Chronic obstructive pulmonary disease mortality in Spain between 1999 and 2019.

INTRODUCTION: Mortality from COPD has decreased in Spain in recent years, but it is unknown whether this decline has been homogeneous among the different regions. METHODS: From the Statistical Portal of the Ministry of Health of Spain we obtained the age-adjusted mortality rates/100,000 inhabitants for men and women in Spain and the Autonomous Communities for the years 1999-2019, using the coding of the International Classification of Diseases (ICD 10, sections J40-J44). With the adjusted rates we performed a jointpoint regression analysis to estimate an annual percentage change (APC), as well as identify possible points of trend change. Statistical significance was considered for a value of p<0.05. RESULTS: During the study period, COPD mortality rates adjusted in Spain decreased from 28.77 deaths/100,000 inhabitants in 1999 to 12.14 deaths/100,000 inhabitants in 2019. We observed a linear decline in COPD mortality in men at national level of -3.67% per year (95% CI -4.1 to -3.4; p<0.001), with differences between the Autonomous Communities. Mortality in women also experienced a decrease in mortality in two phases, with a first period from 1999 to 2006 with a fall of -6.8% per year (95% CI -8.6 to -5.0; p<0.001) and a second period from 2006 to 2019 with a decrease in mortality of -2.1% (95% CI -2.8 to -1.3; p<0.001), with again differences between the Autonomous Communities. CONCLUSION: Mortality rates from COPD have decreased heterogeneously among the different Autonomous Communities in both men and women.

Bictegravir/Emtricitabine/Tenofovir Alafenamide in a Multicentre Cohort: Real-Life Experience From Spain.

BACKGROUND: The evaluation of bictegravir, emtricitabine, and tenofovir alafenamide (BIC/FTC/TAF) in clinical trials has shown high rates of virological suppression but information about its use in real-life settings is scarce. OBJECTIVE: To evaluate the effectiveness, safety, durability, and predictive variables of therapeutic failure of BIC/FTC/TAF in a real-life cohort. METHODS: This observational, retrospective, multicentered cohort study included treatment-naive (TN) and treatment-experienced (TE) adult patients living with HIV (PLWH) who started treatment with BIC/FTC/TAF from January 1, 2019, to January 31, 2022. Treatment effectiveness (based on intention-to-treat [ITT], modified ITT [mITT], and on-treatment [OT]), tolerability, and safety were evaluated in all patients who started BIC/FTC/TAF antiretroviral therapy. RESULTS: We included a total of 505 PLWH of whom 79 (16.6%) were TN and 426 (83.4%) were TE. Patients were followed up for a median (interquartile range [IQR]) of 19.6 (9.6-27.3) months, and 76% and 56% of PLWH reached month 6 and month 12 of treatment, respectively. Rates of TN PLWH with HIV-RNA <50 copies/mL in the OT, mITT, and ITT groups were 94%, 80%, and 62%, respectively, after 12 months of BIC/FTC/TAF treatment. Rates of TE PLWH with HIV-RNA <50 copies/mL were 91%, 88%, and 75% at month 12. The multivariate analysis revealed that neither age, sex, CD4 cell count <200 cells/µL, or viral load >100 000 copies/mL were associated with therapeutic failure. CONCLUSION AND RELEVANCE: Our real-life data showed that BIC/FTC/TAF is effective and safe for use in the treatment of both TN and TE patients in clinical practice.

Knowledge and Perceived Emotions Regarding an Anal Cancer Preventive Program in People Diagnosed With HIV: A Qualitative Study.

BACKGROUND: To the best of our knowledge, no studies have yet examined the emotional repercussions of the care processes among people infected with the human immunodeficiency virus who participate in preventive anal cancer screening programs. OBJECTIVE: This study aimed to explore the knowledge, emotions, sexuality, barriers, and facilitators perceived by this patient group during the process of anal cancer screening and diagnosis. METHODS: Detailed, semistructured, qualitative interviews were completed with 17 men and 3 women to explore their knowledge, experiences, and emotions regarding the screening process. Purposive sampling was conducted on the basis of age, gender, and type of lesion diagnosed in the anal biopsy. RESULTS: Four major themes were identified: 1) knowledge of the disease and its treatment, 2) emotions perceived by the patients, 3) the influence of screening on sexual practices, and 4) facilitators and obstacles during the care provision process. Patients reported appropriate knowledge of anal cancer and human papillomavirus. Predominant emotions were worry and fear with avoidance as one of the coping strategies. CONCLUSION: These results suggest that communication of information and clinical results can be improved. IMPLICATION FOR PRACTICE: Understanding the facilitators and barriers to the program will allow the integration of interventions designed to improve healthcare provision into direct care.

