From Psoriasis to Psoriatic Arthritis: Ultrasound Insights Connecting Psoriasis with Subclinical Musculoskeletal Inflammation and the Path to Psoriatic Arthritis.

PURPOSE OF REVIEW: This review summarizes the literature about the transition from psoriasis to psoriatic arthritis (PsA), focusing on musculoskeletal ultrasound (MSUS) for detecting subclinical inflammation and its role in diagnosis and triage of high-risk patients. RECENT FINDINGS: MSUS effectively detects subclinical musculoskeletal inflammation in patients with psoriasis; however, some of these lesions are non-specific and can be found in healthy individuals. Preliminary evidence suggest that subclinical sonographic findings may predict progression to PsA in psoriasis patients. MSUS can also improve referrals' accuracy and its integration in the PsA classification criteria may improve early PsA detection. MSUS is a valuable tool for detecting subclinical abnormalities in psoriasis patients, which indicate an increased likelihood of progressing to PsA. Its integration into referral protocols and clinical use could improve PsA diagnosis. We propose an MSUS-inclusive algorithm for PsA referrals and triage, which requires validation. The potential of early intervention in reducing PsA progression in psoriasis patients with subclinical inflammation remains to be established.

Long-term outcomes of delayed clozapine initiation in treatment-resistant schizophrenia: a multicenter retrospective cohort study.

BACKGROUND: Clozapine is the only antipsychotic medication with proven efficacy against treatment-resistant schizophrenia. This multicenter retrospective cohort study aimed to evaluate the impact of a delay in clozapine initiation on long-term outcomes. METHODS: Patients who initiated clozapine treatment between July 2009 and December 2018 were included in this study. According to the length of time from the diagnosis of schizophrenia to clozapine initiation, the patients were categorized into one of three groups: early (≤ 9 years), intermediate (10-19 years), and late (≥ 20 years) initiation. The endpoints were psychiatric rehospitalization and all-cause clozapine discontinuation within 3 years. Hazard ratios (HR) and 95% confidence interval (CI) were estimated using the Fine and Gray method or the Cox proportional hazards model. RESULTS: The incidence rates of rehospitalization within three years, according to the cumulative incidence function, were 32.3% for early, 29.7% for intermediate, and 62.2% for late initiation, respectively. Late initiation had a significantly higher risk of psychiatric rehospitalization than early initiation (HR, 2.94; 95% CI, 1.01- 8.55; P = 0.016 by the Gray's test). The risk of psychiatric rehospitalization was not significantly different between the early and intermediate initiation groups. The incidence rate of all-cause clozapine discontinuation within three years using the Kaplan-Meier method was 13.0% for early, 10.6% for intermediate, and 20.1% for late initiation. The risk of all-cause clozapine discontinuation was not significantly among the groups. The late initiation group had more patients discontinuing because of death due to physical diseases than the other groups. CONCLUSIONS: The study suggests that clozapine should be initiated promptly in patients with treatment-resistant schizophrenia to prevent psychiatric rehospitalization during long-term treatment. Further prospective studies with appropriate consideration of confounding factors and large sample sizes are needed to strengthen the evidence.

Analyzing User-Generated Web-Based Posts of Adolescents' Emotional, Behavioral, and Symptom Responses to Beliefs About Depression: Qualitative Thematic Analysis.

