Search

Background: The increasing backlog of chest x-ray (CXR) reports in Scotland is well documented, as is reporting radiographer's (RR) ability to provide a cost effective solution to this. Despite this, only 8 CXR RRs currently work in Scotland. This qualitative descriptive study will explore the perceived reasons for this lack of role development by investigating the relevant enablers and challenges., Method: An 18 question survey was emailed to the members of the Reporting Radiographer Interest Group Scotland regarding the enablers and challenges surrounding CXR RR training and employment in Scotland. All Scotland based RRs were invited to contribute. The survey was live for approximately 6 weeks. Results were then thematically analysed., Results: The survey returned 14 respondents from 9 different health boards, 3 of which were CXR RRs. Currently no CXR RR training is currently ongoing in Scotland with only 1 of the responding health boards claiming they had a sufficient quota of CXR RRs. Five main themes have been uncovered: service development, monetary factors, a lack of support from management, workforce issues and Scottish geopolitical challenges., Conclusion: This survey highlighted a desire for further CXR RR training from the current Scottish RR cohort however there was a lack of confidence that this would be facilitated. Resistance from MSK RRs to expand their scope of practice was also noted., Implications for Practice: It is recommended that the Scottish government increases engagement with the CXR RR service to better tackle historical biases, address infrastructural issues and provide further funding for future training and posts. Further research is also required into the evolving attitudes of managers and radiologists towards CXR RRs as is concerns RRs have over up-skilling to better facilitate workforce development., Competing Interests: Conflict of interest statement None., (Copyright © 2024 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: The persistent shortage of radiographers in the UK has prompted the exploration of innovative education models to enhance practice-based learning. Peer-Assisted Learning (PAL) has been advocated as a viable method to increase clinical training capacity, yet its application in Diagnostic Imaging is constrained by regulations on ionising radiation. This study investigates the perceptions and experiences of final-year undergraduate Diagnostic Imaging students facilitating PAL within a simulated learning environment., Methods: Final-year students were recruited via convenience sampling to act as mentors in simulated role-play activities. Data was collected through semi-structured interviews with three student mentors following the simulation. Thematic analysis of interview transcripts identified key themes related to the research question., Results: The analysis revealed four main themes: RELATIONSHIPS: Students valued the peer-to-peer teaching dynamic and the psychological safety provided by the simulation, which fostered reciprocal learning and enhanced inter-student relationships., Learning Environment: The informal, responsive nature of the simulation was perceived as beneficial for encouraging participation and allowing students to learn from mistakes without real-world consequences., Learning Design: The timing of the simulation was noted as effective, aligning with academic learning. Feedback delivery and mentor preparation were also discussed, with disagreement on the value of the latter noted., Confidence: Students reported increased confidence in their clinical and mentorship abilities., Conclusion: The findings support existing literature on the benefits of PAL and simulation-based education (SBE), highlighting the positive impact on psychological safety, inter-student relationships, and confidence. However, the lack of formal training for mentors suggest areas for further research., Implications for Practice: The study underscores the potential for integrating PAL and SBE in radiography education to enhance readiness for clinical practice and foster effective peer mentoring., Competing Interests: Conflict of interest statement None., (Copyright © 2024. Published by Elsevier Ltd.)

