The dose-dependent effects of transcutaneous electrical nerve stimulation for pain relief in individuals with fibromyalgia: a systematic review and meta-analysis.

ABSTRACT: Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological modality widely used to manage pain; however, its effectiveness for individuals with fibromyalgia (FM) has been questioned. In previous studies and systematic reviews, variables related to dose of TENS application have not been considered. The objectives of this meta-analysis were (1) to determine the effect of TENS on pain in individuals with FM and (2) determine the dose-dependent effect of TENS dose parameters on pain relief in individuals with FM. We searched the PubMed, PEDro, Cochrane, and EMBASE databases for relevant manuscripts. Data were extracted from 11 of the 1575 studies. The quality of the studies was assessed using the PEDro scale and RoB-2 assessment. This meta-analysis was performed using a random-effects model that, when not considering the TENS dosage applied, showed that the treatment had no overall effect on pain (d+ = 0.51, P > 0.050, k = 14). However, the moderator analyses, which were performed assuming a mixed-effect model, revealed that 3 of the categorical variables were significantly associated with effect sizes: the number of sessions ( P = 0.005), the frequency ( P = 0.014), and the intensity ( P = 0.047). The electrode placement was not significantly associated with any effect sizes. Thus, there is evidence that TENS can effectively reduce pain in individuals with FM when applied at high or at mixed frequencies, a high intensity, or in long-term interventions involving 10 or more sessions. This review protocol was registered at PROSPERO (CRD42021252113).

Prevalence of Intoxicating Substance Use Before or During Sex Among Young Adults: A Systematic Review and Meta-Analysis.

Drug use before or during sex is a high-risk sexual behavior associated with adverse health risks and outcomes, such as increasing the likelihood of overdoses and of acquiring sexually-transmitted diseases. This systematic review and meta-analysis of three scientific databases examined the prevalence of the use of intoxicating substances, those tending to excite or stupefy the user on a psychoactive level, before or during sex, among young adults (18-29 years old). A total of 55 unique empirical studies met the inclusion criteria (48,145 individuals; 39% males), were assessed for risk of bias using the tools of Hoy et al. (2012), and were analyzed via a generalized linear mixed-effects model. The results produced a global mean prevalence of this sexual risk behavior of 36.98% (95% CI: 28.28%, 46.63%). Nonetheless, significant differences were identified between different intoxicating substances, with the use of alcohol (35.10%; 95% CI: 27.68%, 43.31%), marijuana (27.80%; 95% CI: 18.24%, 39.92%), and ecstasy (20.90%; 95% CI: 14.34%, 29.45%) significantly more prevalent than that of cocaine (4.32%; 95% CI: 3.64%, 5.11%), heroin (.67%; 95% CI: .09%, 4.65%), methamphetamine (7.10%; 95% CI: 4.57%, 10.88%), and GHB (6.55%; 95% CI: 4.21%, 10.05%). Moderator analyses showed that the prevalence of alcohol use before or during sex differed according to geographical sample origin, and increased as the proportion of ethnic whites in samples increased. The remaining demographic (e.g., gender, age, reference population), sexual (e.g., sexual orientation, sexual activity), health (e.g., drug consumption, STI/STD status), methodological (e.g., sampling technique), and measurement (e.g., timeframe) variables that were examined did not moderate prevalence estimates. Implications for sexual development interventions were discussed.

Effect of Fractional Carbon Dioxide vs Sham Laser on Sexual Function in Survivors of Breast Cancer Receiving Aromatase Inhibitors for Genitourinary Syndrome of Menopause: The LIGHT Randomized Clinical Trial.

