Is Preemptive Kidney Transplantation Associated With Improved Outcomes when Compared to Non-preemptive Kidney Transplantation in Children? A Systematic Review and Meta-Analysis.

Main Problem: Preemptive kidney transplantation (PKT) is performed prior to dialysis initiation to avoid dialysis-related morbidity and mortality in children and adolescents. We undertook a systematic review to compare clinical outcomes in PKT versus kidney transplantation after dialysis initiation in paediatric patients. Methods: The bibliographic search identified studies that compared paediatric recipients of a first or subsequent, living or deceased donor PKT versus non-preemptive kidney transplant. Methodological quality was assessed for all studies. Data were pooled using the random-effects model. Results: Twenty-two studies (n = 22,622) were included. PKT reduced the risk of overall graft loss (relative risk (RR) .57, 95% CI: .49-.66) and acute rejection (RR: .81, 95% CI: .75-.88) compared to transplantation after dialysis. Although no significant difference was observed in overall patient mortality, the risk of patient death was found to be significantly lower in PKT patients with living donor transplants (RR: .53, 95% CI: .34-.83). No significant difference was observed in the incidence of delayed graft function. Conclusion: Evidence from observational studies suggests that PKT is associated with a reduction in the risk of acute rejection and graft loss. Efforts should be made to promote and improve rates of PKT in this group of patients (PROSPERO). Systematic Review Registration: https://clinicaltrials.gov/, CRD42014010565.

Shedding of Hepatitis C Virus Into the Rectum of HIV-infected Men Who Have Sex With Men.

BACKGROUND: For over a decade we have known of an epidemic of sexually transmitted hepatitis C virus (HCV) infection among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM), but there still remains significant controversy over which bodily fluid(s) are responsible for HCV transmission in these men. METHODS: We enrolled HIV-infected MSM with recent and chronic HCV infection and quantified HCV from rectal fluid obtained by blind swab. We compared the rectal HCV viral load (VL) with paired blood HCV VL. RESULTS: We found rectal HCV shedding in 20 (47%) of 43 men, only one (2%) of whom had visible bleeding. Detection of rectal HCV shedding was associated with blood VL > 5 log10 IU/mL (p = .01), and 85% with blood VL > 5 log10 IU/mL had rectal shedding. The HCV VL of the rectal fluid ranged from 2.6 to 5.5 log10 IU/mL. Based on the median rectal fluid VL, the surface of an average human penis would be exposed to at least 2,300 IU of HCV for the duration of anal intercourse. CONCLUSION: This study provides the first direct evidence to our knowledge that a sufficient quantity of HCV is shed into the rectum in HIV-infected men with HCV infection to directly infect an inserted penis or be passed indirectly through fomite-like transmission to the rectum of sex partner. We must develop an appropriate public health campaign to educate MSM about these routes of HCV infection to reverse the HCV epidemic among HIV-infected MSM.

Doppler ultrasound surveillance of recently formed haemodialysis arteriovenous fistula: the SONAR observational cohort study.