BACKGROUND: Depression is common during adolescence. Early intervention can prevent it from developing into more progressive mental disorders. Combining information technology and clinical psychoeducation is a promising way to intervene at an earlier stage. However, data-driven research on the cognitive response to health information targeting adolescents with symptoms of depression is lacking. OBJECTIVE: This study aimed to fill this knowledge gap through a new understanding of adolescents' cognitive response to health information about depression. This knowledge can help to develop population-specific information technology, such as chatbots, in addition to clinical therapeutic tools for use in general practice. METHODS: The data set consists of 1870 depression-related questions posted by adolescents on a public web-based information service. Most of the posts contain descriptions of events that lead to depression. On a sample of 100 posts, we conducted a qualitative thematic analysis based on cognitive behavioral theory investigating behavioral, emotional, and symptom responses to beliefs associated with depression. RESULTS: Results were organized into four themes. (1) Hopelessness, appearing as a set of negative beliefs about the future, possibly results from erroneous beliefs about the causal link between risk factors and the course of depression. We found beliefs about establishing a sturdy therapy alliance as a responsibility resting on the patient. (2) Therapy hesitancy seemed to be associated with negative beliefs about therapy prognosis and doubts about confidentiality. (3) Social shame appeared as a consequence of impaired daily function when the cause is not acknowledged. (4) Failing to attain social interaction appeared to be associated with a negative symptom response. In contrast, actively obtaining social support reduces symptoms and suicidal thoughts. CONCLUSIONS: These results could be used to meet the clinical aims stated by earlier psychoeducation development, such as instilling hope through direct reattribution of beliefs about the future; challenging causal attributions, thereby lowering therapy hesitancy; reducing shame through the mechanisms of externalization by providing a tentative diagnosis despite the risk of stigmatizing; and providing initial symptom relief by giving advice on how to open up and reveal themselves to friends and family and balance the message of self-management to fit coping capabilities. An active counseling style advises the patient to approach the social environment, demonstrating an attitude toward self-action.

Safety and efficacy of ultrasonography of tension after zone II flexor tendon repair: A randomized controlled trial.

BACKGROUND: Primary flexor tendon repairs of lacerations in zone II of the hand are fraught with problems. Traditionally, exercise (active and passive), orthoses, and physical agents are common interventions for the rehabilitation of patients experiencing these issues. One area of focus in this field is how to safely utilize tension to lengthen gliding distance following zone II injury. Finding effective solutions in this area is a key priority for improving patient outcomes and quality of life. PURPOSE: To identify the optimal immobilization position that meets safety standards for tension and is the most efficient, and consequently, to validate our clinical effectiveness. STUDY DESIGN: A cross-sectional study was adopted for the first part of the research (Research 1). A prospective, parallel, 2-group, randomized trial was conducted with concealed allocation and single blinding in the second part of the research (Research 2). METHODS: A total of 60 healthy adults were recruited to select the best-fit protective immobilization position in Research 1, which was confirmed by tendon tension (via Young's modulus) and excursion (via gliding distance). We then randomly assigned 45 patients after zone II flexor tendon repair into two groups in Research 2 to compare functional outcomes. The control group underwent the conventional modified Duran protocol with early passive motion, while the experimental group received the protocol (optimized by Research 1) with early active motion. Ultrasonography was used to measure the tension and excursion of the flexor tendons. The outcomes measured at 16 weeks post-repair included total active motion, strength, the Disabilities of the Arm, Shoulder and Hand, and Strickland scores. RESULTS: Three participants were unable to participate in Research 2 due to medical issues and poor attendance. The investigation found that the safe tendon threshold was 345.09 ± 87.74 kPa for partial active digital motion among the 60 participants. The optimal immobilization position requires the wrist to be neutral with a flexion angle of 30° at the metacarpophalangeal joint. The grip strengths (p = 0.012), ratio of grip strength (p = 0.015), the Disabilities of the Arm, Shoulder and Hand (p = 0.036), and total active motion (p = 0.023) differed significantly between the two groups. CONCLUSIONS: Protective immobilization of the wrist in a neutral flexion position and with the metacarpophalangeal joint flexed at 30° can secure the repaired flexor tendon safely and efficiently. The effects of an early active motion protocol may improve the grip strength and upper limb mobility of individuals after zone II flexor tendon repair. CLINICAL TRIAL REGISTRATION: ChiCTR2000030592.

Aberrant Salience Inventory: A meta-analysis to investigate its psychometric properties and identify screening cutoff scores.