Background: To retrospectively review lateral wall orbital decompression for thyroid eye disease (TED) and to evaluate pre-operative CT scans to analyse the variation in proptosis reduction., Methods: Consecutive lateral wall orbital decompressions performed by a single surgeon were retrospectively reviewed. Pre-operative CT scan features and post-operative proptosis reduction were analysed. The sphenoid trigone cross-sectional areas were summed and multiplied by the slice thickness to yield bone volume. Cumulative extraocular muscle thickness was calculated by combining the maximum thickness of the four recti. "Trigone volume" and "cumulative muscle thickness" were correlated with proptosis reduction at 3 months post-surgery., Results: Out of 73 consecutive lateral wall orbital decompressions, 17 orbits had prior endonasal medial wall orbital decompression. In the remaining 56 orbits, the mean pre-operative and post-operative proptosis were 24.3 ± 1.6 mm and 20.9 ± 2.3 mm respectively. The proptosis reduction ranged from 1 to 7 mm (mean of 3.5 mm ± 1.3 (p < 0.001)). Mean sphenoid trigone volume was 895 ± 434.4 mm 3 . The mean cumulative muscle thickness was 20.4 ± 5 mm. The correlation coefficient between muscle thickness and proptosis reduction was - 0.3 and was statistically significant (p = 0.043). The correlation coefficient between sphenoidal trigone volume and proptosis reduction was 0.2 (p = 0.068). With a multivariate analysis, the coefficient of efficient of regression for muscle thickness was - 0.007 (p = 0.42) and the coefficient of regression for trigone volume was 0.0 (p = 0.046)., Conclusion: Proptosis reduction following lateral wall orbital decompression can be variable. Extraocular muscle thickness had a significant correlation with the outcome, with greater proptosis reduction in orbits with thin muscles. The sphenoidal trigone size had a weak correlation with decompression outcome., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Adolescents living in residential juvenile justice facilities often receive mental health services during their stay to address committed offenses, yet some display challenging behavior during moments of conflict within the facility. These challenging behaviors could result in risk of harm to self or others, or the individual may experience punishment from facility staff. The purpose of this study was to explore the effects of an additive voluntary focused intervention for individuals who continued to display challenging behavior despite participation in "treatment as usual" in a juvenile justice facility. We implemented a self-management intervention, supported through interprofessional collaboration, via telehealth with four male adolescents. Using Behavior Skills Training, we taught participants to self-monitor precursors for challenging behavior and identify an alternative behavior to engage in to prevent overt challenging behavior events. Alternative behaviors were responses incompatible with the challenging behavior, or served as a rule to prompt self-management of further behavior. Results show all four participants increased their selection of alternative behaviors when presented with an evocative situation and a precursor for a severe behavior event during simulations. In addition, three participants stated they would use alternative behaviors across precursors not presented during teaching; however, two participants required booster sessions to maintain appropriate responding during simulations. Outside of simulated sessions, facility staff reported modest decreases in participants' challenging behavior during and after the intervention., Competing Interests: Conflict of InterestOn behalf of all authors, the corresponding author states that there is no conflict of interest., (© Association for Behavior Analysis International 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Prcis: Overall, 63% of glaucoma patients agreed to 45-60 minutes of daily meditation. Predictors of accepting meditation included previous meditation practice, a diagnosis of glaucoma <1 year, and having a marital status of "single"., Purpose: To explore patients' acceptance and barriers towards 45-60 minutes daily meditation for glaucoma management and to identify glaucoma patients with higher perceived stress levels who may benefit more from meditation practice., Methods: Glaucoma patients attending the Royal Victorian Eye and Ear Hospital, Melbourne, Australia outpatient department were invited to complete a patient survey. This survey explored if patients would agree to 45-60 minutes of daily meditation and included the Determinants of Meditation Practice Inventory and Perceived Stress Scale questionnaires. Questionnaire scores were compared across participants' clinical and demographic characteristics using Student t test, ANOVA, and multiple-linear-regression analysis., Results: Of the 123 eligible patients screened, 100 completed the survey (81.3%). Sixty-three (63%) patients would agree to 45-60 minutes of daily meditation if advised by their doctor. Univariate analysis showed increased acceptance of meditation (lower Determinants of Meditation Practice Inventory scores) to be associated with agreeing to meditate 45-60 minutes daily ( P =0.002), currently or previously practicing meditation ( P =0.006 and P =0.0004 respectively), and having a marital status as "single" ( P =0.02). Multivariate regression analysis showed previous meditation practice and a glaucoma diagnosis of <1 year to be predictive of accepting meditation ( P =0.01 and P =0.03 respectively). There were no predictive factors of Perceived Stress Scale scores., Conclusion: Given the high acceptance rate of 45-60 minutes daily meditation (63% of glaucoma patients sampled), this may be recommended for the benefit of patients. Patients who have previously meditated, have a relatively new diagnosis of glaucoma, and are single (marital status) were more accepting of meditation practice., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Interventions to promote evidence-based practices are particularly needed for paraprofessional staff working with minority youth with HIV who have higher rates of HIV infection but lower rates of linkage and retention in care compared to older adults. Utilizing the ORBIT model for behavioral intervention development, we defined and refined a behavioral intervention for providers, Tailored Motivational Interviewing (TMI), to improve provider competence in previous studies (Phase 1a and 1b). The current study focuses on ORBIT Phase 2a-proof of concept. We hypothesized that TMI would be acceptable and feasible and would show a signal of efficacy of improving and maintaining community health worker (CHW) MI competence scores using an innovative statistical method for small N proof-of-concept studies. Method: Longitudinal data were collected from 19 CHWs at 16 youth HIV agencies. CHWs from 8 sites were assigned to the TMI group per the cofunders request. The remaining 8 sites were randomly assigned to TMI or services as usual. MI competence was assessed at baseline and up to 15 times over 2 years. Random coefficient models were utilized to examine time trajectories of competence scores and the impact of the intervention on competence trajectories. Semistructured interviews were conducted to determine barriers and facilitators of TMI. Results: Competence scores in the TMI group significantly increased while the scores of the control group significantly decreased. Further analysis of the intervention group demonstrated that scores significantly increased during the first 3 months after initial workshop and was sustained through the end of the study. Qualitative findings revealed insufficient time and competing priorities as perceived barriers whereas integrating MI into routine agency practices and ongoing training might facilitate implementation. Conclusions: Following a successful proof-of-concept, the next step is a fully randomized pilot study of TMI relative to a control condition in preparation for a stepped-wedge cluster randomized full scale trial. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Introduction: Head stabilization may reduce intra-operative risk during cataract surgery, but could be misinterpreted as "restraint." We wanted to establish patients' attitudes towards the potential use of stability-tape., Materials and Methods: One-hundred consecutive patients attending for local-anaesthetic cataract surgery were asked to complete a pre-operative questionnaire. This explored patient concerns and views regarding intra-operative head movement and the potential use of stability-tape., Results: All 100-patients completed the questionnaire. The median head movement concern score was 2 out of 10 (range 1-9, IQR 1-5). Eighty-four percent felt stability tape should be offered to all patients and 97% would consent for its' use. Only 6% voiced concern about the use of stability-tape (95% CI 2.2%, 12.6%)., Conclusion: Patients had low concern for moving their head during surgery. The concept of stability-tape to minimize head movements during cataract surgery was viewed positively by most patients. This strategy may promote safer surgery in selected cases.

