normal mucosa) and verified whether or not the frame contained one unique landmark. For this research, all frames were extracted from the white-light colonoscopies, and all narrow-band imaging frames were excluded. A DCNN classification model was developed, validated, and tested in separate datasets of images. The primary outcome was the proportion of patients in whom the AI model could identify both ICV and AO, and differentiate them from polyps and normal mucosa, with an accuracy of detecting both AO and ICV above a threshold of 40% (representing a value in which reliable identification of the landmarks can be assumed without increasing false-positive alerts).

Result(s)

We trained a DCNN AI model on 21,503 unaltered frames extracted from the recorded colonoscopy videos of 272 patients, and validated and tested the model on 1,924 (25 patients) and 2,017 (21 patients) unaltered frames, respectively. We applied a transfer learning technique to fine-tune the model parameters to the endoscopic images using a cross-entropy loss function and back-propagation algorithm. After training and validation, the DCNN model could identify both AO and ICV in 18 out of 21 patients (85.71%), if accuracies were above the threshold of 40%. The accuracy of the model for differentiating AO from normal mucosa, and ICV from normal mucosa were 86.37% (95% CI 84.06% to 88.45%), and 86.44% (95% CI 84.06% to 88.59%), respectively. Furthermore, the accuracy of the model for differentiating polyps from normal mucosa was 88.57% (95% CI 86.60% to 90.33%).

Conclusion(s)

The model can reliably distinguish these anatomical landmarks from normal mucosa and colorectal polyps. It can be implemented into automated colonoscopy report generation, photo-documentation, and quality auditing solutions to improve colonoscopy reporting quality.

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Other

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MEDTEQ

Disclosure of Interest

M. Taghiakbari: None Declared, S. Hamidi Ghalehjegh Employee of: Imagia Canexia Health Inc. , E. Jehanno Employee of: Imagia Canexia Health Inc. , T. Berthier Employee of: Imagia Canexia Health Inc. , L. di Jorio Employee of: Imagia Canexia Health Inc. , A. N. Barkun Grant / Research support from: co-awardee in funded research projects with Imagia Canexia Health Inc., Consultant of: Medtronic Inc. and A.I. VALI Inc, E. Deslandres: None Declared, S. Bouchard: None Declared, S. Sidani: None Declared, Y. Bengio: None Declared, D. von Renteln Grant / Research support from: ERBE, Ventage, Pendopharm, and Pentax, Consultant of: Boston Scientific and Pendopharm

Virtual reality-based exposure with applied biofeedback for social anxiety disorder

Introduction

Social Anxiety Disorder (SAD) is considered the most prevalent anxiety disorder with the highest disease burden amongst anxiety disorders. Despite available effective treatment with Cognitive Behavioral Therapy, a majority of individuals with SAD do not seek treatment and many drop out when confronted with elements of exposure. Several studies highlight the many advantages virtual reality exposure holds over in vivo exposure. In this study, we investigate the added effect of real-time biofeedback during virtual reality exposure.

Objectives

The current study is part of a large scale study called VR8. The current study aims to develop and evaluate the feasibility of a VR-biofeedback-intervention for adults with mild to severe social anxiety disorder, before continuing randomized controlled trials.

Methods

Data from semi-structured interviews and surveys will be compared to biodata collected during VR exposure. Participants include a minimum of (n=10) patients and (n=10) clinicians from the Mental Health Services in the Region of Southern Denmark. Surveys include questionnaires used for assessment of anxiety symptoms, usability of technology, and presence in the virtual environment. Collected biodata includes heart rate variability and electrodermal activity. Behavioral markers include eye-gaze. The findings will be analyzed and discussed in a mixed methods design.

Results

The study is ongoing. Preliminary results will be available at presentation.

Conclusions

Successful development and implementation of a biofeedback-informed virtual reality exposure intervention may provide increased reach for patients and individuals who would have otherwise not sought- or dropped out of regular treatment, as well as inform the clinician on how to proceed during virtual exposure.

Conflict of interest

Prof. Stephané Bouchard is consultant to and own equity in Cliniques et Développement In Virtuo, which develops virtual environments, and conflicts of interests are managed according to UQO’s conflict of interests policy; however, Cliniques et Développeme

A119 THE LOCATION-BASED RESECT AND DISCARD STRATEGY FOR DIMINUTIVE COLORECTAL POLYPS: A PROSPECTIVE CLINICAL STUDY

Background

Replacing histopathology evaluation of diminutive polyps with optical polyp diagnosis is considered a cost-effective approach. However, the widespread use of optical diagnosis is limited due to concerns about making incorrect optical diagnoses and the requirements of training, credentialing and auditing of performance.

Aims

This prospective study aimed to evaluate a simplified resect and discard strategy that is not operator dependent.

Methods

The study evaluated a resect and discard strategy that uses anatomical polyp location to classify colon polyps into non-neoplastic or low-risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and optical diagnosis, respectively. The primary outcome was ≥90% agreement with pathology in surveillance interval assignment.

