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Weekend Links (01.23.14)
Douchey things women love about guys, an end to the sea salt vs. regular salt debate, and how to communication better.
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subset: commoncrawl


text:
Outcomes after extrahepatic portosystemic shunt ligation in 49 dogs.
ABSTRACT To evaluate outcomes after attenuation of extrahepatic portosystemic shunts in dogs using surgical silk.
Retrospective study.
Case records were reviewed for degree of surgical attenuation, experience of the primary surgeon, perioperative mortality and problems related to persistent portosystemic shunting or shunt ligation. Presence of portosystemic shunting after surgery was evaluated by ammonia tolerance testing, measurement of postprandial serum bile acid, plasma urea and cholesterol concentrations and liver enzyme activity. The influence of age, postocclusion portal pressure, primary surgeon, degree of attenuation and postoperative biochemical findings on the occurrence of postoperative problems was assessed.
The mortality rate was 2.1%. Shunt attenuation was complete in 34% and partial in 66% of dogs. Portal hypertension necessitating ligature removal was encountered in only one dog. Five dogs experienced neurological abnormalities (seizures or ataxia), possibly as a manifestation of 'postligation seizure syndrome'. Postoperative liver function was normal in 78% of dogs, including 70% with partial shunt attenuation. Experience of the surgeon was related positively to outcome after partial attenuation (P = 0.002). Postoperative biochemical evidence of abnormal liver function was the most sensitive predictor of recurrence of clinical signs referable to persistent portosystemic shunting.
In the hands of an experienced surgeon, surgical attenuation of single extrahepatic shunts was safe and effective, even in animals with partial attenuation. Most dogs with biochemical evidence of persistent shunting suffer relapse of clinical signs within 18 months of surgery. Postligation neurological syndromes of variable intensity may be more common than previously thought.
- SourceAvailable from: Richard Malik
Article: The inheritance of extra-hepatic portosystemic shunts and elevated bile acid concentrations in Maltese dogs.[Show abstract] [Hide abstract]
ABSTRACT: To determine the heritability of extra-hepatic portosystemic shunts and elevated post-prandial serum bile acid concentrations in Maltese dogs. Maltese dogs were recruited and investigated by a variable combination of procedures including dynamic bile acid testing, rectal ammonia tolerance testing, ultrasonography, portal venography, surgical inspection or necropsy. In addition, nine test matings were carried out between affected and affected dogs, and affected and unaffected dogs. In 135 variably related Maltese, shunt status could be confirmed in 113, including 19 with an extra-hepatic portosystemic shunt (17 confirmed at surgery, 2 at necropsy). Rectal ammonia tolerance testing results and post-prandial serum bile acid concentrations were retrievable for 50 and 88 dogs, respectively. Pedigree information was available for these 135 and an additional 164 related dogs. Two consecutive test matings were carried out between two affected animals (whose shunts had been attenuated), with 2 of 8 (25%) of offspring having an extra-hepatic portosystemic shunt. Six test matings were carried out between an affected and an unaffected animal, with 2 of 22 (9%) offspring affected. Heritability of extra-hepatic portosystemic shunt was 0·61 calculated using variance components analysis [95% confidence interval (CI) 0·14 to 1·0, P=0·001]. The best fitting model from segregation analysis was a common, partially penetrant, recessive model (allele frequency 0·34, penetrance 0·99, CI 0·09 to 1·0). The heritability of elevated post-prandial serum bile acid (and thus likely portal vein hypoplasia) was 0·81 (CI 0·43 to 1·0, P=0·2) after logarithmic transformation of post-prandial serum bile acid concentrations. There is strong support for extra-hepatic portosystemic shunts and elevated post-prandial serum bile acid concentrations both being inherited conditions in Maltese.Journal of Small Animal Practice 12/2013; · 0.91 Impact Factor
Article: Markers of hepatic regeneration associated with surgical attenuation of congenital portosystemic shunts in dogs[Show abstract] [Hide abstract]
ABSTRACT: Dogs with congenital portosystemic shunts (CPSS) have liver hypoplasia and hepatic insufficiency. Surgical CPSS attenuation results in liver growth associated with clinical improvement. The mechanism of this hepatic response is unknown, although liver regeneration is suspected. This study investigated whether markers of liver regeneration were associated with CPSS attenuation. Dogs treated with CPSS attenuation were prospectively recruited. Residual liver tissue was collected for gene expression analysis (seven genes) from 24 CPSS dogs that tolerated complete attenuation, 25 dogs that tolerated partial attenuation and seven control dogs. Relative gene expression was measured using quantitative polymerase chain reaction (qPCR). Blood samples were collected before, 24 h and 48 h post-surgery from 36 CPSS dogs and from 10 control dogs. Serum hepatocyte growth factor (HGF) concentration was measured using a canine specific enzyme-linked immunosorbent assay (ELISA). HGF mRNA expression was significantly decreased in CPSS compared to control dogs (P = 0.046). There were significant increases in HGF (P = 0.050) and methionine adenosyltransferase 2 A (MAT2A; P = 0.002) mRNA expression following partial CPSS attenuation. Dogs with complete attenuation had significantly greater MAT2A (P = 0.024) mRNA expression compared to dogs with partial attenuation. Serum HGF concentration significantly increased 24 h following CPSS attenuation (P < 0.001). Hepatic mRNA expression of two markers of hepatocyte proliferation (HGF and MAT2A) was associated with the response to surgery in dogs with CPSS, and serum HGF significantly increased following surgery, suggesting hepatocyte proliferation. These findings support the concept that hepatic regeneration is important in the hepatic response to CPSS surgery.The Veterinary Journal 05/2014; · 2.17 Impact Factor
Article: Long-term survival and quality of life in dogs with clinical signs associated with a congenital portosystemic shunt after surgical or medical treatment.[Show abstract] [Hide abstract]
ABSTRACT: Objective-To compare long-term survival and quality of life data in dogs with clinical signs associated with a congenital portosystemic shunt (CPSS) that underwent medical or surgical treatment. Design-Prospective cohort study. Animals-124 client-owned dogs with CPSS. Procedures-Dogs received medical or surgical treatment without regard to signalment, clinical signs, or clinicopathologic results. Survival data were analyzed with a Cox regression model. Quality of life information, obtained from owner questionnaires, included frequency of CPSS-associated clinical signs (from which a clinical score was derived), whether owners considered their dog normal, and (for surgically treated dogs) any ongoing medical treatment for CPSS. A Mann-Whitney U test was used to compare mean clinical score data between surgically and medically managed dogs during predetermined follow-up intervals. Results-97 dogs underwent surgical treatment; 27 were managed medically. Median follow-up time for all dogs was 1,936 days. Forty-five dogs (24 medically managed and 21 surgically managed) died or were euthanized during the follow-up period. Survival rate was significantly improved in dogs that underwent surgical treatment (hazard ratio, 8.11; 95% CI, 4.20 to 15.66) than in those treated medically for CPSS. Neither age at diagnosis nor shunt type affected survival rate. Frequency of clinical signs was lower in surgically versus medically managed dogs for all follow-up intervals, with a significant difference between groups at 4 to 7 years after study entry. Conclusions and Clinical Relevance-Surgical treatment of CPSS in dogs resulted in significantly improved survival rate and lower frequency of ongoing clinical signs, compared with medical management. Age at diagnosis did not affect survival rate and should not influence treatment choice.Journal of the American Veterinary Medical Association 09/2014; 245(5):527-33. · 1.67 Impact Factor


