Efficacy of internet-delivered cognitive behavioural therapy following an acute coronary event: A randomized controlled trial.

Depression and anxiety are common among people who have experienced an acute coronary event (e.g., heart attack). Multidisciplinary cardiac rehabilitation programs often focus on reducing risk factors associated with future cardiac events, however, mental health interventions are not routinely available. Given known difficulties with access to mental health treatment, the present study sought to explore the efficacy and acceptability of an Internet-delivered cognitive behavioural therapy program (Cardiac Wellbeing Course) among participants who experienced an acute coronary event. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email with a guide. Participants were randomized to the Cardiac Wellbeing Course (n = 25) or waiting-list control group (n = 28). Symptoms were assessed at pre-treatment, post-treatment, and four-week follow-up. Completion rates (84%) and satisfaction ratings (95%) were high. Statistically significant between-group improvements were observed for the treatment group on primary measures of general anxiety (Cohen's d = 1.62; 67% reduction), depression (Cohen's d = 1.09; 61% reduction), and physical activity levels (Cohen's d = 0.27; 70% increase). Statistically significant improvements were also observed on secondary measures of distress (Cohen's d = 0.98; 51% reduction), cardiac anxiety (Cohen's d = 0.92; 34% reduction), and mental-health quality of life (Cohen's d = 0.23; 24% improvement). The changes were maintained at four-week follow-up. The current findings add to the existing literature and highlight the potential of Internet-delivered cognitive behavioural therapy programs among participants who have experienced an acute coronary event.

Making Internet-delivered cognitive behaviour therapy scalable for cancer survivors: a randomized non-inferiority trial of self-guided and technician-guided therapy.

PURPOSE: To compare the effectiveness and acceptability of two low-intensity methods of offering a transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) intervention for treating symptoms of anxiety and depression among cancer survivors. METHODS: Cancer survivors with symptoms of anxiety or depression (n = 86) were randomly assigned to receive a transdiagnostic ICBT programme (Wellbeing After Cancer) that was either guided by a technician (n = 42) or self-guided (n = 44). Measures of anxiety, depression, fear of cancer recurrence, and quality of life were completed at pre-treatment, post-treatment, and 4 weeks following treatment completion. RESULTS: Large within-group effect sizes were observed on measures of depression, anxiety, and mental health-related quality of life (d range, 0.98-1.86) at post-treatment. Medium effects were found for reductions in fear of cancer recurrence (d range, 0.65-0.78). Non-inferiority was established for the primary outcome measures of anxiety and depression. All participants reported high satisfaction ratings of the programme; however, technician-guided participants were slightly more satisfied with their level of support (d = 0.57, p = .014). CONCLUSIONS: The Wellbeing After Cancer Course was associated with improved levels of anxiety, depression, fear of cancer recurrence, and quality of life, regardless of how ICBT was offered. IMPLICATIONS FOR CANCER SURVIVORS: ICBT is emerging as an accessible and effective treatment for depression, anxiety, and fear of cancer recurrence in cancer survivors. The success of non-therapist-guided options increases the potential scalability of ICBT, which is particularly valuable for cancer survivors from rural areas who have less access to mental health services.

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

Emerging evidence from research trials suggests that Internet-delivered cognitive behaviour therapy (ICBT) produces similar symptom improvements whether patients receive weekly therapist support (standard support) or therapist support only when requested (optional support). It remains unknown, however, how many patients receiving ICBT as part of routine clinical care would prefer optional support compared to standard support and how outcomes compare when patients select their preferred treatment option. In this uncontrolled trial, we investigated patient preference and outcomes for standard versus optional support among patients with depression and or anxiety who were offered an 8-week transdiagnostic ICBT intervention in routine care. Of 401 patients accepted for ICBT, 22% selected optional support and 78% selected standard support. At assessment, patients who selected optional support had lower symptoms of anxiety and panic than patients who selected standard support. At post-treatment, both groups achieved similar large improvements in symptoms of anxiety and depression, with improvements sustained at 3-month follow-up. Patients receiving optional support sent and received fewer messages compared to patients receiving standard support. This study demonstrates the potential of optional therapist support to meet the needs and preferences of patients and to also reduce therapist costs in routine care.

