Communicating effectively with inclusion health populations: 2022 ICCH symposium.

OBJECTIVE: To describe communication strategies for clinical practice that allow practitioners to work more effectively with marginalised population groups and to discuss how to incorporate these into medical practice. METHODS: Active practitioners working in inclusion health and people with lived experience of homelessness and the asylum-seeking process shared their perspectives in the symposium at the 2022 International Conference on Communication in Healthcare (ICCH) and a subsequent conference on empathy in healthcare. The views of attendees were sought. SYMPOSIUM DISCUSSION: We describe the perspectives shared at the symposia under two main themes: communication needs in people experiencing homelessness and migrant populations, and trauma-informed practice. CONCLUSIONS: People experiencing homelessness have more communication challenges compared to the general adult population. Migrant, refugee, and asylum-seeking populations also face the complexity of negotiating unfamiliar healthcare, legal and social systems with the added burden of language barriers. Trauma-informed practice provides a useful framework that can improve communication with these groups.

Integrating applied parasitological and molecular epidemiological methodologies to investigate the capacity of Haemonchus contortus to over-winter on pasture in Scotland.

BACKGROUND: The Barber's Pole worm, Haemonchus contortus is of major concern to sheep producers, particularly in the southern hemisphere. This nematode is also commonly found in many sheep flocks in Northern hemisphere countries but is generally not associated with acute clinical pathology. As with other nematode species, the pattern of disease is changing in the United Kingdom. Changes in management practices, climate, anthelmintic resistance prevalence and parasite adaptation are possible factors thought to be responsible for this. METHODS: In the present study, a combination of traditional applied parasitological and molecular species identification techniques were used to assess the capability of H. contortus infective larvae to over-winter on pasture and infect lambs in early spring. RESULTS: Adult and inhibited H. contortus worms were identified in previously worm-free tracer lambs that had grazed contaminated pasture in late winter/early spring (February/March). CONCLUSION: The study illustrated the benefit of using classical applied parasitology techniques in conjunction with molecular species identification methods to explore the epidemiology of gastro-intestinal nematodes of livestock. This study also demonstrated that larvae were able to survive over-winter, albeit in small numbers, and potentially contaminate pastures earlier than previously considered in northern regions of the UK.

Molecular and phenotypic characterisation of fenbendazole resistance in a field-derived isolate of Ostertagia ostertagi.

The prevalence of anthelmintic resistance in the bovine nematode Cooperia oncophora has been well documented globally but lack of efficacy against the more pathogenic nematode species Ostertagia ostertagi is less common. The sensitivity of an O. ostertagi isolate to the benzimidazole class of anthelmintic was investigated using classical parasitological techniques following apparent clinical failure of controlled release fenbendazole capsule administration in first season grazers at pasture. A controlled efficacy test (CET) was conducted in conjunction with sequencing of the ß-tubulin isotype 1 gene of larvae pre- and post-fenbendazole administration. Twelve helminth-naïve calves were infected experimentally with 20,000 third stage larvae; six received oral fenbendazole (7.5 mg/kg bodyweight) 28 days post infection. Total abomasal nematode burdens were compared between treatment and control groups to determine efficacy. Fenbendazole resistance in O. ostertagi was confirmed with a total treatment failure in reducing worm burden: efficacy of 0%. Sequence analysis of the ß-tubulin isotype-1 gene from forty-five infective larvae from both control and treated groups was performed. The three commonest single nucleotide polymorphisms (SNPs) associated with benzimidazole resistance, namely F167Y, E198A and F200Y, were examined. The predominant resistance-associated SNPs were F200Y (78 % control and 79 % treated groups) and F167Y (remaining genotypes) and emphasises the importance of these SNPs in clinical disease in this isolate. The development of diagnostic molecular tools based on a characterised field-derived isolate of benzimidazole-resistant Ostertagia will enable future prevalence surveys to be undertaken to assess the possible risk posed by resistance in this economically important species.

The speech, language and communication needs of rough sleepers in London.

