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Edited by
Allan Young, Institute of Psychiatry, King's College London,Marsal Sanches, Baylor College of Medicine, Texas,Jair C. Soares, McGovern Medical School, The University of Texas,Mario Juruena, King's College London
Bipolar disorders (BD) are recurrent conditions and many clinical and social impairments persist even with optimal pharmacotherapy. This chapter explores the development of psychological treatments, from initial uncertainties about offering therapies for BD, and then following the tentative steps to offer support to individuals with BD and to their families. Much of the focus is on the rationale, evolution and testing of specific psychological treatments. As well as examining any added value attained from providing psychological treatments alongside medications, we also consider how therapies might be further developed in the future. For example, we discuss how network meta-analysis might shed light on active ingredients that are common to all successful therapies and consider if these components might herald the introduction of multi-modal interventions. The chapter ends by noting the progress being made regarding the mediators and moderators of therapeutic effects and highlighting the importance of continuing to undertake efficacy trials but also comparative effectiveness trials that will enable researchers, clinicians and patients to determine how best to deploy psychological treatments in the real world.
Chemical data from three different series of diagenetic illite/smectites (I/S), analyzed statistically by two regresion techniques, indicate that the content of fixed-K per illite layer is not constant, but ranges from ~0.55 per O10(OH)2 for illite layers in randomly interstratified I/S (R=0; >50% smectite layers) to ~ 1.0 per O10(OH)2 for illite layers formed in ordered I/S (R>0; <50% smectite layers). By extrapolation of the experimental data, the following chemical characteristics were obtained for end-member illite derived from the alteration of smectite in bentonite: average fixed-K per illite layer = 0.75 per O10(OH)2; total charge = about -0.8; cation-exchange capacity = 15 meq/100 g; surface area (EGME) = 150 m2/g.
Samples containing illite and illite-smectite, having different crystal shapes (plates, “barrels”, and filaments), were selected for sorption experiments with cesium. There is a positive correlation between total surface area and Cs-sorption capacity, but no correlation between total surface area and the distribution coefficient, Kd. Generally Kd increases with the edge surface area, although “hairy” (filamentous) illite does not fit this pattern, possibly because elongation of crystals along one axis reduces the number of specific sorption sites.
The standard form of the Scherrer equation, which has been used to calculate the mean thickness of the coherent scattering domain (CSD) of illite crystals from X-ray diffraction (XRD) full width data at half maximum (FWHM) intensity, employs a constant, Ksh, of 0.89. Use of this constant is unjustified, even if swelling has no effect on peak broadening, because this constant is valid only if all CSDs have a single thickness. For different thickness distributions, the Scherrer “constant” has very different values.
Analysis of fundamental particle thickness data (transmission electron microscopy, TEM) for samples of authigenic illite and illite/smectite from diagenetically altered pyroclastics and filamentous illites from sandstones reveals a unique family of lognormal thickness distributions for these clays. Experimental relations between the distributions’ lognormal parameters and mean thicknesses are established. These relations then are used to calculate the mean thickness of CSDs for illitic samples from XRD FWHM, or from integral XRD peak widths (integrated intensity/maximum intensity).
For mixed-layer illite/smectite, the measured thickness of the CSD corresponds to the mean thickness of the mixed-layer crystal. Using this measurement, the mean thickness of the fundamental particles that compose the mixed-layer crystals can be calculated after XRD determination of percent smectitic interlayers. The effect of mixed layering (swelling) on XRD peak width for these samples is eliminated by using the 003 reflection for glycolated samples, and the 001, 002 or 003 reflection for dehydrated, K-sa-turated samples. If this technique is applied to the 001 reflection of air-dried samples (Kubler index measurement), mean CSD thicknesses are underestimated due to the mixed-layering effect.
An internal standard X-ray diffraction (XRD) analysis technique permits reproducible and accurate calculation of the mineral contents of rocks, including the major clay mineral families: Fe-rich chlorites + berthierine, Mg-rich chlorites, Fe-rich dioctahedral 2:1 clays and micas, Al-rich dioctahedral 2:1 clays and micas, and kaolinites. A single XRD pattern from an air-dried random specimen is used. Clays are quantified from their 060 reflections which are well resolved and insensitive to structural defects. Zincite is used as the internal standard instead of corundum, because its reflections are more conveniently located and stronger, allowing for a smaller amount of spike (10%). The grinding technique used produces powders free of grains coarser than 20 µm and suitable for obtaining random and rigid specimens.
