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The effectiveness of the technique of revised habituation (Salkovskis & Westbrook, 1989) has received limited attention in the literature. This paper describes a clinical example which demonstrates both the utility and power of this intervention in complex cases of obsessive-compulsive disorder.
STUDY OBJECTIVE: Firstly, to determine the demographic and behavioural characteristics of low fruit and vegetable consumers. Secondly, to investigate whether knowledge and attitudes are barriers to consumption of fruit and vegetables. DESIGN: Cross sectional survey: an interviewer administrated questionnaire was used to assess the demographic, knowledge, attitude, and behavioural characteristics of the respondents. SETTING: England. PARTICIPANTS: Random sample of 5553 men and women aged between 16 and 74 years. Response rate 70%. MAIN RESULTS: The main demographic characteristics of the respondents identified as low consumers of fruit and vegetables (less than daily consumption of either fruit or vegetables) were age, sex, and smoking status. The adjusted odds ratios were 2.59 for those aged 16-24 years compared with those aged 45-74 years, 2.17 for men compared with women, and 1.77 for current smokers compared with never smokers. The most important knowledge and attitude statements after adjusting for the demographic variables were disagreeing with the statement "healthy foods are enjoyable" (odds ratio 1.90) and agreeing with the statement "I don't really care what I eat" (odds ratio 1.76). The impact of knowledge seemed less important than attitudes about a healthy diet in characterising a low fruit and vegetable consumer. CONCLUSIONS: These findings are relevant to future strategies for improving intake of fruit and vegetables, but demonstrate the complexity of interventions required, and the dangers inherent in assuming simplistic relations between psychosocial factors and behaviour.
BACKGROUND AND OBJECTIVE: It has been shown that spa therapy has a lipid-lowering effect. Also, seasonal variations in spa therapy effects have been found for some outcome measures. The aim of the present study is to investigate whether the lipid-lowering effects of spa therapy as a complex health intervention also are subject to seasonal variation. METHOD: The effect of 3-week resident spa therapy at the Austrian spa Bad Tatzmannsdorf was studied in 395 patients with moderate musculoskeletal chronic pain over a time of 2 years. Spa therapy included balneotherapy, exercise therapy, and dietary measures. Total cholesterol (CHOL), HDL, LDL, triglycerides (TG), and the CHOL/HDL ratio were assessed at the beginning and end of therapy. RESULTS: Spa therapy was associated with a decrease of CHOL, HDL, and LDL (p < 0.001). TG and CHOL/HDL did not change. The decrease of lipids was smaller for older patients, females, and normal weight individuals. CHOL decrease showed a seasonal variation independent of weight loss (p = 0.04), being largest in fall (-6.1%) and smallest in spring (-2.4%). CHOL and CHOL/HDL for obese individuals showed the greatest decrease in winter (-10% for CHOL, -9% for CHOL/HDL ratio), whereas corresponding measures increased for normal-weight subjects. CONCLUSIONS: The lipid-lowering effect of spa therapy could be confirmed; it is partly moderated by season. The results suggest that the effect of some components of spa therapy such as exercise therapy, diet, and relaxation may be subject to seasonal variation.
INTRODUCTION: The development of a fistula and/or an abscess are major complications in patients with Crohn's disease. An abscess can involve any of the major viscera, including the liver and spleen. CASE REPORT: A 27-year-old male patient with a 6-month history of NOD2/CARD15-positive Crohn's disease with stenosis of the terminal ileum, previously treated with corticosteroids, was admitted with fever, chills, diarrhea, fatigue and cachexia. Diagnostic work-up revealed sepsis, an abscess in the right hepatic lobe, multiple abdominal collections and right-sided pleural effusion. It was felt that his poor general condition prevented surgical intervention and complex conservative treatment was initiated. It consisted of total parenteral nutrition, antibiotics, percutaneous drainage of the liver abscess, and thoracocentesis. Pus and blood cultures showed Lactobacillus acidophilus. There was a gradual improvement in the patient's condition and the liver abscess decreased in diameter from 14 to 2 cm. Aminosalicylates and enteral nutrition were gradually introduced. The patient was discharged after 9 weeks in good general condition. CONCLUSION: Although extremely rarely, L. acidophilus can cause hepatic abscess and sepsis. This can be explained by immunologic incompetence due to corticosteroid treatment of Crohn's disease.
