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Additive manufacturing permits innovative soft device architectures with micron resolution. The processing requirements, however, restrict the available materials, and joining chemically dissimilar components remains a challenge. Here we report silicone double networks (SilDNs) that participate in orthogonal crosslinking mechanisms—photocurable thiol-ene reactions and condensation reactions—to exercise independent control over both the shape forming process (3D printing) and final mechanical properties. SilDNs simultaneously possess low elastic modulus ( E 100%  < 700kPa) as well as large ultimate strains (d L/L 0 up to ~ 400 %), toughnesses ( U ~ 1.4 MJ·m −3 ), and strengths ( σ ~ 1 MPa). Importantly, the latent condensation reaction permits cohesive bonding of printed objects to dissimilar substrates with modulus gradients that span more than seven orders of magnitude. We demonstrate soft devices relevant to a broad range of disciplines: models that simulate the geometries and mechanical properties of soft tissue systems and multimaterial assemblies for next generation wearable devices and robotics. Additive manufacturing processing requirements pose restrictions on materials and joining chemically dissimilar components. Here the authors use silicone double networks that participate in orthogonal crosslinking mechanisms for independent control of the shape forming process and final mechanical properties.

A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD). To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely. We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition. Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, = 0.006; psychosocial functioning: SMD -0.51, = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, < 0.0007; suicide-related outcomes: risk ratio 0.10, < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, = 0.002; psychosocial functioning: SMD -0.45, = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, = 0.03; suicide-related outcomes: SMD -0.96, = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, = 0.002). There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.

To review the effectiveness of psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features. We included randomized clinical trials on psychological therapies for adolescents with BPD and BPD features. Data were extracted and assessed for quality according to Cochrane guidelines, and summarized as mean difference (MD) with 95% confidence intervals (CI) for continuous data and as Odds ratios (OR) with 95% CI for dichotomous data. Risk of bias was assessed using Cochrane's risk of bias tool for each domain. When possible, we pooled trials into meta-analyses, and used Trial Sequential Analysis (TSA) to control for random errors. Quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). 10 trials on adolescents with BPD or BPD features were included. All trials were considered at high risk of bias, and the quality of the evidence was rated as \"very low\". We did TSA on the primary outcome and found that the required information size was reached. The risk of random error was thus discarded. Only 10 trials have been conducted on adolescents with BPD or BPD features. Of these only few showed superior outcomes of the experimental intervention compared to the control intervention. No adverse effects of the interventions were mentioned. Attrition rates varied from 15-75% in experimental interventions. The overall quality was very low due to high risk of bias, imprecision and inconsistency, which limits the confidence in effect estimates. Due to the high risk of bias, high attrition rates and underpowered studies in this area, it is difficult to derive any conclusions on the efficacy of psychological therapies for BPD in adolescence. There is a need for more high quality trials with larger samples to identify effective psychological therapies for this specific age group with BPD or BPD features.

Purpose To determine the impact of socioeconomic position (SEP) and distance to provider on outpatient mental health care utilization among incident users of antidepressants. Method A nationwide register-based cohort study of 50,374 person-years. Results Persons in low SEP were more likely to have outpatient psychiatrist contacts [odds ratio (OR) 1.25; confidence interval (CI) 1.17–1.34], but less likely to consult a co-payed psychologist (OR 0.49; CI 0.46–0.53) and to get mental health service from a GP (MHS-GP) (OR 0.81; CI 0.77–0.86) compared to persons in high SEP after adjusting for socio-demographics, comorbidity and car ownership. Furthermore, persons in low SEP who had contact to any of these therapists tended to have lower rates of visits compared to those in high SEP. When distance to services increased by 5 km, the rate of visits to outpatient psychiatrist tended to decrease by 5% in the lowest income group (IRR 0.95; CI 0.94–0.95) and 1% in the highest (IRR 0.99; CI 0.99–1.00). Likewise, contact to psychologists decreased by 11% in the lowest income group (IRR 0.89; CI 0.85–0.94), whereas rate of visits did not interact. Conclusion Patients in low SEP have relatively lower utilization of mental health services even when services are free at delivery; co-payment and distance to provider aggravate the disparities in utilization between patients in high SEP and patients in low SEP.

