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OBJECTIVES: The study investigated whether depressed older adults retrieve fewer specific memories and more categoric memories than non-depressed older adults on the autobiographical memory test (AMT). The second objective was to investigate the relationship between AMT performance and both working memory and intelligence quotient (IQ). DESIGN: The study was cross-sectional, involving a single interview with each participant. METHODS: A group of 17 depressed participants was matched for age, gender and education with a group of 17 non-depressed participants. All were screened for cognitive impairment. Participants completed the AMT, spatial span and letter-number sequencing subtests of the Wechsler Memory Scale III and the Wechsler Test of Adult Reading. RESULTS: The depressed group retrieved significantly fewer specific memories than the non-depressed group, but did not differ in their categoric memory recall. Specific memory scores were positively correlated with measures of working memory, but not with IQ. Categoric memory scores were negatively correlated with measures of working memory, but not with IQ. CONCLUSIONS: Depression adversely affects older adults' ability to retrieve specific memories. Working memory capacity was related to specific autobiographical memory retrieval independently of IQ. A strong relationship between AMT performance and spatial span is discussed. [ABSTRACT FROM AUTHOR]

Front-line caregivers in nursing homes frequently provide bereavement support to family members before and after the death of a nursing home resident. Use of the evidence-based guideline 'Family Bereavement Support Before and After the Death of a Nursing Home Resident' (Davidson, 2002) can reduce uncertainty and increase the confidence of staff providing before and after death care to families, and can ensure all families receive consistent bereavement support. [ABSTRACT FROM AUTHOR]

Question: How effective is the STEPPS programme for people with a borderline personality disorder?Patients: 165 people with DSM-IV borderline personality disorder (>=18 years; 83% female). Main exclusions: psychotic or primary neurological disorder; cognitive impairment; substance abuse or dependence; recent suicidal thoughts or self-harm behaviour.Setting: Outpatient setting, Iowa, USA; recruitment 2002-2006. Intervention: Systems Training for Emotional Predictability and Problem Solving (STEPPS) plus usual care or usual care alone (including medication, individual psychotherapy and case management). STEPPS is a manual-based group treatment programme involving psychoeducation, and emotion and behaviour management skills training, delivered in once weekly 2-hour sessions over 20 weeks, which includes education for a friend or relative. Outcomes: Primary outcome: symptoms (Zanarini Rating Scale for Borderline Personality Disorder Affective (ZRS-BPD), a scale which assesses cognitive disturbance, disturbed relationships, and impulsivity). Secondary outcomes: thoughts, feelings and behaviour (Borderline Evaluation of Severity Over Time scale (BESOT)); positive and negative disposition (Positive and Negative Affect Schedule (PANAS)); Beck Depression Inventory (BDI); Symptom Checklist-90-Revised (SCL90R); Social Adjustment Scale (SAS); Barratt Impulsiveness Scale (BIS); use of medication or other therapies; physician or crisis contact; suicide or self-harm. Outcomes were assessed every 4 weeks during treatment, and every 3 months post-intervention.Patient follow-up:58.2% at 20 weeks, 75.2% included in post-treatment 20 week intention-to-treat (ITT) analysis; 49.7% assessed at least once during 1 year follow-up.METHODSDesign: Randomised controlled trial.Allocation: Unconcealed.Blinding: Unclear.Follow-up period: One year (post-intervention).MAIN RESULTSThe STEPPS intervention plus usual care improved total symptoms at the end of 20 weeks' treatment compared to usual care alone (mean decrease in ZRS-BPD score from baseline: 9.1 with STEPPS vs 3.9 with control; p = 0.001). For secondary outcomes at 20 weeks, the STEPPS group showed significantly greater improvement than controls on global functioning and depression measures (CGI-S and CGI-I, GAS, BDI, SCL90R Global Severity Index), impulsiveness (BIS), negative affect (PANAS), and thoughts and feelings (BESOT). The primary outcome (ZRS-BPD) was not reported over post-intervention follow-up; there were no significant differences between treatment groups in changes in any of the secondary outcome scales from the end of treatment to one year follow-up. Emergency department visits were significantly less frequent with STEPPS compared to control (visits in an average of: 0.97 months per year with STEPPS vs 1.53 months per year with control, p = 0.04).CONCLUSIONSSTEPPS plus treatment as usual for people with borderline personality disorder, can improve symptoms, behaviour and global functioning across a range of scales. Outcomes remain relatively stable after 1 year. [ABSTRACT FROM AUTHOR]

