Recurrent FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking.
We performed a retrospective multicentre study of ...patients with recurrent FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical and prognostic variables independently associated with final diagnosis and mortality.
Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR = 5.2; p < 0.001), contributory history (OR = 10.4; p < 0.001), and abnormal clinical examination (OR = 4.0; p = 0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p = 0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death.
This study extends the known yield of recurrent FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow-up. Moreover, their overall prognosis is excellent.
Fully automated self-help interventions can serve as highly cost-effective mental health promotion tools for massive amounts of people. However, these interventions are often characterised by poor ...adherence. One way to address this problem is to mimic therapy support by a conversational agent. The objectives of this study were to assess the effectiveness and adherence of a smartphone app, delivering strategies used in positive psychology and CBT interventions via an automated chatbot (Shim) for a non-clinical population — as well as to explore participants' views and experiences of interacting with this chatbot. A total of 28 participants were randomized to either receive the chatbot intervention (n=14) or to a wait-list control group (n=14). Findings revealed that participants who adhered to the intervention (n=13) showed significant interaction effects of group and time on psychological well-being (FS) and perceived stress (PSS-10) compared to the wait-list control group, with small to large between effect sizes (Cohen's d range 0.14–1.06). Also, the participants showed high engagement during the 2-week long intervention, with an average open app ratio of 17.71 times for the whole period. This is higher compared to other studies on fully automated interventions claiming to be highly engaging, such as Woebot and the Panoply app. The qualitative data revealed sub-themes which, to our knowledge, have not been found previously, such as the moderating format of the chatbot. The results of this study, in particular the good adherence rate, validated the usefulness of replicating this study in the future with a larger sample size and an active control group. This is important, as the search for fully automated, yet highly engaging and effective digital self-help interventions for promoting mental health is crucial for the public health.
•To our knowledge, this is the first RCT for promoting mental health in a non-clinical population via a conversational agent.•Completer analysis showed significant interaction effects on well-being and perceived stress compared to a control group.•Participants showed high engagement, with an average open app ratio of 17.71 times during the intervention.•Qualitative data add important knowledge specific for a Chatbot, including the ability to build a relationship with its user.•The results validated the usefulness of replicating this small-scale pilot study in a future full-scale RCT.
There is need for more cost and time effective treatments for depression. This is the first randomised controlled trial in which a blended treatment--including four face-to-face sessions and a ...smartphone application--was compared against a full behavioural treatment. Hence, the aim of the current paper was to examine whether a blended smartphone treatment was non-inferior to a full behavioural activation treatment for depression.
This was a randomised controlled non-inferiority trial (NCT01819025) comparing a blended treatment (n=46) against a full ten-session treatment (n=47) for people suffering from major depression. Primary outcome measure was the BDI-II, that was administered at pre- and post-treatment, as well as six months after the treatment.
Results showed significant improvements in both groups across time on the primary outcome measure (within-group Cohen's d=1.35; CI -0.82, 3.52 to d=1.47; CI -0.41, 3.35; between group d=-0.13 CI -2.37, 2.09 and d=-0.10 CI -2.53, 2.33). At the same time, the blended treatment reduced the therapist time with an average of 47%.
We could not establish whether the blended treatment was non-inferior to a full BA treatment. Nevertheless, this study points to that the blended treatment approach could possibly treat nearly twice as many patients suffering from depression by using a smartphone application as add-on. More studies are needed before we can suggest that the blended treatment method is a promising cost-effective alternative to regular face-to-face treatment for depression.
Cognitive Behavioral Therapy Treatment of Depression With Smartphone Support NCT01819025.
Objectives Evaluating and comparing the effectiveness of two smartphone-delivered treatments: one based on behavioural activation (BA) and other on mindfulness. Design Parallel randomised controlled, ...open, trial. Participants were allocated using an online randomisation tool, handled by an independent person who was separate from the staff conducting the study. Setting General community, with recruitment nationally through mass media and advertisements. Participants 40 participants diagnosed with major depressive disorder received a BA treatment, and 41 participants received a mindfulness treatment. 9 participants were lost at the post-treatment. Intervention BA: An 8-week long behaviour programme administered via a smartphone application. Mindfulness: An 8-week long mindfulness programme, administered via a smartphone application. Main outcome measures The Beck Depression Inventory-II (BDI-II) and the nine-item Patient Health Questionnaire Depression Scale (PHQ-9). Results 81 participants were randomised (mean age 36.0 years (SD=10.8)) and analysed. Results showed no significant interaction effects of group and time on any of the outcome measures either from pretreatment to post-treatment or from pretreatment to the 6-month follow-up. Subgroup analyses showed that the BA treatment was more effective than the mindfulness treatment among participants with higher initial severity of depression from pretreatment to the 6-month follow-up (PHQ-9: F (1, 362.1)=5.2, p<0.05). In contrast, the mindfulness treatment worked better than the BA treatment among participants with lower initial severity from pretreatment to the 6-month follow-up (PHQ-9: F (1, 69.3)=7.7, p<0.01); BDI-II: (F(1, 53.60)=6.25, p<0.05). Conclusions The two interventions did not differ significantly from one another. For participants with higher severity of depression, the treatment based on BA was superior to the treatment based on mindfulness. For participants with lower initial severity, the treatment based on mindfulness worked significantly better than the treatment based on BA. Trial registration Clinical Trials NCT01463020.
