Use and Engagement With Low-Intensity Cognitive Behavioral Therapy Techniques Used Within an App to Support Worry Management: Content Analysis of Log Data

BACKGROUND

Low-intensity cognitive behavioral therapy (LICBT) has been implemented by the Improving Access to Psychological Therapies services across England to manage excessive worry associated with generalized anxiety disorder and support emotional well-being. However, barriers to access limit scalability. A solution has been to incorporate LICBT techniques derived from an evidence-based protocol within the Iona Mind Well-being app for Worry management (IMWW) with support provided through an algorithmically driven conversational agent.

OBJECTIVE

This study aims to examine engagement with a mobile phone app to support worry management with specific attention directed toward interaction with specific LICBT techniques and examine the potential to reduce symptoms of anxiety.

METHODS

Log data were examined with respect to a sample of "engaged" users who had completed at least 1 lesson related to the Worry Time and Problem Solving in-app modules that represented the "minimum dose." Paired sample 2-tailed t tests were undertaken to examine the potential for IMWW to reduce worry and anxiety, with multivariate linear regressions examining the extent to which completion of each of the techniques led to reductions in worry and anxiety.

RESULTS

There was good engagement with the range of specific LICBT techniques included within IMWW. The vast majority of engaged users were able to interact with the cognitive behavioral therapy model and successfully record types of worry. When working through Problem Solving, the conversational agent was successfully used to support the user with lower levels of engagement. Several users engaged with Worry Time outside of the app. Forgetting to use the app was the most common reason for lack of engagement, with features of the app such as completion of routine outcome measures and weekly reflections having lower levels of engagement. Despite difficulties in the collection of end point data, there was a significant reduction in severity for both anxiety (t53=5.5; P<.001; 95% CI 2.4-5.2) and low mood (t53=2.3; P=.03; 95% CI 0.2-3.3). A statistically significant linear model was also fitted to the Generalized Anxiety Disorder-7 (F2,51=6.73; P<.001), while the model predicting changes in the Patient Health Questionnaire-8 did not reach significance (F2,51=2.33; P=.11). This indicates that the reduction in these measures was affected by in-app engagement with Worry Time and Problem Solving.

CONCLUSIONS

Engaged users were able to successfully interact with the LICBT-specific techniques informed by an evidence-based protocol although there were lower completion rates of routine outcome measures and weekly reflections. Successful interaction with the specific techniques potentially contributes to promising data, indicating that IMWW may be effective in the management of excessive worry. A relationship between dose and improvement justifies the use of log data to inform future developments. However, attention needs to be directed toward enhancing interaction with wider features of the app given that larger improvements were associated with greater engagement.

Combination of Low-Intensity Rosuvastatin and Ezetimibe on HbA1c Levels in Patients without Diabetes: A Randomized IDEAL Trial

There is a dearth of studies investigating whether the combination of low-intensity statins with ezetimibe can reduce the risk of diabetes in patients requiring statin therapy. Therefore, we aimed to evaluate the effects of combination therapy on the prevention of glycated hemoglobin (HbA1c) elevation in patients without diabetes. Sixty-eight patients were randomly assigned in a 1:1 ratio to receive a combination of low-intensity rosuvastatin (5 mg/day) and ezetimibe (10 mg/day) or high-intensity rosuvastatin (20 mg/day). The primary endpoint was the absolute difference in the HbA1c levels at 12 weeks. The HbA1c level showed an overall elevation of 0.11% at 12 weeks compared to that at baseline (mean ± standard deviation: 5.78 ± 0.3%, 95% confidence interval [CI]: 5.86-6.07, p = 0.044). The HbA1c levels did not differ between the groups at 12 weeks (least square mean difference: 0.001, 95% CI: 0.164-0.16, p = 0.999). Our study found that the combination of low-intensity rosuvastatin and ezetimibe did not yield significant differences in HbA1c levels compared to high-intensity rosuvastatin alone after 12 weeks in patients without diabetes. This suggests that the combination of low-intensity rosuvastatin and ezetimibe may not be an effective strategy for preventing HbA1c elevation in patients without diabetes requiring statins.