For individuals receiving treatment in residential juvenile facilities, the inability to tolerate typical but unpleasant stimulus events may manifest in aggressive behavior toward staff or other residents. Such behaviors can lead to loss of privileges, interfere with other treatments, and contribute to negative staff-student relationships. As a procedure, tolerance training (TT) involves systematically increasing the duration of exposure to an undesired stimulus event or situation. The current study evaluated the effects of a procedure to increase tolerance of aversive situations for four adolescents who were receiving treatment for sexual offenses in a residential detention facility. Results from single-subject experimental designs indicate that TT increased all four adolescents' ability to tolerate a non-preferred stimulus event. We briefly discuss the clinical implications of the use of behavior-analytic procedures to improve skill sets for adolescents in residential treatment facilities.

Background: This case illustrates the relationship between gut, hormonal, and brain function in that dietary changes, mindfulness interventions, and detoxification led to resolution of disabling psychiatric symptoms and protracted psychotropic medication withdrawal symptoms., Summary: A 50-year-old partnered, unemployed, Caucasian female with a history of major depressive disorder, multiple suicide attempts, extensive trauma and abuse, and substance abuse presented for outpatient management. The patient reported limited benefit from over two decades of conventional treatment with psychotropic medications. She presented with depression and symptoms of protracted withdrawal after self-discontinuation of multiple psychiatric medications and was prescribed a dietary, detoxification, and supplementation regimen by the primary author. Additional lifestyle interventions implemented included daily meditation, dry-skin brushing, and coffee enemas., Conclusion: This case exemplifies dramatic clinical remission after cessation of medication treatment and engagement of lifestyle interventions, which include dietary change, meditation, and detoxification. As such, when limited results are achieved by psychotropic medication, tapering combined with dietary interventions as the first-line therapy should be considered. This case is also evidence of the role of lifestyle interventions in treating protracted withdrawal symptoms associated with discontinuing psychotropic medications.

Background Major depressive disorder (MDD) is a complex bio-psycho-social syndrome that affects millions of individuals and is one of the leading causes of impaired quality of life (QOL). In addition to the symptoms of depression and low mood, many individuals with MDD also suffer from isolation without the sense of a supportive, surrounding community. Given the challenges of treating individuals with MDD, social isolation and a lack of communal connection, this randomized controlled trial was designed to determine the efficacy of a multimodal, online and community-based lifestyle intervention for improving depressive symptoms and QOL in individuals with a history of MDD. Materials and methods The study enrolled 71 female or male participants between the ages of 20 and 64 with a self-reported BMI between 18.4 and 34.9 kg/m 2  and a history of MDD. Individuals were randomized to either participate in a 44-day multimodal, online, community-based lifestyle intervention or placed on a wait list where they would complete the intervention at a later date. The multimodal intervention involved a self-directed learning program where individuals were guided to make lifestyle changes including adopting a whole-foods diet, increasing movement, and adopting stress management and mindfulness practices. All participants completed the 36-Item Short Form Health Survey (SF-36), the Cleveland Clinic Center for Functional Medicine's Medical Symptoms Questionnaire (MSQ), and the Patient Health Questionnaire-9 (PHQ-9) before and after the online program to assess health-related QOL, overall symptom burden, and depressive symptom burden, respectively.  Results A total of 37 participants were randomized to participate in the multimodal intervention with 26 completing all three study questionnaires at both study time points; 34 participants were randomized to the wait list control group with 27 completing all three study questionnaires at both study time points. There were no clinically or statistically significant differences between the control group or the intervention group at baseline. The control group showed no clinically nor statistically significant changes in the MSQ, PHQ-9 or any of the eight subdomains of the SF-36 from the beginning to the end of the 10-week study period. When compared to the control group, the intervention group showed statistically and clinically significant improvements in median (M) scores of the SF-36 subdomains of vitality and mental health, and clinically but not statistically significant improvements in the subdomain of emotional role functioning. There were additional statistically and clinically significant improvements in the mean score of the MSQ and M scores of the PHQ-9 (treatment pre-intervention M = 10.5, inter-quartile range [IQR] = 14, to treatment post-intervention M = 5, IQR = 8.25; control pre-intervention M = 15, IQR = 8, to control post-intervention M = 13.5, IQR = 12.5). Conclusions  Our randomized controlled study provides evidence for the role of a multimodal, online and community-based lifestyle intervention to improve depressive symptoms, QOL, and total symptom burden in individuals with a history of MDD. Given the growing challenges of effectively supporting individuals suffering with MDD, it appears critical to further explore the utilization of novel, multimodal and self-directed lifestyle interventions., Competing Interests: The study was funded by the study participants themselves. The study authors contributed their time to complete the study as volunteers without financial compensation. Kelly Brogan, who is the founder of the Vital Mind Reset (VMR) program that was utilized as the multimodal online, community-based lifestyle intervention for the study, utilized the funds provided by study participants as described previously to pay for the expenses of the study., (Copyright © 2020, Abbott et al.)