Background: Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure. Objective: To assess the feasibility of performing a randomised controlled trial that examines whether, by informing early and effective salvage intervention of fistulas that would otherwise fail, Doppler ultrasound surveillance of developing arteriovenous fistulas improves longer-term arteriovenous fistula patency. Design: A prospective multicentre observational cohort study (the 'SONAR' study). Setting: Seventeen haemodialysis centres in the UK. Participants: Consenting adults with end-stage renal disease who were scheduled to have an arteriovenous fistula created. Intervention: Participants underwent Doppler ultrasound surveillance of their arteriovenous fistulas at 2, 4, 6 and 10 weeks after creation, with clinical teams blinded to the ultrasound surveillance findings. Main outcome measures: Fistula maturation at week 10 defined according to ultrasound surveillance parameters of representative venous diameter and blood flow (wrist arteriovenous fistulas: ≥ 4 mm and > 400 ml/minute; elbow arteriovenous fistulas: ≥ 5 mm and > 500 ml/minute). Mixed multivariable logistic regression modelling of the early ultrasound scan data was used to predict arteriovenous fistula non-maturation by 10 weeks and fistula failure at 6 months. Results: A total of 333 arteriovenous fistulas were created during the study window (47.7% wrist, 52.3% elbow). By 2 weeks, 37 (11.1%) arteriovenous fistulas had failed (thrombosed), but by 10 weeks, 219 of 333 (65.8%) of created arteriovenous fistulas had reached maturity (60.4% wrist, 67.2% elbow). Persistently lower flow rates and venous diameters were observed in those fistulas that did not mature. Models for arteriovenous fistulas' non-maturation could be optimally constructed using the week 4 scan data, with fistula venous diameter and flow rate the most significant variables in explaining wrist fistula maturity failure (positive predictive value 60.6%, 95% confidence interval 43.9% to 77.3%), whereas resistance index and flow rate were most significant for elbow arteriovenous fistulas (positive predictive value 66.7%, 95% confidence interval 48.9% to 84.4%). In contrast to non-maturation, both models predicted fistula maturation much more reliably [negative predictive values of 95.4% (95% confidence interval 91.0% to 99.8%) and 95.6% (95% confidence interval 91.8% to 99.4%) for wrist and elbow, respectively]. Additional follow-up and modelling on a subset (n = 192) of the original SONAR cohort (the SONAR-12M study) revealed the rates of primary, assisted primary and secondary patency arteriovenous fistulas at 6 months were 76.5, 80.7 and 83.3, respectively. Fistula vein size, flow rate and resistance index could identify primary patency failure at 6 months, with similar predictive power as for 10-week arteriovenous fistula maturity failure, but with wide confidence intervals for wrist (positive predictive value 72.7%, 95% confidence interval 46.4% to 99.0%) and elbow (positive predictive value 57.1%, 95% confidence interval 20.5% to 93.8%). These models, moreover, performed poorly at identifying assisted primary and secondary patency failure, likely because a subset of those arteriovenous fistulas identified on ultrasound surveillance as at risk underwent subsequent successful salvage intervention without recourse to early ultrasound data. Conclusions: Although early ultrasound can predict fistula maturation and longer-term patency very effectively, it was only moderately good at identifying those fistulas likely to remain immature or to fail within 6 months. Allied to the better- than-expected fistula patency rates achieved (that are further improved by successful salvage), we estimate that a randomised controlled trial comparing early ultrasound-guided intervention against standard care would require at least 1300 fistulas and would achieve only minimal patient benefit. Trial Registration: This trial is registered as ISRCTN36033877 and ISRCTN17399438. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135572) and is published in full in Health Technology Assessment; Vol. 28, No. 24. See the NIHR Funding and Awards website for further award information.

For people with advanced kidney disease, haemodialysis is best provided by an 'arteriovenous fistula', which is created surgically by joining a vein onto an artery at the wrist or elbow. However, these take about 2 months to develop fully ('mature'), and as many as 3 out of 10 fail to do so. We asked whether we could use early ultrasound scanning of the fistula to identify those that are unlikely to mature. This would allow us to decide whether it would be practical to run a large, randomised trial to find out if using early ultrasound allows us to 'rescue' fistulas that would otherwise fail. We invited adults to undergo serial ultrasound scanning of their fistula in the first few weeks after it was created. We then analysed whether we could use the data from the early scans to identify those fistulas that were not going to mature by week 10. Of the 333 fistulas that were created, about two-thirds reached maturity by week 10. We found that an ultrasound scan 4 weeks after fistula creation could reliably identify those fistulas that were going to mature. However, of those fistulas predicted to fail, about one-third did eventually mature without further intervention, and even without knowing what the early scans showed, another third were successfully rescued by surgery or X-ray-guided treatment at a later stage. Performing an early ultrasound scan on a fistula can provide reassurance that it will mature and deliver trouble-free dialysis. However, because scans are poor at identifying fistulas that are unlikely to mature, we would not recommend their use to justify early surgery or X-ray-guided treatment in the expectation that this will improve outcomes.

Transitioning to the radial artery as the preferred access site for cardiac catheterization: an academic medical center experience.

