The High Impact of Low Intensity: Effectiveness of the BounceBack Program for Depression and Anxiety in Ontario

High costs, long wait times, and lack of access to mental health supports in Ontario are leaving millions with unmet treatment needs. To address this need, Ontario launched BounceBack, a large-scale coach-supported intervention grounded in cognitive behavioral therapy (CBT) to target symptoms of anxiety, depression, and functional impairment. The objective of this program evaluation was to examine the effectiveness of the BounceBack program in Ontario by exploring (a) changes in participants' depression and anxiety symptoms and functional impairment (as measured by the PHQ-9, GAD-7, and WSAS, respectively); and (b) rates for recovery and reliable improvement. Multilevel modelling (MLM) results indicated that participants reported significant improvements in their depression, anxiety, and functioning symptoms over time, which are not better accounted for by other demographic factors. Higher baseline severity of symptoms were associated with greater decreases in these symptoms. The strong recovery and reliable improvement rates identified further support the effectiveness of BounceBack as a potent intervention that leads to improvements in symptoms of anxiety and/or depression for the majority of its participants.

DNA methylation differences in stress-related genes, functional connectivity and gray matter volume in depressed and healthy adolescents

BACKGROUND

Studies in adult depressed patients have indicated that altered DNA methylation patterns at genes related to serotonin and HPA axis functioning (e.g., SLC6A4, FKBP5) are associated with changes in frontolimbic functional connectivity and structure. Here, we examined whether these associations can be generalized to adolescents.

METHODS

25 adolescents with depression (Mean age = 15.72 ± 0.94 SD; 20 girls) and 20 healthy controls (Mean age = 16.05 ± 1.5 SD; 16 girls) underwent a functional and structural magnetic resonance imaging protocol, which included a resting-state assessment and measures of brain morphometry. DNA was obtained from saliva. Levels of SLC6A4 and FKBP5 methylation were determined using pyrosequencing.

RESULTS

SLC6A4 methylation was linked to amygdala-frontal operculum resting-state functional connectivity (rs-FC), regardless of diagnosis, and was differentially associated with inferior orbitofrontal gyrus (IFOG) gray matter (GM) volume in adolescents with depression and controls. Replicating and extending previous findings in adults, FKBP5 methylation was associated with IFOG GM volume in depressed and healthy adolescents, as well as orbitofrontal cortex (OFC)-rostral prefrontal cortex (RPFC) connectivity in healthy adolescents only.

LIMITATIONS

Effects of medication use or genotype cannot be ruled out. Further, the relatively small sample size and predominately female sample may limit generalizability.

CONCLUSIONS

These findings suggest that previously observed associations between SLC6A4 and FKBP5 methylation and frontolimbic processes in adult depressed patients can be in part generalized to adolescent patients. Further, findings suggest that measuring peripheral methylation at these genes deserves further attention as potential markers of typical and atypical development.

Persistence and innovation effects in genetic and environmental factors in negative emotionality during infancy: A twin study

Background

Difficult temperament in infancy is a risk factor for forms of later internalizing and externalizing psychopathology, including depression and anxiety. A better understanding of the roots of difficult temperament requires assessment of its early development with a genetically informative design. The goal of this study was to estimate genetic and environmental contributions to individual differences in infant negative emotionality, their persistence over time and their influences on stability between 5 and 18 months of age.

Method

Participants were 244 monozygotic and 394 dizygotic twin pairs (49.7% male) recruited from birth. Mothers rated their twins for negative emotionality at 5 and 18 months. Longitudinal analysis of stability and innovation between the two time points was performed in Mplus.

Results

There were substantial and similar heritability (approximately 31%) and shared environmental (57.3%) contributions to negative emotionality at both 5 and 18 months. The trait’s interindividual stability across time was both genetically- and environmentally- mediated. Evidence of innovative effects (i.e., variance at 18 months independent from variance at 5 months) indicated that negative emotionality is developmentally dynamic and affected by persistent and new genetic and environmental factors at 18 months.

Conclusions

In the first two years of life, ongoing genetic and environmental influences support temperamental negative emotionality but new genetic and environmental factors also indicate dynamic change of those factors across time. A better understanding of the source and timing of factors on temperament in early development, and role of sex, could improve efforts to prevent related psychopathology.

