Sexual abuse and suicidal issues in Australian young people. An interim report

BACKGROUND

Youth suicide remains a significant issue in Australian society with suicide rates among young males being of particular concern. While there are many antecedents for suicidal behaviours one that is often overlooked is sexual abuse. In particular, sexual abuse in males has the potential to be an easily overlooked issue and yet may lead to significant emotional distress.

OBJECTIVE

The objective of this study was to identify if sexual abuse played a significant role in depression and suicide risk, including suicidal intent.

DISCUSSION

This study supports an apparent high prevalence of sexual abuse in young Australians and indicates that such abuse contributes to a number of health risk behaviours including self harm and suicidal intent. General practitioners need to be aware of this as a suicidal risk factor and need to raise it in discussion with any young person who presents with significant health risk behaviours such as drug taking, sexual risk taking and self harm.

Molecular determinants of the granulocyte-macrophage colony-stimulating factor receptor complex assembly

The granulocyte-macrophage colony-stimulating factor (GM-CSF) receptor (GMR) is composed of two chains that belong to the superfamily of cytokine receptors typified by the growth hormone receptor. A common structural element found in cytokine receptors is a module of two fibronectin-like domains, each characterized by seven beta-strands denoted A-G and A'-G', respectively. The alpha-chain (GMRalpha) confers low affinity GM-CSF binding (K(d) = 1-5 nM), whereas the beta-chain (beta(c)) does not bind GM-CSF by itself but confers high affinity binding when associated with alpha (K(d) = 40-100 pM). In the present study, we define the molecular determinants required for ligand recognition and for stabilization of the complex through a convergence of several approaches, including the construction of chimeric receptors, the molecular dynamics of our three-dimensional model of the GM.GMR complex, and site-directed mutagenesis. The functional importance of individual residues was then investigated through ligand binding studies at equilibrium and through determination of the kinetic constants of the GM.GMR complex. Critical to this tripartite complex is the establishment of four noncovalent bonds, three that determine the nature of the ligand recognition process involving residues Arg(280) and Tyr(226) of the alpha-chain and residue Tyr(365) of the beta-chain, since mutations of either one of these residues resulted in a significant decrease in the association rate. Finally, residue Tyr(365) of beta(c) serves a dual function in that it cooperates with another residue of beta(c), Tyr(421) to stabilize the complex since mutation of Tyr(365) and Tyr(421) result in a drastic increase in the dissociation rate (Koff). Interestingly, these four residues are located at the B'-C' and F'-G' loops of GMRalpha and of beta(c), thus establishing a functional symmetry within an apparently asymmetrical heterodimeric structure.

Safety and immunogenicity of a new Neisseria meningitidis serogroup C-tetanus toxoid conjugate vaccine in healthy adults

We evaluated the safety and immunogenicity of a single dose of a new serogroup C O-deacetylated meningococcal polysaccharide-tetanus toxoid conjugate vaccine in 30 healthy adult volunteers. The vaccine was well tolerated with no serious adverse events and minimal local reactions and systemic symptoms. All subjects developed a fourfold or greater increase in serum bactericidal antibody (SBA) to serogroup C meningococcus. SBA geometric mean titre increased from 11 to 3649 (p<0.001). Serogroup C-specific IgG levels increased postvaccination from 0.65 to 17.02 microg/ml (p<0.001). Bactericidal titres pre- and postimmunisation showed significant correlation with serogroup C-specific IgG (r(2)=0.693). Antibody levels fell by 6 months postvaccination, however, meningococcal C IgG avidity increased indicating the successful induction of a T-cell-dependent antibody response.

CONCLUSION

meningococcal C-tetanus toxoid conjugate vaccine is immunogenic and well tolerated in healthy adults.

Increased dietary micronutrients decrease serum homocysteine concentrations in patients at high risk of cardiovascular disease

BACKGROUND

Elevated blood homocysteine is a risk factor for cardiovascular disease. A 5-micromol/L increase is associated with an approximately 70% increase in relative risk of cardiovascular disease in adults. For patients with established risk factors, this risk is likely even greater.