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Page 1
386 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013
CanJPsychiatry 2013;58(7):386–392
Key Words: chronic
major depressive
disorder, antidepressants,
psychotherapy, systematic
Received June 2012, revised,
and accepted October 2013.
In Review
Psychotherapy, Antidepressants, and Their Combination for
Chronic Major Depressive Disorder: A Systematic Review
Jan Spijker, MD, PhD1; Annemieke van Straten, PhD2; Claudi L H Bockting, PhD3;
Jolanda A C Meeuwissen, MSc4; Anton J L M van Balkom, MD, PhD5
1 Director, Program for Mood Disorders Pro Persona, Mental Health Care, Nijmegen, the Netherlands; Professor of Chronic Depression, Behavioural Science
Institute, Radboud University, Nijmegen and Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands.
Correspondence: Netherlands Institute of Mental Health and Addiction (Trimbos Institute), PO Box 725, 3500 AS Utrecht, the Netherlands; email@example.com.
2 Professor, Department of Clinical Psychology, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam,
the Netherlands.
3 Professor, Department of Clinical Psychology, Rijks Universiteit Groningen, Groningen, the Netherlands.
4 Senior Research Associate, Program Innovation of Mental Health, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands.
5 Professor, Evidence-Based Psychiatry, Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Centre, and
GGZ inGeest, Amsterdam, the Netherlands.
Objective: Recommendations for treatment of chronic major depressive disorder (cMDD)
are mostly based on clinical experiences and on the literature on treatment-resistant
depression (TRD) but not on a systematic review of the literature.
Method: We conducted a systematic review of 10 randomized controlled trials (RCTs), with
17 comparisons between antidepressants (ADs), psychotherapy, or the combination of both
Results: The best evidence is for the combination of psychotherapy and ADs,
and especially for the combination of the cognitive behavourial analysis system of
psychotherapy and ADs. Evidence is very weak for both ADs alone and psychotherapy
alone. Assessment of TRD was mostly absent in the studies.
Conclusion: The best treatment for cMDD is a combination of psychotherapy and ADs.
However, there is a lack of well-performed RCTs in both ADs and psychotherapy and their
combination for cMDD. Therefore, the conclusions are preliminary.
Psychothérapie, antidépresseurs, et leur combinaison pour le
trouble dépressif majeur chronique : une revue systématique
Objectif : Les recommandations de traitement du trouble dépressif majeur chronique
(TDMc) sont principalement basées sur les expériences cliniques et la littérature sur la
dépression réfractaire au traitement (DRT) mais pas sur une revue systématique de la
Méthode : Nous avons mené une revue systématique de 10 essais randomisés contrôlés
(ERC), ainsi que 17 comparaisons entre antidépresseurs (AD), psychothérapie, ou
combinaison des deux interventions.
Résultats : La meilleure évidence va à la combinaison de psychothérapie et AD, et
spécialement à la combinaison du système d'analyse cognitivo-comportementale
de la psychothérapie avec les AD. L'évidence est très faible pour les AD seuls et la
psychothérapie seule. L'évaluation de la DRT était presque absente des études.
Conclusion : Le meilleur traitement du TDMc est une combinaison de psychothérapie
et d'AD. Cependant, les ERC bien menés sur les AD et la psychothérapie, et sur leur
combinaison pour le TDMc, font défaut. Ces conclusions sont donc préliminaires.
Page 2
The Canadian Journal of Psychiatry, Vol 58, No 7, July 2013 W 387
Psychotherapy, Antidepressants, and Their Combination for Chronic Major Depressive Disorder: A Systematic Review
AD antidepressant
BSP brief supportive psychotherapy
CBASP cognitive behavourial analysis system of psychotherapy
CBT cognitive-behavourial therapy
CMA Comprehensive Meta Analyses
DSM Diagnostic and Statistical Manual of Mental Disorders
cMDD chronic MDD
DD double depression
ECT electroconvulsive therapy
ES effect size
IPT interpersonal psychotherapy
MDD major depressive disorder
MDE major depressive episode
RCT randomized controlled trial
TRD treatment-resistant depression
Clinical Implications
• The preferred treatment for patients with cMDD is a
combination of ADs and psychotherapy, and probably
CBASP is the psychotherapy of first choice although
other psychotherapies may be as beneficial.
• An assessment of TRD is necessary in all patients with
• We found a limited number of RCTs.
• The studies were rather heterogeneous in design and
impact. In the general population, about 20% of people with
MDE develop a chronic course1 and in depressed patients
around 20% to 30% fulfill the criteria for chronicity.2,3
The 12-month prevalence of cMDD in the United States
is 1.5%.4
hronic major depressive disorder is a major public
health problem owing to its high prevalence and great
In the DSM-IV,5 cMDD is classified as an MDD lasting
more than 2 years, in which criteria for MDE are continually
met. But also DD (that is, dysthymic disorder and an MDE)
and recurrent depression without interepisodic recovery
are considered as forms of cMDD. There is convincing
evidence that there are more similarities than dissimilarities
between these forms of cMDD.6 Moreover, there is reason
to speculate that depressive disorders as a group can better
be divided in acute and chronic forms.7
The consequences of a course of cMDD are serious, with
an increased risk for suicidality,8 comorbidity with other
psychiatric Axis I and II disorders, and increased disability
in physical and psychosocial functioning.4
There is significant overlap between cMDD and TRD,
although the terms are certainly not identical. Many
people with cMDD have not been treated or have received
inadequate treatment and therefore cannot be considered
to have TRD. For instance, a study among 801 patients
with cMDD who sought treatment in mental health care,
revealed that only 33% had received an adequate trial of
AD medication.9 The term TRD in itself is problematic
because the definitions vary. Mostly it is expressed as the
number of nonsuccessful biological treatments,10,11 thereby
ruling out psychological treatment for cMDD. However, in
most treated patients with cMDD, there is some form of
TRD that complicates treatment. Therefore, clinicians and
patients struggle with this condition, which many times
endangers the therapeutic relationship because pessimism
dominates the interaction.12
There is a need to describe the therapeutic options for
cMDD but former reviews on cMDD13–15 did not make a
systematic evaluation of the literature. The most recent
systematic review on chronic depression combined cMDD
and dysthymia. This review was focused exclusively
on psychotherapeutic interventions or the combination
of psychotherapy and medication and omitted the
pharmacological options.16 For this review, 16 studies
were selected but 7 of them were exclusively aimed at
patients with dysthymia. This review found psychotherapy
less effective, compared with pharmacotherapy, and
combination therapy superior to either monotherapy, but
the results were largely attributable to the studies with only
patients with dysthymia.16 Therefore, we will present a
new systematic review of the literature on pharmacological
and psychological interventions and their combination
for cMDD. We excluded dysthymia but included DD and
recurrent depression without interepisodic recovery in our
definition of cMDD. We compare the results of our review
on cMDD with the literature on TRD as these 2 conditions
frequently co-occur.
For our review, we used the database on psychological
treatment of depression.16,17 This database also includes
studies on combined treatment and comparisons with
pharmacotherapy.17 This database was developed through a
comprehensive literature search (from 1996 to January 2012)
in which 9011 abstracts were included from PubMed (1629
abstracts), PsycINFO (2439 abstracts), Embase (2606),
and the Cochrane Central Register of Controlled Trials
(2337). These abstracts were identified by combining terms
indicative of psychological treatment and depression. Also
the primary studies from 42 meta-analyses of psychological
treatment for depression were included in the database.
We did an extra literature search to also include papers on
pharmacotherapy only. We used the search terms (major)
unipolar depression, chronic, ADs, therapy, treatment,
and the limits RCT, meta-analysis, systematic review
and adults (18 to 65 years). Searches were performed in
PsycINFO, MEDLINE, Cochrane, and Embase databases
until September 2011. In addition, the reference lists of all
included studies were searched for other relevant studies.
Page 3
388 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013
In Review
For our study, we included the studies on psychological,
pharmacological, and combined treatment in adults
(>18 years of age) with a diagnosis of cMDD that was
established with a diagnostic interview. The studies were
RCTs, and compared the effect of the intervention to a
control group, another active treatment, or a combined
treatment. Studies on adolescent and children were excluded.
Comorbidity with somatic or psychiatric disorders was not
used as an exclusion criterion.
We recorded major characteristics of the selected studies
as characteristics of the target group (age, percentage of
women, percentage married), the definition of cMDD,
recruitment method, type of treatment, exclusion criteria
(anxiety disorders, substance-related disorders, personality
disorders), type of treatment (medication, psychotherapy,
combination), country where the study was conducted, and
whether the study was conducted in a subsample of a larger
study or not. Information on TRD of the index MDE (if
present) was also recorded.
We assessed validity of the included studies using
numerous basic criteria: allocation to conditions conducted
by an independent (third) party, blinding of the assessors
of outcome, and completeness of follow-up data. We only
checked for the adequacy of randomization concealment
in the medication studies as it is not possible in the
psychotherapy studies to conceal the randomization to the
All effects between the intervention and control group
(or another active treatment) were expressed as the
standardized difference between the 2 groups (Hedges g).
All ESs were calculated in CMA. CMA can handle data in
different formats (for example, mean scores on posttest as
well as percentage improved) and convert them to Hedges
d. ESs of 0.8 can be assumed to be large, while ESs of 0.5
are moderate and ESs of 0.2 are small.18
Characteristics of the Included Studies
Seven studies from the database met our inclusion criteria,
and in the additional search for pharmacological treatment
3 more studies were found. Thus, in total, we selected 10
studies; 3 studies on pharmacologic treatment of cMDD,19–21
3 studies on psychotherapy,22–24 and 4 on combination
treatment.25–29 In total, 2316 patients were included in the
studies. Selected characteristics of the studies are presented
online in eTable 1.
Four studies included patients with cMDD, DD, and
recurrent MDD without interepisodic recovery, 2 on cMDD
and DD; 1 on cMDD, DD, and some dysthymic patients, 1 on
cMDD and recurrent MDD without inter-episodic recovery,
and 2 on cMDD only. Eight studies were aimed at adult
depressed outpatients, and only one focused on inpatients.
In most studies females were overrepresented and the mean
age was mostly over 40 years. Information on TRD was
presented in only 2 studies; 2 other studies used TRD as an
exclusion criterion. The number of sessions varied between
11 and 24 for the psychotherapy studies, and mostly the
therapy had an individual basis. In one study, the Inventory
for Depressive Symptomatology was used to calculate ESs,
in the other studies, the Hamilton Depression Rating Scale.
Three studies were a subsample of a larger trial.
Quality of the Studies
The quality of the included studies varied. Blinding of the
