Post-treatment Outcomes Research Articles

What's New in Pediatric Orthopaedic Health Care Disparities?

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future. We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers. A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care. Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable. Level IV-narrative review.

Multiple Treatment Modalities for Management of Missing Molars – A Case Series

Cases with missing molars do need a well-executed treatment plan and a thorough knowledge of biomechanics to treat which usually leads to its prosthetic rehabilitation instead of orthodontic management by the orthodontists. Its orthodontic management is not only time consuming but also requires patience and proper treatment strategy involving right choice of appliance and auxiliaries to achieve the best possible results. Here in this case series we have tried to show different treatment modalities in cases with missing permanent molars leading to ideal post treatment outcomes.

“I've never been able to burp”: Preliminary description of retrograde cricopharyngeal dysfunction in children

ObjectiveRetrograde cricopharyngeal dysfunction was recently described by Bastian in 2019 and is characterized by an inability to belch, abdominal or chest pressure, odd gurgling noises, and occasional difficulty vomiting. Symptoms tend to worsen with carbonated beverages. Currently, the recommended treatment is cricopharyngeus muscle botulinum toxin injections. Prior studies have included few pediatric patients within larger datasets comprised primarily of adults. We describe our preliminary experience in pediatric patients, including presenting symptoms, treatment approach, and post-treatment outcomes. MethodsRetrospective chart review of pediatric patients (aged <18 years) diagnosed with retrograde cricopharyngeal dysfunction based on clinical history by the senior author. Medical records were reviewed for presenting symptoms, prior testing and treatment, details of treatment, and postoperative outcomes. ResultsFive patients with average age of 14 ± 4 (3 females, 2 males) were included. Presenting symptoms included lifelong or nearly lifelong inability to burp (n = 5), bloating (n = 5), awkward gurgling noises (n = 3), and worsening of symptoms with carbonated beverages (n = 5). Two patients had prior normal upper endoscopy. All patients underwent cricopharyngeal botulinum toxin injection under general anesthesia, with 25–50 units of botulinum toxin injected to the posterior cricopharyngeus across 4–5 locations. All patients had resolution of symptoms with follow-up of 1.5–10 months. ConclusionsRetrograde cricopharyngeal dysfunction may be underdiagnosed due to lack of awareness of the condition. Now that the phenomenon of inability to belch has a name and is being reported in the literature, we will likely see more adult and pediatric patients with these symptoms. Pediatric patients may respond similarly to adults. Larger studies with longer-term follow-up and targeted patient-reported outcome measures are needed to characterize disease presentation and treatment outcomes.

Management and outcomes of femoral periprosthetic fractures at the hip : data from the characteristics, outcomes and management of periprosthetic fracture service evaluation (COMPOSE) cohort study.

The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression. In all, 417 fractures (77%) were managed operatively and 122 (23%) conservatively. The median time to surgery was four days (interquartile range (IQR) 2 to 7). Of those undergoing surgery, 246 (59%) underwent revision and/or fixation and 169 (41%) fixation alone. The surgical strategy used differed by Unified Classification System for PPF type, with the highest rate of revision in B2/B3 fractures (both 77%, 176/228 and 24/31, respectively) and the highest rate of fixation alone in B1- (55/78; 71%) and C-type (49/65; 75%) fractures. Cemented stem fixation (odds ratio (OR) 2.66 (95% confidence interval (CI) 1.42 to 4.99); p = 0.002) and B2/B3 fracture type (OR 7.56 (95% CI 4.14 to 13.78); p < 0.001) were predictors of operative management. The median length of stay was 15 days (IQR 9 to 23), 12-month reoperation rate was 5.6% (n = 30), and 30-day readmission rate was 8.4% (n = 45). The 30-day and 12-month mortality rates were 5.2% (n = 28) and 21.0% (n = 113). Nonoperative treatment, older age, male sex, admission from residential or nursing care, and sustaining the PPF around a revision prosthesis were significant predictors of an increased 12-month mortality. Femoral hip PPFs have mortality, reoperation, and readmission rates comparable with hip fracture patients. However, they have a longer wait for surgery, and surgical treatment is more complex. There is a need to create a national framework for data collection for this heterogeneous group of patients in order to understand the outcomes of different approaches to treatment. Cite this article: Bone Joint J2022;104-B(8):997-1008 .