[Effectiveness of the vagino-rectal exudate self-sampling for prenatal screening of Streptococcus agalactiae infection. GALL study]. / Efectividad de la autotoma del exudado vaginorrectal para el cribado prenatal de la infección por Streptococcus agalactiae. Estudio GALL.

OBJETIVE: To evaluate the effectiveness of vagino-rectal swab autotomy for prenatal screening for GBS infection and to identify the barriers and facilitators encountered by the pregnant woman for this intervention. DESIGN: Cross-sectional study of diagnostic tests. PARTICIPANTS AND SITE: A total of 213 pregnant women who attended the primary care midwife's office in 6 health centers of the Basque Health Service/Osakidetza in Bizkaia, who met the inclusion criteria and agreed to participate in the study, participated in the study. MAIN MEASUREMENTS: The result of the vagino-rectal culture obtained by the pregnant woman was compared with the result of the vagino-rectal culture taken by the midwife in consultation on the same day, and the barriers and facilitators encountered by the women in the self-test were collected. RESULTS: Self-testing as a test for GBS was found to have a sensitivity of 93.3% (95% CI 78.7-98.2), a specificity of 99.4% (95% CI 96.5-99.9), a positive predictive value of 96% (95% CI 82.8-99.4) and a negative predictive value of 98.8% (95% CI 95.6-99.7). 27.3% of respondents encountered some difficulty in the collection, only 4.8% did not feel qualified, 84.2% felt comfortable, 99.5% considered the information provided to be adequate and complete, 94.7% did not find the steps to follow complicated, and 96% were satisfied with the study. CONCLUSIONS: Self-collection of vagino-rectal exudate for GBS detection has proved to be valid and reliable, which would make it possible to offer this option to pregnant women in the systematic screening for GBS infection.

Hallazgo histopatológico de Strongyloides stercoralis en enfermedad de Crohn: reporte de caso / Histopathologic finding of Strongyloides stercoralis in a patient with Crohn's disease: Case report

Resumen Caso clínico: Se describe un caso clínico poco frecuente en un paciente inmunocomprometido con hallazgo histopatológico de infestación parasitaria. Es un paciente masculino de edad media que habita en zona subtropical con diagnóstico de enfermedad de Crohn tratado con corticoide e inmunomoduladores, presentaba dolor abdominal y anemia crónica de 1 año de evolución, analítica negativa para parásitos, reactantes de fase aguda normales, gastroscopia y colonoscopia previas (6 meses) sin hallazgos relevantes. Por la persistencia del cuadro clínico se repitieron los estudios endoscópicos en los que se visualizaron hemorragias subepiteliales con resultados histopatológicos de Strongyloides stercoralis. Conclusión: En el contexto de un paciente inmunocomprometido, en zona endémica y con evolución tórpida, debe obligar a realizar un diagnóstico diferencial en el que se debe sospechar siempre de infestación parasitaria. Aunque la endoscopia no se necesita para el diagnóstico de estrongiloidiasis, su intervención puede ser oportuna.

Abstract Clinical case: The following is a rare clinical case in an immunocompromised patient with histopathological findings of parasitic infestation. The patient is a middle-aged male who lives in a subtropical area and has a diagnosis of Crohn's disease treated with corticosteroids and immunomodulators. The patient presented with abdominal pain and chronic anemia for 1 year, with negative laboratory tests for parasites and normal acute phase reactants. Gastroscopy and colonoscopy were performed before the consultation (6 months) without relevant findings. Due to the persistence of the symptoms, endoscopic studies were repeated, finding subepithelial bleeding with histopathological results of Strongyloides stercoralis. Conclusion: In the context of an immunocompromised patient living in an endemic area and with a torpid evolution, a differential diagnosis should be made always suspecting a parasitic infestation. Although endoscopy is not necessary to diagnose strongyloidiasis, its use may be convenient.

Neural dynamics of pride and shame in social context: an approach with event-related brain electrical potentials.