OBJECTIVES: To evaluate procedural and safety metrics of transradial (TR) versus transfemoral (TF) cardiac catheterization (CATH) and percutaneous coronary interventions (PCI) during a complete institutional transition from TF to TR as the preferred access. BACKGROUND: The TR approach has been shown to reduce complications compared to TF for CATH and PCI, but concerns of longer procedure times have limited utilization in the United States. METHODS: 4,172 consecutive CATH and PCI procedures were performed (2,665 TF; 1,507 TR) at Wake Forest Baptist Medical Center from January 2009 to November 2010. We assessed in-hospital procedural and safety metrics. RESULTS: After 6 months of a preferred TR strategy, TR to TF crossover rate was 9.1%, and 65% of all cases were TR procedures. For the cath lab (all TF + TR), we observed small but significant increases in procedural metrics for Preferred TR (last third) compared to Preferred TF (first third). This appeared to be due to increased access times, procedure length, fluoroscopy times, and contrast use for TR versus TF (propensity score matched). Nonetheless, over the course of the study, there was a trend for a decrease in all procedural metrics with TR use. Access site complications (2.3% TF, 1.2% TR) and bleeding (2.5% TF, 2.1% TR), both P < 0.05, decreased over the course of the study. CONCLUSIONS: Our observations support the concept that complete transition of a cath lab to a preferred TR strategy is feasible, achieves lower rates of vascular and bleeding complications but with modest increases in overall procedural metrics.

Evaluation of Tissue Apposition and Seroma Prevention in an Ovine Model of Surgical Dead Space Using a Novel Air-Purged Vacuum Closure System.

Background: Postoperative complications associated with seroma formation resulting from surgical dead space continue to present a challenge in modern surgery. There is an unmet need for new technologies that address surgical dead space as well as prevent seroma formation and associated downstream postoperative complications. Methods: The novel implantable tissue apposition and drainage system ENIVO was developed and tested in a bilateral ovine external abdominal oblique (EAO) resection model of surgical dead space. The ENIVO system is a portable powered pump and wound interface featuring air-purged vacuum closure (APVC) that delivers a sustained level of vacuum pressure (80 and 100 mmHg) to the treatment site with an intermittent burst of sterile filtered air through the implanted wound interface. Seroma area, seroma volume, and drain migration were assessed at postoperative days 7 and 14, and all animals were euthanized at day 28 with gross assessment of treatment efficacy including the presence of residual seroma and tissue apposition. Results: The bilateral model created relatively uniform defects of ~120 cm2 following excision of ~30 to 50 g of EAO muscle. Median seroma area of ENIVO-treated defects was statistically smaller than standard of care (SoC)-treated defects at days 7 and 14. Median seroma volume at 14 days was significantly reduced in ENIVO-treated defects relative to SoC-treated defects [1.3 (IQR 0.0-79.5) mL and 188.5 (IQR 27.6-342.9) mL, respectively]. At postoperative day 28, 40% (n = 4/10) of SoC defects showed a residual seroma, whereas in contrast, none of the ENIVO-treated defects showed signs of a residual seroma. Median tissue apposition scoring was higher in the ENIVO treatment group [3 (IQR 3-3)] compared with the SoC group [3 (IQR 0-3)]. Conclusions: The ENIVO system represents a new approach to dead space management and seroma prevention and was shown to outperform a SoC surgical drain in a challenging large defect model of surgical dead space management and seroma prevention.

Chronic kidney disease and dipstick proteinuria are risk factors for stent thrombosis in patients with myocardial infarction.

