The Inventory of Callous-Unemotional Traits (ICU) self-report version: Factor structure, measurement invariance, and predictive validity in justice-involved male adolescents.

The Inventory of Callous-Unemotional Traits (ICU) is a widely used measure of callous-unemotional (CU) traits that may aid in the assessment of the diagnostic specifier "with limited prosocial emotions," which has been added to diagnostic criteria for conduct disorder. Though there is substantial support for use of the ICU total score, the scale's factor structure has been highly debated. Inconsistencies in past factor analyses may be largely attributed to failure to control for method variance due to item wording (i.e., half of the items being worded in the callous direction and half worded in the prosocial direction). Thus, the present study used a multitrait-multimethod confirmatory factor analytic approach that models both trait and method variance to test the factor structure of the ICU self-report in a clinically relevant, high-risk sample of justice-involved male adolescents (N = 1,216). When comparing the fit of empirical and theoretical models, goodness of fit indices (χ² = 1105.877, df = 190, root-mean-square error of approximation = .063, comparative fit index = .916, Tucker-Lewis index = .878, standardized root-mean-square residual = .051) provided support for a hierarchical four-factor model (i.e., one overarching callous-unemotional factor, four latent trait factors) when accounting for method variance (i.e., covarying positively worded items). This factor structure is consistent with the way the ICU was constructed and with criteria for the limited prosocial emotions specifier. In addition, measurement invariance of this factor structure across age, race, and ethnicity was supported, and the predictive validity of the ICU was supported across these demographic groups in predicting self-reported antisocial behavior and rearrests over a 5-year period following an adolescent's first arrest. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Characterisation of Symptom and Polysomnographic Profiles Associated with Cardiovascular Risk in a Sleep Clinic Population with Obstructive Sleep Apnoea.

Aim: Recent data have identified specific symptom and polysomnographic profiles associated with cardiovascular disease (CVD) in patients with obstructive sleep apnoea (OSA). Our aim was to determine whether these profiles were present at diagnosis of OSA in patients with established CVD and in those with high cardiovascular risk. Participants in the Sydney Sleep Biobank (SSB) database, aged 30-74 years, self-reported presence of CVD (coronary artery disease, cerebrovascular disease, or heart failure). In those without established CVD, the Framingham Risk Score (FRS) estimated 10-year absolute CVD risk, categorised as "low" (<6%), "intermediate" (6-20%), or "high" (>20%). Groups were compared on symptom and polysomnographic variables. Results: 629 patients (68% male; mean age 54.3 years, SD 11.6; mean BMI 32.3 kg/m2, SD 8.2) were included. CVD was reported in 12.2%. A further 14.3% had a low risk FRS, 38.8% had an intermediate risk FRS, and 34.7% had a high risk FRS. Groups differed with respect to age, sex and BMI. OSA severity increased with established CVD and increasing FRS. The symptom of waking too early was more prevalent in the higher FRS groups (p=0.004). CVD and FRS groups differed on multiple polysomnographic variables; however, none of these differences remained significant after adjusting for age, sex, and BMI. Conclusion: Higher CVD risk was associated with waking too early in patients with OSA. Polysomnographic variations between groups were explained by demographic differences. Further work is required to explore the influence of OSA phenotypic characteristics on susceptibility to CVD.

Familism moderates the association between parent-child conflict, interpersonal needs, and suicidal ideation among adolescents.

Within the framework of the interpersonal theory of suicide, parent-child conflict in adolescence may be associated with suicidal ideation through increases in thwarted interpersonal needs (i.e., perceived burdensomeness and thwarted belongingness). Familism, a cultural value that emphasizes prioritizing familial interconnectedness and honor, may moderate the association between parent-child conflict and thwarted interpersonal needs. This study examined the relationship between parent-child conflict, familism, and suicidal ideation through the interpersonal theory of suicide. Participants were N = 250 psychiatrically hospitalized adolescents aged 12-17 years (Mage = 14.84, 60.8% female; 41.9% Hispanic, 21.5% African American/Black, 26.0% Caucasian). Participants completed survey and interview measures prior to discharge from psychiatric hospitalization. There was a significant conditional indirect effect of parent-child conflict on suicidal ideation through thwarted interpersonal needs [F (3, 246) = 54.41, p < .01], such that the strength of the indirect effects family conflict on suicidal ideation via thwarted interpersonal needs increased as familism increased. Findings indicate that the relationship between parent-child conflict and thwarted interpersonal needs may be exacerbated when levels of familism are also high. For youth who endorse high levels of familism, parent-child conflict may be particularly pernicious. Interventions targeting the family environment are needed to potentially improve adolescents' interpersonal functioning and protect against suicidal ideation.

