Recommendations for mental health professionals in the NICU

This article describes recommended activities of social workers, psychologists and psychiatric staff within the neonatal intensive care unit (NICU). NICU mental health professionals (NMHPs) should interact with all NICU parents in providing emotional support, screening, education, psychotherapy and teleservices for families. NMHPs should also offer educational and emotional support for the NICU health-care staff. NMHPs should function at all levels of layered care delivered to NICU parents. Methods of screening for emotional distress are described, as well as evidence for the benefits of peer-to-peer support and psychotherapy delivered in the NICU. In the ideal NICU, care for the emotional and educational needs of NICU parents are outcomes equal in importance to the health and development of their babies. Whenever possible, NMHPs should be involved with parents from the antepartum period through after discharge.

Patients' perception about risks and benefits of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after orthopedic surgery: a qualitative study

Background

The 9th edition of the American College of Chest Physicians’ Antithrombotic Therapy and Prevention of Thrombosis guidelines emphasize the importance of considering the risk–benefit ratio of “patient-important” outcomes. However, little is known about patients’ perception and understanding regarding the different outcomes of antithrombotic treatment after orthopedic surgery, and the factors that influence their decision to use these treatments. Using a series of semi-structured interviews, we explored patients’ understanding and perception concerning the benefits and risks of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after joint replacement surgery.

Methods

A series of semi-structured interviews were conducted with patients who had undergone knee or hip replacement surgery at a tertiary care hospital (Brigham and Women’s Hospital, Boston, MA) in 2014. Discussions were recorded and transcribed. Two investigators independently coded and analyzed the data to identify important themes and concepts using the constant comparative method.

Results

Of 64 patients who were invited, 12 patients (19 %) completed the interviews. The majority of patients (92 %) were aware of the benefits of antithrombotic therapy for reducing the risk of blood clots, while less than half of them had a clear understanding of deep vein thrombosis and pulmonary embolism. While all patients were aware of risk of minor bleeding, only 6 patients (50 %) considered the risk of major bleeding as a possible side effect of antithrombotic treatment. Overall, patients perceived bleeding as a less important outcome than a thrombotic event. The lack of awareness about the risk of major bleeding, the assumption that a short-term exposure would not meaningfully affect bleeding risk, and the assumption that bleeding is a controllable event influenced their perception. Most patients (83 %) stated that their decision to use antithrombotic medications was mainly based on the trust in their physician’s expertise.

Conclusions

Patients perceived thrombotic events as more important outcomes than bleeding events. Patients’ understanding of thrombotic and bleeding events varies and may play a key role in their preferences. The majority of patients stated that trust in their physician’s expertise had a large influence on their decision to use antithrombotic medications.

Deep vein thrombosis and pulmonary embolism in the military patient

OBJECTIVES

Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is a common, potentially lethal condition and a cause of long-term morbidity and functional limitation. This paper is a clinical review focused on military epidemiology, evidence-based recommendations for prevention, diagnosis and management of VTE and occupational considerations in a military population.

METHODS

A literature review was conducted through Pubmed and Embase for systematic reviews, meta-analyses and clinical trials relating to VTE. Guidelines from the National Institute for Health and Care Excellence, British Thoracic Society and the American College of Chest Physicians were reviewed and recommendations considered.

RESULTS

Acute morbidity from VTE can range from limb pain and swelling to life-threatening cardiovascular compromise. Long-term sequelae include postthrombotic syndrome, chronic thrombosis and pulmonary hypertension. Diagnosis should follow a validated pathway depending on the patient's prerest probability. The management of the condition should vary with attention to risk stratification.

DISCUSSION

Prompt initiation of anticoagulation reduces symptoms, rates of recurrent VTE and death but treatment must be balanced against the risk of major haemorrhage. Military operations expose personnel to a unique combination of risk factors for VTE and operating in austere environments can increase the challenge of diagnosis, prognostication and management. Furthermore, there are implications for troop attrition, operational readiness and return to work.

Teenagers' understandings of and attitudes towards vaccines and vaccine-preventable diseases: a qualitative study

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Explored understandings of diseases and knowledge and experiences of vaccination.

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Teenagers had limited knowledge and little direct experience of the diseases.

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Participants attitudes towards receiving vaccines’ varied.

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The success of mass immunisation programmes is associated with disease perceptions.

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Need to engage with teenagers to address misconceptions about vaccines and diseases.

Background

To examine immunisation information needs of teenagers we explored understandings of vaccination and vaccine-preventable diseases, attitudes towards immunisation and experiences of immunisation. Diseases discussed included nine for which vaccines are currently offered in the UK (human papillomavirus, meningitis, tetanus, diphtheria, polio, whooping cough, measles, mumps and rubella), and two not currently included in the routine UK schedule (hepatitis B and chickenpox).

Methods

Twelve focus groups conducted between November 2010 and March 2011 with 59 teenagers (29 girls and 30 boys) living in various parts of Scotland.

Results

Teenagers exhibited limited knowledge and experience of the diseases, excluding chickenpox. Measles, mumps and rubella were perceived as severe forms of chickenpox-like illness, and rubella was not associated with foetal damage. Boys commonly believed that human papillomavirus only affects girls, and both genders exhibited confusion about its relationship with cancer. Participants considered two key factors when assessing the threat of diseases: their prevalence in the UK, and their potential to cause fatal or long-term harm. Meningitis was seen as a threat, but primarily to babies. Participants explained their limited knowledge as a result of mass immunisation making once-common diseases rare in the UK, and acknowledged immunisation's role in reducing disease prevalence.