assessors was reported in 3 studies; only the 3 AD studies
used a double-blind design. In 5 studies, randomization was
centrally organized by a computer program. In the other
studies, no information was given on the randomization
procedure. Intention-to-treat analyses were conducted
in 6 studies, and 2 studies reported the completers-only
analyses. In the remaining 2 studies it was not clear how
missing data were handled. The quality of the treatment
implementation in the studies was good: in all studies
the therapist were trained for the therapy; in 6 studies a
treatment manual was used, and in 7 studies the integrity of
the treatment was checked during the study.
Because of the design of 3 of the selected studies, more than
10 comparisons could be made between different treatment
conditions, resulting in total 17 comparisons (Table 2).
AD Treatment
Only one comparison between AD treatment and placebo
was found. This was the Agosti and Ocepek-Welikson
study,22 which was part of the National Institute of Mental
Health Treatment of Depression Collaborative Research
Program, a placebo-controlled study of psychotherapy for
outpatients with unipolar depression.30 In a subsample of 20
patients with cMDD, with a mean duration of depression of
15.9 years (SD 7.9), imipramine was not more effective than
placebo (ES = –0.11; not significant). In a small study with
48 patients with cMDD,19 fluoxetine was compared with
clomipramine and there was not a significant difference
between the 2 ADs (ES = 0). The other 2 comparisons
on pharmacological treatment of cMDD came from the
same study: an RCT on AD treatment in 635 patients with
chronic depression (294 with cMDD and 341 with DD),
who were randomized to 12 weeks acute treatment with
either sertraline or imipramine.20 Remission rates were 36%
for sertraline and 40% for imipramine and not significantly
different, resulting in an ES of 0.02. Further, there were no
differences in remission rates between the patients with
cMDD and those with DD. In the follow-up, 168 patients
who had not responded to sertraline or imipramine were
switched to the other AD.21 The differences in remission
rates were as follows: 32% in the sertraline group and
23% in the imipramine group, resulting in an ES of 0.27,
favouring sertraline (not significant).
Psychotherapeutic Treatment
The psychotherapies in the selected studies were CBT, IPT,
BSP, and CBASP. CBASP is an individual-based form of
psychotherapy especially developed for cMDD.31
Page 4
The Canadian Journal of Psychiatry, Vol 58, No 7, July 2013 W 389
Psychotherapy, Antidepressants, and Their Combination for Chronic Major Depressive Disorder: A Systematic Review
In the before-mentioned study of Agosti and Ocepek-
Welikson,22 response rates of CBT, compared with placebo
(N = 16), and IPT, compared with placebo (N = 14), were not
significantly different, resulting in an ES of 0 for CBT and
–0.11 for IPT. In the study of Harpin et al,23 12 patients with
cMDD (mean duration of depression was 17.8 years) were
randomized to CBT during 10 weeks or wait-list control.
There was a moderate effect for CBT (ES = 0.52), although
not significant. Only one recent study directly compared
2 forms of psychotherapy. In this trial of 29 patients with
cMDD, CBASP was more effective than IPT after 16 weeks
of acute phase treatment, with an ES of 0.66, but this effect
was not significant.24
Psychotherapeutic Treatment, Compared With AD
In 3 studies, psychotherapy was compared with pharmaco-
therapy. In the study of Agosti and Ocepek-Welikson,22
CBT and IPT, compared with imipramine, were studied in
patients with cMDD, resulting in nonsignificant ESs of 0.10
for CBT and 0 for IPT. In a third study with 681 patients
with cMDD, DD, and recurrent depression with incomplete
interepisodic recovery, CBASP was compared with the AD
nefazodone and the combination of both during 12 weeks.25
Nefazadone and CBASP were almost equally effective
(ES = 0.04; nonsignificant).
Combination of Psychotherapy and AD Treatment,
Compared With AD Treatment
The combination of psychotherapy and ADs for cMDD
was compared with pharmacotherapy in 1 study with 45
inpatients with cMDD. They were randomized to either
a clinical IPT program plus pharmacotherapy or the
control condition with clinical management, including
pharmacotherapy. There was a moderate effect for IPT plus
pharmacotherapy (ES = 0.53) although not significant.26
In the study by Keller et al,25 a moderate and significant
effect was found for combination treatment of CBASP and
nefazodone, compared with nefazodone alone (ES = 0.50).
In the study by Kocsis et al,27 491 patients with cMDD, who
did not respond to AD treatment during 12 weeks, were
randomized to combined treatment of CBASP and ADs,
compared with BSP and ADs, compared with continuation
of AD treatment alone in optimal dosing, all during another
12 weeks. The combination of psychotherapy (CBASP
Table 2 Comparisons for ADs, psychotherapy, and combination therapy for cMDD
Intervention N
Mean (SD)
end point Control N
Mean (SD)
end pointg95% CI
Agosti and Ocepek-
Imipramine 2010.3 (7.7)Placebo 159.5 (5.7)–0.11–0.77 to 0.54
Aguglia et al19
Fluoxetine 2414.3Clomipramine2412.3 0–0.65 to 0.65
Keller et al20
Sertraline 42613.6Imipramine 20914.10.02–0.16 to 0.21
Thase et al21
Imipramine 11715.3 (9.4)Sertraline5012.8 (8.4)0.27–0.06 to 0.60
Agosti and Ocepek-
CBT 169.5 (7.2)Placebo 159.5 (5.7)0–0.69 to 0.69
Agosti and Ocepek-
IPT 14 10.3 (8.4)Placebo 159.5 (5.7)–0.11–0.82 to 0.60
Harpin et al23
CBT616.3 (14.6)Wait-list 623.3 (10.0)0.52–0.55 to 1.58
Schramm et al24
CBASP 1411.21 (10.84)IPT 1518.87 (11.71)0.66–0.07 to 1.39
Agosti and Ocepek-
CBT 169.5Imipramine 2010.3 (7.7)0.10–0.54 to 0.75
Agosti and Ocepek-
IPT 1410.3 (8.4)Imipramine 2010.3 (7.7)0–0.67 to 0.67
Keller et al25
CBASP 22014.7 (10.38)Nefazodone21615.1 (10.14)–0.04–0.15 to 0.23
Schramm et al26
IPT + AD249.95 (7.44)AD + clinical
2114.05 (7.93)0.53–0.06 to 1.11
Keller et al25
22014.7 (10.38) Nefazodone2269.7 (9.77)0.500.31 to 0.68
Kocsis et al27
9412.28 (8.44)AD 38412.02 (8.39)0.03–0.28 to 0.22
Keller et al25
21615.1 (10.14)CBASP 2269.7 (0.7)0.540.35 to 0.73
Kocsis et al27
AD + CBASP18912.77 (8.45)AD + BSP 19511.29 (8.30)0.18–0.03 to 0.38
AD + CBASP 6923.1 (13.6)AD + CAU 7333.2 (13.9)0.73 0.33 to 1.13
CAU = care as usual
Page 5
390 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013
In Review
and BSP) and ADs was not more effective than ADs alone
Combination of Psychotherapy and ADs, Compared
With Psychotherapeutic Treatment
Only one comparison was found: in the Keller et al study,25
a moderate and significant effect was found for combination
treatment of CBASP and nefazodone, compared with
CBASP alone (ES = 0.54).
Combination of Psychotherapy and ADs, Compared
With Combination of Psychotherapy and ADs
In the study by Kocsis et al,27 a small, not significant
effect was found for the combination of CBASP and
ADs, compared with BSP and ADs (ES = 0.18). Finally,
Wiersma et al28,29 randomized 142 patients with cMDD,
DD, and recurrent depression with incomplete interepisodic
recovery to CBASP and ADs or care as usual (other
forms of psychotherapy and ADs) during 52 weeks. The
combination with CBASP yielded a great and significant
effect (ES = 0.73) in a completers-only analysis, but only
during a 1-year follow-up period.
Unfortunately, the literature on treatment options for cMDD
is limited. We found only 4 comparisons on AD treatment of
cMDD, 4 on psychotherapy, 4 that compared psychotherapy
to pharmacotherapy, and 6 on combination therapy. Most
of the studies included DD and (or) recurrent depression
without interepisodic recovery in their definition of cMDD.
The information on TRD of cMDD in these studies was
largely absent or TRD was used as an exclusion criterion.
Despite this meagre outcome, some evidence appears form
this review of the literature.
The evidence for AD treatment for cMDD is very weak.
There is only one placebo-controlled trial with a negative
outcome. However, this was a very small study. In direct
comparisons between ADs, there were no differences
between ADs or only a small advantage for the selective
serotonin reuptake inhibitor sertraline, compared the
tricyclic AD imipramine.
These findings are neither in line with the extensive literature
on AD treatment of TRD nor with clinical practice. ADs are
widely used as therapeutic monotherapy for patients with
cMDD. There is ample evidence for the efficacy of ADs in
case of TRD.32–34 Most reviews suggest an AD algorithm
with consecutive medication steps, including augmenting
and combining strategies.35,36 In clinical practice, many
patients with cMDD are also treatment resistant and
therefore the recommendations about how to treat TRD
in the guidelines for MDD37,38 seem to be applicable in
the treatment of cMDD. But strictly speaking, we must
conclude that there is a lack of evidence for using ADs in
patients with cMDD.
Unfortunately, the evidence
interventions for cMDD is also not convincing. From the
4 studies on psychotherapy for cMDD that we found, 2
for psychotherapeutic
were negative, 1 found a positive though not a significant
effect, and 1 demonstrated superiority for CBASP over IPT.
However, all studies were very small. Not surprisingly,
no differences were found in direct comparisons between
psychotherapy and ADs, and also not in the adequately
performed and large study of Keller et al.25
Although, in view of the paucity of studies, definitive
conclusions are very premature, it is striking that the limited
effects of ADs and psychotherapy for cMDD are in sharp
contrast with the well-established positive effects of both
interventions in nonchronic MDD,39,40 albeit that these
treatments effects are overestimated owing to publication
bias.40,41 The results of this review lend support to the notion
that, in general, treatment effects in cMDD are smaller,
compared with those in nonchronic MDD. Interestingly, this
effect was indeed found for psychotherapy in dysthymia,16
another form of chronic depression, but the efficacy of ADs
in dysthymia is well established.42 Although in the DSM-5,
chronic depressive disorder is proposed as a combination
of dysthymic disorder and cMDD, the conclusion of our
review lends some support for the idea that the treatment
effect for ADs differs between patients with dysthymic
disorder and cMDD. It is possible that TRD also is at stake
in this respect and that studies that included dysthymic
patients did not select many patients with TRD in contrast
to studies of patients with cMDD.
The best evidence from the selected studies comes for the
combination of psychotherapy and ADs, and more precisely
for the combination of CBASP and ADs. Moderate-to-large
and significant effects were found for this combination in
2 studies. The pioneering study of Keller et al25 found the
combination of nefazodone and CBASP superior to both
nefazodone and CBASP alone. The superiority of CBASP
plus medication was partially replicated in a recent study
of Wiersma.29 However, the last study reported completers-
only analyses and superiority of CBASP and medication only
appeared toward the end of this long-term study (1 year).
Further, superiority of the CBASP and ADs combination
was not demonstrated in the study by Koscis et al27 after
a treatment period of 12 weeks. Thus there is conflicting
evidence regarding CBASP combination therapy. The
combination of IPT and ADs was also favourable in
depressed inpatients.26 Combination treatment is probably
better, no matter what kind of psychotherapy. However,
in a direct comparison between CBASP and IPT, CBASP
was superior,24 giving more credits to the combination of
CBASP and medication.
There are several limitations to our review. First, the
paucity of the studies limits any definitive conclusions
on the optimal treatment for cMDD. Especially, there
are too little studies on monotherapy with either ADs or
psychotherapy. Second, the 10 studies differed in many
aspects as characteristics of the patients, seize, in- and