Importance: Survivors of breast cancer present more severe symptoms of genitourinary syndrome of menopause (GSM) than patients without history of breast cancer. Recently, new treatments, such as vaginal laser therapy, have appeared, but evidence of their efficacy remains scarce. Objective: To assess the safety and efficacy of carbon dioxide (CO2) vs sham vaginal laser therapy after 6 months of follow-up in survivors of breast cancer with GSM receiving aromatase inhibitors. Design, Setting, and Participants: This prospective double-blind sham-controlled randomized clinical trial with two parallel study groups was performed during October 2020 to March 2022 in a tertiary referral hospital. Survivors of breast cancer using aromatase inhibitors were assessed for eligibility, and eligible patients were randomized into the 2 treatment groups. Follow-up was conducted at 6 months. Data were analyzed in July 2022. Interventions: All patients from both groups were instructed to use the first-line treatment (FLT) based on nonhormonal moisturizers and vaginal vibrator stimulation. Patients for each group were allocated to 5 monthly sessions of fractional CO2 laser therapy (CLT) or sham laser therapy (SLT). Main Outcomes and Measures: The primary outcome was sexual function, evaluated through Female Sexual Function Index (FSFI) score. Other subjective measures of efficacy included a visual analog scale of dyspareunia, vaginal pH, a Vaginal Health Index, quality of life (assessed via Short-Form 12), and body image (assessed with the Spanish Body Image Scale). Objective measures of efficacy included vaginal maturation index, vaginal epithelial elasticity (measured in Pascals) and vaginal epithelial thickness (measured in millimeters). Measures were assessed before and after the intervention. Tolerance (measured on a Likert scale), adverse effects, and estradiol levels were recorded. Results: Among 211 survivors of breast cancer assessed, 84 women were deemed eligible and 72 women (mean [SD] age, 52.6 [8.3] years) were randomized to CLT (35 participants) or SLT (37 participants) and analyzed. There were no statistically significant differences between groups at baseline. At 6 months, both groups showed improvement in FSFI (mean [SD] score at baseline vs 6 months: CLT, 14.8 [8.8] points vs 20.0 [9.5] points; SLT, 15.6 [7.0] points vs 23.5 [6.5] points), but there was no significant difference between CLT and SLT groups in the improvement of sexual function evaluated through the FSFI test overall (mean [SD] difference, 5.2 [1.5] points vs 7.9 [1.2] points; P = .15) or after excluding women who were not sexually active (mean [SD] difference, 2.9 [1.4] points vs 5.5 [1.1] points; P = .15). There were also no differences between improvement of the 2 groups at 6 months of follow-up in the other assessed subjective outcomes, including dyspareunia (mean [SD] difference, -4.3 [3.4] vs -4.5 [2.3]; P = .73), Vaginal Health Index (mean [SD] difference, 3.3 [4.1] vs 5.0 [4.5]; P = .17), body image (mean [SD] difference, -3.7 [4.5] vs -2.7 [4.8]; P = .35), and quality of life (mean [SD] difference, -0.3 [3.6] vs -0.7 [3.2]; P = .39). Similarly, there were no differences in improvements in objective outcomes, including vaginal pH (mean [SD] difference, -0.6 [0.9] vs -0.8 [1.2]; P = .29), vaginal maturation index (mean [SD] difference, 10.2 [17.4] vs 14.4 [17.1]; P = .15), vaginal epithelial thickness (mean [SD] difference, 0.021 [0.014] mm vs 0.013 [0.012] mm; P = .30), vaginal epithelial elasticity (mean [SD] difference, -1373 [3197] Pascals vs -2103 [3771] Pascals; P = .64). There were significant improvements in the overall analysis regardless of group in many outcomes. The 2 interventions were well tolerated, but tolerance was significantly lower in the CLT group than the SLT group (mean [SD] Likert scale score, 3.3 [1.3] vs 4.1 [1.0]; P = .007). No differences were observed in complications or serum estradiol levels. Conclusions and Relevance: In this randomized clinical trial, vaginal laser treatment was found to be safe after 6 months of follow-up, but no statistically significant differences in efficacy were observed between CLT and SLT. Trial Registration: ClinicalTrials.gov identifier: NCT04619485.

Dynamics of Humoral and Cellular Responses in Renal Transplant Recipients Receiving 3 Doses of SARS-CoV-2 mRNA Vaccine.