Conclusions

While it is welcome that fewer teenagers have experienced vaccine-preventable diseases, this presents public health advocates with the challenge of communicating benefits of immunisation when advantages are less visible. The findings are timely in view of the Joint Committee on Vaccination and Immunisation's recommendation that a booster of meningitis C vaccine should be offered to teenagers; that teenagers did not perceive meningitis C as a significant threat should be a key concern of promotional information. While teenagers’ experiences of immunisation in school were not always positive, they seemed enthusiastic at the prospect of introducing more vaccines for their age group.

P3-16-04: A Novel Monoclonal Antibody to Secreted Frizzled Related Protein 2 Inhibits Triple Negative Breast Carcinoma Growth Rate In Vivo

Background: Secreted frizzled related protein 2 (SFRP2) is a novel angiogenesis factor expressed in the endothelium of a wide variety of human tumors including triple negative breast cancer and angiosarcoma. We previously reported generating a monoclonal antibody against SFRP2 that inhibits endothelial cell and angiosarcoma tube formation in vitro, and decreased tumor volume of the SVR angiosarcoma in vivo. The objectives of these studies were to determine pharmacokinetic (PK) and pharmacodynamic (PD) parameters of the SFRP2 MAb, and evaluate its efficacy in a triple negative breast cancer xenograft.

Methods: 125 I-SFRP2 MAb was administered to nude mice i.v. via tail vein injections at 0.4 mg/kg, 4 mg/kg, or 10 mg/kg in mice with or without tumor. Blood organ, and tumor samples were collected at various time points from 5 min to 21 days. Radiolabeled SFRP2 MAb in serum and tissues was determined using a gamma counter. PK parameters were determined based on mean concentration values for 3–5 animals per time point. In vivo efficacy study: MDA-MB-231 human breast cancer xenografts were established in 6-week-old female nude mice. Mice were inoculated with 1 × 106 cells s.c.. Treatment began on day 16 after tumor inoculation when average tumor size was 200 mm3. Animals were randomly assigned (n = 12 per group) to buffer control, SFRP2 MAb 4 mg/kg iv twice weekly; Avastin (Roch) 5 mg/kg iv twice weekly, or IGg control 4 mg/kg iv twice weekly. Tumors were harvested when the tumor diameter reached 2 cm or at 28 days. Tumor volumes were measured with a caliper. Growth rates (percent change per day) were compared with the formula ((Final volume- initial volume)/ initial volume) x 100 / number of days. Differences in growth rate between treated and control were analyzed with a two-tailed t-test.

Results: PK and PD: SFRP2 MAb was long circulating in the blood with an average t1/2 in the range of 53–89 hr. In addition, the SFPR2 MAb was found to preferentially target the tumors versus all other organs except for the liver. For example, in tumor bearing mice, the blood/tissue ratio on day 14 was smallest in the liver (15:1) and tumor (16:1) as compared to all other organs (range: 39:1 to 255:1) proving that the tumor was a prime organ for accumulation of the SFRP2 MAb. The SFPRP2 MAb in tumor bearing and non-tumor bearing mice exhibited dose-independent kinetics as a one-way ANOVA analysis comparing t1/2 at different dose levels was not statistically significant (p=0.2847 and 0.1204, respectively). However, there was statistically significant difference in t1/2 of the SFPR2 MAb in tumor-bearing and non-tumor bearing mice (p=0.0386). Efficacy in triple negative breast cancer: There was a 40% decrease in growth rate between SFRP2 MAb and control (p=0.03) and a 20% inhibition of growth rate between Avastin and control (p=0.40). The IgG negative control had no effect on tumor growth.

Conclusion: The SFRP2 MAb was long circulating and the tumor was a prime organ for accumulation of the SFRP2 MAb. SFRP2 MAb slowed the growth of a human triple negative breast cancer xenograft in a tumor model that was not sensitive to Avastin. We conclude that SFRP2 is a novel therapeutic target for breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-16-04.

The effect of applying NICE guidelines for the investigation of stable chest pain on out-patient cardiac services in the UK

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) recently released guidelines for the investigation of chest pain of recent onset. There is no published data regarding their impact on out-patient cardiac services.

AIM

This study was undertaken to assess the likelihood of coronary artery disease (CAD) in Rapid Access Chest Pain Clinic (RACPC) patients and the resultant investigation burden if NICE guidance was applied.

METHODS

Five hundred and ninety-five consecutive patients attending two RACPCs over 6 months preceding release of the NICE guidelines [51% male; median age 55 (range 22-94) years] were risk stratified using NICE criteria and the resultant investigations evaluated.

RESULTS

One hundred and six (18%) patients had a likelihood of CAD <10%, 123 (21%) between 10% and 29%, 175 (29%) between 30% and 60%, 141 (24%) between 61% and 90% and 50 (8%) >90%. NICE would have recommended 443 (74%) patients for no cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac testing and 73 (12%) for invasive angiography. Relative to existing practice, there would have been a trend towards reduced functional cardiac testing (-24%, P = 0.06), no significant change in CCT (43%, P = 0.436) and a significant increase in invasive angiography (508%, P < 0.001). The cost of investigations recommended by NICE would have been £15,881 greater than existing practice.

CONCLUSION

This study suggests patients attending RACPC will have a greater likelihood of CAD than predicted by NICE. Differences between recommended investigations and existing practice will guide investment in cardiac services. Individual hospitals should assess their RACPC cohorts prior to implementing the NICE guidelines.