Power differentials in bullying: individuals in a community context

Central to the definition of bullying is the abuse of power. Power relationships are inherent in social groups, by virtue of differing size, strength, age, socioeconomic status (SES), or social connectedness of individuals. Beyond the influence of these individual characteristics, environmental factors have the potential to affect the power dynamic in bullying and victimization, but are a relatively unexplored research area. In particular, we know little about how the community-level factors relate to bullying in the adolescent population. The present study is guided by a social ecological perspective to gain a deeper understanding of the individual and built community characteristics (e.g., parks, recreational spaces, buildings that facilitate social interaction and community connectedness) that contribute to the power dynamics related to victimization or bullying in traditional and electronic contexts. Data were collected from 17,777 students in Grades 6 to 10 as part of the 2009/2010 Health Behavior in School-aged Children (HBSC) Survey, from Geographical Information Systems (GIS) data, and from 2006 Canadian Census data. Two nested models were run using HLM with age, gender, ethnicity, SES, social inclusion factors (e.g., collective efficacy), and community resource factors (e.g., access to recreation) as predictors. Characteristics of individuals that placed them at a power disadvantage (being younger, female, and having low SES) were linked to higher rates of victimization. Lower individual collective efficacy was also associated with higher rates of traditional and electronic victimization. Community recreational opportunities were associated with decreased victimization in both contexts. The relative importance of individual and built environmental factors and conceptualization of bullying interactions within a social ecology model are discussed.

The role of human papillomavirus in screening for cervical cancer

PURPOSE

To review the options for effectively screening for cervical cancer, including human papilloma virus (HPV) identification, cytologic screening, colposcopy, or a combination approach. Current pathophysiology, diagnostic criteria, treatment approaches, and patient preparation and education related to cervical cancer screening and prevention are also included.

DATA SOURCES

Comprehensive review of current literature, including research and review articles.

CONCLUSION

Because the Papanicolau (Pap) smear is a screening tool, not a diagnostic tool, further studies must be done to identify the actual nature of discovered abnormalities. Of particular concern is the classification of atypical squamous cells of undetermined significance (ASCUS), which may simply indicate inflammation, or may be the first indicator of serious pathology. Following ASCUS Pap smears with HPV screening will allow for a clarification of the best approach to treatment. A screening algorithm supported by a review of the literature is proposed.

IMPLICATIONS FOR PRACTICE

Cervical cancer is a preventable disease caused by certain forms of HPV. Current screening protocols are based on the use of the Pap smear; and in areas where this test is routine and available, morbidity and mortality rates have dropped dramatically. Many women throughout the world and in underserved regions of the U. S. do not have adequate access to routine screening with Pap smear technology. As long as women continue to die needlessly of cervical cancer, more comprehensive and accessible screening methods must be explored. (Cutting the unnecessary worldwide and in the U. S.).

Dysmenorrhea

Dysmenorrhea is a common complaint that causes considerable disruption in a woman's life. Accurate diagnosis of primary and secondary causes with appropriate therapeutic intervention leads to significant improvements in quality of life.

Diagnostic evaluation for hypertension

Evaluation and management of hypertension requires careful monitoring by the practitioner. A positive patient-provider relationship and an individualized approach to treatment are essential for a positive therapeutic outcome.

Congestive heart failure

The differentiation between systolic and diastolic CHF is clinically important because it allows one to formulate an appropriate therapeutic regimen. As a rule, ACE inhibitors have become a major component in the treatment of systolic heart failure; diuretics, digoxin, and other vasodilators are used in conjunction with them. Optimal therapy for diastolic heart failure remains to be defined. Further research is required for this subset of patients. Numerous other support measures, such as counseling, activity, diet, patient knowledge of medications, and compliance, all affect the patient's outcome.