Introduction: While extant research has looked at parole and its various actors as an institution, few studies recount the parole experience from the perspective of parolees. Additionally, despite the prevalence of substance use disorders (SUDs) within the criminal justice system, research that assesses the additional challenges this population faces throughout parole supervision is even scarcer., Methods: To address this gap, we analyze in-depth qualitative interviews (n = 51) conducted with reentering men with SUDs as they navigate parole in Pennsylvania. Three independent coders identified all narratives relating to a broad theme of "parole and probation experiences." The authors then completed iterative rounds of more fine-grained independent coding within that theme., Results: Our results emphasize that SUDs present a significant barrier to reentry success, and the tension of surveillance and revocation is amplified for those enduring simultaneous reentry and recovery. Importantly, our respondents regard parole officers more positively than they view parole as an institution, yet this perception of officers does not equate to provision of reintegration and recovery support. Respondents perceive that parole presents unnecessary additional hurdles to their reentry success, and their perceived risk level impacts their surveillance intensity., Conclusions: The information gleaned through inclusion of perspectives from those enduring parole supervision calls for a critical assessment of current parole practices. Further, the current approach to SUDs within community supervision criminalizes relapse without provision of treatment resources or support., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: The prison-based Therapeutic Community (TC) is widely used within correctional institutions to address substance use disorders (SUDs). While most evaluations of the prison-based TC find the program to be effective, recent mixed evidence and the continued surge of the opioid crisis call for deeper investigation into program operations, barriers to engagement, and sources of treatment effect heterogeneity. Notably lacking from prior evaluations, and critical to our understanding of variable program engagement, is first-hand experiences and perceptions from program participants., Methods: To assess prison-based TC resident perceptions of the program and their recommendations for improvement, we utilize data from the Therapeutic Community Prison Inmate Network Study (TC-PINS), a longitudinal data collection effort conducted in one prison-based TC unit within a Pennsylvania state prison. Specifically, we assess resident responses to the open-ended item "What can the TC do better?" Analyzing 470 responses to this question by 177 residents, two independent coders identified seven substantive categories of recommended changes or improvements to their TC program., Results: Residents provided tangible recommendations for improvement of their prison-based TC program based on their experiences and perceptions. Importantly, a number of their recommendations directly counter the intended model of the TC, which highlights imperative issues underlying the translation of the TC model within the prison environment. Resident suggestions include enhanced structure, increased individualization, expanded curriculum, stricter enforcement of rules, and improved or more experienced staff. Additionally, many question the coercive nature of TC program participation within this prison system., Conclusions: Resident recommendations for program improvement unveil important sources of treatment effect heterogeneity and highlight tangible program changes that can be implemented to reduce barriers to treatment engagement. We provide suggested changes to this prison-based TC based on resident perceptions and discuss both the importance and relative ease of eliciting this critical participant feedback., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Streptococcus agalactiae (group B Streptococcus; GBS) remains a dominant cause of serious neonatal infections. One aspect of GBS that renders it particularly virulent during the perinatal period is its ability to invade the chorioamniotic membranes and persist in amniotic fluid, which is nutritionally deplete and rich in fetal immunologic factors such as antimicrobial peptides. We used next-generation sequencing of transposon-genome junctions (Tn-seq) to identify five GBS genes that promote survival in the presence of human amniotic fluid. We confirmed our Tn-seq findings using a novel CRISPR inhibition (CRISPRi) gene expression knockdown system. This analysis showed that one gene, which encodes a GntR-class transcription factor that we named MrvR, conferred a significant fitness benefit to GBS in amniotic fluid. We generated an isogenic targeted deletion of the mrvR gene, which had a growth defect in amniotic fluid relative to the wild type parent strain. The mrvR deletion strain also showed a significant biofilm defect in vitro. Subsequent in vivo studies showed that while the mutant was able to cause persistent murine vaginal colonization, pregnant mice colonized with the mrvR deletion strain did not develop preterm labor despite consistent GBS invasion of the uterus and the fetoplacental units. In contrast, pregnant mice colonized with wild type GBS consistently deliver prematurely. In a sepsis model the mrvR deletion strain showed significantly decreased lethality. In order to better understand the mechanism by which this newly identified transcription factor controls GBS virulence, we performed RNA-seq on wild type and mrvR deletion GBS strains, which revealed that the transcription factor affects expression of a wide range of genes across the GBS chromosome. Nucleotide biosynthesis and salvage pathways were highly represented among the set of differentially expressed genes, suggesting that MrvR may be involved in regulating nucleotide availability., Competing Interests: The authors have declared that no competing interests exist.

Prison-based therapeutic communities (TCs) are a widespread, effective way to help incarcerated individuals address substance abuse problems. The TC philosophy is grounded in an explicitly relational paradigm that entails building community and conditioning residents to increasingly take responsibility for leadership therein. Although TCs are based on cultivating a network that continuously integrates new residents, many common structural features can jeopardize TC goals and are hence discouraged (e.g., clustering, homophily). In light of this tension, analyzing the TC from a network perspective can offer new insights to its functioning, as well as to broader questions surrounding how networks integrate new members. In this study we examine a men's TC unit in a Pennsylvania prison over a 10-month span. Using data on residents' informal networks, we examine: (1) how well individuals integrate into the TC network across time, (2) what predicts how well residents integrate into the TC, and (3) how well the TC network structure adheres to theoretical ideals. Results suggest that individual integration is driven by a range of hypothesized factors and, with limited exceptions, the observed TC is able to foster a network structure and integrate residents consistent with TC principles. We discuss the implications of these results for evaluating TCs and for understanding the process of network integration.

Background: The Therapeutic Community (TC) is a common treatment modality for incarcerated individuals with substance use disorders. TCs rely on peer group processes to promote lasting behavioral and identity change, yet prior research has not adequately tested the peer influence mechanisms underlying the theoretical model. This study applied dynamic network analysis to estimate peer influence processes central to TC philosophy., Methods: A stochastic actor-oriented model (SAOM) was applied to ten months of social network data collected from prisoner surveys within a TC unit (N = 62) in a medium-security Pennsylvania prison. Respondents (N = 177, 84% of unit) completed at least one prison survey and provided network and community role model nominations., Results: Although residents' levels of treatment engagement were significantly correlated with their nominated peers, estimates of peer influence for treatment engagement were non-significant in longitudinal network models. Nor were estimates of peer influence significantly greater for peers perceived as community role models. Rather, inmates connected with peers who were of similar treatment engagement as themselves (i.e., a peer selection process), and the latter primarily resulted from racial homophily in the TC social network., Conclusions: Inconsistent with the desired treatment model, treatment engagement diffusion was not evident in the sampled TC. Results suggested that highly-engaged residents clustered together at the center of the TC's social structure but had little impact on less-engaged and peripheral inmates. The relatively short (i.e., four-month) program length and moderate-to-low treatment fidelity likely contributed to the lack of peer influence processes., (Copyright © 2019. Published by Elsevier B.V.)