Compare the Efficacy of Oral Versus Intravenous Medicine in Treatment of Spontaneous Bacterial Peritonitis

Objective: The purpose of this study is to determine whether or not oral medication is more effective than intravenous medication in the treatment of peritonitis caused by bacteria. Study Design:Comparative study Place and Duration: Department of Internal Medicine Gangaram hospital Lahore and Medical ward, THQ Hospital Dargai, from October, 2021 to March, 2022. Methods: There were 102 cases of both genders having spontaneous bacterial peritonitis because of cirrhosis were included. Included patients were aged between 18-60 years.After taking informed written consent, detailed demographics of enrolled cases were recorded. Patients were equally divided in two groups. Group I received intravenous antibiotic in 51 patients and group II received oral antibiotics in 51 patients. Post-treatment outcomes were compared among both groups. SPSS 22.0 was used to analyze all data. Results: We found that effectiveness in group I was higher 47 (92.2%) as compared to group II44 (86.3%) but not a significant difference observed. Frequency of mortality in group II was 4 (7.8%) and in group I 3 (5.9%). Diarrhea, nausea, vomiting, rashes and gastrointestinal distress were the most common adverse effects in both groups. Conclusion: We concluded in this study that the use of antibiotics orally and intravenously for SBP treatment was affective equally. There was no any significant difference observed in both procedures. Keywords: Cirrhosis, Oral Antibiotics, Intravenous Antibiotics, SBP, Efficacy

Photobiomodulation and trigger band technique on groin adductor strain in athletes

Aim of the study: In athletes, groin pain-related adductor strain is a common problem in sports medicine, like groin injuries, so the study investigated the effect of Photobiomodulation (905 nm) and Trigger Band Technique (TBT) on handball athletes' groin adductor strain. Methods: Forty handball athletes with adductor groin strain were divided into an experimental group (A) that received Diode laser 905nm, TBT, and medical treatment, while control group (B) received sham laser with TBT and medical treatment for four weeks. Outcome measures investigated Copenhangen hip and groin outcome score, pressure algometry, creatine kinase, and lactate dehydrogenase levels. Results: Both groups showed a significant improvement in the post-treatment outcome measures, where experimental group showed more significant improvement than the control group with p-value &gt;0.05. Conclusion: results imply that treatment of handball athlete's groin adductor strain by TBT and low-level laser is more effective than TBT alone.

Prevalence of keratoconus in Ghana: A hospital-based study of tertiary eye care facilities.

To estimate the prevalence of keratoconus in tertiary eye care facilities in Ghana. In this hospital-based retrospective cohort study, medical records of patients from tertiary/referral eye care facilities in Ghana were reviewed. Included in the study were records of individuals who visited the eye care facilities and were diagnosed of keratoconus within the period of January 2016 to December 2019 inclusive. Data on patients' demographics, severity of keratoconus, mode of diagnosis, treatment, and visual acuity outcomes were analysed. Out of the total of 142,209 records reviewed, 75 patients were diagnosed of keratoconus in at least one eye (127 eyes; 86.8% bilateral cases), representing a prevalence estimate of 53 per 100000 (95% confidence interval (CI): 41 to 65 per 100000). The mean ± SD age of patients at the time of diagnosis was 21.1 ± 9.5 years (66.2% males). The mean ± SD keratometry in keratoconus patients was 52.1 ± 7.0: majority (76.5%) of the cases were moderate to severe keratoconus. The main primary treatment regimen was corneal transplant (58.8%) followed by spectacles (25.0%), crosslinking (8.8%) and rigid contact lens (7.3%). There was a significant association between post-treatment visual acuity outcomes and treatment type (p < 0.001). Our study represents the first prevalence estimate of keratoconus in Ghana. The prevalence of keratoconus estimated in our study is lower than that reported in countries with tropical climates. This could be due to lower uptake of referrals, underdiagnosis and/or misdiagnosis of the condition in lower-level health facilities.

