Microbiological insights into respiratory infections and the opportunities for inhaled therapy

Respiratory infections represent the fourth most common cause of all deaths across age groups and countries. Treating these infections appropriately is a clear clinical priority and here we outline the types of therapy that are in current use for some of these infections. It is important that treatments are further improved and the potential of inhaled delivery to fulfil this need is considered. We describe novel methodologies that are being applied for the identification and enumeration of microorganisms in the respiratory tract, and propose that ways of improving therapy may arise from understanding better the etiology of respiratory infection and the impact of inhaled drug therapies. The potential for translational benefits for patients are also discussed.

Non-replication of the association between 5HTTLPR and response to psychological therapy for child anxiety disorders

Background We previously reported an association between 5HTTLPR genotype and outcome following cognitive–behavioural therapy (CBT) in child anxiety (Cohort 1). Children homozygous for the low-expression short-allele showed more positive outcomes. Other similar studies have produced mixed results, with most reporting no association between genotype and CBT outcome. Aims To replicate the association between 5HTTLPR and CBT outcome in child anxiety from the Genes for Treatment study (GxT Cohort 2, n = 829). Method Logistic and linear mixed effects models were used to examine the relationship between 5HTTLPR and CBT outcomes. Mega-analyses using both cohorts were performed. Results There was no significant effect of 5HTTLPR on CBT outcomes in Cohort 2. Mega-analyses identified a significant association between 5HTTLPR and remission from all anxiety disorders at follow-up (odds ratio 0.45, P = 0.014), but not primary anxiety disorder outcomes. Conclusions The association between 5HTTLPR genotype and CBT outcome did not replicate. Short-allele homozygotes showed more positive treatment outcomes, but with small, non-significant effects. Future studies would benefit from utilising whole genome approaches and large, homogenous samples.

The Cognitive Behaviour Therapy Scale for Children and Young People (CBTS-CYP): development and psychometric properties

Background: There is increased interest in developing training in cognitive behaviour therapy (CBT) with children and young people. However, the assessment of clinical competence has relied upon the use of measures such as the Cognitive Therapy Scale-Revised (CTSR: Blackburn et al., 2001) which has been validated to assess competence with adults. The appropriateness of this measure to assess competence when working with children and young people has been questioned. Aim: This paper describes the development and initial evaluation of the Cognitive Behaviour Therapy Scale for Children and Young People (CBTSCYP) developed specifically to assess competence in CBT with children and young people. Method: A cross section of child CBT practitioners (n = 61) were consulted to establish face validity. Internal reliability, convergent validity and discriminative ability were assessed in two studies. In the first, 12 assessors independently rated a single video using both the Cognitive Behaviour Therapy Scale for Children and Young People (CBTS-CYP) and Cognitive Therapy Scale-Revised (CTS-Revised: Blackburn et al., 2001). In the second, 48 different recordings of CBT undertaken with children and young people were rated on both the CBTS-CYP and CTS-R. Results: Face validity and internal reliability of the CBTS-CYP were high, and convergent validity with the CTS-R was good. The CBTS-CYP compared well with the CTSR in discriminative ability. Conclusion: The CBTS-CYP provides an appropriate way of assessing competence in using CBT with children and young people. Further work is required to assess robustness with younger children and the impact of group training in reducing interrater variations.

Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program

Background Anorexia Nervosa (AN) is a highly life-threatening disorder that is extremely difficult to treat. There is evidence that family-based therapies are effective for adolescent AN, but no treatment has been proven to be clearly effective for adult AN. The methodological challenges associated with studying the disorder have resulted in recommendations that new treatments undergo preliminary testing prior to being evaluated in a randomized clinical trial. The aim of this study was to provide preliminary evidence on the effectiveness of a treatment program based on a novel adaptation of Dialectical Behavior Therapy (DBT) for adult Anorexia Nervosa (Radically Open-DBT; RO-DBT) that conceptualizes AN as a disorder of overcontrol. Methods Forty-seven individuals diagnosed with Anorexia Nervosa-restrictive type (AN-R; mean admission body mass index = 14.43) received the adapted DBT inpatient program (mean length of treatment = 21.7 weeks). Results Seventy-two percent completed the treatment program demonstrating substantial increases in body mass index (BMI; mean change in BMI = 3.57) corresponding to a large effect size (d = 1.91). Thirty-five percent of treatment completers were in full remission, and an additional 55% were in partial remission resulting in an overall response rate of 90%. These same individuals demonstrated significant and large improvements in eating-disorder related psychopathology symptoms (d = 1.17), eating disorder-related quality of life (d = 1.03), and reductions in psychological distress (d = 1.34). Conclusions RO-DBT was associated with significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating-disorder related psychopathology and increases in eating disorder-related quality of life in a severely underweight sample. These findings provide preliminary support for RO-DBT in treating AN-R suggesting the importance of further evaluation examining long-term outcomes using randomized controlled trial methodology.