Child and adolescent suicide is a growing and pressing problem, and it is currently the second leading cause of death among people aged 10­34. One theory of suicide, called the interpersonal theory of suicide, proposes that suicide ideation is related to two main risk factors: feeling that one's life is a burden on others (called perceived burdensomeness) and feeling like one is disconnected from others (called thwarted belongingness). In this theory, risk factors like parent-child conflict may be related to suicide ideation through increases in perceived burdensomeness and thwarted belongingness. It is possible that cultural values that prioritize family connectedness and honor (called familism) may also impact these relationships. The current study looked at how parent-child conflict, familism, and adolescent suicide ideation were related to one another in the context of the interpersonal theory of suicide. Participants in the study were 250 adolescents in a psychiatric hospital who completed survey and interview measures before being discharged. Results found parent-child conflict was related to suicide ideation through increases in one's perceived burdensomeness and thwarted belongingness (higher parent-child conflict was related to higher ratings of perceived burdensomeness and thwarted belongingness, which was related to higher ratings of suicide ideation), and the strength of the relationship between parent-child conflict, perceived burdensomeness, and thwarted belongingness increased as ratings of familism increased. These results indicate that parent-child conflict may have an especially strong relationship with thoughts of suicide in adolescents who also report a high level of familism. Therefore, suicide-related interventions that target the family environment may help prevent and treat adolescent suicide ideation.

The Brief Adolescent Depression Screen: A Brief Screening Tool for Depression and Suicidal Behavior in Inpatient Adolescents.

Background: In clinical settings, there is significant need for brief, easily-administered assessment tools for adolescent depression that can be used by mental health clinicians from a variety of training backgrounds. Existing depression screening tools do not assess for duration and consistency of symptoms, two key indicators of pathological depression. Objective: The Brief Adolescent Depression Screen (BADS) was developed to screen for major and persistent depressive disorders in adolescents in order to meet the assessment needs in an inpatient setting, and the validity of this tool was tested. Method: The current study used a sample of 396 inpatient adolescents to assess the screening utility of the BADS for detecting whether the adolescent meets criteria for a depressive diagnosis according to a well-validated semi-structured interview, as well as detecting a positive history of suicidal behavior. Further, the screening utility of this measure was compared to the utility of an established depression rating scale. Results: Analyses first determined the duration of depressive symptoms on the BADS that optimally screened for the presence of Major Depressive Disorder and Persistent Depressive Disorder. Findings indicated that, using these optimal screening cut-offs, the BADS showed a strong screening utility, resulting in a sensitivity and specificity for identifying full depressive diagnoses and a positive history of suicidal behavior with similar or greater accuracy than an established rating scale. Conclusions: These findings provide initial evidence to suggest that the BADS may be a helpful screening tool for adolescent depressive disorders in inpatient settings.

Developing Cutoff Scores for the Inventory of Callous-Unemotional Traits (ICU) in Justice-Involved and Community Samples.

Objective: The recent addition of the callous-unemotional (CU) traits specifier, "with Limited Prosocial Emotions (LPE)," to major classification systems has prompted the need for assessment tools that aid in the identification of elevations on these traits for diagnostic purposes. The goal of the current study was to use and evaluate multiple methods for establishing cutoff scores for the multi-informant questionnaire, the Inventory of Callous-Unemotional Traits (ICU).Method: The present study compared the clinical utility of various proposed cutoff methods and scores (i.e., empirically derived cutoffs using receiver operating characteristic (ROC), normative cutoffs, and rational scoring approximations of LPE criteria) in both a longitudinal sample of justice-involved male adolescents (N = 1,216; Mage = 15.29, SD = 1.29) and a cross-sectional sample of school children (N = 289; Mage = 11.47 years; SD = 2.26).Results: Methods resulted in a range of cutoff scores with substantial diagnostic overlap and validity. Specifically, they designated justice-involved adolescents at risk for later delinquency, aggression, and rearrests, and they designated school children more likely to be rated by parents and teacher as having conduct problems and rated by peers as being rejected and mean.Conclusions: The results lead to ranges of ICU scores that have support for their validity and can help to guide clinical decisions about children and adolescents who may be elevated on CU traits.