Results

Overall, 1117 patients undergoing complete colonoscopy were included and 482 (43.1%) had at least one diminutive polyp. Surveillance interval agreement between the location-based resect and discard strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0% (95% CI = 0.96 - 0.98), surpassing the ≥90% benchmark. Optical diagnoses using NICE and Sano classifications reached 89.1% and 90.01% agreement, respectively (p &lt;0.0001), and were inferior to the location-based strategy. The location-based resect and discard strategy allowed a 69.7% (95% CI = 0.67 - 0.72) reduction in pathology examinations compared with 55.3% (95% CI = 0.52 - 0.58) (NICE and Sano) and 41.9% (95% CI = 0.39 - 0.45) (WASP) with optical diagnosis.

Conclusions

The location-based resect and discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥90% quality benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided.

Funding Agencies

None

Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel

BACKGROUND

Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release.

PURPOSE

To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI.

METHODS

For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors?

FINDINGS

The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist.

CONCLUSIONS

In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

Comparison of MI, Chromocult® coliform, and Compass CC chromogenic culture-based methods to detect Escherichia coli and total coliforms in water using 16S rRNA sequencing for colony identification

The MI, Chromocult^® coliform, and Compass CC chromogenic culture-based methods used to assess water quality by the detection of Escherichia coli and total coliforms were compared in terms of their specificity and sensitivity, using 16S rRNA sequencing for colony identification. A sewage water sample was divided in 2-μL subsamples for testing by all three culture-based methods. All growing colonies were harvested and subjected to 16S rRNA sequencing. Test results showed that all E. coli colonies were correctly identified by all three methods, for a specificity and a sensitivity of 100%. However, for the total coliform detection, the MI agar, Chromocult^® coliform agar, and Compass CC agar were specific for only 69.2% (9/13), 47.2% (25/53), and 40.5% (17/42), whereas sensitive for 97.8% (45/46), 97.5% (39/40), and 85.7% (24/28), respectively. Thus, given the low level of specificity of these methods for the detection of total coliforms, confirming the identity of total coliform colonies could help to take public health decisions, in particular for cities connected to a public drinking water distribution system since the growth of few putative total coliform colonies on chromogenic agar is problematic and can lead to unnecessary and costly boiling notices from public health authorities.

Rapid molecular identification of fecal origin-colonies growing on Enterococcus spp.-specific culture methods

The mEI, Chromocult^® enterococci, and m-Enterococcus culture-based methods used to assess water quality by the detection of Enterococcus spp. were first compared in terms of sensitivity using (1) 41 different type strains of Enterococcus spp. and (2) environmental colonies identified by 16S rRNA sequencing. Then, two specific-rtPCR assays targeting Enterococcus spp. and Enterococcus faecalis/faecium were tested for their ability to confirm the identity of putative enterococcal colonies. The mEI, Chromocult^® enterococci, and m-Enterococcus methods detected β-glucosidase activity for 28 (68.3%), 32 (78.0%), and 12 (29.3%) of the 41 reference enterococcal strains tested, respectively. Analysis with environmental colonies showed that mEI and Chromocult^® enterococci media had false positive rates of 4.3% and 5.0%, respectively. Finally, the two rtPCR assays showed a specificity of 100%. Only two (2/19) colonies of E. faecium isolated from mEI agar were not detected by the Enterococcus faecium rtPCR assay, for a sensitivity of 89.5%. Our results showed that Chromocult^® enterococci medium recovered more E. faecalis/faecium cells than the two other methods. Thus, the use of Chromocult^® enterococci combined with the Enterococcus faecalis/faecium rtPCR assay showed the best combination to decrease the high false-positive rate obtained when the entire Enterococcus genus is targeted.

Comparison of four β-glucuronidase and β-galactosidase-based commercial culture methods used to detect Escherichia coli and total coliforms in water

The MI agar, Colilert(®), Chromocult coliform(®) agar, and DC with BCIG agar chromogenic culture-based methods used to assess microbiological quality of drinking water were compared in terms of their ubiquity, sensitivity, ease of use, growth of atypical colonies and affordability. For ubiquity, 129 total coliform (representing 76 species) and 19 Escherichia coli strains were tested. Then, 635 1-L well water samples were divided into 100 mL subsamples for testing by all four methods. Test results showed that 70.5, 52.7, 36.4, and 23.3% of the non-E. coli total coliform strains and 94.7, 94.7, 89.5, and 89.5% of the 19 E. coli strains yielded a positive signal with the four methods, respectively. They also yielded a total coliform positive signal for 66.5, 51.7, 64.9, and 55.0% and an E. coli positive signal for 16.1, 14.8, 17.3, and 13.4% of the 635 well water samples tested, respectively. Results showed that Colilert(®) is the most expensive method tested in terms of reactants, yet it is the easiest to use. Large numbers of atypical colonies were also often observed on Chromocult coliform(®) and DC with BCIG, thereby challenging the target microorganism count. Thus, the MI agar method seems to be the best option for the assessment of drinking water quality.