Serotonin transporter [corrected] methylation and response to cognitive behaviour therapy in children with anxiety disorders

Anxiety disorders that are the most commonly occurring psychiatric disorders in childhood, are associated with a range of social and educational impairments and often continue into adulthood. Cognitive behaviour therapy (CBT) is an effective treatment option for the majority of cases, although up to 35-45% of children do not achieve remission. Recent research suggests that some genetic variants may be associated with a more beneficial response to psychological therapy. Epigenetic mechanisms such as DNA methylation work at the interface between genetic and environmental influences. Furthermore, epigenetic alterations at the serotonin transporter (SERT) promoter region have been associated with environmental influences such as stressful life experiences. In this study, we measured DNA methylation upstream of SERT in 116 children with an anxiety disorder, before and after receiving CBT. Change during treatment in percentage DNA methylation was significantly different in treatment responders vs nonresponders. This effect was driven by one CpG site in particular, at which responders increased in methylation, whereas nonresponders showed a decrease in DNA methylation. This is the first study to demonstrate differences in SERT methylation change in association with response to a purely psychological therapy. These findings confirm that biological changes occur alongside changes in symptomatology following a psychological therapy such as CBT.

Anticoagulant rodenticide uptake in resistant rat populations

The use of potent anticogulant rodenticide ‘resistance-breakers’ is avoided due to their higher toxicity and potential to be more hazardous in the environment [6]. However, in areas where practitioners seek to control resistant rodent infestations, their use may pose less of a risk than applications of ineffective baits. Compounds to which rodents are resistant to, do not provide effective control and create a long-term source of AR in the environment. The higher quantities of anticoagulant rodenticide used show that using ineffective compounds may extend both the period and severity of exposure to non-target animals to anticoagulant rodenticides. Conversely the effective use of resistance-breakers to control anticoagulant rodenticide-resistant rat populations results in lower environmental exposure of anticoagulant rodenticides for non-targets. Of course, the relative toxicity of the different anticoagulant rodenticides will also play an important part in overall risk assessments. However, this can be outweighed by the relative exposure to different anticoagulant rodenticides in such situations.