BACKGROUND: The original SARS-CoV-2 vaccination regimen (2 doses) induces insufficient short-term response in kidney transplant (KT) recipients. This study assessed the response to a third dose and the long-term immunogenicity after 2 doses in KT. METHODS: We analyzed the dynamics of the humoral and cellular response by monitoring SARS-CoV-2 IgG antibodies against the Spike-protein (IgG-Spike) and QuantiFERON SARS-CoV-2 IFN-γ release assay 6 mo after the second dose (T2) and 28 d after the third dose of mRNA vaccines (T3) to KT and controls (dialysis patients and healthy individuals). RESULTS: At T2, the percentage of IgG-Spike+ KT and dialysis patients decreased (KT 65.8%-52.6%, hemodialysis 92.6-81.5%, and peritoneal dialysis 100%-90%), whereas 100% of healthy controls remained positive. About the cellular response, the percentage of responders decreased in all groups, especially in KT (22.4%-9.2%, P = 0.081). At T3, 92% of KT, 94%-98% of dialysis patients, and 100% of healthy controls were IgG-Spike+. In terms of antibody titers, patients and controls showed a reduction between T2 and T3 and about 80% of dialysis patients and 100% of controls achieved high titers after the third dose (>1479.5 Binding Antibody Units/mL), whereas this percentage was only 50% in KT. With respect to the cellular response, only KT displayed a significant rise after the third dose. CONCLUSIONS: The third dose of mRNA vaccine improves both humoral and cellular responses, but less effectively in KT compared with dialysis patients and healthy controls.

Prevalence of Parental Violence Toward Teachers: A Meta-Analysis.

A growing literature on parental violence toward teachers has examined the prevalence of these incidents, yet there is considerable variation across studies. There is a need for a systematic and comprehensive review to assess the extent of parent-perpetrated violence toward teachers. Using a meta-analytic approach, we examined the prevalence of violence directed against teachers by parents and how these rates vary by reporting timeframe and type of violence. We identified 5,340 articles through our initial screening process, and our final analysis included 8 studies that met criteria for this meta-analysis. Our findings show that teachers are more likely to experience non-physical forms of violence as compared to physical violence and that rates are lower as the severity and intrusiveness of the violent act increases. Implications for research and practice are discussed.

Adverse childhood experiences and body dysmorphic symptoms: A meta-analysis.

Adverse childhood experiences (ACEs) are considered a risk factor for the development of various forms of mental disorders, including body dysmorphic disorder (BDD). The aim of the present work was to examine the association between ACEs and BDD symptomatology and to identify features of studies that might moderate this association. We conducted a three-level meta-analysis of 27 articles that included 9167 participants. Results showed that the types of ACE examined (total ACE, abuse, neglect, teasing, and bullying) were positively associated with BDD symptomatology. Specifically, a low to moderate association was found for ACE overall, defined as abuse, neglect, bullying, or teasing (r = 0.289, 95% confidence interval (CI) [.240,.337), for bullying (r = 0.282, 95% CI [.206,.354]), and for abuse (r = 0.223, 95% CI [.169,.276]) were found; and a moderate to large association was found for experienced teasing (r = 0.423, 95% CI [.360,.482]). In addition, moderator analyses of the association between ACE and BDD symptomatology resulted in a predictive model in which the type of ACE, type of sample, and gender of participants moderated the magnitude of the association between ACEs and BDD symptomatology.

Negative immune responses to two-dose mRNA COVID-19 vaccines in renal allograft recipients assessed with simple antibody and interferon gamma release assay cellular monitoring.

Studies are urgently needed to characterize immunogenicity, efficacy, and safety of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines in kidney transplant (KT) recipients, excluded from major clinical trials. Complex ELISPOT and other cellular response techniques have been applied, but simpler tools are needed. An easy-to-use real-world monitoring of SARS-CoV-2 IgG antibodies against the Spike protein and QuantiFERON® SARS-CoV-2 IFNγ release assay (IGRA) were performed at baseline and 28 days after the second dose in KT recipients and controls (dialysis patients and healthy ones). All healthy controls and >95% dialysis controls became positive for anti-S IgG antibodies, while only 63.3% of KT patients seroconverted with a very low antibody level. A positive IGRA was documented in 96.9% of controls, 89.3% peritoneal dialysis, 77.6% hemodialysis, 61.3% of KT patients transplanted more than 1 year ago and only 36% of those transplanted within the previous 12 months. Overall, 100% of healthy controls, 95.4% of dialysis patients and 78.8% KT recipients developed any immune response (humoral and/or cellular) against SARS-CoV-2. KT patients showed low rates of immune responses to mRNA Coronavirus infectious disease 2019 vaccines, especially those with recent transplantations. Simple humoral and cellular monitoring is advisable, so that repeated doses may be scheduled according to the results.