The neural underpinnings of social emotions such as pride and shame are largely unknown. The present study aims to add evidence by exploiting the advantage of event-related brain electrical potentials (ERP) to examine the neural processes as they unfold over time. For this purpose, a dot-estimation task was adapted to explore these emotions as elicited in a simulated social context. Pride prompted an early negativity seemingly originated in medial parietal regions (precuneus) and possibly reflecting social comparison processes in successful trials. This was followed by a late positivity originated in medial frontal regions, probably reflecting the verification of singularly successful trials. Shame, in turn, elicited an early negativity apparently originated in the cuneus, probably related to mental imagery of the social situation. It was followed by a late positivity mainly originated in the same regions as the early negativity for pride, then conceivably reflecting social comparison processes, in this occasion in unsuccessful trials. None of these fluctuations correlated with self-reported feelings of either emotion, suggesting that they instead relate to social cognitive computations necessary to achieve them. The present results provide a dynamic depiction of neural mechanisms underlying these social emotions, probing the necessity to study them using an integrated approach with different techniques.

Replacing the Z-phenyl Ring in Tamoxifen® with a para-Connected NCN Pincer-Pt-Cl Grouping by Post-Modification †.

Post-modification of a series of NCN-pincer platinum(II) complexes [PtX(NCN-R-4)] (NCN = [C6H2(CH2NMe2)2-2,6]-, R = C(O)H, C(O)Me and C(O)Et), X = Cl- or Br-) at the para-position using the McMurry reaction was studied. The synthetic route towards two new [PtCl(NCN-R-4)] (R = C(O)Me and C(O)Et) complexes used above is likewise described. The utility and limitations of the McMurry reaction involving these pincer complexes was systematically evaluated. The predicted "homo-coupling" reaction of [PtBr(NCN-C(O)H-4)] led to the unexpected formation of 3,3',5,5'-tetra[(dimethylamino)methyl]-4,4'-bis(platinum halide)-benzophenone (halide = Br or Cl), referred to hereafter as the bispincer-benzophenone complex 13. This material was further characterized using X-ray crystal structure determination. The applicability of the pincer complexes in the McMurry reaction is shown to open a route towards the synthesis of tamoxifen-type derivatives of which one phenyl ring of Tamoxifen® itself is replaced by an NCN arylplatinum pincer fragment. The newly synthesized derivatives can be used as potential candidates in anti-cancer drug screening protocols. Two NCN-arylpincer platinum tamoxifen type derivatives, 5 and 6, were successfully synthesized and of 5 the separation of the diastereomeric E-/Z-forms was achieved. Compound 6, which is the pivaloyl protected NCN pincer platinum hydroxy-Tamoxifen® derivative, was obtained as a mixture of E-/Z-isomers. The new derivatives were further analyzed and characterized with 1H-, 13C{1H}- and 195Pt{1H}-NMR, IR, exact mass MS and elemental analysis.

Vasculitis leucocitoclásticas como manifestación extraintestinal dermatológica rara de la enfermedad inflamatoria intestinal asociada con Clostridium: reporte de un caso / Leukocytoclastic vasculitis as a rare extraintestinal dermatologic manifestation of inflammatory bowel disease associated with Clostridium difficile: Case report

Resumen Las vasculitis leucocitoclásticas se definen como el daño e inflamación de las paredes vasculares, son aquellas vasculitis de pequeños vasos que anatomopatológicamente presentan leucocitoclasia y puede observarse como una manifestación extraintestinal de la enfermedad inflamatoria intestinal. En la colitis ulcerativa se presentan en menor frecuencia, por inmunocomplejos generados en la mucosa intestinal debido a la exposición del tejido linfoide submucoso a antígenos fecales; podrían precipitarse en las paredes de los pequeños vasos. Se pueden asociar con Clostridium difficile, que es un bacilo grampositivo esporulado, anaerobio estricto, que se encuentra normalmente en el medio ambiente y produce colitis, que se manifiesta como un cuadro diarreico presentado después de la ingesta de antibióticos y altera la flora bacteriana común de este órgano. El caso se trata de un paciente 36 años de edad con cuadro de diarreas líquidas con moco y escaso sangrado; se realizó un estudio endoscópico y anatomopatológico en el que se observó colitis ulcerativa con coproparasitario positivo para antígeno de C. difficile, y en su hospitalización presentó lesiones dérmicas petequiales y necróticas en el cuarto dedo de la mano izquierda, que en la biopsia dio como resultado vasculitis de pequeños vasos. En este artículo se revisan de forma práctica los aspectos relacionados con la fisiopatología, histología, tratamiento y diagnósticos de la manifestación extraintestinal dermatológica rara, como la vasculitis leucocitoclástica en pacientes con colitis ulcerativas asociadas con Clostridium.

