Does diagnostic complexity predict response to online interventions for youth anxiety?

Purpose: There is now substantial evidence to demonstrate the efficacy of online, cognitive-behavioural therapy (CBT) for the treatment of youth anxiety disorders. However, approximately 30% of youth will retain an anxiety diagnosis at 12-months following treatment. There has been some suggestion that internet-based interventions may not be suitable for more complex diagnostic presentations, however, there has been no empirical examination of predictors of outcome for youth receiving online CBT. The aim of this paper was to determine whether diagnostic profile predicted response to online CBT for youth anxiety. Methods: Participants were 154 youth (aged 7 to 18 years) diagnosed with a principal anxiety disorder who participated in an online cognitive-behavior intervention (BRAVE-ONLINE) as part of two randomized controlled trials. Measures included diagnostic interviews as well as a number of self-report measures of anxiety. Youth receiving online CBT were assessed prior to treatment, at 12 weeks following baseline assessment, and at 12-month follow-up. Diagnostic profile at baseline is described by type of principal anxiety diagnosis, severity of anxiety and presence of comorbid anxiety and non-anxiety. Treatment outcome was conceptualized as treatment 'response' (loss of primary diagnosis) and as 'remission' (loss of all anxiety diagnoses/ symptoms). Results and Conclusions: Results indicate that the majority of youth respond well to online CBT at 12-month follow-up. Comorbidity with other anxiety disorders was the most robust predictor of poorer response and remission, however only for those youth with 3 or more comorbid anxiety disorders. While youth with comorbid anxiety do respond to internet interventions, it seems that the presence of multiple anxiety disorders may limit its impact. The findings of this study have the potential to identify the types of patients for whom online CBT may be most appropriate and the circumstances under which it should not be offered as first line of treatment

Using stepped-care approaches within internet-based interventions for youth anxiety: Three case studies.

Background There are a lack of clear guidelines for the dissemination of Internet-based cognitive behaviour therapy (ICBT) for childhood and adolescent anxiety in routine care. While self-guided ICBT has greater reach than therapist-guided ICBT, it is plagued by problems of low program adherence and many young people are not successfully treated. It is important that we identify models of ICBT that are accessible, but provide the right support, at the right time to those who need it. Stepped-care models of ICBT offer one potential solution. Objective This case study examined the application of stepped-care within an ICBT intervention for childhood and adolescent anxiety, in which young people were stepped up from self-guided to therapist-guided ICBT. Methods Three case studies are presented and include young males (aged 11–12 years) who participated in BRAVE Stepped-Care, a new ICBT program incorporating two treatment steps: Step 1 – five sessions of self-guided ICBT and Step 2 – five sessions of therapist-guided ICBT. Participants completed diagnostic assessments at pre- and post-treatment, along with a battery of self-report questionnaires. Step-up requirements were determined at a mid-treatment assessment. Treatment response was determined by change on diagnostic severity and presence of diagnosis and changes in self-reported anxiety symptoms (through T-scores and Reliable Change Indices). Results In-depth examination of the three case studies showed that decisions to step-up from Step 1 to Step 2 were complex and required consideration of program engagement and adherence, as well as changes on self-reported anxiety, behavioural indicators of anxiety and parent perspectives. Results showed that non-responders at mid-treatment who were stepped-up to therapist-guided ICBT after Step 1 were able to increase engagement and response to treatment in Step 2, such that they were free of their primary anxiety diagnosis at post-treatment. Conclusions The findings highlight the importance of early assessment of engagement and non-response within self-guided ICBT programs for youth anxiety and the positive changes that can subsequently occur when therapist-guidance is introduced mid-treatment for non-responders. The efficacy of stepped-care ICBT models needs to be confirmed in larger randomised controlled trials

Unsettling moods in rural midwifery practice.

Background: Rural midwifery and maternity care is vulnerable due to geographical isolation, staffing recruitment and retention. Highlighting the concerns within rural midwifery is important for safe sustainable service delivery. Method: Hermeneutic phenomenological study undertaken in New Zealand (NZ). 13 participants were recruited in rural regions through snowball technique and interviewed. Transcribed interview data was interpretively analysed. Findings are discussed through the use of philosophical notions and related published literature. Findings: Unsettling mood of anxiety was revealed in two themes (a) 'Moments of rural practice' as panicky moments; an emergency moment; the unexpected moment and (b) 'Feelings of being judged' as fearing criticism; fear of the unexpected happening to 'me' fear of losing my reputation; fear of feeling blamed; fear of being identified. Conclusions: Although the reality of rural maternity can be more challenging due to geographic location than urban areas this need not be a reason to further isolate these communities through negative judgement and decontextualized policy. Fear of what was happening now and something possibly happening in the future were part of the midwives' reality. The joy and delight of working rurally can become overshadowed by a tide of unsettling and disempowering fears. Implications: Positive images of rural midwifery need dissemination. It is essential that rural midwives and their communities are heard at all levels if their vulnerability is to be lessened and sustainable safe rural communities strengthened