exclusion criteria, intervention, duration, and quality of the
study. Therefore, it was not possible to meta-analyze the
effects and we could only provide ESs for each separate
study. Even these ESs must be compared with great caution.
Page 6
The Canadian Journal of Psychiatry, Vol 58, No 7, July 2013 W 391
Psychotherapy, Antidepressants, and Their Combination for Chronic Major Depressive Disorder: A Systematic Review
Third, most studies included patients with DD or recurrent
depression without interepisodic recovery and even some
dysthymic patients26 in the inclusion criteria. There seem
to be some differences in treatment effects in dysthymic
patients, compared with patients with cMDD, but it is yet
unknown if there are also differences between the variants
of chronic major depression (that is, cMDD, DD, recurrent
depression without interepisodic recovery). Fourth,
information on TRD was mostly absent, and, interestingly,
the study with the largest ESs for the combination therapy25
had excluded TRD. It is important that TRD is assessed and
reported in each study in the treatment of depression but
especially in studies in cMDD it seems mandatory.
In conclusion, the evidence for any therapeutic intervention
for cMDD is very limited. Psychotherapy in combination
with AD medication may be beneficial for cMDD. CBASP
may be a promising treatment for cMDD, though evidence
is momentarily rather mixed. The most recent study
indicates that psychotherapy in cMDD may take longer
before it produces change in symptomatology.29 Our results
are in close agreement with other systematic reviews and
meta-analyses that found combination treatment superior
for depression,40 and especially in the more severe,
recurrent, or chronic depression.43–45 Still, there is an urgent
need for more high-quality RCTs for combination therapy
with the available ADs and psychotherapies, with adequate
randomization procedures, blinding of the assessors, and the
inclusion of all randomized respondents in the final analysis.
Important research questions include the following: What is
the most cost-effective combination therapy? What intensity
of treatment is needed? What is the optimal duration of
the combination? And, what are the long-term benefits of
combination therapy? Further, not all patients can profit
from psychotherapeutic interventions, and alternatives
for combination therapy must be developed, especially
biological interventions like repetitive transcranial magnetic
stimulation.46 There is, of course, a biological option: ECT
with good evidence for efficacy in severe, psychotic, and
TRD47; however, ECT has not been studied adequately for
patients with cMDD, and further, it may not be acceptable
for many patients with cMDD.
Because cMDD is a very complex and, by nature, persistent
condition it is unrealistic to expect recovery from a single
intervention or even combination of 2 interventions.
Therefore, care for cMDD should be organized in a way
that multiple, successive treatment and rehabilitation
interventions can be applied to reach and maintain long-
term symptomatic and functional improvement. Disease
management programs are most suitable for that goal and
have proven to be effective.15,48,49 The burden of disease in
cMDD is immense and justifies intensive and prolonged
treatment efforts.
Dr Spijker has been on speakers' bureaus for AstraZeneca,
Eli Lilly, GlaxoSmithKline, Lundbeck, and Servier.
The Canadian Psychiatric Association proudly supports the
In Review series by providing an honorarium to the authors.
1. Spijker J, Bijl RV, de Graaf R, et al. Duration of major depressive
episodes in the general population. Results of the Netherlands
Mental Health Survey and Incidence Study (NEMESIS). Br J
Psychiatry. 2002;181:208–213.
2. Rush AJ, Laux G, Giles DE. Clinical characteristics of outpatients
with chronic major depression. J Affect Disord. 2005;34:25–32.
3. Gilmer WS, Gollan JK, Wisniewski SR, et al. Does the duration of
the index episode affect the treatment outcome of major depressive
disorder. A STAR*D report. J Clin Psychiatry. 2008;69;1246–1256.
4. Blanco C, Okuda M, Markowitz JC, et al. The epidemiology of
chronic major depressive disorder and dysthymic disorder: results
from the National Epidemiologic Survey on Alcohol and Related
Conditions. J Clin Psychiatry. 2010;71:1645–1656.
5. American Psychiatric Association (APA). Diagnostic and statistical
manual of mental disorders. 4th ed, text revision. Washington (DC):
6. McCullough JP, Klein DN, Borian FE, et al. Group comparison of
DSM-IV subtypes of chronic depression. Validity of the distinctions.
J Abnorm Psychol. 2003;112:614–622.
7. Rhebergen D, Beekman ATF, de Graaf R, et al. The three-year
naturalistic course of major depressive disorder, dysthymic disorder
and double depression. J Affect Disord. 2009;25:450–459.
8. Spijker J, de Graaf R, ten Have M, et al. Predictors of suicidality
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9. Kocsis JH, Gelenberg AJ, Rothbaum B, et al. Chronic forms of
major depression are still undertreated in the 21th century:
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J Affect Disord. 2008;110:55–61.
10. Ruhe HG, van Rooijen G, Spijker J, et al. Staging methods for
treatment resistant depression. A systematic review. J Affect Disord.
11. Mahli GS, Paker GB, Crawford J, et al. Treatment resistant
depression. Resistant to definition? Acta Psychiatr Scand.
12. Koekkoek BG, van Meijle B, Schene A, et al. Clinical problems in
the long-term care of patients with chronic depression. J Adv Nurs.
13. Howland RH. Chronic depression. Hosp Community Psychiatry.
14. Rush AJ, Thase ME. Strategies and tactics in the treatment of
chronic depression. J Clin Psychiatry. 1997;58(Suppl 13):14–22.
15. Keitner GI, Ryan CE, Solomon DA. Realistic expectations and a
disease management model for depressed patients with persistent
symptoms. J Clin Psychiatry. 2006;67:1412–1421.
16. Cuijpers P, van Straten A, Schuurmans J, et al. Psychotherapy for
chronic major depression and dysthymia: a meta-analysis. Clin
Psychol Rev. 2010;30:51–62.
17. Coordinating Committee Meta-analytic Studies in Psychotherapy.
Psychotherapy: randomized controlled and comparative trials
[Internet]. Amsterdam (NL): VU University Amsterdam; 2012
[cited 2012 Apr 14]. Available from:
18. Cohen J. Statistical power analysis for the behavorial sciences. 2nd
ed. Hillsdale (NJ): Erlbaum; 1998.
19. Agulia E, de Vana M, di Grazia MF. [Role of selective serotonin
reuptake inhibitors on the treatment of chronic and (or) resistant
major depression.] Giornale di Neuropsicofarmacologia.
1995;17:73–77. Italian.
20. Keller MB, Gelenberg AJ, Hirschfeld RM, et al. The treatment
of chronic depression, part 2: a double bind, randomized trial of
sertraline and imipramine. J Clin Psychiatry. 1998;59:598–607.
21. Thase ME, Rush J, Howland RH, et al. Double-blind switch study
of imipramine or sertraline treatment of antidepressant-resistant
chronic depression. Arch Gen Psychiatry. 2002;59:233–239.
Page 7
392 W La Revue canadienne de psychiatrie, vol 58, no 7, juillet 2013
In Review
22. Agosti V, Ocepek-Welikson K. The efficacy of imipramine and
psychotherpay in early-onset chronic depression: a re-analysis of
the National Institute of Mental Health Treatment of Depression
Collaborative Research Program. J Affect Disord. 1997;43:181–186.
23. Harpin R, Liberman R, Marks I, et al. Cognitive-behavior therapy
for chronically depressed patients: a controlled pilot study. J Nerv
Ment Dis. 1982;170:295–301.
24. Schramm E, Zobel I, Dykierek P, et al. Cognitive behavioral analysis
system of psychotherapy versus interpersonal psychotherapy for
early-onset chronic depression: a randomized pilot study. J Affect
Disord. 2011;129(1–3):109–116.
25. Keller MB, McCullough JP, Klein DN, et al. A comparison of
nefazodone, cognitive behavorial analysis system of psychotherapy
and their combination for the treatment of chronic depression.
N Engl J Med. 2000;342:1462–1470.
26. Schramm E, Schenider D, Zobel L, et al. Efficacy of interpersonal
psychotherapy plus pharmacotherapy in chronically depressed
inpatients. J Affect Disord. 2008;109:65–73.
27. Kocsis JH, Gelenberg AJ, Rothbaum BO, et al; REVAMP
investigators. Cognitive behavorial analysis system of
psychotherapy and brief supportive psychotherapy for augmentation
of antidepressant nonresponse in chronic depression: the REVAMP
Trial. Arch Gen Psychiatry. 2009;66(11):1178–1788.
28. Wiersma J, van Schaik DJ, van Oppen P, et al. Treatment of
chronically depressed patients: a randomised controlled trial
testing the effectiveness of 'Cognitive Behavorial Analysis System
of Psychotherapy' (CBASP) for chronic depression versus usual
secondary care. BMC Psychiatry. 2008;25:8–18.
29. Wiersma J. 2011. Psychological characteristics and treatment of
chronic depression [doctoral thesis]. [Amsterdam (NL)]: Vrije
30. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental
Health Treatment of Depression Collaborative Research Program.
General effectiveness of treatments. Arch Gen Psychiatry
31. McCullough JP. Treatment for chronic depression. Cognitive
behavorial analysis system of psychotherapy. New York (NY):
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32. Thase ME, Rush AJ. When at first you don't succeed: sequential
strategies for antidepressant nonresponders. J Clin Psychiatry.
1997;58(Suppl 13):23–29.
33. Nelson JC. Managing treatment resistant major depression. J Clin
Psychiatry. 2003;64:5–12.
34. DeBattista C. Augmentation and combination strategies for
depression. J Psychopharmacol. 2006;20(3):11–18.
35. Aldi MA, Bauer M, Rush AJ. Algorithms and collaborative-care
systems for depression: are they effective and why? A systematic
review. Biol Psychiatry. 2006;59:1029–1038.
36. Spijker J, Nolen WA. An algorithm for the pharmacological
treatment of depression. Acta Psychiatric Scand. 2010;121:180–189.
37. The National Institute for Clinical Excellence (NICE). Depression:
the treatment and management of depression in adults (update).
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38. American Psychiatric Association (APA). Practice guideline for
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39. Williams JW, Mulrow CD, Chiquette E, et al. A systematic review
of newer pharmacotherapies for depression in adults: evidence
report summary. Ann Intern Med. 2000;132:749–756.
40. Cuijpers P, Andersson G, Donker T, et al. Psychological treatment of
depression. Results of a series of meta-analyses. Nord J Psychiatry.
41. Turner EH, Matthews AM, Linardatos E, et al. Selective publication
of antidepressant trials and its influence on apparent efficacy. New
Engl J Med. 2008;358(3):252–260.
42. Silva de Lima M, Moncrieff J, Soares B. Drugs versus placebo for
dysthymia. Cochrane Database Syst Rev. 2005;(2):CD001130. doi:
43. Pampallona S, Bollini P, Tibaldi G, et al. Combined
pharmacotherapy and psychological treatment for depression. Arch
Gen Psychiatry. 2004;61:714–719.
44. Friedman MA, Detweiler-Bedel JB, Leventhal HE, et al. Combined
psychotherapy and pharmacotherapy for the treatment of major
depressive disorder. Clin Psychol Sci Pract. 2004;11:47–68.
45. Maat de SM, Dekker J, Schoevers RA, et al. Relative efficacy of
psychotherapy and combined therapy in the treatment of depression:
a meta-analysis. Eur Psychiatry. 2006;22:1–8.
46. Lam RW, Chan P, Wilkins-Ho M, et al. Repetitive transcranial
magnetic stimulation for treatment-resistant depression: a systematic
review and meta-analysis. Can J Psychiatry. 2008;53:621–631.
47. UK ECT Review Group. Efficacy and safety of electroconvulsive
therapy in depressive disorders: a systematic review and meta-
analysis. Lancet. 2003;361:799–808.
48. Badamgarav E, Weingarten SR, Henning JM, et al. Effectiveness of
disease management programs in depression: a systematic review.
Am J Psychiatry. 2003;160:2080–2090.
49. Neumeyer-Gromen A, Lampert T, Stark, K, et al. Disease
management programs for depression. A systematic review
and meta-analysis of randomized controlled trials. Med Care.


