Stricture dilation via balloon-assisted endoscopy in Crohn's disease: approach and intraprocedural outcomes with the single-balloon and double-balloon systems.

Background: Despite recent emerging literature involving the utility of endoscopic balloon dilation (EBD) of strictures via balloon-assisted endoscopy (BAE), specifically regarding the management of Crohn's disease (CD), the optimal clinical approach with balloon systems has been largely neglected in academic literature. Objectives: This study assesses the intra-procedural success and safety of EBD via BAE for small bowel CD strictures while detailing our clinical approach and technique. Secondarily, we compare the single-balloon endoscope (SBE) and double-balloon endoscope (DBE) systems for EBD-related outcomes. Design: Retrospective consecutive patient cohort analysis. Methods: We retrospectively assessed a consecutive small bowel CD patient cohort undergoing BAE at the University of Alberta Hospital endoscopy unit from 2013 to 2020. The primary endpoint discerned the safety and immediate success rate of EBD during endoscopy, and comparisons of the dilation parameters and efficacy of SBE versus DBE were assessed as secondary outcomes. Results: During the study period, 87 patients (44 male) with a mean age of 56 ± 14.7 years underwent 179 endoscopic procedures (92 DBE and 87 SBE). Of 358 strictures encountered, 320 (89.4%) were successfully dilated and traversed. The mean maximum dilation diameter was 15.76 ± 2.10 mm. There were no perforations or major adverse events. Conclusion: EBD via BAE is a safe procedure in small bowel CD with a high intraprocedural success rate. Overall, SBE had a higher success rate in traversing strictures before and after dilation using our technique. This analysis is limited by the retrospective nature of our study and must be balanced against the inherent benefits of the DBE system.

Outcome and approach of small-bowel stricture dilation using balloon-assisted endoscopy in patients with Crohn's disease This study investigated the safety and success of using balloon-assisted endoscopy as a method to dilate small bowel strictures in patients with Crohn's disease. As a secondary outcome, we compared the overall safety and success between two different types of endoscopic systems: the single- and double-balloon systems.

Access to therapy for child sexual abuse survivors: Preliminary dialogue of barriers and facilitators between caregivers.

BACKGROUND: Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality. OBJECTIVES: To present preliminary qualitative results from caregivers of CSA survivors. METHODS: This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology. RESULTS: A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care). CONCLUSION: The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/focus group also achieved engagement goals in a population that is typically difficult to reach. Overall, the response rate (12%) was equivalent to reported registrant attendance rates for general business to consumer webinars and the recommended focus group size. This preliminary approach warrants replication in other populations outside our clinical context.

Synchronous Web-Based Psychotherapy for Mental Disorders From a Health Quality Perspective: Scoping Review.