INTRODUCTION: The Aberrant Salience Inventory (ASI) is a useful tool to measure salience abnormalities among the general population. There is strong clinical and scientific evidence that salience alteration is linked to psychosis. To the present day, no meta-analysis evaluating ASI's psychometric properties and screening potential has been published. MATERIALS AND METHODS: PubMed, Google Scholar, Scopus, and Embase were searched using terms including "psychosis," "schizophrenia," and "Aberrant Salience Inventory." Observational and experimental studies employing ASI on populations of non-psychotic controls and patients with psychosis were included. ASI scores and other demographic measures (age, gender, ethnicity) were extracted as outcomes. Individual patients' data (IPD) were collected. Exploratory factor analysis (EFA) was performed on the IPD. RESULTS: Eight articles were finally included in the meta-analysis. ASI scores differ significantly between psychotic and non-psychotic populations; a novel three-factor model is proposed regarding subscales structure. Theoretical positive predictive values (PPVs) and negative predictive values (NPVs) were calculated and presented together with different cutoff points depending on preselected specific populations of interest. DISCUSSION: PPV and NPV values reached levels adequate for ASI to be considered a viable screening tool for psychosis. The factor analysis highlights the presence of a novel subscale that was named "Unveiling experiences." Implications regarding the meaning of the new factor structure are discussed, as well as ASI's potential as a screening tool.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis.

OBJECTIVES: We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted. REVIEW METHODS: Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS. RESULTS: The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference. CONCLUSION: Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Sexual risk behaviour reduction interventions in primary care in Organization of Economic Cooperation and Development countries. A systematic review.

BACKGROUND: Sexually transmitted infections are a major public health issue, both in France and worldwide. Primary healthcare professionals play a key role in sexual health and prevention, but few take on this subject. Prevention strategies are diverse, thus risk reduction strategies focussing on behavioural changes are still needed. PURPOSE: We conducted a systematic review to analyse risk reduction interventions focussing on behavioural change in OECD countries in primary healthcare settings to help develop a prevention tool easy to apply in primary care. METHODS: We searched for English- or French-language controlled trials in PubMed, Cochrane Library, Scopus, PsycINFO, PsycArticle, PBSC, SocINDEX, Google Scholar, and CAIRN, supplemented with the bibliographies of previous systematic reviews. Thirty controlled, randomized, or nonrandomized trials were included in the systematic review. We did not conduct any meta-analysis due to the diversity of populations, outcomes and study designs. RESULTS: There are efficient interventions in primary healthcare settings for reducing sexual risk behaviours and/or incident STI. Their efficiency seems to grow with the length and intensity of the intervention. Most interventions target only young, high-risk patients, and their long-term impact is uncertain. Most included studies had an overall risk of bias estimated as high or with some concerns. CONCLUSIONS: Some tools could be used in primary care, with possible efficiency though results are difficult to generalize, and value should be assessed in daily practice. Future research should also focus on older population given the epidemiological evolutions, but also lower-risk population to target all patients seen in primary care settings.

Impeding and facilitating factors for the implementation of alcohol interventions in hospitals: a qualitative and exploratory study among Dutch healthcare professionals.

BACKGROUND: Non-moderated alcohol use is more prevalent among hospitalized patients compared to the general population. However, many hospitals fail to find and intervene with people with alcohol problems. We aimed to conduct an exploration of impeding and facilitating factors experienced by healthcare professionals in implementation of alcohol interventions in Dutch general hospitals. In addition, we explored the alcohol interventions used in the selected hospitals and involved stakeholders. METHODS: Through a qualitative study, semi-structured telephone interviews were conducted with twenty healthcare professionals working in or in collaboration with six different general hospitals. RESULTS: Healthcare professionals indicated impeding and facilitating factors in the areas of motivation, knowledge and skills, patient characteristics, protocol, internal and external collaboration/support, resources, role suitability and societal support. Five different categories of approaches to identify and intervene with non-moderated alcohol use and 18 involved stakeholders from both inside and outside the hospital were found. CONCLUSIONS: Implementation of alcohol interventions for patients in Dutch general hospitals still seems to be in its infancy. Respondents emphasized the importance of one clear protocol on how to tackle alcohol problems within their hospital, repeated training on alcohol-related knowledge and skills, (clinical) "champions" that support healthcare professionals and developing and maintaining collaborations with stakeholders within and outside the hospital.

Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care.

BACKGROUND: Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence. MATERIALS AND METHODS: Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral. RESULTS: Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites. CONCLUSIONS: Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care. IMPLICATIONS FOR PRACTICE: Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

Finding Relevant Psychoeducation Content for Adolescents Experiencing Symptoms of Depression: Content Analysis of User-Generated Online Texts.

BACKGROUND: Symptoms of depression are frequent in youth and may develop into more severe mood disorders, suggesting interventions should take place during adolescence. However, young people tend not to share mental problems with friends, family, caregivers, or professionals. Many receive misleading information when searching the internet. Among several attempts to create mental health services for adolescents, technological information platforms based on psychoeducation show promising results. Such development rests on established theories and therapeutic models. To fulfill the therapeutic potential of psychoeducation in health technologies, we lack data-driven research on young peoples' demand for information about depression. OBJECTIVE: Our objective is to gain knowledge about what information is relevant to adolescents with symptoms of depression. From this knowledge, we can develop a population-specific psychoeducation for use in different technology platforms. METHODS: We conducted a qualitative, constructivist-oriented content analysis of questions submitted by adolescents aged 16-20 years to an online public information service. A sample of 100 posts containing questions on depression were randomly selected from a total of 870. For analysis, we developed an a priori codebook from the main information topics of existing psychoeducational programs on youth depression. The distribution of topic prevalence in the total volume of posts containing questions on depression was calculated. RESULTS: With a 95% confidence level and a ±9.2% margin of error, the distribution analysis revealed the following categories to be the most prevalent among adolescents seeking advice about depression: self-management (33%, 61/180), etiology (20%, 36/180), and therapy (20%, 36/180). Self-management concerned subcategories on coping in general and how to open to friends, family, and caregivers. The therapy topic concerned therapy options, prognosis, where to seek help, and how to open up to a professional. We also found young people dichotomizing therapy and self-management as opposite entities. The etiology topic concerned stressors and risk factors. The diagnosis category was less frequently referred to (9%, 17/180). CONCLUSIONS: Self-management, etiology, and therapy are the most prevalent categories among adolescents seeking advice about depression. Young people also dichotomize therapy and self-management as opposite entities. Future research should focus on measures to promote self-management, measures to stimulate expectations of self-efficacy, information about etiology, and information about diagnosis to improve self-monitoring skills, enhancing relapse prevention.

Understanding the pre-medical emergency team tier of a mature rapid response system: A content analysis of guidance documents.

BACKGROUND: The pre-medical emergency team (pre-MET) tier of rapid response systems (RRSs) includes extended activation criteria to identify earlier clinical deterioration and a ward-based patient review that is undertaken by the affected patient's admitting team or covering doctors. There is limited understanding of the structure and processes of the pre-MET RRS tier that are expected to guide clinicians' actions and subsequent patient safety outcomes. OBJECTIVE: The aim of the study was to describe the structure and processes of the pre-MET RRS tier in one acute care setting. METHODS: An exploratory descriptive design involving document analysis was used. Guidance documents (policies, procedures, guidelines, charts, educational materials) were obtained from one health service with a mature, multitiered RRS in Melbourne, Australia. Documents were analysed using content analysis. Concept- and data-driven approaches were used to construct a coding frame. RESULTS: Nineteen guidance documents supporting the pre-MET RRS tier on general wards were analysed. The coding frame consisted of seven main categories: Defining the Pre-MET RRS Tier, Essential Resources for Operationalisation, Recognising Pre-MET Events, Pathways for Activation, Exceptions to the Rule, Clinician Responses to Pre-MET Events, and Recording Pre-MET Events. The structures and processes of the pre-MET RRS tier were largely consistent with national guidelines, but there were internal inconsistencies in pre-MET activation criteria and unclear recommendations for modifying criteria. Pathways for activating the pre-MET RRS tier were complex and involved many steps, including validation processes before escalation of care to doctors. Responses to pre-MET events were seldom aligned to specific clinician types or groups, with nurses and allied health clinicians being under-represented. CONCLUSIONS: We identified opportunities to improve guidance documents supporting the pre-MET RRS tier that may assist other health services engaged in planning or evaluating pre-MET strategies. Further research is needed to understand clinicians' use of the pre-MET RRS tier to inform targeted strategies to optimise its design and implementation.