text:
Ice Cream & Sorbet
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The Vietnamese love drinking superstrong iced coffee combined with copious amounts of sweetened condensed milk. Joann...
F&W's Grace Parisi experiments with ever-versatile caramel in making this sticky sauce.
Sophie Dahl's coconut frozen yogurt with a swirl of mango is like a tropical take on the classic orange Creamsicle. T...
Dessert Tips from F&W Editors
For a fun yet elegant dessert, Daniel Boulud tops an easy, creamy ginger-mascarpone mousse with chopped mangoes and p...
"My passion for halvah (the sesame-seed candy) is no secret. I love its crunchy, gritty, nutty flavor. I first starte...
Inspired by the ripe mangoes at a farmers' market along the drive to Mount Kenya Safari Club, Hubert Des Marais came ...
Using fresh-squeezed ruby red grapefruit juice makes all the difference in these sweet-and-tart pops.
Rori Trovato of Rori's Artisanal Creamery in Santa Barbara, California, creates all kinds of ice creams. Ironically, ...
Folding apple butter into vanilla ice cream is a great way to add elegance. Green Aisle Grocery's Adam Erace also add...
Yigit Pura perfected this crisp-creamy French dessert while working at restaurant Daniel in New York City. His update...
Chef James Holmes of Olivia, in Austin, topped raw oysters with this sweet-savory sorbet before deciding it would mak...
What makes these banana splits from Sweet Rose Creamery in Santa Monica, California, so good is the insanely fudgy ch...
This sundae from Ruby Jewel Scoops in Portland, Oregon, is a riff on the Almond Joy candy bar. The coconut crispies a...
Slideshow: More Frozen Desserts
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Jeni Britton Bauer of Jeni's Splendid Ice Creams in Columbus, Ohio, says the secret to a perfect layered terrine is t...
The French macaron is a simple cookie made with almonds, sugar and egg whites. The recipe here includes green tea pow...
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text:
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... Our first stop was the greenhouse where they graft tomato varieties together to produce a strain with the best of all qualities. Their latest creation is worth 12 times its weight in gold. Next we visited the algae biofuel lab, where scientists are working out how to cost effectively mass produce algae biofuel for aviation fuel in partnership with Airbus. They're also investigating solar energy for ...
`the night before'
Its 5:55pm and the excitement is heating up in the Lomax household...
With the emotional farewell to Dougie (to see the gorgeous Nikki and Bella) and the arrival of Granny and Pops, it finally seems to be real!
DInner tonight is steak and chips, and an early bed due to the early wake up time of 3:30 am (except for Jemima who ...
The Making of Harry Potter
Today we went to the Warner Bros studio where the Harry Potter movies were filmed. We saw the Great Hall set. In the Great Hall was the House Point Counter, the long tables set for a feast and the teachers table at the front. We saw how the candles floated. We also saw the costumes used in the films. We saw the props used for the Chocolate Feast and the Yule Ball.
We saw the Gryffindor boys dormitory and ...
England on the 4th of July..how ironic.
... well as the other campus thats near by. Afterwards some of us decided to head to Asda, which is their version of Walmart (actually its owned by Walmart) to pick up some necessities.
Although nothing extremely interesting has happened yet, I'm definitely excited to be here and blessed to be able to spend my 2nd summer in a row in Europe, but this time with some of my best friends and boyfriend. I can't wait to for the experience to come :)
2weeks 4days
Less than three weeks now! Gosh I'm excited! My parents and aunti have set up a party as a leaving du, as well as birthday party for my aunti. I'm very excited to see everyone but I think its going to hit me in the next few days. I'm dead excited and have told my story and goal to so many people over the past 6months, but Tiny nerves have started appearing when I tell the plan and how close it all is. 2weeks and 4days. Waow! Chiang mai - here I ...


