Cognitive-behavioural versus cognitive-analytic guided self-help for mild-to-moderate anxiety: a pragmatic, randomised patient preference trial.

BACKGROUND: Guided self-help (GSH) for anxiety is widely implemented in primary care services because of service efficiency gains, but there is also evidence of poor acceptability, low effectiveness and relapse. AIMS: The aim was to compare preferences for, acceptability and efficacy of cognitive-behavioural guided self-help (CBT-GSH) versus cognitive-analytic guided self-help (CAT-GSH). METHOD: This was a pragmatic, randomised, patient preference trial (Clinical trials identifier: NCT03730532). The Beck Anxiety Inventory (BAI) was the primary outcome at 8- and 24-week follow-up. Interventions were delivered competently on the telephone via structured workbooks over 6-8 (30-35 min) sessions by trained practitioners. RESULTS: A total of 271 eligible participants were included, of whom 19 (7%) accepted being randomised and 252 (93%) chose their treatment. In the preference cohort, 181 (72%) chose CAT-GSH and 71 (28%) preferred CBT-GSH. BAI outcomes in the preference and randomised cohorts did not differ at 8 weeks (-0.80, 95% confidence interval (CI) -4.52 to 2.92) or 24 weeks (0.85, 95% CI -2.87 to 4.57). After controlling for allocation method and baseline covariates, there were no differences between CAT-GSH and CBT-GSH at 8 weeks (F(1, 263) = 0.22, P = 0.639) or at 24 weeks (F(1, 263) = 0.22, P = 0.639). Mean BAI change from baseline was a reduction of 9.28 for CAT-GSH and 9.78 for CBT-GSH at 8 weeks and 12.90 for CAT-GSH and 12.43 for CBT-GSH at 24 weeks. CONCLUSIONS: Patients accessing routine primary care talking treatments prefer to choose the intervention they receive. CAT-GSH expands the treatment offer in primary care for patients with anxiety seeking a brief but analytically informed GSH solution.

A meta-analytic review of the effectiveness of psychological treatment of functional/dissociative seizures on non-seizure outcomes in adults.

Psychological therapies are considered the treatment of choice for functional/dissociative seizures (FDSs). Although most previous studies have focused on seizure persistence or frequency, it has been argued that well-being or health-related quality of life outcomes may actually be more meaningful. This study contributes by summarizing and meta-analyzing non-seizure outcomes to quantify the effectiveness of psychological treatment in this patient group. A pre-registered systematic search identified treatment studies (e.g., cohort studies, controlled trials) in FDSs. Data from these studies were synthesized using multi-variate random-effects meta-analysis. Moderators of treatment effect were examined using treatment characteristics, sample characteristics, and risk of bias. A total of 171 non-seizure outcomes across 32 studies with a pooled sample size of N = 898 yielded a pooled effect-size of d = .51 (moderate effect size). The outcome domain assessed and the type of psychological treatment were significant moderators of reported outcomes. Greater rates of improvement were demonstrated for outcomes assessing general functioning. Behavioral treatments emerged as particularly effective interventions. Psychological interventions are associated with clinical improvements across a broad array of non-seizure outcomes, over and above seizure frequency, in adults with FDSs.

Risk factors for symptomatic anastomotic postoperative recurrence following ileo-colic resection in Crohn's disease.

AIM: Crohn's disease is a chronic inflammatory bowel disease characterized by alternating periods of exacerbation and remission. Surgical resection is not curative and postoperative recurrence (POR) remains a challenge in these patients. The aim of this study was to identify clinical variables that influence the risk of symptomatic anastomotic POR in patients with ileo-colonic Crohn's disease. METHOD: A retrospective study of Crohn's disease patients who had undergone ileo-colic resection between January 2014 and December 2018 was performed. For each patient, data including demographic information, Crohn's disease clinical setting, preoperative radiological data, operative and histological data, pre- and postoperative medication history and postoperative clinical course, including recurrence of disease, were extracted. Symptomatic anastomotic POR was defined as symptoms of Crohn's disease in the presence of confirmed anastomotic POR (endoscopic and/or radiological POR). RESULTS: For the study period, 104 patients were eligible and included for analysis. The cumulative probability of symptomatic anastomotic POR was 14%, 30%, 42%, 50% and 50% at 1, 2, 3, 4 and 5 years, respectively. Two clinical variables on multivariate analysis were associated with increased risk of symptomatic anastomotic POR, namely age <17 years at diagnosis [hazard ratio (HR) 2.17, p = 0.019] and gastrointestinal involvement (extent) >30 cm (HR 1.85, p = 0.048). CONCLUSION: This study describes the natural history of POR after ileo-colic resection for Crohn's disease, as defined by endoscopic, radiological and clinical outcomes. Age <17 years at diagnosis and gastrointestinal involvement (extent) >30 cm were independent risk factors for symptomatic anastomotic POR.

