The Effectiveness of Psychosocial Interventions for Psychological Outcomes in Pediatric Oncology: A Systematic Review

Context

This review summarizes the current randomized controlled trials literature on psychological and physical outcomes of psychosocial interventions in pediatric oncology.

The Techniques for Overcoming Depression Questionnaire: Mokken Scale Analysis,Reliability, and Concurrent Validity in Depressed Cardiac Patients

The Techniques for Overcoming Depression (TOD) questionnaire assesses the frequency with which patients being treated for depression use cognitive-behavioral techniques in daily life. This study examined its latent structure, reliability and concurrent validity in depressed cardiac patients. The TOD was administered at the initial and final treatment sessions in three trials of cognitive behavior therapy (CBT) (n = 260) for depression in cardiac patients. Mokken scaling was used to determine its dimensionality. The TOD is unidimensional in depressed cardiac patients, both at the initial evaluation (H = .46) and the end of treatment (H = .47). It is sensitive to change and the total score correlates with therapist ratings of the patient’s socialization to CBT (r = .40, p < .05), homework adherence (r = .36, p < .05), and use of cognitive-behavioral techniques (r = .51, p < .01). TOD scores were associated with post-treatment depression scores in two of the trials (p < .01 in both analyses). The TOD is a unidimensional, reliable, valid, and clinically informative measure of self-reported use of cognitive-behavioral techniques for overcoming depression in cardiac patients. Studies of the TOD in other depressed patient populations are needed.     

Distinct Roles of Emotion Reactivity and Regulation in Depressive and Manic Symptoms Among Euthymic Patients

Investigating differences in the ways that people react to mood-evoking stimuli and regulate subsequent emotions may help to elucidate important mechanisms underlying depressed or hypomanic mood states. Euthymic young adults with bipolar disorder (n = 23) or depression (n = 21) were recruited for a study of emotion and mood. Two mood inductions assessed for differences in mood reactivity. Participants completed measures of current symptoms and emotion regulation strategies. Maladaptive (B = 0.42, p = .021) and adaptive (B = ?0.26, p = .011) emotion regulation strategies were significantly associated with depressive symptoms. Bipolar diagnosis (B = 5.51, p = .035), and threat mood reactivity (B = ?0.26, p = .015) were associated with hypomanic symptoms. Interaction terms for mood reactivity and emotion regulation were not significant in either model, although net regression indicated significant differences in two trends. Depressed moods, associated with MDD or BD, may be initiated and maintained primarily due to poor choice of emotion regulation strategies. Elevated mood states are more specific to bipolar disorder, and may be triggered by mood reactivity, rather than regulation.     

Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial

Purpose

Family members of patients who die in the intensive care unit (ICU) may experience symptoms of stress, anxiety, depression, posttraumatic stress disorder (PTSD), and/or prolonged grief. We evaluated whether grief symptoms were alleviated if the physician and the nurse in charge at the time of death sent the closest relative a handwritten condolence letter.

Methods

Multicenter randomized trial conducted among 242 relatives of patients who died at 22 ICUs in France between December 2014 and October 2015. Relatives were randomly assigned to receiving (n = 123) or not receiving (n = 119) a condolence letter. The primary endpoint was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary endpoints included HADS, complicated grief (ICG), and PTSD-related symptoms (IES-R) at 6 months. Observers were blinded to group allocation.

Results

At 1 month, 208 (85.9%) relatives completed the HADS; median score was 16 [IQR, 10–22] with and 14 [8–21.5] without the letter (P = 0.36). Although scores were higher in the intervention group, there were no significant differences regarding the HADS-depression subscale (8 [4–12] vs. 6 [2–12], mean difference 1.1 [?0.5 to 2.6]; P = 0.09) and prevalence of depression symptoms (56.0 vs. 42.4%, RR 0.76 [0.57–1.00]; P = 0.05). At 6 months, 190 (78.5%) relatives were interviewed. The intervention significantly increased the HADS (13 [7–19] vs. 10 [4–17.5], P = 0.04), HADS-depression subscale (6 [2–10] vs. 3 [1–9], P = 0.02), prevalence of depression symptoms (36.6 vs. 24.7%, P = 0.05) and PTSD-related symptoms (52.4 vs. 37.1%, P = 0.03).