Given the high proportion of inmates with histories of substance use disorders in the era of mass incarceration, many correctional institutions have integrated the prison-based Therapeutic Community (TC) into their programming. While most evaluations provide evidence of lowered rates of relapse and recidivism, the majority of TC graduates still have negative outcomes post-release. Filling an important gap in the TC treatment literature, we analyze quantitative measures of treatment engagement alongside qualitative narratives from prison-based TC residents, providing an essential look into the black box of TC treatment mechanisms. Quantitative results show more between-person variation than within-person change, reflecting trivial increases in treatment engagement throughout time in the program. Qualitative results unpack these findings, pointing to processes of selection bias, heterogeneous treatment effects, and program fidelity lapses. In combination, our mixed data identify tangible modifications to program implementation that could strengthen desired post-release outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The adaptive cellular response to low oxygen tensions is mediated by the hypoxia-inducible factors (HIFs), a family of heterodimeric transcription factors composed of HIF-α and HIF-β subunits. Prolonged HIF expression is a key contributor to cellular transformation, tumorigenesis and metastasis. As such, HIF degradation under hypoxic conditions is an essential homeostatic and tumour-suppressive mechanism. LIMD1 complexes with PHD2 and VHL in physiological oxygen levels (normoxia) to facilitate proteasomal degradation of the HIF-α subunit. Here, we identify LIMD1 as a HIF-1 target gene, which mediates a previously uncharacterised, negative regulatory feedback mechanism for hypoxic HIF-α degradation by modulating PHD2-LIMD1-VHL complex formation. Hypoxic induction of LIMD1 expression results in increased HIF-α protein degradation, inhibiting HIF-1 target gene expression, tumour growth and vascularisation. Furthermore, we report that copy number variation at the LIMD1 locus occurs in 47.1% of lung adenocarcinoma patients, correlates with enhanced expression of a HIF target gene signature and is a negative prognostic indicator. Taken together, our data open a new field of research into the aetiology, diagnosis and prognosis of LIMD1 -negative lung cancers., (© 2018 The Authors. Published under the terms of the CC BY 4.0 license.)

Objective: To describe components fundamental to the process of linking pharmacy to the delivery of public health services in a sustainable way., Summary: Pharmacists deliver public health services with varying frequency. A literature review was conducted to create a set of fundamental links necessary for pharmacists to deliver public health services in a sustainable way. The service needed to be in alignment with public health priorities, be incorporated in the pharmacy curriculum, have postgraduate training opportunities, have a policy or legal platform supporting the service, and have a business model for financial sustainability. Immunization delivery was identified as an exemplary public health service delivered by pharmacists. Additional services evaluated were tobacco cessation counseling, transitions of care, hypertension screening, and substance abuse counseling., Conclusion: Pharmacists are well positioned to provide public health services. Although pharmacists can offer these services, their delivery is variable because of unclearly defined links in the process necessary for their implementation. This article identifies actionable steps to establish sustainable methods for community pharmacists to deliver public health services., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Restoration and management of natural ecosystems is a critical strategy in mitigating global biodiversity loss. This is exemplified in the American Midwest by efforts aimed at reclaiming historical grasslands lost to high-yield agriculture. While restorations traditionally take the form of plant reintroduction and management, advances in microbial analyses suggest that soil communities could be indicators restoration success. However, current understanding of key microbial taxa and functional activities in both natural and restored ecosystems is limited. Here, we investigated the impact of nearly 30 years of carefully managed restoration on soil microbial communities at the Nachusa Grasslands in northern Illinois, USA. We characterized bacterial and archaeal communities in a chronosequence of restored tallgrass prairies ranging from 1 to 27 years old across a growing season and compared them to communities in pre-restoration agricultural fields and remnant prairies. Results indicate that older restorations harboured communities statistically distinct from newer restorations. These communities converged toward those in local prairie remnants, suggesting that plant-focussed restoration has yielded soil bacterial communities reflective of a successful restoration. Recovery of microbial clades within the Verrucomicrobia and Acidobacteria are an important feature of this convergence, and these groups could be targeted for future soil-focussed, bottom-up restoration studies., (© 2017 Society for Applied Microbiology and John Wiley & Sons Ltd.)

As core components of the microRNA-induced silencing complex (miRISC), Argonaute (AGO) proteins interact with TNRC6 proteins, recruiting other effectors of translational repression/mRNA destabilization. Here, we show that LIMD1 coordinates the assembly of an AGO-TNRC6 containing miRISC complex by binding both proteins simultaneously at distinct interfaces. Phosphorylation of AGO2 at Ser 387 by Akt3 induces LIMD1 binding, which in turn enables AGO2 to interact with TNRC6A and downstream effector DDX6. Conservation of this serine in AGO1 and 4 indicates this mechanism may be a fundamental requirement for AGO function and miRISC assembly. Upon CRISPR-Cas9-mediated knockout of LIMD1, AGO2 miRNA-silencing function is lost and miRNA silencing becomes dependent on a complex formed by AGO3 and the LIMD1 family member WTIP. The switch to AGO3 utilization occurs due to the presence of a glutamic acid residue (E390) on the interaction interface, which allows AGO3 to bind to LIMD1, AJUBA, and WTIP irrespective of Akt signaling., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Psychological therapy services are often required to demonstrate their effectiveness and are implementing systematic monitoring of patient progress. A system for measuring patient progress might usefully 'inform supervision' and help patients who are not progressing in therapy., Aims: To examine if continuous monitoring of patient progress through the supervision process was more effective in improving patient outcomes compared with giving feedback to therapists alone in routine NHS psychological therapy., Method: Using a stepped wedge randomized controlled design, continuous feedback on patient progress during therapy was given either to the therapist and supervisor to be discussed in clinical supervison (MeMOS condition) or only given to the therapist (S-Sup condition). If a patient failed to progress in the MeMOS condition, an alert was triggered and sent to both the therapist and supervisor. Outcome measures were completed at beginning of therapy, end of therapy and at 6-month follow-up and session-by-session ratings., Results: No differences in clinical outcomes of patients were found between MeMOS and S-Sup conditions. Patients in the MeMOS condition were rated as improving less, and more ill. They received fewer therapy sessions., Conclusions: Most patients failed to improve in therapy at some point. Patients' recovery was not affected by feeding back outcomes into the supervision process. Therapists rated patients in the S-Sup condition as improving more and being less ill than patients in MeMOS. Those patients in MeMOS had more complex problems.

