A Precision Treatment Model for Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression Among University Students: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Guided internet-delivered cognitive behavioral therapy (i-CBT) is a low-cost way to address high unmet need for anxiety and depression treatment. Scalability could be increased if some patients were helped as much by self-guided i-CBT as guided i-CBT. Objective: To develop an individualized treatment rule using machine learning methods for guided i-CBT vs self-guided i-CBT based on a rich set of baseline predictors. Design, Setting, and Participants: This prespecified secondary analysis of an assessor-blinded, multisite randomized clinical trial of guided i-CBT, self-guided i-CBT, and treatment as usual included students in Colombia and Mexico who were seeking treatment for anxiety (defined as a 7-item Generalized Anxiety Disorder [GAD-7] score of ≥10) and/or depression (defined as a 9-item Patient Health Questionnaire [PHQ-9] score of ≥10). Study recruitment was from March 1 to October 26, 2021. Initial data analysis was conducted from May 23 to October 26, 2022. Interventions: Participants were randomized to a culturally adapted transdiagnostic i-CBT that was guided (n = 445), self-guided (n = 439), or treatment as usual (n = 435). Main Outcomes and Measures: Remission of anxiety (GAD-7 scores of ≤4) and depression (PHQ-9 scores of ≤4) 3 months after baseline. Results: The study included 1319 participants (mean [SD] age, 21.4 [3.2] years; 1038 women [78.7%]; 725 participants [55.0%] came from Mexico). A total of 1210 participants (91.7%) had significantly higher mean (SE) probabilities of joint remission of anxiety and depression with guided i-CBT (51.8% [3.0%]) than with self-guided i-CBT (37.8% [3.0%]; P = .003) or treatment as usual (40.0% [2.7%]; P = .001). The remaining 109 participants (8.3%) had low mean (SE) probabilities of joint remission of anxiety and depression across all groups (guided i-CBT: 24.5% [9.1%]; P = .007; self-guided i-CBT: 25.4% [8.8%]; P = .004; treatment as usual: 31.0% [9.4%]; P = .001). All participants with baseline anxiety had nonsignificantly higher mean (SE) probabilities of anxiety remission with guided i-CBT (62.7% [5.9%]) than the other 2 groups (self-guided i-CBT: 50.2% [6.2%]; P = .14; treatment as usual: 53.0% [6.0%]; P = .25). A total of 841 of 1177 participants (71.5%) with baseline depression had significantly higher mean (SE) probabilities of depression remission with guided i-CBT (61.5% [3.6%]) than the other 2 groups (self-guided i-CBT: 44.3% [3.7%]; P = .001; treatment as usual: 41.8% [3.2%]; P < .001). The other 336 participants (28.5%) with baseline depression had nonsignificantly higher mean (SE) probabilities of depression remission with self-guided i-CBT (54.4% [6.0%]) than guided i-CBT (39.8% [5.4%]; P = .07). Conclusions and Relevance: Guided i-CBT yielded the highest probabilities of remission of anxiety and depression for most participants; however, these differences were nonsignificant for anxiety. Some participants had the highest probabilities of remission of depression with self-guided i-CBT. Information about this variation could be used to optimize allocation of guided and self-guided i-CBT in resource-constrained settings. Trial Registration: ClinicalTrials.gov Identifier: NCT04780542.

Study protocol for pragmatic trials of Internet-delivered guided and unguided cognitive behavior therapy for treating depression and anxiety in university students of two Latin American countries: the Yo Puedo Sentirme Bien study.