The Mood Disorder Assessment Schedule: Initial validation of a new measure for early identification of bipolar spectrum disorders in inpatient adolescents.

Due to the significant impairment associated with subthreshold bipolar symptomatology and the harmful effects of delayed diagnosis, there is a great need for diagnostic tools that can facilitate early identification of bipolar spectrum disorders. The Mood Disorder Assessment Schedule (MDAS) is a newly developed measure that focuses on autonomous changes in mood and energy, a key indicator of bipolar spectrum problems which is not included in current diagnostic tools for bipolar disorders. The current study tested the ability of the MDAS to identify individuals at risk for bipolar spectrum disorders. In a cross-sectional sample of 396 inpatient adolescents, the MDAS identified a group of individuals with several bipolar spectrum disorder (BSD) indicators, including greater manic and depressive symptoms, affective lability, suicidal behavior, adverse reactions to antidepressants, and a family history of bipolar disorder and suicidal behavior. When compared to a standard diagnostic interview for bipolar disorders (i.e., Kiddie Schedule for Affective Disorders and Schizophrenia [KSADS]), the MDAS yielded stronger clinical utility in its ability to identify individuals with BSD indicators. Therefore, the MDAS appears to be a promising diagnostic tool for identifying adolescents at risk for BSDs and may help facilitate earlier diagnosis and prevent harmful effects of improper treatment.

Inventory of Callous-Unemotional Traits (ICU) Factor Structure and Measurement Invariance in an Adolescent Multinational Sample.

OBJECTIVE: The Inventory of Callous-Unemotional Traits (ICU) is a widely used, comprehensive measure of callous-unemotional (CU) traits. While the ICU total score is used frequently in research, the scale's factor structure remains highly debated. Inconsistencies in past factor structure research appear to be largely due to the use of small non-representative samples and failure to control for method variance (i.e., item wording direction). METHOD: The current study used a multitrait-multimethod (MTMM) confirmatory factor analysis (CFA) approach that considers both trait and method variance to test the factor structure of a 22-item version of the self-report ICU in a multinational community sample of 4,683 adolescents (ages 11-17). RESULTS: Results showed that a hierarchical four-factor model (i.e., one overarching CU factor, four latent trait factors) that controlled for method variance (i.e., by allowing residuals from positively worded items to covary) provided the best fit (χ2 = 2797.307, df = 160, RMSEA=.059, CFI=.922, TLI=.888, SRMR=.045). CONCLUSIONS: After controlling for method variance, the best-fitting factor structure is consistent with how the ICU was developed and corresponds to the four symptoms of Limited Prosocial Emotions (LPE) specifier in the DSM-5 criteria for Conduct Disorder (CD). In addition, measurement invariance of this factor structure across age (i.e., younger versus older adolescents) and sex was supported. As a result, mean differences in ICU total score across age and sex can be interpreted as reflecting true variations in these traits. Further, we documented that boys generally scored higher than girls on the ICU, and this sex difference was larger in later adolescence.

Influence of enzyme immobilization and skin-sensor interface on non-invasive glucose determination from interstitial fluid obtained by magnetohydrodynamic extraction.

We integrated a magnetohydrodynamic fluid extractor with an amperometric glucose biosensor to develop a wearable device for non-invasive glucose monitoring. Reproducible fluid extraction through the skin and efficient transport of the extracted fluid to the biosensor surface are prerequisites for non-invasive glucose monitoring. We optimized the enzyme immobilization and the interface layer between the sensing device and the skin. The monitoring device was evaluated by extracting fluid through porcine skin followed by glucose detection at the biosensor. The biosensor featured a screen-printed layer of Prussian Blue that was coated with a layer containing glucose oxidase. Both physical entrapment of glucose oxidase in chitosan and tethering of glucose oxidase to electrospun nanofibers were evaluated. Binding of glucose oxidase to nanofibers under mild conditions provided a stable biosensor with analytical performance suitable for accurate detection of micromolar concentrations of glucose. Hydrogels of varying thickness (95-2000 µm) as well as a thin (30 µm) nanofibrous polycaprolactone mat were studied as an interface layer between the biosensor and the skin. The effect of mass transfer phenomena at the biosensor-skin interface on the analytical performance of the biosensor was evaluated. The sensing device detected glucose extracted through porcine skin with an apparent (overall) sensitivity of -0.8 mA/(M·cm2), compared to a sensitivity of -17 mA/(M·cm2) for measurement in solution. The amperometric response of the biosensor correlated with the glucose concentration in the fluid that had been extracted through porcine skin with the magnetohydrodynamic technique.