BACKGROUND: There is very little awareness of the speech, language and communication needs (SLCN) of rough sleepers. The small amount of documentation that does exist involves a wider group of homeless adults (not just rough sleepers), and reports that communication needs are an area of concern. AIMS: To investigate: (1) the reported prevalence of SLCN amongst UK nationals recorded on the Combined Homeless and Information Network (CHAIN) as sleeping on the streets of London; (2) whether rough sleepers with reported SLCN differ from those without; and (3) what factors best predict patterns of rough sleeping and accommodation stays. METHODS & PROCEDURES: A data set of 513 participants was provided by CHAIN, which contained information relating to all new rough sleepers and people with long-term histories of rough sleeping (UK nationals only) recorded by street outreach teams in London between 1 April and 30 June 2013. Also included was data about UK nationals provided with support by the Homelessness and Brain Injury Project. The data set contained information including basic demographics, communication skills, health and social care needs, and institutional background and extended to a 5-year period. OUTCOMES & RESULTS: (1) SLCN data were often not recorded with data available for only 62% of individuals on the CHAIN databases. However, for those with SLCN data, the prevalence of SLCN was significantly higher than for the general population (17.1%; p < 0.001). (2) There were no significant differences between those with and without SLCN on additional risk factors, quarters rough sleeping, accommodation stays or staff-recorded alerts. (3) There was a positive correlation between rough sleeping and additional risk factors for those with SLCN (r = 0.32, p < 0.001) and for those without (r = 0.25, p < 0.001). Regression analysis indicated that additional risk factors were more predictive than SLCN in explaining the number of quarters rough sleeping and accommodation stays. CONCLUSIONS & IMPLICATIONS: SLCN are highly prevalent amongst rough sleepers and significantly greater than for the UK general population. SLCN are not clearly related to rough sleeping behaviour, but the presence of additional risk factors is highly significant in this regard. Homelessness organizations should provide training for staff in SLCN in order to promote better recording of SLCN, inclusive communication and appropriate support to people who are homeless. Further research is also needed to understand better the communication needs of rough sleepers. What this study adds What is already known on the subject There is very little literature concerning the SLCN of rough sleepers, but that which exists suggests that communication needs are an area of concern. There is relatively little awareness of SLCN in practice in this field. What this paper adds to existing knowledge This study is the first to provide information on SLCN recording in this population. It reports large-scale prevalence data on SLCN in rough sleepers, showing a significantly higher risk in this group. Unexpectedly, SLCN did not clearly relate to patterns of rough sleeping and accommodation, but this may be due to the relatively crude data available in routine practice. What are the potential or actual clinical implications of this work? Wider awareness and training on SLCN in the homelessness sector is needed coupled with more systematic and objective assessment of communication in rough sleepers.

A complex systems approach to the study of change in psychotherapy.

BACKGROUND: A growing body of research highlights the limitations of traditional methods for studying the process of change in psychotherapy. The science of complex systems offers a useful paradigm for studying patterns of psychopathology and the development of more functional patterns in psychotherapy. Some basic principles of change are presented from subdisciplines of complexity science that are particularly relevant to psychotherapy: dynamical systems theory, synergetics, and network theory. Two early warning signs of system transition that have been identified across sciences (critical fluctuations and critical slowing) are also described. The network destabilization and transition (NDT) model of therapeutic change is presented as a conceptual framework to import these principles to psychotherapy research and to suggest future research directions. DISCUSSION: A complex systems approach has a number of implications for psychotherapy research. We describe important design considerations, targets for research, and analytic tools that can be used to conduct this type of research. CONCLUSIONS: A complex systems approach to psychotherapy research is both viable and necessary to more fully capture the dynamics of human change processes. Research to date suggests that the process of change in psychotherapy can be nonlinear and that periods of increased variability and critical slowing might be early warning signals of transition in psychotherapy, as they are in other systems in nature. Psychotherapy research has been limited by small samples and infrequent assessment, but ambulatory and electronic methods now allow researchers to more fully realize the potential of concepts and methods from complexity science.

Dose Timing of D-Cycloserine to Augment Exposure Therapy for Social Anxiety Disorder: A Randomized Clinical Trial.