Types and mechanisms of idiographic change during guided self-help for anxiety.

OBJECTIVES: To compare idiographic change during two formats of guided self-help (GSH); cognitive-behavioural therapy guided self-help (CBT-GSH) and cognitive analytic therapy guided self-help (CAT-GSH). DESIGN: Qualitative inductive thematic analysis. METHODS: Semi-structured interviews with N = 17 participants with a reliable change outcome on the GAD-7 after completing GSH for anxiety. Changes were categorised and themes extracted. RESULTS: No differences between CAT-GSH and CBT-GSH were found regarding types of change reported. The five overarching themes found were personal qualities of success, enlightenment through understanding, specific tools and techniques, changes to relationships and tailoring support. Four themes maximally differentiated between the two different types of GSH; CAT-GSH enabled relational insight and change whilst CBT-GSH enabled better understanding of anxiety, new coping techniques and supportive relationships. CONCLUSIONS: Both common and model-specific factors contribute to patient change during GSH. Whilst all forms of GSH are grounded in the psychoeducational approach, separate theoretical foundations and associated methods facilitate different types of ideographic change.

A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures.

BACKGROUND: Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. METHODS: This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. RESULTS: Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. CONCLUSIONS: The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Optimal assessment of paediatric IBD with MRI and barium follow-through.

OBJECTIVES: The present UK criterion standard for assessing children with suspected inflammatory bowel disease (IBD) is upper endoscopy, ileocolonoscopy, and barium follow-through (BaFT). Significant doses of radiation, unpalatable contrast, and volume intolerance are involved with BaFT. Practice in investigating Crohn disease (CD) is changing with the increasing use of magnetic resonance imaging (MRI). The aim of the present study was to compare BaFT and a new abdominal MRI protocol in a paediatric IBD population. METHODS: All consecutive patients with a new diagnosis of IBD or requiring reassessment from September 2008 to December 2010 were investigated with both abdominal MRI and BaFT in accordance with a specific local paediatric IBD protocol. The studies were reported by nonblinded radiologists with an interest in gastrointestinal imaging. The reports were compared in conjunction with case note review. RESULTS: Eighty-seven patients underwent both BaFT and MRI abdomen. Thirty-one percent of patients had additional pathology on MRI, not seen on the BaFT. Sixty-seven percent of patients (n=59) had an MRI finding equivalent to BaFT. Using histology as a criterion standard for detecting terminal ileal disease, BaFT had a sensitivity and specificity of 76% and 67%, and MRI had a sensitivity and specificity of 83% and 95%, respectively. CONCLUSIONS: This is the largest series of small bowel MRI in a paediatric population. MRI reports were at least equivalent to BaFT. MRI had higher sensitivity and, particularly, specificity in detecting terminal ileal pathology. These findings suggest that MRI should become the criterion standard investigation in children with IBD in centres with appropriate expertise, with zero radiation exposure being highly advantageous.

Associations between treatment adherence-competence-integrity (ACI) and adult psychotherapy outcomes: A systematic review and meta-analysis.

