The Killing of a Sacred Veneer: Depressive Symptoms in Athletes

Within the past decade, there has been a growing research interest on mental health issues in athletes. Within this increasing area of research, research on depressive symptoms in athletes has been central. However, the overall depression-related evidence-base is still fragmented and several important areas of research remain under explored. The overall aim of this PhD was to map topics that have received little scholarly attention in the past, and to empirically explore novel research questions that could contribute to future research and applied work to improve support and prevention initiatives in athletes. Study 1 The aim was to describe methodological characteristics of the research that has assessed depressive symptoms in athletes, and to map the variables that have been tested concerning these symptoms. A review framework proposed by Arksey and O’Malley (2005) was utilised, and of 6983 records screened, 157 studies were included. Most studies were cross-sectional, with samples including current male and female athletes from multiple sports and levels. Non-athlete comparison groups frequently consisted of student samples. Twenty-eight different depression scales were utilised, of which CES-D, BDI, BDI-II, and the PHQ-9 were most common. The most frequently tested variables in relation to depressive symptoms were identified as proximal contextual and interpersonal factors (67.9%), including sport-specific (e.g., type of sport) (36.4%), and generic (e.g. social support) (31.5%) factors. Within-individual factors (e.g. cognitive vulnerability) accounted for 17.2% of all observed topics/variables tested in relation to depressive symptoms, and 9.3% tested depressive symptoms in relation to comorbid disorders. Macro-level variables (e.g. ethnicity) accounted only for 5% of all observations. Considering that current knowledge about depressive symptoms in athletes is largely based on cross-sectional data, and few studies have explored potential underlying mechanisms (e.g. cognitive vulnerability), more longitudinal research is needed to identify underlying vulnerabilities that predict individual differences in depressive symptoms over time. This would further improve future applied work to develop evidence-based intervention and prevention to target relevant mechanisms that increase athletes’ likelihood of experiencing elevated depressive symptoms. The type of measures utilized across the reviewed studies were also highly variable, and different cut-off scores were used to identify athletes with clinically significant depressive symptom severity. Considering the methodological heterogeneity across studies, future studies could benefit from conducting more fine-grained analyses to explore the type of symptoms athletes may be experiencing rather than merely reporting prevalence rates based on a single cut-off score. This could improve our current understanding of the type of issues that may be especially relevant in the athlete populations. Study 2 As identified in study 1 interpreting depressive symptom prevalence across previous studies is complicated considering the range of different measures and cut-off scores that have been utilized in previous studies. Furthermore, we know little about the type of symptoms that may be especially relevant in athletes. Hence, the aim of study 2 was to explore the prevalence of specific symptoms of depression in athletes, and to test differences in athletes’ likelihood of exhibiting these symptoms depending on their age, sex, the type of sport, and the level of competition in which they engage. A sample of Icelandic male and female team sport athletes competing in football, handball, and basketball (N=894, 18-42 years) were included in the study. The football sample represented 20.3% of the Icelandic adult football population (N=2170 across 105 teams) with a total of 441 participants included (age range 18-41 years, male 70.1%). For basketball, the sample represented 36.1% of the Icelandic adult basketball population (N=659 across 56 teams) with a total of 238 participants (age range 18-41 years, male 62.6%). For, handball, sample represented 26.5% of the Icelandic handball population (N=812 across 20 teams) with a total of 215 participants (age range 18-42 years, male 51.2%). Of the athletes exhibiting clinically significant depressive symptoms on the Patient Health Questionnaire (PHQ-9), 37.5% did not exhibit core symptoms of depression (i.e., depressed mood, a lack of interest). Compared to males, females were significantly more likely to exhibit depressed mood, feelings of worthlessness/guilt, problems with sleep, fatigue, appetite, and concentration. Within males, differences were mostly related to neurovegetative aspects of depression (sleep and appetite), whereas in females, differences were related to cognitive/emotional aspects (e.g. depressed mood, guilt/worthlessness). The findings underline the importance of exploring specific symptoms of depression to provide a richer understanding of depressive symptomology in athletes – consequently allowing future research to identify and target risk factors that may be linked to these specific symptoms. Study 3 As identified in study 1, understanding individual differences in vulnerability to depression