Who benefits most from therapist-assisted internet-delivered cognitive behaviour therapy in clinical practice? Predictors of symptom change and dropout.

Internet-delivered cognitive behavioral therapy (ICBT) is effective for treating anxiety and depression, but not for all patients. Predictors of dropout and outcomes from ICBT remain unclear and the literature could benefit from study of response to ICBT among larger community samples using advanced statistical techniques. In this study, we sought to identify predictors of dropout and symptom change in a large community sample (n = 1201) who received therapist-assisted transdiagnostic ICBT targeting anxiety and/or depression. Logistic regression was used to assess dropout, and showed that those who fully completed ICBT lessons (n = 880) were older and endorsed lower psychological distress at intake than those who only partially completed ICBT lessons (n = 321). During the course of therapy, patients responded to the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 at six time points. Autoregressive latent trajectory models were fitted to this data to assess the ability of demographic variables, program engagement, psychological and medical service usage, and psychological distress to explain individual variance in initial symptom levels and symptom change over time. Higher symptom scores at pre-treatment were predictive of greater symptom improvement. Symptom improvement was greater in those who were off work on disability and those without higher post-secondary education. Clinical implications are discussed.

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.

Revision of the ununited one-bone forearm.

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4-36 months). The postoperative follow-up period averaged 29.7 months (range, 11-61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Tenolysis and capsulectomy after hand fractures.

There are well established operative procedures for salvage of function after fracture healing. When hand therapy measures have not achieved a satisfactory range of motion, it is reasonable to remove any hardware, if present, and lyse tendon adhesions that prevent tendon gliding. The exact cause of restricted motion and the location of adhesions are not always predictable preoperatively, so the surgeon should anticipate additional procedures such as dorsal/palmar capsulectomies in combination with extensor and/or flexor tenolysis. The use of local anesthesia for direct patient input during the procedure offers great advantages. In the ideal situation there should be a demonstrable functional need in a compliant patient with a well healed fracture and workable articular surfaces. Competent hand therapy should be available postoperatively. The patient's main risk is worsening of the situation if surgery is unsuccessful. A marginal finger with poor neurovascular status may be better served by going to arthrodesis or even amputation. Tenolysis and capsulectomy, when indicated, are useful procedures in the salvage of these difficult problems.

Extensor tendon injuries at the distal interphalangeal joint.

The treatment options for the soft-tissue mallet finger, in both its acute and chronic forms, continue to generate some degree of controversy. Priority always should be given to nonoperative management of these injuries. This translates into a 6- to 8-week period of uninterrupted immobilization of the DIP joint with an external splint. Splinting has been shown to be highly effective, safe, and reproducible for both acute and chronic lesions. Even in the presence of an open injury, the value of splinting must be appreciated by the practitioner. The conversion of an acute closed soft-tissue injury to an open one is to be discouraged because of unacceptable complication rates. When surgery is contemplated, our first option would be the placement of a transarticular Kirschner wire at the DIP joint. If external splinting fails in an acute injury, an argument certainly can be made for a second trial of conservative management, and we offer this alternative to such patients. We find that some patients will not tolerate a second period of immobilization, and in most cases, we offer surgery in these failed cases. Surgical choice, again, would be a transarticular Kirschner wire. Another choice would be one of the salvage procedures, such as central slip tenotomy, with the expectation of a good result. In summary, mallet injuries are treated using closed, nonoperative techniques. The period of time after injury that this nonoperative treatment can be delayed and still be effective is being extended and the absolute outside time limit still is not known. When surgery is done, we prefer the simple placement of a transarticular Kirschner wire for 6 to 8 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Extensor tendon grafting on the dorsum of the hand in massive tendon loss.

After severe injury to the dorsum of the hand, it may not be possible to directly repair the extensor tendons. Patients in this article were treated by initial skin replacement with pedicle flaps for coverage prior to extensor tendon grafting. Multiple operative procedures were necessary, but restoration was uniformly successful.

Treatment of the chronic boutonniere deformity by extensor tenotomy.

