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Cognitive-behavioural therapy (CBT) is an effective treatment for depressed adults. CBT interventions are complex, as they include multiple content components and can be delivered in different ways. We compared the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT interventions for adult depression. We conducted a systematic review of randomised controlled trials in adults with a primary diagnosis of depression, which included a CBT intervention. Outcomes were pooled using a component-level network meta-analysis. Our primary analysis classified interventions according to the type of therapy and delivery mode. We also fitted more advanced models to examine the effectiveness of each content component or combination of components. We included 91 studies and found strong evidence that CBT interventions yielded a larger short-term decrease in depression scores compared to treatment-as-usual, with a standardised difference in mean change of −1.11 (95% credible interval −1.62 to −0.60) for face-to-face CBT, −1.06 (−2.05 to −0.08) for hybrid CBT, and −0.59 (−1.20 to 0.02) for multimedia CBT, whereas wait list control showed a detrimental effect of 0.72 (0.09 to 1.35). We found no evidence of specific effects of any content components or combinations of components. Technology is increasingly used in the context of CBT interventions for depression. Multimedia and hybrid CBT might be as effective as face-to-face CBT, although results need to be interpreted cautiously. The effectiveness of specific combinations of content components and delivery formats remain unclear. Wait list controls should be avoided if possible.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
To evaluate the impact and burden of the new National Healthcare Safety Network surveillance definition, mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI), in hematology, oncology, and stem cell transplant populations.
Retrospective cohort study.
Two hematology, oncology, and stem cell transplant units at a large academic medical center.
Central line–associated bloodstream infections (CLABSIs) identified during a 14-month period were reviewed and classified as MBI-LCBI or non-MBI-LCBI (MBI-LCBI criteria not met). During this period, interventions to improve central line maintenance were implemented. Characteristics of patients with MBI-LCBI and non-MBI-LCBI were compared. Total CLABSI, MBI-LCBI, and non-MBI-LCBI rates were compared between baseline and postintervention phases of the study period.
Among 66 total CLABSI cases, 47 (71%) met MBI-LCBI criteria. Patients with MBI-LCBI and non-MBI-LCBI were similar in regard to most clinical and demographic characteristics. Between the baseline and postintervention study periods, the overall CLABSI rate decreased from 3.37 to 3.21 infections per 1,000 line-days (incidence rate ratio, 0.95; 4.7% reduction, P=.84), the MBI-LCBI rate increased from 2.08 to 2.61 infections per 1,000 line-days (incidence rate ratio, 1.25; 25.3% increase, P=.44), and the non-MBI-LCBI rate decreased from 1.29 to 0.60 infections per 1,000 line-days (incidence rate ratio, 0.47; 53.3% reduction, P=.12).
Most CLABSIs identified among hematology, oncology, and stem cell transplant patients met MBI-LCBI criteria, and CLABSI prevention efforts did not reduce these infections. Further review of the MBI-LCBI definition and impact is necessary to direct future definition changes and reporting mandates.
Oxidative stress and neurotrophic factors have been implicated in the pathophysiology of bipolar disorder. Our objective was to determine whether plasma glutathione or brain-derived neurotrophic factor (BDNF) levels were abnormal in bipolar disorder and therefore useful as possible biomarkers.
Blood samples were collected from subsyndromal, medicated bipolar I patients (n = 50), recruited from OXTEXT, University of Oxford, and from 50 matched healthy controls. Total and oxidized glutathione levels were measured using an enzymatic recycling method and used to calculate reduced, percentage oxidized, ratio of reduced:oxidized and redox state. BDNF was measured using an enzyme-linked immunoassay. Self-monitored mood scores for the bipolar group were available (Quick Inventory of Depressive Symptomatology and the Altman Self-Rating Mania Scale) over an 8-week period.
Compared with controls, bipolar patients had significantly lower levels of total glutathione and it was more oxidized. BDNF levels were not different. Age of illness onset but not current mood state correlated with total glutathione levels and its oxidation status, so that lower levels of total and reduced glutathione were associated with later onset of disease, not length of illness.
Plasma glutathione levels and redox state detect oxidative stress even in subsyndromal patients with normal BDNF. It may relate to the onset and development of bipolar disorder. Plasma glutathione appears to be a suitable biomarker for detecting underlying oxidative stress and for evaluating the efficacy of antioxidant intervention studies.