are still under explored in athletes. Therefore, the main aim of this study was to fill this gap by testing the influence of depressive rumination (repetitive thought processes in response to depressed mood) on the likelihood of experiencing clinically significant depressive symptoms in athletes. Depressive rumination, as defined in the Response Styles Theory, is a well-supported cognitive vulnerability factor to depression within the general and clinical populations – but previous research in athletes has not explored this relationship. In this study, athletes’ profiles on the two underlying factors of depressive rumination, brooding (maladaptive) and reflective rumination (adaptive) were tested on athletes’ likelihood of exhibiting clinically relevant depressive symptoms. A total of 286 competitive athletes from 54 different types of sports were included in the study (62.0% male, age range 18-69 years). The majority of athletes were UK citizens (88.0 %) of white/Caucasian ethnic background (92.2 %). More than half of the athletes (53.5 %) had been selected to represent their country at some point during their athletic careers, and 30.5 % were currently competing at international/top tier professional level. The Patient Health Questionnaire 9 (PHQ – 9) was utilized to measure depressive symptoms, and the Ruminative Responses Scale (RRS-short form) was used to measure the two underlying dimensions of depressive rumination, brooding and reflective rumination. Compared to athletes with a low brooding/reflection profile, athletes with a high brooding/reflection profile had significantly higher odds of experiencing clinically relevant depressive symptoms (OR=15.24, 95% CI=4.37–53.24). A low brooding/ high reflection profile was not, however, related to increased odds. The findings validate findings in the general and clinical populations in the current athlete sample, suggesting that brooding rumination may be an important vulnerability factor explaining individual differences in depressive symptoms in athletes. This implicates that applied work may benefit from targeting brooding tendencies to help vulnerable athletes to develop more beneficial responses to negative mood. However, future research should validate the theoretical model of the response styles theory in longitudinal designs. Furthermore, as implicated by the theoretical model, depressive rumination should be related to increased depressive symptoms when individuals are experiencing stressful life situations. Hence, future studies should test whether athletes with a higher tendency to engage in depressive rumination (especially brooding) compared to those with a low tendency, are more likely to exhibit increased levels of depressive symptoms when athletes experience increased levels of stress in their lives. This would provide stronger empirical support for depressive rumination as a potential underlying mechanism, consequently supporting the utility of targeting depressive rumination in treatment and prevention of depressive symptoms in athletes. Study 4 In-line with suggestions for future research proposed by study 3, the aim was to validate the vulnerability-stress account of the response styles theory using a longitudinal research design. That is, study four tested whether between-athlete differences in the tendency to brood and/or reflect in response to negative mood, measured at the beginning of the study (i.e., baseline), would predict increases in depressive symptoms when levels of stress increased over the one-year study period. A total of 79 Icelandic elite and national team athletes were included in the study (M= 23.5, SD=4.8, age range 18-37), with the majority being female athletes (n=60, 75.9%). Athletes competed in handball (n=22, 27.8%), football (n=14, 17.7%), basketball (n=26, 32.9%), Icelandic equitation (n=8, 10.1 %), and mixed martial arts and/or Brazilian jiu-jitsu (n=9, 11.4%). While depressive rumination (brooding and reflection) were measured at baseline, stress and depressive symptoms were assessed at baseline, at 6-months and 12-months post-baseline. The results showed that higher perceived stress and brooding, but not reflective rumination, independently predicted higher depressive symptom scores over the study period. Furthermore, brooding rumination measured at baseline significantly moderated the effects of individual fluctuations in perceived stress on depressive symptoms. Hence, athletes who reported high brooding tendencies in the beginning of the study were more likely than those who reported a low tendency, to experience significantly higher increases in depressive symptoms when stress levels increased over the study period. The findings supported initial findings in study three and demonstrated the validity of exploring individual differences in depressive symptoms through the lens of the response styles theory in future research in the athletes. The findings also highlight that athletes who develop brooding rumination as a response to negative affect may be especially vulnerable to experiencing elevated depressive symptoms when levels of perceived stress increase. Future research may benefit from examining the influence of sport-specific developmental trajectories to better understand, and hence prevent, the development of brooding tendencies in athlete