The current status of anticoagulant resistance in rats and mice in the UK

Introduction: Resistance to anticoagulants in Norway rats (Rattus norvegicus) and house mice (Mus domesticus) has been studied in the UK since the early 1960s. In no other country in the world is our understanding of resistance phenomena so extensive and profound. Almost every aspect of resistance in the key rodent target species has been examined in laboratory and field trials and results obtained by independent researchers have been published. It is the principal purpose of this document to present a short synopsis of this information. More recently, however, the development of genetical techniques has provided a definitive means of detection of resistant genotypes among pest rodent populations. Preliminary information from a number of such surveys will also be presented. Resistance in Norway rats: A total of nine different anticoagulant resistance mutations (single nucleotide polymorphisms or SNPs) are found among Norway rats in the UK. In no other country worldwide are present so many different forms of Norway rat resistance. Among these nine SNPs, five are known to confer on rats that carry them a significant degree of resistance to anticoagulant rodenticides. These mutations are: L128Q, Y139S, L120Q, Y139C and Y139F. The latter three mutations confer, to varying degrees, practical resistance to bromadiolone and difenacoum, the two second-generation anticoagulants in predominant use in the UK. It is the recommendation of RRAG that bromadiolone and difenacoum should not be used against rats carrying the L120Q, Y139C and Y139F mutations because this will promote the spread of resistance and jeopardise the long-term efficacy of anticoagulants. Brodifacoum, flocoumafen and difethialone are effective against these three genotypes but cannot presently be used because of the regulatory restriction that they can only be applied against rats that are living and feeding predominantly indoors. Our understanding of the geographical distribution of Norway rat resistance in incomplete but is rapidly increasing. In particular, the mapping of the focus of L120Q Norway rat resistance in central-southern England by DNA sequencing is well advanced. We now know that rats carrying this resistance mutation are present across a large part of the counties of Hampshire, Berkshire and Wiltshire, and the resistance spreads into Avon, Oxfordshire and Surrey. It is also found, perhaps as outlier foci, in south-west Scotland and East Sussex. L120Q is currently the most severe form of anticoagulant resistance found in Norway rats and is prevalent over a considerable part of central-southern England. A second form of advanced Norway rat resistance is conferred by the Y139C mutation. This is noteworthy because it occurs in at least four different foci that are widely geographically dispersed, namely in Dumfries and Galloway, Gloucestershire, Yorkshire and Norfolk. Once again, bromadiolone and difenacoum are not recommended for use against rats carrying this genotype and a concern of RRAG is that continued applications of resisted active substances may result in Y139C becoming more or less ubiquitous across much of the UK. Another type of advanced resistance, the Y139F mutation, is present in Kent and Sussex. This means that Norway rats, carrying some degree of resistance to bromadiolone and difenacoum, are now found from the south coast of Kent, west into the city of Bristol, to Yorkshire in the north-east and to the south-west of Scotland. This difficult situation can only deteriorate further where these three genotypes exist and resisted anticoagulants are predominantly used against them. Resistance in house mice: House mouse is not so well understood but the presence in the UK of two resistant genotypes, L128S and Y139C, is confirmed. House mice are naturally tolerant to anticoagulants and such is the nature of this tolerance, and the presence of genetical resistance, that house mice resistant to the first-generation anticoagulants are considered to be widespread in the UK. Consequently, baits containing warfarin, sodium warfarin, chlorophacinone and coumatetralyl are not approved for use against mice. This regulatory position is endorsed by RRAG. Baits containing brodifacoum, flocoumafen and difethialone are effective against house mice and may be applied in practice because house mouse infestations are predominantly indoors. There are some reports of resistance among mice in some areas to the second-generation anticoagulant bromadiolone, while difenacoum remains largely efficacious. Alternatives to anticoagulants: The use of habitat manipulation, that is the removal of harbourage, denial of the availability of food and the prevention of ingress to structures, is an essential component of sustainable rodent pest management. All are of importance in the management of resistant rodents and have the advantage of not selecting for resistant genotypes. The use of these techniques may be particularly valuable in preventing the build-up of rat infestations. However, none can be used to remove any sizeable extant rat infestation and for practical reasons their use against house mice is problematic. Few alternative chemical interventions are available in the European Union because of the removal from the market of zinc phosphide, calciferol and bromethalin. Our virtual complete reliance on the use of anticoagulants for the chemical control of rodents in the UK, and more widely in the EU, calls for improved schemes for resistance management. Of course, these might involve the use of alternatives to anticoagulant rodenticides. Also important is an increasing knowledge of the distribution of resistance mutations in rats and mice and the use of only fully effective anticoagulants against them.

Clinical predictors of response to cognitive-behavioural therapy in pediatric anxiety disorders: the Genes for Treatment (GXT) Study

Objective The Genes for Treatment study is an international, multisite collaboration exploring the role of genetic, demographic, and clinical predictors in response to cognitive-behavioral therapy (CBT) in pediatric anxiety disorders. The current article, the first from the study, examined demographic and clinical predictors of response to CBT. We hypothesized that the child’s gender, type of anxiety disorder, initial severity and comorbidity, and parents’ psychopathology would significantly predict outcome. Method A sample of 1,519 children 5 to 18 years of age with a primary anxiety diagnosis received CBT across 11 sites. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each time point (posttreatment, 3-, 6-, and/or 12-month follow-up) and analyzed using linear and logistic mixed models. Separate analyses were conducted using data from posttreatment and follow-up assessments to explore the relative importance of predictors at these time points. Results Individuals with social anxiety disorder (SoAD) had significantly poorer outcomes (poorer response and lower rates of remission) than those with generalized anxiety disorder (GAD). Although individuals with specific phobia (SP) also had poorer outcomes than those with GAD at posttreatment, these differences were not maintained at follow-up. Both comorbid mood and externalizing disorders significantly predicted poorer outcomes at posttreatment and follow-up, whereas self-reported parental psychopathology had little effect on posttreatment outcomes but significantly predicted response (although not remission) at follow-up. Conclusion SoAD, nonanxiety comorbidity, and parental psychopathology were associated with poorer outcomes after CBT. The results highlight the need for enhanced treatments for children at risk for poorer outcomes.

