Cost-effectiveness of varying degrees and models of therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy: Evidence from a randomized controlled trial.

In routine care, Internet-delivered Cognitive Behaviour Therapy (ICBT) is often delivered with therapist support via emails/phone calls, but the cost-effectiveness of varying amounts of therapist support or having therapists specialized in ICBT is not known. This study compared the cost-effectiveness of specialized therapists providing ICBT support once-weekly (1WS) versus providing support once-weekly supplemented with a one-business-day response to patient emails (1W/1BD-S). We further compared the cost-effectiveness of 1W support offered by therapists employed in a specialized clinic (1WS) versus community clinics where therapists primarily deliver face-to-face therapy (1WC). Patients were randomly allocated to groups: 1WS group (n = 216), 1W/1BD-S group (n = 233), and 1WC group (n = 226). At baseline, 12, 24 and 52-week follow-up, patients completed the Treatment Inventory of Costs in Patients with Psychiatric Disorders questionnaire (TiC-P) adapted for use in Canada to assess healthcare use and productivity losses. Additionally, to assess Quality Adjusted Life Years (QALYs) gained, patients completed the EQ-5D-5L at the same time periods. We quantified uncertainties by one-way and probabilistic sensitivity analysis and reported Incremental cost-effectiveness ratios (ICER), cost-effectiveness planes and acceptability curves. Cost-effectiveness over 52 weeks was CAD 3072/QALY for 1WC, CAD 3244/QALY for 1W/1BD-S, and CAD 3528/QALY for 1WS. Our model suggests that 1WS is the best strategy since the incremental cost per QALY is below the $50,000 threshold (ICER is CAD 42,328/QALY compared to the next most effective, 1WC). 1W/1BD-S is dominated by the other strategies. The cost-effectiveness acceptability curves suggest that the 1WS group has a higher probability for cost-effectiveness (38 %) than 1W/1BD-S (30 %) and 1WC (32 %) when the willingness to pay is $50,000 per QALY. These results have important implications for health policymakers deciding on delivery of ICBT for the treatment of anxiety and/depressive disorders.

Internet-delivered cognitive behaviour therapy for chronic health conditions: self-guided versus team-guided.

There is growing interest in offering Internet-delivered cognitive behaviour therapy (ICBT) to individuals with chronic health conditions, with this process often being guided by a single clinician. Due to lack of full time personnel, it is sometimes necessary to have multiple clinicians offer guidance or for no guidance to be offered. In this randomized trial, we compared team-guided ICBT (n = 90) to self-guided ICBT (n = 88). Participants completed measures at pre-, post-, and 3-months post-ICBT. Both groups showed similar rates of treatment completion and large improvements on depression and anxiety at post-treatment and follow-up. Unexpectedly, more participants in the self-guided versus team-guided condition showed clinically significant improvement on depression at post-treatment (76.5% vs 49.2%) and follow-up (70% vs 45.6%). Thus, team-guided ICBT may not provide significant benefits compared to self-guided ICBT. However, it may be an alternative approach to consider among a population of high risk individuals that wants or requires closer monitoring of symptoms.Trail registration TRN: NCT03500237; Date: April 18, 2018.

Juvenile Gouldian finches (Erythrura gouldiae) form sibling subgroups during social integration.

The formation of social relationships in complex groups is critical in shaping patterns of social organization and behavioral development. In many birds, young individuals remain dependent on their parents for extended periods but must abruptly transition to navigating interactions in the wider group after independence. While lack of social relationships during this period is detrimental in the development of later social skills, little is known about the social relationships juveniles form after independence in many bird species. In this study, we describe patterns of social interactions in juvenile Gouldian finches (Erythrura gouldiae) during transitions from family groups into flocks of unfamiliar individuals. Twenty juveniles from four families were introduced into two flocks. After introductions, juveniles showed a gradient of approach rates with most approaches directed toward siblings, followed by juvenile peers, adult females, and lastly adult males. Significant preferences for siblings resulted in the emergence of sibling subgroups within the larger social network. This intentional self-assortment of siblings suggests that sibling subgroups are an important bridge linking social connections within the family and the wider group. Such findings suggests that sibling relationships have a critical role in the socialization after independence, as well as structuring the social organization of Gouldian finch flocks.

