Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment.

Background: Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial. Methods: Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens. Results: 137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder. Conclusion: Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

Three heads are better than one: Psychiatry trainees' experiences of a psychotherapy written case supervision group with three co-supervisors.

OBJECTIVE: The aim of this project was to evaluate the experiences of Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees in a regional centre who participated in a psychodynamic psychotherapy written case supervision group with three co-supervisors. METHOD: A web-based survey was sent to RANZCP trainees. Descriptive statistics were performed, and written feedback was analysed. RESULTS: A total of 8 of 10 eligible trainees completed the survey. All respondents stated that the group met their training needs. The average rating of feeling understood by supervisors was 91 (maximum 100). Positive feedback was received about the variety and breadth of experience provided by the co-supervisors. Trainees felt that 1:1 supervision was important to complement group supervision. CONCLUSIONS: The supervision group model with three co-supervisors is competently meeting the training needs of RANZCP trainees as well as providing a deep learning experience. This model may be of use in other services, particularly in regional settings.

Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder.

BACKGROUND: Clinical trials provide consistent evidence for buprenorphine's efficacy in treating opioid use disorder (OUD). While the Drug Addiction Treatment Act of 2000 requires physicians to combine medication-assisted treatment (MAT) with behavioral intervention, there is no clear evidence for what form or elements of psychotherapy are most effective when coupled with MAT to treat OUD. This investigation involves focus groups designed to collect patient opinions about a specific psychotherapy, called START NOW, as well as general beliefs about various elements of psychotherapy for treating OUD. Our analysis reveals trends about patient preferences and strategies for improving OUD treatment. METHODS: Subjects included patients enrolled in buprenorphine/naloxone MAT at our institution's office-based opioid treatment program. All subjects participated in a single START NOW group session, which was led by a provider (physician or nurse practitioner trained and standardized in delivering START NOW). Consented subjects participated in satisfaction surveys and audio-recorded focus groups assessing individual beliefs about various elements of psychotherapy for treating OUD. RESULTS: Overall, 38 different focus groups, 92 participation events, and 44 unique subjects participated in 1-to-6 different START NOW session/audio-recorded focus group sessions led by a certified moderator. Demographic data from 36/44 subjects was collected. Seventy-five percent (33/44) completed the START NOW Assessment Protocol, which revealed self-reported behavioral trends. Analysis of all 92 START NOW Satisfaction Questionnaire results suggests that subjects' opinions about START NOW improved with increased participation. Our analysis of audio-recorded focus groups is divided into three subsections: content strategies for new psychotherapies, implementation strategies, and other observations. For example, participants request psychotherapies to target impulsivity and to teach future planning and build positive relationships. CONCLUSIONS: The results of this study may guide implementation of psychotherapy and improve the treatment of OUD, especially as it relates to improving the modified START NOW program for treating OUD. Our study also reveals a favorable outlook of START NOW with increased participation, suggesting that any initial reticence to this program can be overcome to allow for effective implementation.

New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery.

BACKGROUND: The opioid crisis is a well-known public health issue. The risk of new long-term opioid prescription-filling behavior has been investigated after certain spinal procedures and total knee and hip arthroplasty. However, this has not been examined after many other common orthopaedic procedures. The purpose of this study was to determine the rates of long-term opioid prescription-filling behavior after common orthopaedic surgical procedures in patients who were not taking opioids preoperatively. METHODS: This study utilized the Virginia All-Payer Claims Database (APCD), an insurance claims database with data from 3.7 to 4 million patients per year. Patients who underwent orthopaedic procedures and who had not filled an opioid prescription in the time period from 2 weeks to 1 year preceding the surgical procedure were selected for evaluation in our study. The percentage of these patients who then filled at least 10 prescriptions or a 120-day supply of opioids in the time period from 90 to 455 days following the surgical procedure was calculated for the 50 most commonly billed orthopaedic surgical procedures. RESULTS: The rate of long-term opioid prescription-filling behavior in patients who were not taking opioids preoperatively for the 50 most common orthopaedic procedures was 5.3% (95% confidence interval, 5.1% to 5.5%). The highest rates were observed after spinal procedures. The lowest rates were seen after anterior cruciate ligament (ACL) reconstruction. Revision surgical procedures were found to have a significantly higher rate than primary procedures (p < 0.05). The rate was also related to increasing case complexity. CONCLUSIONS: New long-term opioid prescription-filling behavior is common after orthopaedic surgical procedures in patients who were not taking opioids preoperatively. Risk factors include spine surgery, revision surgery, and cases with increased complexity. Orthopaedic surgeons need to be aware of this risk. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonlinearity in stock networks.