Identifying integrated health services and social care research priorities in kidney disease in Wales: research prioritisation exercise

Objectives To identify the shared research priorities of patients, caregivers and multidisciplinary renal health and social care professionals across Wales for integrated renal health and social care in Wales.Design Research priority setting exercise adapted from the James Lind Alliance national priority setting partnership framework in UK healthcare.Setting Two workshops: one in North Wales with patients, caregivers and multidisciplinary renal health and social care professionals and one in South Wales with the Welsh Renal Clinical Network (commissioners of renal services in Wales). Additional input provided from stakeholders via email correspondence and face to face communications.Participants Academics n=14, patients n=16, family/carers n=6, multidisciplinary renal healthcare professionals n=40, local authority councils n=3, renal charities n=6 wider third sector organisations n=8, renal industries n=4, Welsh government social care n=3, renal service commissioners n=8.Results 38 research priority questions grouped into 10 themes were agreed. The themes included: (1) integrating health and social care, (2) education, (3) acute kidney injury, (4) chronic kidney disease and cardiovascular disease, (5) transplantation, (6) dialysis, (7) personalised medicines, (8) cross-cutting priorities, (9) specific social contexts and (10) transitional services and children. Research questions were broad and covered a range of health and social care topics. Patient and professional perspectives broadly overlapped. Research priority setting activities revealed gaps in knowledge in overall service provision and potential areas for service improvement.Conclusions Mapping priorities in health services and social care highlighted the research needed to support renal health services delivery and commissioning in Wales

Limited Copies and Leased References for Distributed Persistent Objects

As businesses become global organisations and as e-commerce opens up markets to customers across the Internet, demand grows for increasingly ambitious distributed software applications and platforms. Where these applications run over potentially huge collections of data, sophisticated management of data storage and communication is required. There is a need for well-integrated persistence and distribution support that considers the implications for long-term maintenance of valuable persistent data. Orthogonal persistence is intended to ease the programmer's job by providing support for data management that is integrated with a programming language. The simplicity of the orthogonal persistence model argues for its use in distributed systems, in order to make life simpler for the application programmer. PJRMI is an implementation of Java RMI for the orthogonally-persistent PJama platform. This dissertation addresses two problem areas raised by combining orthogonal persistence with support for distributed applications. These problem areas are illustrated by PJRMI. The first problem is raised as a consequence of attempting to provide the illusion of a persistent connection between stores. Distribution-related errors easily break this illusion. In an open system, it can be difficult to determine when an object should become persistent by remote reachability. In the long term, persistent references to remote objects threaten the maintainability of the persistent stores involved. A solution has been implemented to address the problems raised by maintaining persistent references between distributed stores. Greater autonomy of individual stores is achieved by limiting remote access to objects to a duration of time associated with a specific distributed application's lifetime. Within the application's lifetime, the benefits are retained of persistence of inter-store references for resilience. The second problem is encountered when copying object graphs between stores. Large object graphs tend to build up in persistent stores over time. Copying such large object graphs can be prohibitively expensive in terms of resources and performance. A programmer may assume that the size of graph they are copying is acceptable, based on their knowledge of a system in its infancy. However, the problem is that, in a long-lived system, their assumptions may be challenged, since the size of an object graph and the context in which it is used are more likely to change during a persistent object graph's lifetime. The combination of a typically statically-defined policy for passing objects to remote sites and programmer assumptions that fail to take into account the lifetime of an object can also result in other problems. These problems include failure to support different requirements on remote use of the same object graph by different applications during that object graph's lifetime. A solution has been implemented to address the problems raised by remote copying of large object graphs. Flexibility of control over such copying is achieved. Separation of policy from object definition ensures flexibility. Choice of object-copying policy for a specific distributed application's lifetime provides control, while ensuring it is adaptable to changes in size of persistent object graphs over their lifetime and to changes in the context in which these graphs are used