Multiparametric comparison of chromogenic-based culture methods used to assess the microbiological quality of drinking water and the mFC method combined with a molecular confirmation procedure

MI agar and Colilert(®), as well as mFC agar combined with an Escherichia coli-specific molecular assay (mFC + E. coli rtPCR), were compared in terms of their sensitivity, ease of use, time to result and affordability. The three methods yielded a positive E. coli signal for 11.5, 10.8, and 11.5% of the 968 well water samples tested, respectively. One hundred and thirty-six (136) samples gave blue colonies on mFC agar and required confirmation. E. coli-specific rtPCR showed false-positive results in 23.5% (32/136) of cases. In terms of ease of use, Colilert was the simplest method to use while the MI method provided ease of use comparable to all membrane filtration methods. However, the mFC + E. coli rtPCR assay required highly trained employees for confirmation purposes. In terms of affordability, and considering contamination rate of well water samples tested, the Colilert method and the mFC + E. coli rtPCR assay were at least five times more costly than the MI agar method. Overall, compared with the other two methods tested, the MI agar method offers the most advantages to assess drinking water quality.

GRIN planar waveguide concentrator used with a single axis tracker

It is generally accepted that small to medium level concentrators could be used as cost-competitive replacements for tracked solar panels. The objective is to design a system that can reach a good level of sun concentration with only one sun-tracking axis and is cheap to fabricate. As the most critical parameter for all concentrator designs, optical efficiency needed improvement to reduce the cost of power produced by our system. By using a graded-index planar waveguide with an index profile similar to SELFOC fiber, the ray’s path can be controlled. Also, the concentrator can be fabricated in a single block, which reduces Fresnel reflections. Overall, the optical efficiency can be improved by as much as 33% compared to the same system made with a homogeneous waveguide. Furthermore, the ability to cost-effectively fabricate the concentrator by molding can be preserved, making it possible to reduce the cost of the solar power produced.

GRIN planar waveguide concentrator used with a single axis tracker

It is generally accepted that small to medium level concentrators could be used as cost-competitive replacements for tracked solar panels. The objective is to design a system that can reach a good level of sun concentration with only one sun-tracking axis and is cheap to fabricate. As the most critical parameter for all concentrator designs, optical efficiency needed improvement to reduce the cost of power produced by our system. By using a graded-index planar waveguide with an index profile similar to SELFOC fiber, the ray's path can be controlled. Also, the concentrator can be fabricated in a single block, which reduces Fresnel reflections. Overall, the optical efficiency can be improved by as much as 33% compared to the same system made with a homogeneous waveguide. Furthermore, the ability to cost-effectively fabricate the concentrator by molding can be preserved, making it possible to reduce the cost of the solar power produced.

Graded-index planar waveguide solar concentrator

Planar waveguides are useful to transport, concentrate and distribute light uniformly over large dimensions. Their capacity to collect and gather light efficiently over a large distance is interesting for many applications, like backlighting and solar concentration. For these reasons, the possibility of making them even more efficient could be of considerable interest for the community. The observation of the ray path inside a graded-index (GRIN) fiber inspired the development of a similar technology inside planar waveguides. In this Letter, we show that it has the potential to dramatically increase the efficiency of planar waveguide-based solar concentrators or backlighting using GRIN planar waveguides.

[Attitudes of general physicians and family medicine residents towards patients with borderline personality disorder]

OBJECTIVES

Several studies suggest that health professionals show negative attitudes towards people with Borderline Personality Disorder (BPD). Many publications have focused on the attitudes of nurses or other type of clinicians like social workers or psychologists. Few researches concern the attitudes of general physicians towards BPD even if they are the main professionals involved in the evaluation and treatment of these patients. Additionally, patients with BPD frequently consult general physicians and, because of the difficulties interacting with these patients, they do not always receive the treatments required by their condition. This research aims to assess the attitudes of general physicians and family medicine residents regarding patients presenting with this disorder.

METHOD

Forty family medicine residents and thirty-five general physicians were compared to thirty-nine mental health professionals using the Attitudes toward people with BPD Scale (ABPDS; Bouchard, 2001). This measure has two subscales labeled Comfort when interacting with someone who has BPD and Positives perceptions about BPD. The internal consistency of the scale as well as the two distinct factors are satisfactory. The participants also complete a socio-demographic questionnaire. Means, t tests, ANOVAs and factorial ANOVAs are completed in order to compare the three groups on the ABPDS and explore the influence of variables such as sex, age, years of experience, and professional setting (urban or rural) on the results.

RESULTS

The results show that general physicians have similar attitudes than mental health professionals towards people presenting with BPD and that family medicine residents present less positive attitude than the other two groups. In addition, clinicians with less experience tend to have less positive attitudes towards people with BPD and clinicians from urban settings seem to have more positive attitude. It was difficult to determinate which variables influence the results because the years of experience, the professional settings and the title of the participants are extremely related. The factorial ANOVAs show no interaction effect between these three variables.

CONCLUSION

Several studies show that health professionals present negative attitudes toward patients with BPD. This study reveals that general physicians and family medicine residents show respectively similar attitudes or less positive attitudes than other mental health professionals. These results underline the importance of providing specific training about BPD to family medicine residents. Because general physicians guide the evaluations and interventions concerning these patients and mental health professionals interact regularly with BPD, it will be helpful if all the clinicians receive more specific training regarding this disorder.