Alexithymia and Adult Attachment: Investigating the Mediating Role of Fear of Intimacy and Negative Mood Regulation Expectancies.

Literature suggests an association between alexithymia and insecure adult attachment, but the mediation factors involved in this relationship are under-investigated. The study was carried out to test the possible mediation roles of the fear of intimacy and negative mood regulation expectancies in explaining this relationship. A convenience sample of 258 Polish adults (mean age: 30; 45% male), completed self-reporting measures related to adult attachment (RAAS), alexithymia (TAS-20), fear of intimacy (FIS) and negative mood regulation expectancies (NMRE). The results showed that alexithymia directly and indirectly predicts insecure adult attachment. Alexithymia positively predicts the fear of intimacy, which, in turn, positively predicts insecure adult attachment. Finally, alexithymia negatively predicts NMRE which, in turn, predict insecure adult attachment. It emerges from our data that the fear of intimacy and NMRE may be mediating factors in the relationship between alexithymia and adult attachment. Limitations, future directions of research and guidance for intervention are discussed.

Vaginal laser therapy for genitourinary syndrome of menopause - systematic review.

BACKGROUND: Genitourinary syndrome of menopause (GSM) can have a great impact on the quality of life (QOL), and affects between 53.8% and 90% of postmenopausal women. The literature suggests that vaginal laser therapy could be an effective treatment for GSM symptoms, but its efficacy and safety have not been established and international societies do not endorse its use. Despite that, there has been an increase in the use of vaginal laser therapy globally over the last decade. OBJECTIVE: The objective of this review is to evaluate the literature which assesses the efficacy and safety of the vaginal laser therapy in the treatment of GSM. METHODS: A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing evidence for the efficacy and safety of vaginal laser therapy for GSM or vulvovaginal atrophy up to June 2021. RESULTS: A total of 64 studies were finally included in the review. There were 10 controlled intervention studies, 7 observational cohort and cross-sectional studies and 47 before-after studies without a control group. CONCLUSION: Vaginal laser seems to improve scores on the Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) in GSM over the short term. Safety outcomes are underreported and short-term. Further well-designed clinical trials with sham-laser control groups and evaluating objective variables are needed to provide the best evidence on efficacy.

Genitourinary Syndrome of Menopause Assessment Tools.

New therapeutic options are being considered to treat genitourinary syndrome of menopause (GSM), such as vaginal laser, ospemifene, or prasterone, but there is no explicit agreement in the scientific community for its use. Some concerns have arisen on how to evaluate the improvement of GSM symptoms. In 2003, the FDA suggested possible end points for this purpose: change in severity of symptoms, change in vaginal pH, and change in vaginal maturation index (VMI). Contrarily, the most common assessment tools used to quantify severity and improvement of GSM nowadays are the visual analog scale of GSM symptoms, the vaginal health index, and the female sexual function index. In our opinion, subjective and objective variables to evaluate GSM can be differentiated, and not many of the considered objective outcomes are used in the recent literature assessing GSM. There is the possibility that some therapies present only subjective improvement, giving place to a possible placebo effect that is not being evaluated. To conclude, there is a demand to evaluate whether vaginal pH and VMI are enough to assess objectively GSM changes or new objective approaches should be audited.

Mortality in Hemodialysis Patients with COVID-19, the Effect of Paricalcitol or Calcimimetics.