Importance: Findings suggest that the efficacy of D-cycloserine (DCS) for enhancing exposure therapy may be strongest when administered after sessions marked by low fear at the conclusion of exposure practice. These findings have prompted investigation of DCS dosing tailored to results of exposure sessions. Objective: To compare tailored postsession DCS administration with presession DCS administration, postsession DCS administration, and placebo augmentation of exposure therapy for social anxiety disorder. Design, Setting, and Participants: This double-blind randomized clinical trial involved adults with social anxiety disorder enrolled at 3 US university centers. Symptom severity was assessed at baseline, weekly during treatment, and at 1-week and 3-month follow-up. Data analysis was performed from September 2019 to March 2020. Interventions: Participants completed a 5-session treatment and received pills commensurate with their condition assignment at sessions 2 through 5, which emphasized exposure practice. Main Outcomes and Measures: Symptom severity was evaluated by the Liebowitz Social Anxiety Scale and Social Phobic Disorders-Severity Form as administered by independent evaluators. Results: A total of 152 participants were enrolled (mean [SD] age, 29.24 [10.16] years; 84 men [55.26%]). Compared with placebo, presession and postsession conditions showed greater symptom improvement (b = -0.25; 95% CI, -0.37 to -0.13; P < .001; d = 1.07; and b = -0.20; 95% CI, -0.32 to -0.07; P = .002; d = 0.85) and lower symptom severity (b = -0.51; 95% CI, -0.81 to -0.21; P < .001; d = 0.76; and b = -0.49; 95% CI, -0.80 to -0.18; P = .002; d = 0.72) at 3-month follow-up. No differences were found between presession and postsession conditions. The tailored condition showed no advantage over placebo. Compared with the tailored condition, presession and postsession conditions evidenced greater decreases (b = -0.22; 95% CI, -0.34 to -0.10; P < .001; d = 0.94; and b = -0.17, 95% CI, -0.29 to -0.04; P = .008; d = 0.72) and lower symptom severity (b = -0.44, 95% CI, -0.73 to -0.14; P = .004; d = 0.64; and b = -0.41, 95% CI, -0.72 to -0.11; P = .008; d = 0.61) at 3-month follow-up. Conclusions and Relevance: Administration of DCS enhanced exposure therapy for social anxiety disorder when given before or after the exposure session. However, the study failed to achieve the aim to develop a tailored clinical application. Trial Registration: ClinicalTrials.gov Identifier: NCT02066792.

Sudden gains and patterns of symptom change in cognitive-behavioral therapy for treatment-resistant depression.

OBJECTIVE: The sudden gain (SG; large symptom improvements in one between-session interval) has been identified as a consistent predictor of better outcomes at posttreatment and over follow-up in cognitive-behavioral therapy (CBT) for depression. Other defined trajectories of symptom change in CBT, including linear (consistent changes in depression), log-linear (symptom change concentrated in early or late sessions), one-step (substantial change in depression symptoms between two adjacent sessions), and cubic (symptom decrease, increase, and decrease), also predict better treatment outcomes. METHOD: We explored whether these patterns of symptom change occurred and predicted outcome in a sample of 156 adults with treatment-resistant depression who participated in a randomized controlled trial of CBT as an adjunct to pharmacotherapy (Wiles et al., 2013). Depression symptoms were assessed weekly with the Beck Depression Inventory-II. RESULTS: Multilevel modeling revealed that both SGs and having a defined trajectory predicted lower depression severity at 6- and 12-month follow-up, even controlling for baseline depression symptoms, early slopes of change, and symptom variability. CONCLUSIONS: These findings highlight the importance of examining longitudinal data and the robustness of the sudden gain pattern. They further suggest that having a defined symptom trajectory might confer its own advantages in predicting depression outcomes. Clinicians could use weekly depression scores to identify these key patterns of change to guide treatment decisions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

First detection of ivermectin resistance in oesophagostomum dentatum in pigs.

In 2016 suspected reduced ivermectin (IVM) efficacy in Oesophagostomum species in pigs was reported in England. Following this initial report, APHA raised awareness amongst private pig veterinary practitioners of the need to monitor the efficacy of the worm control on pig units. In 2017 another veterinary practitioner highlighted a potential in-field lack of IVM efficacy in treating Oesophagostomum species in sows on another breeder-finisher unit. In this trial, the efficacy of IVM against Oesophagostomum species worms has been investigated to determine whether suspected reduced efficacy (52% reduction in mean faecal egg count 14 days post ivermectin administration) on a mixed indoor and outdoor breeder-finisher pig farm in England reflected true IVM resistance under controlled experimental conditions. On days 0 and 40 of the trial, twenty helminth-naive pigs were artificially infected per os with 5000 Oesophagostomum L3 obtained from the farm under investigation. The pigs were allocated to treatment or control groups (n = 10 per group). Treatment group pigs received IVM (0.3 mg kg body weight) by sub-cutaneous injection as per manufacturer's instructions on day 44. Control group animals were left untreated. Faecal worm egg counts were monitored throughout the trial from day 15 post infection to determine time to patency. On day 50 all pigs were euthanased to assess the worm burdens. Resistance to IVM was confirmed in Oesophagostomum dentatum based on the results of a faecal egg count reduction test (FECRT) and a controlled efficacy test (CET). Efficacy based on mean reduction in faecal egg count of IVM-treated pigs compared to untreated control pigs was 86%. Mean reduction in IVM-treated pig worm burdens was 5% against an adult worm population and 94% against an L3/L4 population. The apparent discrepancy between FECRT and CET efficacy results appears to be due to egg development and/or oviposition suppression in IVM-treated female worms. The detection of IVM resistance in Oesophagostomum species worms for the first time in UK pigs is particularly important considering the global situation where resistance to pyrantel, levamisole and benzimidazole anthelmintics in Oesophagostomum species in pigs have already been reported. The results also provide an opportunity to discuss the wider issue of anthelmintic usage and efficacy on pig farms and highlight the need for wider surveillance for the occurrence of anthelmintic resistance in pigs.

