Cognitive behavioural therapy and third-wave approaches for anxiety and related disorders in older people.

BACKGROUND: Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders. OBJECTIVES: To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over. To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome. DATA COLLECTION AND ANALYSIS: Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study. MAIN RESULTS: We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management. Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation. CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5). Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate). Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment. Other outcomes and time points are reported in the results section of the manuscript. AUTHORS' CONCLUSIONS: CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.

Efficacy and Safety of Radiofrequency Ablation of Thyroid Nodules: A Multi-institutional Prospective Cohort Study.

BACKGROUND: Radiofrequency ablation (RFA) has been recently adopted into the practice of thyroidology in the United States, although its use as an alternative to traditional thyroid surgery in Asia and Europe came near the turn of the 21st century. In the United States, only a few studies with small sample sizes have been published to date. We examined outcomes of benign thyroid nodules treated with RFA from 2 North American institutions. METHODS: We performed a prospective, multi-institutional cohort study of thyroid nodules treated with RFA between July 2019 and January 2022. Demographics, sonographic characteristics of thyroid nodules, thyroid function profiles, procedural details, complications, and nodule volume measurements at 1, 3, 6, and 12 months follow-up were evaluated. Adjusted multivariate logistic regression analysis was performed to identify sonographic features associated with treatment failure. RESULTS: A total of 233 nodules were included. The median and interquartile range of volume reduction rate (VRR) at 1, 3, 6, and 12 months were 54% [interquartile range (IQR): 36%-73%], 58% (IQR: 37%-80%), 73% (IQR: 51%-90%), and 76% (IQR: 52%-90%), respectively ( P <0.001). Four patients presented with toxic adenomas. All patients were confirmed euthyroid at 3-month postprocedure follow-up. Two patients developed temporary hoarseness of voice, but no hematoma or nodular rupture occurred postprocedure. Elastography was significantly associated with VRR. Compared with soft nodules, stiff nodules were more likely to have a lower VRR (odds ratio: 11.64, 95% confidence interval: 3.81-35.53, P <0.05), and mixed elasticity was also more likely to have a lower VRR (odds ratio: 4.9; 95% confidence interval: 1.62-14.85, P <0.05). CONCLUSIONS: This is the largest multi-institutional North American study examining thyroid nodule treatment response to RFA. RFA is a safe and effective treatment option that allows preservation of thyroid function with minimal risk of procedural complications.

Long-term Quality of Life After Thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Transcervical Approach.

OBJECTIVE: To compare long-term health-related quality of life (HRQOL) after Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and transcervical approach (TCA) thyroidectomy. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: A web-based survey was distributed to patients at our institution who met the criteria for TOETVA and underwent thyroidectomy by TOETVA or TCA between August 2017 and October 2021. All survey participants were at least 6 months postsurgery. Minors, non-English speakers, and patients who received concomitant neck dissection or reoperative thyroidectomy were excluded from the study. The survey assessed quality of life through 4 standardized instruments: the Dermatology Life Quality Index (DLQI), the Eating Assessment Tool (EAT-10), the Voice Handicap Index (VHI-10), and the Short Form Health Survey (SF-36). RESULTS: A total of 108 TOETVA and 129 TCA patients were included in the study. The median age of respondents was 44 (36, 54; 25th, 75th percentile) years and median time from surgery to survey was 35 (22, 45; 25th, 75th percentile) months. TOETVA group DLQI (0.63 vs 0.99; P = .17), VHI-10 (1.94 vs 1.67; P = .35), EAT-10 (2.14 vs 2.32; P = .29), SF-36 physical component (52.25 vs 51.00; P = .25), and SF-36 mental component (47.74 vs 47.29; P = .87) scores were all similar to those of the TCA group. Scrutinizing specific DLQI questions, individuals in the TOETVA group were less self-conscious of their skin as compared to the TCA group (Q2; 0.08 vs 0.26, P = .03). CONCLUSION: Long-term HRQOL after TOETVA is similar to TCA, with significantly lower skin-related self-consciousness.

Transoral endoscopic vestibular approach Sistrunk procedure (TEVAS)-case report and scoping review.