Errors in accuracy are low, <2 wt. % deviation from actual values for individual minerals, as tested on artificial shale mixtures. No normalization is applied and thus, for natural rocks, the analysis is tested by the departure of the sum of the measured components from 100%. Our approach compares favorably with other quantitative analysis techniques, including a Rietveld-based technique.
The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.
Methods
The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.
Results
About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15–20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.
Conclusions
The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.
Two independent methods of crystal-size distribution analysis were compared: the Bertaut-Warren-Averbach XRD technique (MudMaster computer program) and high-resolution transmission electron microscopy (HRTEM). These techniques were used to measure thickness distributions of illite crystals (fundamental particles) from sets of illite-smectites from shales and bentonites that had expandabilities ranging from 86%S to 6%S. The illite-smectites were treated with a polymer (polyvinylopyrolidone, PVP) to separate them into fundamental particles for XRD and HRTEM investigations.
A systematic difference between XRD and HRTEM results was observed: XRD (area-weighted distributions) detected a larger fraction of thick (>4 nm) and a smaller fraction of thin crystals as compared to HRTEM (number-weighted distributions). As a result, XRD-determined distributions have larger mean thickness values and larger distribution parameters (α and β2). The measurements performed by the two techniques were verified by modeling XRD patterns of the PVP-illites, using the measured distributions as inputs. The modeling indicated that the XRD-determined distributions are very accurate. Selecting broader thickness distributions in MudMaster further improved the modeling results. The HRTEM measurements underestimate the proportion of coarse particles, in particular in shale samples, and this inaccuracy is attributed to the effect of using number-weighted (rather than area-weighted) distributions and to inaccurate counting statistics for thick crystals.
The swelling properties of smectite-type clay particles (including montmorillonite) are of interest in various industries. A fundamental understanding of the surface properties of smectite particles at the sub-micron level would facilitate investigation of the effect of distributed properties such as charge and elemental composition. Swelling and delamination of SWy-2 Na-montmorillonite (Na-Mnt) nano-clay particles were studied here using size distributions obtained by sedimentation field-flow fractionation (SdFFF). Fractions were examined by electron microscopy and inductively-coupled optical emission spectroscopy (ICP-OES). Two distinct populations were observed in the size distribution of SWy-2 Na-Mnt particles (bimodal size distribution), with mean equivalent spherical diameters of ~60 nm and 250 nm, respectively. In contrast, the size distribution of STx-1 Ca-montmorillonite (Ca-Mnt) particles showed only one peak with a mean equivalent spherical diameter of ~410 nm, which changed to 440 nm after 4 days of hydration. Analyses of the fractions by ICP-OES obtained along the size distribution of Na-Mnt showed an abundance of Ca and Mg in the fractions below 250 nm, and confirmed the presence of Fe and Mg as isomorphous substituents. Electron micrographs of the fractions obtained from Na-Mnt size distributions were used to calculate the thickness of the clay particles. Bridging forces between pure orMgsubstituted montmorillonite and either Ca2+ or Na+ were calculated using semi-empirical methods. The results demonstrated that swelling and delamination of Na-Mnt clay particles are dictated by properties such as elemental composition and surface charge which are distributed along the size distribution.
Chlorite is a layered silicate mineral group of importance in geology, agriculture, and in the processing of mineral resources. A more detailed analysis of the surface charge of chlorite minerals is important in order to improve our fundamental understanding of such particle structures and their behavior in suspension. In this study, the anisotropic surface charging of chlorite has been established using Atomic Force Microscopy surface-force measurements with a silicon nitride tip. The surface-charge densities and surface potentials at the chlorite basal-plane surfaces and edge surface were obtained by fitting force curves with the Derjaguin-Landau-Verwey-Overbeek theoretical model. The results show that at pH 5.6, 8.0, and 9.0 the chlorite mica-like face is negatively charged with the isoelectric point (IEP) less than pH 5.6. In contrast, the chlorite brucite-like face is positively charged in this pH range and the IEP is greater than pH 9.0. The surface charging of the chlorite edge surface was found to be pH-dependent with the IEP occurring at pH 8.5, which is slightly greater than the edge surfaces of talc and muscovite due to the larger content of magnesium hydroxide at the chlorite edge surface. Findings from the present research are expected to provide a fundamental foundation for the analysis of industrial requirements, e.g. collector adsorption, slime coating, and particle interactions in the area of mineral-processing technology.