Stock networks, constructed from stock price time series, are a well-established tool for the characterization of complex behavior in stock markets. Following Mantegna's seminal paper, the linear Pearson's correlation coefficient between pairs of stocks has been the usual way to determine network edges. Recently, possible effects of nonlinearity on the graph-theoretical properties of such networks have been demonstrated when using nonlinear measures such as mutual information instead of linear correlation. In this paper, we quantitatively characterize the nonlinearity in stock time series and the effect it has on stock network properties. This is achieved by a systematic multi-step approach that allows us to quantify the nonlinearity of coupling; correct its effects wherever it is caused by simple univariate non-Gaussianity; potentially localize in space and time any remaining strong sources of this nonlinearity; and, finally, study the effect nonlinearity has on global network properties. By applying this multi-step approach to stocks included in three prominent indices (New York Stock Exchange 100, Financial Times Stock Exchange 100, and Standard & Poor 500), we establish that the apparent nonlinearity that has been observed is largely due to univariate non-Gaussianity. Furthermore, strong nonstationarity in a few specific stocks may play a role. In particular, the sharp decrease in some stocks during the global financial crisis of 2008 gives rise to apparent nonlinear dependencies among stocks.

Tailored Educational Approaches for Consumer Health: A Model to Address Health Promotion in an Era of Personalized Medicine.

PURPOSE: To develop a model, based on market segmentation, to improve the quality and efficiency of health promotion materials and programs. DESIGN: Market segmentation to create segments (groups) based on a cross-sectional questionnaire measuring individual characteristics and preferences for health information. Educational and delivery recommendations developed for each group. SETTING: General population of adults in Virginia. PARTICIPANTS: Random sample of 1201 Virginia residents. Respondents are representative of the general population with the exception of older age. MEASURES: Multiple factors known to impact health promotion including health status, health system utilization, health literacy, Internet use, learning styles, and preferences. ANALYSIS: Cluster analysis and discriminate analysis to create and validate segments. Common sized means to compare factors across segments. RESULTS: Developed educational and delivery recommendations matched to the 8 distinct segments. For example, the "health challenged and hard to reach" are older, lower literacy, and not likely to seek out health information. Their educational and delivery recommendations include a sixth-grade reading level, delivery through a provider, and using a "push" strategy. CONCLUSION: This model addresses a need to improve the efficiency and quality of health promotion efforts in an era of personalized medicine. It demonstrates that there are distinct groups with clearly defined educational and delivery recommendations. Health promotion professionals can consider Tailored Educational Approaches for Consumer Health to develop and deliver tailored materials to encourage behavior change.

Smooth information flow in temperature climate network reflects mass transport.

A directed climate network is constructed by Granger causality analysis of air temperature time series from a regular grid covering the whole Earth. Using winner-takes-all network thresholding approach, a structure of a smooth information flow is revealed, hidden to previous studies. The relevance of this observation is confirmed by comparison with the air mass transfer defined by the wind field. Their close relation illustrates that although the information transferred due to the causal influence is not a physical quantity, the information transfer is tied to the transfer of mass and energy.

Small-world bias of correlation networks: From brain to climate.

Complex systems are commonly characterized by the properties of their graph representation. Dynamical complex systems are then typically represented by a graph of temporal dependencies between time series of state variables of their subunits. It has been shown recently that graphs constructed in this way tend to have relatively clustered structure, potentially leading to spurious detection of small-world properties even in the case of systems with no or randomly distributed true interactions. However, the strength of this bias depends heavily on a range of parameters and its relevance for real-world data has not yet been established. In this work, we assess the relevance of the bias using two examples of multivariate time series recorded in natural complex systems. The first is the time series of local brain activity as measured by functional magnetic resonance imaging in resting healthy human subjects, and the second is the time series of average monthly surface air temperature coming from a large reanalysis of climatological data over the period 1948-2012. In both cases, the clustering in the thresholded correlation graph is substantially higher compared with a realization of a density-matched random graph, while the shortest paths are relatively short, showing thus distinguishing features of small-world structure. However, comparable or even stronger small-world properties were reproduced in correlation graphs of model processes with randomly scrambled interconnections. This suggests that the small-world properties of the correlation matrices of these real-world systems indeed do not reflect genuinely the properties of the underlying interaction structure, but rather result from the inherent properties of correlation matrix.

Identifying causal gateways and mediators in complex spatio-temporal systems.