Sampling of fluid through skin with magnetohydrodynamics for noninvasive glucose monitoring.

Out of 463 million people currently with diabetes, 232 million remain undiagnosed. Diabetes is a threat to human health, which could be mitigated via continuous self-monitoring of glucose. In addition to blood, interstitial fluid is considered to be a representative sample for glucose monitoring, which makes it highly attractive for wearable on-body sensing. However, new technologies are needed for efficient and noninvasive sampling of interstitial fluid through the skin. In this report, we introduce the use of Lorentz force and magnetohydrodynamics to noninvasively extract dermal interstitial fluid. Using porcine skin as an ex-vivo model, we demonstrate that the extraction rate of magnetohydrodynamics is superior to that of reverse iontophoresis. This work seeks to provide a safe, effective, and noninvasive sampling method to unlock the potential of wearable sensors in needle-free continuous glucose monitoring devices that can benefit people living with diabetes.

Conduct Disorders and Empathy Development.

Childhood conduct disorders, a serious mental health concern, put children at risk for significant mental health problems throughout development. Elevations on callous-unemotional (CU) traits designate a subgroup of youth with conduct disorders who have unique causal processes underlying their problem behavior and are at a particularly high risk for serious impairment relative to others with these disorders. As a result, these traits have recently been integrated into major diagnostic classification systems for conduct disorders. Given that CU traits are partly defined by deficits in empathy, we review research on empathy development in typically developing children and use this research to (a) advance theories on the specific emotional deficits that may be associated with CU traits, (b) explain the severe pattern of aggressive behavior displayed by children with elevated CU traits, and (c) suggest possible ways to enhance prevention and treatment for children with conduct disorders and elevated CU traits.

Mortality of native and invasive ladybirds co-infected by ectoparasitic and entomopathogenic fungi.

Harmonia axyridis is an invasive alien ladybird in North America and Europe. Studies show that multiple natural enemies are using Ha. axyridis as a new host. However, thus far, no research has been undertaken to study the effects of simultaneous infection by multiple natural enemies on Ha. axyridis. We hypothesized that high thallus densities of the ectoparasitic fungus Hesperomyces virescens on a ladybird weaken the host's defenses, thereby making it more susceptible to infection by other natural enemies. We examined mortality of the North American-native Olla v-nigrum and Ha. axyridis co-infected with He. virescens and an entomopathogenic fungus-either Beauveria bassiana or Metarhizium brunneum. Laboratory assays revealed that He. virescens-infected O. v-nigrum individuals are more susceptible to entomopathogenic fungi, but Ha. axyridis does not suffer the same effects. This is in line with the enemy release hypothesis, which predicts that invasive alien species in new geographic areas experience reduced regulatory effects from natural enemies compared to native species. Considering our results, we can ask how He. virescens affects survival when confronted by other pathogens that previously had little impact on Ha. axyridis.

Callous-Unemotional Traits and Risk of Gun Carrying and Use During Crime.

OBJECTIVE: With the addition of the "with limited prosocial emotions" specifier within the diagnosis of conduct disorder (DSM-5) and of conduct-dissocial disorder (ICD-11) to designate those with elevated callous-unemotional traits, the authors examined the role that callous-unemotional traits play in the risk for gun carrying and gun use during a crime in a sample at high risk for gun violence. METHODS: Male juvenile offenders (N=1,215) from three regions of the United States were assessed after their first arrest and then reassessed every 6 months for 36 months and again at 48 months. Callous-unemotional traits and peer gun carrying and ownership were measured via self-report after the first arrest (i.e., baseline). Gun carrying and use of a gun during a crime were self-reported at all follow-up points. RESULTS: Callous-unemotional traits at baseline increased the frequency of gun carrying and the likelihood of using a gun during a crime across the subsequent 4 years after accounting for other risk factors. Furthermore, callous-unemotional traits moderated the relationship between peer gun carrying and ownership and participant gun carrying, such that only participants low on callous-unemotional traits demonstrated increased gun carrying as a function of their peers' gun carrying and ownership. CONCLUSIONS: This study demonstrates the importance of considering callous-unemotional traits in gun violence research both because callous-unemotional traits increase gun carrying and use in adolescents and because the traits may moderate other key risk factors. Notably, the influence of peer gun carrying and ownership may have been underestimated in past research for the majority of adolescents by not considering the moderating influence of callous-unemotional traits.