OBJECTIVE

Effects of increased dietary folate and recommended intakes of vitamins B-12 and B-6 on serum total homocysteine (tHcy) were assessed in individuals at high risk of cardiovascular disease.

DESIGN

This trial was conducted at 10 medical research centers in the United States and Canada and included 491 adults with hypertension, dyslipidemia, type 2 diabetes, or a combination thereof. Participants were randomly assigned to follow a prepared meal plan (PMP; n = 244) or a self-selected diet (SSD; n = 247) for 10 wk, which were matched for macronutrient content. The PMP was fortified to provide >/=100% of the recommended dietary allowances for 23 micronutrients, including folate.

RESULTS

Mean folate intakes at 10 wk were 601 +/- 143 microgram/d with the PMP and 270 +/- 107 microgram/d with the SSD. With the PMP, serum tHcy concentrations fell from 10.8 +/- 5.8 to 9.3 +/- 4.9 micromol/L (P < 0.0001) between weeks 0 and 10 and the change was associated with increased intakes of folate, vitamin B-12, and vitamin B-6 and with increased serum and red blood cell folate and serum vitamin B-12 concentrations. tHcy concentrations did not change significantly with the SSD.

CONCLUSIONS

The PMP resulted in increased intakes and serum concentrations of folate and vitamin B-12. These changes were associated with reduced serum tHcy concentrations in persons at high risk of cardiovascular disease.

Community participation in the recruitment and retention of rural doctors: methodological and logistical considerations

Two Queensland rural communities with histories of poor general practitioner (GP) recruitment and retention participated in a process aimed at developing broadly based community action plans to recruit and retain GPs. Despite their very different physical and social characteristics, the two communities developed many similar objectives and strategies, which had the possibility of being implemented more widely. The community participation process can be both time- and cost-effective if consideration is given to a variety of methodological and logistical issues. The process is a means by which communities, Divisions of General Practice, government, academic institutions and others can work together to recruit and retain medical practitioners.

Helicobacter pylori infection and early onset myocardial infarction: case-control and sibling pairs study

OBJECTIVES

To examine the association between coronary heart disease and chronic Helicobacter pylori infection.

DESIGN

Case-control study of myocardial infarction at young ages and study of sibling pairs with one member affected and the other not.

SETTING

United Kingdom.

PARTICIPANTS

1122 survivors of suspected acute myocardial infarction at ages 30-49 (mean age 44 years) and 1122 age and sex matched controls with no history of coronary heart disease; 510 age and sex matched pairs of siblings (mean age 59 years) in which one sibling had survived myocardial infarction and one had no history of coronary heart disease.

MAIN OUTCOME MEASURES

Serological evidence of chronic infection with H pylori.

RESULTS

472 (42%) of the 1122 cases with early onset myocardial infarction were seropositive for H pylori antibodies compared with 272 (24%) of the 1122 age and sex matched controls, giving an odds ratio of 2.28 (99% confidence interval 1.80 to 2.90). This odds ratio fell to 1.87 (1.42 to 2.47; P<0.0001) after smoking and indicators of socioeconomic status were adjusted for and to 1.75 (1.29 to 2.36) after additional adjustment for blood lipid concentrations and obesity. Only 158 of the 510 pairs of siblings were discordant for H pylori status; among these, 91 cases and 67 controls were seropositive (odds ratio 1.33 (0.86 to 2.05)). No strong correlations were observed between H pylori seropositivity and measurements of other risk factors for coronary heart disease (plasma lipids, fibrinogen, C reactive protein, albumin, etc).

CONCLUSION

In the context of results from other relevant studies, these two studies suggest a moderate association between coronary heart disease and H pylori seropositivity that cannot be fully accounted for by other risk factors. But even if this association is causal and largely reversible by eradication of chronic infection, very large randomised trials would be needed to show this.