The safety and efficiency of a 1470 nm laser in obtaining tract hemostasis in tubeless percutaneous nephrolithotomy: a retrospective cross-sectional study

ObjectiveIt is challenging to perform a tubeless percutaneous nephrolithotomy (PNL) in patients with tract bleeding. The present study was designed to study the safety and efficacy of the 1470 nm laser for hemostatic completion in tubeless PNL patients with tract bleeding.Patients and MethodsBetween January 2020 and October 2021, 120 patients were retrospectively included and divided into two groups. The hemostasis group included 60 patients receiving tubeless PNL, in which a 1470 nm laser was used to manage tract bleeding. The other group included 60 patients receiving tubeless PNL in which the hemostasis procedure was not performed, serving as the control group. The differences in the patients’ demographic characteristics, procedural information, and posttreatment outcomes between the two groups were statistically compared.ResultsThe differences associated with sex, age, weight, body mass index, urine culture, stone burden, calyx of puncture, degree of hydronephrosis and comorbidities between the two groups were not statistically significant. Compared with the control group, the hemostasis group showed greatly reduced blood loss (0.61 ± 0.31 vs. 0.85 ± 0.46 g/dL) and decreased postoperative hospitalization duration (2.83 ± 0.81 vs. 4.45 ± 0.91 days). The differences in operative time, stone-free rate, Visual Analogue Score and postoperative complications between the two groups were not statistically significant. In the subgroup analysis, the obese patients and patients with moderate to severe hydronephrosis in the hemostasis group also showed a significantly less blood loss (0.51 ± 0.22 vs. 0.83 ± 0.48 g/dL; 0.54 ± 0.27 vs. 0.85 ± 0.47 g/dL, respectively) and shorter length of postoperative hospitalization (2.62 ± 0.51 vs. 4.47 ± 1.19 days; 2.97 ± 0.63 vs. 4.41 ± 0.91 days, respectively) than those in the control group.ConclusionsOur results demonstrated that 1470 nm laser is a safe, feasible and effective method to obtain tract hemostasis in tubeless PNL.

Prevalence and prognosis from the disability related to spinal tuberculosis: a systematic review

Objective: To review the disabilities caused by Spinal TB in relation to the prevalence and prognosis of the disabilities caused by the disease. Method: We conducted systematic search of the literatures based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PICO criteria. Our inclusion criteria were: 1) Patients with spinal TB; 2) full original articles; 3) articles written in English; 4) the period of publication of articles from 2012 to 2022. Evaluation of each article was done by checklist Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Results: From all articles in the publication year of 2012 to 2022, we reviewed five retrospective cohort studies, all studies coming from Asian countries. The five articles observed the prevalence of disabilities caused by spinal TB reflected through some important outcome variables pre-treatment, where they continued to compare with the post-treatment outcome variables. All of the studies reviewed had agreed that immediate or delayed treatment would give significant benefits to the patients of spinal TB, even better with combined treatments of conventional pre-operative anti-TB drugs and surgical intervention. It was found that poor prognosis associated with preoperative neurological status of the patients. Conclusion: Conventional anti-TB drugs and surgical intervention can be of great help and benefit for patients with spinal TB, reducing their disabilities severity and improving their prognosis.