Pragmatic Evaluation of a Low-Threshold Sports Program for Older Adults in Group Homes

Physical activity (PA) reduces with older age, ill health, and disability. For these groups, guidance recognizes the benefit of small increases in PA and low-intensity PA. This study evaluated a low-threshold intervention that addressed known barriers to older people's participation in PA in residential care and sheltered housing. Ten, competitive sport sessions were delivered by coaches at 49 sites with the aim that they be sustained in-house. Using quasi-experimental methods, participants reported reduced sitting time, increased moderate/vigorous PA, increased participation in sports and improved scores for both health quality of life and fear of falling at 6 months. The program engaged 29% of residents and was sustained at 50% of sites at 8 months. The findings suggest that low-threshold sports programs that overcome known barriers to older people's participation in PA have the potential to provide a gateway to increased PA in group homes and to be sustained in-house.

The Influence on Post-Activation Potentiation Exerted by Different Degrees of Blood Flow Restriction and Multi-Levels of Activation Intensity

(1) Background: To explore the influence on post-activation potentiation (PAP) when combining different degrees of blood flow restriction (BFR) with multi-levels of resistance training intensity of activation. (2) Purpose: To provide competitive athletes with a more efficient and feasible warm-up program. (3) Study Design: The same batch of subjects performed the vertical jump test of the warm-up procedure under different conditions, one traditional and six BFR procedures. (4) Methods: Participants performed seven counter movement jump (CMJ) tests in random order, including 90% one repetition maximum (1RM) without BFR (CON), and three levels of BFR (30%, 50%, 70%) combined with (30% and 50% 1RM) (BFR-30-30, BFR-30-50, BFR-50-30, BFR-50-50, BFR-70-30 and BFR-70-50). Jump height (H), mean power output (P), peak vertical ground reaction force (vGRF), and the mean rate of force development (RFD) were recorded and measured. (5) Results: Significantly increasing results were observed in: jump height: CON (8 min), BFR-30-30 (0, 4 min), BFR-30-50 (4, 8 min), BFR-50-30 (8 min), BFR-50-50 (4, 8 min), BFR-70-30 (8 min), (p < 0.05); and power output: CON (8 min), BFR-30-30 (0, 4 min), BFR-30-50 (4 min), BFR-50-30 (8 min), BFR-50-50 (4, 8 min) (p < 0.05); vGRF: CON (8 min), BFR-30-30 (0, 4 min), BFR-30-50 (4, 8 min), BFR-50-30 (4 min), BFR-50-50 (4, 8 min) (p < 0.05); RFD: CON (8 min), BFR-30-30 (0, 4 min), BFR-30-50 (4 min), BFR-50-30 (4 min), BFR-50-50 (4 min) (p < 0.05). (5) Conclusions: low to moderate degrees of BFR procedures produced a similar PAP to traditional activation. Additionally, BFR-30-30, BFR-30-50, and BFR-50-50 were longer at PAP duration in comparison with CON.

Short-term low-intensity Early Start Denver Model program implemented in regional hospitals in Northern Taiwan

LAY ABSTRACT

The Early Start Denver Model is an evidence-based early intervention program for young and very young children with autism. This interdisciplinary model is used by many types of professionals, such as psychologists, occupational therapists, speech pathologists, early child special educators, and paraprofessionals, as well as by parents. Most previous studies on the Early Start Denver Model were conducted in the West, and there are scarce studies on the topics of generalization in culture and countries outside the Western world. In this study, we evaluated the effect of the Early Start Denver Model with some adaptations, including a lower intensity, shorter duration, and delivery in regional general hospitals in Northern Taiwan. In total, 45 young children with autism, aged 2-4 years, were divided into the Early Start Denver Model and community-based control groups. The children in the Early Start Denver Model group received one-on-one intervention for approximately 8-9 h per week for 6 months. The results revealed that compared with the control group, the Early Start Denver Model group showed greater gains in overall development ability and nonverbal development ability from pre- to post-intervention. However, these differences did not sustain at the 6-month follow-up after the completion of the intervention. Being mindful of some caveats in trial designs, this study provides preliminary evidence to support the effectiveness of the Early Start Denver Model intervention in the regional general hospital settings in the context of Han-Chinese-mainly culture. Our findings can provide helpful information to stakeholders and policymakers of early intervention service systems for children with autism in Taiwan, as well as in Asian countries.