BACKGROUND: The COVID-19 pandemic necessitated rapid changes to health care delivery, including a shift from in-person to digitally delivered psychotherapy. While these changes helped ensure timely psychotherapy provision, many concerns exist, including clinical, cultural, practical, privacy, and security issues. OBJECTIVE: This scoping review systematically mapped existing peer-reviewed research on synchronous, therapist-delivered web-based psychotherapy for individuals with a diagnosed mental illness. Data were analyzed through the lens of the Alberta Quality Matrix for Health (AQMH) to assess to what degree this literature addresses key indicators of health care quality. This analysis aided in the identification and organization of knowledge gaps with regard to web-based psychotherapies, highlighting potential disparities between previously prioritized dimensions of care and those requiring further attention. METHODS: This review adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. We included peer-reviewed primary research studies in the English language investigating synchronous, therapist-delivered remote psychotherapy delivered to adults (aged 18 years and older) with a Diagnostic and Statistical Manual of Mental Disorders or International Statistical Classification of Diseases diagnosed mental illness. All other citations were excluded. Relevant studies were identified through MEDLINE, APA PsycINFO, Embase (OVID), Web of Science: Core Collection (Clarivate), Cochrane Library (Wiley), and Scopus (Elsevier) databases. Databases were searched on March 18, 2021. For every publication that was taken into consideration, the data were charted independently by 2 reviewers, and in the event of a discrepancy, the principal investigator validated the choice of either extractor. Results were thematically described according to the 6 AQMH dimensions: acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety. RESULTS: From 13,209 publications, 48 articles were included, largely from North American studies. Most studies measured treatment effectiveness (n=48, 100%) and acceptability (n=29, 60%) health quality dimensions. Over 80% (40/48) of studies investigated either a cognitive or exposure intervention for either posttraumatic stress disorder or a mood or anxiety disorder, generally indicating comparable results to in-person therapy. Safety (n=5, 10%) was measured in fewer studies, while treatment accessibility, appropriateness, and efficiency were not explicitly measured in any study, although these dimensions were mentioned as a future direction, hypothesis, or potential outcome. CONCLUSIONS: In relation to web-based therapist-delivered psychotherapies for those with a diagnosed mental illness, important aspects of health care quality (accessibility, appropriateness, efficiency, and safety) have received little scientific examination, underscoring a need to address these gaps. There are also significant issues related to the generalizability of this literature, including the underrepresentation of many geographic regions, cultures, populations, clinical contexts, and psychotherapy modalities. Qualitative research in underrepresented populations and settings may uncover important patient and contextual factors important for the future implementation of quality web-based psychotherapy.

Diet and depression: A systematic review of whole dietary interventions as treatment in patients with depression.

BACKGROUND & RATIONALE: Depression is a common mental illness that afflicts over 300 million individuals worldwide. Despite a variety of therapeutic options available, a significant number of depressed patients fail to respond to treatment. Current guidelines for treating depression suggest that supplementation of essential nutrients may be an appropriate adjunctive to treatment, but research investigating full dietary interventions for depressed patients is scarce. STUDY OBJECTIVE: The primary aim of this study was to systematically review published scientific literature investigating full dietary interventions as treatment for individuals with a diagnosis of depression. In doing so, we assessed existing evidence for recommendation of a dietary intervention and reviewed theory of how diet may be important in this context. METHODS: A systematic search was conducted using OVID to search Medline, PsychINFO, and EMBASE, and PubMed for relevant publications. Only studies including full dietary interventions for patients with Major Depressive Episode, Major Depressive Disorder, Persistent Depressive Disorder, Seasonal Affective Disorder, or Dysthymia, as diagnosed using criteria defined in the chapter of "Depressive Disorders" in the DSM, were included. RESULTS: Only five studies met the inclusion criteria for this review. All five studies included in this review reported improvements in mood following dietary intervention as compared to the comparison group. However, heterogeneity in both the dietary intervention and the outcome(s) measured made it difficult to compare these studies against each other and to generalize them to larger populations. CONCLUSION: The findings of this review provide preliminary evidence for the positive impact of dietary interventions in the treatment of depressed patients. However, the mechanism by which particular diets induce positive changes in mood, be it through anti-inflammatory mechanisms or via weight loss in overweight patients, is unclear. Future research investigating the impact of dietary interventions on a large-scale is warranted and needed.

Child sexual abuse survivors: Differential complex multimodal treatment outcomes for pre-COVID and COVID era cohorts.