BACKGROUND: Kidney failure (stage 5 chronic kidney disease [CKD]) is an independent risk factor for stent thrombosis (ST). Moderate (stage 3-4) CKD and proteinuria are both associated with adverse cardiovascular events, including worse outcomes after myocardial infarction (MI). Whether moderate CKD and proteinuria increase the risk of ST after MI is not known. This study evaluated the risk of ST associated with moderate CKD and dipstick proteinuria. METHODS: We retrospectively analyzed clinical and laboratory data from 956 non-stage 5 CKD patients who were admitted with MI and received intracoronary stenting. Clinical follow-up was collected at 1 year for definite or probable ST, as well as for all-cause mortality, nonfatal MI or death, and target vessel revascularization or coronary artery bypass graft surgery. RESULTS: After adjustment for multiple clinical and biochemical covariates, patients with both estimated glomerular filtration rate (GFR) of 15 to 59 mL min(-1) 1.73 m(-2) and > or =30 mg/dL dipstick proteinuria had increased cumulative incidence of ST (hazard rate [HR] 3.69, 95% CI 1.54-8.89), all-cause mortality (HR 2.68, 95% CI 1.34-5.37), and nonfatal MI or death (HR 3.20, 95% CI 1.77-5.81) at 1 year. In addition, estimated GFR of 15 to 59 mL min(-1) 1.73 m(-2) was a significant independent predictor of ST (HR 2.61, 95% CI 1.33-5.10). Dipstick proteinuria > or =30 mg/dL was associated with a trend toward increased risk for all outcomes. CONCLUSIONS: In an acute MI population, moderate CKD was identified as a novel prognostic marker for ST. In addition, patients with both decreased GFR and proteinuria had higher incidences of all-cause mortality and nonfatal MI or death than patients with either condition alone.

Effective communication with older people.

Effective communication with older people is an important aspect of nursing practice. Ineffective communication can lead to older people feeling inadequate, disempowered and helpless. Nurses have a duty to ensure that older people think they are being listened to and that their concerns are being validated in a non-judgemental way. Central to effective communication is the ability of nurses to be self-aware, and monitor their thoughts and feelings about, for example, negative stereotypes associated with the ageing process. Effective communication can sometimes be difficult to achieve due to the effects of ageing, but nurses can overcome some barriers through thoughtful interventions. It is important to treat older people as individuals, and to monitor and adapt communication accordingly. By doing so, nurses can ensure older people feel empowered, respected and able to maintain their independence.

Routine hematologic clinical tests as prognostic markers in patients with acute coronary syndromes.

Prognostic markers are needed to identify patients with acute coronary syndrome (ACS) who are at high risk for adverse events. Although the search for new biomarkers is quite active, prognostic information is available from routine hematologic tests, such as the complete blood count. For example, elevated white blood cell counts during ACS are associated with increased risk of mortality, heart failure, shock, and left ventricular dysfunction. Anemia is associated with increased risk of mortality, whereas elevated platelet counts predict poorer clinical and angiographic outcomes. In this review, we summarize the literature regarding the use of clinical hematology tests including white blood cell count, hemoglobin and hematocrit values, and platelet count as prognostic markers in patients with ACS, and we describe potential mechanisms to explain these associations.

Derived fibrinogen compared with C-reactive protein and brain natriuretic peptide for predicting events after myocardial infarction and coronary stenting.

BACKGROUND: After myocardial infarction (MI), biomarkers can be helpful to identify patients who might benefit from more intensive therapies. The prothrombin time-derived fibrinogen (PTDF) assay is widely available and relatively inexpensive. We determined whether PTDF predicts events in patients with MI and compared this assay with brain natriuretic peptide (BNP) and C-reactive protein (CRP). METHODS: We retrospectively analyzed data from 915 patients admitted with MI. Follow-up was collected at 1 year for major adverse cardiac events (MACE) defined as death from any cause, nonfatal MI or death, target vessel revascularization, or coronary artery bypass grafting. RESULTS: Patients in the fourth quartile of PTDF were older and had more risk factors but fewer ST-elevation MI and lower peak troponin values. The fourth quartiles of PTDF, CRP, and BNP were associated with increased MACE compared with the first quartiles with hazard ratios of 2.08 (1.30-3.33), 1.94 (1.22-3.07), and 2.56 (1.57-4.18), respectively, findings that remained significant after adjustment. When outcomes by strata of PTDF were examined, CRP failed to add additional prognostic value. Higher BNP levels predicted MACE in the upper but not lower stratum of PTDF. CONCLUSION: In patients with MI, PTDF is a predictor of MACE at 1 year, with equivalent value compared to BNP and CRP. With low PTDF levels, neither BNP nor CRP adds prognostic value. At elevated PTDF values, higher BNP, but not CRP, identifies a higher-risk population. Therefore, PTDF can be substituted for CRP, with BNP being useful in the presence of elevated PTDF.