The Effect of Low-Load Resistance Training on Skeletal Muscle Hypertrophy in Trained Men: A Critically Appraised Topic

Clinical Scenario: Resistance training (RT) programs promote skeletal muscle hypertrophy through the progressive physiological stress applied to an individual. Currently, the vast majority of studies regarding the hypertrophic response to RT have focused on either sedentary or untrained individuals. This critically appraised topic focuses on the hypertrophic response to high- and low-load RT in resistance-trained men. Clinical Question: In experienced male weightlifters, does high-load RT lead to greater increases in muscle mass than low-load RT? Summary of Key Findings: Six studies met the inclusion criteria, while 4 studies were included in the analysis. Each of the 4 studies showed that low-load RT elicited hypertrophic gains similar to high-load RT when sets were taken to failure. Three of the studies were not volume equated, indicating a dose-response relationship between training volume-load and skeletal muscle hypertrophy. One of the studies was volume equated, indicating that skeletal muscle hypertrophy could be achieved at levels comparable to those observed in high-load protocols as a result of high levels of metabolic stress and the concomitant recruitment of high-threshold motor units that can occur during fatiguing contractions. Clinical Bottom Line: Evidence suggests that low-load training produces hypertrophic gains similar to those observed in high-load RT protocols when sets are taken to failure in resistance-trained men. Strength of Recommendation: There is moderate to strong evidence to suggest that low-load RT elicits hypertrophic gains similar to those observed in high-load RT protocols when sets are taken to failure in resistance-trained men.

Pilot study of focused ultrasound for drug-resistant epilepsy

Objective

The neuromodulatory effects of focused ultrasound (FUS) have been demonstrated in animal epilepsy models; however, the safety and efficacy of FUS in humans with epilepsy have not been well established. Patients with drug‐resistant epilepsy (DRE) undergoing stereo‐electroencephalography (SEEG) provide an opportunity to investigate the neuromodulatory effects of FUS in humans.

Methods

Patients with DRE undergoing SEEG for localization of the seizure onset zone (SOZ) were prospectively enrolled. FUS was delivered to the SOZ using a neuronavigation‐guided FUS system (ceiling spatial‐peak temporal‐average intensity level = 2.8 W/cm², duty cycle = 30%, modulating duration = 10 min). Simultaneous SEEG recordings were obtained during sonication and for 3 days after treatment. Seizures, interictal epileptiform discharges, and adverse events after FUS were monitored.

Results

Six patients met the eligibility criteria and completed FUS treatment. A decrease in seizure frequency was observed in two patients within the 3‐day follow‐up; however, one patient presented an increase in the frequency of subclinical seizures. Posttreatment magnetic resonance imaging revealed neither lesion nor brain edema. Significant changes in spectral power of SEEG were noted at the targeted electrodes during FUS treatment. One patient reported subjective scalp heating during FUS, and one patient developed transient naming and memory impairment that resolved within 3 weeks after FUS.

Significance

FUS can be safely delivered to the SOZ of patients with DRE, resulting in significant changes in spectral power of SEEG. A larger sample cohort and pursuing optimal sonication parameters will be required to elucidate the neuromodulatory effects of FUS when used for seizure control.

MRI at the Bedside: A Case Report Comparing Fixed and Portable Magnetic Resonance Imaging for Suspected Stroke

Magnetic resonance imaging (MRI) provides high-contrast resolution and is the preferred diagnostic tool for neurological disease. However, long exam times discourage MRI in emergency settings, and high-field MRI scanners (1.5-3T) require dedicated imaging suites. New, portable low-field-strength MRI machines (0.064T) have lower resolution than fixed MRI, but do not require restrictive environments or intrahospital transport. We present a case of a 78-year-old male with altered mental status who underwent 0.064T portable MRI and fixed 3T MRI exams in the emergency department. Imaging showed no evidence of acute infarction or intracranial lesions. The 0.064T images were of poor quality relative to 3T sequences, but the results of the portable MRI agreed with the conventional 3T MRI and a computed tomography scan from the same day. The compatible imaging results suggest that portable, low-field MRI can aid in neurological diagnosis without transporting patients to the MRI suite. Further studies should expand this comparison between high- and low-field MRI to better characterize the role and clinical applications of point-of-care MRI.