Highlights • The first study on Internet-delivered ACT for social anxiety and panic symptoms. • Significant reduction observed in general and social anxiety symptoms. • Promising results for ...reduction of panic symptoms with large within-group effect. • Smartphone applications may be able to partially compensate for lack of therapist support.
Assessment and outcome monitoring are critical for the effective detection and treatment of mental illness. Traditional methods of capturing social, functional, and behavioral data are limited to the ...information that patients report back to their health care provider at selected points in time. As a result, these data are not accurate accounts of day-to-day functioning, as they are often influenced by biases in self-report. Mobile technology (mobile applications on smartphones, activity bracelets) has the potential to overcome such problems with traditional assessment and provide information about patient symptoms, behavior, and functioning in real time. Although the use of sensors and apps are widespread, several questions remain in the field regarding the reliability of off-the-shelf apps and sensors, use of these tools by consumers, and provider use of these data in clinical decision-making.
La polymyosite est une myopathie inflammatoire auto-immune rare, s’associant à un cancer dans 15 à 20 % des cas. L’atteinte cardiaque, probablement sous-estimée pour de nombreux patients, grève le ...pronostic et peut se manifester par des anomalies électriques, une vascularite coronaire, une myocardite inflammatoire, une péricardite ou un prolapsus mitral. Il est souvent difficile d’attribuer une atteinte cardiaque sur la simple biologie (Créatine Kinase CPK ou troponine), souvent le reflet de l’atteinte myositique globale. Nous rapportons ici le cas d’une patiente présentant une myosite auto-immune accompagnée d’une « fausse » élévation de la troponine.
Il s’agit d’une patiente de 58ans souffrant d’une polyarthrite rhumatoïde anti-CCP positive, diagnostiquée 4ans auparavant, traitée par corticoïdes et methotrexate puis abatacept. Depuis plusieurs mois, sont apparus une asthénie, un amaigrissement de 4kg et une faiblesse musculaire des ceintures confirmée par électromyogramme (syndrome myogène). La biologie montrait : CPK à 1884UI/L, ASAT à 68UI/L, troponine ultra sensible (US) à 1088ng/L, BNP<50 ng/L, des anti-Mi2 positifs et des facteurs rhumatoïdes à 3695UI/mL.
La biopsie musculaire est évocatrice d’une myopathie inflammatoire auto-immune en faveur d’une myosite de chevauchement. Le tissu musculaire très altéré, est infiltré par de nombreuses cellules inflammatoires mononucléées, à prédominance endomysial. Certaines fibres sont en voie de nécrose et d’autres sont en voie de myophagocytose. Il n’a pas été vu de granulome, d’atrophie périfasciculaire, ni de franche augmentation du tissu conjonctif. Par ailleurs une origine néoplasique est éliminée.
Sur le versant cardiaque, l’élévation importante de la troponine US (>1000ng/ml) restait stable, contrastant avec une clinique et des explorations cardiaques normales (holter ECG, échographie, IRM cardiaque et coroscanner), faisant évoquer la possibilité d’une interférence sur le dosage de la troponine US avec la présence d’anticors hétérophiles ou anticorps humain anti-murins. Un dosage de la troponine Ic reviendra normal (<0,01μg/L) confirmant cette hypothèse.
L’hypothèse est la présence d’anticorps hétérophile anti-murins possiblement en lien avec la prise d’abatacept, composé d’une protéine de fusion murine, connue pour être responsable d’interférence du dosage de la troponine 1. Le principe de dosage de la troponine consiste à apporter un anticorps anti-troponine qui forme un pont avec les différentes formes de la troponine et émet une lumière détectée par l’automate 2. De ce fait, tout patient possédant des anticorps capables de reconnaître les anticorps utilisés dans ces techniques de type sandwich pourra présenter une élévation apparente de la concentration de troponine.
Certaines trousses de dosage utilisent des anticorps anti-troponine de type murin. L’utilisation thérapeutique d’anticorps monoclonaux murins est à l’origine d’une immunisation, conduisant à la formation d’anticorps humains anti-murins (HAMA) : ces derniers pourront se fixer sur la région idiotypique des anticorps utilisés dans la réaction de dosage et conduire à l’existence de faux positifs. De même, le facteur rhumatoïde est une immunoglobuline spécifique de la partie Fc des molécules d’IgG : ces facteurs pourront former des ponts avec les anticorps utilisés dans la réaction de dosage et conduire là encore à l’existence de faux positifs. L’incidence fréquente des interférences dues aux HAMA et au facteur rhumatoïde a conduit les fabricants à ajouter dans le milieu réactionnel des immunoglobulines bloquantes pour neutraliser les HAMA et le facteur rhumatoïde. Cependant, l’interférence peut se produire si la quantité d’agents bloquants est insuffisante par rapport à la quantité d’anticorps initialement présente dans le sérum du patient.