It is generally accepted that archaic humans of the African later Early and early Middle Pleistocene constituted the source population for anatomically modern humans. Due to limited fossil and archaeological records, however, relatively little is known about the morphology, behaviour and ecology of these presumed ancestors of modern humans. Fragmentary fossils (variously attributed to Homo heidelbergensis, H. rhodesiensis and H. helmei) from across Africa suggest that these archaic humans were both taller and more massive than their extant modern human descendants in this region, and perhaps had a body shape that was stockier and less ‘nilotic’ than seen among extant sub-Saharan Africans. Fragmentary fossils attributed to Homo sapiens, on the other hand, appear to represent individuals closer in body size to the means of recent sub-Saharan Africans. Since body size and shape are critical to the ecology, energetics and thermoregulatory adaptations of early humans, these differences in morphology may signal important adaptive changes at the time of the origins of modern humans. Comparative analyses of femoral and orbital dimensions support the claim that Middle Pleistocene Africans were of greater body size (both stature and mass) and had greater mass/stature ratios than modern Africans, and support the claim that early African H. sapiens were of smaller body size than their Middle Pleistocene ancestors.
Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome.
Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard.
Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85–0.88 v. 0.54–0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001).
The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.
African wild dogs (Lycaon pictus) occupy an ecological niche characterized by hypercarnivory and cursorial hunting. Previous interpretations drawn from a limited, mostly Eurasian fossil record suggest that the evolutionary shift to cursorial hunting preceded the emergence of hypercarnivory in the Lycaon lineage. Here we describe 1.9—1.0 ma fossils from two South African sites representing a putative ancestor of the wild dog. the holotype is a nearly complete maxilla from Coopers Cave, and another specimen tentatively assigned to the new taxon, from Gladysvale, is the most nearly complete mammalian skeleton ever described from the Sterkfontein Valley, Gauteng, South Africa. the canid represented by these fossils is larger and more robust than are any of the other fossil or extant sub-Saharan canids. Unlike other purported L. pictus ancestors, it has distinct accessory cusps on its premolars and anterior accessory cuspids on its lower premolars—a trait unique to Lycaon among living canids. However, another hallmark autapomorphy of L. pictus, the tetradactyl manus, is not found in the new species; the Gladysvale skeleton includes a large first metacarpal. Thus, the anatomy of this new early member of the Lycaon branch suggests that, contrary to previous hypotheses, dietary specialization appears to have preceded cursorial hunting in the evolution of the Lycaon lineage. We assign these specimens to the taxon Lycaon sekowei n. sp.
We use spectral sequence techniques to compute centralizers of elements within graded Lie algebras, and the methods are then applied to the calculation of unique normal forms of elements within one-parameter matrix Lie
algebras. A finiteness criterion for unique normal forms is presented.
Samples of yellow-fever vaccine prepared from homogenized chick embryos, and of an experimental measles vaccine prepared from chick embryo cells, have each been shown to contain a contaminant virus similar in properties to an avian leukosis virus. Young adult males injected with the yellow-fever vaccine did not develop neutralizing antibodies for Rous sarcoma virus.
We present equivalent width measurements and limits of six diffuse interstellar bands (DIBs, λ 4428, λ 5705, λ 5780, λ 5797, λ 6284, and λ 6613) in seven damped Lyα absorbers (DLAs) over the redshift range 0.091 ≤ z ≤ 0.524, sampling 20.3 ≤ log N(Hi) ≤ 21.7. Based upon the Galactic DIB–N(H i) relation, the λ 6284 DIB equivalent width upper limits in four of the seven DLAs are a factor of 4–10 times below the λ 6284 DIB equivalent widths observed in the Galaxy, but are not inconsistent with those present in the Magellanic Clouds. Assuming the Galactic DIB–E(B − V) relation, we determine reddening upper limits for the DLAs in our sample. Based upon the E(B − V) limits, the gas-to-dust ratios, N(H i)/E(B − V), of the four aforementioned DLAs are at least ~5 times higher than that of the Galactic ISM and are more consistent with the Large Magellanic Cloud. The ratios of two other DLAs are at least a factor of a few times higher. The best constraints on reddening derive from the upper limits for the λ 5780 and λ 6284 DIBs, which yield E(B − V) ≤ 0.08 mag for four of the seven DLAs and are more consistent with the Magellanic Clouds rather than the Galaxy. Our results suggest that, in DLAs, quantities related to dust, such as reddening and metallicity, appear to have a greater impact on DIB strengths than does H i gas abundance. The molecules responsible for the DIBs in DLA selected sightlines are underabundant relative to sightlines in the Galaxy of similarly high N(H i). Using DIBs to study the ISM of DLAs provide evidence that at least some population of DLAs are more Magellanic-like than Galactic-like.