Planar waveguide concentrator used with a seasonal tracker

Solar concentrators offer good promise for reducing the cost of solar power. Planar waveguides equipped with a microlens slab have already been proposed as an excellent approach to produce medium to high concentration levels. Instead, we suggest the use of a cylindrical microlens array to get useful concentration without tracking during the day. To use only a seasonal tracking system and get the highest possible concentration, cylindrical microlenses are placed in the east-west orientation. Our new design has an acceptance angle in the north-south direction of ±9° and ±54° in the east-west axis. Simulation of our optimized system achieves a 4.6× average concentration level from 8:30 to 16:30 with a maximum of 8.1× and 80% optical efficiency. The low-cost advantage of waveguide-based solar concentrators could support their use in roof-mounted solar panels and eliminate the need for an expensive and heavy active tracker.

[Stalemates and opportunities in the treatment of borderline personality disorder]

Borderline personality disorder is a serious mental health problem for which one of its main characteristics is significant difficulties in relationships with others. These relational problems have the unfortunate consequence of fostering negative attitudes among mental health professionals and contributing to the stigmatization of people suffering from this disorder. In this article, the author emphasizes the importance of taking into account the parameter of the therapeutic frame within which the feeling of facing a stalemate in the treatment of borderline personality disorder patients occurs. Six general strategies are presented that enable the therapist to limit or hinder the risk of stalemate in treatment. This article then presents the commonalities between treatments teams that tend to feel comfortable and efficacious in their management of borderline personality disorder patients. Finally, a case history is used to illustrate how some stalemates can in fact be seen as opportunities for growth for both the patient and the therapist. In order to avoid the vicious circle of negative interactions with patients already hypersensitive to inconsistencies and rejection, the author concludes by insisting on the necessity that more mental health professional have access to training programs and workshops specifically addressing how to better manage and treat people with BPD.

Intérêt clinique d’une conception neuroscientifique du trouble de personnalité limite : dysfonctionnements du système exécutif et de la théorie de l’esprit

Le trouble de personnalité limite (TPL) est un problème psychopathologique complexe et les données récentes issues des neurosciences permettent une compréhension plus précise des bases neurobiologiques de ses manifestations. Cet article vise à étayer la proposition que le TPL dépend en partie d’un dysfonctionnement frontal et exécutif qui perturbe les mécanismes nécessaires au fonctionnement optimal des inférences propres à l’utilisation d’une « théorie de l’esprit ». Pour soutenir ce propos, quatre ensembles d’observations sont examinés : les parallèles entre la personnalité dite frontale et le TPL, la présence de déficits cognitifs de type frontal chez le TPL, les conséquences sur le développement cérébral d’une enfance marquée par l’abus et la négligence et enfin, les résultats des études d’imagerie cérébrale. Cet article s’inscrit dans un courant de pensée qui vise l’intégration de la perspective neuroscientifique du TPL aux conceptualisations psychopathologiques actuelles. L’objectif étant d’offrir une conceptualisation du TPL qui évite la traditionnelle dichotomie esprit/cerveau, psychologie/biologie et de dégager des points de convergence entre la psychologie clinique et la neurobiologie.

Relationship quality and stability in couples when one partner suffers from borderline personality disorder

The main goal of the present study was to examine and compare the psychosocial functioning of 35 couples including a woman diagnosed with borderline personality disorder (BPD) to that of a nonclinical control sample of 35 couples. The BPD status of women from the clinical group and the prevalence of personality disorder in their partner were ascertained through the SCID-II. Participants completed self-report measures of couple functioning. A majority of couples in which the woman suffered from BPD (68.7%) evidenced frequent episodes of breakups and reconciliations and, over an 18-month period, nearly 30% of these couples dissolved their relationship. Nearly half of the men involved in a romantic relationship with a woman suffering from BPD met criteria for one personality disorder or more. As compared with nonclinical couples, clinical couples showed lower marital satisfaction, higher attachment insecurity, more demand/withdraw communication problems, and higher levels of violence.

Borderline personality disorder and couple dysfunctions

The central characteristics of borderline personality disorder (BPD) are bound to be associated with the development and maintenance of couple dysfunction. Although seven of the nine diagnostic criteria of BPD in the DSM-IV-TR refer directly to interpersonal functioning, very few empiric studies have addressed the exact nature of the relationship between BPD and couple functioning. This article examines recent studies describing couple outcomes--union formation and durability, partner choice, relationship satisfaction, intimate violence, attachment security, and sexual functioning--associated with BPD. The relationship between couple dynamics (including partner personality characteristics) and BPD symptomatology is probably bidirectional or reciprocal. The review concludes with an exploration of diagnostic and treatment implications.