Identifying regions important for spreading and mediating perturbations is crucial to assess the susceptibilities of spatio-temporal complex systems such as the Earth's climate to volcanic eruptions, extreme events or geoengineering. Here a data-driven approach is introduced based on a dimension reduction, causal reconstruction, and novel network measures based on causal effect theory that go beyond standard complex network tools by distinguishing direct from indirect pathways. Applied to a data set of atmospheric dynamics, the method identifies several strongly uplifting regions acting as major gateways of perturbations spreading in the atmosphere. Additionally, the method provides a stricter statistical approach to pathways of atmospheric teleconnections, yielding insights into the Pacific-Indian Ocean interaction relevant for monsoonal dynamics. Also for neuroscience or power grids, the novel causal interaction perspective provides a complementary approach to simulations or experiments for understanding the functioning of complex spatio-temporal systems with potential applications in increasing their resilience to shocks or extreme events.

Nephrographic and pyelographic analysis of CT urography: differential diagnosis.

OBJECTIVE: The differential diagnosis of renal disease is extensive. The purpose of this article is to enable the reader to recognize and understand the abnormal nephrographic patterns encountered in practice. CONCLUSION: Recognizing the different nephrographic patterns on CT urography can be invaluable in understanding the morphologic and physiologic condition of the kidney and ultimately diagnosing the disease process.

Nephrographic and pyelographic analysis of CT urography: principles, patterns, and pathophysiology.

OBJECTIVE: Careful analysis of the nephrogram is an integral component of the evaluation of the kidneys during CT urography. This is a review of the anatomy and physiology required to produce a normal nephrogram, as well as the basic principles affecting the interpretation of the nephrogram. CONCLUSION: The eight abnormal nephrographic patterns will be illustrated and discussed. This review will enable the reader to recognize and understand the abnormal nephrographic patterns encountered in practice.

A viable foal obtained by equine somatic cell nuclear transfer using oocytes recovered from immature follicles of live mares.

The presence of heterogenous mitochondria from the host ooplast affects the acceptance of offspring obtained by somatic cell nuclear transfer. This might be avoided by obtaining oocytes from selected females, but is then complicated by low numbers of available oocytes. We examined the efficiency of equine somatic cell nuclear transfer using oocytes recovered by transvaginal aspiration of immature follicles from 11 mares. Use of metaphase I oocytes as cytoplasts and of scriptaid (a histone deacetylase inhibitor) treatment during oocyte activation were evaluated to determine if these approaches would increase blastocyst production. In experiment 1, blastocyst development was 0/14 for metaphase I oocytes and 4/103 (4%) for metaphase II oocytes. Three blastocysts were transferred to recipient mares, resulting in two pregnancies and one live foal, which died shortly after birth. In experiment 2, blastocyst development was 2/47 (4%) for control oocytes and 1/83 (1%) for scriptaid-treated oocytes. No foals were born from two blastocysts transferred in the control group. The blastocyst from the scriptaid treatment resulted in birth of a live foal. In conclusion, this is apparently the first report of production of a viable cloned foal from oocytes collected from immature follicles of live mares, supporting the possibility of cloning using oocytes from selected mares.

Evaluation of foal production following intracytoplasmic sperm injection and blastocyst culture of oocytes from ovaries collected immediately before euthanasia or after death of mares under field conditions.

OBJECTIVE: To evaluate the efficiency of foal production following intracytoplasmic sperm injection (ICSI) and blastocyst culture of oocytes from mares that died or were euthanized under field conditions. DESIGN: Prospective case series. ANIMALS: 16 mares (age, 3 to 19 years) that died or were euthanized for various causes. PROCEDURES: Ovaries were collected immediately before euthanasia (n = 10) or after death (6). Ovaries were transported to the laboratory for oocyte recovery (15 mares), or oocytes were recovered at a remote location and shipped to the laboratory (1). Oocytes underwent ICSI, and presumptive zygotes were cultured for 7 to 10 days. Blastocysts were shipped to embryo transfer facilities for transcervical transfer to recipient mares. RESULTS: Ovaries were processed 30 minutes to 12 hours (mean ± SD, 4.6 ± 3.3 hours) after mares' deaths. A mean of 14.1 ± 8.6 oocytes/mare were cultured, and 110 of 225 (49%) matured. Twenty-one blastocysts developed after ICSI and were transferred to recipient mares. Thirteen pregnancies were established; 10 healthy foals were produced from 6 donor mares. The number of blastocysts produced per mare and number of live foals produced per mare were significantly correlated with the number of oocytes recovered. CONCLUSIONS AND CLINICAL RELEVANCE: Foals were produced from mares after death or euthanasia under field conditions. Proportions of foals born overall (10 foals/16 mares) and mares from which ≥ 1 foal was produced (6/16) were greater than those reported following recovery and oviductal transfer of oocytes to inseminated recipients after death of donor mares under field conditions.

Psychiatric comorbidities in patients with celiac disease: Is there any concrete biological association?

