Superficial Siderosis After Traumatic Brain Injury: A Case Report.

Superficial siderosis (SS) is a rare condition in which chronic accumulation of the blood in the subarachnoid space over time leads to the buildup of hemosiderin deposits, which in turn cause neurological dysfunction in those affected. While reversibility of the damage done by this condition is nearly impossible, early detection can allow for immediate surgical intervention and thus prevent further progression of ataxia, hearing loss, and other neurological deficits caused by SS. We present a case of a 53-year-old male who was successfully diagnosed with SS secondary to a chronic post-traumatic pseudomeningocele and underwent surgical repair with the resolution of his symptoms. We aim to encourage more extensive workups for common neurological dysfunctions such as tinnitus or vertigo in patients who have a history of traumatic brain injury or any significant motor vehicle accidents.

Coaching Program to Address Burnout, Well-Being, and Professional Development in Pediatric Surgery Trainees: A Randomized Controlled Trial.

OBJECTIVE: To assess impact of participation in a positive psychology coaching program on trainee burnout and well-being. BACKGROUND: Coaching using principles of positive psychology can improve well-being and reduce physician burnout. We hypothesized that participation in a coaching program would improve pediatric surgery trainee well-being. METHODS: With IRB approval, a coaching program was implemented during the COVID-19 pandemic (9/2020-7/2021) in the American Pediatric Surgical Association. Volunteer pediatric surgery trainees (n=43) were randomized to receive either one-on-one quarterly virtual coaching (n=22) from a pediatric surgeon trained in coaching skills or wellness reading materials (n=21). Participants completed pre- and post-study surveys containing validated measures including PERMA (positive emotion, engagement, relationships, meaning, accomplishment), professional fulfillment, burnout, self-valuation, gratitude, coping skills, and workplace experiences. Results were analyzed using Wilcoxon rank sum test, Kruskal-Wallis test, or chi-square test. RESULTS: Forty trainees (93%) completed both the baseline and year-end surveys and were included in the analysis. Twenty-five (64%) were female, mean age 35.7 (SD 2.3), 65% first-year fellows. Coached trainees showed an improved change in PERMA (P=0.034), burnout (P=0.024), and gratitude (P=0.03) scores from pre- to post-coaching compared to non-coached trainees. Coping skills also improved. More coaching sessions was associated with higher self-valuation scores (P=0.042), and more opportunities to reflect was associated with improved burnout and self-valuation. CONCLUSIONS: Despite the stress and challenges of medicine during COVID-19, a virtual positive psychology coaching program provided benefit in well-being and burnout to pediatric surgery trainees. Coaching should be integrated into existing wellness programs to support acquisition of coping skills that help trainees cope with the stressors they will face during their careers.

Is Attachment and Biobehavioral Catch-up effective for parents with insecure attachment states of mind?

Prior research suggests that attachment-based interventions, including Attachment and Biobehavioral Catch-up (ABC), may be less effective at enhancing parenting quality among parents who self-report having an insecure attachment style. The current study tested whether effects of ABC on parental behavior were moderated by categorical and dimensional measures of attachment obtained via Adult Attachment Interviews with 454 parents who were approximately 34 years old, primarily female, and predominantly White or African American. Parents randomized to ABC exhibited higher sensitivity and positive regard, and lower intrusiveness shortly after the intervention than parents randomized to the control intervention (|ß|s = .10-.27). The effect of ABC on intrusiveness persisted 2 years later. Effects at either timepoint were not significantly moderated by parents' attachment representations.

The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: A randomized control study.

PURPOSE: Cognitive behavioural therapy (CBT) has been found to be an effective treatment for OCD, but there remains a significant proportion of individuals who fail to show a treatment response. Aerobic exercise has previously been associated with decreases in anxiety and depression, as well as improvements in OCD symptoms in small-scale studies. The purpose of the present research was to use a randomized control trial design to examine the effects of exercise alone and in combination with CBT, on OCD symptoms and secondary symptoms. METHOD: 125 participants were randomly assigned to one of four treatment groups: waitlist control, exercise, CBT, and CBT with exercise. OCD symptom severity was measured at four points over the course of treatment, secondary outcome measures were gathered at three points over treatment. RESULTS: CBT alone and combined with exercise was associated with significantly greater OCD symptom reduction than exercise alone or the control groups. Total exercise frequency predicted OCD symptom reduction in the groups in which exercise was measured. Group membership did not significantly predict reductions in secondary outcome measures. CONCLUSION: Exercise frequency, rather than the presence or absence of exercise, appears to predict OCD symptom reduction, as did participation in CBT.

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach.

Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.