Germany’s 2019 Digital Healthcare Act (Digitale-Versorgung-Gesetz, or DVG) created a number of opportunities for the digital transformation of the healthcare delivery system. Key among these was the creation of a reimbursement pathway for patient-centered digital health applications (digitale Gesundheitsanwendungen, or DiGA). Worldwide, this is the first structured pathway for “prescribable” health applications at scale. As of October 10, 2023, 49 DiGA were listed in the official directory maintained by Germany’s Federal Institute for Drugs and Medical Devices (BfArM); these are prescribable by physicians and psychotherapists and reimbursed by the German statutory health insurance system for all its 73 million beneficiaries. Looking ahead, a major challenge facing DiGA manufacturers will be the generation of the evidence required for ongoing price negotiations and reimbursement. Current health technology assessment (HTA) methods will need to be adapted for DiGA.
Methods
We describe the core issues that distinguish HTA in this setting: (i) explicit allowance for more flexible research designs, (ii) the nature of initial evidence generation, which can be delivered (in its final form) up to one year after becoming reimbursable, and (iii) the dynamic nature of both product development and product evaluation. We present the digital health applications in the German DiGA scheme as a case study and highlight the role of RWE in the successful evaluation of DiGA on an ongoing basis.
Results
When a DiGA is likely to be updated and assessed regularly, full-scale RCTs are infeasible; we therefore make the case for using real-world data and real-world evidence (RWE) for dynamic HTAs.
Conclusions
Continous evaluation using RWD is a regulatory innovation that can help improve the quality of DiGAs on the market.
Cost-effective treatments are needed to reduce the burden of depression. One way to improve the cost-effectiveness of psychotherapy might be to increase session frequency, but keep the total number of sessions constant.
Aim
To evaluate the cost-effectiveness of twice-weekly compared with once-weekly psychotherapy sessions after 12 months, from a societal perspective.
Method
An economic evaluation was conducted alongside a randomised controlled trial comparing twice-weekly versus once-weekly sessions of psychotherapy (cognitive–behavioural therapy or interpersonal psychotherapy) for depression. Missing data were handled by multiple imputation. Statistical uncertainty was estimated with bootstrapping and presented with cost-effectiveness acceptability curves.
Results
Differences between the two groups in depressive symptoms, physical and social functioning, and quality-adjusted life-years (QALY) at 12-month follow-up were small and not statistically significant. Total societal costs in the twice-weekly session group were higher, albeit not statistically significantly so, than in the once-weekly session group (mean difference €2065, 95% CI −686 to 5146). The probability that twice-weekly sessions are cost-effective compared with once-weekly sessions was 0.40 at a ceiling ratio of €1000 per point improvement in Beck Depression Inventory-II score, 0.32 at a ceiling ratio of €50 000 per QALY gained, 0.23 at a ceiling ratio of €1000 per point improvement in physical functioning score and 0.62 at a ceiling ratio of €1000 per point improvement in social functioning score.
Conclusions
Based on the current results, twice-weekly sessions of psychotherapy for depression are not cost-effective over the long term compared with once-weekly sessions.
Twice weekly sessions of cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for major depressive disorder (MDD) lead to less drop-out and quicker and better response compared to once weekly sessions at posttreatment, but it is unclear whether these effects hold over the long run.
Aims
Compare the effects of twice weekly v. weekly sessions of CBT and IPT for depression up to 24 months since the start of treatment.
Methods
Using a 2 × 2 factorial design, this multicentre study randomized 200 adults with MDD to once or twice weekly sessions of CBT or IPT over 16–24 weeks, up to a maximum of 20 sessions. Main outcome measures were depression severity, measured with the Beck Depression Inventory-II and the Longitudinal Interval Follow-up Evaluation. Intention-to-treat analyses were conducted.
Results
Compared with patients who received once weekly sessions, patients who received twice weekly sessions showed a significant decrease in depressive symptoms up through month 9, but this effect was no longer apparent at month 24. Patients who received CBT showed a significantly larger decrease in depressive symptoms up to month 24 compared to patients who received IPT, but the between-group effect size at month 24 was small. No differential effects between session frequencies or treatment modalities were found in response or relapse rates.