Me, Myself, and My Thoughts: The Influence of Brooding and Reflective Rumination on Depressive Symptoms in Athletes in the United Kingdom

Individual differences in vulnerability to depression are still underexplored in athletes. We tested the influence of different brooding and reflective rumination profiles (i.e. repetitive thought processes in response to low/depressed mood) on the odds of experiencing clinically relevant depressive symptoms in competitive athletes (N=286). The Patient Health Questionnaire 9 (PHQ – 9) and the Ruminative Responses Scale (RRS-short form) were utilized to measure depression and rumination, respectively. Compared to athletes with a low brooding/reflection profile, athletes with a high brooding/reflection profile had significantly higher odds of experiencing clinical levels of depressive symptoms (OR=13.40, 95% CI=3.81– 47.11). A high reflection/low brooding profile was not, however, related to increased odds of depressive symptoms. Future research could extend our findings by exploring determinants of ruminative tendencies, especially brooding, in athletes. Furthermore, psychological interventions targeting rumination could be examined as a potential prevention and treatment approach to tackling depressive symptoms in athletes

Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis

OBJECTIVETo estimate the regression, persistence, and progression of untreated cervical intraepithelial neoplasia grade 2 (CIN2) lesions managed conservatively as well as compliance with follow-up protocols.DESIGNSystematic review and meta-analysis.DATA SOURCESMedline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1 January 1973 to 20 August 2016.ELIGIBILITY CRITERIAStudies reporting on outcomes of histologically confirmed CIN2 in non-pregnant women, managed conservatively for three or more months.DATA SYNTHESISTwo reviewers extracted data and assessed risk of bias. Random effects model was used to calculate pooled proportions for each outcome, and heterogeneity was assessed using I-2 statistics.MAIN OUTCOME MEASURESRates of regression, persistence, or progression of CIN2 and default rates at different follow-up time points (3, 6, 12, 24, 36, and 60 months).RESULTS36 studies that included 3160 women were identified (seven randomised trials, 16 prospective cohorts, and 13 retrospective cohorts; 50% of the studies were at low risk of bias). At 24 months, the pooled rates were 50% (11 studies, 819/1470 women, 95% confidence interval 43% to 57%; I-2= 77%) for regression, 32% (eight studies, 334/1257 women, 23% to 42%; I-2= 82%) for persistence, and 18% (nine studies, 282/1445 women, 11% to 27%; I-2= 90%) for progression. In a subgroup analysis including 1069 women aged less than 30 years, the rates were 60% (four studies, 638/1069 women, 57% to 63%; I-2= 0%), 23% (two studies, 226/938 women, 20% to 26%; I-2= 97%), and 11% (three studies, 163/1033 women, 5% to 19%; I-2= 67%), respectively. The rate of non-compliance (at six to 24 months of follow-up) in prospective studies was around 10%.CONCLUSIONSMost CIN2 lesions, particularly in young women (< 30 years), regress spontaneously. Active surveillance, rather than immediate intervention, is therefore justified, especially among young women who are likely to adhere to monitoring.</p

Risk of thrombosis and bleeding in gynecologic cancer surgery: systematic review and meta-analysis

Objective: This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery.Data sources: We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice.Study eligibility criteria: Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin &lt;70 g/L.Methods: Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty.Results: We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was &lt;1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and &gt;2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from &lt;0.1% to 1.3%. Median risks of bleeding requiring reintervention were &lt;1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures.Conclusion: Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding

Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

Context: Stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) are associated with physical and psychological morbidity, and large societal costs. The long-term effects of delivery modes on each kind of incontinence remain uncertain.Objective: To investigate the long-term impact of delivery mode on SUI and UUI.Evidence acquisition: We searched Medline, Scopus, CINAHL, and relevant major conference abstracts up to October 31, 2014, including any observational study with adjusted analyses or any randomized trial addressing the association between delivery mode and SUI or UUI >= 1 yr after delivery. Two reviewers extracted data, including incidence/prevalence of SUI and UUI by delivery modes, and assessed risk of bias.Evidence synthesis: Pooled estimates from 15 eligible studies demonstrated an increased risk of SUI after vaginal delivery versus cesarean section (adjusted odds ratio [aOR]: 1.85; 95% confidence interval [CI], 1.56-2.19; I-2 = 57%; risk difference: 8.2%). Metaregression demonstrated a larger effect of vaginal delivery among younger women (p = 0.005). Four studies suggested no difference in the risk of SUI between spontaneous vaginal and instrumental delivery (aOR: 1.11; 95% CI, 0.84-1.45; I-2 = 50%). Eight studies suggested an elevated risk of UUI after vaginal delivery versus cesarean section (aOR: 1.30; 95% CI, 1.02-1.65; I-2 = 37%; risk difference: 2.6%).Conclusions: Compared with cesarean section, vaginal delivery is associated with an almost twofold increase in the risk of long-term SUI, with an absolute increase of 8%, and an effect that is largest in younger women. There is also an increased risk of UUI, with an absolute increase of approximately 3%.Patient summary: In this systematic review we looked for the long-term effects of childbirth on urinary leakage. We found that vaginal delivery is associated with an almost twofold increase in the risk of developing leakage with exertion, compared with cesarean section, with a smaller effect on leakage in association with urgency. (C) 2016 European Association of Urology. Published by Elsevier B.V

Burden of Disease Caused by Otitis Media: Systematic Review and Global Estimates

<div><h3>Background</h3><p>Otitis media (OM) is a leading cause of health care visits and drugs prescription. Its complications and sequelae are important causes of preventable hearing loss, particularly in developing countries. Within the Global Burden of Diseases, Injuries, and Risk Factors Study, for the year 2005 we estimated the incidence of acute OM, chronic suppurative OM, and related hearing loss and mortality for all ages and the 21 WHO regional areas.</p> <h3>Methods</h3><p>We identified risk factors, complications and sequelae of OM. We carried out an extensive literature review (Medline, Embase, Lilacs and Wholis) which lead to the selection of 114 papers comprising relevant data. Data were available from 15 of the 21 WHO regions. To estimate incidence and prevalence for all countries we adopted a two stage approach based on risk factors formulas and regression modelling.</p> <h3>Results</h3><p>Acute OM incidence rate is 10.85% i.e. 709million cases each year with 51% of these occurring in under-fives. Chronic suppurative OM incidence rate is 4.76‰ i.e. 31million cases, with 22.6% of cases occurring annually in under-fives. OM-related hearing impairment has a prevalence of 30.82 per ten-thousand. Each year 21thousand people die due to complications of OM.</p> <h3>Conclusions</h3><p>Our study is the first attempt to systematically review the available information and provide global estimates for OM and related conditions. The overall burden deriving from AOM, CSOM and their sequelae is considerable, particularly in the first five years of life and in the poorest countries. The findings call for incorporating OM-focused action within preventive and case management strategies, with emphasis on the more affected.</p> </div

Does ungulate foraging behavior in forest canopy gaps produce a spatial subsidy with cascading effects on vegetation?

Concentrated foraging in forest canopy gaps by large ungulates may produce a pulsed spatial resource subsidy with cascading effects on the composition and developmental trajectory of gap vegetation. To test this hypothesis, we investigated the influence of white-tailed deer (Odocoileus virginianus) use of 12 artificial canopy gaps in a hemlock-northern hardwood forest. Ground-layer vegetation was monitored and available reactive nitrogen was assayed using resin beads deployed under the snowpack (March–April) and soon after snowmelt (May). Deer use of openings was consistent with the forage maturation hypothesis, with the greatest levels of use occurring in small gaps. Allometric relationships suggest that mean localized winter pulses of deer-excreted N may be on par and/or in excess of annual atmospheric N deposition in the region. Correspondingly, deer access plots contained significantly more reactive N than exclosure plots soon after snowmelt (P = 0.036) in April. While the pulse was indistinguishable by May, our nonmetric multidimensional scaling ordination results suggest that plant community composition in exclosure and control plots reflects this pulsed gradient in N availability. Given the importance of canopy disturbances and gaps to the perpetuation of forest ecosystems, localized and/or heterogeneous impacts may be magnified as forests turn over