Longitudinal changes in intolerance of uncertainty and worry severity during CBT for generalized anxiety disorder.

Intolerance of uncertainty (IU) is a key construct in generalized anxiety disorder (GAD), but little is known about the concurrent and temporal patterns of associations between IU and GAD symptom severity during treatment. In addition, most of the extant literature focuses on IU as a unidimensional construct, whereas some researchers conceptualize IU as being comprised of two dimensions, inhibitory and prospective IU. Ninety individuals with GAD completed measures of IU and worry severity at pre-treatment, session 4, session 8, and end of treatment (session 12), during group-based cognitive behavior therapy (CBT) for GAD. Longitudinal multilevel modeling showed that IU predicted worry severity concurrently, but not prospectively over time; this pattern of associations was found with the total IUS score and the inhibitory (but not prospective) subscale score. Further, the relationship between IU total scores and worry severity became stronger over time. The relationship between inhibitory (but not prospective) IU and worry also became stronger over time. When the order of the variables in the model was reversed, worry severity also predicted concurrent but not future IU. Therefore, change in IU is associated with change in worry throughout the course of CBT, particularly as treatment progresses, though its directional association as a cause and/or effect remains unclear.

Timing of adoption is associated with electrophysiological brain activity and externalizing problems among children adopted internationally.

This study investigated middle childhood resting electroencephalography (EEG) and behavioral adjustment in 35 internationally adopted children removed from early caregiving adversity between 6 and 29 months of age. Older age of adoption was associated with more immature or atypical profiles of middle childhood cortical function, based on higher relative theta power (4-6 Hz), lower relative alpha power (7-12 Hz), lower peak alpha frequency, and lower absolute beta (13-20 Hz) and gamma (21-50 Hz) power. More immature or atypical EEG spectral power indirectly linked older age of adoption with increased risk for externalizing problems in middle childhood. The findings add to existing evidence linking duration of early adverse exposures with lasting effects on brain function and behavioral regulation even years after living in a stable adoptive family setting. Findings underscore the need to minimize and prevent children's exposures to early caregiving adversity, especially in the first years of life. They call for innovative interventions to support neurotypical development in internationally adopted children at elevated risk.

Prospective risk from prenatal anxiety to post traumatic stress following childbirth: The mediating effects of acute stress assessed during the postnatal hospital stay and preliminary evidence for moderating effects of doula care.

OBJECTIVE: Growing literature has identified childbirth as a potentially traumatic event, following which mothers may develop symptoms of Post-Traumatic-Stress-Following-Childbirth. The current study is the first to prospectively examine a pathway of risk from mothers' prenatal trait-anxiety, to Acute-Stress-Immediately-Following-Childbirth, and later symptoms of Post-Traumatic-Stress-Following-Childbirth, in a low-risk community sample. Auxiliary analyses explored whether doula care during childbirth moderated risk. METHOD: 149 pregnant women were randomly selected. Prenatal trait-anxiety was assessed toward the end of pregnancy, Acute-Stress-Immediately-Following-Childbirth at two-days post-partum, and symptoms of Post-Traumatic-Stress-Following-Childbirth at one-month post-partum. RESULTS: Results indicated a significant indirect pathway from prenatal trait-anxiety to Post-Traumatic-Stress-Following-Childbirth, through Acute-Stress-Immediately-Following-Childbirth. Two groups were generated ad hoc for auxiliary analyses: participants who opted to receive doula care during childbirth (n=21; 14%) versus participants who received care as usual (n=128; 86%). Analyses provided preliminary support for doula care as a potential moderator of risk. CONCLUSIONS: Results point toward prenatal trait-anxiety and Acute-Stress-Immediately-Following-Childbirth as significant risk factors for Post-Traumatic-Stress-Following-Childbirth. Findings inform preventive screening implicating the prenatal period as well as the postnatal hospital stay as important time windows for preventive screening. Finally, preliminary support for moderating effects of doula care suggest that preventive interventions administered during the perinatal period may effectively reduce anxiety-related risk for Post-Traumatic-Stress-Following-Childbirth.

Excessive reassurance seeking in depression versus obsessive-compulsive disorder: Cross-sectional and cognitive behavioural therapy treatment comparisons.