Clinical health problem: failure to thrive

Families in which NOFTT is present need interventions that target behaviors and identify stressors that contribute to decreased caloric intake. A holistic approach to the situation is required, to deal with considering the problem which may stem from multiple sources. Maternal perceptions of health and diet can be influenced by the practitioner in a sensitive manner, encouraging balance. Infant feeding difficulties can be identified by the practitioner and appropriate referrals can be made to FTT clinics that are experienced in working with these infants and their caregivers. Public health nurses can be utilized to further assess families, follow up on health teaching, and provide referrals to community resources to alleviate stressors. Management of NOFTT by a practitioner in the primary care setting is feasible and cost-effective.

[Relationship between respiratory reserve in the flow-volume curve and the expected ergometric capacity]

To evaluate the physical work capacity in patients with chronic obstructive lung disease (COLD) it was checked, if determination of breathing reserve can replace the exercise test with blood gas analysis. In 28 patients with lung disease and 7 healthy subjects the flow-volume-curve under resting conditions and during the forced breathing maneuver to measure the breathing reserve and the exercise test with blood gas analysis were examined. A correlation was found between both. Therefore, in patients with COLD the determination of breathing reserve is a practicable method for estimating the physical work capacity, especially in cases with absent breathing reserve. Nevertheless, for medical opinion exercise testing is necessary.

Microcirculation of the fingernail fold in CAPD patients: preliminary observations

OBJECTIVE

To study changes in the peritoneal microcirculation during continuous ambulatory peritoneal dialysis (CAPD) by studying change in the microcirculation of the fingernails of CAPD patients.

SETTING

A university department.

DESIGN

A cross-sectional study of 10 nondiabetic patients on CAPD.

INTERVENTION

Hemorrheological tests of fingernail microcirculation using equipment built at our university.

MAIN OUTCOME MEASURES

Microcirculation was characterized by estimation of capillary density, red blood cell (RBC) column diameter, torque index, and RBC flow velocity semiquantitatively using videocapillaroscopy at the fingernail fold and plasma viscosimetry. Findings were correlated with treatment duration, peritoneal clearance, state of capillary morphology and hemodynamics, and lipid and fibrinogen levels.

RESULTS

Treatment duration was significantly correlated (p < or = 0.05) with low-density lipoprotein (LDL) (r = 0.776) and clearances of urea (r = -0.583), uric acid (r = -0.666), and potassium (r = -0.764). Changes in capillary morphology were correlated to clearances of urea (r = 0.643) and uric acid (r = 0.701). The fibrinogen concentration increases plasma viscosity (r = 0.799) and deteriorates the capillary state (r = -0.706). In addition, plasma viscosity correlates to cholesterol (r = 0.620, NS) and LDL (r = 0.781), but not to high-density lipoprotein and triglycerides.

CONCLUSION

CAPD treatment results in lipid abnormalities and high fibrinogen levels that may cause microvascular damage and poor perfusion. These interactions may explain the deterioration of peritoneal transport in some CAPD patients.

Comparison of three methods of measurement of pulmonary artery catheter readings in critically ill patients

BACKGROUND

Pulmonary artery catheter readings are critical for clinical decision making and therapeutic intervention in critically ill patients. Research data of digital display versus graphic strip chart recording of hemodynamic pressures during spontaneous breathing and mechanical ventilation are inconclusive.

OBJECTIVES

To compare three methods of measurement of hemodynamic pressure readings from the pulmonary artery catheter in critically ill patients during mechanical ventilation and spontaneous breathing.

METHODS

A nonrandomized, repeated-measures design was used to compare hemodynamic pressures (right atrial, systolic, diastolic, and wedge pressures) from the pulmonary artery catheter in cardiovascular patients during mechanical ventilation (n = 25) and again during spontaneous breathing (n = 19).

RESULTS

Using repeated measures analysis of variance, statistically significant differences were noted in the pulmonary artery diastolic, wedge, and right atrial pressure during mechanical ventilation. During spontaneous breathing, significant differences occurred in pulmonary artery systolic and wedge pressures only. No statistically significant difference occurred in the systolic pressure during mechanical ventilation, or the pulmonary artery diastolic and right atrial pressures during spontaneous breathing.

CONCLUSIONS

The results of this study indicate that graphic recording is the most reliable means of measuring hemodynamic pressure at end-expiration. Further research is needed to validate these findings with other models of monitoring equipment and other patient populations.