Celiac disease (CD) is a unique autoimmune disorder that occurs in genetically susceptible individuals after the ingestion of gluten, a protein found in wheat and some other cereals. The immunologically based inflammation induces atrophy of the villous structure of the jejunum, leading to malabsorption of variable severity. Subclinical and nonspecific forms of CD have been found to be increasingly common with a classic presentation of malabsorption syndrome (reference A). We present a case of OCD (obsessive compulsive disorder) in combination with depressive symptoms with the further complication of eating disorder not otherwise specified, in an adolescent male, for whom psychiatry was consulted because of treatment-refractory weight loss. We compare the elements of the case to other descriptions in the current, English language professional literature. Our literature review includes multiple search terms for the professional journals including, but not limited to, psychiatric comorbidities in celiac disease, behavioral disturbances of celiac disease, celiac disease in psychiatry, etc., to establish a possible association of psychiatric disorders, especially obsessive compulsive disorder and Celiac disease.

Physical and clinicopathologic findings in foals derived by use of somatic cell nuclear transfer: 14 cases (2004-2008).

OBJECTIVE: To describe the health status of foals derived by use of somatic cell nuclear transfer (NT) at a university laboratory. DESIGN: Retrospective case series. ANIMALS: 14 live-born NT-derived foals. PROCEDURES: Medical records from 2004 through 2008 were evaluated to identify all pregnancies resulting in live-born NT-derived foals. Information obtained included gestation length, birth weight, foaling complications, gross abnormalities of the fetal membranes, appearance of the umbilicus, mentation of the foal, limb deformities, and any other abnormalities detected in the neonatal period. Clinicopathologic data were also evaluated when available. Records of 4 recipient mares during gestation were included. RESULTS: Six foals were clinically normal for all evaluated variables. The most common abnormalities detected in the remaining 8 foals included maladjustment, enlarged umbilical remnant, and angular deformity of the forelimbs. Two foals died within 7 days after parturition; in the remaining foals, these conditions all resolved with medical or surgical management. Large offspring syndrome and gross abnormalities of the fetal membranes were not detected. The 12 surviving foals remained healthy. CONCLUSIONS AND CLINICAL RELEVANCE: Associated problems of calves resulting from use of NT have been reported, but there are few data on the outcome of foals resulting from adult somatic cell NT in horses. Although this population of foals had a lower perinatal mortality rate than has been reported for NT-derived calves, some NT-derived foals required aggressive supportive care. Birth of foals derived from NT should take place at a center equipped to handle critical care of neonates.

The Napranum social and emotional wellbeing week.

OBJECTIVE: A week-long intensive outreach project to the Indigenous community of Napranum was undertaken by a Community Forensic Mental Health Service with the aim of developing the community's capacity for primary and secondary prevention of forensic mental health problems. METHOD: The process of developing and implementing the project is described. The outcome is evaluated by means of qualitative feedback from community members and participants. RESULTS: The project was requested by the local community; planning involved extensive consultation between Queensland Health, community leaders and local service providers; and it was delivered with extensive contributions from other Queensland Health services, various non-government organizations, Indigenous opinion-leaders and public media, and an NRL football team. The outcomes are sustainable at a local level. CONCLUSIONS: This form of community engagement may contribute to destigmatization of mental illness in Indigenous communities, increased engagement between these communities and mental health service providers, and increased cohesiveness and morale of these communities.

Effect of sperm extract injection volume, injection of PLCzeta cRNA, and tissue cell line on efficiency of equine nuclear transfer.

We evaluated the effect of different activation methods on blastocyst development after equine nuclear transfer. All activation treatments were followed by incubation in 2 mM 6-dimethylaminopurine for 4 h. In Experiment 1, reconstructed oocytes were injected with sperm extract for 0.1, 0.2, 0.4, 0.8, or 1.6 sec using a FemtoJet injection device, then treated with ionomycin. The blastocyst rate (9.8%) for 0.1-sec injection was significantly higher than that for 0.2 sec (0%) or 0.8 sec (1.4%). In Experiment 2, injection of murine PLCzeta cRNA before or after ionomycin treatment did not increase blastocyst development (0 and 4.5%) over a control treatment (injection of sperm extract after ionomycin exposure; 5.6%). Transfer of 10 blastocysts produced in Experiments 1 and 2 resulted in five pregnancies, all lost before 70 days of gestation. In Experiment 3, cells from a second biopsy sample from the same horse produced significantly more blastocysts than did the original sample (4/44 vs. 0/58; p < 0.05). Transfer of these four blastocysts produced two viable foals. In Experiment 4, blastocyst development rates did not differ between oocytes in metaphase I or II at the time of nuclear transfer (16.7 and 3.0%, respectively). A healthy foal was produced from a blastocyst originating from a metaphase I oocyte.