Background: Biases in beliefs about the self are associated with psychopathology and depressive and anxious mood, but it is not clear if both negative and positive beliefs are associated with depression or anxiety. We examined these relationships in people who present with a wide range of depressive and anxious mood across diagnostic categories., Methods: We probed positive and negative beliefs about the self with a task in which 74 female participants with either affective disorder (depression and/or anxiety), borderline personality disorder or no psychiatric history indicated the degree to which 60 self-related words was "like them" or "not like them". Depressive and anxious mood were assessed with the Beck Depression Inventory-II and the Beck Anxiety Inventory., Results: The participants with no psychiatric history (n=25) reported a positive bias in their beliefs about the self, the participants with affective disorder (n=23) reported no bias, and the participants with BPD (n=26) reported a negative bias. Two hierarchical multiple regressions demonstrated that the positive and negative beliefs contributed additively to the ratings of depression (corrected for anxiety), but did not contribute to the ratings of anxiety (corrected for depression)., Limitations: Despite the apparent small sample size, the regression analyses indicated adequate sampling. Anxiety is a much more heterogeneous condition than is depression, so it may be difficult to find relevant self-descriptors. Only measures of endorsement were used., Conclusions: Biases in beliefs about the self are associated with depressed, but not anxious mood, across diagnostic categories., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Aims and method To assess the feasibility of conducting a larger, definitive randomised controlled trial of manual-assisted cognitive therapy (MACT), a brief focused therapy to address self-harm and promote engagement in services. We established recruitment, randomisation and assessment of outcome within a sample of these complex patients admitted to a general hospital following self-harm. We assessed symptoms of depressed mood, anxiety and suicidality at baseline and at 3 months' follow-up. Results Twenty patients were randomised to the trial following an index episode of self-harm, and those allocated to MACT demonstrated improvement in anxiety, depression and suicidal ideation. Clinical implications It is feasible to recruit a sample of these complex patients to a randomised controlled trial of MACT following an index episode of self-harm. There is preliminary support that MACT could be an acceptable and effective intervention in patients with personality disorder and substance misuse.

The effectiveness of less versus more intensive psychological therapies in reducing suicidal behavior and depression in suicidal patients with borderline personality disorder (BPD) was examined. Electronic databases were searched. Trials were separated into less versus more intensive therapies. Suicidal acts and depression outcome data were assessed. Six trials met search criteria (cognitive-behavioral therapy for personality disorder, mentalization-based therapy, dialectical behavior therapy). Seven measures of suicidal acts and two measures of depression were used in studies. Both less and more intensive therapies report significant decreases in suicidal behaviors. Apart from one small trial, both less and more intensive therapies report decreases in depression with no differences between therapies and control conditions. Two follow-up studies showed that reductions in suicidal behavior and depression are maintained over time. The authors conclude that both less and more intensive therapies are effective in treating depression and suicidal behaviors in patients with BPD. Clinicians should deliver the least intensive interventions that will provide these significant health gains.

Keratin 7 (K7) is a Type II member of the keratin superfamily and despite its widespread expression in different types of simple and transitional epithelia, its functional role in vivo remains elusive, in part due to the lack of any appropriate mouse models or any human diseases that are associated with KRT7 gene mutations. Using conventional gene targeting in mouse embryonic stem cells, we report here the generation and characterisation of the first K7 knockout mouse. Loss of K7 led to increased proliferation of the bladder urothelium although this was not associated with hyperplasia. K18, a presumptive type I assembly partner for K7, showed reduced expression in the bladder whereas K20, a marker of the terminally differentiated superficial urothelial cells was transcriptionally up-regulated. No other epithelia were seen to be adversely affected by the loss of K7 and western blot and immunofluorescence microscopy analysis revealed that the expression of K8, K18, K19 and K20 were not altered in the absence of K7, with the exception of the kidney where there was reduced K18 expression.

The purpose of this study was to describe the knowledge and skills nurses need to be successful clinical instructors. A formal learning needs assessment was conducted to measure the orientation learning needs of new part-time clinical nursing faculty at one university. An existing, validated learning needs instrument was modified and administered online. The respondents (n=44; 16.6%) unanimously identified five essential learning needs for nursing clinical instructors, thus providing sound justification upon which to base an instructor orientation program. From these results, essential content for an orientation workshop to be followed by an online orientation course is outlined. Future research is needed to evaluate the outcomes of clinical instructor orientation; that is, whether participants have acquired the knowledge and skills needed to competently facilitate student learning in the clinical setting.