Background: This case report illustrates that the use of a series of lifestyle interventions delivered via the "Vital Mind Reset" online program led to the resolution of disabling psychiatric symptoms., Summary: A 40-year-old, married, Caucasian female, with onset of suicidal ideation as a teenager, was treated with antidepressants and was later formally diagnosed with dissociative identity disorder (DID), borderline personality traits, and bipolar disorder (BD). In the ensuing years, the patient was treated with 35 psychiatric medications. Additionally, she experienced numerous hospitalizations and received over 30 electroconvulsive therapy (ECT) treatments. Despite this extensive conventional treatment, she reported limited gains. In October 2017, the patient committed to the Vital Mind Reset (VMR) online program and implemented a series of lifestyle changes over 44 days, starting with 30 days of dietary, meditation, and lifestyle protocols, followed by supplementation. Notably, the patient has since resolved both physical and psychiatric symptoms including fatigue, acne, migraines, cold sweats, dizziness, nausea, blood sugar crashes, resting tremors, brain fog, anxiety, depression, suicidal ideation, auditory hallucinations, and delusions. In this patient's case, hypertension, bradycardia, headaches, increased frequency of mania, tremors, insomnia, and weight gain accompanied her medications. This case exemplifies the dramatic resolution of disabling psychiatric symptoms after engagement in the lifestyle interventions outlined in the VMR program, medication taper, and supplementation. When medication demonstrates limited clinical yield and a plethora of side effects, tapering combined with lifestyle interventions and supplementation should be considered as first-line therapy. This case is evidence of the potential for healing and resolution of severe and persistent psychiatric illness with dietary and lifestyle changes.

Background: This case report illustrates the use of a lifestyle intervention program entitled "Vital Mind Reset" which led to the alleviation of disabling schizophrenic symptomology., Summary: A 22-year-old male with onset of Tourette's Syndrome and depression with suicidal ideation as a teenager began declining in mental vitality, resulting in the eventual diagnosis of treatment-resistant schizophrenia at the age of 17. At this time, he was admitted to an adolescent mental health ward due to delusional thinking and auditory hallucinations. Despite administration of a multitude of antipsychotic medications throughout the ensuing years, he was admitted yearly to the same hospital during the winter months until 2015. The patient began the Vital Mind Reset (VMR) program in 2017, committing to a series of lifestyle interventions which included dietary modifications, daily meditations, and detoxification practices. After completing the program, the patient experienced significantly improved quality of life, as he was once again able to leave his house. One year after completing the program, his physicians reported his schizophrenia appeared "to be in remission." Given these results, when medication and conventional therapies gain limited progress, lifestyle interventions outlined in the VMR program should be considered, perhaps even as first-line therapy. This case defies the chronicity of severe psychiatric symptomologies such as schizophrenia and exemplifies the potential for healing and resolution of persistent psychiatric illness.

Background: Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome. Studies reporting surgical outcomes are often on small cohorts and with limited information on functional improvement., Purpose: To report the 2-year clinical and functional outcomes in a series of patients undergoing HAT repair augmented with a ligament augmentation and reconstruction system (LARS) ligament., Study Design: Case series; Level of evidence, 4., Methods: Between October 2012 and December 2016, a total of 142 patients with symptomatic HAT tears underwent open bursectomy, V-Y lengthening, and reattachment of the tendon with suture anchors augmented with a LARS ligament. This included 132 women (93%) with a mean age of 64.3 years (range, 43-84 years), a mean body mass index of 28.2 kg/m 2 (range, 20.0-41.3 kg/m 2 ), and an average duration of symptoms of 4.0 years (range, 6 months-20 years). Following surgery, patients underwent a graduated rehabilitation program consisting of hydrotherapy and land-based exercises. Patient-reported outcome measures (PROMs) were evaluated preoperatively and at 3, 6, 12, and 24 months postoperatively with the Harris Hip Score, Oxford Hip Score, 12-item Short Form Health Survey, and visual analog scale (VAS) for pain. Hip range of motion, hip abduction strength, 30-s single-leg stance (SLS), and 6-minute walk test (6MWT) capacity were evaluated. Patient satisfaction and perceived global rating of change were evaluated postsurgery. Analysis of variance was employed to evaluate clinical improvement over time., Results: A significant improvement ( P < .05) was demonstrated up to 24 months in all PROMs and clinical scores, including hip range of motion in all planes, hip abductor strength limb symmetry indices (mean ± SD; presurgery, 90.1% ± 42.5%; 24 months, 102.6% ± 15.0%), and the 6MWT (presurgery, 421.8 ± 91.9 m; 24 months, 509.7 ± 105.1 m). Furthermore, several variables, including pain (VAS and pain scores during the 6MWT and 30-s SLS) and patient-perceived improvement (global rating of change), continued to improve from 12 to 24 months. At 24 months, 95.7% of patients were satisfied with their surgical outcome (excluding 3 patients who underwent reoperation within the 24-month period). There was a 5.6% (n = 8) failure rate over the study period., Conclusion: HAT repair augmented with a synthetic ligament demonstrated significantly improved clinical and functional outcomes, high levels of patient satisfaction, and a relatively low failure rate up to 24 months postsurgery., Registration: ACTRN12616001655437 (Australian New Zealand Clinical Trials Registry)., Competing Interests: One or more of the authors declared the following potential conflict of interest or source of funding: This research was assisted by 2 research grants awarded from the Hollywood Private Hospital Research Foundation (RF063) and Corin. G.C.J. has stock in Orthocell. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