ABO blood types: influence on infarct size, procedural characteristics and prognosis.

INTRODUCTION: Patients with non-O blood groups have higher plasma von Willebrand factor (vWF) levels than those with type O. vWF mediates platelet adhesion, aggregation and thrombosis. These considerations likely explain the prior observations that non-O patients have higher rates of arterial and venous thromboembolic events. However, the effect of blood group status on size of MI, procedural findings and outcomes after PCI for MI have not been reported. METHODS: We analyzed 1198 patients who underwent percutaneous coronary intervention for acute myocardial infarction between 10/03 and 8/06, and who had ABO blood group status and clinical follow-up. RESULTS AND CONCLUSIONS: Patients with O blood type were slightly older (62 +/- 13 vs. 60 +/- 13 years; p = 0.017) had a higher prevalence of hypercholesterolemia (67% vs. 58%; p = 0.002), and had a higher burden of atherosclerosis with more vascular disease (17% vs. 13%; p = 0.017) and higher prevalence of previous PCI (22% vs. 17%; p = 0.025). Non-O blood group patients had larger infarcts as measured by median peak troponin (33 vs. 24; p = 0.037), total CK (721 vs. 532; p = 0.012) and CK-MB (101 vs. 68; p = 0.010). At PCI, non-O patients had increased visible thrombus and reduced TIMI flow pre-procedure. However, there were no differences in procedural success, in-hospital blood transfusion or occurrence of MACE at 1 year follow-up. Our data demonstrate that non-O compared to O blood groups patients have higher thrombus burden despite less extensive atherosclerosis. Nevertheless, outcomes at 1 year were similar.

Negative self-imagery among adolescents with social phobia: a test of an adult model of the disorder.

Based on findings from the adult literature, this study examined the role of negative self-images (NSI) in social phobia during adolescence. NSI was manipulated among 21 nonphobic (IMAG) adolescents (M age = 14.05 years, SD = 1.56) during two social tasks. Self and observer-rated anxiety and performance as well as co-occurring cognition were compared to 21 adolescents with social phobia (SOC) and 21 control adolescents not instructed to use self-imagery. Few differences in observer-rated anxiety or performance were found between the IMAG and control groups, whereas SOC adolescents were consistently rated as more anxious and poorer social performers. Nonsignificantly higher rates of anxiety were reported by the IMAG group compared to controls, but anxiety was not associated with decrements in performance or social skill. A significantly fewer number of on-task thoughts reported by IMAG adolescents suggests that inability to attend to the interaction itself, rather the presence of NSI, served to increase anxiety.

SET-C versus fluoxetine in the treatment of childhood social phobia.

OBJECTIVE: To determine the efficacy of fluoxetine, pill placebo, and Social Effectiveness Therapy for Children (SET-C) for children and adolescents with social phobia. METHOD: Youths ages 7 to 17 were randomly assigned to one of the treatment conditions. Outcome was evaluated using self-reports, parent ratings, independent evaluator ratings, and behavioral assessment. RESULTS: Both fluoxetine and SET-C were more efficacious than placebo in reducing social distress and behavioral avoidance and increasing general functioning. SET-C was superior to fluoxetine on each of these measures and was the only treatment superior to placebo in terms of improving social skills, decreasing anxiety in specific social interactions, and enhancing ratings of social competence. Furthermore, whereas fluoxetine appears to exert maximum effect by 8 weeks, SET-C provides continued improvement through week 12. CONCLUSIONS: Both fluoxetine and SET-C are efficacious for social phobia, although SET-C appears to provide added benefit by enhancing social skills.

Social anxiety disorder in childhood and adolescence: descriptive psychopathology.