Conclusions
Although a higher session frequency leads to better outcomes in the acute phase of treatment, the difference in depression severity dissipated over time and there was no significant difference in relapse.
Fast-and-frugal trees (FFTs) are simple algorithms that facilitate efficient and accurate decisions based on limited information. But despite their successful use in many applied domains, there is no widely available toolbox that allows anyone to easily create, visualize, and evaluate FFTs. We fill this gap by introducing the R package FFTrees. In this paper, we explain how FFTs work, introduce a new class of algorithms called fan for constructing FFTs, and provide a tutorial for using the FFTrees package. We then conduct a simulation across ten real-world datasets to test how well FFTs created by FFTrees can predict data. Simulation results show that FFTs created by FFTrees can predict data as well as popular classification algorithms such as regression and random forests, while remaining simple enough for anyone to understand and use.
Are difficult decisions best made after a momentary diversion of thought? Previous research addressing this important question has yielded dozens of experiments in which participants were asked to choose the best of several options (e.g., cars or apartments) either after conscious deliberation, or after a momentary diversion of thought induced by an unrelated task. The results of these studies were mixed. Some found that participants who had first performed the unrelated task were more likely to choose the best option, whereas others found no evidence for this so-called unconscious thought advantage (UTA). The current study examined two accounts of this inconsistency in previous findings. According to the reliability account, the UTA does not exist and previous reports of this effect concern nothing but spurious effects obtained with an unreliable paradigm. In contrast, the moderator account proposes that the UTA is a real effect that occurs only when certain conditions are met in the choice task. To test these accounts, we conducted a meta-analysis and a large-scale replication study (N = 399) that met the conditions deemed optimal for replicating the UTA. Consistent with the reliability account, the large-scale replication study yielded no evidence for the UTA, and the meta-analysis showed that previous reports of the UTA were confined to underpowered studies that used relatively small sample sizes. Furthermore, the results of the large-scale study also dispelled the recent suggestion that the UTA might be gender-specific. Accordingly, we conclude that there exists no reliable support for the claim that a momentary diversion of thought leads to better decision making than a period of deliberation.
By their very nature eHealth applications – including telemedicine, AI-based medicine and ‘smart’ medical devices – are ubiquitous: These tools may be used by the physician next door as well as in the most remote locations abroad. Moreover, highly sensitive medical data may flow around the world within a split second. Against this backdrop, eHealth and telemedicine services can be provided from – and the necessary data can be transferred to – virtually every corner of the world. By contrast, the scope of application of regulation relating to AI-driven medicine, as well as eHealth and telemedicine, is usually confined to the legislating state. Moreover, the number and complexity of rules and regulations in this field vary considerably from state to state. Does this mean that international MedTech businesses may simply set up camp in the jurisdiction most favourable to their business models? For practitioners in telemedicine, the MedTech industry providing AI applications or digital medical devices such as eHealth apps, as well as for patients, it is essential to know which laws govern activities undertaken in cross-border scenarios. This concerns licensing requirements and the level of data protection as well as contract and tort law applicable to eHealth, telemedicine and telesurgery services.
Fecal incontinence (FI) is defined as the involuntary loss of solid or liquid stool and has an enormous impact on quality of life. Continence depends on a number of factors including cognitive function, stool volume and stool consistency, colonic transit, rectal compliance, anal sphincter function, anorectal sensation, and anorectal reflexes. Loss of continence often results from impairment in any of these factors. Initial evaluation consists of a focused history and a physical examination looking for potential reversible and/or treatable factors. First-line treatment include dietary, behavioral, and pharmacologic management approaches in community-dwelling and long-term care settings. If first-line treatments are not effective, additional evaluation with anorectal manometry and other tests may be warranted. Surgical treatments for FI may improve symptoms and more efficacy data is needed, especially among older adults. Therapeutic options using behavioral, pharmacological, and surgical approaches can lead to symptomatic improvements or cure for FI and increased quality of life for the older patient.