Process analysis of trauma-focused cognitive behavioural therapy for individuals with schizophrenia

Objective. Therapeutic alliance, modality, and ability to engage with the process of therapy have been the main focus of research into what makes psychotherapy successful. Individuals with complex trauma histories or schizophrenia are suggested to be more difficult to engage and may be less likely to benefit from therapy. This study aimed to track the in-session ‘process’ of working alliance and emotional processing of trauma memories for individuals with schizophrenia. Design. The study utilized session recordings from the treatment arm of an open randomized clinical trial investigating trauma-focused cognitive behavioural therapy (TF-CBT) for individuals with schizophrenia (N = 26). Method. Observer measures of working alliance, emotional processing, and affect arousal were rated at early and late phases of therapy. Correlation analysis was undertaken for process measures. Temporal analysis of expressed emotions was also reported. Results. Working alliance was established and maintained throughout the therapy; however, agreement on goals reduced at the late phase. The participants appeared to be able to engage in emotional processing, but not to the required level for successful cognitive restructuring. Conclusion. This study undertook novel exploration of process variables not usually explored in CBT. It is also the first study of process for TF-CBT with individuals with schizophrenia. This complex clinical sample showed no difficulty in engagement; however, they may not be able to fully undertake the cognitive–emotional demands of this type of therapy. Clinical and research implications and potential limitations of these methods are considered.

The application of a domains based analysis to family processes: implications for assessment and therapy

Social domains are classes of interpersonal processes each with distinct procedural rules underpinning mutual understanding, emotion regulation and action. We describe the features of three domains of family life – safety, attachment and discipline/expectation – and contrast them with exploratory processes in terms of the emotions expressed, the role of certainty versus uncertainty, and the degree of hierarchy in an interaction. We argue that everything that people say and do in family life carries information about the type of interaction they are engaged in – that is, the domain. However, sometimes what they say or how they behave does not make the domain clear, or participants in the social interactions are not in the same domain (there is a domain mismatch). This may result in misunderstandings, irresolvable arguments or distress. We describe how it is possible to identify domains and judge whether they are clear and unclear, and matched and mismatched, in observed family interactions and in accounts of family processes. This then provides a focus for treatment and helps to define criteria for evaluating outcomes.

Aberrant brain responses to emotionally valent words is normalised after cognitive behavioural therapy in female depressed adolescents

AbstractBackground Depression in adolescence is debilitating with high recurrence in adulthood, yet its pathophysiological mechanism remains enigmatic. To examine the interaction between emotion, cognition and treatment, functional brain responses to sad and happy distractors in an affective go/no-go task were explored before and after Cognitive Behavioural Therapy (CBT) in depressed female adolescents, and healthy participants. Methods Eighty-two Depressed and 24 healthy female adolescents, aged 12 to 17 years, performed a functional magnetic resonance imaging (fMRI) affective go/no-go task at baseline. Participants were instructed to withhold their responses upon seeing happy or sad words. Among these participants, 13 patients had CBT over approximately 30 weeks. These participants and 20 matched controls then repeated the task. Results At baseline, increased activation in response to happy relative to neutral distractors was observed in the orbitofrontal cortex in depressed patients which was normalized after CBT. No significant group differences were found behaviourally or in brain activation in response to sad distractors. Improvements in symptoms (mean: 9.31, 95% CI: 5.35-13.27) were related at trend-level to activation changes in orbitofrontal cortex. Limitations In the follow-up section, a limited number of post-CBT patients were recruited. Conclusions To our knowledge, this is the first fMRI study addressing the effect of CBT in adolescent depression. Although a bias toward negative information is widely accepted as a hallmark of depression, aberrant brain hyperactivity to positive distractors was found and normalised after CBT. Research, assessment and treatment focused on positive stimuli could be a future consideration. Moreover, a pathophysiological mechanism distinct from adult depression may be suggested and awaits further exploration.