Although the presentation of social anxiety disorder (SAD) in adults is well documented, less is known about its clinical manifestation in children and adolescents. To date, most studies have included combined samples of children and adolescents despite the fact that this age range represents an extensive period of growth and development. This study compares and contrasts the clinical presentation of SAD among children (ages 7-12) and adolescents (ages 13-17). One hundred and fifty children (n=74) and adolescents (n=76) with a primary diagnosis of SAD participated in the study. The assessment battery included clinical ratings and behavioral observation as well as parental and self-report. The results indicate that, although the symptom presentation of children and adolescents with primary SAD shares many features, children tend to present with a broader pattern of general psychopathology, while adolescents have a more pervasive pattern of social dysfunction and may be more functionally impaired as a result of their disorder. These findings suggest that interventions for SAD need to carefully consider clinical presentation of the disorder as it manifests in childhood and adolescence.

Development of an abbreviated Social Phobia and Anxiety Inventory (SPAI) using item response theory: the SPAI-23.

An abbreviated version of the Social Phobia and Anxiety Inventory (SPAI) was developed using methods based in nonparametric item response theory. Participants included a nonclinical sample of 1,482 undergraduates (52% female, mean age = 19.4 years) as well as a clinical sample of 105 individuals (56% female, mean age = 36.4 years) diagnosed with either generalized (73%) or specific social phobia (27%). Twenty-three of the 45 SPAI items demonstrated good discrimination along the social anxiety continuum. In addition, option characteristic curves (OCCs) indicated that the SPAI's 7-point scale may generate errors in ranking individuals. Thus, options were collapsed to improve item performance. No gender differences emerged between any of the items' OCCs, suggesting that items function similarly among men and women. The abbreviated version also correlated highly with the original 45-item SPAI and exhibited similar patterns of correlations with measures of social anxiety. The SPAI-23 has considerable practical benefits, including a screening of both social and agoraphobic anxiety as well as decreased assessment and scoring time.

Sofosbuvir in the treatment of early HCV infection in HIV-infected men.

BACKGROUND: There is an international epidemic of hepatitis C virus (HCV) infection among HIV-infected men who have sex with men. We previously showed that adding telaprevir to pegylated interferon (IFN) and ribavirin (RBV) both shortened treatment and increased the cure rate of early HCV in these men. Whether shortening treatment of early HCV using IFN-free regimens would be similarly successful has not yet been demonstrated. METHODS: We performed a pilot study of treatment with sofosbuvir (SOF) + RBV for 12 weeks in early genotype 1 HCV infection in HIV-infected men. The primary endpoint was SVR 12. RESULTS: Twelve men were treated with 12 weeks SOF + RBV and 11 (92%) achieved SVR 12. Most (63%) were actively using recreational drugs, mostly methamphetamine. The one man who failed had laboratory results more characteristic of chronic than of early HCV infection. The overall safety profile was similar to that known for SOF + RBV. CONCLUSIONS: The success of this short-duration IFN-free treatment in early HCV infection is proof in principle that enhanced treatment responsiveness is an inherent characteristic of early HCV infection and not a function of IFN treatment itself. Future studies should now be done with more potent regimens to try to further shorten therapy. In the mean time, in clinical practice early HCV infection should be treated immediately after detection to take advantage of short-duration treatments, as well as to decrease further HCV transmission among HIV-infected MSM.

Preliminary evidence for sleep complaints among children referred for anxiety.

BACKGROUND AND PURPOSE: Clinical observation suggests that sleep complaints are common among youth with anxiety disorders though empirical data documenting this co-occurrence of symptoms are generally unavailable. PATIENTS AND METHODS: Based on retrospective chart reviews, the current study examined rates of several types of parent-reported sleep complaints among a sample of (n=35) purely anxious children and adolescents (ANX). Sleep complaints were examined in terms of age (children versus adolescents) and type of anxiety diagnosis (generalized anxiety versus other anxious diagnoses). Rates of sleep complaints among anxious youth also were compared to those among (n=38) healthy control children and (n=33) children referred for sleep problems. RESULTS: The presence of at least one intermittent sleep complaint was reported by 83% of parents of ANX, with almost half reporting at least one frequent sleep complaint. Rates of sleep complaints among anxious children versus adolescents were similar. Children with generalized anxiety disorder (GAD) had a significantly greater number of sleep complaints than children with other types of anxiety disorders, though rates for specific items varied. Although parents of sleep-referred children reported the highest rates of sleep complaints overall, the frequency of several specific types of sleep complaints was highly similar among ANX and sleep-referred children. CONCLUSIONS: Findings indicate that certain sleep complaints are common among ANX. The need for appropriate assessment practices is discussed.