BACKGROUND: Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly prevalent among university students and predict impaired college performance and later life role functioning. Yet most students do not receive treatment, especially in low-middle-income countries (LMICs). We aim to evaluate the effects of expanding treatment using scalable and inexpensive Internet-delivered transdiagnostic cognitive behavioral therapy (iCBT) among college students with symptoms of MDD and/or GAD in two LMICs in Latin America (Colombia and Mexico) and to investigate the feasibility of creating a precision treatment rule (PTR) to predict for whom iCBT is most effective. METHODS: We will first carry out a multi-site randomized pragmatic clinical trial (N = 1500) of students seeking treatment at student mental health clinics in participating universities or responding to an email offering services. Students on wait lists for clinic services will be randomized to unguided iCBT (33%), guided iCBT (33%), and treatment as usual (TAU) (33%). iCBT will be provided immediately whereas TAU will be whenever a clinic appointment is available. Short-term aggregate effects will be assessed at 90 days and longer-term effects 12 months after randomization. We will use ensemble machine learning to predict heterogeneity of treatment effects of unguided versus guided iCBT versus TAU and develop a precision treatment rule (PTR) to optimize individual student outcome. We will then conduct a second and third trial with separate samples (n = 500 per arm), but with unequal allocation across two arms: 25% will be assigned to the treatment determined to yield optimal outcomes based on the PTR developed in the first trial (PTR for optimal short-term outcomes for Trial 2 and 12-month outcomes for Trial 3), whereas the remaining 75% will be assigned with equal allocation across all three treatment arms. DISCUSSION: By collecting comprehensive baseline characteristics to evaluate heterogeneity of treatment effects, we will provide valuable and innovative information to optimize treatment effects and guide university mental health treatment planning. Such an effort could have enormous public-health implications for the region by increasing the reach of treatment, decreasing unmet need and clinic wait times, and serving as a model of evidence-based intervention planning and implementation. TRIAL STATUS: IRB Approval of Protocol Version 1.0; June 3, 2020. Recruitment began on March 1, 2021. Recruitment is tentatively scheduled to be completed on May 30, 2024. TRIAL REGISTRATION: ClinicalTrials.gov NCT04780542 . First submission date: February 28, 2021.

Executive dysfunction in patients with chronic primary insomnia treated with clonazepam.

Clonazepam (CNZ) is a drug used for insomnia treatment. Our objective was to search CNZ effects on executive functions (EF) in patients with chronic primary insomnia (CPI)-CNZ treated. Ninety participants were studied divided into three groups: a group of patients with CPI only (n = 30), a group of patients with CPI-CNZ treated (n = 30) and a healthy control drug-free subjects group (n = 30). EF were examined by means of E-Prime and by the Tower of London tests. Data of the EF were compared between groups, and correlation calculations between EF and CNZ dose were performed. Patients with CPI-CNZ treated showed more deleterious effects on EF (attention, inhibition, working memory, planning, cognitive flexibility, and monitoring) than patients with CPI only. Attention and cognitive flexibility correlated with CNZ dose. In conclusion, CNZ treatment was associated with deficits in some EF in patients with CPI-CNZ treated compared to CPI only and controls. We found a dose dependency between CNZ and some EF deficits.

Extraction, stability, and separation of betalains from Opuntia joconostle cv. using response surface methodology.

Betalains were extracted and analyzed from Opuntia joconostle (the prickly pear known as xoconostle in Mexico). For the extraction, two solvent systems were used, methanol/water and ethanol/water. A three-variable Box-Behnken statistical design was used for extraction: solvent concentration (0-80%, v/v), temperature (5-30 °C), and treatment time (10-30 min). The extraction and stability of betalains from xoconostle were studied using response surface methodology (RSM). Techniques such as UV-vis, column chromatography, and HPLC were employed for the separation and analysis of the main pigments present in the extracts. Maximum pigment concentration (92 mg/100 g of fruit) was obtained at a temperature of 15 °C and a time of 10 min for methanol/water (20:80), whereas maximum stability of the pigment was observed at pH 5 and a temperature of 25 °C. HPLC chromatograms showed the main betalains of the xoconostle characterized were betalain, betanidin, and isobetalain.

