Psychosocial treatment of obsessive-compulsive disorder

Although progress is being made in the application of cognitive therapy to obsessive-compulsive disorder (OCD), behavior therapy, especially exposure and response prevention, is currently the nonpharmacological treatment of choice. The behavioral model of OCD states that obsessive fears give rise to anxiety. This anxiety is then reduced by compulsive behaviors, which are thus maintained by negative reinforcement.While the model falls short of explaining the acquisition of obsessions, it does give an adequate account of the maintenance of compulsive behaviors. For the most part, behavior therapy has been at least as effective as medication and shows lasting benefits at follow up. Impediments to progress in treatment include noncompliance, severe depression, personality disorders and overvalued ideas. Treatment guidelines for behavior therapy are presented. In the cognitive model of OCD, automatic thoughts involving overestimated perceived personal responsibility and exaggerated perceived threat lead to anxiety; compulsive rituals function to reduce this anxiety. The effectiveness of cognitive therapy in the treatment of OCD is assessed and some treatment guidelines are provided. Although behavior therapy is the treatment of choice for OCD, patients can benefit from the addition of antidepressant medication or cognitive therapy, at least during the initial stages of treatment.     

Primary mucinous carcinoma of the skin

Only twenty-seven cases of primary mucinous carcinoma of the skin have been reported. Three additional cases are included in this paper. The clinical presentation is distinctive; they are found most commonly in middle-aged, black males in the head and neck region as painless nodules, usually less than 3 cm in diameter. Previous reports have indicated the probable sweat gland origin of these tumours; one of our cases demonstrates a transition from a solid hidradenoma-like pattern to nests of tumour cells floating in mucin lakes, adding support for the sweat gland hypothesis. The clinical behaviour is relatively benign; late recurrences are common but metastases are rare. Only one case had widespread metastases. Although the histological appearance is distinctive, other primary sites first must be excluded. Local excision is the treatment of choice.     

Do Outcomes from Transcatheter Aortic Valve Implantation Vary According to Access Route and Valve Type? The UK TAVI Registry

Objectives

To determine whether outcomes from transcatheter aortic valve implantation (TAVI) vary according to access route and valve type in a real‐world population.

Background

Registry and uncontrolled trial data have found that patients undergoing nonfemoral TAVI have higher early and late mortality. It is not clear whether worse outcomes relate directly to access route. There have been no direct comparisons of outcomes according to valve type.

Methods

Data were collected prospectively on 1,620 patients undergoing TAVI in the UK and compared in 4 groups: SAPIEN transfemoral (TF); SAPIEN transapical (TA); CoreValve TF, CoreValve subclavian. Univariable and multivariable regression analysis was performed to identify independent predictors of mortality.

Results

Mortality in patients undergoing SAPIEN TAVI via a TA approach was higher than with TF at 30 days (11.2% vs. 4.4%, P < 0.01), 1 year (28.7% vs. 18.1%, P = 0.01), and 2 years (56.0% vs. 43.5%, P = 0.01). Logistic EuroSCORE was higher in TA patients (22.5 ± 12.9% vs. 17.7 ± 11.1%, P < 0.0001). After multivariable analysis TA access was associated with increased mortality at 30 days (OR 2.56, 95% CI 1.46–4.48, P < 0.01) and 2 years (OR 1.75, 1.08–2.74, P = 0.02). There was no significant difference in mortality at any time‐point between patients treated with SAPIEN (n = 812) and CoreValve (n = 808) prostheses. CoreValve‐treated patients had a higher rate of permanent pacemaker implantation (23.1% vs. 7.2%, P < 0.0001), and grade ≥2 aortic regurgitation on postprocedure echocardiography (13.0% vs. 7.3%, P < 0.01).

Conclusions

Patients undergoing TA TAVI experienced increased early and late mortality compared to a TF approach. Survival was not influenced by valve type. (J Interven Cardiol 2014;27:86–95)

     

Subcutaneous morphoea: a clinical study of sixteen cases

Sixteen patients had biopsy-proved inflammatory sclerosis of the panniculus or fascia, which usually was seen in a generalized distribution. Although the sclerosis involved the digits of five patients, it was the result of centrifugal spread of the sclerosis and was not accompanied by ulcers, calcinosis, distal phalangeal resorption or telangiectasia. Four patients may have had digital vasopasm in the extremities involved in the sclerotic process. Five patients also had cutaneous lesions of dermal morphoea or lichen sclerosus et atrophicus. Four patients had a reduced carbon monoxide diffusing capacity, and one of these had roentgenographic evidence of pulmonary fibrosis. In three patients, oesophageal motility or barium swallow studies showed evidence of sclerodermatous changes. The sclerotic process was a contributory cause of the death of one patient. Five patients had peripheral eosinophilia. Six patients seemed to have responded to anti-inflammatory agents. We believe that subcutaneous morphoea is generally more inflammatory than generalized morphoea of the dermal type and may be more likely to progress to mild systemic sclerosis. We suggest that response of subcutaneous morphoea to anti-inflammatory agents is simply a reflection of the degree of inflammation present.     