This case series aims to further the understanding of psychotropic drug withdrawal symptoms, as well as how individuals may be supported using holistic approaches for long term mood support. A secondary objective is to contribute to the evidence base for differentiating psychotropic drug withdrawal from the resurgence of psychiatric symptoms. Patients are described in two groups based on the timeline of psychotropic tapering. Group A illustrates cases of tapering safely from psychotropic medications under the supervision of the author of this case series, and Group B describes cases of individuals who sought mood support for protracted withdrawal symptoms. Both groups were treated with dietary changes, mindfulness practices, detoxification-supported gut health protocols, hormonal regulation, and treatment of comorbidities. Use of complementary medicine reduced many of the acute symptoms of psychotropic drug withdrawal, such as sleep disturbances, decreased concentration, nausea/headaches, and depression, making the process more manageable for patients. Additionally, many of the initial psychiatric complaints were kept in remission. These methods present a sustainable alternative to long-term treatment of mood symptoms and comorbid chronic illnesses. This case series indicates the benefits of integrating holistic and conventional medicine in psychotropic drug tapering, and a call for further trials to create an evidence-based database to guide future treatment and taper protocols.

This article was migrated. The article was marked as recommended. Introduction The move towards value-based care and population health has highlighted the prominent role of social and behavioral factors in determining health outcomes. Patient-centered behavioral guidance to improve patient self-management is recognized as an evidence-based intervention for a variety of chronic conditions but has yet to be adopted as a core competency or core entrustable professional activity (EPA). Motivational Interviewing (MI) is an evidence-based behavioral intervention involving an integrated set of competencies, featuring reflective listening, affirmation, evocation, and collaborative planning. An MI encounter is an observable, discrete task that can be framed as an EPA. Successful implementation of EPAs in the workplace requires institutional engagement, a thoughtful curricular approach, faculty development, and feasible, valid workplace-based assessment (WBA). Methods We implemented competency-based MI training and assessed competency outcomes for students and faculty. After joining the Association of American Medical Colleges Core EPA Pilot, we applied an iterative group process to develop an EPA and workplace-based assessment based on established MI competencies. Results Drawing upon nine years of developing MI curriculum, we present competency data for a student training study and a faculty coaching study, describe how we transitioned training from the classroom to the clinical setting employing an EPA framework, and present a one-page schematic and related WBA for an EPA based on MI. Conclusion We propose that MI is a core EPA for future physicians practicing value-based care, and offer a roadmap for curriculum implementation., (Copyright: © 2019 Engle B et al.)

Background: A 38-year-old, female with a history of GAD, MDD, AN, and PTSD wanted to taper her multiple medications in preparation for pregnancy. Benzodiazepine medications, such as Klonopin and Restoril; antidepressants, such as Effexor; and anticonvulsant medications, such as Lamictal, can be habit-forming, and withdrawal symptoms can occur upon discontinuation of use. Polypharmacy can be implicated in poor clinical outcomes, and a strategic and supported medication taper may improve those outcomes., Summary: After the primary MD unsuccessfully attempted to taper off the patient's psychotropic medications without lifestyle interventions, she was stabilized on a minimal regimen by an outside reproductive psychiatrist throughout her pregnancy. A second tapering was implemented by the primary MD after the patient had given birth and had established changes to her lifestyle. These lifestyle interventions included dietary changes, use of detoxification protocols, contemplative practices, and strategic supplement support in the setting of a powerful mindset shift. The patient experienced remarkable symptom remission after strategic discontinuation of medications through the addition of the lifestyle interventions. She also was able to heal the root-cause drivers of her psychiatric diagnoses. Currently she is symptom-free and medication-free after nearly 21 years., Conclusions: This case demonstrates the effectiveness of lifestyle interventions and psychospiritual support to enable dramatic clinical change without withdrawal syndrome after cessation of medication. More important, the initial failed tapering underpins the notion that a diligent meditation practice may be necessary to heal root-cause drivers of psychiatric symptoms and withdrawal syndrome. The results may serve to inform practitioners assisting patients who wish to discontinue benzodiazepine and other psychotropic medications or patients who would like to try a nonpharmaceutical approach as a first-line therapy.