BACKGROUND: Percutaneous balloon valvuloplasty has proven to be acutely effective in the treatment of congenital valvar aortic stenosis; however, the intermediate- and long-term effectiveness of the procedure remain to be documented. METHODS AND RESULTS: To assess the intermediate-term effectiveness of balloon valvuloplasty, repeat catheterization was performed in 27 of 30 children 1.7 +/- 0.1 years after balloon valvuloplasty for congenital aortic stenosis (AS). In 33 children the peak AS gradient was reduced acutely by 55% from 77 +/- 4 to 35 +/- 3 mm Hg (p less than 0.001), and left ventricular systolic pressure was reduced from 176 +/- 4 to 138 +/- 4 mm Hg (p less than 0.001). Despite a technically adequate valvuloplasty procedure, three patients had inadequate relief of obstruction and required complex surgical intervention. Twenty-seven of the 30 patients available for late reevaluation (90%) enrolled in the follow-up study. The peak AS gradient remained significantly reduced compared with that present before valvuloplasty (29 +/- 3 versus 77 +/- 4 mm Hg, p less than 0.001). Furthermore, there was no difference in peak AS gradient at follow-up compared with that immediately after valvuloplasty. The greatest increase in gradient at reevaluation was 14 mm Hg. Twenty of 27 patients (74%) had no change in the degree of aortic insufficiency at follow-up compared with that present before valvuloplasty. At follow-up, 16 patients had no aortic insufficiency at all, and only two had moderate-to-severe (3-4+) insufficiency. Femoral artery injury was documented in four patients, three of whom were under 12 months of age at valvuloplasty. CONCLUSIONS: Balloon aortic valvuloplasty provides safe and effective intermediate-term gradient relief without early restenosis in children and adolescents with congenital AS.
As alternatives to per os feeding and nutritional support increase in number and complexity, the interventional radiologist has come to play a more significant role in the creation and maintenance of nutritional access. In very difficult access cases, the concerted effort of the nutritional surgeon and the radiologist is often required. We describe several such situations which have been successfully managed at our institution. The indications for and techniques of percutaneous reestablishment of surgically placed jejunostomy tubes, the percutaneous conversion of gastrostomy to jejunostomy tubes with retention of the gastrostomy tube, and percutaneous placement of an inferior vena caval Hickman catheter are all described in detail.
High initial technical success rates for superficial femoral artery revascularization are possible using multiple modalities. For these interventions to pose a serious challenge to open surgical bypass, improved primary patency in mid- and long-term follow-up must be achieved. In several smaller studies, covered stenting of the superficial femoral artery has shown superior patency at 2 years after intervention. The ongoing VIBRANT trial randomizes patients to superficial femoral artery intervention with either bare nitinol stents or Viabahn covered stents. The 3-year outcomes data from this trial will better define the role of percutaneous intervention for complex superficial femoral artery disease.
The widely discussed 1989 study by Spiegel and colleagues, which suggested that a psychosocial group intervention affected survival in metastatic breast cancer, was not replicated by Goodwin and colleagues in 2001. We analyze methodological issues in both studies, including issues of sampling, randomization, interpretation, and the adequacy and validity of psychosocial constructs and measures to assess hypothesized ingredients of change. The notion of psychogenicity is introduced, conceived as the ability of psychosocial interventions to elicit changes hypothesized to be linked to desired medical outcomes. These considerations lead to the conclusion that there is insufficient evidence to be able to generalize from either study for or against the notion that psychosocial interventions can affect survival in breast cancer. The failure to incorporate into research designs a comprehensive understanding of how coping patterns and related factors may interact with psychosocial interventions to influence cancer progression, and to address hypothesized mediating mechanisms is discussed. Finally, strategies are proposed for future biopsychosocial and intervention research in the field of biopsychooncology.
The measurement and prediction of scattered radiation dose to staff in diagnostic radiology is particularly important, owing to the increased use and complexity of interventional radiology. The air kerma-area product and scattered radiation dose in the vicinity of the patient couch, for both overcouch and undercouch X-ray tube geometries, were simultaneously monitored. The scattered radiation distribution at the couchside was deduced at a range of tube potentials for both overcouch and undercouch X-ray tube geometries. The variation of scattered radiation with field size on both geometries was investigated, as well as the variation with focus-table distance on an overcouch tube geometry. It was discovered that the scattered radiation dose at a point correlated with the air kerma-area product and the result may be used for radiation protection purposes. A method of predicting the scattered radiation dose at a given position is described.
