Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

Educational resources for vascular laboratory education in vascular surgery residencies and fellowships: Survey of Vascular Surgery Program Directors.

OBJECTIVE: The Registered Physician in Vascular Interpretation (RPVI) credential is a prerequisite for certification by the Vascular Surgery Board of the American Board of Surgery. Of concern, as more current trainees and recent program graduates take the Physician Vascular Interpretation (PVI) examination, vascular surgery trainee pass rates have decreased. Residents and fellows have a lower PVI examination pass rates than practicing vascular surgeons. The purpose of this study was to assess current vascular laboratory (VL) training for vascular surgery residents and fellows and to identify gaps that residency and fellowship programs might address. METHODS: Program directors (PDs) of Accreditation Council for Graduate Medical Education-accredited vascular surgery programs (107 fellowships, 53 integrated residency programs) were surveyed using a web-based tool. Responses were submitted anonymously. Data collected included information about the program, the PD, accreditation status of the VL, and the curriculum used to meet the PVI prerequisites. Concurrent data (June 2017) on the credentials of all PDs were obtained from the Alliance for Physician Certification and Advancement (APCA). RESULTS: Sixty-one of 117 PDs participated in the survey (52% response rate). Of these, 44 individuals (72% of responders) reported they held the RPVI and/or Registered Vascular Technologist credential. Records from APCA indicated that 51 of 117 PDs of accredited vascular surgery residencies and fellowships (44%) had an RPVI/Registered Vascular Technologist credential. Ninety-four percent reported that their VL was accredited. Practical VL experience for trainees was reported to be 20 hours or less by 62% of respondents. The use of a structured curriculum for practical experience was reported by only 15 programs. Programs with fellowships established for more than 10 years were more likely to have a structured program for didactic instruction (P = .03). Only 23 programs reported a dedicated VL rotation. Didactic instruction provided was 20 hours or less for 75% of the cohort. CONCLUSIONS: In the absence of a standardized VL curriculum, there is variation in the VL instruction provided to trainees. Fellowship programs with longer histories have more structured instruction, but time allocated to VL education is substantially less than the 30 hours of didactic and 40 hours of practical experience recommended by the APCA. Programs and learners may benefit from the development of VL training guidelines and curriculum resources.

Up-and-Over Technique for Implantation of Iliac Branch Devices After Prior Aortic Endograft Repair.

PURPOSE: To describe a modified up-and-over access technique for treatment of iliac artery aneurysms in patients with prior bifurcated stent-grafts for endovascular aneurysm repair (EVAR). TECHNIQUE: This technique uses a coaxial 12-F flexible sheath that is docked with a through-and-through wire into a 7-F sheath advanced from the contralateral femoral approach. This maneuver allows both sheaths to be moved as a unit while maintaining position of the apex of the system as it loops over the flow divider, avoiding damage to or displacing the extant endograft. Once the 12-F sheath is positioned in the iliac limb of the aortic stent-graft and secured in place with the through-and-through wire, the repair is extended into the internal iliac artery using a bridging stent-graft or covered stent introduced via a coaxial sheath. CONCLUSION: The up-and-over technique with a flexible 12-F sheath mated with a 7-F sheath from the opposite side allows bilateral femoral access to be used for iliac branch device placement after prior aortic endograft procedures that create a higher, acutely angled bifurcation. Use of a through-and-through wire and a coaxial sheath for stent delivery creates a very stable platform for intervention.

The effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for psychogenic nonepileptic seizures.

This study utilized a nonconcurrent case-series design to examine the effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for people with psychogenic nonepileptic seizures. A key aim of the study was to investigate the relationship between psychological flexibility (a key process within ACT), psychological health, quality of life, and seizure frequency. Six participants completed the study, with reliable and clinically significant changes in psychological flexibility, quality of life, and psychological health observed in the majority of participants. Notable reductions in self-reported seizure frequency were also observed. The implications of these findings for clinical practice are discussed and recommendations for future research suggested.

Reclaiming Autologous Amputated Tissue for Limb Salvage of a Diabetic Foot Burn with Underlying Critical Limb Ischemia.