Conclusions

In relatives of patients who died in the ICU, a condolence letter failed to alleviate grief symptoms and may have worsened depression and PTSD-related symptoms. Trial registration Clinicaltrials.gov Identifier: NCT02325297.

     

A Nonrandomized Comparison Study of Self-Hypnosis,Yoga, and Cognitive-Behavioral Therapy to Reduce Emotional Distress in Breast Cancer Patients

The authors asked breast cancer (BC) patients to participate in 1 of 3 mind-body interventions (cognitive-behavioral therapy (CBT), yoga, or self-hypnosis) to explore their feasibility, ease of compliance, and impact on the participants’ distress, quality of life (QoL), sleep, and mental adjustment. Ninety-nine patients completed an intervention (CBT: n = 10; yoga: n = 21; and self-hypnosis: n = 68). Results showed high feasibility and high compliance. After the interventions, there was no significant effect in the CBT group but significant positive effects on distress in the yoga and self-hypnosis groups, and, also, on QoL, sleep, and mental adjustment in the self-hypnosis group. In conclusion, mind–body interventions can decrease distress in BC patients, but RCTs are needed to confirm these findings.     

Evaluating the efficacy of a self-guided Web-based CBT intervention for reducing cancer-distress: a randomised controlled trial

Purpose

This study evaluated the efficacy of a self-guided Web-based cognitive behaviour therapy (CBT) intervention compared to an attention control in improving cancer-related distress, health-related quality of life (HRQOL), and maladaptive coping, among people recently diagnosed with cancer.

Methods

Sixty individuals with cancer diagnosed in the previous 6 months and receiving treatment with curative intent were randomised to receive either the 6-week intervention Cancer Coping Online (CCO: n = 30) or the 6-week Web-based attention control (n = 30). Outcome measures, including cancer distress (the Posttraumatic Stress Scale—Self-Report), general distress (Depression Anxiety Stress Scale), quality of life (EORTC QLQ-C30), and coping (mini-MAC), were administered at baseline, immediately post-intervention, and at 3 and 6 months post-intervention.

Results

Significant main effects for time were found for cancer distress, global QOL, physical function, role function, social function, and anxious preoccupation. Post hoc between-group comparisons showed CCO participants had statistically significantly higher physical functioning compared to controls at 3 months of follow-up (d = ?0.52, p = 0.02). Furthermore, compared to controls, post hoc comparisons found moderate between-group effect sizes favouring CCO post-intervention for cancer distress (d = 0.43) and anxious preoccupation (d = 0.38), and at 6 months of follow-up for global QOL (d = ?0.43).

Conclusions

These results provide preliminary support for the potential efficacy of a self-guided Web-based CBT programme in improving aspects of HRQOL, cancer-related distress, and anxious preoccupation after cancer diagnosis. This paper provides justification for, and will help inform the development of, subsequent larger multi-site studies.

     

Randomized controlled pilot trial of mindfulness-based stress reduction compared to psychoeducational support for persistently fatigued breast and colorectal cancer survivors

Purpose

Cancer-related fatigue (CRF) is a disruptive symptom for many survivors. Despite promising evidence for efficacy of mindfulness-based stress reduction (MBSR) in reducing CRF, no trials comparing it to an active comparator for fatigued survivors have been published. The purpose of this trial was to compare MBSR to psychoeducation for CRF and associated symptoms.

Methods

Breast (n = 60) and colorectal (n = 11) cancer survivors (stage 0–III) with clinically significant CRF after completing chemotherapy and/or radiation therapy an average of 28 months prior to enrollment were randomized to MBSR or psychoeducation/support groups (PES). MBSR focused on mindfulness training; PES focused on CRF self-management. Outcomes included CRF interference (primary), CRF severity and global improvement, vitality, depression, anxiety, sleep disturbance, and pain. Outcomes were assessed at baseline (T1), post-intervention (T2), and 6-month follow-up (T3) using intent-to-treat analysis.