Emergency contraception in Nairobi, Kenya: knowledge, attitudes and practices among policymakers, family planning providers and clients, and university students

To gauge knowledge, attitudes, and practices about emergency contraception in Nairobi, Kenya, we conducted a five-part study. We searched government and professional association policy documents, and clinic guidelines and service records for references to emergency contraception. We conducted in-depth interviews with five key policymakers, and with 93 family planning providers randomly selected to represent both the public and private sectors. We also surveyed 282 family planning clients attending 10 clinics, again representing both sectors. Finally, we conducted four focus groups with university students. Although one specially packaged emergency contraceptive (Postinor levonorgestrel tablets) is registered in Kenya, the method is scarcely known or used. No extant policy or service guidelines address the method specifically, although revisions to several documents were planned. Yet policymakers felt that expanding access to emergency contraception would require few overt policy changes, as much of the guidance for oral contraception is already broad enough to cover this alternative use of those same commodities. Participants in all parts of the study generally supported expanded access to emergency contraception in Kenya. They did, however, want additional, detailed information, particularly about health effects. They also differed over exactly who should have access to emergency contraception and how it should be provided.

The role of a hydrofibre dressing in squamous cell carcinoma of the anal canal

This report describes an unusual presentation of squamous cell carcinoma of the anal canal involving the vagina; radical surgery resulted in a large cavity wound.

How accurately do we estimate patients' weight in emergency departments?

OBJECTIVE

To assess the accuracy of estimates of patients' weight made by physicians, nurses, and patients themselves in emergency departments.

DESIGN

Observational prospective study.

SETTING

Tertiary referral centre in Vancouver, BC.

PARTICIPANTS

Eleven attending physicians, 26 nurses, and a convenience sample of 117 patients.

INTERVENTIONS

Patients themselves, attending physicians, and nurses independently estimated the weight of 117 patients. An investigator weighed each patient.

MAIN OUTCOME MEASURES

Mean error was determined by subtracting actual weight from estimated weight and dividing by actual weight; 95% confidence intervals (CI) were calculated.

RESULTS

Mean error in estimates was 3.1% (95% CI 2.7 to 3.5) for patients, 8.4% for nurses (CI 7.6 to 9.2), and 8.1% (CI 7.1 to 9.1) for physicians. Weight was estimated within 5% of actual weight by 32% of nurses, 39% of physicians, and 82% of patients. Weight was estimated within 10% of actual weight by 66% of nurses, 66% of physicians, and 97% of patients. Estimates out by more than 15% were made by 11% of nurses, 16% of physicians, and 1% of patients.

CONCLUSIONS

Patient estimates were most accurate. Physician and nurse estimates were unreliable.

Nutritionally complete prepared meal plan to reduce cardiovascular risk factors: a randomized clinical trial

OBJECTIVE

To compare a nutritionally complete prepared meal plan that meets national dietary guidelines to usual-care dietary therapy for hypertension, dyslipidemia, and glycemic control.

DESIGN

Randomized, controlled trial.

SUBJECTS/SETTING

Outpatients with hypertension, dyslipidemia, or diabetes mellitus (n = 251) were recruited at 6 medical centers in the United States and Canada.

INTERVENTION

The prepared meal plan, which was developed by university-based nutrition and cardiovascular scientists and food technologists at Campbell's Center for Nutrition & Wellness (CCNW), provided the optimal levels of macronutrients and micronutrients recommended for cardiovascular risk reduction in a variety of prepackaged meals and snacks. After a 4-week pretrial period to assess baseline state, participants were randomized to the CCNW plan or "usual-care" diet for 10 weeks.

MAIN OUTCOME MEASURES

Blood pressure, carbohydrate metabolism, lipoproteins, homocysteine, weight, nutrient intake, compliance.

STATISTICAL ANALYSES PERFORMED

Repeated measures analysis of variance.