OBJECTIVE: To provide a comprehensive assessment of the association between psychological treatment adherence/competence/integrity (ACI) and clinical outcomes. METHOD: The review protocol was preregistered (CRD42020193889). Studies that assessed ACI-outcome relationships for adult psychotherapy were searched across three databases (Scopus, PsycINFO, MEDLINE). Random effects meta-analyses were conducted on adherence-outcome, competence-outcome, and integrity-outcome relationships. Separate analyses were performed for studies with hierarchical (i.e., patients nested within therapist) versus nonhierarchical study designs. Moderator analyses were performed according to predefined clinical and methodological features. GRADE assessments rated the quality of each meta-analytic comparison. RESULTS: The review identified 62 studies suitable for inclusion (45 adherence-outcome, 39 competence-outcome, and seven integrity-outcome effect sizes; N = 8,210 across all analyses). No significant adherence-outcome association was found. A small significant positive association was found only in nonhierarchical studies between competence and outcome, r = 0.17, 95% CI [0.07-0.26], p < .001, ∼d = .34, GRADE = moderate. Small-to-moderate significant positive associations between integrity and outcome were found for both nonhierarchical, r = 0.15, 95% CI [0.06-0.23], p < .001, ∼d = .30, GRADE = high, and hierarchical study designs, r = 0.23, 95% CI [0.01, 0.43], p < .044, ∼d = .47, GRADE = low. Diagnosis, treatment modality and year of publication significantly moderated the strength of ACI-outcome correlations. CONCLUSIONS: Competence and integrity are significantly associated with clinical outcome, with a magnitude comparable to wider common factors. Further research is required to study these process-outcome associations with greater precision in routine-care settings and to understand the role of moderating variables. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Acute pancreatitis: the role of imaging in diagnosis and management.

Acute pancreatitis is one of the more commonly encountered aetiologies in the emergency setting and its incidence is rising. Presentations range from a mild-self limiting condition which usually responds to conservative management to one with significant morbidity and mortality in its most severe forms. While clinical criteria are necessary to make the initial diagnosis, contrast-enhanced CT is the mainstay of imaging and has a vital role in assessing the extent and evolution of the disease and its associated complications. The purpose of this article is to summarise the natural course of acute severe pancreatitis, clarify confusing nomenclature, demonstrate the morphological stages in conjunction with radiological scoring systems and illustrate the complications. We will review and illustrate the increasing and significant role interventional radiology has in the management of these patients, which are often life-saving and surgery-sparing.

Radiological incidence of parastomal herniation in cancer patients with permanent colostomy: what is the ideal size of the surgical aperture?

BACKGROUND: Parastomal herniation frequently complicates stoma formation. Aperture size has been shown to be an independent predictor of hernia development but there is a paucity of data regarding the ideal stoma diameter. The aim of this study was to establish the radiological incidence of herniation in patients with a permanent colostomy and correlate it with the size of the abdominal wall defect in order to identify an aperture diameter associated with a reduced herniation risk. METHODS: All patients who underwent permanent colostomy formation for colorectal cancer over a five-year period in a single institution were recruited to the study. Patient demographics, operative details and stoma-related symptoms were recorded. Post-operative CT scans were reviewed for evidence of parastomal herniation. The diameter of the abdominal wall defect was measured radiologically. RESULTS: 43 patients (mean age 69 years) were included in the analysis. Radiologically, 25/43 (58%) had evidence of a parastomal hernia. The median aperture diameter was 35 mm (range 25-58 mm) in patients with a parastomal hernia and 22 mm (range 10-36 mm) in patients without herniation (p < 0.0001). There were no cases of herniation with an abdominal wall defect size <25 mm. The median follow up was 26.0 months (range 6-55) in patients with herniation as opposed to 16.0 months (range 7-36) in patients without herniation (p = 0.11). CONCLUSION: The majority of patients with a permanent colostomy develop a parastomal hernia within the first two post-operative years. Parastomal herniation appears unlikely to develop with an abdominal wall defect diameter ≤25 mm provided this does not enlarge with time. Surgical techniques that utilise stapling devices to form a 'custom-made' and rigid trephine might reduce the herniation risk.

Dynamic MRI (dMRI) as a guide to therapy in children and adolescents with persistent full thickness rectal prolapse: a single centre review.