Background/aims: To report refractive outcomes from an National Health Service (NHS) cataract surgery service and assess if results meet suggested benchmark standard., Methods: Details of all patients undergoing cataract surgery in the Southern General and New Victoria hospitals in Glasgow, UK, between November 2006 and December 2016 were prospectively entered into an electronic database. Patients were reviewed 4 weeks postoperatively in the eye clinic and underwent refraction at their local optometrist prior to this appointment. Surgically uncomplicated cases with in the bag' non-toric intraocular lens implantation were included. Patients with previous laser refractive procedures or failing to achieve 6/12 acuity or better postoperatively were excluded. Proximity to targeted postoperative refraction was documented., Results: Over this 10-year period, 11 083 eyes underwent cataract surgery. Of these, 8943 eyes of 6936 patients (80.69%) met the inclusion criteria and had both target and postoperative outcome refraction recorded. The mean difference between the targeted and outcome refraction was -0.07 D (SD 0.67). The mean absolute error was 0.50 D. Postoperative refraction was within 1 D of target refraction for 7938 eyes (88.76%) and within 0.50 D for 5577 eyes (62.36%)., Conclusion: Refractive outcomes following routine cataract surgery reported here are well within the targets recommended by the Royal College of Ophthalmologists and European guidelines, but suggest that higher cataract refractive outcome benchmark standards may not yet be a realistic expectation for all NHS units with current biometry practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Spondylodiscitis represents a condition with significant heterogeneity. A significant proportion of patients are managed without surgical intervention, but there remains a group where surgery is mandated. The aim of our study was to create a scoring system to guide clinicians as to which patients with spondylodiscitis may require surgery., Methods: A retrospective analysis of patients presenting to our institution with a diagnosis of spondylodiscitis between 2005 and 2014 was performed. Data for 35 variables, characterised as potential risk factors for requiring surgical treatment of spondylodiscitis, were collected. Logistic regression analysis was performed to evaluate the predictability of each. A prediction model was constructed, and the model was externally validated using a second series of patients from 2014 to 2015 meeting the same standards as the first population. The predicted odds were calculated for every patient in the data set. Receiver operating characteristic (ROC) curves were created, and the area under curve (AUC) was determined., Results: Sixty-five patients were identified. Surgery was deemed necessary in 21 patients. Six predictors: distant site infection, medical comorbidities, the immunocompromised patient, MRI findings, anatomical location and neurology, were found to be the most consistent risk factors for surgical intervention. An internally validated scoring system with an AUC of 0.83 and an Akaike information criterion (AIC) of 115.2 was developed. External validation using a further 20 patients showed an AUC of 0.71 at 95% confidence interval of 0.50-0.88., Conclusions: A new scoring system has been developed which can help guide clinicians as to when surgical intervention may be required. Further prospective analyses are required to validate this proposed scoring system. These slides can be retrieved under Electronic Supplementary Material.

Objective: The goal of this research is to develop a machine learning supervised classification model to automatically code clinical encounter transcripts using a behavioral code scheme., Methods: We first evaluated the efficacy of eight state-of-the-art machine learning classification models to recognize patient-provider communication behaviors operationalized by the motivational interviewing framework. Data were collected during the course of a single weight loss intervention session with 37 African American adolescents and their caregivers. We then tested the transferability of the model to a novel treatment context, 80 patient-provider interactions during routine human immunodeficiency virus (HIV) clinic visits., Results: Of the eight models tested, the support vector machine model demonstrated the best performance, achieving a .680 F1-score (a function of model precision and recall) in adolescent and .639 in caregiver sessions. Adding semantic and contextual features improved accuracy with 75.1% of utterances in adolescent and 73.8% in caregiver sessions correctly coded. With no modification, the model correctly classified 72.0% of patient-provider utterances in HIV clinical encounters with reliability comparable to human coders (k = .639)., Conclusions: The development of a validated approach for automatic behavioral coding offers an efficient alternative to traditional, resource-intensive methods with the potential to dramatically accelerate the pace of outcomes-oriented behavioral research. The knowledge gained from computer-driven behavioral research can inform clinical practice by providing clinicians with empirically supported communication strategies to tailor their conversations with patients. Lastly, automatic behavioral coding is a critical first step toward fully automated eHealth/mHealth (electronic/mobile Health) behavioral interventions., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Graves' disease is known as a chronic and incurable disease. The typical treatment is symptom-based and consists of medications, radioiodine, or surgery. These last two treatments are routinely offered to the 50% of patients that do not respond to drug therapy. Here we report the case of a patient who was able to normalize her thyroid hormones as well as her autoimmune markers in 6 months with the exclusive implementation of lifestyle interventions., Summary: A 34-year-old Dutch, Caucasian female diagnosed with Graves' disease since 2014 implemented lifestyle modifications, which included dietary change to an ancestral type of diet, oral health interventions, practice of kundalini yoga, avoidance of environmental toxicants (by only eating organic food, drinking filtered water, and using natural products to clean her house or for her personal hygiene) and supportive supplements when necessary. The patient did not take any antithyroid drugs or beta-blockers during this period nor any other type of medication that could have had immunosuppressant effects. After 6 months of engaging in these lifestyle interventions, her thyroid analysis normalized and no anti-thyrotropin receptor antibodies were negative., Conclusion: This case report demonstrates that Graves' disease can effectively be put into lasting remission without conventional medical interventions. It also emphasizes the importance of a healthy lifestyle as a first line intervention for all patients but especially in the particular case of patients suffering from Graves' disease.

Objective: Successful weight loss interventions for African-Americans adolescents are lacking. Cognitive-behavioral interventions seek to develop weight loss skills (e.g., counting calories, goal setting, managing one's environment). Little is known about how well adolescents implement such skills in their daily lives. Study aims were to (1) examine weight loss skills utilization at midpoint and end of a 6-month cognitive-behavioral/motivational interviewing weight loss sequential multiple assignment randomized trial (SMART), and (2) determine if greater skill utilization predicted weight loss at treatment end and 3 months post-treatment., Method: One hundred and eighty six African-Americans adolescents with obesity and their caregiver were first randomly assigned to complete 3 months of cognitive-behavioral and motivational interviewing family-based weight loss treatment in their home or in the research office (Phase 1). Nonresponders (i.e., those who lost < 3% of initial weight, n = 161) were rerandomized to 3 months of continued skills training (n = 83) or contingency management (n = 78) for Phase 2; responders were allocated to 3 months of relapse prevention (n = 20). Adolescents' frequency of weight loss skills utilization was assessed via questionnaire at treatment midpoint and end., Results: Higher treatment attendance was associated with better skill utilization. Higher skill utilization was associated with more weight loss at treatment end, whereas higher baseline confidence was associated with more weight loss at follow-up., Conclusions: This study indicates the importance of attending weight loss intervention sessions to develop and strengthen weight loss skills in African-American adolescents with obesity, and strengthening confidence to use such skills for continued weight loss., (Copyright © 2018. Published by Elsevier Inc.)