RESULTS

Lipoproteins, carbohydrate metabolism, blood pressure, and weight improved on both plans. Mean differences (+/- standard deviation) between baseline and follow-up for the CCNW plan and the usual-care plan, respectively, were total cholesterol, -0.41 +/- 0.64 and -0.20 +/- 0.50 mmol/L (between-group P < .01); plasma glucose, -0.7 +/- 1.7 and -0.3 +/- 1.3 mmol/L (P < .05); systolic blood pressure, -5.2 +/- 10.0 and -4.7 +/- 9.0 mm Hg (P = .67), diastolic blood pressure, -3.8 +/- 5.9 and -2.2 +/- 5.5 mm Hg (P < .05); and homocysteine, -1.3 +/- 3.8 and 0.2 +/- 3.4 mumol/L (P < .01). The CCNW plan led to greater weight loss than the usual-care diet (-5.5 +/- 3.8 kg vs -3.0 +/- 3.2 kg, P < .0001).

APPLICATIONS/CONCLUSION

The nutritionally complete CCNW plan offers greater improvements in lipids, blood sugars, homocysteine, and weight loss than usual-care diet therapy. This prepackaged comprehensive nutrition program can augment both the prescription and practice of optimal dietary therapy.

The type of somatic mutation at APC in familial adenomatous polyposis is determined by the site of the germline mutation: a new facet to Knudson's 'two-hit' hypothesis

APC is often cited as a prime example of a tumor suppressor gene. Truncating germline and somatic mutations (or, infrequently, allelic loss) occur in tumors in FAP (familial adenomatous polyposis). Most sporadic colorectal cancers also have two APC mutations. Clues from attenuated polyposis, missense germline variants with mild disease and the somatic mutation cluster region (codons 1,250-1,450) indicate, however, that APC mutations might not result in simple loss of protein function. We have found that FAP patients with germline APC mutations within a small region (codons 1,194-1,392 at most) mainly show allelic loss in their colorectal adenomas, in contrast to other FAP patients, whose 'second hits' tend to occur by truncating mutations in the mutation cluster region. Our results indicate that different APC mutations provide cells with different selective advantages, with mutations close to codon 1,300 providing the greatest advantage. Allelic loss is selected strongly in cells with one mutation near codon 1,300. A different germline-somatic APC mutation association exists in FAP desmoids. APC is not, therefore, a classical tumor suppressor. Our findings also indicate a new mechanism for disease severity: if a broader spectrum of mutations is selected in tumors, the somatic mutation rate is effectively higher and more tumors grow.

How reliable is emergency department triage?

STUDY OBJECTIVE

To measure interrater and intrarater agreement for an emergency department triage system.

METHODS

A 2-phase experimental study was conducted using previously described in-person scripted encounters with emergency nurses who perform patient triage and attending emergency physicians at a tertiary referral center. Standardized patient scenarios were presented twice over 6 weeks. Participants rated severity for each patient using a 5-tier triage system (nurses only) and estimated the probability of hospital admission, the most appropriate time frame to physician evaluation (5 choices, from "Immediate" to "More than 24 hours"), the need for a monitored ED bed, and the need for diagnostic services. Interrater agreement was measured by a coefficient of agreement for multiple raters and multiple categories.

RESULTS

Of the 37 participants (fewer than 90% of those eligible), 19 (51%) completed both phases (12 nurses, 7 physicians). Four (33%) of the nurses assigned the same severity ratings for the 5 cases in phase 2 as they did in phase 1. Intrarater agreement among the 12 nurses rating triage severity was.757. Interrater agreement of nurses and physicians was substantial regarding need for ED monitoring, and moderate to substantial for other triage assessments.

CONCLUSION

There was general agreement in interrater assessment of triage classification. Continued work is necessary to more fully delineate areas of variation.

Meningococcal serogroup C conjugate vaccine is immunogenic in infancy and primes for memory