A patient with a chronic boutonniere deformity often experiences more difficulty because of the hyperextension deformity at the distal joint, rather than the lack of extension at the proximal interphalangeal joint. It is in these cases that restoration of flexion at the terminal joint by tenotomy of the terminal extensor tendon is of most value.

The operative repair of chronic nontraumatic extensor tendon subluxations in the hand.

The authors study the literature and the surgical treatment in chronic nonrheumatoid cases. Their technique employs one-half of the extensor digitorum communis tendon as a tether on the central extensor tendon, recentralizing it over the metacarpophalangeal joint.

Fractures of the distal interphalangeal joint.

Displaced fractures at the distal end of the middle phalanx require reduction if function is to be restored at the distal joint. Fractures at the base of the distal phalanx take on additional significance because of the insertions of the flexor and extensor tendons. The palmar articular fracture, when displaced, needs surgical replacement to restore flexor profundus function. In contrast, the displaced dorsal lip fracture, the mallet fracture, can be treated closed with the expectation of excellent results.

Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis.

Eighteen patients with symptomatic radioscaphoid arthritis had scaphoid excision and capitolunate arthrodesis. Eight patients also had a silicone scaphoid replacement. The follow-up period averaged 3 years. Fusion was solid in 12 cases at an average of 8 weeks, and pain was significantly less at follow-up evaluation. Six patients had a pseudarthrosis and five had persistent pain. Immobilization in the pseudarthrosis group averaged 6 weeks, which was significantly less than the group that fused. Two patients underwent successful repeat fusions. Wrist extension averaged 26 degrees, flexion 34 degrees, radial deviation 11 degrees, and ulnar deviation 24 degrees. Grip strength averaged 25 kg. Presence of an implant had no significant effect on motion or strength. Pin track infection and pseudarthrosis were the main complications. Pain relief, functional motion, good strength, and patient satisfaction can be expected after scaphoid excision and solid capitolunate arthrodesis. Kirschner wires should be buried subcutaneously to avoid infection. The addition of a scaphoid implant offered no advantage over simple scaphoid excision.

Arthroplasty of the metacarpophalangeal joints with use of silicone-rubber implants in patients who have rheumatoid arthritis. Long-term results.

The long-term results of 144 arthroplasties of the metacarpophalangeal joints, with use of silicone-rubber implants, were reviewed for twenty-seven patients (thirty-six hands) who had rheumatoid arthritis. The operations were all performed or supervised by the same surgeon. All patients had an arthroplasty of the metacarpophalangeal joint of all four fingers, and all had subjective and objective clinical evaluation and roentgenographic assessment. Relief of pain, the cosmetic appearance of the hand, the range of motion of the metacarpophalangeal and proximal interphalangeal joints, and the presence of residual deformity were evaluated. The average duration of follow-up was eight years and six months (range, five years to sixteen years and three months). Preoperatively, the mean active-extension deficit of the metacarpophalangeal joints ranged from 53 degrees (index finger, right hand) to 70 degrees (little finger, left hand) and the mean flexion ranged from 84 degrees (index finger, right hand) to 94 degrees (little finger, left hand). At the early follow-up evaluation (average, four months postoperatively; range, two to six months), the mean extension deficit had improved to a range of 7 degrees (little finger, right hand) to 19 degrees (index finger, left hand), and mean flexion ranged from 56 degrees (little finger, left hand) to 66 degrees (ring fingers). The range of motion had improved from a non-functional arc of flexion to a more functional arc of extension. At the time of the latest follow-up visit, the motion of the metacarpophalangeal joints had not deteriorated.(ABSTRACT TRUNCATED AT 250 WORDS)

Fractures of the shaft of the radius after treatment of Colles fractures with pins and plaster or external fixation.

Refracture of the radius through a pin site after the removal of pins and plaster or an external fixator for Colles fracture is rarely mentioned in the literature. We present the details of three such cases and review two others reported in the literature. Our aim is to alert orthopedists to the potential for this complication. Patients with superficial or deep pin tract infections appear to be at greater risk.

Enkephalin is a competitive antagonist of cholecystokinin in the gastrointestinal tract, as predicted from prior conformational analysis.