Background: Thyroglossal duct cyst (TGDC) is the most common congenital neck mass among the pediatric population. Less than 10% of the cases occur in adults. The standard of care for TGDC is surgical treatment with the Sistrunk procedure via a traditional transverse cervicotomy. This technique involves the resection of the cyst with its tract and the central portion of the hyoid bone body to avoid recurrence. The transoral vestibular approach has gained popularity as an alternative approach to open neck surgery in order to eliminate the transcervical scar associated with these procedures. Methods: We describe a case of an endoscopic Sistrunk procedure performed by the transoral vestibular approach. A scoping review of the transoral endoscopic vestibular approach Sistrunk procedure (TEVAS) was performed. The PubMed, Medline, Cochrane, Lilacs, Scielo, Mary Ann Libert and Scopus databases were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting inclusion and exclusion criteria. Results: The case was successful and without complications. Five studies were included in the final analysis for this review. Conclusions: This novel approach to the Sistrunk procedure is an effective alternative way to treat TGDC in selected patients who are motivated to avoid a visible neck scar.

Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience.

BACKGROUND: Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study. METHODS: A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response. RESULTS: A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules. CONCLUSION: To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

Handheld Autofluorescence Imaging System for Intraoperative Parathyroid Detection.

Introduction: Hypoparathyroidism and hypocalcemia are common complications after thyroid surgery. Parathyroids may be incidentally damaged or removed because they are difficult to distinguish from surrounding tissue. Intraoperative optical technologies such as near infrared autofluorescence (NIRAF) are becoming increasingly popular to help identify parathyroids during thyroid surgery. The objective of this video is to introduce a developing NIRAF device called hANDY-i and compare the device with existing Food and Drug Administration approved technology. Materials and Methods: hANDY-i is developed by Optosurgical, LLC. The device consists of a coaxial 785 nm laser excitation module and coregistred red-green-blue and near-infrared cameras. Operation of the device and output from preliminary intraoperative use are shown. Results: hANDY-i performs well, producing intuitive side-by-side NIRAF and RGB images of the operating field. The device demonstrates high contrast between suspected parathyroid glands and surrounding tissue. Operating theater, overhead lamps, and surgical headlights can all be used with the device. The device is also shown to be effective in both in vivo and ex vivo applications. Conclusions: The prototype described advance NIRAF technology by reducing light sensitivity and improving output representation. In doing so, hANDY-i makes NIRAF more accessible and less obstructive to the surgical workflow. Sources of Funding: This study was supported by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under Award Number R43EB030874. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Yoseph Kim is an employee of Optosurgical LLC. Jaepyeong Cha has ownership stake in Optosurgical LLC. For all other authors, no competing financial interests exist.Runtime of video: 7 mins 14 secs.

Parathyroid gland detection using an intraoperative autofluorescence handheld imager - early feasibility study.

Introduction: Parathyroid glands may be compromised during thyroid surgery which can lead to hypoparathyroidism and hypocalcemia. Identifying the parathyroid glands relies on the surgeon's experience and the only way to confirm their presence was through tissue biopsy. Near infrared autofluorescence technology offers an opportunity for real-time, non-invasive identification of the parathyroid glands. Methods: We used a new research prototype (hANDY-I) developed by Optosurgical, LLC. It offers coaxial excitation light and a dual-Red Green Blue/Near Infrared sensor that guides anatomical landmarks and can aid in identification of parathyroid glands by showing a combined autofluorescence and colored image simultaneously. Results: We tested the imager during 23 thyroid surgery cases, where initial clinical feasibility data showed that out of 75 parathyroid glands inspected, 71 showed strong autofluorescence signal and were correctly identified (95% accuracy) by the imager. Conclusions: The hANDY-I prototype demonstrated promising results in this feasibility study by aiding in real-time visualization of the parathyroid glands. However, further testing by conducting randomized clinical trials with a bigger sample size is required to study the effect on levels of hypoparathyroidism and hypocalcemia.

TOETVA parathyroid autofluorescence detection: hANDY-i endoscopy attachment.

Background: Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Currently, no standardized methods exist for locating parathyroid glands (PGs) in patients undergoing TOETVA, which can lead to parathyroid injury and subsequent hypocalcemia. This early feasibility study describes and evaluates the hANDY-i endoscopic attachment for detecting PGs in transoral thyroidectomy. Methods: We used a prototype parathyroid autofluorescence imager (hANDY-i) that was mounted to a 10-mm 0-degree endoscope. The device delivers a split screen view of Red-green-blue (RGB) and near-infrared autofluorescence (NIRAF) which allows for simultaneous anatomical localization and fluorescence visualization of PGs during endoscopic thyroid dissection. Results: One cadaveric case and two patient cases were included in this study. The endoscopic hANDY-i imaging system successfully visualized PGs during all procedures. Conclusion: The ability to leverage parathyroid autofluorescence during TOETVA may lead to improved PG localization and preservation. Further human studies are needed to assess its effect on postoperative hypocalcemia and hypoparathyroidism.