Comparison of three methods of measurement of pulmonary artery catheter readings in critically ill patients

BACKGROUND: Pulmonary artery catheter readings are critical for clinical decision making and therapeutic intervention in critically ill patients. Research data of digital display versus graphic strip chart recording of hemodynamic pressures during spontaneous breathing and mechanical ventilation are inconclusive. OBJECTIVES: To compare three methods of measurement of hemodynamic pressure readings from the pulmonary artery catheter in critically ill patients during mechanical ventilation and spontaneous breathing. METHODS: A nonrandomized, repeated-measures design was used to compare hemodynamic pressures (right atrial, systolic, diastolic, and wedge pressures) from the pulmonary artery catheter in cardiovascular patients during mechanical ventilation (n = 25) and again during spontaneous breathing (n = 19). RESULTS: Using repeated measures analysis of variance, statistically significant differences were noted in the pulmonary artery diastolic, wedge, and right atrial pressure during mechanical ventilation. During spontaneous breathing, significant differences occurred in pulmonary artery systolic and wedge pressures only. No statistically significant difference occurred in the systolic pressure during mechanical ventilation, or the pulmonary artery diastolic and right atrial pressures during spontaneous breathing. CONCLUSIONS: The results of this study indicate that graphic recording is the most reliable means of measuring hemodynamic pressure at end-expiration. Further research is needed to validate these findings with other models of monitoring equipment and other patient populations.

Determination of glomerular filtration rate (GFR) on two consecutive days using inulin in a single-sample plasma clearance method

Reliable estimation of the GFR is essential in nephrological practice for the early recognition and follow-up of latent or residual renal disturbance. The GFR of ten healthy volunteers on two consecutive days and of 40 patients with different renal diseases were investigated by means of a plasma slope clearance technique. After injection of 5 g/50 ml inulin solution, eight plasma samples were taken at 10, 20, 30, 40, 120, 180, 240, 300 min p.i. and analyzed with the aid of a fully enzymatic method. The results were correlated on the basis of 1- and 2-compartment models (1 CM, 2 CM) and the one-sample method (1 S), using only the plasma inulin concentration of the 240 min p.i. sample. The accuracy of the GFR data of volunteers estimated in these models was checked by comparison with the standardized agewise normal values, while for the patient group we found in terms of equations of correlation: 1. GFR (2 CM) = 4.46 + 0.763*GFR (1 S), n = 31, r = 0.985 2. GFR (2 CM) = 1.27*GFR (1 CM)0.9, n = 40, r = 0.996 3. GFR (1 CM) = 0.568*(GFR[1 S] + 5.85)1.11, derived The single-sample method using inulin is closely correlated to multi-sample methods but much more suitable for patients and staff. Therefore, it is recommended for clinical use.

The competitive effects of horizontal mergers in the hospital industry: a closer look

Woolley (1989) attempted to analyze the competitive impact of horizontal hospital mergers using the 'event study' method. Woolley characterized his results as consistent with traditional 'oligopoly' theories of market behavior. We scrutinize in detail a large number of his events, however, and find that most either generated concentration increases too small to plausibly produce market power, or could not have conferred monopoly returns on firms improperly characterized as rivals. Accordingly, any observed abnormal returns are likely attributable to some other cause; we suggest some alternative interpretations of his results. Our paper highlights the need for care in the selection of events and the identification of rivals when applying the event study method to the analysis of mergers.

[Simultaneous determination of the GRF and the ERPF (effective renal plasma flow) using a single blood sample in the slope clearance with 99mTc-DTPA and I 131-hippurate]

In patients with various indications to renal split function diagnostics the plasma slope clearance of the Tc99m-DTPA and J131-Hippurate to the estimation of GFR and ERPF were performed with two or three blood samples in the monocompartment model (1 KM). In comparison these functional parameters were calculated on the basis of the only least blood sample (single-point procedure--EPV). The results of linear regression GFR (1 KM) = 12.7 + 0.978 * GFR (EPV), r = 0.986, N = 102 or ERPF (1 KM) = 22 + 1.13 * ERPF (EPV), r = 0.889, N = 68 may recommend the use as patient-safe procedure especially in poor venous access. Two short BASIC programs for estimation of GFR and ERPF are presented and the error ranges discussed.