Abstract Leukocytoclastic vasculitis is defined as the damage and inflammation of the vascular walls. The term refers to vasculitis of the small vessels that anatomopathologically present leukocytoclasia and it can be seen as an extra-intestinal manifestation of inflammatory bowel disease. In ulcerative colitis, it occurs less frequently due to immune complexes produced in the intestinal mucosa by exposure of the submucosal lymphoid tissue to fecal antigens, which could precipitate in the walls of the small vessels. This condition can be associated with Clostridium difficile, which is a gram-positive, sporulated, strict anaerobic bacillus, normally found in the environment. It causes colitis that manifests as a diarrheal disease following the ingestion of antibiotics that alter the common bacterial flora of this organ. This is the case report of a 36-year-old patient with liquid diarrhea with mucus and scarce bleeding. Endoscopic and anatomopathological studies were performed, finding ulcerative colitis with positive coproparasite for Clostridium difficile antigen. The patient was hospitalized, and during his stay, he presented with petechiae and necrotic skin lesions on the fourth finger of the left hand. Skin biopsy showed small vessel vasculitis. This article is a practical review of the pathophysiology, histology, treatment, and diagnosis of a rare dermatologic extraintestinal manifestation, namely, leukocytoclastic vasculitis, in patients with C. difficile-associated ulcerative colitis.

Ultrasonographic Size of the Thenar Muscles of the Nondominant Hand Correlates with Total Body Lean Mass in Healthy Subjects.

RATIONALE AND OBJECTIVES: Sarcopenia is associated with adverse outcomes in clinical situations such as elderly population, in-hospital setting and oncologic patients. However, no direct measurement of muscular mass is routinely available for clinicians. The aim of this study was to assess the correlation between thenar musculature of the nondominant hand evaluated by ultrasound and body fat-free mass. MATERIALS AND METHODS: In this one-center, cross-sectional, observational study, the width and depth of thenar muscles of both hands was assessed by ultrasonography. Nondominant hand musculature was taken as reference as a better estimator of total body muscular mass. These data were compared to body composition by bioimpedance analysis and dual-energy X-ray absorptiometry (DXA), hand grip strength, arm muscular area and physical activity (with International Physical Activity Questionnaire ). Statistical correlation was determined for each parameter. RESULTS: We obtained ultrasonographic measurements, International Physical Activity Questionnaire and hand grip strength from 83 subjects, whereas bioimpedance was performed in 64 subjects and DXA in 29 subjects. The strongest correlations were found between longitudinal thenar depth vs fat-free mass index (fat-free mass in DXA [kg]/height2 [m]) (r = 0.63, p < 0.001, 95%CI 0.34-0.81), longitudinal depth and hand dynamometry (r = 0.72, p < 0.001, 95%CI 0.59-0.81), longitudinal depth and DXA fat-free total mass (r = 0.76, p < 0.001, 95%CI 0.54-0.88), transversal thenar depth vs fat-free mass index (r = 0.67, p < 0.001, 95%CI 0.41-0.83), transversal width and DXA fat-free total mass (r = 0.62, p < 0.001, 95%CI 0.33-0.8), transversal depth and DXA nonfat total mass (r = 0.81, p < 0.001, 95%CI 0.63-0.91). CONCLUSION: Ultrasonographic examination of the nondominant thenar musculature is a fast and simple way of assessing total body fat-free mass, showing a good correlation with body composition measured by bioimpedance analysis and DXA, hand grip strength and arm muscular area.

Biodegradable and Antimicrobial PLA-OLA Blends Containing Chitosan-Mediated Silver Nanoparticles with Shape Memory Properties for Potential Medical Applications.