Maltrato entre iguales e intento suicida en sujetos adolescentes escolarizados / Maltrato entre pares e intentos suicidas em adolescentes escolarizados / Peer mistreatment and suicide attempt in adolescents that go to school

Objetivo: Conocer la relación entre el maltrato entre iguales y el intento suicida en sujetos adolescentes escolarizados. Método: Aplicación a 723 sujetos adolescentes escolarizados de un cuestionario que incluye escalas Likert que evalúan dificultades escolares (desempeño escolar y maltrato), ideas y pensamientos suicidas, sentimientos de soledad y de abandono, aislamiento, y antecedente de intento suicida. Para estimar la fuerza de asociación entre las dificultades escolares con las variables estudiadas utilizamos el estadístico OR (odds ratio en inglés y razón de momios en español). Consideramos que existe asociación cuando el OR es superior a uno. Resultados: Las dificultades escolares se asociaron con significancia estadística a las variables estudiadas. Conclusiones: Las experiencias de victimización ponen al sujeto adolescente en mayor situación de riesgo de sufrir desajustes psicosociales.

Objetivo: Conhecer a relação entre o maltrato entre pares e intento suicida em adolescentes escolarizados. Método: Aplicação a 723 adolescentes escolarizados de um questionário que inclui escalas de Likert para avaliar as dificuldades escolares (desempenho escolar e maltrato), ideias e pensamentos suicidas, sentimentos de solidão e abandono, solamento e antecedente de intento suicida. Para estimar a força de associação entre as dificuldades escolares com as variáveis estudadas utilizou-se o estatístico OR (odds ratio, em inglês e razón de momios, em espanhol). Considerou-se que existia associação quando o OR foi superior a 1. Resultados: As dificuldades escolares associaram-se com significância estadística com as variáveis estudadas. Conclusões: As experiências de vitimização expõem o adolescente a um maior risco de sofrer desajustes psicossociais.

Objective: To know the relationship between peer mistreatment (bullying) and suicide attempts for teenagers that go to school. Method: Appling a questionnaire to 723 adolescents that go to school, including Likert scales that evaluate difficulties at school (school performance and mistreatment), suicidal ideas and thoughts, feelings of loneliness and abandonment, isolation, previous suicide attempts. To estimate the strength of association between the difficulties at school and the variables under study the OR (odds ratio) statistic was used. And association is considered to exist when OR was superior to 1. Results: Difficulties at school were associated to the studied variables with statistical significance. Conclusions: Victimization experiences place the teenager at higher risk of suffering psychosocial imbalance.

El servicio de urgencias en un hospital de tercer nivel: su comportamiento durante cinco años: estudio preliminar / The emergency service in a third level hospital: its benavior during five years: a preliminary study

Antecedentes: un servicio de urgencias es aquel capaz de proporcionar una atención médica inmediata a las contingencias de un padecimiento que ocurren en forma aguda. Objetivo: mostrar el comportamiento del servicio de urgencias adultos del Hospital Regional General Ignacio Zaragoza de enero de 1989 a diciembre de 1993. Material y métodos: en un estudio observacional, prolectivo y descriptivo se incluyeron todos los adultos que asistieron al servivio de Urgencias del Hospital Regional General Ignacio Zaragoza. Resultados: se atendieron un total de 231,229 pacientes en la consulta de urgencias. El 84 por ciento egresó a su domicilio. Conclusión ocho de cada diez admisiones al servicio de urgencias pudieron haber sido sustituidas por otras alternativas de atención médica

Tuberculosis del aparato digestivo: epidemiología y diagnóstico / Tuberculosis of the digestive tract: epidemiology and diagnosis

La tuberculosis es un padecimiento bacteriano, crónico, causado por mycobacterium tuberculosis. Es una enfermedad común desde la antigüedad, pero fue descrita en Europa entre los siglos XVII y XIX. En la actualidad la incidencia del padecimiento se ha incrementado nuevamente en forma alarmante, lo que nos obliga a adquirir conocimientos para diagnosicarla de manera oportuna y tratarla eficazmente la tuberculosis del aparato digestivo es provocada por la diseminación hematógena del bacilo Mycobacterium tuberculosis, a partir de órganos linfáticos o genitourinarios o bien por la ingestión de alimentos contaminados. Debido a su inicio insidioso, muchas veces el diagnóstico es difícil. Raramente se observa el microorganismo en el líquido de paracentesis. La tuberculosis del aparato digestivo puede manifestarse en diferentes órganos, con diversos síntomas y signos, por lo cual no debe olvidarse al determinar un diagnóstico