Objective: This paper reviews the literature linking physical violence, directed towards self or others, to serotonergic and dopaminergic psychiatric drugs and general medications., Design/methodology/approach: Data about side effects, pharmacogenetics and homeostasis are obtained from articles, electronic Medicines Compendium, DSM-IV-TR, British National Formulary (BNF) and academic books. Statistics have been obtained from articles, The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Risk, Manchester, Mental Health Equalities, National Mental Health Development Unit and the NHS Health and Social Care Information Centre. Classification for neurotoxic conditions and mental illness are obtained from the DSM-IV-TR, DSM-V and ICD-10., Findings: Psychiatric drugs and some general medications have effects that are not always the ones intended. Reactions to different drugs and drug-drug combinations are governed by individual metabolising rates. Phase 1 metabolism takes place via the cytochrome P450 enzymes with 57 human genes identified that are genetically variable i.e. polymorphic. The population are coded as poor, extensive (known as normal), intermediate or ultra rapid metabolisers. Variations in the serotonin transporter gene (5-HTTLPR) and serotonin receptors (5-HT) influence the outcome of serotonergic medications. It is established genetic polymorphisms in the CYP450 and serotoninergic metabolising system cause higher drug blood levels which are associated with neuropsychiatric adverse drug reactions (ADRs), such as akathisia. If not recognised, akathisia, which often precedes violence, suicidality, homicide, mania and psychosis, may be mistaken for new or emergent mental illness and treated with further ineffective, counter-productive psychiatric drugs., Research Limitations/implications: The absence of pharmaceutical data for CYP450 diminishing, null/non- functioning or multiple polymorphisms and variations in the 5-HTTLPR and 5-HT, linking general medications and psychiatric drugs with neuropsychiatric behavioural reactions is notable. There is limited information linking psychiatric drug disruption of homeostasis and neurotransmitters with violence. These issues indicate a need for greater pharmaceutical transparency and further research into the role of CYP450, 5-HTTLPR and 5-HT polymorphism associated neuropsychiatric ADRs for all psychiatric drugs and serotonergic general medications., Practical Implications: Safer prescribing is important and could be achieved by individual genotype testing, which would identify persons with genetic polymorphisms, who are unable to metabolise drugs. Prevention of violence would enhance peoples' well being, ground floor practitioner and public safety., Conclusion: This paper is the first review that implicates certain drugs as a cause of violence due to pharmacogentic polymorphisms and neurotransmitter disruption.

Introduction: Temporal headache often results in an Ophthalmology referral to rule out giant cell arteritis (GCA). When clinical suspicion of GCA is low, alternative diagnoses should be considered. Temporomandibular disorder (TMD) commonly causes a temporal headache., Materials and Methods: Patients referred with a temporal headache attending the Friday emergency ophthalmology clinic from February to July 2017 were assessed for GCA using the American College of Rheumatology (ACR) diagnostic criteria and TMD using a validated screening questionnaire., Results: Ten symptomatic patients presented and were screened for TMD during this period. Four had mild TMD, two moderate, and three severe. The mean TMD score in patients with less than 3 ACR GCA criteria was 14.75 (SD 4.03) versus 6.8 (SD 3.06) in patients with 3 or more criteria (p = 0.0075)., Conclusion: TMD is an important cause of a temporal headache in patients unlikely to have GCA. Onward referral to dentistry for further management may be merited.

Purpose: To objectively measure head drift during cataract surgery, and subjectively simulate eye movements and assess impact on surgical technique., Materials and Methods: Twelve consecutively recorded routine cataract operations in the Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, were reviewed. The speculum was used as a fixed point and correlated with a superimposed virtual ruler to measure maximum head drift in each direction throughout the operations. To simulate intraoperative eye movement, we attached string to the cataract surgical simulator (Eyesi) eye and manually induced abduction and adduction. A calibrated scale secured to the Eyesi head ensured 5 mm eye movements were consistently created. Ophthalmology trainees performed the continuous curvilinear capsulorhexis (CCC) exercise without and with sequential eye movements. Movements were induced every three seconds. Scores were compared using a paired Student's T-test., Results: Mean head drift in the surgical recordings was 3.1 mm medially (range 2-7 mm), 2.9 mm laterally (range 2-4 mm), 2.6 mm superiorly (range 1-5 mm), and 1.9 mm inferiorly (range 1-4 mm). In 11 of 12 cases, the operating microscope had to be adjusted for head drift. Six junior trainees completed the CCC module on the Eyesi without then with eye movements. After introducing eye movements the mean Eyesi score reduced from 92.7 to 76.9 (P = 0.014), 'roundness of rhexis' score reduced from 89.4 to 57.5 (P = 0.020), and trainees operated 17 s faster (P = 0.016)., Conclusion: This study objectively demonstrates the under-reported clinical scenario of head drift during cataract surgery. By manipulating the Eyesi we have shown that eye movements reduce the quality of cataract surgery.