The safety, immunogenicity, and immunologic priming of 2 dosages (2 microgram or 10 microgram) of a meningococcal C oligosaccharide-CRM197 conjugate vaccine was evaluated in 114 infants vaccinated at ages 2, 3, and 4 months. Antibody persistence and response to boosting with 10 microgram of meningococcal C polysaccharide were assessed. The meningococcal conjugate vaccine produced fewer local reactions than concurrent routine immunizations. Total serogroup C-specific immunoglobulin geometric mean concentration (GMC) increased from 0.3 microgram/mL before vaccination to 13.1 microgram/mL at age 5 months. Serum bactericidal antibody (SBA) geometric mean titers (GMTs) rose from <1:4 to 1:1057 at 5 months and fell by 14 months to 1:19. Following boosting, anti-C-specific immunoglobulin GMC rose to 15.9 microgram/mL and SBA GMT to 1:495. Antibody responses in the 10-microgram dose cohort were significantly higher at 5 months (P<.01) than in the 2-microgram dose cohort but were lower after polysaccharide boosting (P=.02). This meningococcal conjugate vaccine was well tolerated and immunogenic and induced immunologic memory in infants.

Nutrient-induced insulin resistance

Impaired function of the hormone insulin (insulin resistance) is a major feature of type 2 diabetes, a condition that is expected to afflict over 200 million people by early next century. Intensive investigation has failed to find a genetic basis for insulin resistance in the majority of cases. In this brief review the evidence that insulin resistance may be caused by excess nutrient supply will be presented. Both excess glucose and excess fat can cause insulin resistance in muscle and fat tissue, while excess fat can cause impaired suppression of endogenous glucose production. Each nutrient may impair insulin action by several mechanisms, at least one of which may be common to both.

The "distal-dorsal difference" as a possible predictor of secondary Raynaud's phenomenon

OBJECTIVE

To investigate the possibility that a hand distal-dorsal difference in temperature of greater than 1 degree C (fingers colder than the dorsum) at a room temperature of 30 degrees C is a good predictor of secondary Raynaud's phenomenon (RP).

METHODS

We imaged the hands of patients with primary Raynaud's phenomenon (PRP) and systemic sclerosis (SSc) using a thermal camera at room temperatures of 23 and 30 degrees C. From these images we measured the distal-dorsal difference in temperature for all fingers excluding the thumbs. At a room temperature of 23 degrees C we also performed a cold challenge test using water at 15 degrees C for 1 min and thermally imaged the rewarming process for 15 min. Several variables were derived from the rewarming curve. The procedure was repeated within 3 days to assess reproducibility.

RESULTS

The best discriminator between PRP and SSc was found to be a distal-dorsal difference of > 1 degree C at 30 degrees C (p = 0.005). There is reasonable reproducibility when considering groups of patients. However, the intra-subject standard deviations were large, indicating that measurements for the same patient on separate visits may vary considerably.

CONCLUSION

Our results suggest that the finding of a distal-dorsal difference of > 1 degree C (cold fingers) at 30 degrees C in a patient with RP is specific for underlying connective tissue disease.

Anesthetic efficacy of the mylohyoid nerve block and combination inferior alveolar nerve block/mylohyoid nerve block

OBJECTIVE

The purpose of this study was to measure the degree of anesthesia obtained with the mylohyoid nerve block and the combination mylohyoid nerve block/conventional inferior alveolar nerve (IAN) block in mandibular teeth.

STUDY DESIGN

With the use of a repeated-measures design, 30 subjects randomly received each of 3 combinations of injections at 3 separate appointments. The combinations were as follows: mylohyoid nerve block (1.8 mL of 2% lidocaine with 1:100,000 epinephrine) + IAN block (3.6 mL of 2% lidocaine with 1:100,000 epinephrine); mock mylohyoid nerve block + IAN block (3.6 mL of 2% lidocaine with 1:100,000 epinephrine); mylohyoid nerve block (1.8 mL of 2% lidocaine with 1:100,000 epinephrine) + mock IAN block. The mylohyoid injections were aided by the use of a peripheral nerve stimulator. Mandibular anterior and posterior teeth were blindly tested with a pulp tester at 4-minute cycles for 60 minutes postinjection. Anesthesia was considered successful when 2 consecutive 80 readings were obtained.

RESULTS

One hundred percent of the subjects had lip numbness with the mylohyoid nerve block + IAN block and mock mylohyoid nerve block + IAN block techniques. For these 2 techniques, anesthetic success rates were higher in posterior teeth (73% to 93%) than in anterior teeth (33% to 60%). There were no significant differences (P > .05) between the 2 techniques. The mylohyoid nerve block + mock IAN block technique resulted in a very low success rate (0% to 17%) and was significantly different (P < .05) from the mylohyoid nerve block + IAN block technique.