Background: The involvement of people with anti-social personality disorder (ASPD) in clinical trials is necessary to developing effective treatment. Low literacy level, however, may be a barrier to their understanding and therefore their engagement in research., Aim: Our aim was to find a preferred and most easily understandable way of communicating about research participation with men who have ASPD., Methods: Twenty-five men with ASPD who were using mental health services, research experienced and research naïve participated in the study. Literacy levels were assessed. A list of research terms was generated, and statements were developed to ascertain if the terms were understood. The research terms were 'randomisation', 'informed consent', 'confidentiality' and a research question 'why carry out research?' The participants ranked their preferred way of explaining these terms and the method of communicating these., Results: Those with research experience understood the research terms better. The research naïve and the research experienced men differed in literacy level. Those with below average literacy preferred shorter wordings of research terms than those with average literacy and answered fewer questions correctly. The majority stated a preference for discussion with a researcher before agreeing to take part in research. The least preferred communication methods were those that relied on technology., Conclusions: Researchers should be able to find and use terms that are readily understood and do so. Low literacy levels impair understanding of research terms., (2011 John Wiley & Sons, Ltd.)

Introduction: To evaluate the relationship between maternal temperature elevation and occiput posterior position at birth as well as the association of fetal head position and temperature elevation on method of birth among women receiving epidural analgesia., Methods: We conducted a secondary analysis of data from the Fetal Orientation during Childbirth by Ultrasound Study (FOCUS), which used serial ultrasounds to evaluate the effect of epidural anesthesia on fetal position at birth in low-risk women. The current analysis was limited to the 1428 study participants who received epidural analgesia., Results: In our population, 47% (n = 669) of women had a maximum intrapartum temperature greater than or equal to 99.6°F (37.6°C). The prevalence of fetal occiput posterior position at admission did not differ between women who later developed temperature elevations (24.4%) and those who did not (23.6%, P= .70). Women who developed an elevated temperature greater than or equal to 99.6°F (37.6°C) had an increased risk of occiput posterior fetal head position at birth regardless of the amount of temperature elevation (odds ratio [OR]= 2.0; 95% confidence interval [CI], 1.5-2.8); the association persisted after control for potentially confounding factors (adjusted OR = 1.5; 95% CI, 1.1-2.1). The cesarean birth rate among women with both temperature elevation and occiput posterior position at birth was more than 12 times the rate of women with neither risk factor (adjusted OR = 12.6; 95% CI, 7.5-21.2)., Discussion: Intrapartum temperature elevation among women receiving epidural analgesia, even if only to 99.6°F (37.6°C), is associated with approximately a 2-fold increase in the occurrence of occiput posterior fetal head position at birth. Additionally, although this observational study cannot establish causal links, our findings suggest that the relationship between epidural-related intrapartum temperature elevation and occiput posterior position at birth could contribute to an increased cesarean birth rate among women receiving epidural analgesia for pain relief in labor., (© 2011 by the American College of Nurse‐Midwives.)

Background: Longer-term follow-up of patients with borderline personality disorder have found favourable clinical outcomes, with long-term reduction in symptoms and diagnosis., Aims: We examined the 6-year outcome of patients with borderline personality disorder who were randomised to 1 year of cognitive-behavioural therapy for personality disorders (CBT-PD) or treatment as usual (TAU) in the BOSCOT trial, in three centres across the UK (trial registration: ISRCTN86177428)., Method: In total, 106 participants met criteria for borderline personality disorder in the original trial. Patients were interviewed at follow-up by research assistants masked to the patient's original treatment group, CBT-PD or TAU, using the same measures as in the original randomised trial. Statistical analyses of data for the group as a whole are based on generalised linear models with repeated measures analysis of variance type models to examine group differences., Results: Follow-up data were obtained for 82% of patients at 6 years. Over half the patients meeting criteria for borderline personality disorder at entry into the study no longer did so 6 years later. The gains of CBT-PD over TAU in reduction of suicidal behaviour seen after 1-year follow-up were maintained. Length of hospitalisation and cost of services were lower in the CBT-PD group compared with the TAU group., Conclusions: Although the use of CBT-PD did not demonstrate a statistically significant cost-effective advantage, the findings indicate the potential for continued long-term cost-offsets that accrue following the initial provision of 1 year of CBT-PD. However, the quality of life and affective disturbance remained poor.

People with chronic pain commonly complain of sleep disturbance. This study reports the characteristics of the pain and sleep of a large sample of patients with chronic pain (n = 160). This study compared subgroups of good sleepers with pain (n = 48) and poor sleepers with pain (n = 108). Poor sleepers with pain were younger and reported more pain, pain-related disability, depression, pain-related anxiety, and dysfunctional beliefs about sleep. Using simultaneous regression analysis, this study examined the roles of pain, dysfunctional beliefs about sleep, pain-related disability, depression, and pain-related anxiety in predicting concurrent sleep quality. The findings are relevant to the development of models of sleep disturbance comorbid with chronic pain.

Background: Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive., Method: This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning., Results: The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others., Conclusions: CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group.