Must interesting things be pleasant? A test of competing appraisal structures.

What makes something interesting? Appraisal research has proposed two appraisal structures for the emotion of interest. One model (Smith & Ellsworth, 1985) contends that appraised pleasantness is central to interest, whereas an alternative model (Silvia, 2005b) contends that pleasantness is unnecessary for interest. An experiment tested these competing predictions. Participants viewed calming and disturbing paintings, rated each picture for appraisals, and reported their experienced interest and pleasantness/ enjoyment. Within-person analyses found that (a) interest and pleasantness were essentially unrelated; (b) appraised novelty- complexity positively predicted interest, but negatively predicted pleasantness; and (c) disturbing pictures were highly interesting but unpleasant, whereas calming pictures were highly pleasant but uninteresting. The results thus strongly suggest that interesting things needn't be pleasant. Implications for in vivo (versus retrospective) tests of competing appraisal predictions are considered.

Cognitive correlates of social phobia among children and adolescents.

We examined different cognitive phenomena in relation to social phobia among children (aged 7 to 11) and adolescents (aged 12-16) separately. Fifty socially phobic youths were compared to 30 normal control children on measures of social anxiety, social expectation as well as self- and observer-rated performance during two social tasks involving a same-aged peer. Additionally, a video-mediated recall procedure was conducted immediately following the two behavioral tasks to examine specific types of self-talk. Results indicated that socially phobic youths had lower expectations of their performance and rated their actual performance worse than controls during a social interaction task, but not a read-aloud task. Self-ratings of decreased performance among socially phobic youths were corroborated by blind observers. Although differences in specific types of self-talk were found between the two groups, these findings were generally moderated by age. Furthermore, certain cognitive symptoms associated with the disorder were more commonly found among older socially phobic youths. The current findings highlight the importance of considering developmental factors in the presentation and treatment of social phobia in youths.

Efficacy of three treatment protocols for adolescents with social anxiety disorder: a 5-year follow-up assessment.

Few studies have reported long-term follow-up data in adults and even fewer in adolescents. The purpose of this work is to report on the longest follow-up assessment in the literature on treatments for adolescents with social phobia. A 5-year follow-up assessment was conducted with subjects who originally received either Cognitive Behavioral Group Therapy for Adolescents (CBGT-A), Social Effectiveness Therapy for Adolescents--Spanish version (SET-Asv), or Intervención en Adolescentes con Fobia Social--Treatment for Adolescents with Social Phobia (IAFS) in a controlled clinical trial. Twenty-three subjects completing the treatment conditions were available for the 5-year follow-up. Results demonstrate that subjects treated either with CBGT-A, SET-Asv and IAFS continued to maintain their gains after treatments were terminated. Either the CBGT-A, SET-Asv and IAFS can provide lasting effects to the majority of adolescents with social anxiety. Issues that may contribute to future research and clinical implications are discussed.

Pretreatment attrition and childhood social phobia: Parental concerns about medication.

Pretreatment attrition, the systematic self-exclusion of potential participants during the recruitment phase of a study, poses a significant threat to the external validity of randomized clinical trials. Very little is known about the factors that contribute to pretreatment attrition, especially among families seeking treatment for a child. The current study assessed pretreatment attrition in a randomized clinical trial of behavior therapy, fluoxetine, and placebo for child and adolescent social phobia. Reluctance toward medication treatment accounted for 44.7% of study refusals and was disproportionately common among ethnic minority families. Parents were particularly worried about the potential for side effects or physical/psychological dependency upon the medication. Results are discussed in terms of the implications for external validity in future psychopharmacological clinical trials.