PHOTODAMAGE AND SKIN CANCER AMONG PARAQUAT WORKERS

Background. Some workers in paraquat manufacturing, exposed to bipyridines, have developed pigmentation and keratosis on sun-exposed skin. This condition has been described as skin-malignancy or premalignancy. This study was designed to clarify the pathologic features of these lesions and to explore the etiologic role played by bipyridine. Methods. Twenty-three biopsy specimens, obtained from the affected skin of 10 workers, were scrutinized by a dermatopathologist. A total of 242 exposed workers from 28 paraquat factories were examined and interviewed during the period from 1983 to 1991. The severity of the characteristic skin lesions was graded from the lowest to the highest response to analyze the data by Mantel extension for a trend that focused on the heavy exposure to bipyridines as risk factor. Results. All pathology specimens showed various degrees of solar damage: early actinic change, solar lentigo, actinic keratosis (AK), AK coexisting with squamous cell carcinoma (sec), and sec. Six specimens from four workers were sec or sec in situ. Three of six sec showed the coexistence of AK. Of the workers, 133 had skin lesions ranging in severity from grade 1 to grade 3 on sun-exposed areas. The severity of skin changes is strongly associated with heavy exposure to bipyridines (P < 0.0001). Conclusion. This pathologic study proves that all the lesions showed either photodamage or skin cancer. The strong trend in the correlation between severity of photo-damage and exposure to bipyridine leads to the speculation about the synergistic role of bipyridine exposure and the solar effect in causing these malignant and premalignant skin lesions.     

Correlation between Laser Fluorescence Readings and Volume of Tooth Preparation in Incipient Occlusal Caries In Vitro

Objective:  This study evaluated the correlation between laser fluorescence readings and the extent of incipient occlusal caries as measured by the volume of tooth preparation in vitro.
Materials and Methods:  One hundred and three permanent molars and premolars containing incipient occlusal pit-and-fissure caries and sound occlusal surfaces (1/4 of the sample, control) were selected. DIAGNOdent (KaVo Dental Corporation, Lake Zurich, IL, USA) readings were obtained according to manufacturer instructions. Caries was removed with 1/4 round burs in high speed. The volume of tooth preparation was measured using a surrogate measure based on the amount of composite needed to fill the preparations. Sensitivity and specificity using different cutoff values were calculated for lesions/preparations extending into dentin. The results were analyzed statistically.
Results:  The Pearson correlation for preparation volume and DIAGNOdent reading measurements was low ( r  = 0.285). Sensitivity and specificity of DIAGNOdent for detection of dentinal lesions were 0.83 and 0.60, and 0.66 and 0.73 for the cutoff values of 20 and 30, respectively.
Conclusions:  Within the limitations of this study, laser fluorescence measured with DIAGNOdent does not correlate well with extent of carious tooth structure in incipient occlusal caries.

CLINICAL SIGNIFICANCE

Clinicians should not rely only on DIAGNOdent readings to determine the extension of incipient occlusal caries.
( J Esthet Restor Dent 22:31–41, 2010)     

IgH AND TcR-γ GENE REARRANGEMENTS IDENTIFIED IN HODGKIN'S DISEASE BY PCR DEMONSTRATE LACK OF CORRELATION BETWEEN GENOTYPE,PHENOTYPE, AND EPSTEIN–BARR VIRUS STATUS

Analysis of IgH and TcR-γ genes using consensus primers identifying junctional regions of rearranged genes by polymerase chain reaction (PCR) was performed on tissues involved by Hodgkin's disease (HD) in 90 cases and was correlated with the immunophenotype of Hodgkin and Reed–Sternberg (HRS) cells and the presence of Epstein–Barr virus (EBV) within these cells. Clonal IgH gene rearrangements were found in 1/5 cases of lymphocyte predominance (LP) subtype and none was positive for EBV. In 85 cases of classic HD, no IgH or TcR-γ gene rearrangements were found in 51 (60 per cent) cases. A similar percentage, but not the same cases, were of null (non-B, non-T) phenotype. Of 30 cases where a B phenotype was assigned to HRS cells, nine had IgH gene rearrangements, three had TcR-γ gene rearrangements, and two had both genes rearranged. None of the five cases assigned to T phenotype of HRS cells showed rearrangement of TcR-γ genes, but two cases showed rearranged IgH genes. Among 41 cases of null phenotype, ten had IgH gene rearrangements, five had TcR-γ gene rearrangements, and three cases had both genes rearranged. Whereas EBV was detectable in HRS cells in 17/43 classic HD cases of assigned B phenotype, EBV was also detectable in 2/5 cases of assigned T phenotype and in 21 cases with the null phenotype. Furthermore, there was no correlation of EBV with the presence or lack of IgH or TCR-γ gene rearrangements. Of the remainder, half (30 per cent) expressed antigens associated with lymphocytes without an appropriate genotype. The results confirm lymphocyte-lineage committed cells at the origin of HRS cells in 40 per cent of cases. Any hypothesis of a non-lymphocytic origin of HRS cells will require the inducibility of CD30 on candidate precursors and the methodology for probing genetic events in such cells to be addressed. © 1997 by John Wiley & Sons, Ltd.     

The Perils of Medicalization for Population Health and Health Equity

Policy Points

• Medicalization is a historical process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and “diagnosed and treated” as individual pathologies and problems by medical authorities.
• Medicalization in the United States has led to a conflation of “health” and “health care” and a confusion between individual social needs versus the social, political, and economic determinants of health.
• The essential and important work of population health science, public health practice, and health policy writ large is being thwarted by a medicalized view of health and an overemphasis on personal health services and the health care delivery system as the major focal point for addressing societal health issues and health inequality.
• Increased recognition of the negative consequences of a medicalized view of health is essential, with a focus on education and training of clinicians and health care managers, journalists, and policymakers.

     

Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring

Policy Points

• Social indicators of young peoples’ conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being.
• There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators.
• Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.