PET imaging of mGluR5 in Alzheimer's disease.

BACKGROUND: Metabotropic glutamate subtype 5 receptors (mGluR5) modulate synaptic transmission and may constitute an important therapeutic target in Alzheimer's disease (AD) by mediating the synaptotoxic action of amyloid-ß oligomers. We utilized the positron emission tomography (PET) radioligand [18F]FPEB to investigate mGluR5 binding in early AD. METHODS: Sixteen individuals with amnestic mild cognitive impairment (MCI) due to AD or mild AD dementia who were positive for brain amyloid were compared to 15 cognitively normal (CN) participants who were negative for brain amyloid. Diagnostic groups were well balanced for age, sex, and education. Dynamic PET scans were acquired for 60 min, starting at 60 min after the initial administration of up to 185 MBq of [18F]FPEB using a bolus-plus-constant-infusion method (Kbol = 190 min). Equilibrium modeling with a cerebellum reference region was used to estimate [18F]FPEB binding (BPND) to mGluR5. Analyses were performed with and without corrections for gray matter atrophy and partial volume effects. RESULTS: Linear mixed model analysis demonstrated a significant effect of group (p = 0.011) and the group × region interaction (p = 0.0049) on BPND. Post hoc comparisons revealed a significant reduction (43%) in mGluR5 binding in the hippocampus of AD (BPND = 0.76 ± 0.41) compared to CN (BPND = 1.34 ± 0.58, p = 0.003, unpaired t test) participants, and a nonsignificant trend for a reduction in a composite association cortical region in AD (BPND = 1.57 ± 0.25) compared to CN (BPND = 1.86 ± 0.63, p = 0.093) participants. Exploratory analyses suggested additional mGluR5 reductions in the entorhinal cortex and parahippocampal gyrus in the AD group. In the overall sample, hippocampal mGluR5 binding was associated with episodic memory scores and global function. CONCLUSIONS: [18F]FPEB-PET revealed reductions in hippocampal mGluR5 binding in early AD. Quantification of mGluR5 binding in AD may expand our understanding of AD pathogenesis and accelerate the development of novel biomarkers and treatments.

Statin Use and Risk of Cognitive Decline in the ADNI Cohort.

OBJECTIVE: To investigate associations between statin use and cognitive change, as well as diagnostic conversion, in individuals with cognitively normal (CN) status, mild cognitive impairment (MCI), and dementia due to Alzheimer disease (AD-dementia). METHODS: A multicenter cohort study with 1629 adults 48 to 91 years old with CN status, early MCI (EMCI), late MCI (LMCI), or AD-dementia at baseline followed prospectively for 24 months. Statin use was assessed at baseline, and cognition was measured over time with a composite memory score, a composite executive function score, and a global cognition score (Alzheimer's Disease Assessment Scale). Conversion to a more impaired diagnostic category was determined by clinician assessment. Repeated measures linear mixed-effects models were used to evaluate associations between statin use and change in cognition over time. Cox proportional hazards models were used to evaluate associations between statin use and time to diagnostic conversion. All models were stratified by baseline diagnostic group. RESULTS: Statin use was not associated with change in cognitive measures for CN, LMCI, or AD-dementia participants. Among EMCI participants, statin use was associated with a significantly slower rate of decline on the memory composite, but no other cognitive measure. Statin use was not associated with time to conversion for any diagnostic group. CONCLUSIONS: This study did not support an association between statin use and diagnostic conversion but suggested a possible association between statin use and cognitive change in EMCI. Additional randomized clinical trials of statins may be warranted in the prodromal EMCI stage of AD.