Low and High-Intensity Ultrasound in Dairy Products: Applications and Effects on Physicochemical and Microbiological Quality

Milk and dairy products have a major role in human nutrition, as they contribute essential nutrients for child development. The nutritional properties of dairy products are maintained despite applying traditional processing techniques. Nowadays, so-called emerging technologies have also been implemented for food manufacture and preservation purposes. Low- and high-intensity ultrasounds are among these technologies. Low-intensity ultrasounds have been used to determine, analyze and characterize the physical characteristics of foods, while high-intensity ultrasounds are applied to accelerate particular biological, physical and chemical processes during food product handling and transformation. The objective of this review is to explain the phenomenology of ultrasounds and to detail the differences between low and high-intensity ultrasounds, as well as to present the advantages and disadvantages of each one in terms of the processing, quality and preservation of milk and dairy products. Additionally, it reviews the rheological, physicochemical and microbiological applications in dairy products, such as raw milk, cream, yogurt, butter, ice cream and cheese. Finally, it explains some methodologies for the generation of emulsions, homogenates, crystallization, etc. Currently, low and high-intensity ultrasounds are an active field of study, and they might be promising tools in the dairy industry.

Eight-Week Low-Intensity Squat Training at Slow Speed Simultaneously Improves Knee and Hip Flexion and Extension Strength

Considering that the squat exercise requires flexion and extension of the knee and hip joints, a resistance training program based on squat exercises should efficiently increase the flexion and extension strength of both the knee and hip. To our knowledge, however, no study has simultaneously investigated the effects of squat training on both flexion and extension strength in both the knee and hip. Low-intensity squat exercises at slow speeds can be expected to effectively and safely improve knee and hip flexion and extension strength in a wide range of individuals. This study aimed to clarify whether knee and hip flexion and extension strength improved after an 8-week low-intensity squat training program at slow speed. Twenty-four untrained young men were randomly assigned to a training or control group. Participants in the training group performed 40% one-repetition maximum parallel squats at slow speed (4 s for concentric/eccentric actions), 3 days per week for 8 weeks. Before and after the intervention, isometric peak torque of the knee and hip flexors and extensors during maximal voluntary contraction (MVC) was determined. For the knee flexors and extensors, muscle volume was also measured. There were significant training-induced increases in peak torque (P < 0.05). The training effects on knee and hip extension torque (effect size = 0.36-0.38) were higher than those on knee and hip flexion torque (effect size = 0.09-0.13). The squat training used here increased both knee and hip flexion and extension strength, but the training effects on the flexion strength were less than those on the extension strength. Regarding the knee extensors, a significant training-related increase in muscle volume was found (P < 0.05) without neuromuscular adaptations. In addition, there were significant correlations between the training-induced increases in muscle volume and peak torque of KE. These results suggest that muscle hypertrophy may be responsible for increased muscle strength of the knee extensors after an 8-week low-intensity squat training program at slow speed.

Preliminary clinical outcomes of a short-term low-intensity Early Start Denver Model implemented in the Taiwanese public health system

LAY ABSTRACT

The Early Start Denver Model is a comprehensive naturalistic developmental behavioral intervention for young children with autism spectrum disorder. Rigorous studies indicate that long-term, high-intensity Early Start Denver Model in home-based settings can help young children with autism spectrum disorder have great progress in language, cognitive development, and adaptive skills and reduce overall symptom severity. In accordance with the current limitations in resourcing for early intervention in Taiwan, this study evaluated the effects of implementing the Early Start Denver Model in the Taiwanese public health system with some adaptations, including lower intensity, shorter duration, and delivery in general hospitals. A total of 16 children with autism spectrum disorder, aged between 25 and 46 months, received approximately 8 h per week one-on-one Early Start Denver Model intervention. After 6 months of intervention, the children showed great improvements in language and overall cognitive functioning and reduced symptom severity in communication and play. This study suggests that directly delivering the Early Start Denver Model in community-based hospitals may be an effective intervention, which can make more young children with autism spectrum disorder in Taiwan access the Early Start Denver Model service.