The forward lunge (FL) may be a promising movement to assess functional outcome after ACL reconstruction. Thus, we aimed to investigate the FL movement pattern before and after ACL reconstruction with a comparison to healthy controls to determine if differences were present. Twenty-eight ACL injured participants and 28 matched healthy controls were included. They performed FL movements while sagittal plane biomechanics of the knee and electromyography (EMG) of nine leg muscles was assessed. The ACL injured group was tested before and 10 months after surgery. The perceived knee function and activity level was assessed by questionnaires. The ACL injured group performed the FL significantly slower than the controls before surgery (mean difference: 0.41 s [95%CI: 0.04-0.79 s; p<0.05]) while they performed the FL as fast as the controls after surgery (~28% movement time reduction post-surgery). Perceived knee function and activity level improved significantly post-surgery. The knee joint flexion angle, extensor moment, power, angular velocity in the ACL injured group did not differ from pre to post-surgery. For the ACL injured group, the peak knee extensor moment observed both pre and post-surgery was significantly lower when compared to the controls. The EMG results showed minimal differences. In conclusion, at 10 months post-surgery, the FL was performed significantly faster and the movement time was comparable to that of the controls. While the perceived knee function and activity level improved post-surgery, the knee joint biomechanics were unchanged. This may reflect that knee joint function was not fully restored.

Studies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence. Participants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments. 97 of the original sample of 111 participants (87%) participated. They were aged 19–23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population. Although stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis. •Studies of borderline personality disorder from adolescence to adulthood are lacking.•Borderline personality disorder in adolescence is a psychopathology severity marker.•Borderline personality disorder in adolescence leads to adult functional impairment.•Early interventions for borderline personality disorder need a broad focus.

The objective of this work is to present a musculo-skeletal model of the lumbar spine, which can be shared and lends itself to investigation in many locations by different researchers. This has the potential for greater reproducibility and subsequent improvement of its quality from the combined effort of different research groups. The model is defined in a text-based, declarative, object-oriented language in the AnyBody Modelling System software. Text-based models will facilitate sharing of the models between different research groups. The necessary data for the model has been taken from the literature. The work resulted in a detailed lumbar spine model with seven rigid segments with 18 degrees-of-freedom and 154 muscles. The model is able to produce a maximum extension moment of 238 Nm around L5/S1. Moreover, a comparison was made with in vivo intradiscal pressure measurements of the L4–5 disc available from the literature. The model is based on inverse dynamics, where the redundancy problem is solved using optimization in order to compute the individual muscle forces and joint reactions. With the presented model it is possible to investigate a range of research questions, because the model is relatively easy to share and modify due to the use of a well-defined and self-contained scripting language. Validation is though still necessary for specific cases.

ObjectivesThis study aimed to investigate the perspectives of clozapine-naïve outpatients with treatment-resistant schizophrenia on clozapine commencement and the barriers and facilitators of it.DesignA mixed-methods convergent design was employed using both qualitative and quantitative data on the same items.SettingIn-home visits or meetings at three Mental Health outpatient facilities in Region Zealand East, Denmark.ParticipantsClozapine-eligible, yet clozapine-naïve, outpatients with schizophrenia. A convenience sample of 206 patients with schizophrenia treated with antipsychotic polypharmacy (APP) was screened for clozapine eligibility. Clozapine eligibility included recurrent/continued prescription of APP throughout the past year, ≥ 3 different antipsychotics (APs) trialled at a therapeutic dose and ≥2 APs trialled adequately before current treatment. All eligible patients able to provide written informed consent were invited to participate.MethodsThe participants’ perspectives were assessed qualitatively through semistructured interviews and quantitatively with closed-ended questions, numerical scale ratings, and standardised patient-reported outcome measures. Moreover, the participants’ sociodemographic and clinical characteristics were collected through case files, participant questionnaires, and clinical ratings made by the participants’ treating clinicians. Interviews were transcribed verbatim and analysed thematically. Quantitative data were analysed with descriptive statistics. Finally, qualitative and quantitative results were compared and merged to draw meta-inferences.ResultsEighteen patients were included, 10 (56%) were men and the median age was 30.0 years (IQR 24.8–37.8). Nine participants (50%) were willing to commence clozapine if offered now, nine were not. No apparent clinical or socioeconomic differences were observed between refusers and acceptors; however, the acceptors rated their subjective recovery on the Brief INSPIRE-O significantly lower than the refusers did, and qualitatively, they all expressed subjective distress due to their current symptoms. Three themes characterised the refusers’ reasons for not accepting clozapine: ‘Reconciliation with the current situation warrants no change in treatment’, ‘Clozapine is a last-resort treatment for last-resort people’ and ‘Permanent or situational reluctance due to practical aspects of treatment’. In the vast majority of cases, blood sampling had little or no impact on the participants’ current willingness to commence clozapine, and quantitatively, blood sampling ranked lowest of the suggested barriers, whereas hospital admission for clozapine commencement ranked highest. The adverse side effects of clozapine, sedation and, weight gain in particular, were considered a major barrier if previously encountered with ineffective AP trials. The introduction of individualised commencement plans mitigating personal barriers was highlighted as the facilitator with the greatest impact on clozapine willingness, able to turn refusals into acceptance.ConclusionsPatients tend to prefer the predictability in status quo over switching to clozapine if they previously have trialled multiple APs with inadequate symptom reduction and subsequent deterioration/rehospitalisation or AP-induced weight gain and sedation. Moreover, the impression that clozapine treatment was unmanageable or a last-resort option further accentuated their reluctance to switch. Antipsychotic-trial fatigue and the stigma of clozapine as a last-resort treatment should be avoided by adhering to guidelines, thereby limiting the number of antipsychotics trialled before offering clozapine. Fortunately, it seems as if the patient’s willingness to trial clozapine is positively impressionable to the conversation about customised commencement plans offering commencement on the patient’s terms. For patients with subjective distress due to their symptoms, such plans can even reverse an initial clozapine refusalCite Now

