Manoharan Andiappan

Cognitive behaviour therapy for chronic fatigue syndrome in adults: face to face versus telephone treatment: a randomized controlled trial.

BACKGROUND Previous research has shown that face to face cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS)/Myalgic Encephalomyelitis (ME). However, some patients are unable to travel to the hospital for a number of reasons. AIMS The aim of this study was to assess whether face to face CBT was more effective than telephone CBT (with face to face assessment and discharge appointment) for patients with CFS. METHOD Patients aged 18-65 were recruited from consecutive referrals to the Chronic Fatigue Syndrome (CFS) Research and Treatment Unit at The South London and Maudsley NHS Trust in London. Participants were randomly allocated to either face to face CBT or telephone CBT by a departmental administrator. Blinding of participants and care givers was inappropriate for this trial. A parallel-groups randomised controlled trial was used to compare the two treatments. The primary outcomes were physical functioning and fatigue. RESULTS Significant improvements in the primary outcomes of physical functioning and fatigue occurred and were maintained to one year follow-up after discharge from treatment. Improvements in social adjustment and global outcome were noted and patient satisfaction was similar in both groups. CONCLUSIONS Results from this study indicate that telephone CBT with two face to face appointments is a mild to moderately effective treatment for CFS and may be offered to patients where face to face treatment is not a viable option. Despite these encouraging conclusions, dropout was relatively high and therapists should be aware of this potential problem.

The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial.

Insomnia is a very common and disabling symptom. Whilst evidence for the efficacy of cognitive behavioural therapy for people diagnosed with insomnia (CBT‐I) is strong, few people seek help and not many services offer CBT‐I. Less intensive adaptations of CBT‐I have been shown to be valuable, and given the size of the problem and low rates of help‐seeking, an accessible intervention with a large capacity is needed. Day‐long CBT‐I psycho‐educational workshops (each for up to 30 people), to which members of the public with insomnia symptoms could self‐refer, have been developed. This randomised controlled trial aimed to evaluate the effectiveness of these workshops. Baseline measures were taken from 151 participants, who were then randomised to experimental or waiting‐list control groups. Scores of the experimental group and the control group were compared 3 months after baseline. Random effects models found a significant interaction between time and group, indicating differences between the control and experimental groups on the Insomnia Severity Index (ISI). Post hoc analyses indicated that ISI scores decreased significantly in the experimental group, but not in the control group. Promising results were also found on corroborative sleep diary measures. Access to the workshops was good, with 50% of participants having never previously sought help for sleep difficulties from their GP. CBT‐I workshops proved to be both accessible and effective in reducing insomnia symptoms in the medium term. They may represent a feasible brief intervention with the potential to address unmet treatment needs of adults complaining of insomnia symptoms.

Questionnaires for 360-degree assessment of consultant psychiatrists: development and psychometric properties

BACKGROUND Expert clinical judgement combines technical proficiency with humanistic qualities. AIMS To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback. METHOD Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients. RESULTS Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbachs alpha >0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Erho(2)) of 0.75. CONCLUSIONS Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.

Comparing the In Vivo Diagnostic Accuracy of Digital Periapical Radiography with Cone-beam Computed Tomography for the Detection of Vertical Root Fracture

INTRODUCTION The purpose of this study was to determine whether there is a difference in the in vivo diagnostic accuracy of digital radiography (DR) and cone-beam computed tomography (CBCT) imaging in the detection of vertical root fracture (VRF). The presence/absence of VRF was confirmed by visual inspection of the extracted root surface and was the reference standard against which both imaging modalities were compared. METHODS Twenty-one unsalvageable teeth from 20 patients that had been radiographed and scanned with CBCT imaging were included in the study. The teeth were atraumatically extracted and visually inspected under a microscope to confirm the presence/absence of fracture. The widest point of each fracture was recorded using an optical coherence tomography scanner in order to quantify the size of fractures. Images were viewed under standardized conditions by 13 examiners and repeated 2 weeks later to assess their consistency. RESULTS DR and CBCT imaging showed similarly poor sensitivity of 0.16 and 0.27, respectively. Both imaging modalities had similarly high specificity of 0.92 and 0.83, respectively. There was no statistical difference between the diagnostic accuracy of either imaging modality. Fracture width did not affect the detection rate of either imaging modality. Receiver operating characteristic analysis revealed mean Az values of 0.535 and 0.552 for DR and CBCT imaging, respectively. CONCLUSIONS Both DR and CBCT imaging have significant limitations when detecting vertical root fractures.