Implementing screening, brief intervention and referral to treatment in a French cohort of people living with HIV: a pilot study.

OBJECTIVES: Screening, brief intervention and referral to treatment (SBIRT) is an evidence-based practice used to identify, reduce and prevent problematic use and abuse of, and dependence on, tobacco, alcohol and psychoactive substances. To date, the pertinence of this practice among people living with HIV (PLHIV) is unknown. In this pilot study, we aimed to assess the acceptability of SBIRT in a cohort of HIV-infected out-patients who were asked about their consumption of alcohol, tobacco and psychoactive substances. METHODS: A monocentric study was performed at the University Hospital of Montpellier. In a 6-month period, 20 trained physicians screened for the consumption of alcohol [using the Alcohol Use Disorders Identification Test (AUDIT)], tobacco (using the Short Fagerstrom Test) and psychoactive substances [using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) V3.0] via an auto-questionnaire and proposed a brief intervention to patients with misusage. RESULTS: One thousand and eighteen PLHIV completed the questionnaire, and 861 [84.6%; 95% confidence interval (CI) 82.2-86.7%] PLHIV returned it to the physician. Among the latter, 650 patients wished to discuss the answers with their physician (75.5%; 95% CI 72.5-78.3%), and brief interventions were realized in 405 patients (62.3%). CONCLUSIONS: SBIRT is a simple screening and harm reduction tool that is well accepted by PLHIV in out-patient clinics. This method could be implemented in routine HIV care to screen and manage patients systematically for harmful substance use.

Barriers and facilitators to the implementation of brief interventions targeting smoking, nutrition, and physical activity for indigenous populations: a narrative review.

OBJECTIVE: This narrative review aimed to identify and categorize the barriers and facilitators to the provision of brief intervention and behavioral change programs that target several risk behaviors among the Indigenous populations of Australia, Canada, and New Zealand. METHODS: A systematic database search was conducted of six databases including PubMeD, Embase, CINAHL, HealthStar, PsycINFO, and Web of Science. Thematic analysis was utilized to analyze qualitative data extracted from the included studies, and a narrative approach was employed to synthesize the common themes that emerged. The quality of studies was assessed in accordance with the Joanna Briggs Institute's guidelines and using the software SUMARI - The System for the Unified Management, Assessment and Review of Information. RESULTS: Nine studies were included. The studies were classified at three intervention levels: (1) individual-based brief interventions, (2) family-based interventions, and (3) community-based-interventions. Across the studies, selection of the intervention level was associated with Indigenous priorities and preferences, and approaches with Indigenous collaboration were supported. Barriers and facilitators were grouped under four major categories representing the common themes: (1) characteristics of design, development, and delivery, (2) patient/provider relationship, (3) environmental factors, and (4) organizational capacity and workplace-related factors. Several sub-themes also emerged under the above-mentioned categories including level of intervention, Indigenous leadership and participation, cultural appropriateness, social and economic barriers, and design elements. CONCLUSION: To improve the effectiveness of multiple health behavior change interventions among Indigenous populations, collaborative approaches that target different intervention levels are beneficial. Further research to bridge the knowledge gap in this topic will help to improve the quality of preventive health strategies to achieve better outcomes at all levels, and will improve intervention implementation from development and delivery fidelity, to acceptability and sustainability.

Renal denervation for mild-moderate treatment-resistant hypertension : A timely intervention?

