An abnormally displaced scaphoid fracture: a case report

Scaphoid fractures are generally known to be difficult to diagnose and difficult to heal. In some reports, up to 40% of scaphoid fractures were reported to be missed at initial presentation. Clinical examinations and plain radiographs are generally poor at identifying scaphoid fractures immediately after injury. In this study we report a scaphoid fracture that has no difficulty in diagnosis because of a very strange and abnormal displacement

Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) protocol : a pragmatic multi-centre randomised controlled trial of cast treatment versus surgical fixation for the treatment of bi-cortical, minimally displaced fractures of the scaphoid waist in adults

BACKGROUND: A scaphoid fracture is the most common type of carpal fracture affecting young active people. The optimal management of this fracture is uncertain. When treated with a cast, 88 to 90 % of these fractures unite; however, for the remaining 10-12 % the non-union almost invariably leads to arthritis. The alternative is surgery to fix the scaphoid with a screw at the outset. METHODS/DESIGN: We will conduct a randomised controlled trial (RCT) of 438 adult patients with a "clear" and "bicortical" scaphoid waist fracture on plain radiographs to evaluate the clinical effectiveness and cost-effectiveness of plaster cast treatment (with fixation of those that fail to unite) versus early surgical fixation. The plaster cast treatment will be immobilisation in a below elbow cast for 6 to 10 weeks followed by mobilisation. If non-union is confirmed on plain radiographs and/or Computerised Tomogram at 6 to 12 weeks, then urgent surgical fixation will be performed. This is being compared with immediate surgical fixation with surgeons using their preferred technique and implant. These treatments will be undertaken in trauma units across the United Kingdom. The primary outcome and end-point will be the Patient Rated Wrist Evaluation (a patient self-reported assessment of wrist pain and function) at 52 weeks and also measured at 6, 12, 26 weeks and 5 years. Secondary outcomes include an assessment of radiological union of the fracture; quality of life; recovery of wrist range and strength; and complications. We will also qualitatively investigate patient experiences of their treatment. DISCUSSION: Scaphoid fractures are an important public health problem as they predominantly affect young active individuals in the more productive working years of their lives. Non-union, if untreated, can lead to arthritis which can disable patients at a very young age. There is a rapidly increasing trend for immediate surgical fixation of these fractures but there is insufficient evidence from existing RCTs to support this. The SWIFFT Trial is a rigorously designed and adequately powered study which aims to contribute to the evidence-base to inform clinical decisions for the treatment of this common fracture in adults. TRIAL REGISTRATION: The trial is registered with the International Standard Randomised Controlled Trial Register ( ISRCTN67901257 ). Date registration assigned was 13/02/2013

Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders

<p>Abstract</p> <p>Background</p> <p>Despite international guidelines describing psychotherapy as first choice for people with personality disorders (PDs), well-designed research on the effectiveness and cost-effectiveness of psychotherapy for PD is scarce. Schema therapy (ST) is a specific form of psychological treatment that proved to be effective for borderline PD. Randomized controlled studies on the effectiveness of ST for other PDs are lacking. Another not yet tested new specialized treatment is Clarification Oriented Psychotherapy (COP). The aim of this project is to perform an effectiveness study as well as an economic evaluation study (cost effectiveness as well as cost-utility) comparing ST versus COP versus treatment as usual (TAU). In this study, we focus on avoidant, dependent, obsessive-compulsive, paranoid, histrionic and narcissistic PD.</p> <p>Methods/Design</p> <p>In a multicentered randomized controlled trial, ST, and COP as an extra experimental condition, are compared to TAU. Minimal 300 patients are recruited in 12 mental health institutes throughout the Netherlands, and receive an extensive screening prior to enrolment in the study. When eligible, they are randomly assigned to one of the intervention groups. An economic evaluation and a qualitative research study on patient and therapist perspectives on ST are embedded in this trial. Outcome assessments (both for clinical effectiveness and economic evaluation) take place at 6,12,18,24 and 36 months after start of treatment. Primary outcome is recovery from PD; secondary measures include general psychopathological complaints, social functioning and quality of life. Data for the cost-effectiveness and cost-utility analyses are collected by using a retrospective cost interview. Information on patient and therapist perspectives is gathered using in-depth interviews and focus groups, and focuses on possible helpful and impeding aspects of ST.</p> <p>Discussion</p> <p>This trial is the first to compare ST and COP head-to-head with TAU for people with a cluster C, paranoid, histrionic and/or narcissistic PD. By combining clinical effectiveness data with an economic evaluation and with direct information from primary stakeholders, this trial offers a complete and thorough view on ST as a contribution to the improvement of treatment for this PD patient group.</p> <p>Trial registration</p> <p>Netherlands Trial Register (NTR): <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=566">NTR566</a></p