L’atteinte cardiaque dans les myosites est importante pour le pronostic. Elle est présente pour 10 à 15 % des patients présentant des myosites, à type trouble de conduction, trouble du rythme ou de la repolarisation, ou plus rarement d’une vascularite coronarienne ou une cardiomyopathie inflammatoire responsable d’une insuffisance cardiaque congestive. D’où l’intérêt d’effectuer des explorations cardiaques avec à minima ECG, Holter-ECG, échographie voire scintigraphie ou IRM cardiaque.
Des troponines US élevées au cours des myosites doit faire évoquer des interférences dans ce contexte auto-immun. Nous préconisons dans ce cas, après réalisation d’un bilan cardiaque exhaustif, le dosage de la troponine Ic.
The need for cost-effective interventions for people suffering from major depressive disorders is essential. Behavioral activation is an intervention that can largely benefit from the use of new ...mobile technologies (for example smartphones). Therefore, developing smartphone-based behavioral activation interventions might be a way to develop cost-effective treatments for people suffering from major depressive disorders. The aim of this study will be to test the effects of a smartphone-delivered behavioral activation treatment.
The study will be a randomized controlled trial with a sample size of 120 participants, with 60 patients in each group. The treatment group includes an 8-week smartphone-based behavioral activation intervention, with minimal therapist contact. The smartphone-based intervention consists of a web-based psychoeducation, and a smartphone application. There is also a back-end system where the therapist can see reports from the patients or activities being reported. In the attention control group, we will include brief online education and then recommend use of a smartphone application that is not directly aimed at depression (for example, 'Effective meditation'). The duration of the control condition will also be 8 weeks. For ethical reasons we will give the participants in the control group access to the behavioral activation treatment following the 8-week treatment period.
We believe that this trial has at least three important implications. First, we believe that smartphones can be integrated even further into society and therefore may serve an important role in health care. Second, while behavioral activation is a psychological treatment approach for which there is empirical support, the use of a smartphone application could serve as the therapist's prolonged arm into the daily life of the patient. Third, as we have been doing trials on guided Internet treatment for more than 10 years it is now time to move to the next generation of information technology - smartphones - which are not only relevant for Swedish conditions but also for developing countries in the world which are increasingly empowered by mobile phones with Internet connection.
ClinicalTrials.gov NCT01463020.
Smartphone technology presents a novel and promising opportunity to extend the reach of psychotherapeutic interventions by moving selected parts of the therapy into the real-life situations causing ...distress. This randomised controlled trial will investigate the effects of a transdiagnostic, Internet-administered cognitive behavioural (iCBT) self-help program for anxiety, supplemented with a smartphone application. The effect of added therapist support will also be studied.
One hundred and fifty participants meeting diagnostic criteria for social anxiety disorder and/or panic disorder will be evenly randomised to either one of three study groups: 1, smartphone-supplemented iCBT with therapist support; 2, smartphone-supplemented iCBT without therapist support; or 3, an active waiting list control group with delayed treatment. Primary outcome measure will be the Generalised Anxiety Disorder 7-item self-rating scale. Secondary measures include other anxiety, depression and quality of life measures. In addition to pre- and post-treatment measurements, the study includes two mid-treatment (days 24 and 48) and two follow-up assessments (12 and 36 months) to assess rapid and long-term effects.
To our knowledge, this is the first study to investigate the effectiveness of smartphone-supplemented iCBT for anxiety disorders. Hence, the findings from this trial will constitute great advancements in the burgeoning and promising field of smartphone-administered psychological interventions. Limitations are discussed.
Clinicaltrials.gov: NCT01963806.
Background
An intervention, consisting of an ACT-based smartphone-application and a web-based psychoeducation, has been developed. The smartphone-application, together with the psychoeducation, aims ...to function as a self-help intervention for living consistently with one's values. The study is an exploratory investigation of this new smartphone-based tool.
Case description
Primarily, the study aims at investigating a new field, providing a basis for generating hypotheses for further research. The first aim of this initial, exploratory study was to examine if this intervention had an effect on the variables of: valued actions, psychological flexibility, and life satisfaction as well as the states of depression, anxiety and stress, for a non-clinical sample of 11 Swedish Iphone users. This was made with a quasi-experimental pretest-posttest design without control group. The second aim was to investigate how the participants experienced the intervention, as measured by a qualitative questionnaire.
Discussion and evaluation
The group analyses showed that the participants increased their valued action and psychological flexibility significantly during the intervention. Furthermore, value-based actions and psychological flexibility showed small effect sizes when comparing pretest and posttest score. However, the design of the study makes it impossible to draw any certain conclusions. The qualitative questionnaire showed a general positive experience of the intervention.
Conclusions
The results from the present study indicated that the intervention should be studied further. The findings also generated a number of hypotheses that could be investigated in further research.
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