Predictability of overbite control with the Invisalign appliance comparing SmartTrack with precision bite ramps to EX30

Although the Invisalign appliance has reported difficulty in achieving the overbite outcomes predicted by ClinCheck software (Align Technology, Santa Clara, Calif), the effect of modifications to the material and components of the appliance are largely unquantified. This study aimed to investigate and determine the accuracy of Invisalign in correcting a deep overbite by comparing the predicted outcome from ClinCheck to the achieved posttreatment outcome for treatment groups that use different components of the appliance system. A retrospective study was conducted using pretreatment and posttreatment intraoral scans and predicted outcomes (ClinCheck) stereolithography files of 2 groups of consecutively treated adult patients from private specialist orthodontic practices, 1 group treated with EX30 material with no bite ramps (n= 29) and 1 treated with the newer SmartTrack material and precision bite ramps (n= 39). Inclusion criteria comprised nonextraction treatment, with a minimum of 14 dual arch Invisalign aligners using a 2-weekly aligner change protocol. Geomagic Control X software (3D Systems, Rock Hill, SC) was used to measure overbite in the pretreatment, posttreatment, and predicted outcome stereolithography files for each patient. Results were compared with a previously published treatment group that used SmartTrack material and no precision bite ramps. The regression coefficient analysis indicated that for both groups, the deeper the pretreatment overbite and the greater overbite reduction projected according to ClinCheck, there is a linear increase in the discrepancy of overbite expression posttreatment. ClinCheck overpredicted overbite reduction in 96.6% of patients with precision bite ramp in which, on average, 43.4% of the prescribed overbite reduction was expressed. For EX30 patients, ClinCheck overpredicted overbite reduction in 87.2% of patients in which, on average, 55.1% of the prescribed overbite reduction was expressed. The use of precision bite ramps does not appear to significantly improve the ability of SmartTrack material to predictably open the bite. SmartTrack material with or without bite ramps does not appear to produce better bite opening predictability than that seen with EX30 material.

Cognitive remediation for people with bipolar disorder: The contribution of session attendance and therapy components to cognitive and functional outcomes

BackgroundCognitive remediation (CR) can reduce cognitive and functional difficulties in people with bipolar disorder (BD). To date, there is limited evidence on the contribution of session attendance and therapy components to treatment outcomes. This study explores whether attendance and core CR components contribute to treatment outcomes. MethodsThis is a secondary analysis using data from a randomized controlled trial comparing CR plus treatment-as-usual (TAU; n = 40) to TAU only (n = 40) in euthymic people with BD. Session attendance was measured by number of sessions and by achieving therapy completion, pre-defined as attending ≥20 sessions. We used instrumental variable analysis to examine the effect of attendance on treatment outcomes. We then considered the association between core therapy components (i.e., massed practice, errorless learning, strategy use, therapist contact) and post-treatment outcome changes using correlation. ResultsThe CR group improved significantly in measure of global cognition, psychosocial functioning, and goal attainment. Therapy recipients attended 27.1 sessions on average, with 32 (80%) completing the minimum number of 20 sessions. Attending more sessions and achieving therapy completion were associated with improved treatment outcomes, but this relationship was not significant within the subgroup of CR completers. Improvement in psychosocial functioning was associated with therapist contact and goal attainment with selecting useful strategies during therapy. ConclusionsOur findings highlight the relevance of session attendance, specifically the importance of achieving a minimum threshold of CR sessions, for outcome improvement. Strategy use and therapist contact might facilitate improvements in psychosocial functioning and personal recovery goals.

Keeping track: An intra-UK comparison of orthodontic commissioning and treatment outcome assessments.

Across the United Kingdom (UK), National Health Service (NHS) orthodontic treatment is commissioned differently across the devolved nations. There is a relative paucity in the literature describing the way in which the orthodontic services in each country are commissioned and treatment outcomes measured. To highlight the differences in the following: commissioning of primary care orthodontic services across the UK; assessment of treatment outcomes; and the potential impacts these differences have on contractors, performers and patient care. Data were collected using an online mixed-methods approach. Systematic content analysis was used to extract the required information from the websites and guidance documents of orthodontic service providers, which was then catalogued and verified electronically by senior dental advisors in the four devolved UK nations. The Index of Orthodontic Treatment Need (IOTN) is a mandatory needs assessment tool used across all four nations, with an agreed minimum threshold of a dental health component (DHC) score of 3 and an aesthetic component (AC) score of 6 for NHS treatment. While the peer assessment rating (PAR) is the most utilised method of assessing post-treatment outcomes, it is applied differently by each country. While NHS orthodontic services across the UK share mutual elements of service delivery, there are significant differences in the prior approval process and assessment of treatment outcomes. More research is required to assess the economic feasibility of orthodontic treatment from the associated treatment outcomes.