Nonideal mixing in many fermentation processes can lead to concentration gradients in nutrients, oxygen, and pH, among others. These gradients are likely to influence cellular behavior, growth, or yield of the fermentation process. Frequency of exposure to these gradients can be defined by the circulation time distribution (CTD). There are few examples of CTDs in the literature, and experimental determination of CTD is at best a challenging task. The goal in this study was to determine whether computational fluid dynamics (CFD) software (FLUENT 4 and MixSim) could be used to characterize the CTD in a single-impeller mixing tank. To accomplish this, CFD software was used to simulate flow fields in three different mixing tanks by meshing the tanks with a grid of elements and solving the Navier-Stokes equations using the kappa-epsilon turbulence model. Tracer particles were released from a reference zone within the simulated flow fields, particle trajectories were simulated for 30 s, and the time taken for these tracer particles to return to the reference zone was calculated. CTDs determined by experimental measurement, which showed distinct features (log-normal, bimodal, and unimodal), were compared with CTDs determined using CFD simulation. Reproducing the signal processing procedures used in each of the experiments, CFD simulations captured the characteristic features of the experimentally measured CTDs. The CFD data suggests new signal processing procedures that predict unimodal CTDs for all three tanks.

The Shedler Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a) is a clinician-rated assessment providing descriptions of personality disorder prototypes using a Q-sort procedure. This study aims to investigate the degree to which there is agreement between patients' and clinicians' accounts of personality pathology on a modified version of the SWAP-200 using Bland Altman analysis with the data from 23 clinician-patient pairs. Poor agreement was found between clinicians and patients on personality prototypes. Even the best agreement found between patients and clinicians on the avoidant prototype was poor--the patients' ratings were up to 43.5 per cent below and 32.9 per cent above the clinicians' ratings. This is an unacceptable degree of variation. The difference between the clinician and patient ratings are large when expressed as a percentage of the possible scores (as obtained on the clinician rating scale). The patient ratings vary between being 40.8 to 91.1% below the clinician ratings, and 32.9 to 99.7% above the clinician ratings.

Front-line caregivers in nursing homes frequently provide bereavement support to family members before and after the death of a nursing home resident. Use of the evidence-based guideline "Family Bereavement Support Before and After the Death of a Nursing Home Resident" (Davidson, 2002) can reduce uncertainty and increase the confidence of staff providing before and after death care to families, and can ensure all families receive consistent bereavement support.

Objectives: This study examined whether older people who were depressed or had engaged in parasuicidal behaviour could be identified by a decrease in positive future-directed thinking in the absence of any increase in negative future-directed thinking, in comparison with a community control group., Design: A mixed design was used that compared three groups (community controls, depressed controls and parasuicidal participants) in terms of future-directed thinking (positive and negative), in relation to three future time periods (one week, one year and 5-10 years)., Methods: In all, 22 participants over 65 years of age, who had been admitted to hospital following a non-fatal suicidal act, were compared with 22 older people being treated for depression and 22 older community volunteers who were not experiencing any significant psychological symptoms. The main measure was an adaptation of the traditional verbal fluency paradigm and attempted to quantify future-directed thinking., Results: Parasuicidal and depressed participants showed decreased positive future thinking, but no increase in negative future thinking, in comparison with the community control group., Conclusions: The results confirm that older parasuicidal and older depressed participants are characterized by a reduction in positive anticipation and that this may be accounted for by depression rather than hopelessness.

Objective: To evaluate the clinical outcome and histologic findings of pregnancies in which placental surface cysts were detected on prenatal sonography., Methods: A computerized search of our obstetric sonographic database from 1988 through 2000 identified 34 cases. Results of pathologic examinations, when performed, were obtained. Sonographic features were correlated with histologic findings and clinical parameters., Results: On review of available microscopic slides, in all cases in which the cyst was seen at pathologic examination, there was subchorionic fibrin with central cyst formation. All pregnancies resulted in live births, although intrauterine growth restriction occurred in 4 (12%) of 34. Three (11%) of 28 cases with placental pathologic findings had maternal floor infarction. Only 2 significant associations between sonographic features and postnatal findings were found. In all cases of intrauterine growth restriction, average cyst size was larger than 4.5 cm. Of 12 cysts larger than 4.5 cm, 4 (33%) had intrauterine growth restriction. Of 22 cysts smaller than 4.5 cm, there were no instances of intrauterine growth restriction (P = .01). Of 32 cases with 3 or fewer cysts, only 2 had intrauterine growth restriction, whereas in 2 cases with more than 3 cysts, both had intrauterine growth restriction (P = .01)., Conclusions: Most placental surface cysts are associated with a normal pregnancy outcome. Most such cysts are related to cystic change in an area of subchorionic fibrin. Cysts larger than 4.5 cm or more than 3 in number are more frequently associated with intrauterine growth restriction.

Objectives: To determine whether thyroxine treatment is effective in patients with symptoms of hypothyroidism but with thyroid function tests within the reference range, and to investigate the effect of thyroxine treatment on psychological and physical wellbeing in healthy participants., Design: Randomised double blind placebo controlled crossover trial., Setting: Outpatient clinic in a general hospital., Participants: 25 patients with symptoms of hypothyroidism who had thyroid function tests within the reference range, and 19 controls., Methods: PARTICIPANTS were given thyroxine 100 microgram or placebo to take once a day for 12 weeks. Washout period was six weeks. They were then given the other to take once a day for 12 weeks. All participants were assessed physiologically and psychologically at baseline and on completion of each phase., Main Outcome Measures: Thyroid function tests, measures of cognitive function and of psychological and physical wellbeing., Results: 22 patients and 19 healthy controls completed the study. At baseline, patients' scores on 9 out of 15 psychological measures were impaired when compared with controls. Patients showed a significantly greater response to placebo than controls in 3 out of 15 psychological measures. Healthy participants had significantly lower scores for vitality when taking thyroxine compared to placebo (mean (SD) 60 (17) v 73 (16), P<0.01). However, patients' scores from psychological tests when taking thyroxine were no different from those when taking placebo except for a poorer performance on one visual reproduction test when taking thyroxine. Serum concentrations of free thyroxine increased and those of thyroid stimulating hormone decreased in patients and controls while they were taking thyroxine, confirming compliance with treatment. Although serum concentrations of free triiodothyronine increased in patients and controls taking thyroxine, the difference between the response to placebo and to thyroxine was significant only in the controls., Conclusions: Thyroxine was no more effective than placebo in improving cognitive function and psychological wellbeing in patients with symptoms of hypothyroidism but thyroid function tests within the reference range. Thyroxine did not improve cognitive function and psychological wellbeing in healthy participants.