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson.

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

Prevalence of lower limb venous disease in surgeons: a case study and results of a survey by the BAOMS Reconstruction Surgical Subspecialty Interest Group.

We report a case of venous leg ulceration in a reconstructive oral and maxillofacial surgeon. An online survey was created by the British Association of Oral and Maxillofacial Surgeons (BAOMS) Reconstruction Surgical Subspecialty Interest Group (SSIG), primarily to target head and neck surgeons, to investigate the perceived risk and occurrence of venous leg disease. Two respondents had received treatment for lower limb venous disease thus compromising their ability to work, while 13 had symptoms of early venous disease. Our study shows an interesting area of concern for occupational health in surgeons, particularly in those carrying out long operations, as will be the case for members of the Reconstruction SSIG.

Corrigendum to "Transdiagnostic internet-delivered cognitive behaviour therapy with therapist-support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial" [Internet Interv. 22 (2020) 1-16/100347].

[This corrects the article DOI: 10.1016/j.invent.2020.100347.].

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support.

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients (n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.

Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial.

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists (n = 233); 2) once-weekly support also offered by specialized therapists (n = 216); or 3) once-weekly support offered by community clinic therapists (n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients (M: 13 versus 9) and required more therapist time over treatment (M: 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

Results of flap reconstruction: categorisation to reflect outcomes and process in the management of head and neck defects.

The reporting of the outcomes of flap reconstruction is often based on numerical success rates. Whilst this remains a useful variable with which to measure success, it is limited in its ability to reflect the complex processes involved. The lack of consistency in the categorisation of outcomes of flap reconstruction in the head and neck could potentially lead us to lose the opportunity to fully capture the implications of its success or failure, or both. We propose a classification that moves away from primarily reporting the results of its binary nature, and focuses more on the process of reconstruction, particularly in the head and neck.

Adipose-only sentinel lymph nodes: a finding during the adaptation of a sentinel lymph node mapping algorithm with indocyanine green in women with endometrial cancer.

OBJECTIVE: To identify factors that affect successful adaptation of sentinel lymph node mapping and those that lead to unintended adipose-only sentinel lymph node identification. METHODS: Surgical and pathological data were prospectively collected on patients with endometrial cancer who underwent sentinel lymph node mapping with indocyanine green with or without pelvic and/or para-aortic lymph node dissection between November 2013 and April 2017. All mapping cases were performed with the robotic system. Adipose-only specimens were defined as a sentinel lymph node without a pathologically identified lymph node after ultrastaging. RESULTS: A total of 202 patients were included: 83% had endometrioid pathology, 12% serous, 3% carcinosarcoma, and 2% clear cell, with mixed pathology noted in 2%. The bilateral sentinel lymph node detection rate was 66%, and the rate of mapping at least a unilateral sentinel lymph node was 86%. Neither the bilateral nor the unilateral sentinel lymph node mapping rate changed with increased surgeon experience. The rate of adipose-only sentinel lymph node identification was more frequent when comparing the first 10 cases (37%), cases 11 - 30 (28%), and > 30 cases (9%) (P = 0.006). Body mass index > 30 kg/m2, uterine fibroids, The International Federation of Gynecology and Obstetrics (FIGO) grade, and histology were not found to have a statistically significant impact on either sentinel lymph node identification or adipose-only sentinel lymph node identification. Adipose-only sentinel lymph nodes were more likely with increased time from cervical injection to identification of the sentinel lymph node in the right hemipelvis. The median range was 28 min (14-73) for true sentinel lymph node identification vs 33 min (23-74) for adipose-only sentinel lymph node identification (P = 0.02). CONCLUSION: Patient and surgeon factors did not impact the identification of sentinel lymph nodes over time. Adipose-only sentinel lymph nodes were more frequently identified in the initial cases and represent a potential complication to adapting sentinel lymph node biopsy without lymphadenectomy. The increase in adipose-only sentinel lymph node identification that was associated with time from cervical injection may represent delayed or disrupted uptake of indocyanine green.