BACKGROUND: Diabetes mellitus is a worldwide pandemic that impacts more than 387 million people, with 29 million individuals affected in the United States alone. Diabetic patients have a 25% lifetime risk of developing a diabetic foot ulcer (DFU). Having a DFU is associated with a risk of recurrence approaching 70%. In addition, 1 in 6 patients with DFU will have a lower-limb amputation, with an associated increase in mortality ranging from 47% to 70%. Therefore, limb salvage is critical in patients with DFU. CASE STUDY: This article describes the case of a 70-year-old man with diabetes mellitus, end-stage renal disease, and peripheral arterial occlusive disease who presented with a 1.5% total-body-surface-area, third-degree burn to the left hallux with dry gangrene extending to the midfoot. Ankle brachial indexes were 0.66 on the left and 0.64 on the right. Toe pressures on the left were absent because of extensive dry gangrene. His right foot had a prior transmetatarsal amputation. Using a retrograde pedal approach, a chronic total occlusion of the left posterior tibial artery was recanalized with balloon angioplasty. He then underwent a transmetatarsal amputation with closure, except that the plantar medial side could not be closed without tension. Therefore, an autologous full-thickness skin graft, from the amputation specimen, was used to bridge the defect. DISCUSSION: At 32-week follow-up, the wound was healed, the graft had fully incorporated, and the patient was ambulating well using custom orthotic footwear. The creative use of amputated tissue to assist with wound coverage has not been well described in the literature.

Pornography Addiction in Adults: A Systematic Review of Definitions and Reported Impact.

INTRODUCTION: Self-perceived pornography addiction (SPPA) has increasingly emerged as a concept in research and popular culture, and commentators warn of the reported negative impact that it has. Despite this, "pornography or porn addiction" is not a formally recognized disorder and there is disagreement among researchers regarding its definition or even its existence. Therefore, how SPPA is operationalized often varies, and this is likely to influence the conclusions made about the impact of SPPA. AIM: This review aimed to examine what the supposed impact of SPPA is, and how the concept is operationalized. METHODS: A systematic review of quantitative and qualitative peer-reviewed journal articles was conducted. The following databases were searched up to November 2015: CINAHL (2001-2015), Embase (1974-2015), Medline (1946-2015), PsychARTICLES (1980), and PsychInfo (1806-2015). Terms used were porn*, sexually explicit material, SEM, erotic*, nonparaphilic, cyberpornography, addict*, problematic, excess*, compul*, impul*, impact, effec*, behav*, and cause. An asterisk after a term means that all terms that begin with that root were included in the search. MAIN OUTCOME MEASURES: A review of the the current literature pertaining to SPPA and its reported impact. RESULTS: We found that SPPA is most frequently operationalized as excessive pornography use and negative consequences. As a result, researchers tended to focus on the frequency of pornography use and related impact as determinants of SPPA. SPPA is reported to affect users and their partners in similar ways, such as increased feelings of isolation and relationship breakdowns. However, we found some methodologic limitations of the primary studies, which limit the strength of the conclusions that can be drawn. Limitations include the lack of representative samples and inadequate measurements of SPPA and its impact. CONCLUSION: There still exist a debate regarding the definition and etiology of SPPA as distinct from self-perceived sex addiction. As such, the research landscape is shaped by different theoretical perspectives. Without evidence to suggest one theoretical position as superior to another, clinicians might be at risk of recommending treatment that is in line with their theoretical perspective (or personal biases) but at odds with the motivations driving an individual to engage in particular sexual behaviors. In light of these findings, the review concludes with recommendations for future research.

Perceived barriers and facilitators to positive therapeutic change for people with intellectual disabilities: Client, carer and clinical psychologist perspectives.

Studies have highlighted successful outcomes of psychological therapies for people with intellectual disabilities. However, processes underlying these outcomes are uncertain. Thematic analysis was used to explore the perceptions of three clinical psychologists, six clients and six carers of barriers and facilitators to therapeutic change for people with intellectual disabilities. Six themes were identified relating to: what the client brings as an individual and with regard to their wider system; therapy factors, including the therapeutic relationship and adaptations; psychologists acting as a 'mental health GP' to coordinate care; systemic dependency; and the concept of the revolving door in intellectual disability services. The influence of barriers and facilitators to change is complex, with facilitators overcoming barriers and yet simultaneously creating more barriers. Given their potential impact on the psychologists' roles and access to therapy for people with intellectual disabilities, findings suggest these factors should be formulated as part of the therapeutic process.