BACKGROUND: Renal denervation (RDN) has been proposed as a novel antihypertensive intervention for treating resistant hypertension. It remains to be investigated which patient groups can potentially benefit from RDN. The present study aimed to evaluate the efficacy and safety of RDN in patients with mild-moderate resistant hypertension, i. e., systolic office blood pressure (BP) of 140-160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by ambulatory BP monitoring (ABPM) of 135-150 mm Hg. METHODS: We evaluated data from four relevant clinical studies, all conducted in Europe, comprising 185 eligible patients. The patients' age was 62.1 ± 10.3 years and 73% were male (RDN group n = 149, control group n = 36). RESULTS: A self-control comparison showed that RDN led to significantly reduced ABPM at the 6­month follow-up (systolic ABPM: 147.3 ± 13.4 mm Hg vs. 136.9 ± 15.5 mm Hg; diastolic ABPM: 81.1 ± 9.6 mm Hg vs. 76.2 ± 9.7 mm Hg; p < 0.001). RDN was associated with a greater improvement in ABPM as compared with that in the control group (∆systolic-ABPM: -10.4 ± 9.4 vs. -3.5 ± 9.6 mm Hg, p < 0.001; ∆diastolic-ABPM: -5 ± 5.8 vs. -2.1 ± 5.5 mm Hg; p = 0.005, respectively). The decrease of office BP in the RDN group was also statistically significant. RDN led to a reduced number of antihypertensive medications. No severe adverse events were found during follow-up. Regression analysis showed that the available baseline characteristics did not correlate with the ABPM improvement after RDN. CONCLUSION: RDN appears to be a safe and effective intervention for patients with mild-moderate resistant hypertension; however, randomized studies are warranted.

A Web-Based Intervention (MotivATE) to Increase Attendance at an Eating Disorder Service Assessment Appointment: Zelen Randomized Controlled Trial.

BACKGROUND: Early assessment and treatment of eating disorder patients is important for patient outcomes. However, up to a third of people referred for treatment do not access services and 16.4% do not attend their first scheduled assessment appointment. MotivATE is a fully automated, novel, Web-based program intended to increase motivation to change eating disorder behaviors, designed for delivery at the point of invitation to an eating disorder service, with the aim of increasing service attendance. OBJECTIVE: This paper assesses the impact of MotivATE on attendance at assessment when compared with treatment-as-usual. METHODS: A Zelen randomized controlled design was used. All individuals referred to a specialist eating disorder service, Kimmeridge Court in Dorset, UK, over the course of a year (October 24, 2016-October 23, 2017) were randomized to treatment-as-usual only or treatment-as-usual plus an additional letter offering access to MotivATE. Attendance at the initial scheduled assessment appointment was documented. Logistic regression analysis assessed the impact of MotivATE on attendance at assessment. Additional analyses based on levels of engagement with MotivATE were also undertaken. RESULTS: A total of 313 participants took part: 156 (49.8%) were randomized to treatment-as-usual and 157 (50.2%) were randomized to receive the additional offer to access MotivATE. Intention-to-treat analysis between conditions showed no impact of MotivATE on attendance at assessment (odds ratio [OR] 1.35, 95% CI 0.69-2.66, P=.38). Examination of the usage data indicated that only 53 of 157 participants (33.8%) in the MotivATE condition registered with the Web-based intervention. An analysis comparing those that registered with the intervention with those that did not found greater attendance at assessment in those that had registered (OR 9.46, 95% CI 1.22-73.38, P=.03). CONCLUSIONS: Our primary analyses suggest no impact of MotivATE on attendance at the first scheduled assessment appointment, but secondary analyses revealed limited engagement with the program and improved attendance in those who did engage. It is unclear, however, if engagement with the program increased motivation and, in turn, attendance or if more motivated individuals were more likely to access the intervention. Further research is required to facilitate engagement with Web-based interventions and to understand the full value of MotivATE for users. TRIAL REGISTRATION: ClinicalTrials.gov NCT02777944; https://clinicaltrials.gov/ct2/show/NCT02777944 (Archived by WebCite at http://www.webcitation.org/75VDEFZZ4).