Results

Between-group differences in CRF interference were not significant at any time point; however, there was a trend favoring MBSR (d = ?0.46, p = 0.073) at T2. MBSR participants reported significantly greater improvement in vitality (d = 0.53, p = 0.003) and were more likely to report CRF as moderately to completely improved compared to the PES group (χ2 (1) = 4.1765, p = 0.041) at T2. MBSR participants also reported significantly greater reductions in pain at T2 (d = 0.53, p = 0.014). In addition, both MBSR and PES produced moderate-to-large and significant within-group improvements in all fatigue outcomes, depression, anxiety, and sleep at T2 and T3 compared to T1.

Conclusion

MBSR and PES appear efficacious for CRF and related symptoms. Larger trials including a usual care arm are warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT01724333.

     

Homework Completion via Telephone and In-Person Cognitive Behavioral Therapy Among Latinos

Homework completion in cognitive behavioral therapy (CBT) for depression is an integral ingredient in treatment that often goes unreported. Furthermore, many studies of homework completion focus on patient adherence without considering the therapists’ role in reviewing and reinforcing this behavior. No studies to date have assessed the relationship between homework variables and outcomes among Latinos receiving CBT for depression. Since this population has often been difficult to engage in CBT, this study aims to assess whether homework completion and therapist review of homework are related to improved outcomes in a CBT intervention (telephone or in person) for Latinos with depression. We found that higher homework completion was significantly related to lower depression scores at the end of final treatment (as measured by PHQ-9) (B?=???1.38, p?<?.01). However, the significant association of homework with depression went away when clinician review of homework was included in a subsequent step of the model (B?=???0.42, p?=?.45). The number of times a clinician actively reviewed homework was still significantly related to a decrease in PHQ-9 when controlling for demographic factors (B?=???1.23, p?<?.01). This study found that homework is a predictor of improved outcomes in CBT for depression but highlights the role of therapists reviewing homework as a predictor of lower depression symptoms among Spanish speaking Latinos from low socioeconomic backgrounds.     

Quality indicators of continuous renal replacement therapy (CRRT) care in critically ill patients: a systematic review

Objectives

Renal replacement therapy is increasingly utilized in the intensive care unit (ICU), of which continuous renal replacement therapy (CRRT) is most common. Despite CRRT being a relatively invasive and resource intensive technology, there remains wide practice variation in its application. This systematic review appraised the evidence for quality indicators (QIs) of CRRT care in critically ill patients.

Design

A comprehensive search strategy was developed and performed in five citation databases (Medline, Embase, CINAHL, Cochrane Library, and PubMed) and select grey literature sources. Two reviewers independently screened, selected, and extracted data using standardized forms. Each retrieved citation was appraised for quality using the Newcastle–Ottawa Scale (NOS) and Cochrane risk of bias tool. Data were summarized narratively.

Measurements and main results

Our search yielded 8374 citations, of which 133 fulfilled eligibility. This included 97 cohort studies, 24 randomized controlled trials, 10 case-control studies, and 2 retrospective medical audits. The quality of retrieved studies was generally good. In total, 18 QIs were identified that were mentioned in 238 instances. Identified QIs were classified as related to structure (n = 4, 22.2 %), care processes (n = 9, 50.0 %), and outcomes (n = 5, 27.8 %). The most commonly mentioned QIs focused on filter lifespan (n = 98), small solute clearance (n = 46), bleeding (n = 30), delivered dose (n = 19), and treatment interruption (n = 5). Across studies, the definitions used for QIs evaluating similar constructs varied considerably. When identified, QIs were most commonly described as important (n = 144, 48.3 %), scientifically acceptable (n = 32, 10.7 %), and useable and/or feasible (n = 17, 5.7 %) by their primary study authors.

Conclusions

We identified numerous potential QIs of CRRT care, characterized by heterogeneous definitions, varying quality of derivation, and limited evaluation. Further study is needed to prioritize a concise inventory of QIs to measure, improve, and benchmark CRRT care for critically ill patients.