One Year On: Evaluation of the Cambridgeshire and Peterborough Staff Mental Health Service, a Bespoke Mental Health Clinic for Healthcare Workers

AimsThe Staff Mental Health Service (SMHS) at the Cambridgeshire and Peterborough NHS Foundation Trust is a multidisciplinary team providing rapid access assessments and treatments to NHS staff in all roles. The service was launched in September 2020 and obtained recurrent funding in 2021. Previously we reported initial clinical findings from the service suggesting high rates of moderate to severe depression, anxiety, and post-traumatic stress symptoms (Kaser et al. 2021). In this report, we present the clinical and demographic findings, and post-treatment outcomes from the first-year evaluation of the SMHS.MethodsDemographic and clinical data were collected as part of service evaluation at the SMHS. Depression, anxiety, and posttraumatic stress symptoms were evaluated by Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Assessment (GAD-7), and Posttraumatic Symptom Checklist – Civilian Version (PCL-C). Non-parametric Wilcoxon rank test was used to compare pre- and post-treatment symptom scores.ResultsThe service received 515 referrals in the first year. 39.6% of the patients were off work at the time of the referral. 81.2% patients were female and 75.3% were of white ethnicity. Median time from referral to assessment was 14 days. According to the clinical data (n = 320), 85.3% of the patients had moderate to severe depressive symptoms (mean PHQ-9: 16.25 ± 6.1), and 80.9% of the patients had moderate to severe levels of anxiety symptoms (mean GAD-7: 13.62 ± 4.7). Staff patients endorsed high levels of traumatic stress with 82.5% scoring higher than the established cut-off (PCL-C &gt; 14) (PCL-C mean score: 19.14 ± 5.7). Analyses from patients completing treatment at the service showed significant improvements in depression (Z=−3.38, p = 0.001), anxiety (Z= -4.09, p &lt; 0.001), and PTSD symptoms (Z= -4.99, p &lt; 0.001).ConclusionThe Staff Mental Health Service had a persistent noticeable demand in its first year corresponding to two percent of the total workforce of the local trusts. Healthcare workers presenting to the service had high rates of moderate to severe depression, anxiety, and PTSD symptoms. Multidisciplinary treatment at the SMHS led to significant improvements in psychiatric symptoms. A health economics analysis of the service is currently underway.

Prognosis of Guillain-Barré Syndrome Linked to COVID-19 Vaccination.

There have been increasing reports of Guillain–Barré syndrome (GBS), a rare but debilitating neurological disease, occurring post-COVID-19 vaccination. However, the outcomes and relationships between patient demographics and clinical outcomes of post-COVID-19 vaccination GBS remain unclear. To bridge this gap, our study investigates the outcomes and clinical factors associated with poorer GBS outcomes following COVID-19 vaccination. We conducted a review and pooled analysis of detailed data extracted from 57 published cases with the relevant search strategies and criteria. The groups compared included male versus female patients, 1st dose versus 2nd dose and early onset versus late onset of GBS. Multivariate regression analysis was performed to compare the vaccine type, clinical severity and post-treatment outcomes between these groups of patients. Our results highlight for the first time that females were significantly more likely to have severe clinical presentation and poorer outcomes compared to males. Additionally, viral vector vaccines were the predominant vaccine type administered in early-onset post-COVID-19-vaccination GBS and GBS occurring after the 1st vaccination dose. It was also shown that reported cases of post-vaccination GBS generally displayed a positive response to conventional treatment and had favourable post-treatment outcomes. Through this study, we have established important links and provided assuring evidence for treatment response and post-treatment outcomes of GBS occurring post-COVID-19 vaccination. While the COVID-19 vaccination brings about much greater benefits than risks, our findings provide further impetus for greater vigilance in certain patient groups and more studies to explore the mechanisms behind these links.