Implicit and explicit self-esteem discrepancies in people with psychogenic nonepileptic seizures.

PURPOSE: Self-esteem (SE), or one's sense of competence and worth, is reduced in many mental and physical disorders. Low SE is associated with perceived stigma and disability and poor treatment outcomes. The present study examined implicit and explicit SE (automatic and deliberate views about the self) in people with epilepsy and people with psychogenic nonepileptic seizures (PNESs). Discrepancies between implicit SE and explicit SE have been found to correlate with psychological distress in disorders often associated with PNESs but are relatively unexplored in PNESs. We hypothesized that, compared with epilepsy, PNESs would be associated with lower self-reported SE and greater discrepancies between implicit SE and explicit SE. METHODS: Thirty adults with PNESs, 25 adults with epilepsy, and 31 controls without a history of seizures were asked to complete the Rosenberg Self-esteem Scale as a measure of explicit SE and an Implicit Relational Assessment Procedure as a measure of implicit SE. The State-Trait Anxiety Inventory and Patient Health Questionnaire-15 (a somatic symptom inventory) were also administered. RESULTS: We found significant group differences in explicit (p<0.001) but not implicit SE. Patients with PNESs reported lower SE than the other groups. No group differences were found in implicit SE. Implicit-explicit SE discrepancies were larger in the group with PNESs than in the other groups (p<0.001). Higher frequency of PNESs (but not epileptic seizures) was associated with lower explicit SE (rs=-.83, p<0.01) and greater SE discrepancies (i.e., lower explicit relative to implicit SE; rs=.65, p<0.01). These relationships remained significant when controlling for anxiety and somatization. CONCLUSION: Patients with PNESs had lower explicit SE than those with epilepsy or healthy controls. In keeping with our expectations, there were greater discrepancies between implicit SE and explicit SE among patients with PNESs than in the other groups. Our results, including the strong relationship between PNES frequency, anxiety, and explicit-implicit SE discrepancies, support the interpretation that PNESs serve to reduce cognitive dissonance, perhaps protecting patients' implicit SE.

Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease.

OBJECTIVE: Although smoking cessation is recommended for all patients with peripheral artery disease, there are little data regarding the prevalence of smoking among patients at the time of angiography or the effect of smoking cessation on clinical outcomes. METHODS: Consecutive patients with claudication or critical limb ischemia who underwent peripheral angiography from 2006 to 2013 were included in an observational cohort analysis. Smoking status was assessed at the time of angiography and during follow-up clinic visits. Kaplan-Meier analysis was used to assess the relationship between smoking cessation, mortality, and amputation-free survival. RESULTS: Among 739 patients (423 men and 316 women; mean age, 60 ± 12 years), 204 (28%) remained active smokers at the time of lower extremity angiography. At the time of angiography, the mean number of cigarettes smoked per day was 16 ± 10, and the mean pack-years was 40 ± 25. During the course of the subsequent year, 61 patients (30%) successfully quit smoking and maintained continued abstinence. Baseline medication use between groups did not differ significantly. The mean ankle-brachial index was also similar for quitters vs nonquitters (0.53 ± 24 vs 0.49 ± 0.22; P = .3). During follow-up to 5 years, patients who quit smoking had significantly lower all-cause mortality (14% vs 31%; hazard ratio, 0.40; 95% confidence interval, 0.18-0.90) and improved amputation-free survival (81% vs 60%; hazard ratio, 0.43, 95% confidence interval, 0.22-0.86) compared with patients who continued smoking, with most of the difference driven by reduced mortality among patients who quit smoking. The findings remained significant on multivariable analysis. CONCLUSIONS: Approximately one-third of active smokers with peripheral artery disease successfully quit smoking ≤ 1 year after lower extremity angiography. Patients who quit smoking have lower mortality and improved amputation-free survival compared with patients who continue smoking.

Endovascular recanalization of infrapopliteal occlusions in patients with critical limb ischemia.