INTRODUCTION: Full thickness rectal prolapse (FTRP) tends to be self-limiting in children and is usually managed expectantly. However, it may persist and therefore requires surgical correction. There is no consensus upon operative management, and no one procedure has uniformly good outcomes. The aim of this study was to determine whether pre-operative diagnostic dMRI findings might help identify the operative approach best suited to the anatomical abnormality of the individual child. METHODS: A retrospective review of ten children with persistent FTRP who had been evaluated pre-operatively with dMRI between 2002 and 2010 was performed. In this preliminary work, MRI findings were not used to direct surgical management. Data collected included: age at presentation, underlying medical conditions, timing and findings of dMRI (specifically, descent of rectum from pubococcygeal (PC) line on straining), timing and type of surgery, surgical outcomes, and length of follow-up. RESULTS: Ten children (two female) with a median age of 11 years 2 months (range 8-15 years) with FTRP refractory to conservative treatment underwent diagnostic pre-operative dMRI. Median perineal descent from PC line on straining during dMRI was 3.5 cm (range 1-4 cm). Three of the seven children with severe descent initially underwent a Delorme's procedure, and all required surgical revision. Five with severe descent and one with moderate descent achieved a cure following rectopexy. Two patients with mild descent underwent a Delorme's procedure. One achieved a cure, and the other developed recurrence. Of the ten patients, seven had no prolapse at the last clinic review, and three have persisting symptoms. Median follow-up was 3.5 years (range 1-6). CONCLUSION: The findings from this small study favour rectal suspension techniques for surgical management of moderate to severe perineal descent on dMRI. Delorme's procedure should only be applied to those with mild descent. Pre-operative dMRI assessment may have a potential role in guiding surgical intervention for children. However, future prospective studies will be required to confirm this assertion.

Multidetector computed tomography of the acute abdomen in the immunocompromised host: a pictorial review.

Immunocompromised patients include those receiving chemotherapy for malignant disease, post-transplant patients, patients with acquired immunodeficiency syndrome (AIDS), and those receiving steroids for autoimmune diseases. Advances in transplantation, oncology, and the treatment of AIDS have extended these patients' life expectancies and thereby increased the immunocompromised population. Classical clinical signs of abdominal sepsis may be absent in the immunocompromised host. Consequently, the radiologist is increasingly called on to diagnose specific acute intra-abdominal complications associated with immunodeficiency. This review describes the etiology of the acute abdomen in this heterogeneous group of immunocompromised patients, causes including opportunistic infections, neutropenic enterocolitis, complications of therapy, and opportunistic neoplasms. The typical radiological appearances of these conditions on multidetector computed tomography are illustrated. The challenges and limitations of multidetector computed tomography in diagnosing these conditions are discussed.

Multidetector helical CT in the evaluation of acute small bowel obstruction: comparison of non-enhanced (no oral, rectal or IV contrast) and IV enhanced CT.

PURPOSE: To compare accuracy of non-enhanced CT (NECT) (no oral or IV contrast) and enhanced CT (ECT) (IV enhanced only) to diagnose small bowel obstruction and evaluate reviewer's experience impact. MATERIALS AND METHODS: Ninety-nine adult patients underwent 105 NECT and ECT (6 patients had 2 examinations) on a four-detector CT. An abdominal radiologist, an abdominal imaging fellow, a second-year radiology resident retrospectively reviewed NECTs and ECTs separately and independently blinded to outcome. Discrepancy of diameter of proximal and distal small bowel+/-a transition was considered indication of mechanical bowel obstruction. Reference standard was surgery in 26 and chart review in 79. RESULTS: Mechanical obstruction was present in 56% (59/105). The average sensitivity, specificity, negative and positive predictive and accuracy values for NECT were 88.1% (CI: 80-96%), 77% (CI: 65-89%), 83.0% (CI: 72-95%), 83% (CI: 74-92%), and 83% (CI: 76-90%) with no significant difference between three reviewers. The corresponding numbers for ECT were 87.6% (CI: 79-96%), 75% (CI: 63-88%), 82.6.0% (CI: 71-94%), 82.1% (CI: 73-92%), and 82% (CI: 75-90%) (p>0.5). Area under curve (AUC) of ROC curves of three reviewers did not show significant statistical difference (p>0.5). CONCLUSIONS: NECT and ECT have comparable accuracy to diagnose mechanical small bowel obstruction and can be interpreted by reviewers with different levels of expertise.

The acute abdomen in the immune compromised host.

Recent advances in transplantation, oncology and AIDS therapy have greatly increased life expectancies of patients diagnosed with malignancy, auto-immune disorders and organ failure. However, as this immune compromised population grows, complications of such therapies have become a major source of morbidity and mortality. Classical clinical and laboratory evidence of intra-abdominal pathology may be absent in the immune compromised host. Consequently, the radiologist is increasingly called upon to diagnose acute intra-abdominal complications associated with immunodeficiency. This review explores the aetiology of the acute abdomen in the immune compromised host. The typical radiological appearances of the commonest conditions are illustrated. The challenges and limitations in the radiological diagnosis of these conditions are discussed.