Systematic review registration

PROSPERO CRD42015015530.

     

A recovery program to improve quality of life,sense of coherence and psychological health in ICU survivors: a multicenter randomized controlled trial,the RAPIT study

Purpose

The aim of this randomized controlled trial (RCT) was to test the effectiveness of a post-ICU recovery program compared to standard care during the first year after ICU discharge.

Methods

A pragmatic, non-blinded, multicenter, parallel-group RCT was conducted between December 2012 and December 2015, at ten intensive care units (ICUs) in Denmark. We randomly assigned 386 adult patients (≥18 years) after receiving mechanical ventilation (≥48 h) to standard care (SC) plus a nurse-led intensive care recovery program or standard care alone after ICU discharge (190 intervention, 196 SC). Primary outcome was health-related quality of life (HRQOL) at 12 months. Secondary outcomes were sense of coherence (SOC), anxiety, depression, and post-traumatic stress disorder (PTSD) assessed at 3 and 12 months after ICU discharge including utilization of healthcare services at 12 months.

Results

At 12 months, we found no differences in HRQOL between groups (mean difference in the Physical Component Summary score, 1.41 [95 % CI, ?1.53 to 4.35; p = 0.35] (n = 235); and in the Mental Component Summary score, 1.92 [95 % CI, ?1.06 to 4.90; p = 0.11] (n = 235). No differences were found on self-reported SOC (p = 0.63), anxiety (p = 0.68), depression (p = 0.67), PTSD (p = 0.27), or the utilization of healthcare services including rehabilitation. We found a difference on anxiety, when a cut-off point ≥11 was applied, in per protocol analysis of complete cases at 3 months favoring the intervention (8.8 % vs. 16.2 %, p = 0.04).

Conclusions

The tested recovery program was not superior to standard care during the first 12 months post-ICU.

Trial registration

The trial is registered at Clinicaltrials.gov, identification no. NCT01721239.

     

A Multi-Level Investigation of the Association between Sensory Features in Boys and Adolescents with ASD and Their Mothers’ Anxiety and Depression

The association between boys’ Sensory Features (SF) and their mothers’ anxiety and depression was investigated in two groups of boys with ASD (M age Gp 1 = 7.5 yr.; M age Gp 2 = 14.3 yr). Mothers completed the Sensory Profile (SP) on their sons, and the GAD7 and PHQ9 on themselves. Results indicated significant associations between mothers’ GAD7 scores and the boys’ SP quadrant scores (global level), between GAD7 scores and Auditory, Visual and Touch Processing Domains (subscale level), and between boys’ specific SF-related Visual and Touch behaviours and specific symptoms of mothers’ GAD7 and PHQ9 scores (item level). Implications for clinical interventions with parents of these children are described.     

Predictors of Adherence and Outcome in Internet-Based Cognitive Behavior Therapy Delivered in a Telephone Counseling Setting

This study investigated predictors of adherence and outcome in a sample of callers to a national crisis telephone counseling service who were randomized to receive a 6-week, online, self-administered psychoeducation and cognitive behavioral therapy (CBT) intervention. Age, sex, relationship status, employment status, level of education, baseline depression symptom severity, and motivation to undertake the intervention were examined as predictors of adherence to the intervention in participants assigned to receive the online intervention (n = 83). Predictors of depression outcome were assessed using mixed models repeated measures ANOVA, comparing the two web-CBT intervention groups to the tracking and control groups (n = 155). Lower baseline depression severity was significantly associated with greater adherence to the intervention. A significant interaction was found between measurement occasion and motivation to undertake the intervention. At 6 month follow-up, participants with low and moderate levels of motivation had lower depressive symptoms than those with high levels of motivation. At 12 month follow-up, those with moderate levels of motivation had lower depressive symptoms than those with high motivation. The findings suggest that lower pre-intervention depression symptoms may positively influence adherence to online treatment for depression, while low and moderate levels of motivation appear to be optimal for treatment outcome. The factors that relate to adherence and outcome need to be understood to prevent dropout and maximize treatment effectiveness in online interventions.     

Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial

Purpose

Guidelines recommend administering antibiotics within 1 h of sepsis recognition but this recommendation remains untested by randomized trials. This trial was set up to investigate whether survival is improved by reducing the time before initiation of antimicrobial therapy by means of a multifaceted intervention in compliance with guideline recommendations.

Methods

The MEDUSA study, a prospective multicenter cluster-randomized trial, was conducted from July 2011 to July 2013 in 40 German hospitals. Hospitals were randomly allocated to receive conventional continuous medical education (CME) measures (control group) or multifaceted interventions including local quality improvement teams, educational outreach, audit, feedback, and reminders. We included 4183 patients with severe sepsis or septic shock in an intention-to-treat analysis comparing the multifaceted intervention (n = 2596) with conventional CME (n = 1587). The primary outcome was 28-day mortality.

Results

The 28-day mortality was 35.1% (883 of 2596 patients) in the intervention group and 26.7% (403 of 1587 patients; p = 0.01) in the control group. The intervention was not a risk factor for mortality, since this difference was present from the beginning of the study and remained unaffected by the intervention. Median time to antimicrobial therapy was 1.5 h (interquartile range 0.1–4.9 h) in the intervention group and 2.0 h (0.4–5.9 h; p = 0.41) in the control group. The risk of death increased by 2% per hour delay of antimicrobial therapy and 1% per hour delay of source control, independent of group assignment.

Conclusions

Delay in antimicrobial therapy and source control was associated with increased mortality but the multifaceted approach was unable to change time to antimicrobial therapy in this setting and did not affect survival.

     

Comparison of alcoholic chlorhexidine and povidone–iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study

Purpose

Compare the effectiveness of different cutaneous antiseptics in reducing risk of catheter-related infection in intensive care unit (ICU) patients.

Methods

We compared the risk of central venous catheter-related infection according to four-step (scrub, rinse, dry, and disinfect) alcoholic 5 % povidone–iodine (PVI-a, n = 1521), one-step (disinfect) alcoholic 2 % chlorhexidine (2 % CHX-a, n = 1116), four-step alcoholic <1 % chlorhexidine (<1 % CHX-a, n = 357), and four-step aqueous 10 % povidone–iodine (PVI, n = 368) antiseptics used for cutaneous disinfection and catheter care during the 3SITES multicenter randomized controlled trial. Within this cohort, we performed a quasi-experimental study (i.e., before–after) involving the four ICUs which switched from PVI-a to 2 % CHX-a. We used propensity score matching (PSM, n = 776) and inverse probability weighting treatment (IPWT, n = 1592). The end point was the incidence of catheter-related infection (CRI) defined as catheter-related bloodstream infection (CRBSI) or a positive catheter tip culture plus clinical sepsis on catheter removal.

Results

In the cohort analysis and compared with PVI-a, the incidence of CRI was lower with 2 % CHX-a [adjusted hazard ratio (aHR), 0.51; 95 % confidence interval (CI) (0.28–0.96), p = 0.037] and similar with <1 % CHX-a [aHR, 0.73; (0.36–1.48), p = 0.37] and PVI [aHR, 1.50; 95 % CI (0.85–2.64), p = 0.16] after controlling for potential confounders. In the quasi-experimental study and compared with PVI-a, the incidence of catheter-related infection was again lower with 2 % CHX-a after PSM [HR, 0.35; 95 % CI (0.15, 0.84), p = 0.02] and in the IPWT analysis [HR, 0.31; 95 % CI (0.14, 0.70), p = 0.005]. The incidence of CRBSI or adverse event was not significantly different between antiseptics in all analyses.

Conclusions

In comparison with PVI-a, the use of 2 % CHX-a for cutaneous disinfection of the central venous catheter insertion site and maintenance catheter care was associated with a reduced risk of catheter infection, while the benefit of <1 % CHX-a was uncertain.Clinical trials identifier: NCT01479153.