The comparative biology of New Zealand oystercatchers

Oystercatchers comprise a distinctive group of mollusc-eating shorebirds. They form an extremely uniform monogeneric family which has not undergone any major adaptive radiations into a diversity of ecological niches, but rather has dispersed from original centres of distribution to occupy identical niches in new geographical localities. The uniformity of structure and habit displayed within the group has been attributed by Larson (1957) to a high ecobiotic specialisation with centripetal selection involved. Throughout their range, oystercatchers exploit identical ecological niches which require specialised habits for successful utilisation. The specialised feeding habits of oystercatchers are well documented (Murphy, 1925; Dewar, 1940; Larson, 1957; Tinbergen and Norton-Griffiths, 1964; Dare, 1966), and a natural consequence of this specialisation is that it is restrictive to adaptive radiation

Time-limited dynamic psychotherapy for psychiatric patients with personality disorders : a randomized controlled trial [Elektronisk resurs]

This thesis presents data collected from a randomized controlled trial (RCT) for psychiatric outpatients with at least one diagnosis of Personality Disorder (PD). There is a high prevalence of PD among patients from both primary care and psychiatry, and these patients are often considered difficult to treat. Further, there is little evidence suggesting that any psychological treatment is effective for PD. Within the context of a RCT, we examined the clinical utility of a manualized psychodynamic treatment possessing some empirical evidence for treating other psychiatric conditions. Out of 371 consecutive patients assessed for eligibility, 159 were non-PD, and 56 PD patients were unwilling to participate. The remaining 156 PD patients were randomized to either a manualized version of Supportive-Expressive Psychotherapy (SEP) (n=80) or to a control condition (n=76) that consisted of non-manualized community delivered psychodynamic treatment (CDPT). In study I, we explored the extent to which the treatments were able to a) reduce the prevalence of PD diagnoses and reduce their severity, b) decrease the number of PD features, c) reduce the overall levels of psychiatric severity, d) improve global level of functioning, and e) demonstrate cost-effectiveness in reducing health care consumption (as measured by number of visits after termination of treatment). Results demonstrated that patients improved significantly in all aspects, but that no significant difference between the two treatments was found. However, SEP was more cost effective than CDPT. In study II, significant patient variables were tested for the purpose of exploring whether they either moderated or predicted the reduction of psychiatric symptoms (SCL-90). We found that intake level of PD criteria was associated with poorer outcome in both treatments and also that higher vindictiveness predicted a better outcome. Further, patients high in dominance showed greater improvements following CDPT than SEP. Study III explored to what extent quality of object relation and ego functions, psychological mindedness, interpersonal problems, and some big five personality traits (viz., neuroticism, agreeableness and extraversion), improved after treatment. We found significant improvements for most variables, but effect sizes and reliable change indices (RCI) showed that improvements were small to moderate, and few patients recovered to a healthy level. Study IV had two purposes: (a) identify baseline measures which can identify patients nonresponse to treatment at respective endpoint, (b) create a prediction index for identifying these severe nonresponders in the future. Fifty-four socio-demographic and clinical pre-treatment variables were used to identity those with extreme non-responder (ENR) status as defined by psychiatric symptoms and PD severity. Social withdrawal for CDPT and high levels of anxiety for SEP discriminated ENR in reducing symptomatic distress. Measures indicating detachment and social withdrawal discriminated ENR for both treatments in reducing PD severity. In addition, alexithymia in CDPT and not believing in one s social capacity for SEP further discriminated ENR. Thus, discrimination of ENR was found to be domain specific. The main conclusions from the trial are that: 1) it is possible to treat PD condition in one year with reasonably good results, 2) SEP is slightly better at reducing level of personality disorderness, while CDPT is somewhat better at reducing psychiatric severity, 3) it is possible to define patients variables that predict and moderate outcome, 4) it is possible to predict extreme non-response to treatment with high level of accuracy, and 5) SEP seems to be slightly more cost effective than CDPT. Our outcome results are comparable with those from other psychotherapy trials for PD patients, supporting the validity of our results. The fact that the study was conducted in a real-world clinical psychiatric setting in which patients did not primarily ask for psychotherapy supports the ecological validity of our findings. The main effects of the trial do not indicate that manualized psychotherapy is more efficacious that non-manualized psychodynamic treatment except in terms of costeffectiveness. However, our results do not indicate that manualized therapy leads to worst outcome. Some issues that were not explored or failed in this trial should be addressed in future research. Psychoanalytically based attachment measure that has empirical support for prediction of outcome can be tried, since the KAPP did not show predictive validity in this study. The clinical utility of a four dimensional psychological model for classifying severe PD conditions and plan treatment accordingly is worth exploring as an alternative to DSM. Finally longer treatment periods over a few years should be explored to increase the external validity of clinical trials