Academic Background of Irish Orthopaedic Trainees

Introduction Academic achievement may be used to distinguish between trainees in competition for training or consultant posts. This study aimed to quantify the academic achievement among orthopaedic trainees in Ireland. Methods A web-based questionnaire was distributed to all trainees on the Irish Trauma and Orthopaedics specialist training programme. Questions included current year of training and attainment of higher degrees, publications, grants and prizes. Results Thirty-eight of 51 trainees completed the questionnaire (74%). All had commenced or completed a higher degree, more frequently a taught programme among ST3 and ST4 trainees and research based among the more senior years. Thirty-five (69%) had at least one peer-reviewed publication at the time of appointment. All continued some research activity. A majority aspire to a predominantly clinical career. Discussion Levels of academic achievement remain high among Irish orthopaedic trainees. Although junior trainees have fewer publications at appointment, all continue research on the training programme.

Patient Perspectives on Strengths and Challenges of Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy: Using the Patient Voice to Improve Care.

Therapist-assisted internet-delivered cognitive behaviour therapy (T-ICBT) involves patients reading online treatment materials, completing relevant exercises, and receiving therapist support. This study aimed to understand the preferences and recommendations of 225 patients enrolled in a T-ICBT course for depression and anxiety via an online therapy unit in collaboration with community mental health clinics dispersed across one Canadian province. An open-ended survey asked participants their opinions of the course and responses were analyzed using a content analysis approach. Patient comments addressed many strengths of the course (64%), with some opportunities for improvement (36%). Most-appreciated features included ability to download content for future use, reading other patients' experiences, and content of lessons. Patients made suggestions for improving the breadth of patient stories, timeline of the course, and matching availability of the therapist to patient need. Patient feedback regarding preferences provides valuable information for improving the patient-centered nature of T-ICBT.

Attitudes to trainee-led surgical mentoring.

BACKGROUND: Surgical mentorship remains important especially in an era of run-through training but can be hindered by the 'generation gap' between consultants and students. To cater for this, we established a trainee-led mentorship programme for medical students interested in surgery and herein report our initial findings. AIM: Our aim is to assess the attitudes of surgical mentors and mentees to a newly established surgical trainee-led mentorship programme to determine factors desirable for its successful delivery. METHODS: Six first year surgical trainees enrolled as mentors in September 2014. Ninety students enrolled as mentees. During the second semester both mentees and mentors were surveyed by an anonymous questionnaire to assess attitudes to the programme. RESULTS: Data was collected from 85 respondents. Eighty-nine percent of mentees felt their participation had positively impacted their decision to pursue a surgical career. The main benefits were found to be in improving technical skills (40%), providing surgical career guidance (35%) and information about surgical training programmes (14%). Of the mentor qualities most appreciated, 89% preferred institutional proximity while 30 and 27% valued enthusiasm and approachability. Ninety-three percent felt gender is unimportant; 49% preferred a mentor in their speciality of interest. Mentors valued this responsibility drawing greater job satisfaction. CONCLUSION: Our study, the first to describe the experience and potential benefits of a surgical trainee-led mentoring programme in Ireland, demonstrates a significant appetite amongst students and surgical trainees for mentorship. Further evaluation of the importance of mentoring programmes and the role of trainees in their delivery are necessary.

Randomized controlled trial of internet-delivered cognitive behaviour therapy comparing standard weekly versus optional weekly therapist support.

