Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.

The Search for Differentiated Meaning is a Precursor to Illusory Correlation

An experiment (N= 60) was conducted to examine the hypothesis that the illusory correlation effect is underpinned by a process of seeking to identify meaningful differences between social categories. It was reasoned that the effect would be weaker in an experimental condition in which the identity of the majority and minority groups was based on a characteristic (right- and left-handedness, respectively) that was less relevant to evaluative differentiation than in a control condition. This argument was supported by the predicted differences (a) in levels of illusory correlation across control and experimental conditions and (b) self-reports indicating that control participants sought to develop more differentiated impressions of groups than did participants in the experimental condition. The results support claims that the stereotyping process underpinning illusory correlation is structured by social meaning.

Contact and Attitudes Toward International Students in Australia

The current study investigated the impact of intercultural contact between domestic and international students on attitudes toward international students, and potential mediators of this relationship. A total of 247 Australian-born domestic undergraduates completed a survey of the quantity and quality of their contact with international students, levels of intergroup anxiety (IA) and intercultural communication emotions (ICE), and their attitudes toward international students. Positive quality of intercultural contact, less IA, and more positive ICE were all related to more positive attitudes toward international students. In addition, ICE mediated the relationship between positive quality of contact and attitudes, and between IA and attitudes. Quality of contact exerted both direct and indirect effects (via IA and intercultural communications emotions) on intergroup attitudes. Results highlight the importance of addressing communication barriers and the emotions associated with these when promoting positive interactions between domestic and international students. Suggestions are made for a theoretical integration of intergroup and communication-based perspectives when considering attitudes toward linguistically diverse outgroups like international students.

Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

LX4211, a dual SGLT1/SGLT2 inhibitor, improved glycemic control in patients with type 2 diabetes in a randomized, placebo-controlled trial

Thirty-six patients with type 2 diabetes mellitus (T2DM) were randomized 1:1:1 to receive a once-daily oral dose of placebo or 150 or 300 mg of the dual SGLT1/SGLT2 inhibitor LX4211 for 28 days. Relative to placebo, LX4211 enhanced urinary glucose excretion by inhibiting SGLT2-mediated renal glucose reabsorption; markedly and significantly improved multiple measures of glycemic control, including fasting plasma glucose, oral glucose tolerance, and HbA(1c); and significantly lowered serum triglycerides. LX4211 also mediated trends for lower weight, lower blood pressure, and higher glucagon-like peptide-1 levels. In a follow-up single-dose study in 12 patients with T2DM, LX4211 (300 mg) significantly increased glucagon-like peptide-1 and peptide YY levels relative to pretreatment values, probably by delaying SGLT1-mediated intestinal glucose absorption. In both studies, LX4211 was well tolerated without evidence of increased gastrointestinal side effects. These data support further study of LX4211-mediated dual SGLT1/SGLT2 inhibition as a novel mechanism of action in the treatment of T2DM.

Isotope turnover studies in uncontrolled diabetes and the effects of insulin

Turnover rates of glucose, free fatty acids (FFA) and leucine have been measured in newly diagnosed, uncontrolled insulin-dependent diabetic (IDD) patients. The results have been compared with data collected from the same patients while on conventional insulin therapy as well as after overnight intravenous infusion of insulin with sustained normoglycaemia. The data have been analysed by compartmental and non-compartmental methods and the results have been compared with simultaneously collected data on respiratory exchange. Oxidation rates of 14C-labelled substrates have also been measured. Tracer studies were done on established diabetics after insulin withdrawal and subsequent intravenous infusion of insulin at different rates. The results confirm the in vivo importance of the glucose-fatty acid cycle, indicating that when glucose, FFA and ketone bodies are available in excess it is FFA and ketones that are metabolized in preference to glucose. The data emphasize the importance of increased production rates rather than decreased utilization rates in producing high concentrations of substrates in the plasma of insulin-deficient patients.

Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding

OBJECTIVE

To compare the cost-effectiveness of levonorgestrel intrauterine system (LNG-IUS) (Mirena; Schering Co., Turku, Finland) and thermal balloon ablation (Thermachoicetrade mark; Gynecare Inc., Menlo Park, CA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

An open, pragmatic, prospective randomised trial.

SETTING

A menstrual disorders clinic at National Women's Hospital, Auckland, New Zealand.

POPULATION

Seventy-nine women with self-defined heavy menstrual bleeding randomised to the LNG-IUS (40 women) or the thermal balloon ablation (39 women).

METHODS

Decision tree modelling using primary source data was used to identify the incremental cost-effectiveness of the two treatments.

MAIN OUTCOME MEASURES

Direct and indirect costs of medical treatment, including treatment costs, subsequent medical procedures, lost income and medical treatment for failed procedures. The change in quality of life as assessed by the Short Form-36 (SF-36) measured between time of treatment and 24 months was the primary outcome measure. Economic modelling examined the expected cost and outcome for a woman entering each treatment. Sensitivity analysis explored the robustness of the results.

RESULTS

The expected cost of treatment was $NZ1241 ($US869) for the LNG-IUS and $NZ2418 ($US1693) for the thermal balloon ablation. The LNG-IUS was associated with an increase of 15 points on the SF-36 scale, compared with 12 points for the thermal balloon ablation. Sensitivity analysis indicates that the results are robust to a 25% decrease in the price of the primary cost drivers and to variations in the rates of failed treatment between the conditions.

CONCLUSION

The LNG-IUS would appear to be cost-effective when compared with the thermal balloon ablation for treatment of heavy menstrual bleeding.

Are adjuvant therapies for tonsillectomy evidence based?

Our aim was to ascertain the current practice of adjuvant therapy for tonsillectomy and to determine whether it is evidence based. Anonymized postal questionnaires were sent to all UK otolaryngology consultants registered with the specialty association, and a literature search was performed using relevant search terms in all possible combinations. Among the responders there was little enthusiasm for routine intra-operative local anaesthesia, post-operative topical benzydamine hydrochloride (Difflam) spray or post-operative antibiotics. This is consistent with the lack of robust evidence to support any of these practices. Paracetamol (acetaminophen) is prescribed by almost 90 per cent for post-operative analgesia, and the current literature supports its efficacy and safety. Further, most practitioners combine paracetamol with opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs). Evidence to support the additional use of these agents is, however, non-existent or limited. Some aspects of tonsillectomy care are uniform and evidence based. Others are heterogeneous and suffer from lack of adequate data in the literature.

Coronary heart disease risk assessment in diabetes mellitus: comparison of UKPDS risk engine with Framingham risk assessment function and its clinical implications

AIMS

To assess differences between absolute coronary heart disease (CHD) risks calculated by Joint British Societies (JBS) risk calculator and UKPDS risk engine and its impact on CHD primary prevention management in diabetes mellitus (DM).

METHODS

Seven hundred Type 2 DM patients without arterial complications were identified from nine general practices in the Scarborough area. Their absolute 10-year CHD risks were calculated. The differences in the proportion of patients identified for aspirin and statin under JBS and National Institute for Clinical Excellence (NICE) guidelines by these two methods were determined. The proportion of additional patients identified for statin in the Scarborough population as a consequence of CHD risk threshold reduction from 30 to 15% (as recommended by NICE) was also determined.

RESULTS

UKPDS risk engine calculated significantly higher mean 10-year CHD risk (UKPDS vs. JBS, 21.5 vs. 18.3%, P < 0.0001). Both methods identified approximately 65% of patients to be eligible for aspirin and statin if NICE recommendations were followed. At a risk threshold of 30%, the UKPDS risk engine identified more patients for statin. Reducing the CHD risk threshold from 30 to 15% for statin initiation will identify an additional 0.5% of the total population for this treatment.