Moderate Effects of Low-Intensity Behavioral Intervention

We compared clinical outcomes in a treatment group of 98 individuals who received between 8 and 15 weekly hours (M = 10.6; SD = 1.7) of applied behavior analysis (ABA) intervention with a comparison group of 73 individuals who received another provision, including some ABA, (between 1.4-8 weekly hours, M = 5.7; SD = 1.6). After 2 years, the treatment group made greater gains than the comparison group on language and social skills, and other areas assessed by the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP). We evaluated the outcome on adaptive skills for a smaller sample of participants using the Vineland Adaptive Behavior Scales II (VABS), but found no significant differences between the treatment (n = 17) and comparison groups (n = 11). Although the treatment group made important and clinically meaningful gains, the gains were moderate. These findings underline the importance of intervention intensity and provide further support for a dose-response relationship between ABA intervention hours and outcomes.

Preparing to launch the 'Thinking Healthy Programme' perinatal depression intervention in Urban Lima, Peru: experiences from the field

BACKGROUND

An estimated 19-25% of perinatal women in low- and middle-income countries are affected by depression which, untreated, is associated with multiple health problems for mothers and children. Nonetheless, few perinatal women have access to depression care. The Thinking Healthy Programme (THP), promoted by the World Health Organization (WHO), is an evidence-based, non-specialist delivered depression intervention that addresses this care gap. However, the WHO THP manual explains intervention delivery but not the antecedents to implementation. Here, we describe a principled, planned approach leading to the implementation of THP in Lima, Peru by the non-profit organization Socios En Salud with community health workers (CHW) to inform its implementation in other settings.

METHODS

The Replicating Effective Programs (REP) framework guided THP implementation, following four phases: (I) pre-conditions; (II) pre-implementation; (III) implementation; and (IV) maintenance and evolution. This paper centers on REP phases I and II, including (1) documented high perinatal depression rates in Peru; (2) designation of perinatal depression as a government priority; (3) THP Implementation Team orientation and training; (4) data collection plan development; (5) public health system coordination; (6) CHW selection and training; and (7) THP launch.

RESULTS

Between December 2016 and March 2017, a THP training program was developed and seven CHW were trained to deliver the intervention to 10 perinatal women, the first of whom was enrolled on 17 April 2017.

CONCLUSIONS

THP was rapidly implemented by a community-based organization with no prior experience in delivering non-specialist perinatal depression care. The steps followed may inform the implementation of THP in other settings.

Guided parent-delivered cognitive behaviour therapy for children with anxiety disorders: Outcomes at 3- to 5-year follow-up

OBJECTIVES

Brief guided parent-delivered cognitive behaviour therapy (CBT) has been developed to meet the demand for non-intensive interventions for children with anxiety disorders, and initial trials have shown it to be effective for children with a range of anxiety disorders. This study examined outcomes 3-5 years post-treatment.

DESIGN

A long-term follow-up (LTFU) cohort study.

METHODS

Families who (1) completed at least 50% of allocated treatment sessions of guided parent-delivered CBT for childhood anxiety as part of a randomized control trial (RCT), (2) provided consent to be recontacted, (3) had not received further mental health interventions, and (4) were contactable were invited to take part. Fifty-seven families (29% of the original sample) completed structured diagnostic interviews on average 50 months after treatment (39-61 months).

RESULTS

At LTFU, 79% of the assessed children who had received the treatment no longer met criteria for their primary diagnosis, 63% did not meet criteria for any anxiety disorder, and 61% did not meet criteria for any DSM-IV disorder. Treatment gains were mostly maintained (60%), and some children went on to recover during the follow-up period without additional input from mental health services (19%). Few young people had relapsed since their last assessment (12%). Mean scores on standardized symptom questionnaires were within the normal range.