To use shape memory materials based on poly (lactic acid) (PLA) for medical applications is essential to tune their transition temperature (Ttrans) near to the human body temperature. In this study, the combination of lactic acid oligomer (OLA), acting as a plasticizer, together with chitosan-mediated silver nanoparticles (AgCH-NPs) to create PLA matrices is studied to obtain functional shape memory polymers for potential medical applications. PLA/OLA nanocomposites containing different amounts of AgCH-NPs were obtained and profusely characterized relating their structure with their antimicrobial and shape memory performances. Nanocomposites exhibited shape memory responses at the temperature of interest (near physiological one), as well as excellent shape memory responses, shorter recovery times and higher recovery ratios (over 100%) when compared to neat materials. Moreover, antibacterial activity tests confirmed biocidal activity; therefore, these functional polymer nanocomposites with shape memory, degradability and biocidal activity show great potential for soft actuation applications in the medical field.

Development and Evaluation of a Sensitive Bacteriophage-Based MRSA Diagnostic Screen.

Engineered luciferase reporter bacteriophages provide specific, sensitive, rapid and low-cost detection of target bacteria and address growing diagnostic needs in multiple industries. Detection of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization and antibiotic susceptibility play a critical supportive role in preventing hospital-acquired infections and facilitating antibiotic stewardship. We describe the development and evaluation of a novel phage-based MRSA diagnostic screen for nasal swab specimens. The screen utilizes two luciferase reporter phages capable of recognizing genetically-diverse Staphylococcus aureus. The beta-lactam antibiotic cefoxitin is included to differentiate between resistant (MRSA) and susceptible organisms. The screen positively identified 97.7% of 390 clinical MRSA isolates at low bacterial concentrations. At higher inoculums, 93.5% of 123 clinical non-MRSA Staphylococcus aureus yielded appropriate negative results. Although cross-reactivity of the phage cocktail was observed with other staphylococcal and bacillus species, these false positives were absent under selective conditions. MRSA remained detectable in the presence of 38 distinct competing species and was accurately identified in 100% of 40 spiked nasal specimens. Thus, this six-hour screen sensitively detected MRSA both in vitro and in human nasal matrix.

Prescreening for European Prevention of Alzheimer Dementia (EPAD) trial-ready cohort: impact of AD risk factors and recruitment settings.

BACKGROUND: Recruitment is often a bottleneck in secondary prevention trials in Alzheimer disease (AD). Furthermore, screen-failure rates in these trials are typically high due to relatively low prevalence of AD pathology in individuals without dementia, especially among cognitively unimpaired. Prescreening on AD risk factors may facilitate recruitment, but the efficiency will depend on how these factors link to participation rates and AD pathology. We investigated whether common AD-related factors predict trial-ready cohort participation and amyloid status across different prescreen settings. METHODS: We monitored the prescreening in four cohorts linked to the European Prevention of Alzheimer Dementia (EPAD) Registry (n = 16,877; mean ± SD age = 64 ± 8 years). These included a clinical cohort, a research in-person cohort, a research online cohort, and a population-based cohort. Individuals were asked to participate in the EPAD longitudinal cohort study (EPAD-LCS), which serves as a trial-ready cohort for secondary prevention trials. Amyloid positivity was measured in cerebrospinal fluid as part of the EPAD-LCS assessment. We calculated participation rates and numbers needed to prescreen (NNPS) per participant that was amyloid-positive. We tested if age, sex, education level, APOE status, family history for dementia, memory complaints or memory scores, previously collected in these cohorts, could predict participation and amyloid status. RESULTS: A total of 2595 participants were contacted for participation in the EPAD-LCS. Participation rates varied by setting between 3 and 59%. The NNPS were 6.9 (clinical cohort), 7.5 (research in-person cohort), 8.4 (research online cohort), and 88.5 (population-based cohort). Participation in the EPAD-LCS (n = 413 (16%)) was associated with lower age (odds ratio (OR) age = 0.97 [0.95-0.99]), high education (OR = 1.64 [1.23-2.17]), male sex (OR = 1.56 [1.19-2.04]), and positive family history of dementia (OR = 1.66 [1.19-2.31]). Among participants in the EPAD-LCS, amyloid positivity (33%) was associated with higher age (OR = 1.06 [1.02-1.10]) and APOE ɛ4 allele carriership (OR = 2.99 [1.81-4.94]). These results were similar across prescreen settings. CONCLUSIONS: Numbers needed to prescreen varied greatly between settings. Understanding how common AD risk factors link to study participation and amyloid positivity is informative for recruitment strategy of studies on secondary prevention of AD.