BACKGROUND: In COVID-19 patients, low serum vitamin D (VD) levels have been associated with severe acute respiratory failure and poor prognosis. In regular hemodialysis (HD) patients, there is VD deficiency and markedly reduced calcitriol levels, which may predispose them to worse outcomes of COVID-19 infection. Some hemodialysis patients receive treatment with drugs for secondary hyperparathyroidism, which have well known pleiotropic effects beyond mineral metabolism. The aim of this study was to evaluate the impact of VD status and the administration of active vitamin D medications, used to treat secondary hyperparathyroidism, on survival in a cohort of COVID-19 positive HD patients. METHODS: A cross-sectional retrospective observational study was conducted from 12 March to 21 May 2020 in 288 HD patients with positive PCR for SARS-CoV2. Patients were from 52 different centers in Spain. RESULTS: The percent of HD patients with COVID-19 was 6.1% (288 out of 4743). Mortality rate was 28.4% (81/285). Three patients were lost to follow-up. Serum 25(OH)D (calcidiol) level was 17.1 [10.6-27.5] ng/mL and was not significantly associated to mortality (OR 0.99 (0.97-1.01), p = 0.4). Patients receiving active vitamin D medications (16/94 (17%) vs. 65/191(34%), p = 0.003), including calcimimetics (4/49 (8.2%) vs. 77/236 (32.6%), p = 0.001), paricalcitol or calcimimetics (19/117 (16.2%) vs. 62/168 (36.9%); p < 0.001), and also those on both paricalcitol and calcimimetics, to treat secondary hyperparathyroidism (SHPTH) (1/26 (3.8%) vs. 80/259 (30.9%), p < 0.001) showed a lower mortality rate than patients receiving no treatment with either drug. Multivariate Cox regression analysis confirmed this increased survival. CONCLUSIONS: Our findings suggest that the use of paricalcitol, calcimimetics or the combination of both, seem to be associated with the improvement of survival in HD patients with COVID-19. No correlation was found between serum VD levels and prognosis or outcomes in HD patients with COVID-19. Prospective studies and clinical trials are needed to support these findings.

Elder Mistreatment in an Italian Population: Prevalence and Correlates.

This study aimed to examine the prevalence of elder mistreatment (EM) in an Italian population and to determine the risk factors. The sample consisted of 393 older adults (Mage = 77.07; standard deviation = 9.45) of whom 60.1% were females. The prevalence of EM was of 20.1%. Older elders who were separated, divorced, with a poor state of health, and problems of autonomy were more likely to experience EM. The most common forms of EM were physical/sexual (9.9%) and emotional mistreatment (9.9%). The most common perpetrators were paid caregivers and members of the victim's family. A path analysis model suggested that limited autonomy and poor perceived health status appeared to be predictors of EM. We conclude that the results of this study have important implications in terms of reducing mistreatment of older adults. Understanding EM is essential to promoting equality, tolerance, and supportive attitudes and developing better prevention policies and practices.

Homicide as a Source of Posttraumatic Stress?: A Meta-Analysis of the Prevalence of Posttraumatic Stress Disorder After Committing Homicide.

There is a growing body of literature on the diagnosis of posttraumatic stress disorder (PTSD) after committing homicide that has examined the prevalence of this phenomenon among individuals who have been convicted, but these studies considerably vary. The present study was the first meta-analysis to synthesize scientific evidence regarding the prevalence of offense-related PTSD among convicted killers. A total of 691 articles were identified through an initial screening process, and the final analysis included 11 studies that met the analysis criteria. We examined the prevalence of PTSD after committing homicide and explored how these rates varied by sample type, offender type, diagnosis timeframe, and diagnosis type. Among adult offenders, the pooled prevalence was 42.6%, 95% CI [38.0%, 47.4%], for current full-criteria homicide-related PTSD and 13.1%, 95% CI [9.9%, 17.2%], for current partial-criteria homicide-related PTSD. For mixed offenders (i.e., killers and violent offenders), the pooled prevalence of current full-criteria offense-related PTSD was 33.1% (95% CI [14.1, 59.8]). Thus, we found that PTSD prevalence was higher in killers than mixed offenders, although this difference was not statistically significant. Finally, among youth mixed offenders, the pooled prevalence for current full-criteria offense-related PTSD was 5.3%, 95% CI [2.9%, 9.5%]. These findings provide evidence of the high rate of this phenomenon, especially among convicted adults.

Physical, Emotional, and Sexual Victimization Across Three Generations: a Cross-Sectional Study.

Using data gathered from grandparents (G1), parents (G2), and young adults (G3), this study examines the continuity of intergenerational victimization (physical, emotional, and sexual) across three generations. The study included data from 168 participants within three generations: grandparents, G1 (19.2% male, 80.8% female, M = 78.13 years old); parents, G2 (25.5% male, 74.5% female, M = 50.13 years old); and young adults, G3 (40% male, 60% female, M = 21.10 years old). The data is analyzed at two levels: (1) bivariate analyses to address relationships between the variables studied by Spearman's correlations, and (2) a path model to examine the intergenerational abuse simultaneously considering all variables. Overall, path modeling showed that experienced abuse demonstrated continuity from G1 to G2 and from G2 to G3. Specifically, findings indicated that grandparents' physical and psychological victimization has a direct effect on parents' sexual and physical abuse victimization, respectively. Additionally, parents' physical victimization has a direct effect on young adults' psychological and sexual victimization, while parents' psychological victimization has a direct effect on young adults' physical and sexual victimization. These findings highlight the need for preventive interventions focused on breaking intergenerational cycles of abuse.