Repetitive transcranial magnetic stimulation reduces cortisol concentrations in bulimic disorders

BACKGROUND In people with bulimic eating disorders, exposure to high-calorie foods can result in increases in food craving, raised subjective stress and salivary cortisol concentrations. This cue-induced food craving can be reduced by repetitive transcranial magnetic stimulation (rTMS). We investigated whether rTMS has a similar effect on salivary cortisol concentrations, a measure of hypothalamic-pituitary-adrenal axis (HPAA) activity. METHOD We enrolled twenty-two female participants who took part in a double-blind randomized sham-controlled trial on the effects of rTMS on food craving. Per group, eleven participants were randomized to the real or sham rTMS condition. The intervention consisted of one session of high-frequency rTMS delivered to the left dorsolateral prefrontal cortex (DLPFC). Salivary cortisol concentrations were assessed at four time points throughout the 90-min trial. To investigate differences in post-rTMS concentrations between the real and sham rTMS groups, a random-effects model including the pre-rTMS cortisol concentrations as covariates was used. RESULTS Salivary cortisol concentrations following real rTMS were significantly lower compared with those following sham rTMS. In this sample, there was also a trend for real rTMS to reduce food craving more than sham rTMS. CONCLUSIONS These results suggest that rTMS applied to the left DLPFC alters HPAA activity in people with a bulimic disorder.

Outcome, Costs and Patient Engagement for Group and Individual CBT for Depression: A Naturalistic Clinical Study

BACKGROUND AND METHOD This naturalistic study was undertaken in routine settings and compared the clinical effectiveness, costs, treatment preference, attrition and patient satisfaction of Group and Individual CBT. RESULTS No significant differences were found in depressive and distress symptoms between group and individual CBT at post-treatment and follow-up. Individual CBT was 1.5 times more expensive to provide than Group CBT and the wider costs of other supports were similar between study arms suggesting a cost-effectiveness advantage for Group CBT. Patients preferred individual treatment at baseline but, despite this, there were no between-group differences in attrition or satisfaction. CONCLUSION A larger RCT study is needed, but running CBT groups for depression could be considered more frequently by clinicians.

The Effect of Alteration of the Exposure Parameters of a Cone-beam Computed Tomographic Scan on the Diagnosis of Simulated Horizontal Root Fractures

INTRODUCTION The purpose of this study was to determine the effect of alteration of the exposure parameters of a cone-beam computed tomographic (CBCT) scan on the detection of the presence or absence of simulated horizontal root fractures (HRFs). METHODS CBCT scans of the lower incisor region of 5 human, dentate, dry mandibles were performed with 11 different exposure parameters. Ten teeth were extracted, and simulated HRFs were created near the apical thirds of the root. The fragments were reattached and the teeth replanted. The mandibles were rescanned over the same range of exposure parameters. Receiver operator characteristic analysis and kappa analyses were performed to assess diagnostic accuracy and intra- and interexaminer agreement for each scan setting. RESULTS The overall Az value (area under receiver operator curve) for the manufacturers default setting was 0.95. The sensitivity was 0.94 and the specificity 0.96. A reduction in the tube current to 2 mA at 360° or 180° of rotation had no significant impact on the Az value, sensitivity, or specificity of CBCT imaging in the detection simulated HRFs. A reduction in the current to 1 mA at 360° or 180° of rotation significantly reduced the Az value (0.9 and 0.75, respectively) in comparison with the manufacturers default setting (P < .05). CONCLUSIONS CBCT scans are an accurate and reliable technique to detect HRFs. Within the limitations of this study, it is possible to reduce the radiation dose by altering the exposure parameters without a significant reduction in the diagnostic quality of the CBCT scan generated for the detection of HRFs.