ObjectivesClozapine is continuously underused. The existing systematic reviews addressing barriers to clozapine prescribing primarily focus on clinical staff’s attitudes and perceived barriers to prescribing. However, a preliminary literature search revealed additional literature on the subject not previously included in systematic reviews, including literature on patient perspectives. A scoping review is warranted to map the scope of primary studies on patients’ and/or clinicians’ perspectives on clozapine treatment and to identify gaps in research.DesignA scoping review was designed and reported in accordance with established guidelines for scoping reviews.Data sourcesThe electronic databases Cochrane Library, CINAHL, Web of Science, PsycINFO, MEDLINE, EMBASE, Google Scholar and two grey literature databases were searched. Furthermore, citation tracking of selected studies was undertaken.Eligibility criteriaWe included primary, empirical studies reporting clinicians’ and/or patients’ perspectives on clozapine treatment. No limitation was set for the year of publication or type of primary study.Data extraction and synthesisTwo researchers independently screened for studies, extracted the data and coded the content. Findings were summarised visually and narratively.Results146 studies were included. Most studies reported on patients’ or clinicians’ perspectives on active clozapine treatment or on clinicians’ perspectives on barriers to clozapine initiation in general. Three gaps in research were identified: (1) clozapine-eligible, yet clozapine-naïve, patients’ attitudes towards clozapine commencement, (2) clinicians’ reasons for clozapine withholding and perceived facilitators of clozapine treatment in specific patient-cases and (3) patient and clinician perspectives on clozapine discontinuation, continuation and rechallenge in specific patient cases.ConclusionsResearch on clozapine perspectives tends to repeat itself. Future studies addressing the identified gaps in evidence could provide the insights needed to optimise clozapine utilisation.

Background: The formulations of post-traumatic stress disorder (PTSD) and the newly included disorder complex PTSD (CPTSD) in the 11th edition of the International Classification of Diseases (ICD-11) have not been evaluated on a broad range of maladaptive personality traits. Objective: The aim of this study was to evaluate ICD-11 PTSD and CPTSD on maladaptive personality traits. Method: In a cross-sectional study of 106 Danish outpatients with ICD-10 PTSD, we used the International Trauma Questionnaire (ITQ) to identify patients with either ICD-11 PTSD or CPTSD (N = 84). We utilized the Personality Inventory for DSM-5 (PID-5) from the alternative model of personality disorders in DSM-5, section III, to evaluate personality trait differences between ICD-11 PTSD and CPTSD. Furthermore, PID-5 was also used to investigate relationships between personality traits and ICD-11 PTSD/CPTSD symptom clusters. The Life Event Checklist was used to assess traumatic experiences, and the MINI International Neuropsychiatric Interview was applied to assess comorbidity. Results: Patients with ICD-11 PTSD or CPTSD had elevated scores on personality traits indicative of internalizing psychopathology. However, higher impairment levels of the trait domains Negative Affectivity (d= 0.75) and Psychoticism (d = 0.80) discriminated patients with ICD-11 CPTSD from patients with PTSD. The PID-5 trait domain Detachment was moderately positively correlated to most of the ITQ symptom clusters and, the ITQ Negative Self-concept symptom cluster showed a relatively high number of significant correlations across all the PID-5 trait domains and facets. The PID-5 domain Negative Affectivity and almost all the encompassing facets were significantly correlated with DSO symptom clusters. Conclusions: The findings demonstrate the relevance of applying dimensional assessment of personality features to study the psychopathology of ICD-11 PTSD and CPTSD and potential differences. The results suggest that CPTSD is a more debilitating disorder than PTSD considering the severity of the personality features. * There are differences in the personalities of people with PTSD and those with CPTSD. * Individuals identified with CPTSD have scored higher on the trait domains Negative Affectivity and Psychoticism. * Understanding these differences may lead to better diagnosis and treatment of both these groups.