Excessive reassurance seeking (ERS) has been hypothesized as an important maintenance factor in depression and obsessive compulsive disorder (OCD). The present study examined the types of ERS in depression and OCD, the effects of CBT on ERS, predictors of ERS reduction, and the relation between ERS reduction and symptom change. METHOD: Treatment-seeking participants diagnosed with a depressive disorder (N = 361) or OCD (N = 156) completed the Reassurance Seeking Scale (RSS) and symptom measures before and following CBT treatment. Measures of intolerance of uncertainty and distress tolerance were completed pre-treatment as potential predictors of ERS change. RESULTS: Individuals with depression demonstrated higher pre-treatment ERS related to social attachment compared to those with OCD. ERS significantly decreased over treatment in both groups and change in ERS predicted symptom change among both OCD and depression groups. Higher pre-treatment intolerance of uncertainty significantly predicted less ERS change regardless of diagnosis. Distress tolerance was not associated with ERS changes. CONCLUSION: ERS is significantly related to symptom severity cross-sectionally as well as over treatment in depression and OCD, though types of ERS may differ. Higher intolerance of uncertainty may impede the reduction of ERS in CBT.

Reassurance seeking in the anxiety disorders and OCD: Construct validation, clinical correlates and CBT treatment response.

BACKGROUND: Reassurance seeking has been hypothesized to be a key factor in the maintenance of anxiety and obsessive-compulsive disorders according to contemporary cognitive-behavioural therapy (CBT) approaches. The present study sought to examine the structure, clinical correlates, and malleability of reassurance seeking in the context of CBT treatment. METHODS: Treatment-seeking participants (N = 738) with DSM-IV-TR (American Psychiatric Association, 2000) panic disorder with agoraphobia (PD/A), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) completed the Reassurance Seeking Scale (RSS) with other symptom measures prior to and following CBT treatment. RESULTS: A confirmatory factor analysis supported a three factor solution: the need to seek excessive reassurance regarding decisions, attachment and the security of relationships, and perceived general threat and anxiety. The RSS was moderately correlated with general measures of anxiety and depression as well as disorder-specific symptom scales. Further, CBT was found to produce changes in reassurance seeking across CBT treatments and these reductions were significantly associated with disorder-specific clinical improvement. CONCLUSION: Reassurance seeking appears to be a common factor across anxiety disorders and its reduction in CBT treatment is associated with improved clinical outcomes.

Changes in post-event processing during cognitive behavioural therapy for social anxiety disorder: A longitudinal analysis using post-session measurement and experience sampling methodology.

PURPOSE: Post-event processing (PEP) is posited to be an important factor in the maintenance of social anxiety symptoms. Previous research has demonstrated that general PEP tendencies are sensitive to treatment. However, it remains unclear how momentary PEP following social interactions changes over the course of treatment for social anxiety disorder. The purpose of the present study was to examine how both momentary and general PEP change over the course of treatment, and how such changes predict treatment outcome. METHOD: Participants (N = 60) with social anxiety disorder were enrolled in group cognitive behavioural therapy. All participants completed measures of PEP and social anxiety symptom severity at five time points over treatment. A subset (N = 33) also completed repeated experience sampling measurements of PEP following social interactions across the course of treatment. RESULTS: Both general and momentary PEP decreased over the course of treatment. Decreases in both types of PEP predicted lower social anxiety symptom severity following treatment. CONCLUSION: The results of the study demonstrate that momentary experiences of PEP can be influenced by treatment, and can in turn impact treatment outcome. The findings have significant clinical and theoretical implications.

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions.

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.

Electronic Patient-Reported Outcomes: Semi-Automated Data Collection in the Interventional Radiology Clinic.

INTRODUCTION: Patient-reported outcomes are important for clinical research and will likely be used in the near future as a metric for physician reimbursement. This study aims to evaluate the implementation of an electronic data collection system for deep vein thrombosis and lymphedema quality-of-life (QOL) questionnaires in a tertiary care interventional radiology practice. METHODS: A single provider's clinic patients were automatically e-mailed validated questionnaires 1 week before their appointments. If not completed via e-mail, the questionnaire was administered on an electronic tablet in clinic by a research coordinator. Patients were also sent postprocedure questionnaires. RESULTS: In all, 106 patients visited the clinic for a pre-intervention venous consultation. Of them, 96% (n = 102 of 106) completed the pre-intervention questionnaire: 48% (n = 47 of 98) via e-mail and 52% (n = 51 of 98) via tablet. Of the patients who had procedures and were sent questionnaires, 49% (n = 26 of 53) were seen in person. Of the postprocedure in-person clinic patients, 76% (n = 20 of 26) completed the questionnaire via e-mail, and the remainder with the tablet in clinic. Twenty-seven of the 53 (51%) patients did not return for follow-up and instead were sent an electronic questionnaire as their only source of follow-up, of which 74% (n = 20 of 27) complied. CONCLUSION: After an initial introduction to electronic QOL reporting, patients were more likely to complete the questionnaires remotely for their follow-up appointment. A semi-automated electronic QOL system allows physicians to collect patient outcome data even in the absence of a clinic visit.

Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting.

OBJECTIVES: Exposure and response prevention (ERP) remains the most empirically supported psychological treatment for obsessive compulsive disorder (OCD). Clinical guidelines recommend the addition of cognitive approaches to ERP although the presumed additive benefits have not been directly tested. The aim of this was to compare a treatment that integrated cognitive therapy with ERP (ERP + CT) to traditional, manualized ERP to test the additive benefits. DESIGN: A longitudinal, randomized control trial design was used. METHODS: Participants (N = 127) with OCD were randomly assigned to receive individual outpatient ERP or ERP + CT. Obsessive-compulsive symptom severity measures were completed pre- and post-treatment and at 6-month follow-up. RESULTS: While both conditions led to significant symptom and obsessive belief reduction, ERP + CT led to significantly greater symptom and belief reduction as compared to ERP across all main symptom presentations of OCD. Based on a priori definitions of effectiveness, more patients in ERP + CT compared to the ERP group were also deemed treatment responders. CONCLUSIONS: The results of this study suggest that cognitive therapy can be readily integrated with ERP to improve clinical outcomes beyond ERP alone. PRACTITIONER POINTS: Both ERP and ERP + CT were effective, however a course of ERP + CT was significantly more effective at reducing symptoms of OCD than the ERP treatment condition. Significantly more participants who received ERP + CT experienced clinically significant change in OCD symptoms compared to those who received ERP. OCD symptom dimension did not significantly impact response to either ERP or ERP + CT treatments.

SOCE and STIM1 signaling in the heart: Timing and location matter.

Store operated Ca2+ entry (SOCE) is an ancient and ubiquitous Ca2+ signaling pathway discovered decades ago, but the function of SOCE in human physiology is only now being revealed. The relevance of this pathway to striated muscle was solidified with the description of skeletal myopathies that result from mutations in STIM1 and Orai1, the two SOCE components. Here, we consider the evidence for STIM1 and SOCE in cardiac muscle and the sinoatrial node. We highlight recent studies revealing a role for STIM1 in cardiac growth in response to developmental and pathologic cues. We also review the role of STIM1 in the regulation of SOCE and Ca2+ store refilling in a non-Orai dependent manner. Finally, we discuss the importance of this pathway in ventricular cardiomyocytes where SOCE contribute to developmental growth and in pacemaker cells where SOCE likely has a fundamental to generating the cardiac rhythm.

Assessment of Inter- and Intraobserver Reliability and Accuracy to Evaluate Apical Vertebral Rotation Using Four Methods: An Experimental Study Using a Saw Bone Model.

STUDY DESIGN: After placing a thoracic three-vertebra segment saw bones model on a standardized turntable, a series of anteroposterior (AP) radiographs were obtained and then set in increments to 90° rotation. Then the specimen was instrumented with 35-mm pedicle screws bilaterally and the rotation process and image acquisition were repeated. OBJECTIVE: Assess reliability and accuracy of spine surgeons evaluating apical vertebral rotation (AVR) through surgeon's visual x-ray estimation, Nash-Moe system, Upasani trigonometric method, and Upasani grading system. BACKGROUND CONTEXT: Accurate assessment of AVR is one measure surgeons can evaluate the success of intervention and potential loss of correction in scoliotic deformities. METHODS: Eighty-four representative images of uninstrumented and instrumented vertebral segments were blinded. AVR was estimated by five experienced spinal deformity surgeons using the four techniques. The surgeons' grading, estimates, and errors compared to actual rotation were calculated. Inter- and intraobserver reliability were calculated using interclass correlation (ICC). RESULTS: Each surgeon's error for simple visual estimation for uninstrumented segments was 8.7° to 17.4° (average error = 12.4°), and for instrumented segments it was 7.7° to 11.3° (average error = 9.5°). Error for the Upasani trigonometric method was -6.7° to 11.6° (average error = 0.9°). There was relatively poor accuracy for Nash-Moe system (38.2%-53.9%) compared with the Upasani grading system (76.74%-80.23%). Interobserver reliability using the Nash-Moe method was good (0.844), with intraobserver reliability from fair to excellent (0.684-0.949). Interobserver reliability for the Upasani grading method was good (0.829), with intraobserver reliability from fair to good (0.751-0.869). We found excellent interobserver reliability for Upasani trigonometric classification (0.935) with fair to excellent intraobserver reliability (0.775-0.991). The interobserver reliability of surgeons' visual estimates was good (0.898) and the intraobserver reliability from good to excellent (0.866-0.99) without pedicle screws, and interobserver reliability was excellent (0.948) and intraobserver reliability also excellent (0.959-0.986) with pedicle screws. CONCLUSIONS: We confirm that both techniques described by Upasani have good reliability and accuracy, appearing more accurate than surgeon's visual estimates or Nash-Moe system. LEVEL OF EVIDENCE: Level III.