The detection of periapical pathoses in root filled teeth using single and parallax periapical radiographs versus cone beam computed tomography - a clinical study.

AIM To clinically assess the diagnostic yield from single parallel periapical, two parallax radiographs and cone beam computed tomography (CBCT) by comparing the prevalence of periapical lesions associated with individual roots, and the total number of root canals in root-treated teeth in patients referred for root canal retreatment. METHODOLOGY Single and parallax periapical radiographs, and CBCT scans, were taken of 100 teeth in 78 patients who had been referred for root canal retreatment. The presence of a periapical lesion associated with each specific root and the number of identifiable root canals were assessed using each imaging modality by a consensus panel of two examiners. The number of root canals was confirmed using the dental-operating microscope during treatment. In addition, the panel was asked to decide whether they felt they had adequate information to manage each case. RESULTS A total of 209 paired roots were assessed for periapical lesions. Lesions were identified in 41%, 38% and 68% of paired roots when using single radiographs, two parallax radiographs and CBCT respectively. The number of root canals identified were 186, 218, 242 and 239 when using parallel, parallax, CBCT and the dental-operating microscope, respectively. CONCLUSIONS CBCT detected significantly more periapical lesions and root canals than both single and parallax periapical radiographs. There was no significant difference between CBCT and the clinical microscope in the identification of root canals. Whilst two parallax radiographs detect significantly more root canals than a single radiograph, they did not increase detection of periapical lesions when compared to a single periapical radiograph.

Malocclusion, orthodontic treatment, and the Oral Health Impact Profile (OHIP-14): Systematic review and meta-analysis

OBJECTIVE To synthesize evidence on the impact of malocclusion and its associated treatment on peoples quality of life across studies that used the Oral Health Impact Profile (OHIP-14) questionnaire in the adult population. MATERIALS AND METHODS A systematic search of the English literature using Medline, PubMed, and EMBASE yielded 98 unique citations. Studies using OHIP-14 with individuals 15 years of age and older were included. After initial screening, 64 citations were excluded and another 9 were excluded after reading full text reports; the remaining 25 were included in the review. All studies were observational and used one of three study designs: 11 compared the same group before and after treatment (pre-post design), 10 compared groups with and without malocclusion (independent groups design) and four compared an orthodontically treated group with an independent group requiring treatment (treated-untreated groups design). Only three studies using the pre-post design and four using the independent groups design reported comparable OHIP-14 data and were combined in separate meta-analyses. Meta-analysis was carried out using metan command in Stata. RESULTS The standardized mean difference (SMD) in OHIP-14 total score was 1.29 (95% CI: 0.67 to 1.92) for the three studies using the pre-post design. Similarly, the SMD score was 0.84 (95% CI: 0.25 to 1.43) for the four studies using the independent groups design. There was evidence of high heterogeneity and publication bias among the studies included. CONCLUSIONS This meta-analysis revealed that OHIP-14 scores were significantly lower after receiving treatment for malocclusion and in individuals without malocclusion/orthodontic treatment need compared to those with such condition (independent groups).

Dental Age Estimation: A Test of the Reliability of Correctly Identifying a Subject Over 18 Years of Age Using the Gold Standard of Chronological Age as the Comparator

This study was designed to test the reliability of using the third molars to demarcate between child and adult status. A total of 2000 dental panoramic tomographs were used for assessment of the calculated age using the 8‐stage system of tooth development and applied to all four third molars. The LL8 was also assessed using this 8‐stage system. For each tooth development stage, the Normal distribution and percentile summary data were estimated. The calculated dental age compared with the chronological age was statistically significantly different (p < 0.001) for both females and males giving underestimates of the true age. Comparison of single tooth dental age and chronological age was only slightly different. The most important finding is that the assignment to above or below the 18‐year threshold, in the age range 17 years to 19 years, could be wrong on up to 50% of occasions.