Dr. F, an oncologist in a small community practice, has been asked by a pharmaceutical company to conduct early-phase clinical trials involving several new investigational chemotherapeutic agents that do not yet have FDA approval. These would be very small phase I trials, with the possibility of conducting some phase I/II and phase II trials in the future as well. The reimbursement he will receive for the research will substantially increase the income of his practice, provided that he is able to recruit and retain a sufficient number of subjects. “More importantly, though,” Dr. F thinks to himself, “I have so little to offer many of my sickest patients now. The best thing about doing clinical research is being able to offer them something new, that just might be their best hope.”
Dr. G treats patients with hemophilia. Although treatments have improved dramatically in recent years, hemophilia is a devastating, and devastatingly expensive, chronic disease. Because she has high hopes about promising experimental technologies, she also conducts research. She prides herself on the research partnerships she develops with patient–subjects who seek to contribute to the development of better treatments. Recently, however, she has received inquiries from patients with hemophilia from around the world who want to enroll in her research because the experimental interventions are provided free of charge. These patients tell her that they cannot afford standard therapies, and that enrolling in her research is their only hope for treatment. Dr. G is troubled by this reasoning, and discusses it with a colleague, who responds, “Lots of people enroll in research to get treatment.[…]
Money plays a powerful role in modern medicine, both in terms of how
health services are organized and delivered and increasingly in how
physicians understand themselves and their work. The phrase “the
hegemony of money” is intended to capture that power.
Health care reform has been stalled since the Clinton health care initiative, but the political difficulties internal to that initiative and the ethical problems that provoked it -- of cost, coverage, and overall fairness, for example -- have only gotten worse. This collection examines the moral principles that must underlie any new reform initiative and the processes of democratic decision-making essential to successful reform. This volume provides careful analyses that will allow the reader to short-circuit the mythmaking, polemics, and distortions that have too often characterized public discussion of health care reform. Its aim is to provide the moral foundations and institutional arrangements needed to drive any new health care initiative and so to stimulate a reasoned discussion before the next inevitable round of reform efforts.
Foreword by Thomas H. Murray. Contributors: Howard Brody, Norman Daniels, Theodore Marmor, Tobie H. Olsan, Uwe E. Reinhardt, Gerd Richter, Rory B. Weiner, Lawrence W. White
Wade L. Robison is the Ezra A. Hale Professor in Applied Ethics at the Rochester Institute of Technology and recipient of the Nelson A. Rockefeller Prize for Social Science and Public Policy for his book Decisions in Doubt: The Environment and Public Policy. Timothy H. Engström is Professor of Philosophy at the Rochester Institute of Technology and recipient of the Eisenhart Award for Outstanding Teaching.
The fundamental health care issue in the United States is neither excessive costs nor lack of access, but lack of national purpose. We have no consensus about what we want or expect from a health care system. In the absence of such a consensus, entrepreneurial forces remain in ascendancy. Instead of solving the costs and access problems, these forces have shifted costs to others while making access to services even more difficult. Defining a purpose for the health care system means seeking self-consciously to discern its proper goals, rather than assuming that these goals are self-evident or can be safely inferred from the priorities of doctors, hospitals, insurers, or other powerful actors. A health care system is, finally, a political and social creation, and decisions about it are decisions about national values. It is argued that health security and social solidarity are the true goals of the American health care system, and that even those who are currently well insured would be prudent to support coverage for everyone. In the final section, three ethical prerequisites for achieving these goals are presented.
The demise of the Clinton health care reform initiative in 1994 was only the most recent in a long series of failed efforts to provide access to health services to all Americans. Universal coverage has been a prominent part of the national consciousness since 1912. When this goal—long ago realized by other industrial democracies—will be achieved in the United States is a matter of uncertainty. What is not uncertain is that the pressure for it will increase in the years ahead, and that it will be a growing part of national politics for the next decade as the traditional employer-based system continues to unravel. This chapter addresses some of the components of an interim ethic, reforms in our thinking that will be important in achieving a more just and inclusive system.
Misidentifying the Problem
For the past several decades, most observers have characterized the key issues in U.S. health care as ones of cost control and expansion of access. The available information seems to confirm this assessment.
Cost escalation is such that in the nineteen year period between 1980 and 1999, expenditures for health care quadrupled, from $1,000 per capita to over $4,000 per capita and from 9 percent of the gross domestic product (GDP) to over 13 percent.