CONCLUSIONS

Both methods are comparable in identifying at-risk patients under NICE recommendations. A high proportion has risk levels that merits primary CHD prevention. Lowering the risk threshold for statin treatment has a small numerical impact on the whole population.

Semiautomated data analysis of flow cytometric estimation of fetomaternal hemorrhage in D- women

BACKGROUND

Accurate and reliable measurement of the volume of fetal D+ cells in D- women is required for adequate anti-D prophylaxis. A semiautomated flow cytometry assay based on a standardized calibration curve that was created with simulated fetomatemal hemorrhage (FMH) mixtures was developed.

STUDY DESIGN AND METHODS

A calibration range of 0.083- to 2-percent D+ cells in the D-RBC mixtures (2-44 mL calculated FMH) was analyzed by use of a flow cytometer (XL-MCL, Coulter Electronics Ltd). Linear regression analysis of the calibration curve data with computer software (Excel, Microsoft) allowed semiautomated determination of the FMH volume. To optimize the assay, fresh versus frozen and thawed RBCs, RBCs from adults who are heterozygous for D or cord RBCs, and indirect- or direct-labeling techniques were evaluated by use of MoAbs.

RESULTS

Fresh RBCs from adults heterozygous for D were chosen for routine use, although equivalent calibration curves were obtained with all cells tested (n = 12 calibration assays; r2 = 0.999; mean SD, 14%). A monoclonal anti-D reagent (Therad 10, Diagnostics Scotland) worked well in both indirect-(anti-IgG F(ab)-FITC) and direct-(anti-D-FITC) labeling methods compared to the use of BRAD-3 FITC. In routine practice, the FMH volumes obtained were mainly lower than those obtained in the Kleihauer Betke test when there was less than 4 mL of FMH.

CONCLUSION

Semiautomated data acquisition and calibration curve analysis represents a further step toward standardization of flow cytometry for accurate FMH quantification and facilitates evaluation and control of day-to-day variations between laboratories, flow cytometers, and operators.

Extension of the therapeutic window for recombinant tissue plasminogen activator with argatroban in a rat model of embolic stroke

BACKGROUND AND PURPOSE

Argatroban, a specific thrombin inhibitor, has been shown to reduce ischemic lesion size after focal cerebral ischemia in rats. In addition, recombinant tissue plasminogen activator (rtPA) has been shown to reduce ischemic lesion size in both rats and humans if given within 3 hours of symptom onset. We tested the hypothesis that the administration of argatroban with rtPA could extend the treatment window of stroke to 4 hours without increasing gross cerebral hemorrhage rates or reducing efficacy.

METHODS

Male Wistar rats were subjected to middle cerebral artery (MCA) occlusion by a single fibrin-rich clot. After embolization, rats were administered argatroban at the following dose levels: 2.08, 6.25, and 18.75 microgram . kg(-1). min(-1). In a second experiment, rats received argatroban (6.25 microgram . kg(-1). min(-1)) or argatroban in combination with rtPA 4 hours after MCA occlusion. Tissue sections were then analyzed for lesion volume, gross hemorrhage and fibrin deposition.

RESULTS

The 6.25 microgram. kg(-1). min(-1) dose demonstrated a significant reduction (P<0.05) in lesion volume after 48 hours (27.2+/-6.3%) compared with controls (35.3+/-3.7%). A significant reduction (P<0.05) in lesion volume was observed in the argatroban-plus-rtPA group (17.1+/-10.4%) compared with controls (35.3+/-3.7%). No increase in hemorrhagic transformation was observed. Fibrin deposition in the ipsilateral cortical microvasculature was significantly decreased in the 4-hour combination argatroban-plus-rtPA group compared with the controls (P<0.05).

CONCLUSIONS

This study demonstrates that the combination of argatroban and rtPA extends the window of opportunity for treatment of stroke to 4 hours without increasing hemorrhagic transformation.