Economic evaluation of specialist nursing interventions is challenging because of the complex nature of interventions and the difficulty of describing nursing outcomes in simple ways. This article discusses data from a study of Macmillan specialist cancer nursing. Resource-use data and nursing-outcome data were collated from 76 case studies of patients referred to 12 specialist cancer and palliative nursing teams (home-based and hospital-based) in the UK. Specific outcomes related to nursing were defined, and cost and nursing outcome data were analysed together. The data suggested that patients who reported better nursing outcomes had a higher proportion of specialist nursing interventions than those reporting poor nursing outcomes (45% versus 25%). Also, the overall pattern of health-care use was different for those patients who reported positive nursing outcomes. This suggests that positive nursing outcomes can influence patients' access to other health services. The data supported specific hypotheses regarding ways that specialist nurses can influence the cost-effectiveness of care. These data do not constitute a comparative evaluation study, as no control group was identified. Such results are nevertheless important as this type of data has not been gathered previously.
Health and health care delivery continue as dominant domestic issues in the United States. Health also represents a highly sophisticated social work practice area, requiring specific expertise for intervention with complex biopsychosocial patient care issues. Current social work curriculum content must reflect contemporary practice issues and educational resources must be improved to meet the documented need for adequately prepared health care professionals. This paper proposes a curriculum template for practice education and offers additional recommendations to enhance the educational process through increased field and academic collaboration.
BACKGROUND: We wanted to examine the association between Medicaid managed care (MMC) and changing immunization coverage in New Mexico, a predominantly rural, poor, and multiethnic state. METHODS: As part of a multimethod assessment of MMC, we studied trends in quantitative data from the National Immunization Survey (NIS) using temporal plots, Fisher's exact test, and the Cochran-Armitage trend test. To help explain changes in immunization rates in relation to MMC, we analyzed qualitative data gathered through ethnographic observations at safety net institutions: income support (welfare) offices, community health centers, hospital emergency departments, private physicians' offices, mental health institutions, managed care organizations, and agencies of state government. RESULTS: Immunization coverage decreased significantly after implementation of MMC, from 80% in 1996 to 73% in 2001 for the 4:3:1 vaccination series (Fisher's exact test, P = .031). New Mexico dropped in rank among states from 30th for this vaccination series in 1996 to 50th in 2001. A significant decreasing trend (Cochran-Armitage P = .025) in coverage occurred between 1996 and 2001. Findings from the ethnographic study revealed conditions that might have contributed to decreased immunization coverage: (1) reduced funding for immunizations at public health clinics, and difficulties in gaining access to MMC providers; (2) informal referrals from managed care organizations and contracting physicians to community health centers and state-run public health clinics; and (3) increased workloads and delays at community health centers, linked partly to these informal referrals for immunizations. CONCLUSIONS: Medicaid reform in New Mexico did not improve immunization coverage, which declined significantly to among the lowest in the nation. Reduced funding for public health clinics and informal referrals may have contributed to this decline. These observations show how unanticipated and adverse consequences can result from policy interventions in complex insurance systems.
A descriptive literature review was conducted to examine conceptual and methodological issues of interventions aimed at improving both physical activity and diet behaviors according to critical elements established by Sidani and Braden (1998). The method of the review of 30 articles describing 17 intervention studies focused on the following nine elements: (a) relevance of the intervention to the targeted outcome; (b) theoretical components of the intervention; (c) intervention components; (d) complexity, strength, and integrity of the intervention; (e) extraneous factors; (f) adherence to the intervention and retention; (g) reliability and validity of the outcome measures; (h) expected outcomes; and (i) effectiveness of the intervention. The results were that the interventions were relevant and included multiple components, but most interventions lacked an explicit theoretical framework. Adherence to the intervention and retention were problems. Overall, to varying degrees and for those completing the programs, the interventions were effective for increasing physical activity, lowering dietary fat, weight loss, and reducing risk for illness. Twelve "lessons learned" evolved that have practical and research implications. One salient lesson and future priority is to incorporate theory to reveal the intervention content and mechanisms to modify physical activity and dietary behaviors concurrently so that future interventions are more efficacious and efficient. Another lesson revealed the need for more sensitive measures, and examination of ways to improve intervention adherence and retention and prevent relapse.