Uvite, CaMg3(Al5Mg)(Si6O18)(BO3)3(OH)3(OH), is a new mineral of the tourmaline supergroup. It occurs in the Facciatoia quarry, San Piero in Campo, Elba Island, Italy (42°45′04.55″N, 10°12′50.89″E) at the centre of a narrow (2–3 cm wide) vein composed of aggregates of dark brown to black tourmaline, penetrating (magnesite + dolomite)-rich hydrothermally altered metaserpentinite. Crystals are euhedral and up to 1 cm in size, brown with a vitreous lustre, conchoidal fracture and grey streak. Uvite has a Mohs hardness of ~7½, a calculated density of 3.115 g/cm3 and is uniaxial (–). Uvite has trigonal symmetry, space group R3m, a = 15.9519(10) Å, c = 7.2222(5) Å, V = 1597.3(1) Å3 and Z = 3. The crystal structure was refined to R1 = 1.77% using 1666 unique reflections collected with MoKα X-rays. Crystal-chemical analysis resulted in the empirical crystal-chemical formula $^X ({\rm Ca}_{0.61}{\rm Na}_{{0.35}} \square_{{0.04}})_{\Sigma 1.00}{}^{Y} \left( {{\rm Mg}_{1.50}{\rm Fe}^{2 + }_{0.47} {\rm Al}_{0.71}{\rm Fe}^{3 + }_{0.14} {\rm Ti}_{0.18}} \right)_{\Sigma 3.00}$${}^{Z} \left( {{\rm Al}_{4.54}{\rm Fe}^{3 + }_{0.18} {\rm V}^{3 + }_{0.02} {\rm Mg}_{1.27}} \right)_{\Sigma 6.00}{}^{T}\left[ {{\left( {{\rm Si}_{5.90}{\rm Al}_{0.10}} \right)}_{\Sigma 6.00}{\rm O}_{18}} \right]{\rm } \left( {\rm BO_3} \right)_3^{} {^{\rm O(3)}}\left( {\rm OH} \right)_3{}^{{\rm O}\left( 1 \right)} [\left( {\rm OH} \right)_{0.55}{\rm F}_{0.05}{\rm O}_{0.40}]_{\Sigma 1.00}$
which recast in its ordered form for classification purposes is:
Uvite is a hydroxy-species belonging to the calcic-group of the tourmaline supergroup. The closest end-member compositions of valid tourmaline species are fluor-uvite and feruvite, to which uvite is related by the substitutions W(OH)– ↔ WF– and YMg2+ ↔ YFe2+, respectively. The occurrence of a solid-solution between uvite and magnesio-lucchesiite, according to the substitution ZMg2+ + W(OH)– ↔ ZAl3+ + WO2–, is supported by experimental data. The new mineral was approved by the IMA–CNMNC (IMA 2019-113). Uvite from Facciatoia formed by the reaction between B-rich fluids, released during the crystallisation process of LCT pegmatites, and the surrounding metaserpentinites, altered by contact metamorphism in the aureole of the Miocene Mt. Capanne monzogranitic pluton.
OBJECTIVES/GOALS: To identify the role of sialoglycans in the mechanisms underlying cancer-associated fibroblast-derived exosomes (CAFEX) immuno-regulatory properties. The central hypothesis is that CAFEX manipulates the immune response to allow immunoevasion and glycomic approaches can identify the signaling factors involved. METHODS/STUDY POPULATION: Cancer associated fibroblasts (CAFs) were isolated from primary head and neck tumors, expanded, characterized and cryopreserved prior to experimentation and isolation of CAFEX. Sialoglycan expression was determined using lectin-specific staining of cells and bead-captured CAFEX in combination with flow cytometry analysis. Siglec expression and expression of M2-macrophage markers were also determined by flow cytometry analysis and cytokine bead arrays. Inhibition studies involved either the enzymatic removal of cell-surface sialoglycans or alternatively, a specific small molecule analog inhibitor of sialoglycan transferases. RESULTS/ANTICIPATED RESULTS: Both CAFs and CAFEX expressed abundant levels of cell-surface sialoglycans. CAFEX induced an M2-macrophage phenotype in primary monocytes, based on surface marker expression and cytokine secretion profiles. The induction of the M2 phenotype in macrophages was attenuated upon the removal of sialoglycans from the surface of CAFEX either by enzymatic removal or via a small molecule inhibitor. CAFEX were also able to directly bind members of the Siglec family, which are sialoglycan specific lectin receptors expressed on immune cells, including macrophages. DISCUSSION/SIGNIFICANCE: Collectively, these studies suggest that surface presentation of sialoglycans by CAFEX may induce an immunosuppressive phenotype in monocytes/macrophages. Consequently, this may be a novel mechanism by which cells within the tumor bed facilitate immunoevasion during tumor progression.