Virtual Reality as a Medium to Elicit Empathy: A Meta-Analysis.

The current meta-analysis aims to investigate and clarify existing research on virtual reality (VR) as a medium to elicit empathy. An exhaustive literature search (updated to February 29, 2020) enabled us to locate seven published articles, yielding a total of nine independent samples. The results reveal statistically significant positive changes in perspective-taking outcomes after VR exposure (d+ = 0.51 [95 percent CI: 0.15-0.88]) but they did not note in empathy (d+ = 0.21 [95 percent confidence interval, CI: -0.37-0.79]). A potential limitation of this work is the low number of studies included. Implications and directions for theoretical development and empirical research are also discussed.

Validation of the Beliefs about Children's Adjustment in Same-Sex Families Scale in Italian University Students.

Assessing attitudes toward same-sex parenting has important implications for both intervention and prevention programs designed to foster the tolerance and normality of sexual and family diversity. Few empirically validated measures of rejection of same-sex parenting have been developed. The current study examined the psychometric properties of an Italian translation of the Beliefs about Children's Adjustment in Same-Sex Families Scale, a 14-item scale distributed in two subscales that measure direct and subtle rejection toward same-sex parenting, for its use in assessing heterosexual people's attitudes toward same-sex parents in Italy. The sample consisted of 344 Italian heterosexual university students (113 men) with a mean age of 20.48 years (SD = 1.60). The results showed that the scale has a good factor structure (via confirmatory factor analysis) and satisfactory reliability and acceptable criterion-related validity. Therefore, the BCASSFS can be used to measure opposition toward gay and lesbian parenting in the Italian context.

The association between muscle dysmorphia and eating disorder symptomatology: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Research shows inconsistent findings about the link between muscle dysmorphia (MD) and eating disorder (ED) symptomatology. The aim of this study is to synthesize the scientific evidence available on this topic, the researchers conducted a systematic review and meta-analysis. METHODS: The literature search enabled us to identify 39 published articles, which provided 36 independent estimations of the correlation between the two variables. RESULTS: Our analysis found a positive association between MD and ED symptoms (r+ = .36; 95% CI = 0.30, 0.41). Moderator analyses showed that the type of sample and the tools for assessing MD and ED were statistically associated with the MD-ED effect sizes. The methodological quality of the studies exhibited a positive, statistically significant association with the MD-ED effect sizes. CONCLUSIONS: Higher levels of MD were related to greater ED symptomatology, but several study characteristics may moderate the association between the two variables. In this study, we discuss limitations and implications for clinical practice and future research.

The Relationship Between Internalized Homophobia and Intimate Partner Violence in Same-Sex Relationships: A Meta-Analysis.

A meta-analysis was conducted to investigate the association between internalized homophobia and intimate partner violence (IPV) perpetration and victimization in same-sex relationships. The literature search and the application of the inclusion criteria made it possible to identify 10 studies, 2 of which were excluded due to missing data. Therefore, eight studies were finally included in the meta-analysis. The results showed positive and statistically significant associations between internalized homophobia and IPV perpetration and victimization, indicating that higher levels of internalized homophobia were related to higher levels of IPV. Specifically, the pooled effect size for the relationship between internalized homophobia and IPV perpetration (all forms), it was r+ = .147, 95% confidence interval (CI) = [.079, .214]; for the association between internalized homophobia and physical/sexual IPV perpetration, it was r+ = .166, 95% CI [.109, .221]; p < .0001; for the relationship between internalized homophobia and psychological IPV perpetration, it was r+ = .145, 95% CI [.073, .216]; and for the association between internalized homophobia and any type of IPV victimization, it was r+ = .102, 95% CI [.030, .173]. Implications of these results for clinical practice and future research are discussed.