     

Are Negative Automatic Thoughts Associated with ADHD in Adulthood?

Recent randomized controlled trials indicate that cognitive-behavioral therapy (CBT) for adults with attention-deficit/hyperactivity disorder (ADHD) is an efficacious treatment. Although treatments for adults with ADHD target negative automatic thoughts, there is a lack of empirical evidence demonstrating that such cognitions are associated with ADHD. The goal of this study was to assess the relationship between ADHD and negative automatic thoughts typically associated with depression in a group of adults diagnosed with ADHD (n = 81). Across the sample, self, collateral, and clinician ratings of inattentive ADHD symptom severity, but not hyperactive-impulsive symptom severity, were significantly associated with negative automatic thoughts after considering the role of current depressive symptom severity. Subsequent categorical analyses were conducted by subdividing the ADHD sample into those with (n = 34) and without (n = 47) a comorbid depression diagnosis, and adding a control group (n = 43). Analyses indicated that (a) the ADHD group with comorbid depression reported significantly more negative automatic thoughts than both controls and the ADHD group without comorbid depression, and (b) the ADHD group without comorbid depression reported significantly more negative automatic thoughts than controls. These findings provide an empirical basis for adult ADHD CBT to target negative automatic thoughts, which share a relationship with ADHD even after accounting for the confounding role of depression. Modification of negative automatic thoughts may be a mechanism of change in adult ADHD CBT and should be considered in future research.     

Cognitive Behavioral Therapy Versus Progressive Muscle Relaxation Training for Multiple Somatoform Symptoms: Results of a Randomized Controlled Trial

Although unexplained multiple symptoms and somatoform disorders are a highly prevalent condition in primary practice, few randomized controlled trials of cognitive behavioral therapy (CBT) have been conducted. Moreover, most of these trials have used only the usual medical treatment or wait list control groups. The present study included 134 outpatients showing at least two medically unexplained symptoms. They were randomly assigned to eight weekly group sessions of either CBT or progressive muscle relaxation (PMR) or wait list control and were assessed before and after treatment as well as 6 months after the end of treatment. The number and intensity of somatoform symptoms were the primary outcome measures; depression, anxiety and physical and mental health constituted the secondary outcome measures. CBT showed small effects (Cohen’s d = 0.44) for the treatment of somatoform disorders. Benefits of the treatment were sustained over 6 months of follow-up. However, no differential effects of CBT and PMR were found. In conclusion, both CBT and PMR appear to be effective treatments for multiple somatoform symptoms.     

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

Purpose

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications.

Methods

During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications.

Results

Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient.

Conclusions

Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

     

Changes in Anxiety Sensitivity Following Group Cognitive-Behavior Therapy for Social Anxiety Disorder and Panic Disorder

The current study examined changes in anxiety sensitivity following cognitive behavior therapy as a predictor of treatment outcome in patients with social anxiety disorder (SAD) and patients with panic disorder (PD). One-hundred ninety-seven patients with a principal diagnosis of SAD (n = 108) or PD (n = 89) completed the Anxiety Sensitivity Index (ASI; Reiss et al in Behav Res Ther 24:1–8, 1986), Depression Anxiety Stress Scales (DASS-21; Lovibond and Lovibond in Behav Res Ther 33:335–343, 1995), Social Phobia Inventory (SPIN; Connor et al in Br J Psychiatry 176:379–386, 2000) and Panic Disorder Severity Scale-Self Report (PDSS-SR; Houck et al in Depress Anxiety 15:183–185, 2002; Shear et al in Am J Psychiatry 154:1571–1575, 1997) pre and post disorder specific treatment. For the SAD group, changes on ASI Physical and ASI Social subscales made significant contributions to the prediction of posttreatment social anxiety symptoms over and above pretreatment social anxiety symptoms and changes in depression scores. For the PD group, changes on the ASI Physical subscale made a significant contribution to the prediction of posttreatment panic symptoms over and above pretreatment panic symptoms and changes in depression scores. The present study provides further support that, while the global construct of anxiety sensitivity is a transdiagnostic factor across the anxiety disorders, the lower-order dimensions of anxiety sensitivity have specificity for particular anxiety disorders.     

Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: a French multicentre randomised controlled trial (OPERA)

Purpose

High-flow nasal cannula (HFNC) oxygen therapy is attracting increasing interest in acute medicine as an alternative to standard oxygen therapy; however, its use to prevent hypoxaemia after major abdominal surgery has not been evaluated. Our trial was designed to close this evidence gap.

Methods

A multicentre randomised controlled trial was carried out at three university hospitals in France. Adult patients at moderate to high risk of postoperative pulmonary complications who had undergone major abdominal surgery using lung-protective ventilation were randomly assigned using a computer-generated sequence to receive either HFNC oxygen therapy or standard oxygen therapy (low-flow oxygen delivered via nasal prongs or facemask) directly after extubation. The primary endpoint was absolute risk reduction (ARR) for hypoxaemia at 1 h after extubation and after treatment discontinuation. Secondary outcomes included occurrence of postoperative pulmonary complications within 7 days after surgery, the duration of hospital stay, and in-hospital mortality. The analysis was performed on data from the modified intention-to-treat population. This trial was registered with ClinicalTrials.gov (NCT01887015).

Results

Between 6 November 2013 and 1 March 2015, 220 patients were randomly assigned to receive either HFNC (n = 108) or standard oxygen therapy (n = 112); all of these patients completed follow-up. The median duration of the allocated treatment was 16 h (interquartile range 14–18 h) with standard oxygen therapy and 15 h (interquartile range 12–18) with HFNC therapy. Twenty-three (21 %) of the 108 patients treated with HFNC 1 h after extubation and 29 (27 %) of the 108 patients after treatment discontinuation had postextubation hypoxaemia, compared with 27 (24 %) and 34 (30 %) of the 112 patients treated with standard oxygen (ARR 4, 95 % CI –8 to 15 %; p = 0.57; adjusted relative risk [RR] 0.87, 95 % CI 0.53–1.43; p = 0.58). Over the 7-day postoperative follow-up period, there was no statistically significant difference between the groups in the proportion of patients who remained free of any pulmonary complication (ARR 7, 95 % CI –6 to 20 %; p = 0.40). Other secondary outcomes also did not differ significantly between the two groups.

Conclusions

Among patients undergoing major abdominal surgery, early preventive application of high-flow nasal cannula oxygen therapy after extubation did not result in improved pulmonary outcomes compared with standard oxygen therapy.

     

Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer

Purpose

To compare the outcomes of partially covered self-expandable metallic stent (SEMS) placement with surgical gastrojejunostomy (GJ) in patients with gastroduodenal obstruction caused by pancreatic cancer.

Methods

The medical records of 107 patients with gastroduodenal obstruction caused by pancreatic cancer who underwent fluoroscopic partially covered SEMS placement (n = 75) or surgical GJ (n = 32) at our institution were reviewed.

Results

The technical (100% vs. 100%; P > 0.999) and clinical (98.7% vs. 96.9%; P = 0.511) success rates were similar between the SEMS and GJ group. The mean gastric outlet obstruction scoring system score was higher in the SEMS group at 1 week after treatment (2.3 ± 0.5 vs. 1.2 ± 0.4; P < 0.001) but was similar between the two groups at 1 month (2.7 ± 0.5 vs. 2.8 ± 0.5; P = 0.242). The median hospital stay was shorter in the SEMS group than in the GJ group (7 vs. 14 days; P < 0.001). The overall complication (22.7% vs. 28.1%; P = 0.547) and reintervention (21.3% vs. 25.0%; P = 0.677) rates were similar between the two groups. The median patency (99 vs. 138 days; P = 0.102) and survival (106 vs. 140 days; P = 0.245) were also similar between the two groups.

Conclusion

The outcomes of partially covered SEMS placement seem to be more favorable than surgical GJ in patients with gastroduodenal obstruction caused by pancreatic cancer.