Multifunctional PLA Blends Containing Chitosan Mediated Silver Nanoparticles: Thermal, Mechanical, Antibacterial, and Degradation Properties.

Poly(lactic acid) (PLA) is one of the most commonly employed synthetic biopolymers for facing plastic waste problems. Despite its numerous strengths, its inherent brittleness, low toughness, and thermal stability, as well as a relatively slow crystallization rate represent some limiting properties when packaging is its final intended application. In the present work, silver nanoparticles obtained from a facile and green synthesis method, mediated with chitosan as a reducing and stabilizing agent, have been introduced in the oligomeric lactic acid (OLA) plasticized PLA in order to obtain nanocomposites with enhanced properties to find potential application as antibacterial food packaging materials. In this way, the green character of the matrix and plasticizer was preserved by using an eco-friendly synthesis protocol of the nanofiller. The X-ray diffraction (XRD) and differential scanning calorimetry (DSC) results proved the modification of the crystalline structure as well as the crystallinity of the pristine matrix when chitosan mediated silver nanoparticles (AgCH-NPs) were present. The final effect over the thermal stability, mechanical properties, degradation under composting conditions, and antimicrobial behavior when AgCH-NPs were added to the neat plasticized PLA matrix was also investigated. The obtained results revealed interesting properties of the final nanocomposites to be applied as materials for the targeted application.

Nrf2-related gene expression is impaired during a glucose challenge in type II diabetic rat hearts.

Diabetic hearts are susceptible to damage from inappropriate activation of the renin angiotensin system (RAS) and hyperglycemic events both of which contribute to increased oxidant production. Prolonged elevation of oxidants impairs mitochondrial enzyme function, further contributing to metabolic derangement. Nuclear factor erythriod-2-related factor 2 (Nrf2) induces antioxidant genes including those for glutathione (GSH) synthesis following translocation to the nucleus. We hypothesized that an acute elevation in glucose impairs Nrf2-related gene expression in diabetic hearts, while AT1 antagonism would aid in Nrf2-mediated antioxidant production and energy replenishment. We used four groups (n = 6-8/group) of 25-week-old rats: 1) LETO (lean strain-control), 2) type II diabetic OLETF, 3) OLETF + angiotensin receptor blocker (ARB; 10 mg olmesartan/kg/d × 8 wks), and 4) ARBM (4 weeks on ARB, 4 weeks off) to study the effects of acutely elevated glucose on cardiac mitochondrial function and Nrf2 signaling in the diabetic heart. Animals were gavaged with a glucose bolus (2 g/kg) and groups were dissected at T0, T180, and T360 minutes. Nrf2 mRNA was 32% lower in OLETF rats compared to LETO and remained suppressed in response to glucose. LETO Nrf2 mRNA increased 25% at T360 in response to glucose while no changes were observed in diabetic hearts. GCLC and GCLM mRNA decreased in diabetic hearts 33% and 44% respectively and remained suppressed in response to glucose while ARB treatment increased GCLM transcripts 90% at T180. These data illustrate that during T2DM and in response to glucose, cardiac Nrf2's adaptive response to environmental stressors such as glucose is impaired in diabetic hearts and that ARB treatment may aid Nrf2's impaired dynamic response.

Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder.

The DSM-5 social anxiety disorder section has recently added the performance-only specifier for individuals whose anxiety is limited to speaking or performing in public. The impact of the DSM-5 performance-only specifier remains a neglected area. The sample comprised 44 healthy controls and 50 adolescents with a clinical diagnosis of SAD (20% met criteria for the performance-only specifier). Findings revealed that adolescents with the specifier had a later age of onset; lower levels of depression, social anxiety symptomatology and clinical severity; and a lesser degree of comorbidity relative to adolescents with SAD but excluding the performance-only specifier. Specifiers only evidenced higher (cognitive) social anxiety symptomatology compared to healthy controls. Results of this study also suggested that the performance-only specifier may correspond to a mild form of social anxiety disorder. Data also revealed that SAD exists on a continuum of severity among healthy controls, specifier participants, and those with both interactional and performance fears, which is consistent with a dimensional structure for SAD. Finally, findings suggested a unique comorbid pattern for specifiers and those adolescents with SAD but excluding the performance-only specifier. The implications of these findings for the etiology, assessment, classification, and treatment of social anxiety in youth are discussed.