Gender Differences in Treatment Outcomes for Eating Disorders: A Case-Matched, Retrospective Pre-Post Comparison.

Eating disorders (EDs) are increasingly emerging as a health risk in men, yet men remain underrepresented in ED research, including interventional trials. This underrepresentation of men may have facilitated the development of women-centered ED treatments that result in suboptimal outcomes for men. The present study retrospectively compared pre- vs. post-treatment outcomes between age-, diagnosis-, and length-of-treatment-matched samples of n = 200 men and n = 200 women with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), or Eating Disorder Not Otherwise Specified (EDNOS), treated in the same setting during the same period, and using the same measurements. Compared to women, men with AN showed marked improvements in weight gains during treatment as well as in ED-specific cognitions and general psychopathology. Likewise, men with BED showed marked weight loss during treatment compared to women with BED; ED-specific cognitions and general psychopathology outcomes were comparable in this case. For BN and EDNOS, weight, ED-specific cognitions, and general psychopathology outcomes remained largely comparable between men and women. Implications for treatments are discussed.

Percutaneous radiofrequency ablation of hepatocellular carcinoma in a recent cohort at a tertiary cancer center: incidence and factors associated with major complications and unexpected hospitalization events.

This study aimed to assess the incidence of and factors associated with major complications, delayed discharge, and emergency room (ER) visits or readmission after percutaneous radiofrequency ablation (RFA) for single hepatocellular carcinoma (HCC) <3 cm in a recent cohort at a tertiary cancer center. A total of 188 patients with treatment-naïve single HCCs <3 cm who underwent RFA between January 2018 and April 2021 were included in the analysis. Univariable and multivariable logistic regression analyses were performed to identify the factors associated with major complications, delayed discharge, and ER visits or readmission. Local tumor progression (LTP) and overall survival were estimated using the Kaplan-Meier method and Cox proportional-hazards regression analysis. Major complications occurred in 3.2% (6/188) of the patients. The longest diameter of the ablation zone was significantly larger in patients with major complications (P=0.023). Delayed discharge occurred in 5.8% (9/188) of the patients, for which albumin-bilirubin grade 3 was identified as an important determinant. No variables other than major complications were significantly associated with ER visits or readmission, which occurred in 7.0% (13/188) of the patients. Major complications, delayed discharge, and ER visits or readmission were not substantially related to the post-treatment outcomes of LTP and overall survival. This study confirmed RFA as a highly safe procedure for single HCCs <3 cm, despite the rapidly changing RFA techniques in the most recent cohort. A large ablation zone and poor liver function were predictors of major complications and delayed discharge, respectively.

Patients' Perceptions and Outcome Measures after Undergoing the Enhanced Transtheoretical Model Intervention (ETMI) for Chronic Low Back Pain: A Mixed-Method Study.

This study aimed to evaluate the outcome measures and perceptions of patients with chronic low back pain (CLBP) after being treated with the Enhanced Transtheoretical Model Intervention (ETMI). In this process evaluation mixed-methods study, 30 patients with CLBP electronically completed self-reported measures (function, pain, and fear-avoidance beliefs) before and after ETMI treatment. Subsequently, each patient participated in one-on-one, semi-structured interviews, which were audio-recorded, transcribed, coded, and analyzed thematically. Quantitative analysis showed significant improvements in function (p < 0.001), pain (p < 0.001), and fear-avoidance beliefs (p < 0.001) after receiving ETMI treatment, with a large effect size (Cohen’s d = 1.234). Moreover, the average number of physiotherapy sessions was 2.6 ± 0.6 for the ETMI intervention, while the annual average number in Maccabi is estimated at 4.1 ± 1.5. Three main themes emerged from the thematic analysis: (1) communication between the patient and the practitioner; (2) psychosocial treatment elements, and (3) ETMI as a long-term solution for CLBP. The findings of the current study highlight patients’ perceived need for an open and sincere dialogue and for receiving reassurance and encouragement about their LBP. Notably, they had no problem with the fact that they did not receive passive treatment. Accordingly, together with the significant improvement in post-treatment outcome measures, patients perceived the ETMI method as a practical tool for self-managing their back problems in the long term.