Improving motivation to change amongst individuals with eating disorders: A systematic review.

OBJECTIVE: People with eating disorders can have low motivation to change their eating disorder behaviors. Interventions aiming to enhance motivation to change have been increasingly advocated in their treatment. Questions remain regarding the strength of the evidence supporting the effectiveness of interventions that specifically focus on improving motivation. This review explored the evidence for improving motivation to change in eating disorders via clinical interventions. METHOD: Searches of the published and unpublished literature were conducted by searching databases (PubMed, PsychInfo, Web of Science) and trial registries (WHO ICTRP), and by contacting authors. Studies were included if they investigated an intervention for eating disorder patients, included a pre-post outcome measure of motivation to change and were published in English. Risk of bias was also assessed. RESULTS: Forty-two studies were included in the final review. Evidence was found to support the use of interventions to improve motivation to change, though it was unclear whether motivational interventions present a more effective option than approaches that do not exclusively or specifically focus on motivation. However, motivational interventions were identified as being more effective than low intensity treatments. Risk of bias in included studies was generally high. DISCUSSION: Motivation was found to increase across treatments in general, whether or not the focus of the intervention was on enhancing motivation. It is unclear if interventions specifically targeting motivation to change provide additional benefit over and above established treatment approaches.

Academic Physical Medicine and Rehabilitation Acute Care Consultations.

The objective of this study was to describe the provision of Physical Medicine and Rehabilitation acute care consultations in the United States and Canada. Physical Medicine and Rehabilitation department chairs/division directors at academic centers in Canada and the United States were mailed an 18-item questionnaire. Seven of 13 (54%) Canadian and 26/78 (33%) American surveys were returned. A majority of Canadian and American academic institutions provide acute care consultations; however, there were some national differences. American institutions see larger volumes of patients, and more American respondents indicated using a dedicated acute care consultation service model compared with Canadians.

The Global Spine Care Initiative: a review of reviews and recommendations for the non-invasive management of acute osteoporotic vertebral compression fracture pain in low- and middle-income communities.

PURPOSE: The purpose of this review was to develop recommendations for non-invasive management of pain due to osteoporotic vertebral compression fractures (OVCF) that could be applied in medically underserved areas and low- and middle-income countries. METHODS: We conducted a systematic review and best evidence synthesis of systematic reviews on the non-invasive management of OVCF. Eligible reviews were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Low risk of bias systematic reviews and high-quality primary studies that were identified in the reviews were used to develop recommendations. RESULTS: From 6 low risk of bias systematic reviews and 14 high-quality primary studies we established that for acute pain management, in addition to rest and analgesic medication, orthoses may provide temporary pain relief, in addition to early mobilization. Calcitonin can be considered as a supplement to analgesics; however, cost is of concern. Once acute pain control is achieved, exercise can be effective for improving function and quality of life. CONCLUSION: The findings from this study will help to inform the GSCI care pathway and model of care for use in medically underserved areas and low- and middle-income countries. Conservative management of acute pain and recovery of function in adults with OVCF should include early mobilization, exercise, spinal orthosis for pain relief, and calcitonin for analgesic-refractory acute pain. These slides can be retrieved under Electronic Supplementary Material.

Web-Based Health Intervention for Young People Who Have a Parent with a Mental Illness: Delphi Study Among Potential Future Users.