BACKGROUND: Endovascular therapies are increasingly used for treatment of critical limb ischemia (CLI). Infrapopliteal (IP) occlusions are common in CLI, and successful limb salvage may require restoration of arterial flow in the distribution of a chronically occluded vessel. We sought to describe the procedural characteristics and outcomes of patients with IP occlusions who underwent endovascular intervention for treatment of CLI. METHODS: All patients with IP interventions for treatment of CLI from 2006 to 2012 were included. Angiographic and procedural data were compared between patients who underwent intervention for IP occlusions vs IP stenosis. Restenosis was determined by Doppler ultrasound imaging. Limb salvage was the primary end point of the study. Additional end points included primary patency, primary assisted patency, secondary patency, occlusion crossing success, procedural success, and amputation-free survival. RESULTS: A total of 187 patients with CLI underwent interventions for 356 IP lesions, and 77 patients (41%) had interventions for an IP occlusion. Patients with an intervention for IP occlusion were more likely to have zero to one vessel runoff (83% vs 56%; P < .001) compared with interventions for stenosis. Compared with IP stenoses, IP occlusions were longer (118 ± 86 vs 73 ± 67 mm; P < .001) and had a smaller vessel diameter (2.5 ± 0.8 vs 2.7 ± 0.5 mm; P = .02). Wire crossing was achieved in 83% of IP occlusions, and the overall procedural success for IP occlusions was 79%. The overall 1-year limb salvage rate was 84%. Limb salvage was highest in the stenosis group, slightly lower in the successful occlusion group, and lowest in the failed occlusion group (92% vs 75% vs 58%, respectively; P = .02). Unsuccessfully treated IP occlusions were associated with a significantly higher likelihood of major amputation (hazard ratio, 5.79; 95% confidence interval, 1.89-17.7) and major amputation or death (hazard ratio, 2.69; 95% confidence interval, 1.09-6.63). CONCLUSIONS: Successful endovascular recanalization of IP occlusions can be achieved with guidewire and support catheter techniques in most patients. In patients selected for an endovascular-first approach for IP occlusions in CLI, this strategy can be successfully implemented with favorable rates of limb salvage.

Nitinol self-expanding stents vs. balloon angioplasty for very long femoropopliteal lesions.

PURPOSE: To compare the patency rates and clinical outcomes of balloon angioplasty vs. nitinol stent placement for patients with short (≤150 mm) as compared to long (>150 mm) femoropopliteal (FP) occlusive lesions. METHODS: Between 2006 and 2011, 254 patients (134 men; mean age 68 years) underwent FP angioplasty. The majority of patients (64%) were treated for critical limb ischemia. One hundred thirty-nine (55%) patients had short FP lesions ≤150 mm, while 115 patients had long FP lesions >150 mm. The mean lesion length was 78±43 mm in the short FP lesion group and 254±58 mm in the long FP lesion group. Duplex ultrasound follow-up with a peak systolic velocity ratio ≥2.0 was used to define restenosis. RESULTS: The overall procedure success rate was 98%. One hundred forty-eight (58%) patients underwent stent placement. The mean number of stents deployed for treatment of short FP lesions was 1.0±0.4 vs. 2.0±0.7 for long FP lesions (p<0.001). The primary patency rate of short FP lesions treated with balloon angioplasty vs. stenting was 66% vs. 63% at 1 year (p=0.7). For long FP lesions, the 1-year primary patency rates of balloon angioplasty vs. stenting were 34% vs. 49% (p=0.006). Balloon angioplasty of long FP lesions was also associated with significantly lower assisted primary and secondary patency compared to stenting (p<0.05 for all comparisons). Sustained clinical improvement was >90% at 30 days but declined to 62% to 75% at 1 year. CONCLUSION: Balloon angioplasty and stent placement result in similar patency rates and clinical outcomes for shorter to medium-length FP lesions. In comparison, stent placement in long FP lesions is associated with superior outcomes to balloon angioplasty, even when multiple stents are required. Procedure success and clinical improvement can be achieved in the majority of patients, but rates of restenosis remain high.

Anxiety and avoidance in psychogenic nonepileptic seizures: the role of implicit and explicit anxiety.