Comparison of Microbial Count on Various Surfaces in Operating Rooms at Different Times of the Day.

The purpose of this study was to determine the degree of microbial contamination of surfaces in the operating room (OR) and to understand the relationship between time and location of contamination. Five OR surfaces were sampled at two time points on three consecutive Mondays and Thursdays. Each sample was cultured on a blood agar plate and introduced to a liquid nutrient broth. The most sterile surface was the OR lights with only one positive growth sample at each time. At both times, the most commonly contaminated surface was the staff keyboard. Coagulase-negative staphylococcus was the most common isolated species. Contamination rate of OR surfaces was not affected by time of day or day of the week. Simple cleaning and daily decontamination of staff keyboards can significantly reduce bacterial burdens and should be of primary importance to optimize OR sterility. (Journal of Surgical Orthopaedic Advances 27(4):281-285, 2018).

The impact of preoperative opioid use on outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Preoperative opioid use has been correlated to suboptimal outcomes in orthopedic surgery. This study evaluated the effect of preoperative opioid use on outcomes after arthroscopic rotator cuff repair (RCR). METHODS: A retrospective review was performed of 79 patients who underwent arthroscopic RCR; of these, 31 with a history of preoperative opioid use were compared with a control group of 48 patients without a history of preoperative opioid use. Preoperative and postoperative patient-reported outcomes and functional scores were compared. RESULTS: Both cohorts significantly improved on all patient-reported shoulder scores; however, the nonopioid group demonstrated significantly better postoperative patient-reported outcome scores (P = .015) and external rotation measurement (P = .008). Functional outcomes also significantly improved from preoperatively to postoperatively for forward flexion, but no differences were seen between groups. CONCLUSIONS: Patients with a history of preoperative opioid use can still achieve significant improvements in outcomes after arthroscopic RCR, although not to the same extent as opioid-naïve patients. Therefore, orthopedic surgeons must consider a patient's preoperative opioid use and temper expectations with regard to outcomes so that they are able to set realistic postoperative goals for patients undergoing RCR.

The interaction of distress tolerance and intolerance of uncertainty in the prediction of symptom reduction across CBT for social anxiety disorder.

Distress tolerance (DT) and intolerance of uncertainty (IU) have been identified as transdiagnostic processes that predict symptom severity across a range of distinct anxiety disorders. However, the joint effect of these two variables on therapeutic outcome has not yet been examined. It is possible that DT and IU may both impact on treatment response to cognitive-behavioural therapy (CBT) in clients with anxiety, as clients with weak DT and strong IU may be less likely to engage in exposure and cognitive restructuring tasks across treatment due to their associated distress. The purpose of this study was to examine the interaction of DT and IU as predictors of post-treatment symptom severity and treatment response to group CBT in participants with primary DSM-IV-TR diagnosed social anxiety disorder (SAD). Participants (N = 95) with SAD completed 12 weeks of manualized group CBT. Results of multilevel longitudinal analysis demonstrated an interaction effect, such that lower DT and higher IU predicted higher SAD symptom severity across the course of therapy. The findings are discussed in terms of clinical implications for the disorder-specific and transdiagnostic treatment of anxiety disorders.

The creation of the client reflexivity scale: A measure of minute fluctuations in self-awareness and exploration.

OBJECTIVE: to design and pilot a reliable observer-based scale of client reflexivity that can be used on short segments of time ("coding intervals") across therapy sessions. Reflexivity was defined as the level of a client's awareness and exploration of his or her interiority. Interiority was defined as thoughts, feelings, sensations, intentions, and desires. METHOD: The Client Reflexivity Scale (CRS) was designed through the coding of public access therapy videos featuring demonstrations of therapy. Along with the Experiencing Scale, the CRS was then piloted on one good outcome and one poor outcome session of cognitive-behavioural therapy for anxiety. Each session of therapy featured the same therapist but different clients. Two raters coded the sessions. RESULTS: Weighted kappas for inter-rater reliability ranged from 0.74 to 0.81. The level of reflexivity was significantly higher in the good outcome session than the poor outcome session, though the trajectory of reflexivity for both sessions was the same. The CRS was also compared to the Experiencing Scale in order to determine similarities and differences between the scales. CONCLUSIONS: the CRS reliably measured reflexivity within the therapy sessions, and in the future can be layered with other process measures in order to map interactions across therapy sessions.