Background: Predicting how patients with central retinal vein occlusion (CRVO) will respond to intravitreal anti-VEGF is challenging. The purpose of this study was to identify pre-treatment clinical features in CRVO that predict visual acuity (VA) following intravitreal ranibizumab., Methods: Medical records, fundus images and optical coherence tomography (OCT) scans of treatment naïve patients with CRVO receiving PRN intravitreal ranibizumab were retrospectively reviewed. Early Treatment Diabetic Retinopathy Study (ETDRS) VA and central retinal thickness (CRT) were recorded at baseline, 3 and 12 months after starting therapy. Regression analysis was used to determine independent predictors of VA at 3 and 12 months follow-up. Possible predictors included baseline VA, age, presence of cotton wool spots (CWS), haemorrhages (few scattered or multiple deep), foveal detachment, CRT, time from presentation to treatment, number of injections given, presence of RAPD, and cause of CRVO., Results: Data from 52 eyes of 50 patients receiving intravitreal ranibizumab treatment for CRVO were analyzed. The mean pre-treatment VA was 43.3 (SD 22.5) letters, which improved to 52.0 (SD 24.3) letters at 3 months, then dropped to 42.0 (SD 30.26) at 12 months. Baseline CRT reduced from 616.7 μm (SD 272.4) to 346.0 μm (SD 205.2) at 3 months and 304.0 μm (SD 168.3) at 12 months. The following features were predictive of poorer VA after starting intravitreal ranibizumab: Poorer pretreatment VA (3-months, P = 0.010; 12-months, P = 0.006), increasing age (3-months, P = < 0.001; 12-months, P = 0.006), and presence of CWS (3-months, P < 0.001; 12-months, P = 0.045)., Conclusion: Pre-treatment VA, older age, and presence of CWS are easily identifiable clinical features in the hospital setting which help predict visual outcome in patients with CRVO receiving intravitreal ranibizumab.

Introduction: Medical management can have limitations in improving ptosis in patients with myasthenia gravis (MG). We present our experience of ptosis surgery in MG., Materials and Methods: Clinical records of all patients with MG undergoing ptosis surgery from September 2007 to November 2013 in a single center were retrospectively reviewed. Change in upper marginal reflex distance (uMRD) was the main outcome measure., Results: Sixteen external levator advancement (ELA) procedures were performed on 11 MG patients. Fourteen of 16 procedures had pre- and postoperative uMRD documented. Thirteen of 14 procedures had improved lid height; mean increase in uMRD was 2.4 mm (P=0.0005651). Two patients required secondary lid elevation. Postoperative complications included more noticeable diplopia (n=1) and exposure keratopathy (n=1)., Conclusion: Ptosis surgery is a useful adjunct to medical therapy to improve lid height in MG patients with ptosis. Risks of diplopia and exposure keratopathy should be discussed with the patient pre-operatively.

This case report illustrates the relationship between gut, hormonal, and brain function in that dietary change, mindfulness interventions, and detoxification led to resolution of disabling psychiatric symptoms. In this case, a single Caucasian female resolved her symptoms of bipolar disorder (BD) including psychotic features and suicidality, posttraumatic stress disorder symptoms from childhood torture, disordered eating, fibromyalgia, and irritable bowel syndrome through lifestyle interventions. This patient survived a severe trauma history only to develop alcohol dependence, disordered eating, and depressive symptoms, which were treated with a polypharmaceutical psychiatric approach. She was formally diagnosed with BD after being treated with antidepressants and went on to be treated with up to 15 medications in the ensuing years. Disabled by the side effects of her treatment, she worked with her treating psychiatrist to taper off of 4 medications before she learned of nutritional change through a book authored by the author. After completing 1 mo of these recommendations including dietary change, detox, and meditation, she enrolled in the author's online program and went on to resolve her symptoms, physical and psychiatric, to the extent that BD has been removed from her medical record. She has been symptom free for 1 y. This case is evidence of the potential for self-directed healing and resolution of chronic illness.

Background: Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness., Methods: All patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken., Results: 314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution., Conclusion: Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures., Level of Evidence: Level III-Retrospective Cohort Study., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. The aims of this study were to look at whether the management of 5th metatarsal fractures using a virtual fracture clinic model is safe, cost effective and avoids adverse outcomes whilst being acceptable to patients using the service. All patients with a fifth metatarsal fracture between September 2013 and September 2015 had a standardised management plan initiated (blackboot, full weightbearing) in the emergency department (ED). 663 patients met inclusion criteria, 251 (37.5%) Type 1, 111 (17%) Type 2 (Jones'), 281 (42%) Type 3 or distal, 20 (3%) were misdiagnosed, and 4 (0.5%) patient's images were unavailable. 499 (75%) patients were discharged immediately, 47 (7%) had further imaging, 114 (17%) had either ESP or consultant clinic review, and 3 (<1%) transferred their care privately. The average number of clinic visits per patient was 0.17. At a conservative estimate of 1.3 visits per patient in a traditional pathway this saved 779 clinic visits with a cost saving of £60,000 on clinic visits alone. There were 8 (7%) asymptomatic non-unions in Type 2 (Jones') fractures. One patient required surgical intervention. Fifth metatarsal fractures have excellent outcomes with conservative management yet traditionally have required clinic visits to confirm the diagnosis and explain the management and prognosis. Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, that is both safe and cost-effective., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)