This study examined implicit and explicit anxiety in individuals with epilepsy and psychogenic nonepileptic seizures (PNESs) and explored whether these constructs were related to experiential avoidance and seizure frequency. Based on recent psychological models of PNESs, it was hypothesized that nonepileptic seizures would be associated with implicit and explicit anxiety and experiential avoidance. Explicit anxiety was measured by the State-Trait Anxiety Inventory; implicit anxiety was measured by an Implicit Relational Assessment Procedure; and experiential avoidance was measured with the Multidimensional Experiential Avoidance Questionnaire. Although both groups with epilepsy and PNESs scored similarly on implicit measures of anxiety, significant implicit-explicit anxiety discrepancies were only identified in patients with PNESs (p<.001). In the group with PNESs (but not in the group with epilepsy), explicit anxiety correlated with experiential avoidance (r=.63, p<.01) and frequency of seizures (r=.67, p<.01); implicit anxiety correlated with frequency of seizures only (r=.56, p<.01). Our findings demonstrate the role of implicit anxiety in PNESs and provide additional support for the contribution of explicit anxiety and experiential avoidance to this disorder.

Endovascular therapy is effective treatment for focal stenoses in failing infrapopliteal vein grafts.

BACKGROUND: To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. METHODS: We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance. RESULTS: Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. CONCLUSIONS: In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.

A Systematic Quality Review of Single-Case Experimental Designs Using Acceptance and Commitment Therapy in Adult Clinical Populations.

Recent publications within Contextual Behavioral Science provided a rationale for the expansion of intervention efficacy research using methods that capture idiographic factors and processes. We conducted a systematic review of the use and quality of single-case experimental designs (SCED) within the Acceptance and Commitment Therapy (ACT) literature in adult clinical populations. The systematic review was conducted according to PRISMA guidelines and the databases CINAHL, MEDLINE, PsycINFO, PsycArticles and OpenGrey were searched for peer-reviewed articles. Further studies were sought through review of reference lists of all full text studies. Studies were assessed against What Works Clearinghouse (WWC) single-case design standards. Twenty-six studies met eligibility criteria and were conducted within research teams all implementing multiple-baseline designs. Twenty-four studies did not meet WWC standards with most failing to ensure a degree of concurrence across participants. The extent of randomisation methods was also captured. The review highlights the sparsity of SCEDs within ACT literature in clinical populations and current methodological practices. Limitations of the review and implications for future research are discussed.

Angiographic characteristics of femoropopliteal in-stent restenosis: association with long-term outcomes after endovascular intervention.

OBJECTIVES: The purpose of this study was to identify the relationship between angiographic patterns of restenosis and outcomes after endovascular treatment of femoro-popliteal in-stent restenosis (FP-ISR). BACKGROUND: ISR is a frequent clinical problem after femoro-popliteal stenting. METHODS: This was a single center study of all endovascular interventions for FP-ISR from 2006 to 2012. Class I ISR was defined as focal lesions ≤50 mm; Class II ISR as lesions > 50 mm; and Class III ISR as stent chronic total occlusion. Recurrent ISR was defined as peak systolic velocity ratio > 2.4 by duplex ultrasound. RESULTS: Among 75 cases of FP-ISR, 28 (37%) were Class I, 22 (29%) were Class II, and 25 (33%) were Class III. The mean lesion length was 26 mm for Class I, 135 mm for Class II, and 178 mm for Class III ISR. Patients with Class III ISR more frequently had ISR extending into both the superficial femoral and popliteal artery (48% vs. 18%, P = 0.005). Balloon angioplasty was used most frequently to treat Class I ISR, while adjunctive atherectomy and/or stenting was used for almost all cases of Class III ISR. During 2-year follow-up, rates of repeat restenosis were 39% for Class I, 67% for Class II, and 72% for Class III ISR (P = 0.04). Rates of stent occlusion were 8% for Class I, 11% for Class II, and 52% for Class III ISR (P = 0.009). Class III ISR was associated with significantly increased risk of recurrent ISR (HR 2.4, 95% CI 1.1-5.6) and recurrent occlusion (HR 5.8, 95% CI 1.8-19.0) compared to other types of ISR. CONCLUSION: Angiographic patterns of FP-ISR are important determinants of subsequent outcomes. Repeat restenosis and occlusion remain common despite currently available technologies.