Prior calculations based on ECEPP (Empirical Conformational Energies for Peptides Program) of the low energy minima for cholecystokinin (CCK) and Met-enkephalin have demonstrated that significant structural features of these two peptides are identical. This result suggested the possibility that Met-enkephalin, as well as other enkephalin analogues of similar structure, could associate with receptors for CCK. To test this theoretical result, we examined the ability of Met-enkephalin and its analogues to bind to peripheral CCK receptors in the rat gastrointestinal tract; in particular, we measured the ability of the opiate peptide to inhibit the effects of CCK in a physiological assay system which we have previously characterized: CCK-induced contraction of the isolated rat pyloric sphincter. We find that Met-enkephalin is an antagonist of the CCK-8-induced contraction, with a IC50 of 110 nM. Furthermore, antibodies against CCK were found to cross-react with Met-enkephalin and its analogues in a manner which suggests a distinct structure-activity relationship. These experimental results strongly support the theoretical results of conformational analysis showing structural similarity between enkephalin and CCK. They further suggest that enkephalins could modulate the response of CCK systems under physiological conditions.

Tension band arthrodesis of finger joints: a retrospective review of 76 consecutive cases.

Arthrodesis of finger joints is a reliable method of treating finger joint instability and arthritis. Tension band arthrodesis is an effective method of stable fixation that uses readily available and inexpensive materials. Because fixation is rigid, patients are allowed to move adjacent joints, usually within 1 week after surgery. The results of 76 tension band arthrodesis procedures performed since 1982 in 63 patients were reviewed. Follow-up ranged from 6 to 38 months. The average time to radiographic fusion was 12 weeks (range, 4 to 64 weeks). One joint failed to fuse and developed a stable, asymptomatic nonunion; thus the fusion rate was 99%. Technical problems that occur with the method include nonparallel pin placement and penetration of pin tips, leading to painful impingement of the soft tissues. A pin-placement guide has been developed to minimize these problems.

Peripheral factors in the mediation of cholecystokinin-induced satiety as assessed by comparative potencies of cholecystokinin antagonists.

Cholecystokinin COOH-terminal octapeptide (CCK-8) produces a satiating effect in the rat and other animals upon peripheral administration. Although it has been demonstrated that the receptors which mediate this action are located in the periphery and are of the CCK-A subtype, their anatomical location has not been firmly established. A dense population of CCK receptors in the pyloric sphincter has been suggested as a candidate. We here quantify the potency of several CCK antagonists to inhibit the contractile effect of CCK-8 on the rat pyloric sphincter in vitro. The potent and selective antagonist MK-329 has a Schild pK of 8.85; the less potent but selective antagonist lorglumide (CR-1409) a pK of 6.37; the related antagonist phenoxyacetylproglumide (phi oAc proglumide) a pK of 5.1; and the weak parent compound proglumide a pK of about 3.3. These data can be compared with the potencies of these compounds to inhibit the actions of CCK-8 to produce satiety in the rat; this comparison supports the contention that CCK receptors of the rat pyloric sphincter could in part mediate the satiety effect produced by exogenous CCK-8.

The open palm technique.

Dupuytren's disease presents a difficult problem that should not be treated casually. It is a continuing, unpredictable condition in which surgery is the only treatment available when contracture occurs. Surgery itself may cause an acceleration of the disease. Patients should be made aware that this is a continuing problem, often unpredictable in its course, with and without treatment. It is a pervasive disease, and when surgery is unsuccessful, the hand that underwent surgery may worsen. The open palm technique is a useful technique for avoiding complications in the early postoperative period. It is particularly useful in those patients with significant metacarpophalangeal joint contractures at more than one finger. The open palm technique does not affect the long-term outcome in these patients.

Classification of distal radioulnar joint disorders.

The wrist is one of the most complex articulations in the human body. The distal radioulnar joint (DRUJ) is particularly controversial, enduring as the area least understood with regard to anatomy and pathomechanics. The popular systems of classifying DRUJ disorders are based on etiology and treatment, but this approach has inspired schemes that are cumbersome, redundant, and incomplete. The need for an improved system prompted us to devise a simplified system that is based on the pathomechanics of dysfunction and the mechanical requirements for optimal joint function.