text:
Where can I get this?
Can you give a scientific name for it?
Sorry, yes-- it's EREMALCHE ROTUNDIFOLIA. It's beautiful. . .
i have bought Five Spot seedsNemophila maculata (A) from americanmeadows.com. i don't know if this is what you want, but i thought i'd pass it on anyway.
It's pretty ... but I have never seen any seeds for sale.
Perhaps a wildflower seed exchange website? Or a nursery specializing in CA native plants?
Try www.cactusstore.com


text:
Jersey Shore is over
from Skillz – 2012 Rap Up Lyrics on Genius
The show that was once the epitome of ratchedness is finally coming to an end. Thank you Based God. .
To help improve the quality of the lyrics, visit Skillz – 2012 Rap Up Lyrics and leave a suggestion at the bottom of the page


text:
We would like to implement some functionality so that when for some reason an error occurs during publishing or resolving, and we skip over it using a try/catch block, but would still like to notify the user that something was skipped.
The SDL Tridion 2011 Publishing Queue can filter by status. One of these statuses is "Warning". Is it possible to trigger a publish transaction to have a "Warning" status using the API in either template code or a custom resolver?


text:
Shop now and get Free Value Shipping on most orders over $49 to the contiguous 48 states, DC and to all U.S. Military APO/FPO/DPO addresses.
We want to ensure that making a return is as easy and hassle-free as possible! If for any reason you decide that your purchase just isn't for you, simply return the item within 30 days of receipt and we'll cover the cost of return shipping. Learn more about our Return Policy.
The Schrade Out The Front Assisted Open Folding Knife was made to function as the optimal option to make sure you have a top grade utensil that can be opened up using only one hand. An effective assisted open cutting knife can free up one of your hands for more crucial tasks. And thanks to the Schrade Out The Front Assisted Open Folding Knife, receiving a high quality assisted blade hasn't ever been much more attainable. Built using good quality, robust components, the edge on this Assisted Opening Knives designed by the expert knife-smiths at Schrade, will sustain a good edge for an incredibly long period of time before requiring attention. The handle on the Schrade Out The Front Assisted Open Folding Knife can provide a flawless grip in almost any situation. Schrade has been creating good quality cutting instruments for a very long time, and the Schrade Out The Front Assisted Open Folding Knife is the consequence of their tireless endeavors to make sure you are cutting with some of the very best knives offered. For a great way to make sure to are cutting with some of the best utensils the knife industry provides, purchase the Schrade Out The Front Assisted Open Folding Knife.
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text: Web exclusive! Glide around town with this High Sierra® Powerglide Backpack. Price: Price pending The High Sierra® Powerglide Backpack makes commuting a breeze! With smooth rolling corner-mounted wheels and a flush-mounted double-tube telescope handle, moving your possessions is easy as 1-2-3! This high-functioning pack features multiple storage options and convenient corner guards and kick plates to protect it from abrasion while you're travelling through crowds. Featured in deep jade/black 21" x 14" x 9" Corner-mounted wheels Double-tube telescoping handle stows inside a protective zippered compartment Deluxe flush-mounted, double-tube telescoping handle Contoured, adjustable VAPEL™ mesh padded shoulder straps tuck away inside the zippered, padded core back panel Padded computer sleeve holds most 17" notebook computers (max. size 16" x 11" x 1.75") Large, zippered front compartment has premium organizer with media pocket, zippered pocket, multiple open pockets and removable key fob Zippered accessory compartment has a headphone port. Triangle clip to attach a lock or other accessories Corner guards and kick plate VAPEL™ mesh padded grab handle Reflective accents for night safety Imported More


text:
But that's not the context in which Clive chose to frame his question. He chose to explicitly limit the possibilities to either "art" OR "just photographic technical perfection." With the "just" seemingly tipping his personal preference.
I simply logically extended his question into converse equivilency in a bid for confirming clarity.


text:
Ryan Howard, Ben Revere, and RBIs
Posted by Jonathan Nisula, Tue, August 26, 2014 11:00 AM Comments: 76
It's a been argued over and over again, especially in Philadelphia, where Ryan Howard–one of the best RBI men in MLB over the years (2nd overall to only Miguel Cabrera since 2006) calls home.
And no, I'm not talking about whether to refer to multiple runs batted in as "RBI", or "RBIs" (I'll be using the latter in this post). I'm talking about the meaning of the stat.
"RBIs don't matter!", say many believers in advanced metrics and Sabermetrics.
Those that disagree tend to favor, from what I've seen, all the more traditional statistics, like batting average, pitcher wins, and things of that sort.
- Filed under: Analysis, Opinion, Posts, Statistical Analysis


text:
Empathy Skills Develop During Teen Years
Jim LiebeltJim is Senior Writer, Editor and Researcher for the HomeWord Center for Youth and Family at Azusa Pacific University. Jim has over 25 years of experience as a youth and family ministry specialist, and has been on the HomeWord staff since 1998. He has served over the years as a pastor, author, youth ministry trainer, adjunct college instructor and speaker. Jim's culture blog and parenting articles appear on HomeWord.com. Jim is a contributing author of culture and parenting articles to Crosswalk.com. Jim and his wife Jenny live in Olympia, WA.
- 2013 Oct 21
The teen years are often fraught with door-slamming, eye-rolling and seeming insensitivity, even by kids who behaved kindly before. Some parents worry that they're doing something wrong, or that their children will never think of anyone but themselves.
New research shows that biology, not parenting, is to blame.
In adolescence, critical social skills that are needed to feel concern for other people and understand how they think are undergoing major changes. Adolescence has long been known as prime time for developing cognitive skills for self-control, or executive function.
"Cognitive empathy," or the mental ability to take others' perspective, begins rising steadily in girls at age 13, according to a six-year study published recently in Developmental Psychology. But boys don't begin until age 15 to show gains in perspective-taking, which helps in problem-solving and avoiding conflict.
Adolescent males actually show a temporary decline, between ages 13 and 16, in a related skill — affective empathy, or the ability to recognize and respond to others' feelings, according to the study, co-authored by Jolien van der Graaff, a doctoral candidate in the Research Centre Adolescent Development at Utrecht University in the Netherlands. Fortunately, the boys' sensitivity recovers in the late teens. Girls' affective empathy remains relatively high and stable through adolescence.
The findings reflect a major expansion in researchers' understanding of cognitive growth during adolescence, according to a 2012 research review co-authored by Ronald Dahl, a professor of public health at the University of California at Berkeley. Researchers used to believe that both forms of empathy were fully formed during childhood.
Now, it's clear that "the brain regions that support social cognition, which helps us understand and interact with others successfully, continue to change dramatically" in the teens, says Jennifer Pfeifer, an assistant professor of psychology at the University of Oregon in Eugene. Preliminary research in her lab also suggests cognitive empathy rises in teens. The discoveries serve as a new lens for exploring such teen behaviors as bullying and drug abuse.
Source: Wall Street Journal


text:
Whenever I stop even if it's just for a day, small zits come back, so I'm afraid to stop. What are the longtime side effects of this drug? Thank you in advance.
I've been on Doxycycline Hyclate 100 mg/day for acne for 8 months now. When should I stop taking it?
- Posted:
- 30 Jun 2012 by michellerx
- Topics:
- acne, bacterial infection, doxycycline, side effect
Responses (2)
21 Aug 2013
Unfortunately some people are prescribed it for years, been on it 9 month..may be on it for years. I had cystic , pustular Acne very badly as a teen. The only real "Cure" I am aware of and I took for a year that actually got rid of my very bad Acne was Accutane. In the 1990s it was very expensive, must be cheaper now. Was on it for a year. No more acne. I tried every everything first including Retin A.
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Automatic Power and Frequency Control of FM Transmitters
A review of the requirements of an automatic self-monitored FM transmitter are presented. Methods of automatic control of transmitter power output is discussed, and application to a commercial transmitter is shown. Alarm and control functions for frequency monitoring is presented together with the requirements resulting from conventional station operations.
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(January 3, 2012: Somerset, PA 15501) In Tuesday's non-league match, the visiting Penn Cambria Panthers basketball team scored a decisive 65-22 triumph over the Somerset Eagles.
In their next game, the Panthers confront the Bishop Carroll Huskies (Ebensburg, PA) in a Laurel Highlands 1 match, on Thursday, January 5. Penn Cambria will attempt to move on its 5-2 season record. The Huskies enter the match with a 4-4 record after their 74-41 non-league loss to Westmont Hilltop (Johnstown, PA).
With the defeat, Somerset moves to 0-8 on the year. The Eagles travel to Richland (Johnstown, PA) to confront the Rams in a Laurel Highlands 2 match on Friday, January 6. The Rams enter the match with a record of 5-3. Richland lost 62-48 in their recent non-league match against Forest Hills (Sidman, PA)
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Holiday Cocktail Lounge's (Temporary?) Closure May Drive Us to Drink
It's the latest dive bar with an uncertain future.
It's the latest dive bar with an uncertain future.
The beer bar introduces a food menu next week. Plus, eggnog after Christmas?
But what will become of infamous "Busy Chef" manager Dan Kaufman?
On the Beatrice Inn: "The Department may consider actions to revoke or suspend the establishment's permit should it continue to allow patrons to smoke."
Goodbye Knitting Factory, hello City Winery.
The TV pundit demonstrates her favorite classic cocktail, the Jack Rose.
Food critic Adam Platt compiles his annual restaurant guide.
The East Village beer bar opens a new location in Brooklyn.
Daily Intel might be sick of the whole bro thing, but the guys at Lil' Frankie's sure aren't.
Not content to merely conquer the off-the-hook meatpacking brunch scene, restaurant Bagatelle has added a lounge called Rendez-Vouz, or RDV.
Bacon-and-liver sandwich, R.I.P. (for the winter, at least).
When you're rolling with a seven-time restaurateur, you ain't having it.
Did Macao Trading Co. rename a cocktail because some people were offended?
Not only is it for sale, but it may be shutting its doors.
Someone popped a $20,000 bottle of Champagne at Marquee.
Governor Paterson's tax hike on adult beverages could also result in more places to buy them.
The proprietors insist it's only an event space. So why are there drink prices?
The city's quintessential boardwalk bar may have only days left.
Woodson and Ford is accessible via password that's received via text message.
Ceol was shuttered last Friday by the New York Workers' Compensation Board.