Sexual attitudes and activities in women with borderline personality disorder involved in romantic relationships

Women with Borderline Personality Disorder (BPD) are prone to have sexual relationship difficulties and dysfunctional attitudes toward sexuality. A sample of 34 heterosexual couples composed of women meeting BPD criteria was compared to a sample of dating or married women from the general population. A short form of the Sexual Activities and Attitudes Questionnaire (SAAQ) was used to measure six types of sexual attitudes. Women diagnosed with BPD did not differ from controls on the frequency of three types of sexual activities in the last year but their subjective sexual experiences differed: they showed stronger negative attitudes, felt sexually pressured by their partners, and expressed ambivalence toward sexuality. Regression analyses suggest that anxious attachment mediates the association between BPD and feeling pressured to engage in sex.

Self-efficacy and adherence to cognitive-behavioral treatment of insomnia

This study describes a self-efficacy (SE) scale and examines its usefulness in predicting adherence to cognitive-behavioral therapy (CBT) of insomnia. The SE scale, which included three subscales (global, task-related, and self-regulation), was administered to 39 patients receiving CBT for primary insomnia. Participants'daily sleep diaries were used to estimate their adherence to treatment. The results showed that the SE scale has adequate psychometric properties. Treatment adherence increased from Week 2 to Week 7 and decreased during the week following the last therapy session. In general, the global self-efficacy measure was more strongly associated with adherence during the first week of treatment, whereas the task-related efficacy was more strongly associated with adherence behaviors from Weeks 4 to 8. These findings suggest that self-efficacy perceptions are useful in predicting adherence to CBT of insomnia.

Virtual Reality Therapy Versus Cognitive Behavior Therapy for Social Phobia: A Preliminary Controlled Study

Social phobia is one of the most frequent mental disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive behavior therapies (CBT). In this last case, graded exposure to feared social situations is one of the fundamental therapeutic ingredients. Virtual reality technologies are an interesting alternative to the standard exposure in social phobia, especially since studies have shown its usefulness for the fear of public speaking. This paper reports a preliminary study in which a virtual reality therapy (VRT), based on exposure to virtual environments, was used to treat social phobia. The sample consisted of 36 participants diagnosed with social phobia assigned to either VRT or a group-CBT (control condition). The virtual environments used in the treatment recreate four situations dealing with social anxiety: performance, intimacy, scrutiny, and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations. Both treatments lasted 12 weeks, and sessions were delivered according to a treatment manual. Results showed statistically and clinically significant improvement in both conditions. The effect-sizes comparing the efficacy of VRT to the control traditional group-CBT revealed that the differences between the two treatments are trivial.

Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations

Forty-five adults with primary insomnia received cognitive-behavioral therapy (CBT) implemented in a group therapy format, in individual face-to-face therapy or through brief individual telephone consultations. The results indicate that CBT was effective in improving sleep parameters with all 3 methods of treatment implementation, and there was no significant difference across methods of implementation. All 3 treatment modalities produced improvements in sleep that were maintained for 6 months after treatment completion. These results suggest that group therapy and telephone consultations represent cost-effective alternatives to individual therapy for the management of insomnia.

Experiential cognitive therapy in the treatment of panic disorders with agoraphobia: a controlled study

The use of a multicomponent cognitive-behavioral treatment strategy for panic disorder with agoraphobia is actually one of the preferred therapeutic approaches for this disturbance. This method involves a mixture of cognitive and behavioral techniques that are intended to help patients identify and modify their dysfunctional anxiety-related thoughts, beliefs and behavior. The paper presents a new treatment protocol for Panic Disorder and Agoraphobia, named Experiential-Cognitive Therapy (ECT) that integrates the use of virtual reality (VR) in a multicomponent cognitive-behavioral treatment strategy. The VR software used for the trial is freely downloadable: www.cyberpsychology.info/try.htm. Moreover, the paper presents the result of a controlled study involving 12 consecutive patients aged 35-53. The selected subjects were randomly divided in three groups: ECT group, that experienced the Cognitive Behavioral Therapy-Virtual Reality assisted treatment (eight sessions), a CBT group that experienced the traditional Cognitive Behavioral approach (12 sessions) and a waiting list control group. The data showed that both CBT and ECT could significantly reduce the number of panic attacks, the level of depression and both state and trait anxiety. However, ECT procured these results using 33% fewer sessions than CBT. This datum suggests that ECT could be better than CBT in relation to the "cost of administration," justifying the added use of VR equipment in the treatment of panic disorders.

Computer-assisted stereology: point fraction of lung parenchyma and alveolar surface density in fetal and newborn sheep

The aim of this study was to determine the accuracy of a new computer-assisted stereological technique in obtaining structural information of the lung. We compared the point fraction of lung parenchyma (Pp) and alveolar surface density (Sv) obtained by established manual point/intercept counting methods and compared them with those obtained using a computer-assisted method. Lung tissues obtained from normally grown fetal sheep (n = 6) and from newborn lambs with severe lung hypoplasia (n = 5) were inflation fixed via the trachea and processed for light microscopy. In verification-of-technique experiments, Pp and Sv correlated well with known values. There was a significant linear correlation between manual and computer-assisted stereological measurements for values of Pp (r2 = 0.92) and Sv (r2 = 0.98). Our data lead us to believe that the computer-assisted stereological technique described in this study provides accurate estimates of Pp and Sv and hence may be a valuable tool for evaluating the effects of factors upon structural development of the lung.