[Ergometric results of r-erythropoietin treatment of hemodialysis patients]

To investigate the effect of partial correction of anemia in patients maintained by chronic intermittent hemodialysis on exercise capacity, patients underwent a bicycle acido-ergometry before and after treatment with recombinant human erythropoietin. The results demonstrate a (subjective) improvement of exercise capacity without any evidence for that in the pH values.

An improved method to determine renal function using inulin and p-aminohippurate (PAH) steady-state kinetic modeling

Steady-state clearances using inulin and PAH are the most reliable reference procedures if new test substances or techniques are developed to estimate the GFR or the of these methods we developed an open monocompartment model with an expanding distribution volume of the substance of interest. In this model we derived prescriptions for the concentration of inulin and PAH in the infusion procedure. The resulting improvement was verified by the F-test on the variance of plasma concentration in a 3-hour examination of 15 patients. The final results are of direct benefit to the patient because the number of blood samples required for the control of the steady-state plasma level can be reduced. Furthermore, we derived an individual correction of the so-called input steady-state clearance (without urine collection) which relates better to the usual output clearance of inulin or PAH. A PC-BASIC program is available that calculates the proper concentrations for the infusion and executes the complete analysis (GFR, ERPF, filtrate fraction [FF], maximal tubular transport of PAH [TmPAH] and the renal vascular resistance [RVR], each of which is related to the BSA and the age of the patient).

[Pathophysiologic-nephrologic hypothesis of the protective function of an endogenous natriuretic and digoxin-like substance (endoxin) for residual nephrons]

A dualistic function for the natriuretic ATP.inhibiting factor is formulated on the basis of a phenomenon like compensatory renal adaption of residual nephrons: 1. Support of the tubular sodium excretion to the maintenance of homoeostasis of the organism. 2. Inhibition of the forced up vasodilation of the afferent glomerular vessel. It should suggested that the renal vasoconstrictive effect is a part of a protective system for residual nephrons against the pathogenic hyperfiltration and hyperperfusion.

[Steps for solutions and hindrances in progress in relation to an implantable bio-artificial hemofilter-intestine-hybrid kidney]

On the view of 1989 older and modern developments to a bioartificial implantable hybrid kidney are presented. To the realization proof of the implantable hemofilter-intestine-hybrid kidney the routes were described in an experimental rat model to the plasmakinetic simulation of the urea and sodium level as a marker of the hybrid kidney functions. The results of the bioartificial hemofilter-intestine-hybrid kidney development are presented, but significant detail problems must be solved, especially the hemofilter biocompatibility problem.

[Contribution of animal experiments in the problem of a long-term indomethacin therapy in advanced nephron loss]

Residual nephrons are subject to compensatory adaptation at which the glomerular hyperfiltration and convection of macromolecules (proteins) are of pathogenic character in the progression of nephropathy. The influence of indomethacin at dosages of 2 or 3 mg/kg body weight/day was investigated in long-term feeding trials (8 months) on inbred female Wistar rats after unilateral nephrectomy and additional resection of both kidney poles. The results show a significant deterioration of vital prognosis under indomethacin medication independently of the dosage.

[Standardization of methods and assessment of conventional and radionuclide clearance investigations: recommendations of the Renal Diagnostics Study Group of the Society of Nephrology, GDR]

Recommendations of the Study Group "Renal Function Diagnostics" of the Society of Nephrology to the performance of the steady state clearance using inulin or PAH and the slope clearance with radionuclides for estimation of effective renal plasma flow are presented. These investigations are indicated in the early recognition and follow-up of latent or residual disturbance of the renal function in the creatinine-blind area. Recommendations have been done on selection and dosage of test substances, timing of examination and evaluation of results.

[Development of a model as a pathophysiologic study method in clinical and experimental nephrology]

After explanations concerning principal qualities of the models follow examples from nephrology about theoretical and concrete modelling. Consequences for the renal functional, performance and reagibility diagnostics are discussed. The ability of mathematical modellings for statements is shown at the instance of the ureal plasma kinetics in apparative peritoneal detoxication methods and in connection with investigations about the implantable kidney as well as supplemented by explanations concerning the dynamic compartment modelling of the potassium balance.