Improving student writing: working in partnership to develop the Student Academic Literacy Tool (SALT)

Developing an effective academic writing style can be a crucial determinant for degree success in undergraduate programmes which rely almost exclusively on written assessments to measure academic ability. The SALT project has brought together academic staff and students to develop an accessible and useful tool to enable students to recognise the characteristics of academic writing which need to be developed in order to be successful in written assessments. Crucial to the success of the project so far has been the involvement of student research partners as co-creators and owners of the tool. This report describes the development of the project and presents a model of partnership working in academic research which recognises the importance of students as owners of co-created research outputs and intellectual property

Exploring the role of the Phosphatidylinositol-3'-Kinase (PI3K) pathway in primordial follicle activation and subsequent development

Mammalian females form their germ cells (oocytes) before or shortly after birth. The oocytes interact with somatic cells to form primordial follicles, creating the quiescent population from which oocytes will be recruited to grow throughout life. A female’s fertility life span is therefore, dependant on the size of this pool and the rate at which primordial follicle are activated to grow. However, there is still much we do not know about the quiescent follicle population and the mechanisms that control their recruitment into the growing follicle population are still unclear. There is evidence that the phosphoinositide-3-kinase (PI3K) pathway is key to activation of follicle growth. The role of the PI3K pathway has been primarily explored in the rodent model and has highlighted this pathway’s importance both in the activation of quiescent follicle growth and maintaining dormancy of the quiescent follicle population. This thesis aimed to explore if the PI3K pathway played a similar role in a large mono-ovulatory species as it does in the small polyovulatory rodent species. Bovine is a mono-ovulate species, which has similar attributes in its reproduction and folliculogenesis to the human in vivo; therefore using an in vitro bovine model might be a valuable indication of the role of the PI3K pathway in the human. Initial experiments tested if the bovine was a good model for human primordial follicle activation in an in vitro environment. It was observed that the bovine and human had comparative levels of activation and subsequent increases in both the primary and secondary follicle populations within an in vitro culture system. These similarities indicate that the bovine is a relevant model for the human in vitro. It is not possible to culture the entire bovine ovary. Therefore knowing the location of the primordial follicles is important to establishing what region(s) of the ovary to use. The overall concentration of ovarian follicles was higher in the cortex and gradually declined through the consecutive inner layers of the ovary. The distribution of the ovarian follicle populations were different in each distinctive region of the ovary with the quiescent follicles representing a much larger proportion of the ovarian follicle population in the cortex compared to the inner regions of the ovary. The location an ovarian follicle in the ovary was seen to influence its health in both the quiescent and growing follicle populations, with reduced health seen in the IV inner layers of the ovary compared to the cortex. This resulted in very few healthy quiescent follicles outside of the cortex region making it the more favourable region to culture in functional studies. The role of the PI3K pathway was therefore explored using an in vitro bovine model using the pharmacological compounds bpV (HOpic) and 740Y-P, both of which caused an up-regulation of the PI3K-pathway. It was observed that up-regulation of the PI3K pathway caused an increase in the activation of the quiescent follicle population, and the resulting primary follicles were larger in size. However, there was reduced health in both the growing and quiescent follicle populations. The ill health appears to be due to a disruption in the co-ordination of growth between oocyte and granulosa cells in the ovarian follicles, leading to enlarged oocytes in both the primary follicles and quiescent follicles. Although the PI3K pathway caused an increase in quiescent follicle activation and larger primary follicles there was no increase in the number of viable large secondary follicles obtained. The growth of the secondary follicles was unaltered by the initial activation of the quiescent follicles via the PI3K pathway. These experiments show that the PI3K pathway plays a role in primordial follicle activation in large mono-ovulate species. However, up-regulating the PI3K pathway results in a decrease in health of the quiescent and primary follicle populations, thus limiting its immediate value as a therapeutic target. This study has improved our understanding of the role of the PI3K pathway in primordial follicle activation in a large mono-ovulate species. It has highlighted that the up-regulation of the PI3K pathway using both bpV (HOpic) and 740Y-P increases the activation of the bovine ovarian follicles in vitro. However, up-regulating the PI3K pathway disrupts the development of the ovarian follicles resulting in retarded growth and thereby a decrease in the survival of both the quiescent and growing follicle populations. The similarities in activation, growth and development between the bovine and the human in vitro indicate that the results observed in the bovine are a good indication of what would occur in the human. This study has also improved our understanding of the location, distribution and viability of the ovarian follicle population within the ovary