Female-perpetrated intimate partner violence: an examination of three cases using multiple sequential functional analysis.

BACKGROUND: Recent empirical evidence suggests that women assault their intimate partners at approximately the same rate as men. However, a general historical reluctance to acknowledge women as significant perpetrators of intimate partner violence (IPV) has limited clinical understanding of this phenomenon and the processes by which such behaviour may develop. AIM: The following paper uses multiple sequential functional analysis (MSFA), an idiographic case formulation method based on functional analysis, to explore the development and functional value of IPV in the case histories of three women. METHOD: Data from comprehensive clinical interviews, file review and collateral professional interviews are synthesised using MSFA to examine the development and maintenance of IPV across each participant's lifespan. RESULTS: Although there appeared to be important differences between participants, the analyses broadly indicated that all three participants used violence instrumentally to achieve some aspect of control or coercion over their intimate partners, and to meet their primary intimacy needs. CONCLUSIONS: The MSFA appears to be a useful methodology for understanding female-perpetrated IPV and, importantly, may lend itself more readily to effective formulation-informed interventions than other qualitative-narrative case methods. The strengths and limitations of MSFA as a pragmatic case formulation method are discussed.

Mental health mobile application self-help for adolescents exhibiting psychological distress: A single case experimental design.

OBJECTIVES: The present demand for child and adolescent mental health services exceeds the capacity for service provision. Greater research is required to understand the utility of accessible self-help interventions, such as mobile apps. This study sought to investigate whether use of a mental health app, underpinned by CBT, led to changes in psychological distress amongst adolescents. Mechanisms of change were examined, specifically whether changes are attributable to cognitive strategies. DESIGN: This study utilised a multiple-baseline single-case experimental design, tracking variables across baseline and intervention phases. Surveys assessing participant experience were also administered. METHODS: Five participants with moderate-to-severe levels of psychological distress engaged with a CBT-based app over five weeks. Participants were recruited from both a well-being service and the general population. Supplementary weekly calls to participants offered clarification of app content. RESULTS: A small overall effect of the intervention of psychological distress was evident; however, outcomes were dependent on the analysis conducted. The intervention appeared to promote an increase in use of adaptive cognitive strategies but not negative thinking styles. The CBT app did not promote changes in participant well-being. Participant feedback highlighted practical challenges of utilising the app. CONCLUSIONS: The clinical benefits of app-based CBT were small, and a range of barriers to engagement were recognised. While further research is required, caution should be exercised in the interpretation of studies reporting on app effectiveness.

Group psychological intervention for emotional distress in haematopoietic stem cell transplantation: A feasibility randomised clinical trial.

PURPOSE: Haematopoietic stem cell transplantation (HSCT) is an intensive procedure associated with elevated psychological distress, particularly during the initial stages. Based on self-regulatory theory, a prophylactic group intervention was developed to mitigate this distress by targeting perceptions of HSCT and coping. This study evaluated the feasibility of delivering the intervention and of conducting a randomised clinical trial to assess efficacy. METHODS: Adults from consecutive referrals at two transplant centres were randomised to the intervention or to treatment as usual at each site. Psychological distress (primary outcome), HSCT perceptions, and coping were assessed at baseline, on transplant day, and two and four weeks after transplantation. RESULTS: Of 99 eligible patients, 45 consented. Main barriers to consent were insufficient time prior to transplantation, competing priorities, being unwell, and travel distance. Of 21 participants randomised to the intervention, five attended. Main barriers to attendance included insufficient time prior to transplantation and having competing priorities. Groups could not be held sufficiently frequently to enable attendance prior to transplantation, as randomising participants to the control group limited accrual. Anxiety peaked two weeks following transplantation. Depression increased throughout the acute phase. Clinical levels of distress were observed in 42% of patients during HSCT. Intervention effects were small but sample sizes for a full trial appeared feasible. CONCLUSIONS: Multimodal prehabilitation is required but there are specific barriers to delivering a group-based intervention and conducting a trial. Group prehabilitation requires customisation and better integration with routine care, such as patient screening, personalisation, and options for remote delivery.