Bacterial and fungal growth after freezing or refrigerating parenteral nutrient solutions

Parenteral nutrient (PN) solutions were evaluated for growth of pathogenic organisms after refrigeration or freezing and then thawing. Sixteen bags of hypertonic dextrose and amino acid solutions were divided into two series (refrigerated and frozen), inoculated with Escherichia coli. Candida albicans, Staphylococcus aureus, or Streptococcus faecalis, and exposed to freezing or refrigeration. The inoculum concentration was greater than would likely occur with patient contamination of the solution. Microbial growth in the solutions was determined after warming to room temperature and at 17 or 18 hours after reaching room temperature. There was no increased growth of C. albicans in PN solutions that were frozen versus the refrigerated samples. Counts for all of the organisms in the frozen series, immediately after freezing and then thawing, decreased or stayed the same compared with baseline counts. Growth of E. coli, Staph. aureus, and Strep. faecalis increased in the frozen samples compared with the refrigerated samples after room-temperature storage, suggesting a possible increased risk of infectious complications if contaminated solutions are left at room temperature for extended periods. Since no increased risk of microbial growth is likely in frozen versus refrigerated PN solutions that are thawed and promptly infused, batch freezing may be an effective and convenient means of preparing PN solutions for home patients.

[Mediator concepts and modulation of renal compensatory adaptation]

In the renal compensatory adaptation after the definition and the description of the fundamental phenomena of the functional compensation as well as of the structural adaptation is reported on mediator concepts and on modulations of the renal adaptation processes. Issuing from the central position of the sodium balance a mediator concept on natriuretic hormones (Auriculin and Endoxin) is developed which is supplemented by the renotropin mediator concept. The authors deal with the modulation of the renal compensatory adaptation (e.g. influences of age diet and so on). The pharmacotherapeutic modulation of the renal compensatory adaptation is discussed with regard to the stimulation of the tubulosecretory transport of foreign substances with para-amino hippuric acid as principal substance (including own investigations with cyclopenthiazide [Benesal].

[Experimental animal studies of compensatory renal adaptation of residual nephrons in physical stress caused by daily swim training]

The influence of a regular physical training after unilateral nephrectomy carried out on the experimental animal rat on the function of the residual kidney was investigated. A significant decrease of the glomerular filtration rate by 22% and an increase of TmPAH by 36% in the loaded animals could be proved 12 weeks after unilateral nephrectomy and two-month load by swimming training. These findings allow the interpretation that physical conditioning for adapting nephrons may be regarded as progression as well as protection factor. Additional long-term investigations are necessary to clarify this problem and finally to prove present therapeutic recommendations for the physical conditioning with regard to prove protective reactions to the renal compensatory adaptation of the residual nephrons without any doubt.

Prediction of whole blood selenium levels in patients on long-term parenteral nutrition

In an attempt to define clinical variables which might predict the whole blood selenium level prior to supplementation, whole blood selenium levels were determined in 21 home parenteral nutrition patients who were not receiving selenium supplementation. These levels were examined for possible correlations by single and multivariant analysis with the following clinical parameters: age at initiation of home parenteral nutrition, months of home parenteral nutrition received, hematocrit, albumin, estimated length of remaining small bowel, kilocalories per kilogram actual body weight infused per day, grams protein per kilogram actual body weight infused per day, and multiple of ideal body weight. Of all the combinations of variables examined, the best correlation obtained was between whole blood selenium levels and the total kilocalories per kilogram body weight per day delivered intravenously (r = -0.89, p less than 0.001). A statistically significant correlation (r = -0.67, p less than 0.01) was also observed between selenium levels and the grams protein per kilogram actual body weight infused per day. However, inclusion of this or additional variables did not increase the predictive value of the equation describing whole blood selenium levels as a function of the calories delivered. The implication of this study is that patients requiring more intensive nutritional support develop lower selenium levels during the course of treatment. Despite these correlations, no single clinical parameter or combination of parameters, however, was of sufficient predictive value to preclude laboratory determination of whole blood selenium values in deciding which patients might benefit from selenium supplementation.