BACKGROUND: Child sexual abuse (CSA) is a form of early-life trauma that affects youth worldwide. In the midst of the current COVID-19 pandemic, it is imperative to investigate the potential impact of added stress on already vulnerable populations. OBJECTIVE: The aim of this study was to evaluate the effectiveness of a multimodal treatment program on mental health outcomes for youth CSA survivors aged 8-17. Secondary to this, we explored the potential impact of the COVID-19 on treatment outcomes. PARTICIPANTS AND SETTING: Participants of this study were children and youth aged 8-17 who were engaged in a complex multimodal treatment program specifically designed for youth CSA survivors. METHODS: Participants were asked to complete self-report surveys at baseline and at the end of two subsequent treatment rounds. Surveys consisted of measures pertaining to: (1) PTSD, (2) depression, (3) anxiety, (4) quality of life, and (5) self-esteem. RESULTS: Median scores improved for all groups at all timepoints for all five domains. For the pre-Covid participants, the largest improvements in the child program were reported in depression (36.6 %, p = 0.05); in the adolescent program anxiety showed the largest improvement (-35.7 %, p = 0.006). Improvements were generally maintained or increased at the end of round two. In almost every domain, the improvements of the pre-COVID group were greater than those of the COVID-I group. CONCLUSIONS: A complex multimodal treatment program specifically designed for youth CSA survivors has the capacity to improve a number of relevant determinants of mental health and well-being. The COVID-19 pandemic may have retraumatized participants, resulting in treatment resistance.

Five year cost savings of a multimodal treatment program for child sexual abuse (CSA): a social return on investment study.

BACKGROUND: Specialized mental health services for the treatment of Child Sexual Abuse (CSA) are generally expensive and labour intensive. They require a trauma-informed approach that may involve multiple services and therapeutic modalities, provided over the course of several months. That said, given the broad-ranging, long term negative sequelae of CSA, an evaluation of the cost-benefit analysis of treatment is clearly justified. METHODS: We performed a Social Return on Investment (SROI) analysis of data gathered as part of the treatment program at the Be Brave Ranch in Edmonton, Canada to determine the value-for-money of the services provided. We endeavoured to take a conservative, medium-term (5 year) perspective; this is in contrast to short term (1-2 year) effects, which may rapidly dissipate, or long term (15-20 year) effects, which are likely diffuse and difficult to measure. As such, our analysis was based on an average annual intake of 100 children/adolescents (60:40 split) and their families, followed over a five-year timeframe. Financial proxies were assigned to benefits not easily monetized, and six potential domains of cost savings were identified. RESULTS: Our analyses suggest that each dollar spent in treatment results in an average cost savings of $11.60 (sensitivity analysis suggests range of 9.20-12.80). The largest value-for-money was identified as the domain of crisis prevention, via the avoidance of rare but costly events associated with the long term impacts of CSA. Somewhat surprisingly, savings related to the area of criminal justice were minimal, compared to other social domains analysed. Implications are discussed. CONCLUSIONS: Our results support the cost effectiveness of the investment associated with specialized, evidence-based early interventions for CSA. These approaches alleviate severe, negative outcomes associated with CSA, resulting in both economic savings and social benefits. These findings rest upon a number of assumptions, and generalizability of these results is therefore limited to similar programs located in comparable areas. However, the SROI ratio achieved in this analysis, in excess of $11:1, supports the idea that, while costly, these services more than pay for themselves over time.

A Novel 2-week Intensive Multimodal Treatment Program for Child Sexual Abuse (CSA) Survivors is Associated with Mental Health Benefits for Females aged 13-16.

OBJECTIVE: The aim of this study was to evaluate the psychiatric outcomes for the first cohorts of adolescent female Child Sexual Abuse (CSA) survivors after two-weeks in an intensive multimodal treatment program designed for this population. METHODS: Baseline data was collected at intake and again immediately prior to discharge. Data collected included demographic information, as well as measurement of standardized scales for PTSD, depression, anxiety, quality of life, self-esteem, and resilience. Mean scores at baseline and discharge were statistically analyzed to assess for changes following the treatment program on these measures. RESULTS: From the first twenty-seven (27) adolescent female CSA survivors, who completed two-weeks of the multimodal treatment program, all three symptomatic scales showed statistically significant improvements from baseline. There were decreases in mean questionnaire scores for Depression (-23.8%, p = 0.001), Anxiety (-20.6%, p = 0.006), and PTSD (-20.3%, p = 0.002), as well as decrease of nearly 50% in the number of participants who were having active suicidal thoughts. In keeping with this, there were also statistically significant improvements in ratings for Quality of Life (17.6%, p = 0.022), Self-Esteem (22.9%, p = 0.010), and Resilience (6.9%, p = 0.019). CONCLUSION: This study presents preliminary findings from an intensive two-week multimodal treatment program specifically designed to help survivors of child sexual abuse (CSA). The highly positive short-term findings suggest that further longer-term follow-up in larger groups is appropriate. These preliminary results also support ongoing research for such intensive multimodal programs.