Virtual reality assisted cognitive behavioral therapy for the treatment of Panic Disorders with Agoraphobia

The chapter describes the characteristics of the Experiential-Cognitive Therapy (ECT) protocol for Panic Disorder and Agoraphobia. The goal of ECT is to decondition fear reactions, to modify misinterpretational cognition related to panic symptoms and to reduce anxiety symptoms. This is possible in an average of eight sessions of treatment plus an assessment phase and booster sessions, through the integration of Virtual Experience and traditional cognitive-behavioral techniques. We decided to employ the techniques included in the cognitive-behavioral approach because they showed high levels of efficacy. Through virtual environments we can gradually expose the patient to feared situation: virtual reality consent to re-create in our clinical office a real experiential world. The patient faces the feared stimuli in a context that is nearer to reality than imagination. For ECT we developed the Virtual Environments for Panic Disorders--VEPD--virtual reality system. VEPD is a 4-zone virtual environment developed using the Superscape VRT 5.6 toolkit. The four zones reproduce different potentially fearful situations--an elevator, a supermarket, a subway ride, and large square. In each zone the characteristics of the anxiety-related experience are defined by the therapist through a setup menu.

Estimation and application of EMG amplitude during dynamic contractions

The sections above have described an EMG amplitude estimator and an initial application of this estimator to the EMG-torque problem. The amplitude estimator consists of six stages. In the first stage, motion artifact and power-line interference are attenuated. Motion artifact is typically removed with a highpass filter. Elimination of power-line noise is more difficult. Commercial systems tend to use notch filters, accepting the concomitant loss of "true" signal power in exchange for simplicity and robustness. Adaptive methods may be preferable, however, to preserve more "true" signal power. In stage two, the signal is whitened. One fixed whitening technique and two adaptive whitening methods were described. For low-amplitude levels, the adaptive whitening technique that includes adaptive noise cancellation may be necessary. In stage three, multiple EMG channels (all overlying the same muscle) are combined. For most applications, simple gain normalization is all that is required. Stage four rectifies the signal and then applies the power law required to demodulate the signal. In stage six, the inverse of the power law is applied to relinearize the signal. Direct comparison of MAV (first power) to RMS (second power) processing demonstrates little difference between the two. Therefore, unless there is reason to believe that the EMG density departs strongly from that found in the existing studies, RMS and MAV processing are essentially identical. In stage five, the demodulated samples are averaged across all channels and then smoothed (time averaged) to reduce the variance of the amplitude estimate, but at the expense of increasing the bias. For best performance, the window length that best trades off variance and bias error is selected. The advanced EMG processing was next applied to dynamic EMG-torque estimation about the elbow joint. Results showed that improved EMG amplitude estimates led to improved EMG-torque estimates. An initial comparison of different system-identification techniques and model orders was reported. It is expected that these advanced processing and identification algorithms will also improve performance in other EMG applications, including myoelectrically controlled prostheses, biofeedback, and ergonomic assessment.

Expression of neuropeptides in normal and abnormal appendices

BACKGROUND/PURPOSE

Increased neuroproliferation in the appendix associated with an increase in substance P (SP), vasoactive intestinal polypeptide (VIP), and growth-associated protein-43 (GAP-43) has been documented in appendices of adults with acute right lower quadrant (RLQ) abdominal pain and absence of gross or histologic signs of appendiceal inflammation. The authors tested whether these findings were present in children with RLQ pain and a normal appendix.

METHODS

Immunohistochemistry staining of paraffin-embedded appendices was performed with GAP-43, VIP, and SP. The positive control group included appendices with acute inflammation (group I, n = 5); the negative control group included appendices removed incidentally (group II, n = 5); and the experimental group included appendices from children suspected to have acute appendicitis without histologic signs of inflammation (group III, n = 9).

RESULTS

Group I: VIP was strongly expressed in the nerve plexuses. The lamina propria and muscularis showed absent or minimal VIP expression. SP staining was strong in all plexuses and was moderate to strong in the muscularis. SP expression in the epithelium and lamina propria was difficult to quantify secondary to inflammation. Group II: VIP expression was essentially undetectable in the epithelium, lamina propria, and muscularis, and was moderate in the nerve plexuses. Mild SP staining was detected in the nerve plexuses of most specimens, and absent to mild staining was found in the epithelium and muscularis. However, one specimen strongly expressed SP in all layers. Group III: VIP expression was moderate to strong in the lamina propria and muscularis of nearly all specimens, and strong expression was found in all nerve plexuses. All but one specimen strongly expressed SP in plexuses. There was moderate to strong expression of SP in the epithelium, lamina propria, and muscularis in over 50% of specimens. The immunostaining for GAP-43 was very weak and nonspecific and did not help discriminate between the 3 study groups.

CONCLUSIONS

Increased neuroproliferation in the lamina propria and muscularis was evident in patients with abdominal pain and normal appendices compared with appendices removed incidentally. The VIP and SP expression in these patients was similar or higher than that observed in patients with acute inflammation on histology.