Internet-delivered cognitive behaviour therapy (ICBT) is effective for treating anxiety and depression. The relative benefits of offering standard weekly compared to optional weekly therapist support in conjunction with ICBT within routine care has not been examined. Patients seeking ICBT for depression and or anxiety in routine care were randomized to standard (n=92) or optional (n=88) weekly support. The optional approach resulted in therapists receiving half as many messages from (1.70 vs. 3.96) and sending half as many messages to patients (3.62 vs. 7.29). Optional Support was associated with lower completion rates (56.6% versus 82.4%), but, similar to Standard Support, resulted in large reductions on the GAD-7 (within Cohen's d≥1.08; avg. reduction ≥47%) and PHQ-9 (within Cohen's d≥0.82; avg. reduction ≥43%) at post-treatment and 3-month follow-up. Optional weekly support appears clinically effective and acceptable for many patients and may reduce costs, but safety requires monitoring given lower completion rates.

Implementation of internet-delivered cognitive behavior therapy within community mental health clinics: a process evaluation using the consolidated framework for implementation research.

BACKGROUND: Depression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT. METHODS: Therapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation. RESULTS: Analyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care. CONCLUSIONS: The results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings.

Clinical outcomes following spinal fracture in patients with ankylosing spondylitis.

BACKGROUND: Ankylosing spondylitis is a seronegative rheumatoid condition mainly affecting the axial skeleton. It leads to progressive deformity and stiffening of the spine with an increased risk of vertebral fractures and significant neurological deficits compared to the general population. AIM: This study aimed to evaluate the outcomes of patients with ankylosing spondylitis who sustained acute vertebral fractures over a 10-year period. METHODS: A retrospective review of patient records and radiographic images was performed. Mechanism of injury, fracture type, timing of diagnosis, neurological deficit, management and complications were assessed. RESULTS: Twenty-four patients were included. Most (23) sustained low energy injuries. Five (20%) patients had a delayed diagnosis over 24 h after the time of injury. Twelve (50%) of patients had a neurological deficit at the time of admission and most did not recover. Eighteen (75%) patients underwent surgical stabilisation. There were 19 complications (in 15 patients) following surgery. CONCLUSION: Patients with ankylosing spondylitis are at risk of spinal fracture and associated spinal cord injury after relatively minor trauma. Delayed diagnosis places the patient at risk of neurological compromise, and thus a high index of suspicion is needed when assessing this patient group.

Microvascular coupling devices: neglected resource with a short learning curve.

Microvascular couplers have a record of efficiency and efficacy. They have been used in anastomoses in the head and neck in Sunderland since November 2013, where we have investigated the time taken for anastomosis, patency, and cost. We also completed a national survey of the use of couplers in the United Kingdom, in which we recorded the time of anastomosis. The mean (range) time was 4minutes (2minutes 40seconds - 4minutes 10seconds). One flap partially failed. This shows that couplers can save time, they have successful outcomes, and the technique is quick and easy to learn.

Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics.

Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n=458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17-1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.

The medial sural artery perforator flap in intra-oral reconstruction: A Northeast experience.

BACKGROUND: The medial sural artery perforator (MSAP) flap is a fasciocutaneous flap that is gaining popularity for intra-oral reconstructions. The aim of this two-centre review was to evaluate the use of the MSAP flap in intra-oral reconstructions and report our experiences. METHODS: Data were collected prospectively on 35 consecutive intra-oral reconstructions using the free MSAP flap. Patient details and intraoperative flap details were recorded. RESULTS: Thirty-five patients underwent intra-oral reconstruction with a free MSAP flap (26 males and nine females). The average flap dimensions were a length of 8.03 cm, a width of 5.0 cm and a thickness of 7.1 mm. Twenty-two flaps had two perforators, and the average pedicle length was 11.1 cm. There were no flap losses. Ninety-one per cent of donor sites were closed primarily. There were two minor complications related to donor-site wound dehiscence, which required delayed skin grafting. The overall complication rate was 5.7%. CONCLUSIONS: The MSAP flap is a good choice for intra-oral reconstruction. It has reliable anatomy and provides thin, pliable skin with a long pedicle. In addition, donor morbidity is low as the donor site can be closed directly in most cases. It is currently our flap of choice for small intra-oral soft tissue defects.