OBJECTIF: La présente étude visait à évaluer les résultats psychiatriques des premières cohortes d'adolescentes survivantes d'abus sexuels sur des enfants (ASE) après deux semaines d'un programme de traitement multimodal intensif conçu pour cette population. MÉTHODES: Les données de base ont été recueillies à l'admission et de nouveau, immédiatement avant le congé. Les données recueillies comprenaient l'information démographique ainsi que les mesures aux échelles normalisées du trouble de stress post-traumatique (TSPT), de la dépression, de l'anxiété, de la qualité de vie, de l'estime de soi et de la résilience. Les scores moyens à la base et au congé ont été statistiquement analysés pour évaluer les changements suite au programme de traitement sur ces mesures. RÉSULTATS: Pour les vingt-sept (27) premières adolescentes survivantes d'ASE qui ont suivi les deux semaines du programme de traitement multimodal, les trois échelles symptomatiques indiquaient des améliorations statistiquement significatives par rapport à la base. Il y a eu diminution des scores moyens aux questionnaires pour la dépression (−23,8 %, p = 0,001), l'anxiété (−20,6 %, p = 0,006), et le TSPT (−20,3 %, p = 0,002), ainsi qu'une réduction de près de 50 % du nombre de participantes qui avaient une idéation suicidaire active. Dans le même ordre d'idées, il y a aussi eu des améliorations statistiquement significatives des scores de la qualité de vie (17,6 %, p = 0,022), de l'estime de soi (22,9 %, p = 0,010), et de la résilience (6,9 %, p = 0,019). CONCLUSION: Cette étude présente les résultats préliminaires d'un programme de traitement multimodal intensif de deux semaines spécifiquement conçu pour aider les survivants d'abus sexuel sur les enfants (ASE). Les résultats à court terme très positifs suggèrent qu'un suivi à plus long terme pour de grands groupes est approprié. Ces résultats préliminaires suggèrent aussi la poursuite des recherches de tels programmes multimodaux intensifs.

Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures.

BACKGROUND: Evidence for endoscopic balloon dilation of small intestinal strictures in Crohn's disease (CD) using balloon-assisted enteroscopy is scarce. AIM: To evaluate endoscopic balloon dilation for the treatment of small intestinal CD strictures using balloon-assisted enteroscopy. METHODS: Citations in Embase, MEDLINE, and Cochrane were systematically reviewed. In a meta-analysis of 18 studies with 463 patients and 1189 endoscopic balloon dilations, technical success was defined as the ability to dilate a stricture. Individual data were also obtained on 218 patients to identify outcome-relevant risk factors. RESULTS: In the pooled per-study analysis, technical success rate of endoscopic balloon dilation was 94.9%, resulting in short-term clinical efficacy in 82.3% of patients. Major complications occurred in 5.3% of patients. During follow-up, 48.3% of patients reported symptom recurrence, 38.8% were re-dilated and 27.4% proceeded to surgery. On the per-patient-based multivariable analysis, that patients with disease activity in the small intestine had lower short-term clinical efficacy (odds ratio 0.32; 95% confidence interval 0.14-0.73, P = 0.007). Patients with concomitant active disease in the small and/or large intestine had an increased risk to proceed toward surgery (hazard ratio 1.85; 95% confidence interval 1.09-3.13, P = 0.02 and hazard ratio 1.77; 95% confidence interval 1.34-2.34, P < 0.001). CONCLUSIONS: Balloon-assisted enteroscopy for dilatation of CD-associated small intestinal strictures has high short-term technical and clinical efficacy and low complication rates. However, up to two-thirds of patients need re-dilation or surgery.