CONCLUSIONS

Children who recovered from anxiety disorders following brief guided parent-delivered CBT typically maintained good outcomes and few relapsed. These findings suggest that this is a viable first-line, low-intensity treatment approach. This study only included a small subsample of those in the original RCT (29%), and more information is required about those who dropped out of treatment and those who required further intervention immediately after treatment.

PRACTITIONER POINTS

Treatment gains from brief guided parent-delivered cognitive behaviour therapy for children with anxiety are maintained for most children 3-5 years later. The majority of children who completed at least 50% of the intervention required no further mental health intervention in that time. Some children make continued improvement after completing the intervention. Data are based on a sample of families from southern England where the primary caregiving parent was free of mental health difficulties. Further research is needed to explore the mental health needs of those who do not benefit from this intervention.

The outcome and prognostic factors of 248 elderly patients with acute myeloid leukemia treated with standard-dose or low-intensity induction therapy

The prognosis of elderly patients with acute myeloid leukemia (AML) is poor, and the recommendation of standard-dose or low-intensity induction regimen for these patients remains controversial. We retrospectively analyzed treatment outcome and prognostic factors of elderly AML patients who had received either standard-dose or low-intensity induction regimens.Two hundred forty-eight elderly AML patients with good Eastern Cooperative Oncology Group performance status (ECOG PS ≤ 2) received one of three regimens for induction in this study: standard-dose cytarabine plus idarubicin (IA; n = 144) or daunorubicin (DA; n = 42); low-intensity cytarabine, aclarubicin, and granulocyte colony-stimulating factor (G-CSF) (CAG; n = 62).After first induction treatment cycle, the overall complete remission (CR) rate was 42.7%. Patients in IA group had a higher CR rate than in DA or CAG group (49.3%, 35.7%, and 32.3%, respectively; P = 0.046). The 1-year, 3-year, and 5-year overall survival (OS) rates were 42.2%, 18.9%, and 13.5% for these 248 patients, with median survival of 9.2 months. Long-term survival of IA group was better than DA or CAG group. The 1-year, 3-year, and 5-year OS rates of IA group were 45.9%, 23.5%, and 19.4%, respectively, as compared to 39.8%, 8.3%, and estimated 2.4% in DA group, and 34.9%, 15.9%, and 6.3% in CAG group, respectively. Early induction mortality and 2-year relapse rates showed no difference among 3 groups. Univariate analysis and multivariate analysis identified lactic dehydrogenase (LDH) more than two times of upper normal limit at diagnosis and nonremission after first induction cycle as adverse prognostic factors for OS. A simple and valid scoring model was constructed for risk stratification and prediction of long-term survival of elderly AML patients.Standard-dose IA regimen could improve the prognosis of elderly AML patients with good performance status compared with standard-dose DA or low-intensity CAG regimen. All prognostic factors and risk assessment should be considered to ensure that each patient receives the suitable individualized treatment.

Psychological interventions for housebound people with psychosis: service user and therapist perspectives in South East London

BACKGROUND

People with psychosis often have difficulty leaving their homes to perform tasks of daily living, which also limits their access to clinic-based interventions to support recovery. Home-based psychological therapy may offer a solution.

AIM

To examine service user and therapist perspectives on (i) houseboundness in psychosis and (ii) the value of home-based psychological interventions, as a first step towards a systematic evaluation.

METHOD

Semistructured interviews with 10 service users and 12 therapists from a large inner city mental health NHS Foundation Trust were thematically analysed.

RESULTS

Houseboundness most commonly resulted from anxiety, paranoia and amotivation, indicating the potential usefulness of targeted psychological therapies. Home-based therapy was offered unsystematically, with variable goals. Although beneficial for engagement and assessment, little gain was reported from undertaking a full course of therapy at home.

CONCLUSION

Home visits could be offered by psychological therapists to engage and assess housebound service users, but home-based therapy may be best offered on a short-term basis, targeting paranoia, anxiety and amotivation to increase access to other resources. Given the increased cost associated with home-based psychological interventions, a systematic evaluation of their impact is warranted.