Objectives: To evaluate factors that predict HIV testing using the model of health care utilisation as its conceptual framework and to analyse some of the factors that encourage or inhibit seeking an HIV test in this population., Method: A cross sectional questionnaire study in two Genito-Urinary Medicine (GUM) clinics in central Scotland. A final sample of 195 represented a 91% response rate. Participants were categorised by their HIV testing status (already tested, planning to be tested, no intention to seek testing)., Results: The 'already tested' and 'planning to be tested' groups were combined as there were no significant differences on reported risk behaviours. Analysis therefore compared two groups those 'testing' (n = 66) and 'not testing' (n = 129). 67% of those not tested for HIV reported at least one HIV risk factor. Perceived risk was the strongest predictor of HIV testing using our model. Perception of risk and actual risk were not correlated. Those not seeking testing endorsed less benefits of testing and more denial of the need to be tested. Same day testing and testing without an appointment were endorsed as factors to promote testing., Conclusion: To encourage people who have high risk factors to access HIV testing, programmes should: (1) highlight the benefits of testing which would be lost if people do not test, eg. effective drug treatments (2) increase the range of HIV testing services available (eg. same day testing). Furthermore, studies to determine the main predictors of perceived risk are needed if we are to increase testing in relevant populations.

Objective: To document the value of bilateral anterior cingulotomy for patients with intractable chronic noncancer pain., Methods: Twenty-three patients who underwent 28 cingulotomies between 1979 and 1996 for chronic refractory pain were sent questionnaires regarding their subjective response to the surgery and its impact on their pain. Questions dealt with pre- and postoperative pain, ability to resume work or usual activity, medications, family and social interactions, and overall benefit of cingulotomy. Results were compared with long-term (average, 8 yr) clinical follow-up. In 13 patients, pain was predominantly caused by lumbar adhesive arachnoiditis or "failed back." The remainder had venous occlusive disease, ischemic bilateral leg pain, phantom leg pain, postoperative neck pain, or atypical facial pain., Results: Eighteen patients returned questionnaires; two patients died of unrelated causes. Seventy-two percent of patients reported improvement in their pain, 55% were no longer taking narcotics, 67% noted improvement in their family life, and 72% noted improvement in their social interactions. Fifty-six percent of patients reported that the cingulotomy was beneficial, and 28% returned to their usual activities or work. Thirty-nine percent of patients developed transient or well-controlled seizures. Five patients required a second cingulotomy, and one patient did well despite developing brain abscesses. Patient assessments corresponded closely with clinical assessments., Conclusion: Bilateral anterior cingulotomy is safe for patients with refractory chronic pain. Seizures reported in this series were well controlled with medication. More than half of all respondents thought they had a positive outcome and that cingulotomy was beneficial to them. There were no deaths related to the procedure.

We undertook a case-control study of premature infants who developed clinically significant, severe pulmonary hemorrhage (PH) in the presurfactant and surfactant eras to learn more about the cause of severe PH and whether the pathogenesis of severe PH has changed with the advent of surfactant therapy. Severe PH was defined as an acute onset of severe endotracheal bleeding with an acute drop in hematocrit and the development of multilobar infiltrates on chest radiograph. Eleven premature infants from the presurfactant era population and 17 premature infants from the surfactant era population met the criteria for severe PH, all with gestational ages <32 weeks and birth weights <1,500 g (very low birth weight infants). These were each matched by gestational age, date of birth, birth order (for twins), and birth weight to 2 controls. The incidence of severe PH in infants of gestational age <32 weeks was similar in the two eras (1.8% in the presurfactant era and 3.0% in the surfactant era). Severe PH was not associated with maternal characteristics such as drug use or prenatal care, pregnancy complications, evidence of intrauterine anoxia, hyaline membrane disease, frequency of endotracheal suctioning, or patent ductus arteriosus. Premature infants suffering from severe PH in the presurfactant era required more delivery room resuscitation and had more severe early respiratory disease during the first 12 h of life as compared with their controls. However, these differences were not present in the group from the surfactant era. Infants with severe PH were more likely to have birth weights below the third percentile for gestation (severe intrauterine growth restriction). The proportion of infants receiving surfactant, and the number of surfactant doses used, did not differ between severe-PH infants and their controls in the surfactant era group. We conclude that severe intrauterine growth restriction represents a risk factor for severe PH in very low birth weight infants. The introduction of surfactant therapy has not altered the incidence of severe PH, even though it has apparently helped remove the severity of early lung disease as a risk factor. The physiological basis of severe PH requires further investigation.

Depressed and non-depressed (pre-admission and post-detoxification) alcohol-dependent patients were followed-up on two occasions over a period of 5 months following detoxification from alcohol. Detailed measures of alcohol consumption, alcohol-related problems and abstinence status were taken throughout the follow-up period. No significant differences were found between those with a diagnosis of depression and those with alcohol dependence alone, regardless of whether diagnosis of depression was made post-detoxification or pre-admission, on any drinking outcome measure including abstinence status, alcohol consumption, pattern of drinking, or alcohol-related problems. Neither a diagnosis of depression in the post-detoxification period nor in the pre-admission episode was related to drinking outcome at follow-up, which suggests that co-morbid depression does not confer a worse outcome in those with alcohol dependence.