Microbiome analysis as a platform R&D tool for parasitic nematode disease management.

The relationship between bacterial communities and their host is being extensively investigated for the potential to improve the host's health. Little is known about the interplay between the microbiota of parasites and the health of the infected host. Using nematode co-infection of lambs as a proof-of-concept model, the aim of this study was to characterise the microbiomes of nematodes and that of their host, enabling identification of candidate nematode-specific microbiota member(s) that could be exploited as drug development tools or for targeted therapy. Deep sequencing techniques were used to elucidate the microbiomes of different life stages of two parasitic nematodes of ruminants, Haemonchus contortus and Teladorsagia circumcincta, as well as that of the co-infected ovine hosts, pre- and post infection. Bioinformatic analyses demonstrated significant differences between the composition of the nematode and ovine microbiomes. The two nematode species also differed significantly. The data indicated a shift in the constitution of the larval nematode microbiome after exposure to the ovine microbiome, and in the ovine intestinal microbial community over time as a result of helminth co-infection. Several bacterial species were identified in nematodes that were absent from their surrounding abomasal environment, the most significant of which included Escherichia coli/Shigella. The ability to purposefully infect nematode species with engineered E. coli was demonstrated in vitro, validating the concept of using this bacterium as a nematode-specific drug development tool and/or drug delivery vehicle. To our knowledge, this is the first description of the concept of exploiting a parasite's microbiome for drug development and treatment purposes.

Multigeneric resistance to monepantel on a UK sheep farm.

The amino acetonitrile derivative, monepantel, represented the first new broad spectrum anthelmintic to be brought to market for use in sheep for over 25 years when it was introduced in 2009. This study characterised monepantel efficacy, using faecal egg count reduction and controlled efficacy tests, against gastrointestinal nematodes following a report of treatment failure in a UK lowland sheep flock. Twelve lambs were each artificially administered 15,000 infective larvae that had been propagated from lamb faeces collected from the farm of interest. The controlled efficacy test showed that a recommended dose rate of monepantel (2.5 mg/kg body weight) administered at day 28 post infection was ineffective at removing the infection in the treated lambs. The result demonstrated simultaneous resistance to monepantel in Teladorsagia circumcincta, Trichostrongylus vitrinus and Oesophagostomum venulosum with efficacies based on adult worm burden reductions, compared to untreated controls, of 78%, 27% and 22% respectively. Monepantel efficacy based on undifferentiated egg count in treated animals, seven day post administration, compared to untreated controls was 85%. The results raise questions about the origins of, and predisposing factors for, resistance development in the three different species, and reinforces the value of differentiating post treatment faecal egg counts to genus or species level.

Multigeneric resistance to monepantel on a UK sheep farm.

The amino acetonitrile derivative, monepantel, represented the first new broad spectrum anthelmintic to be brought to market for use in sheep for over 25 years when it was introduced in 2009. This study characterised monepantel efficacy, using faecal egg count reduction and controlled efficacy tests, against gastrointestinal nematodes following a report of treatment failure in a UK lowland sheep flock. Twelve lambs were each artificially administered 15,000 infective larvae that had been propagated from lamb faeces collected from the farm of interest. The controlled efficacy test showed that a recommended dose rate of monepantel (2.5 mg/kg body weight) administered at day 28 post infection was ineffective at removing the infection in the treated lambs. The result demonstrated simultaneous resistance to monepantel in Teladorsagia circumcincta, Trichostrongylus vitrinus and Oesophagostomum venulosum with efficacies based on adult worm burden reductions, compared to untreated controls, of 78%, 27% and 22% respectively. Monepantel efficacy based on undifferentiated egg count in treated animals, seven day post administration, compared to untreated controls was 85%. The results raise questions about the origins of, and predisposing factors for, resistance development in the three different species, and reinforces the value of differentiating post treatment faecal egg counts to genus or species level.

Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials.