CONCLUSIONS

The results of this study suggest that the mylohyoid nerve block does not by itself predictably provide pulpal anesthesia in mandibular teeth and does not significantly enhance pulpal anesthesia when administered in combination with the IAN block.

Laser doppler imaging--a new technique for quantifying microcirculatory flow in patients with primary Raynaud's phenomenon and systemic sclerosis

This was a pilot study to investigate the new technique of laser Doppler imaging (scanning laser Doppler) as a tool to quantify microvascular blood flow in the digits of patients with primary Raynaud's phenomenon (PRP) and systemic sclerosis (SSc), and to determine in the first instance whether the flux patterns obtained differ between patients with SSc, patients with PRP, and healthy control subjects. Laser Doppler images of the dorsum of the hand and fingers were acquired at 23 and 30 degrees C in 17 healthy control subjects, 7 patients with PRP, 9 patients with the diffuse cutaneous variant of SSc, and 24 patients with the limited cutaneous variant of SSc. Different flux parameters were compared between groups. Analysis of variance found significant differences between groups in two tests: maximum difference in flux between fingertips of the same hand at 23 degrees C (P = 0.001) and maximum gradient in flux along a finger ("distal-dorsal" flux difference) at 30 degrees C (P = 0. 019). Post hoc tests highlighted the differences between controls and patients with limited cutaneous SSc. This pilot study suggests that laser Doppler imaging may allow objective measurement of microvascular flow in patients with PRP and SSc. This new technique may overcome many of the problems inherent in single-channel laser Doppler equipment.

Achieving dust lead clearance standards after lead hazard control projects: an evaluation of the HUD-recommended cleaning procedure and an abbreviated alternative

The U.S. Department of Housing and Urban Development's (HUD's) Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing strongly recommend that after lead hazard control interventions all walls, ceilings, floors, and other horizontal surfaces be cleaned using a three-step process to reduce lead-contaminated dust and debris. The three steps are: an initial vacuuming using a machine equipped with a high-efficiency particulate air (HEPA) filter (HEPA vacuum), wet wash with a lead cleaner, and a final HEPA vacuum. This study evaluated the effectiveness of two cleaning protocols: (1) the HUD-recommended three-step procedure, and (2) an abbreviated two-step cleaning procedure that omits the final HEPA vacuum. Cleaning procedures were evaluated in 27 dwelling units that had undergone significant lead hazard control interventions likely to produce lead dust. Dust lead samples were collected on floors and in window sills and troughs prior to the lead control hazard intervention, after the wet wash step of the cleaning procedure, and after completion of the second HEPA vacuuming. The results of the study demonstrate that dust lead surface loading on smooth and cleanable surfaces following the three-step and two-step cleaning procedures can achieve 1995 federal guidance dust clearance levels and levels substantially lower. Although the dust lead clearance rates before and after the second HEPA vacuum were the same, the time saved by omitting the second HEPA is small relative to the other elements of the cleaning process.

Prospective family predictors of aggression toward female partners for at-risk young men

Social learning models of the intergenerational transmission of aggression were tested for an at-risk sample of young adult men who entered a longitudinal study (Oregon Youth Study) in Grade 4 and were assessed with a female partner in young adulthood (17-20 years old). The associations of 2 family process variables--parental dyadic aggression and unskilled parenting, assessed both in late childhood and early adolescence with the son's later aggression toward a partner--were examined. Parental antisocial behavior was hypothesized to be associated with both family process variables. Unskilled parenting was hypothesized to play a key role in the son's later aggression toward an intimate partner, mediated by his development of antisocial behavior by adolescence. Fully prospective structural equation models were tested with multimethod, multiagent data, including both observed and reported aggression toward the partner. Findings indicate that the major hypothesized pathways through unskilled parenting practices and the boys' antisocial behavior were implicated in the intergenerational transmission of aggression.