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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.
Since 1985, land retirement has been the primary approach used by the federal government for environmental protection of agricultural landscapes, but increasingly it is being supplemented by conservation initiatives on working lands. This shift logically supports agroforestry and other multifunctional approaches as a means to combine production and conservation. However, such approaches can be complex and difficult to design, contributing to the limited adoption in the USA. To understand and improve the integration of multifunctional landscapes into conservation programs, we worked with 15 landowners in a collaborative design process to build unique conservation plans utilizing agroforestry. We interviewed participants before and after the design process to examine the utility of a personalized design process, applicability of agroforestry to conservation programs and pathways to improve conservation policy. We found that landowners strongly preferred working in person for the design process, and being presented a comparison of alternative designs, rather than a single option, especially for novel systems. Agroforestry was seen as a viable method of generating conservation benefits while providing value to the landowners, each of whom stated they were more inclined to adopt such practices irrespective of financial assistance to do so. For conservation programs, landowners suggested reducing their complexity, inflexibility and impersonal nature to improve the integration of multifunctional practices that appeal directly to the practitioner's needs and preferences. These findings are valuable for conservation policy because they complement previous research theory suggesting the value of working collaboratively with landowners in the design of multifunctional landscapes. Personalized solutions that are developed based on the unique characteristics of the local landscape and the preferences of the individual landowner may be retained beyond a specified payment period, rather than being converted back into annual crop production.
Traditional meta-analyses synthesize aggregate data obtained from study publications or study authors, such as a treatment effect estimate and its associated uncertainty. An increasingly important approach is the meta-analysis of individual participant data (IPD) where the raw individual-level data are obtained for each study and used for synthesis. This study compares and discusses results from an IPD meta-analysis vs standard meta-analysis of randomized controlled trials of exercise cardiac rehabilitation in chronic heart failure (CHF).
Based on a previous systematic review, the Exercise Training Meta-Analysis of Trials for Chronic Heart Failure (ExTraMATCH II) identified and collected IPD from randomized controlled trials (RCTs) that compared exercise rehabilitation with a non-exercise control with a minimum follow-up of six months. For this abstract, the outcome of interest was all-cause mortality. Original IPD were checked for consistency and compiled in a master dataset. Standard meta-analytic models were used for aggregate data whilst two-stage and one-stage approaches, accounting for the clustering of participants within studies, were planned for statistical analyses of IPD.
Overall thirty-three RCTs were included in the original systematic review, whereas within the ExTraMatch II project, IPD on all-cause mortality were obtained from seventeen RCTs of approximately 3,700 patients. From aggregate data there was no significant difference in pooled mortality (relative risk 0.92, 95% confidence interval 0.67 to 1.26). IPD analysis revealed 701 events across exercise and control groups. Our ongoing IPD analyses will allow us to examine how patients’ characteristics (e.g. age, New York Heart Association functional class, ejection fraction) modify treatment benefit.
Given the limitations of current trial level meta-analysis evidence in CHF, access to individual data from several RCTs offers a timely and important opportunity to revisit the question of which CHF patient subgroups benefit most from exercise-based rehabilitation.
To assess trends of mortality attributable to child and maternal undernutrition (CMU), overweight/obesity and dietary risks of non-communicable diseases (NCD) in sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD) Study 2015.
For each risk factor, a systematic review of data was used to compute the exposure level and the effect size. A Bayesian hierarchical meta-regression analysis was used to estimate the exposure level of the risk factors by age, sex, geography and year. The burden of all-cause mortality attributable to CMU, fourteen dietary risk factors (eight diets, five nutrients and fibre intake) and overweight/obesity was estimated.
All age groups and both sexes.
In 2015, CMU, overweight/obesity and dietary risks of NCD accounted for 826204 (95 % uncertainty interval (UI) 737346, 923789), 266768 (95 % UI 189051, 353096) and 558578 (95 % UI 453433, 680197) deaths, respectively, representing 10·3 % (95 % UI 9·1, 11·6 %), 3·3 % (95 % UI 2·4, 4·4 %) and 7·0 % (95 % UI 5·8, 8·3 %) of all-cause mortality. While the age-standardized proportion of all-cause mortality accounted for by CMU decreased by 55·2 % between 1990 and 2015 in SSA, it increased by 63·3 and 17·2 % for overweight/obesity and dietary risks of NCD, respectively.
The increasing burden of diet- and obesity-related diseases and the reduction of mortality attributable to CMU indicate that SSA is undergoing a rapid nutritional transition. To tackle the impact in SSA, interventions and international development agendas should also target dietary risks associated with NCD and overweight/obesity.
The relationship between diversification and labor productivity is a pressing issue for diversified farming systems (DFS), which must compete with the high labor productivity of specialized and mechanized industrial farming systems. Synergies between multiple production systems represent an alternative pathway for enhancing labor productivity, contrasting with the economies of scale achieved by industrial farming. Facing a lack of technical and institutional support for managing diversified systems, DFS turn to grassroots agroecological networks for support. Permaculture is a grassroots network with an emphasis on diversified production that—despite its international scope and high public profile—has received little scholarly attention. In this exploratory study we assessed the relationship between diversification, labor productivity and involvement with permaculture, using data from 196 enterprises (i.e., distinct sources of income or aspects of a farm business) on 36 permaculture farms in the USA. We characterized diversification in two ways: by income at the level of the whole farm, and by labor for production enterprises only. By fitting a multilevel model of labor productivity (enterprises nested within farms) we assessed the evidence for synergies in production, i.e., positive relationships between diversification and returns to labor. Results indicated that both production diversity and level of involvement in the permaculture network had significant positive effects on labor productivity. This effect disappeared, however, when both diversity and participation were at their highest levels. Results also indicate that high levels of diversification shift tree crops from the lowest labor productivity of any type of production enterprise to the highest. Through this first ever (to our knowledge) systematic investigation of permaculture farms, our results provide support for the presence of production synergies in DFS, and for the role of permaculture in helping farmers achieve these synergies.