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Even the most enthusiastic dog-owner will find something to infuriate them in the Dog Vs Bone stage of Hardest Game Ever 2. The challenge is as simple as it is maddening, as you tilt your device to keep the bone neatly balanced on your adorable dog's head. Here's a quick look at how this all works out in practice.
Sony kicks off the PlayStation Experience LIVE and GT follows up with some LIVE...
Posted: Nov 20, 2014
Posted: Oct 29, 2014
Posted: Aug 19, 2014
Posted: Aug 8, 2014


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Super 8 Motel Ketchikan, Ketchikan
Situated in Ketchikan, Super 8 Motel Ketchikan is close to Port of Ketchikan. Additional area attractions include Saxman Totem Park and Ward Lake.
Property Features.
The motel offers a restaurant. Guests are served a complimentary breakfast each morning. Additional amenities include a safe deposit box at the front desk, an elevator (lift), and express check-in. Self parking is complimentary.
Televisions are equipped with cable channels.
No flexibility if you have to change your trip by a day or so. I won't go back
the place smells bad....loud noises throughout the night as guests partied away, float…
Enter dates to check prices
Hotel Info: 866-539-8117from $100
- Deluxe Suite, 1 King Bed
- Standard Room, 1 Queen Bed
- Standard Room, 1 King Bed
- Suite, 2 Queen Beds
- Standard Room, 2 Queen Beds
- Standard Room, 2 Queen Beds
- Standard Room, 1 Queen Bed
- Standard Room, 1 King Bed
- Suite, 1 King Bed
- Deluxe Room, 1 Queen Bed
Recommended hotels
At a glance
Key facts
- Check-in time starts at 3 PM
- Check-out time is noon
- Express check-in
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets allowed
- Free airport shuttle
- Free self parking
In the hotel
- Free continental breakfast daily
- Restaurant
- Personal motorized watercraft on site
- Ecotours nearby
- Kayaking nearby
- Sailing nearby
- Conference space
- 24-hour front desk
- Elevator/lift
- Safe-deposit box at front desk
In the room
- Cable TV channels


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Welcome, Water Sports enthusiast!
The List of Great Ideas
The List is out! Based on our last meeting at Mick's, a lot of you came up with some great ideas! This is what we were hoping to accomplish to make 2012 a much better... Learn more
- Needs a location
- Coming soon
Recent Meetups
September 27, 2014 · 10:00 AMAlgonkian ParkWhere: Algonkian Park, Sterling, Va Time: gather at 0945, boats on the water at 1000 (late comers are on their own) Trip direction: we'll paddle up the creek farther... Learn more
August 23, 2014 · 10:00 AMLake AnnaAlright, folks. In case the weather holds out for us we will meet at Tim's At Lake Anna restaurant. It's at the corner of Rt 522 and Stonewall Court. The forecast is not... Learn more
August 9, 2014 · 10:00 AMAquia CreekAssemble: 0945 (at Aquia Landing Park at the end of Brooke Road) Boats on the water: 1000 Direction: toward Aquia Creek Duration: ~1 hour Rental: this venue has no... Learn more
July 26, 2014 · 10:00 AMFountainhead ParkAssemble: 0945 On the water: 1000 Direction: toward Bull Run Marina Time on Water: approximately two hours; one hour out, ~1 hour back Rental: Fountainhead has kayaks,... Learn more
June 28, 2014 · 7:00 PMPre-fireworks, Tim's RivershoreTim's Rivershore hosts a pre-4th fireworks show the Saturday before Independence Day every year. This is a great time for boaters to raft together for an evening of... Learn more
- See all past Meetups


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Patna: Bihar goverment will install tallest statue of Mahatma Gandhi at the Gandhi Maidan here by the year-end.
The bronze statue of 40 feet height will be installed after construction of a 24-feet pedestal, Building Construction Minister Damodar Raut said on Sunday.
Renowned Delhi-based sculptor Ram Sutar`s firm was awarded a Rs 40-crore contract for the statue last year, he said.


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Miley Cyrus' homeless guy she let speak out for the rights of struggling male models at the MTV VMAs is going to jail. The devilishly handsome shelter dweller Jesse Helt violated his probation by breaking into an apartment so he could get drug money to achieve that heroin tramp look aspiring models crave. And also he probably wanted the heroin. When he appeared on the MTV awards show with Cyrus, the authorities took notice. He'll be spending the next six months in jail where he will have ample time to brush his teeth and figure out his purpose in life, which is almost certainly not giving bullshit speeches about the perils of not landing the Hugo Boss campaign to crowds full of screaming teenagers who can't fathom your pain.
Miley Cyrus' Homeless Hero Jailed
Miley Cyrus Looks Rough
Miley Cyrus wants everyone to know she has been partying it up in Rio. She posted a series of photos explaining she was hungover during her show, because that's what you want to hear when you shell out $500 bones to watch her spread her perineum on a Jumbotron and maybe come close on a few high notes. Professionalism in the music business really flew out the window when performers stopped singing or playing instruments or wearing pants. Normally with this kind of party lifestyle a young lady's looks can go straight to shit. With Cyrus this is kind of redundant and maybe she will age herself to resemble an adult woman and not a hairless keepsake for pedophiles to hang from the rearview of their vans.
When your job is to change costumes and move your lips to the words for an hour it doesn't really matter how fucked up or hungover you are. I wouldn't mind seeing her perform under the influence of krokodil heroin just for a scientific control. My guess, both shows would suck.
Photo Credit: Instagram
Miley Cyrus Ass Disses Mexico (VIDEO)
Miley Cyrus celebrated Mexican Independence Day by having her ass repeatedly slapped with a Mexican flag, while in Mexico. As Miley was bending over and twerking with her drop dead hilarious oversized fake ass, one of her token locally hired day laborer male backup dancers whipped her ass with the symbol of Mexico's national pride, such as it is. Now Mexican lawmakers are threatening to fine her $1,200 dollars or have her detained for 36 hours because they don't understand currency exchange.
Unlike your average Mexican citizen, American pop stars will gladly produce ten years of your salary in order to avoid disappearing under your custody. No word on the guy doing the whipping, but the overwhelming odds are he lacks cash or even basic toiletries so extracting money is a lost cause. He'll probably be put in irons and forced to work the Ensenada parasailing booths. I don't see how Cyrus can go lower in her repeated failed attempts at provoking reaction. Maybe shitting on Ground Zero or face humping the Lincoln Memorial would garner a few headlines. It's not really punk if your Beverly Hills media firms plans it out on paper first. But it is pretty fucking lucrative.
Photo Credit: Instagram
Miley Cyrus Calls the Cops
It's not uncommon for the police to receive calls regarding disoriented elderly women and wandering illegal immigrant children who are still confused after walking a thousand miles in homemade sandals. Miley Cyrus called for the police from a fire station after being followed by a paparazzi snapping she and her sister riding their 3-wheeled motorcycle around Beverly Hills.
Despite what you saw in the Eddie Murphy movies, the Beverly Hills police don't have all that much to do. Providing safe passage for Miley back to her bong and malt-liquor filled dildo hangout seemed like a sensible use of law enforcement resources. Until Suge Knight seeks his revenge, things are kind of slow in the 90210. Why not lend a hand to the less fortunate and small-breasted.
Photo Credit: Fame Flynet
Miley Cyrus Bastardizes The Hippies
Miley Cyrus just released a fairly shitty rudimentary cover of Led Zeppelin's "Baby I'm Gonna Leave You", presumably in correlation to her new art/fashion/whatever the fuck it is Dirty Hippy collection of obnoxious looking shit she paid someone to assemble and took credit for. Cyrus has a few characteristics of actual hippies: an overstated self righteousness, a drug habit, and what is surely a large volume of unprotected sex with people she will regret twenty years from now if she happens to remember.
Most hippies sold out as soon as it stopped being cool, so Cyrus' dabbling in stink culture is pretty typical of the old guard who all took jobs with Monsanto once the pussy dried up. Cyrus will surely offend some diehards who think exploiting their belief system to hawk shitty merchandise at Target is uncouth, but nobody really listens to them anyway since they are toothless and decrepit shack dwellers, plus Cyrus has no idea what hippies believe anyway, she just likes the shiny colors and not having to conform to the conventional standards of beauty or washing.
Photo Credit: Instagram
Miley Cyrus: Artist And Shit Around The Web
Miley Cyrus has joined other talentless celebrities masquerading as visual artists. She has a an art show called "Dirty Hippie" at V Magazine's offices in New York. It's mostly crap like bongs and vibrators with other shit glued to it. Maybe that's art, maybe it isn't, I know I'm not touching it without a double wrap of latex gloves.
Check out Miley's crappy sculptures. (Dlisted)
Jennifer Lopez in a leather dress is still pretty fucking hot. (Huffington Post)
Emily Ratjakowski loves to show off her tits, doesn't she? (Popoholic)
This video of Abigail Ratchford at a photoshoot makes my wiener happy. (COED)
Remember Ashley Simpson? Here is her sideboob. (The Superficial)
Lily Allen in a bikini is a good thing. (Hollywood Tuna)
Jennifer Aniston wore a see-through dress and showed us all her nips. (Drunken Stepfather)