A carotid stenosis model in canines

A carotid stenosis model was developed in canines in order to study the effects of systemic blood pressure and hemodilution on cerebrovascular perfusion and metabolism during cardiopulmonary bypass in the setting of significant coexistent inflow stenosis. Under general anesthesia, through a low midline neck incision, the carotid sheath was entered and the carotid artery was isolated and retracted medially. The vertebral artery could be identified posterolaterally. After ligating the vertebral artery with a 00 silk tie, carotid stenosis was created by tying bilateral carotid arteries over an 18-gauge needle using a 00 silk tie. The needle was then removed, leaving a tight stenosis. To determine the degree of stenosis, arteriograms were performed, revealing high-grade lesions of greater than 90% stenosis in the carotid arteries and absence of flow through the vertebral arteries. Cerebral blood flow studies during cardiopulmonary bypass (CPB) were performed, revealing a significant decline. Carotid arteries were harvested at the conclusion of the experiments, revealing tight lesions on direct inspection. The mean gradient measured across stenotic segments was >25 mm Hg. In conclusion, a carotid stenosis model can be created successfully in dogs by ligating the vertebral arteries bilaterally and simply using the shaft of a needle to standardize the lumen size of the carotid arteries. We found the diameter of an 18-gauge needle sufficient to produce stenoses of greater than 90% as evidenced by arteriograms.

Structures underpinning pretend play and word production in young hearing children and children with hearing loss

Relationships between pretend play and word production were investigated in 10 hearing (H) and 10 toddlers with hearing loss (D) who attended an auditory/oral early intervention program. All children were videotaped interacting in free play with their hearing primary caregiver at 28, 29, and 30 months of age. Group comparisons were made for the scores for highest and mean levels of pretend play and for the underlying structures of decontextualization, decentration, sequencing, and planning. Relationships with word production were then explored for the two groups separately. Results showed significantly higher levels of pretend play for all dimensions for the hearing children and an association between level of pretend play and word production for the children with hearing loss. Associations between word production and sequencing and planning were found for both groups of children. Word production was associated with decontextualization for the hearing children and with decentration for the children with hearing loss. We discuss theoretical implications of the findings together with implications for intervention with toddlers who have hearing loss.

Regional left ventricular systolic function in humans during off-pump coronary bypass surgery

BACKGROUND

Controversy exists as to whether off-pump CABG with local occlusion results in clinically significant myocardial ischemia during the occlusion period. This study was undertaken to delineate the effects of transient local coronary artery occlusion on regional systolic function.

METHODS AND RESULTS

Eight consenting patients undergoing left internal mammary to left anterior descending coronary artery (LAD) bypass were instrumented with a left ventricular pressure catheter and 2 subepicardial cylindrical ultrasonic dimension transducers placed in the minor axis dimension in the region served by the LAD. A digital sonomicrometer was used to collect data before, during, and after coronary occlusion from which percent systolic shortening and pressure-dimension loops were derived. Measuring devices were removed immediately after the final time point. All patients tolerated the procedure well, and there were no complications. Average duration of local occlusion needed for CABG was 15.9+/-4.4 minutes (range, 12 to 26 minutes). Local occlusion was associated with a decrease in peak systolic shortening from 5.8+/-0.8% to 1.8+/-0.8%. In all cases, function returned to baseline after restoration of flow. Pressure-dimension loops confirmed these findings and no evidence of diastolic creep. Linear repression analysis of degree of stenosis versus change in segmental shortening revealed a significant inverse correlation.

CONCLUSIONS

Local occlusion of the LAD resulted in a transient decrease in myocardial function during occlusion with complete recovery during reperfusion. This change was less significant with increasing degrees of coronary stenosis. These data suggest that local occlusion is not associated with permanent myocardial injury but that ischemic changes do occur that may be clinically significant, especially in patients with lesser degrees of coronary stenosis.