BACKGROUND: Young people who have a parent with a mental illness face elevated risks to their mental health and well-being. However, they may not have access to appropriate interventions. Web-based interventions may reach and meet the needs of this at-risk group, yet their preferences regarding the features of this medium are unknown. OBJECTIVE: This study sought to determine the utility of a Web-based intervention to meet the needs of young people who have a parent with a mental illness and their perspectives regarding the types of features of such a website. METHODS: A systematic, 2-round Delphi study was employed to solicit the views of 282 young people aged 16 to 21 years (Round 1, n=14; Round 2, n=268) from urban and regional settings in Australia who self-reported that their parent has a mental illness. "Regional" was used to refer to nonurban participants in the study. After ascertaining whether a Web-based intervention was warranted, Web-based intervention features were identified, including how the site might be facilitated, topics, duration and frequency, and the nature of the professional contact. The extent to which young people agreed on the importance of these factors was assessed. Differences and similarities across gender and location were investigated. A mixed method analytic framework was employed using thematic analysis as well as 2-way between-groups analysis of covariance (ANCOVA) controlling for age and chi-square test of independence analysis. RESULTS: Both rounds highlighted a strong preference for a Web-based intervention. Consensus was reached for a professionally monitored site, young people and professionals having equal input into the weekly facilitated sessions (eg, sharing the lead role in discussions or deciding on relevant session content), unlimited time access, 1-hour, open discussion, weekly sessions over 6 weeks, psychoeducation about mental illness, and considerations for the management of safety violations. There were significant main effects of location type and several of the preferred features for a Web-based intervention for young people who have a parent with a mental illness. However, effect sizes were small to moderate, limiting practical application. CONCLUSIONS: Young people aged 16 to 21 years indicated a need for a professionally monitored, psychoeducational, Web-based intervention, with input from professional facilitators and other young people who have a parent with a mental illness, in addition to recommendations to external resources. These findings may inform the development of future Web-based interventions for this highly vulnerable group.

Complaint-Directed Mini-Interventions for Depressive Symptoms: A Health Economic Evaluation of Unguided Web-Based Self-Help Interventions Based on a Randomized Controlled Trial.

BACKGROUND: Depression prevention and early intervention have become a top priority in the Netherlands, but with considerable room for improvement. To address this, Web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression, and have substantial economic impact. OBJECTIVE: The objective of this economic evaluation was to examine the added value of Web-based, unguided, self-help CDMIs compared with a wait-listed control group with unrestricted access to usual care from both a societal and a health care perspective. METHODS: This health economic evaluation was embedded in a randomized controlled trial. The study entailed 2 arms, in which 3 Web-based CDMIs were compared with a no-intervention waiting-list control group (which received the intervention after 3 months). We conducted measurements at baseline, and at 3 and 6 months. The primary outcome was the rate of responders to treatment on depressive symptoms as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). We estimated change in quality of life by calculating effect sizes (Cohen d) for individual pre- and posttreatment IDS-SR scores using a conversion factor to map a change in standardized effect size onto a corresponding change in utility. We calculated incremental cost-effectiveness ratios using bootstraps (5000 times) of seemingly unrelated regression equations and constructed cost-effectiveness acceptability curves for the costs per quality-adjusted life-year (QALY) gained. RESULTS: Of 329 study participants, we randomly assigned 165 to the CDMI group. At 3 months, the rate of responders to treatment was 13.9% (23/165) in the CDMI group and 7.3% (12/164) in the control group. At 3 months, participants in the CDMI group gained 0.15 QALYs compared with baseline, whereas participants in the control group gained 0.03 QALYs. Average total costs per patient at 3 months were €2094 for the CDMI group and €2230 for the control group (excluding baseline costs). Bootstrapped seemingly unrelated regression equations models resulted in a dominant incremental cost-effectiveness ratio (ie, lower costs and a higher rate of responders to treatment) for the CDMI group compared with the control group at 3 months, with the same result for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. CONCLUSIONS: Brief and low-threshold Web-based, unguided, self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild to moderate depressive symptoms. The CDMIs improved health status, while reducing participant health care costs, and hence dominated the care-as-usual control condition. As intervention costs were relatively low, and the internet is readily available in the Western world, we believe CDMIs can be easily implemented on a large scale. TRIAL REGISTRATION: Netherlands Trial Register NTR4612; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4612 (Archived by WebCite at http://www.webcitation.org/6n4PVYddM).