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Blood Diamond Gallery
Leonardo DiCaprio and Djimon Hounsou have been Oscar nominated for their performances in Edward Zwick's Blood Diamond, an action-adventure that exposes some harsh truths about the conflict diamond trade and child armies in Africa. Check out some photos from the film…
Roll your mouse over the left and right-hand sides of the image and then click to view more pictures.
2 of 9
Read our review of Blood Diamond or our interviews with Leonardo DiCaprio or Jennifer Connelly
Recent Galleries:
- The Gunman (Sean Penn) Photo Gallery
- Fast & Furious 7 First-look Photo Gallery
- Snoopy & Charlie Brown: The Peanuts Movie - Character Poster Gallery
- Unfinished Business (Vince Vaughn) Photo Gallery
- Disney's Frozen Fever Photo Gallery
- Focus - Margot Robbie Photo Gallery
- Focus (Will Smith/Margot Robbie) Photo Gallery
- The Second Best Exotic Marigold Hotel Photo Gallery
- Spectre: Rome Photo Call (Daniel Craig and Monica Bellucci)
- The Second Best Exotic Marigold Hotel Royal Film Performance Photo Gallery


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The Securities Industry and Financial Markets Association has asked the SEC to impose a moratorium on rulings related to market-data fees. SIFMA wants the agency to conduct a regulatory and financial analysis to determine whether proposed fees are fair to firms, vendors and investors. "The SEC cannot simply ignore the conflicts of interest inherent in today's for-profit exchanges," Marc Lackritz, co-chief executive of SIFMA, said in a written statement. "The exchanges' unique regulatory status allows them to profit from their market data without the threat of competition, but this conflicts with their congressional mandate to promote transparency."
View Full Article in:InvestmentNews (free registration) · MarketWatch · Wall Street Journal (tiered subscription model), The
Published in Brief:


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ATSCShort for Advanced Television Systems Committee, it is an international, non-profit organization developing voluntary standards for digital television. The ATSC member organizations represent the broadcast, broadcast equipment, motion picture, consumer electronics, computer, cable, satellite, and semiconductor industries.
Perceptual computing is the ability for a computer to recognize what is going on around it. More specifically, the computer can perceive the... Read More »Apple Pay Promises to Strengthen Payment Security
Experts believe that Apple Pay and other competitive payment systems will be far more secure than cards, even cards equipped with EMV chips. Read More »The Great Data Storage Debate: Is Tape Dead?
Tape clearly is on the decline. But remember, legacy systems can hang for a shockingly long time. Read More »
A network is a group of two or more computer systems or devices, linked together to share resources, exchange files and electronic communications.... Read More »Computer Architecture Study Guide
This Webopedia study guide describes the different parts of a computer system and their relations. Read More »Webopedia Polls
The trend for the past two years has been for shoppers to spend more online during the holiday season. How do you typically shop for holiday... Read More »
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Datamation Hangouts with Tech ExpertsWatch Datamation's editor James Maguire moderate roundtable discussions with tech experts from companies such as Accenture, Dell, Blue Jeans Network, Microsoft and more »


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4-H Cloverbud Connection event set for March 17
All youth in grades K-2 are invited to attend a Cloverbud Connection event and explore and learn about a variety of topics!
Youth will learn and create new things, play games, make new friends and explore the world around them.
The topic of the next session, which is set for March 17, is aerospace.
Sessions are from 2 to 4 p.m. in the Minnesota Extension Office meeting room located in the Douglas County Services Center at 720 Fillmore Street in Alexandria.
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You will need your subscription account number and phone number. Not sure if you have an account? Email us at firstname.lastname@example.com and we can help you.


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Raspberry grand ice cream flavor back at Tom's
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Pilot, 81, critically hurt after Ohio plane crashPilot, 81, critically hurt after Ohio plane crashRobert Syme was attempting to land at a small airport in Westfield Township in Medina County Saturday evening when the landing gear became stuck in the mud, causing the plane to overturn on a grass runway.
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Icebreaker 200 Lightweight LS Pace Crewe
Where to Buy
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Manufacturer's Description
Visit Icebreaker's 200 Lightweight LS Pace Crewe page.
Retailers' Descriptions
Here's what other sites are saying:
On Sale. Free Shipping. Icebreaker Women's Pace LS Crewe FEATURES of the Icebreaker Women's Pace Long Sleeve Crewe Made from 200 gm merino with a touch of Lycra for the ultimate fit Lightweight Naturally odor-resistant Naturally wicking Breathable Raglan sleeves with gussets for wide range of movement Shaped hem for extra coverage Contrast, anti-chafe flatlock stitching SPECIFICATIONS of the Icebreaker Women's Pace Long Sleeve Crewe Lightweight 200 gm merino Slim fit 96% merino wool, 4% elastane
- Moosejaw
the Pace Long Sleeve Crewe Top from Icebreaker is a lightweight baselayer made from Merino wool that is perfect for high-active winter sports. Merino wool isn't like the wool you know: itchy, uncomfortable, and bulky. Instead, with the Pace Long Sleeve Crewe Top, you get a Merino wool blend that is silky to the touch, maintains your body heat, and wicks moisture away. The end result is a comfortable, dry, and happy you. PRODUCT FEATURES: Weight: 200 Lightweight Fabric: 96% merino wool, 4% elastane Fit: Slim Layer: Base Layers Best for: Snow Sports, Running & Fitness Raglan sleeves with gussets for wide range of movement Shaped hem for extra coverage Contrast, anti-chafe flatlock stitching
- Appalachian Outdoors
Knit from Icebreaker merino wool grown on the backs of New Zealand sheep, the Icebreaker Women's Long Sleeve Pace Crewe uses the natural breathability and insulating power of wool to keep you warm in winter. This long underwear top is non-itchy and resists odors, making it the perfect base layer for aerobic winter sports from a long ski tour to a day of snowboarding with friends. This thermal top has a trim athletic fit, thumbholes and gusseted raglan sleeves for ease of movement and comfort under pack straps. Constructed with a shaped hem for great coverage and contrasting flatlock stitching to eliminate chaffing, this long john top will keep pace with your active lifestyle. Once you try the high performance, premium fit and feel of the Icebreaker Long Sleeve Pace Crewe for women, you'll be a fan for life.
- Altrec Outlet
Description of Icebreaker LS Pace Crew - WomensSet the pace with this sizzling new crewe. Every feature is designed to make you fitter, faster and better, from the sleeve gussets for ease of movement to the trim, athletic cut. Lightweight, breathable, temperature controlling and odour resistant, premium merino will keep you feel good while youre exploring the limits of your sport.FeaturesTrim, athletic fitCrewe neckRaglan sleevesSleeve gusset for ease of movementShaped hemContrast flatlock stitchingIcebreaker logo and GT graphic
- US Outdoor Store
Icebreaker 200 Lightweight LS Pace Crewe
currently retails for:
$50.00 - $63.99
$50.00 - $63.99


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Ireland will need to find $65 billion to repay all the bank debt outstanding the Irish government has stated.
After months of speculation the final figure has finally been arrived at. It will mean that Irish taxpayers face a massive bill well into the future to pay off the Celtic Tiger binge.
The final figure includes $40 billion for Anglo Irish Bank, a figure that may go higher, as well as $9 billion for Allied Irish Bank which has now effectively been nationalised, $5 billion for Bank fo Ireland and up to$8 billion for two building societies.
The latest figures reflect the state's fourth effort to make the Irish banking system solvent. The government now says they will publish a four-year-plan showing how they will stabilize the finances of Ireland.
It is believed that savage spending cuts in the next budget totalling as much as $7 billion will be enforced to bring the national debt figure down.
Ireland's travails have made front page headlines across Europe, including in the Financial Times which led with the headlines that " Irish Face 50 billion Euro Bank Rescue" which they explained was a third of gross national product.
In its editorial the Financial Times stated " By finally allowing the public an inkling of the depth of the pit that is Anglo Irish Bank the Uhrish government has taken a step--albeit a small one-- towards solving Ireland's banking crisis."
The economic loss is at last being accounted for .The political irresponsibility that made it possible has yet to face its reckoning." the editorial concluded.
The Irish Times editorial stated that "The final bill had come in" for Ireland's extravagance.
The reaction from the Irish tabloids was more pungent. The Daily Star wrote "Ireland R.I.P" on a tombstone across its front page.
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