Elucidating treatment targets and mediators within a confirmatory efficacy trial: study protocol for a randomized controlled trial of cognitive-behavioral therapy vs. light therapy for winter depression

BackgroundThis study is a confirmatory efficacy trial of two treatments for winter seasonal affective disorder (SAD): SAD-tailored group cognitive-behavioral therapy (CBT-SAD) and light therapy (LT). In our previous efficacy trial, post-treatment outcomes for CBT-SAD and LT were very similar, but CBT-SAD was associated with fewer depression recurrences two winters later than LT (27.3% in CBT-SAD vs. 45.6% in LT). CBT-SAD engaged and altered a specific mechanism of action, seasonal beliefs, which mediated CBT-SAD’s acute antidepressant effects and CBT-SAD’s enduring benefit over LT. Seasonal beliefs are theoretically distinct from LT’s assumed target and mechanism: correction of circadian phase. This study applies the experimental therapeutics approach to determine how each treatment works when it is effective and to identify the best candidates for each. Biomarkers of LT’s target and effect include circadian phase angle difference and the post-illumination pupil response. Biomarkers of CBT-SAD’s target and effect include decreased pupillary and sustained frontal gamma-band EEG responses to seasonal words, which are hypothesized as biomarkers of seasonal beliefs, reflecting less engagement with seasonal stimuli following CBT-SAD. In addition to determining change mechanisms, this study tests the efficacy of a “switch” decision rule upon recurrence to inform clinical decision-making in practice.MethodsAdults with SAD (target N = 160) will be randomzied to 6-weeks of CBT-SAD or LT in winter 1; followed in winter 2; and, if a depression recurrence occurs, offered cross-over into the alternate treatment (i.e., switch from LT➔CBT-SAD or CBT-SAD➔LT). All subjects will be followed in winter 3. Biomarker assessments occur at pre-, mid-, and post-treatment in winter 1, at winter 2 follow-up (and again at mid-/post-treatment for those crossed-over), and at winter 3 follow-up. Primary efficacy analyses will test superiority of CBT-SAD over LT on depression recurrence status (the primary outcome). Mediation analyses will use parallel process latent growth curve modeling.DiscussionConsistent with the National Institute of Mental Health’s priorities for demonstrating target engagement at the level of Research Domain Criteria-relevant biomarkers, this work aims to confirm the targets and mechanisms of LT and CBT-SAD to maximize the impact of future dissemination efforts.Trial registrationClinicalTrials.gov identifier: NCT03691792. Registered on October 2, 2018.

Alternatives to whole gland treatment for localized prostate cancer: a review of novel focal therapies.

The mainstays of the management of clinically localized prostate cancer have historically rested upon active surveillance, radiation therapy, or radical prostatectomy. Although both radiation and surgical treatment of localized prostate cancer can achieve excellent oncologic outcomes, the subsequent potential adverse effects of urinary stress incontinence and erectile dysfunction are unappealing to patients. This has led to investigational studies centered upon focal treatment of the cancerous lesion, with the aim to improve quality-of-life outcomes. In this review, we describe numerous novel modalities, including nanoparticle ablation and irreversible electroporation, which are being utilized for the focal treatment of clinically localized prostate cancer. Although many of these novel therapies are in their investigational infancy, several have revealed very promising results both in their post-treatment pathologic outcomes as well as objective quality-of-life measures. Initial data regarding novel focal therapy for prostate cancer treatment show promising short-term outcomes in regards to oncologic and quality-of-life assessments. Further investigational studies are needed to determine inclusion criteria for the selection of optimal candidates.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders.

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.