Effects of Normative Adjustments to the Montreal Cognitive Assessment.

OBJECTIVE: To investigate optimal cutoff scores and the effects of normative adjustments on the performance of the Montreal Cognitive Assessment (MoCA) as a screening instrument for Mild Cognitive Impairment (MCI) and dementia due to Alzheimer's disease (AD-dementia). METHODS: 499 adults 48 to 91 years-old enrolled in the Alzheimer's Disease Neuroimaging Initiative (ADNI) and were administered the MoCA during baseline. Participants were classified as either cognitively normal (CN), MCI, or AD-dementia by clinical assessment. Receiver operating characteristic (ROC) analyses were performed using raw MoCA scores, education-adjusted MoCA scores, and a regression-based adjustment derived from the National Alzheimer's Coordinating Center data (NACC). Test performance characteristics were calculated for various cutoffs after each normative correction method. RESULTS: Areas under the curve (AUC) were similar for raw, education-adjusted, and NACC-adjusted MoCA scores, and demonstrated minimal improvement when adjustments of increasing complexity were applied. Our results suggest that the optimal cutoff score for distinguising MCI is 24 and for distinguising AD-dementia is 22. CONCLUSIONS: This study adds to the understanding of how normative adjustments affect the sensitivity and specificity of the MoCA. Suggested corrections based on education alone do not yield improved test characteristics, but small improvements are attained when a regression-based correction that accounts for age, sex, and education is applied. Furthermore, optimal cutoffs for distinguishing CN from MCI or CN from AD-dementia were lower than previously reported. Optimal cutoffs to detect MCI and AD-dementia may vary in different populations, and further study is needed to determine appropriate use of the MoCA as a screening tool.

Sleep Disturbance and the Risk of Cognitive Decline or Clinical Conversion in the ADNI Cohort.

BACKGROUND: We investigated the relationship between sleep disturbance and cognitive decline or clinical conversion in individuals with normal cognition (CN), as well as those with mild cognitive impairment (MCI) and dementia due to Alzheimer disease (AD-dementia). METHODS: Secondary analysis of 1,629 adults between 48 and 91 years of age with up to 24 months of follow-up from the ADNI (Alzheimer's Disease Neuroimaging Initiative), a longitudinal cohort study. RESULTS: Sleep disturbance was not associated with decline in memory, executive function, or global cognition. The presence of sleep disturbance did not significantly increase the risk of diagnostic conversion in CN, early MCI, or late MCI participants. CONCLUSION: This study investigated the effect of sleep disturbance on cognitive decline using several outcomes and does not support the hypothesis that sleep disturbance predicts subsequent cognitive decline.

A Latent Profile Analysis of Affective Triggers for Risky and Impulsive Behavior.

Common theoretical models of risky and impulsive behaviors suggest that individuals engage in risky behavior to avoid negative affect or enhance positive affect. However, little research has been done to identify person-centered affective profiles of risky and impulsive behavior, and delineate the individual differences across these profiles. The present study used the Risky, Impulsive, and Self-destructive Behavior Questionnaire in community (N = 439) and incarcerated (N = 262) samples to examine latent affect profiles for risky and impulsive behavior. Four affective profiles emerged: low avoidance and low approach, average avoidance and average approach, high avoidance, and high approach. Conditional probability correlations revealed meaningful differences across these profiles in psychiatric symptomatology, personality characteristics, and behavior. Consideration of affective triggers provides an important framework for dissociating the underlying reasons why individuals engage in risky behavior.

Position in the second stage of labour for women with epidural anaesthesia.

BACKGROUND: Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. OBJECTIVES: To assess the effects of different birthing positions (upright versus recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012) and reference lists of retrieved studies SELECTION CRITERIA: All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted authors to try to obtain missing data. MAIN RESULTS: Five randomised controlled trials, involving 879 women, were included in the review.Overall, we identified no statistically significant difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women), or duration of the second stage of labour measured as the randomisation to birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women). Nor did we identify any clear differences in the incidence of instrumental birth or caesarean section separately, nor in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing, operative birth for fetal distress, low cord pH or admission to neonatal intensive care unit. However, the CIs around each estimate were wide, and clinically important effects have not been ruled out.There were no data reported on excess blood loss, prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death. AUTHORS' CONCLUSIONS: There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.