Academic publishing can be a slow process and situations change in the period between writing a chapter and its publication; such is the case here. On 28 November 2015, the Twitter-sphere was set alight by two tweets from porn performer Stoya in which she accused her one-time boyfriend and regular professional partner, James Deen, of having raped her. More corroborating revelations from female performers surfaced over the following weeks. On Twitter and in the blogospheres – the platforms on which his stardom was staged and framed – Deen's reputation as a ‘feminist porn star’ and playful boy-next- door was trashed and debated. As this book goes to press, the fallout from these revelations is still not settled and the effects of the accusations on Deen, on his career and stardom, are neither clear nor inevitable. In the immediate aftermath, Deen was remarkably silent; a prolific contributor to social media (as this chapter discusses), he has yet to attempt to rehabilitate his reputation – there has been none of the ‘abject contrition’ that often accompanies the mainstream star/celebrity's fall from grace. Perhaps porn stardom and its commercial outcomes will not require the usual rehabilitation through confession, ‘self inspection and public reparation’ (Nunn and Biressi 2010: 53). All that remains to be seen and, while it is tempting to rush in with analysis and prognoses, we leave our original discussion here untouched, not least in the expectation that it will form the backdrop to subsequent analyses of the accusers, the accused, the industry and the culture of porn production.
Most commentators insist on particular forms of ‘talent’ as crucial to ‘stardom’ and, since the physical and acting skills involved in doing sex for camera are rarely acknowledged (Smith 2012), place performers in pornography at the lowest end of the star hierarchy. Porn stars are not accorded the deference given to real stars – they are positioned as lacking the class, authenticity, agency and luminosity of the true star. While pornography studies have burgeoned in recent years, relatively little attention has been paid to individual performers, with the notable exceptions of Hoang 2004, King 2005, Mercer 2006, Nikunen and Paasonen 2007 and Shelton 2002, whose accounts bring into view the complexities of establishing a marketable persona within this uniquely stigmatised entertainment sector.
Older people with dementia are at increased risk of physical decline and falls. Balance and mood are significant predictors of falls in this population. The aim of this study was to determine the effect of a tailored home-based exercise program in community-dwelling older people with dementia.
Forty-two participants with mild to moderate dementia were recruited from routine health services. All participants were offered a six-month home-based, carer-enhanced, progressive, and individually tailored exercise program. Physical activity, quality of life, physical, and psychological assessments were administered at the beginning and end of the trial.
Of 33 participants (78.6%) who completed the six-month reassessment ten (30%) reported falls and six (18%) multiple falls during the follow-up period. At reassessment, participants had better balance (sway on floor and foam), reduced concern about falls, increased planned physical activity, but worse knee extension strength and no change in depression scores. The average adherence to the prescribed exercise sessions was 45% and 22 participants (52%) were still exercising at trial completion. Those who adhered to ≥70% of prescribed sessions had significantly better balance at reassessment compared with those who adhered to <70% of sessions.
This trial of a tailored home-based exercise intervention presents preliminary evidence that this intervention can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia. Future research should determine whether exercise interventions are effective in reducing falls and elucidate strategies for enhancing uptake and adherence in this population.
The concepts of nature, culture and heritage are deeply entwined; their threads run together in some of our finest museums, in accounts of exploration and discovery, in the work of artists, poets andwriters, and in areas that are cherished and protected because of their landscapes and wildlife. The conservation ethic - placing a value on the natural environment - lies at the heart of the notion of "natural heritage", but we need to question how those values originated, were consolidated and ultimately moulded and changed over time. In a contemporary context the connections between nature andculture have sometimes become lost, fragmented, dislocated or misunderstood; where did "natural heritage" begin and how do we engage with the idea of "nature" today? The essays collected here re-evaluate the role of culture in developing the concept of natural heritage, reflecting on the shifts in its interpretation over the last 300 years.
Contributors: Martin Holdgate, Marie Addyman,E. Charles Nelson, Darrell Smith, Andrew Ramsey, Viktor Kouloumpis, Richard Milner, Gina Douglas, Penny Bradshaw, Arthur MacGregor, Chiara Nepi, Hannah Paddon, Stephen Hewitt, Gordon McGregor Reid, Ghillean T Prance, Peter Davis, Christopher Donaldson, Lucy McRobert, Sophie Darlington, Keith Scholey, Paul A. Roncken, Angus Lunn, Juliet Clutton-Brock, Tim Sands, Robert A. Lambert, James Champion,Erwin van Maanen, Heather Prince, Chris Loynes, Julie Taylor, Sarah Elmeligi, Samantha Finn, Owen Nevin, Jared Bowers, Kate Hennessy, Natasha Lyons, Mike Jeffries.