Background: Acute fatty liver is reported to be more common in twin than in singleton pregnancies. We report three cases of biopsy-proven acute fatty liver in triplet gestations., Cases: In all three cases of acute fatty liver complicating triplet pregnancies, the presenting features were vague abdominal complaints with elevated hepatic aminotransferase levels. A liver biopsy was performed in each case, and cesareans were performed immediately after the diagnosis was confirmed histologically. Clinical resolution occurred in all cases, and all infants did well in the neonatal period., Conclusion: Patients with triplet gestations should be monitored closely for the early signs of acute fatty liver. Triplet gestations may contribute to the onset of acute fatty liver by further stressing the fatty acid oxidation capabilities of the susceptible woman.

Intrahepatic cholestasis of pregnancy (ICP) is a disease of the third trimester of pregnancy involving pruritus and elevated bile acid levels. Its pathogenesis likely involves a genetic hypersensitivity to estrogen. Once thought to be benign for both mother and fetus, ICP has been associated with increased rates of fetal morbidity and mortality and an increased risk of maternal coagulopathy. Optimal obstetric management includes delivery after establishment of fetal lung maturity. Many treatments have been proposed for the maternal medical management of ICP, none of which is ideal.

Cognitive therapy for affective disorders has been recently adapted and developed for the treatment of personality disorders. In the present study, a specific and detailed cognitive therapy treatment manual for borderline and antisocial personality disorders was evaluated in a pilot study. The results of a single case series demonstrate that important clinical changes in dysfunctional behaviour and attitudes can be achieved with short-term cognitive therapy in patients with antisocial and borderline personality disorders, although these were not, on the whole, statistically significant.

Background: Depression and alcohol dependence are frequently found to co-exist but the relationship between these disorders requires further elucidation. This study tested several hypotheses related to the relevance of whether the diagnosis of depression was made before admission or after detoxification in the current episode for those with alcohol dependence., Method: The Schedule for Affective Disorders and Schizophrenia (SADS) was administered to obtain Research Diagnostic Criteria (RDC) on 82 randomly selected alcohol dependent in-patients. Alcohol-related (Severity of Alcohol Dependence Questionnaire (SADQ), alcohol consumption and alcohol-related problems), socio-demographic variables and treatment for depression were assessed., Results: For the episode of drinking which led to admission, a diagnosis of major depression was found in the majority of patients (67%). Once detoxification from alcohol took place, only the minority (13%) met criteria for major depression., Conclusions: It is suggested that depression is largely associated with the episode of drinking which led to admission in patients who are dependent on alcohol and may be due to the effect of chronic alcohol intoxication. Socio-demographic and alcohol-related characteristics appear to bear little relation to the presence of depression. Clinicians exercise appropriate judgement in not prescribing antidepressant treatments to patients whose depression may remit with abstinence from alcohol.

Few patients with obsessive-compulsive disorder (OCD) require in-patient treatment. There is sparse information on outcome of OCD patients treated as in-patients. This paper is a descriptive account of the current functioning of 54 OCD patients treated in hospital, on average 10 years prior to the study. Follow-up reveals that outcome for the majority of patients is poor with 29 (59%) of the sample showing at least mild symptomatology or some difficulty in several areas of functioning.

We suggest an explanation for a pediatric paradox: the low-birthweight-specific (LBW) neonatal mortality rate (NMR) for black infants is less than the NMR for white infants, even though the overall NMR for black infants is about twice the overall NMR for white infants. Analyzing the Delivery Interview Program data set--a large matrix of information collected at the Boston Hospital for Women (now the Brigham and Women's Hospital)--we found that, overall, black infants' gestations are about four days shorter than white infants'. However, after stratifying by birthweight, we found a reversal in our data, namely, LBW (< 2,500 g) black infants' gestations are seven days longer than the gestations of LBW white infants. We believe that this increased chronological maturity may account for some of the survival advantage of the LBW black infant compared with the LBW white infant of the same weight.

Alcohol dependence is not a unitary or homogeneous disorder. There is substantial evidence to suggest that in both community and particularly in clinical samples, additional psychopathology is common. Although estimates of additional psychopathology differ according to the samples studied and the instruments used to classify disorders, up to two-thirds of clinical samples of patients with alcohol dependence are likely to have a lifetime diagnosis of another psychiatric disorder. Affective disorder and antisocial personality disorder appear to be the most commonly and consistently reported additional disorders. Women more than men appear to suffer from additional psychopathology, including secondary and primary depression, although this evidence is weakened by there being fewer studies carried out on mixed gender populations. Having an additional psychiatric diagnosis appears to alter the course of alcohol dependence: it may hasten the development of dependence on alcohol and may bring individuals to the attention of treatment agencies more quickly. More recent studies have examined the relationship between alcohol dependence and affective disorder in the current episode. There is consistent evidence to suggest that a diagnosis of depression in the current episode may change to one of alcohol dependence alone, once detoxification or abstinence has been achieved. The prognosis of those who continue to be depressed remains unclear.

One of the most common problems an obstetrician faces is evaluation of a patient for PROM. Proper assessment of the patient requires a careful integration of history, physical examination, and clinical testing. The most commonly used tests are analysis of vaginal pH with nitrazine paper and evaluation of vaginal secretions with the arborization test. When history, nitrazine, and arborization testing are used in combination, 90% of cases will be diagnosed correctly. When the diagnosis is questionable, other modalities, including ultrasound evaluation and intraamniotic dye injection, should be used as indicated.