The purpose of this study was to examine the efficacy of cognitive behavioral therapy (CBT) for anxiety-related disorders based on randomized placebo-controlled trials. We included 41 studies that randomly assigned patients (N = 2,843) with acute stress disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), panic disorder (PD), posttraumatic stress disorder (PTSD), or social anxiety disorder (SAD) to CBT or a psychological or pill placebo condition. Findings demonstrated moderate placebo-controlled effects of CBT on target disorder symptoms (Hedges' g = 0.56), and small to moderate effects on other anxiety symptoms (Hedges' g = 0.38), depression (Hedges' g = 0.31), and quality of life (Hedges' g = 0.30). Response rates in CBT compared to placebo were associated with an odds ratio of 2.97. Effects on the target disorder were significantly stronger for completer samples than intent-to-treat samples, and for individuals compared to group CBT in SAD and PTSD studies. Large effect sizes were found for OCD, GAD, and acute stress disorder, and small to moderate effect sizes were found for PTSD, SAD, and PD. In PTSD studies, dropout rates were greater in CBT (29.0%) compared to placebo (17.2%), but no difference in dropout was found across other disorders. Interventions primarily using exposure strategies had larger effect sizes than those using cognitive or cognitive and behavioral techniques, though this difference did not reach significance. Findings demonstrate that CBT is a moderately efficacious treatment for anxiety disorders when compared to placebo. More effective treatments are especially needed for PTSD, SAD, and PD.

The conditional process model of mindfulness and emotion regulation: An empirical test.

BACKGROUND: The conditional process model (CPM) of mindfulness and emotion regulation posits that specific mediators and moderators link these constructs to mental health outcomes. The current study empirically examined the central tenets of the CPM, which posit that nonreactivity moderates the indirect effect of observation on symptoms of emotional disorders through cognitive emotion regulation strategies. METHODS: A clinical sample (n=1667) of individuals from Japan completed a battery of self-report instruments. Several path analyses were conducted to determine whether cognitive emotion regulation strategies mediate the relationship between observation and symptoms of individual emotional disorders, and to determine whether nonreactivity moderated these indirect effects. RESULTS: Results provided support the CPM. Specifically, nonreactivity moderated the indirect effect of observation on symptoms through reappraisal, but it did not moderate the indirect effect of observation on symptoms through suppression. LIMITATIONS: Causal interpretations are limited, and cultural considerations must be acknowledged given the Japanese sample CONCLUSIONS: These results underscore the potential importance of nonreactivity and emotion regulation as targets for interventions.

A meta-analysis of pharmacotherapy for social anxiety disorder: an examination of efficacy, moderators, and mediators.

INTRODUCTION: Social anxiety disorder (SAD) is among the most prevalent mental disorders, associated with impaired functioning and poor quality of life. Pharmacotherapy is the most widely utilized treatment option. The current study provides an updated meta-analytic review of the efficacy of pharmacotherapy and examines moderators and mediators of treatment efficacy. Areas Covered: A comprehensive search of the current literature yielded 52 randomized, pill placebo-controlled trials of pharmacotherapy for adults diagnosed with SAD. Data on potential mediators of treatment outcome were collected, as well as data necessary to calculate pooled correlation matrices to compute indirect effects. Expert Opinion: The overall effect size of pharmacotherapy for SAD is small to medium (Hedges' g = 0.41). Effect sizes were not moderated by age, sex, length of treatment, initial severity, risk of study bias, or publication year. Furthermore, reductions in symptoms mediated pharmacotherapy's effect on quality of life. Support was found for reverse mediation. Future directions may include sustained efforts to examine treatment mechanisms of pharmacotherapy using rigorous longitudinal methodology to better establish temporal precedence.

Training children's theory-of-mind: A meta-analysis of controlled studies.

BACKGROUND: Theory-of-mind (ToM) refers to knowledge and awareness of mental states in oneself and others. Various training programs have been developed to improve ToM in children. OBJECTIVES: In the present study, we conducted a quantitative review of ToM training programs that have been tested in controlled studies. DATA SOURCES: A literature search was conducted using PubMed, PsycInfo, the Cochrane Library, and manual searches. REVIEW METHODS: We identified 32 papers with 45 studies or experiments that included 1529 children with an average age of 63 months (SD=28.7). RESULTS: ToM training procedures were more effective than control procedures and their aggregate effect size was moderately strong (Hedges' g=0.75, CI=0.60-0.89, p<.001). Moderator analyses revealed that although ToM training programs were generally effective, ToM skill-related outcomes increased with length of training sessions and were significantly higher in active control studies. CONCLUSION: ToM training procedures can effectively enhance ToM in children.