Pulmonary lymphangiectasia revisited

PURPOSE

Pulmonary lymphangiectasia (PL) is a rare, poorly documented disease characterized by abnormal pulmonary lymphatics. Although case reports are published, little is known about survivors past the neonatal period.

METHODS

This is a retrospective review of histologically proven PL in fetuses, infants, and long term survivors since 1965.

RESULTS

Eleven children (8 boys, 3 girls) and 8 aborted fetuses (7 male, 1 female) were identified. The fetuses weighed 463.4 g (177 to 681 g). Six were aborted between 19 to 24 weeks of gestation for multiple malformations or anencephaly, and 2 spontaneously aborted: one with PL only, the other with twin-twin transfusion syndrome. Clinical PL was diagnosed between 0 and 11 months of age. Six children died (2 neonatal, 4 within 10 days), 5 survived. Two deaths occurred after cardiac surgery. Among survivors, the symptomatology and frequency of admissions diminished over time. Symptoms included progressive respiratory distress, chronic cough, recurrent pneumonia, bronchial asthma, and choking. One child with bilateral chylothorax was later diagnosed with Noonan syndrome; 2 patients had minor cardiac malformations. Rapid deterioration occurred with mild respiratory infections with only supportive treatment available. Chest x-ray showed marked hyperinflation with interstitial infiltrate.

CONCLUSIONS

This is the first long-term study of primary PL and will help counsel parents. Although fatal in the neonatal period, survival is possible if diagnosed past the neonatal period and improvement is expected.

Pleuropulmonary blastoma: a rare pathology with an even rarer presentation

BACKGROUND

Pleuropulmonary blastoma is among the rarest tumors of childhood. Three types have been described: cystic, solid, and mixed. To date, bilateral disease has not been documented.

METHODS AND RESULTS

A 5-week-old girl presented with a history of fever. Chest x-ray showed bilateral diffuse cystic lesions. Bowel obstruction developed that required laparotomy. Multiple small bowel polyps were resected. The patient was readmitted 4 months later with deteriorating respiratory status. She underwent sequential thoracotomies for resection of multiple bullae under high-frequency oscillatory ventilation. Small bowel polypectomies were again required because of obstruction. Lung lesions were compatible with pulmonary blastoma but could not be correlated with intestinal polyposis. Bilateral cystic renal lesions were seen on ultrasound scan. Her disease progressed, despite chemotherapy, with the appearance of metastatic iris lesions. She again underwent laparotomies for multiple recurrent generalized small bowel polyps that were causing obstruction. Expanding renal cysts affected kidney function, and she died at 14 months of age.

CONCLUSIONS

The rare association between pleuropulmonary blastoma and Wilms' tumor or nephroblastomatosis is known but rarely reported. Lacking pathological evidence, we can only speculate that this was the case. We have been unable to demonstrate any histological association between the renopulmonary and digestive lesions. Despite many unanswered questions, we are likely dealing with a "syndrome" of sorts with a dire outcome, despite aggressive treatments.

The otolaryngologic manifestations of gastroesophageal reflux: when is a pH study indicated?

PURPOSE

The aim of this study was to evaluate the pertinence of pH studies for persistent ear, nose, and throat (ENT) symptoms and their eventual relationship to gastroesophageal reflux (GER).

METHODS

Retrospective analysis was performed of age, reason for referral, pH study, treatment, and follow-up of patients with ENT symptoms suspected to have GER.

RESULTS

Of 3,000 esophageal pH studies performed over 16 years, 105 children were referred for ENT symptoms by an otorhinolaryngologist to rule out GER. Mean age was 33 months; 65% were boys. Reasons for referral included (number and mean age): stridor (n = 31, 8 months), laryngomalacia (n = 18, 13 months), recurrent otitis (n = 12, 42 months), laryngitis (n = 16, 50 months), dysphonia (n = 14, 59 months), laryngeal papillomatosis (n = 8, 62 months), sinusitis (n = 5, 56 months), and dysphagia (n = 1). Overall, 41% of study results were positive: stridor (58%), laryngomalacia (61%), laryngitis (56%) and sinusitis (40%). Patients with otitis, dysphonia and laryngeal papillomatosis had GER in 1%, 14%, and 25%, respectively. Follow-up in the three larger groups of patients showed resolution of the ENT symptoms after medical treatment of the reflux in 83% of patients with stridor and reflux, 86% with laryngitis and reflux, and 80% with laryngomalacia and reflux. Four fundoplications were performed: one neurologically impaired patient, and four nonresponders.

CONCLUSIONS

The authors recommend that a pH study be performed in children with stridor, laryngomalacia, laryngitis, and sinusitis when faced with failure of the usual treatment. However, a pH study does not seem as beneficial for recurrent otitis, dysphonia, or laryngeal papillomatosis.

Falls from heights among children: a retrospective review

BACKGROUND

Falls are a major cause of emergency room visits and admissions in pediatric hospitals.