Study protocol: a dissemination trial of computerized psychological treatment for depression and alcohol/other drug use comorbidity in an Australian clinical service.

BACKGROUND: The rise of the internet and related technologies has significant implications for the treatment of complex health problems, including the combination of depression and alcohol/other drug (AOD) misuse. To date, no research exists to test the real world uptake of internet and computer-delivered treatment programs in clinical practice. This study is important, as it is the first to examine the adoption of the SHADE treatment program, a DVD-based psychological treatment for depression and AOD use comorbidity, by clinicians working in a publicly-funded AOD clinical service. The study protocol that follows describes the methodology of this dissemination trial. METHODS/DESIGN: 19 clinicians within an AOD service on the Central Coast of New South Wales, Australia, will be recruited to the trial. Consenting clinicians will participate in a baseline focus group discussion designed to explore their experiences and perceived barriers to adopting innovation in their clinical practice. Computer comfort and openness to innovation will also be assessed. Throughout the trial, current, new and wait-list clients will be referred to the research program via the clinical service, which will involve clients completing a baseline and 15-week follow-up clinical assessment with independent research assistants, comprising a range of mental health and AOD measures. Clinicians will also complete session checklists following each clinical session with a client, outlining the extent to which the SHADE computer program was used. Therapeutic alliance will be measured at intake and discharge from both the clinician and client perspectives. DISCUSSION: This study will provide comprehensive data on the factors associated with the adoption of an innovative, computer-delivered evidence-based treatment program, SHADE, by clinicians working in an AOD service. The results will contribute to the development of a model of dissemination of SHADE, which could be applied to a range of technological innovations. CLINICAL TRIALS REGISTRY: Australian Clinical Trial Registration Number: ACTRN12611000382976.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study.

BACKGROUND: Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. METHODS: After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. RESULTS: The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). CONCLUSION: Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

BACKGROUND: The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear. OBJECTIVE: The objective of this study was to evaluate perioperative data and 30-day outcomes of conventional and robot-assisted LRYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. SETTING: University health network, United States. METHODS: We reviewed all conventional and robot-assisted LRYGB cases entered between January 1 and December 31, 2016 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ2, or Fisher's exact tests as appropriate, with P ≤ .05 denoting statistical significance with no adjustment for multiple testing. RESULTS: Of the 39,425 patients who underwent LRYGB, 2822 were robot-assisted. The robot-assisted approach required significantly more time (138 versus 108 min, P < .0001). Rates of organ space infection, bleeding, and other significant adverse events after the conventional and robot-assisted approaches were .3% versus .5% (P = .13), 1.1% versus .8% (P = .11), and 2.3% versus 2.3% (P = .96), respectively. There were also no significant differences in the rates of mortality, length of stay, reoperation, or readmission between the 2 groups. CONCLUSIONS: Robot-assisted LRYGB is an increasingly popular alternative to the conventional laparoscopic approach. According to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the early safety of these 2 techniques is equal, although the robotic approach requires more operative time.

To enforce or engage: the relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients.

Three fundamental clinical issues are consistently associated with treatment engagement and outcomes in substance using populations; coercion, motivation and therapeutic alliance. It is accepted that these factors play an integral role in the success of substance use treatment and particularly that higher motivation and therapeutic alliance are advantageous to treatment outcomes. The impact of coercion on engagement and treatment outcome, on the other hand, is less clear, and the relationship between these three issues has not been adequately explored. The current study aimed to address this gap, by examining the presenting characteristics of clients attending a community drug and alcohol counselling service in relation to coercion, motivation, therapeutic alliance and substance use, as well as the effect that these variables had on treatment outcomes 15 weeks later. A total of 77 clients recruited from the Central Coast Drug and Alcohol Service participated in the study, completing a phone assessment upon treatment entry and 15 weeks post-baseline. Results indicated that facets of motivation and therapeutic alliance played a significant role in client's substance use upon presentation for treatment, although coercion did not. Coercion was not associated with substance use outcomes at 15 week follow up. However, due to a relatively small sample completing post-baseline assessments (n=33), further research is needed to examine the predictive effects of these variables in community drug and alcohol clients.