The development of resistance and the inability of currently approved antiretroviral drugs to completely eradicate HIV-1 have led to increased focus on therapies other than small molecules. Although nucleic acid-based intervention requires complex tasks involving intracellular delivery and/or stable expression in target cells, recent advances in gene therapy methods combined with continued progress in stem cell approaches have made nucleic acid-based compounds excellent candidates for effectively inhibiting intracellular targets. Consequently, multiple nucleic acid-based therapies are being developed. These include antisense nucleic acids, peptide nucleic acids and RNA decoys, which can interfere with HIV-1 replication. More recently, RNA interference, which exploits a novel cellular pathway, has been shown to effectively reduce viral titers in cell culture and promises to be a potential candidate for suppressing HIV replication in vivo. A promising candidate in the midst of these emerging approaches is the aptamer approach, which involves the use of a class of small nucleic acid molecules isolated from combinatorial libraries by an in vitro evolution protocol termed SELEX. Aptamers exhibit exquisite specificity, high affinity and the virtual lack of immunogenicity, features that make them exceptionally well-suited to combat HIV without affecting the host. The powerful nature of these specific antagonists of protein function could lead to the development of an effective anti-HIV therapy. Several highly specific, nucleic acid aptamers targeting select HIV proteins have been described. Investigations with anti-HIV RNA aptamers have shown an effective block to viral replication. This review summarizes the existing nucleic-acid based approaches to block HIV replication and attempts to chart the current progress in the development of aptamers against HIV, their use in inhibiting the virus replication, prospects for their use in the clinic and potential drawbacks.
Today, the majority of pharmaceuticals developed to treat cancers and viral/bacterial infections target cellular, bacterial or viral proteins known to be associated with a given pathology. Although proteins are the focus of most current drug discovery efforts, exciting new research has recently begun which aims to exploit ribonucleic acid (RNA) and RNP particles as novel targets for pharmaceutical development. These RNA-targeted research efforts have been fueled by an increased appreciation for the central role played by RNA and RNA-protein interactions in many biological processes and diseases, together with a better understanding of RNA structure and an improvement in biophysical/biochemical techniques available to study RNA. As for protein targets, genome sequencing is greatly accelerating the identification of human and microbial RNA transcripts for targeted drug discovery. With this explosion in the number of potential RNA and RNP targets, the effective development of specific small molecule RNA-based drugs requires robust and general approaches for detecting and quantifying RNA-ligand interactions, which can be used as high-throughput screens (HTS) and for obtaining rapid structural information to guide rational drug design. In this review, an overview of the potential for therapeutic intervention based on RNA and RNP targets is presented, together with recent efforts to develop generally useful nuclear magnetic resonance (NMR) and fluorescence binding assays for screening and optimizing drugs aimed at RNA and RNP targets.
In order to assess the occurrence and persistence of thought disorder in patients in an alcoholism treatment program, a sample of 81 males were tested at the beginning of treatment and again after 4 weeks. The Whitaker Index of Schizophrenic Thinking (WIST) was used as the indicator of thought disorder, with the following results: (1) the presence of thought disorder, in both the initial testing and the retesting; (2) a mildly significant reduction in impairment scores over the 4-week period; and (3) only a small proportion of the sample (11% of the initial testing and 17% of the second) evidencing no thought disorder. The implication for planning treatment is that complex, cognitive interventions may be ineffective in groups of alcoholic patients, even when the patients have been "detoxed."
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AIM: To explore the feasibility of local interleukin 2 (IL-2) in patients with different forms of abdominal cancer. This required experimentation with the time interval between IL-2 applications and the methods of application. METHODS: Sixteen patients with stages III and IV of gastrointestinal malignancies (primary or metastatic) who were admitted to our Department of Gastroenterology were treated with locoregionally applied IL-2 in low doses. RESULTS: No major problems applying locoregional IL-2 were encountered. In 6 out of 16 patients, a modest but clinically worthwhile improvement was obtained. Adverse effects were minimal. The therapeutic scheme was well tolerated, even in patients in a poor condition. CONCLUSION: This study demonstrates the feasibility of low dose locoregional IL-2 application in advanced abdominal cancer. Local IL-2 therapy gives only negligible adverse effects. The results suggest that it is important to apply intratumorally. Local IL-2 may be given adjunct to standard therapeutic regimes and does not imply complex surgical interventions. These initial results are encouraging.