METHODS

To better understand the epidemiology of falls from height and develop prevention strategies, the authors reviewed all admissions after a fall at a single institution from 1994 to 1997. Inclusion criteria are falls from a minimum height of 10 feet.

RESULTS

Of 1,410 patients admitted after a fall, 64 patients including 45 boys and 19 girls with a mean age of 7.4 years (range, 1 to 18) are included in this study. Fifty (78%) children fell from 20 feet or less (two stories) and 14 (22%) from height greater than 20 feet. Patients mainly fell from balconies (n = 15), windows (n = 13), trees (n = 9), roofs (n = 6), stairs (n = 6), diving board (n = 3) and miscellaneous (n = 12). Over 60% of falls occurred in private houses and during the summer months. Fifty-five patients (86%) sustained only one system injury, two patients had no significant injury, and seven patients had multisystem injury. Major injuries included head trauma (39%), musculoskeletal (34%), abdominal (12%), maxillofacial (8%), and spine (6%). A surgical intervention was required for 43% of intracranial trauma, 39% of musculoskeletal injuries, 60% of facial trauma, and 50% of spine fractures. Mean length of stay in hospital varied according to the injured system. The overall survival rate is 98% with only one death after a fall greater than 50 feet.

CONCLUSIONS

Although rarely mortal, falls from height carry a significant morbidity and are costly to the health care system. To decrease the occurrence of injuries caused by falls, strategies should include awareness campaigns, parent's education about the mechanisms of falls, increase parenteral supervision during playing activities, and legislative measures to ensure the safety of windows and balconies before the onset of summer.

Perineal hemangioma, anorectal malformation, and genital anomaly: a new association?

Two patients presented as full-term baby girls with anorectal and genital malformations with extensive perineal hemangiomas. The first patient had a vestibular anus with a perineal hemangioma involving the bladder, rectal, and vaginal walls. Skin ulcerations required a transverse loop colostomy for wound care. The vulva, urethral opening, and clitoris were deviated to the left, labia minora were absent, and the labia majora were abnormal. The second patient had an anus displaced anteriorly and deviated to the right. The external anal sphincter was hypertrophic on the left and atrophic on the right. Rectal examination showed agenesis of the right levator ani and a dentate line located at the skin level. She had a large perineal, sacral, vaginal, pararectal and retroperitoneal hemangioma and developed extensive skin ulcerations. She had only a hemiclitoris located to the left of the midline, near absence of labia minora, and hypertrophied labia majora. The urethra was displaced to the left and opened in the vestibule. Both patients had a spinal malformation (one with tethered cord and one with spina bifida) and a normal karyotype. Steroids and interferon allowed near-complete resolution of hemangiomas in both patients. The authors were impressed by the similarity of these two cases and could not find any previous description of this association.

Cyclic traction machine for long-term culture of fibroblast-populated collagen gels

Our research group has been investigating the effect of cyclic deformations on the evolution of fibroblast populated collagen gels (FPCG). Since existing traction machines are not designed for such an application, we had to design a cyclic traction machine adapted to tissue culture inside an incubator over an extended period of time. Biocompatible materials were used for fabrication to allow for easy sterilization and to prevent any adverse reaction from the tissue. The traction machine is based on a computer-controlled stepping motor system for easy adjustment of the deformation amplitude and frequency. The maximum stretching speed achieved is around 1 mm/s. The traction machine can measure FPCG mechanical properties and perform rupture tests to determine its ultimate strength. Several FPCGs have been successfully cultured with the machine for up to four weeks without any adverse reaction.

Predictors of post-ERCP complications in patients with suspected choledocholithiasis

BACKGROUND AND STUDY AIMS

Determinants of complications after endoscopic retrograde cholangiopancreatography (ERCP) have not yet been completely characterized.

PATIENTS AND METHODS

Data were collected from an endoscopic database. Univariate analysis and multivariate logistic regression analysis were used to generate the best model of independent predictors of post-ERCP pancreatitis.

RESULTS

The database included 1239 ERCP examinations carried out to investigate suspected choledocholithiasis over a five-year period. From these, 45 patients who developed post-ERCP complications were compared to a random sample of 486 patients who had undergone an uncomplicated ERCP for suspected choledocholithiasis. Univariate analysis demonstrated significant differences between the two patient groups for the following factors: age, using a cut-off point of 59 years (27% vs. 51%, P = 0.002), pancreatic channel opacification (73% vs. 58%, P = 0.05), and absence of common bile duct stones (41% vs. 24%, P = 0.03). Using multivariate logistic regression, the best model for predicting post-ERCP pancreatitis in patients undergoing sphincterotomy included age under 59 years (P = 0.04), and absence of a common bile duct stone (P = 0.004). The model yielded probabilities of developing post-sphincterotomy pancreatitis that ranged from 2.8% if no predictor was present, to 27% when both predictors were present. Among patients in whom a sphincterotomy was not performed, the only significant independent predictor found was pancreatic channel opacification (P = 0.05).

CONCLUSION

Age under 59 years, pancreatic channel opacification, and an absence of common bile duct stones at ERCP are all independent predictors of post-ERCP pancreatitis.