Deinstitutionalization and Psychosocial Rehabilitation

Introduction

Barbacena is a Brazilian city with 140,000 inhabitants, which was known as the “city of madmen” because of the excessive number of patients in psychiatric hospitals. In 2000 it began a deinstitutionalization process, and the patients were transferred to assisted residential services.

Objective

Describe the process of deinstitutionalization and social rehabilitation of psychiatric patients.

Methodology

The following characteristics were studied: sex, age, medication use, psychiatric diagnosis and the development of social skills.

Results

In each therapeutic residence (RT) lives eight patients, supervised by upper and mid-level professionals. Since the implementation of RTs about 400 patients leave the psychiatric hospitals. Most had mental retardation (51.0%), followed by schizophrenia (31.0%). More than half (58.5%) were men. The age ranged from 29 to 97 years, with a average of 64.8 ± 12.4. A decrease in the average dose of neuroleptics was seen after deinstitutionalization. Direct observation of patients in the RT, and the reporting of caregivers has shown that patients have developed wide range of social performance, such as dating, started at professional courses, attending exercise classes, travelling and learn how to use money.

Conclusion

In despite of difficulties in the psychiatric reform process, the community-based treatment and psychosocial rehabilitation approach are the principal models of psychiatric care presently, and the residential services play an important role in this process. The authors emphasize the importance of community support, professional staff and rehabilitation programs as a condition for good outcomes.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Comparative evaluation of dermoscopy and capillaroscopy in Raynaud's phenomenon]

OBJECTIVE

Raynaud's phenomenon (RP) is a common cause for consultation. Capillaroscopy is a well-established technique to detect capillary abnormalities suggestive of a connective tissue disease, but it is sometimes unavailable. The aim of this study was to compare dermoscopy and capillaroscopy in the assessment of RP.

METHODS

This was a prospective single-centre observational study in adult patients consulting for RP at the Hôpital Nord Franche-Comté between January 2014 and June 2015. Dermoscopy was performed at dermatological consultations and capillaroscopy was prescribed. For each capillaroscopy and dermoscopy, the following parameters were examined: normal appearance, giant capillaries, avascular areas, dystrophic capillaries or tortuosity and haemorrhages. Kappa coefficients were calculated.

RESULTS

Twenty-six patients participated in this study. The kappa coefficient was 0.76 for "normal" status, 0.78 for tortuosity, 0.70 for giant capillaries, 0.48 for haemorrhage and 0.62 for avascular areas. The global kappa coefficient was 0.33. Detection of these abnormalities with capillaroscopy was significantly associated with abnormal dermoscopic status (P<0.05). The sensitivity of dermoscopy for the detection of "abnormal" capillaroscopic status was 0.87.

CONCLUSION

The correlation coefficients were good. Despite poor global concordance, 80% of patients had the same status, normal or abnormal, for both capillaroscopy and dermoscopy, which resulted in the same clinical management. Dermoscopy is thus a valuable tool screening for periungual anomalies and provides support for clinical examination by the dermatologist, although the reference method continues to be capillaroscopy.

Hard Two-Photon Contribution to Elastic Lepton-Proton Scattering Determined by the OLYMPUS Experiment

The OLYMPUS Collaboration reports on a precision measurement of the positron-proton to electron-proton elastic cross section ratio, R_{2γ}, a direct measure of the contribution of hard two-photon exchange to the elastic cross section. In the OLYMPUS measurement, 2.01 GeV electron and positron beams were directed through a hydrogen gas target internal to the DORIS storage ring at DESY. A toroidal magnetic spectrometer instrumented with drift chambers and time-of-flight scintillators detected elastically scattered leptons in coincidence with recoiling protons over a scattering angle range of ≈20° to 80°. The relative luminosity between the two beam species was monitored using tracking telescopes of interleaved gas electron multiplier and multiwire proportional chamber detectors at 12°, as well as symmetric Møller or Bhabha calorimeters at 1.29°. A total integrated luminosity of 4.5  fb^{-1} was collected. In the extraction of R_{2γ}, radiative effects were taken into account using a Monte Carlo generator to simulate the convolutions of internal bremsstrahlung with experiment-specific conditions such as detector acceptance and reconstruction efficiency. The resulting values of R_{2γ}, presented here for a wide range of virtual photon polarization 0.456<ε<0.978, are smaller than some hadronic two-photon exchange calculations predict, but are in reasonable agreement with a subtracted dispersion model and a phenomenological fit to the form factor data.

European Survey on Adverse Systemic Reactions in Allergen Immunotherapy (EASSI): a real-life clinical assessment

BACKGROUND

Outside clinical trials, data on systemic reactions (SRs) due to allergen immunotherapy (AIT) are scarce.

METHODS

A prospective, longitudinal, web-based survey of 'real-life' respiratory allergen immunotherapy (AIT) clinical practice was conducted in France, Germany and Spain. SRs were recorded and coded according to the Medical Dictionary for Regulatory Activities (MedDRA) and risk factors associated with SRs were identified.

RESULTS

A total of 4316 patients (corresponding to 4363 ongoing courses of AIT) were included. A total of 109 SRs were recorded, and 90 patients (2.1%) presented at least one SR. Most of the SRs occurred in subcutaneous allergen immunotherapy (SCIT) (89%, n = 97). The most frequently reported symptoms were urticaria, rhinitis, dyspnoea and cough. Respiratory symptoms appeared before skin symptoms. Most SRs occurred during the up-dosing phase (75.8%) and were mild in severity (71.6%). Intramuscular adrenaline was administered in 17 SRs, but only 65% of these were subsequently classified as anaphylaxis. Independent risk factors for SRs during SCIT were as follows: the use of natural extracts (odds ratio, OR) [95% confidence interval (CI)] = 2.74 [1.61-4.87], P = 0.001), the absence of symptomatic allergy medications (1.707 [1.008-2.892], P = 0.047), asthma diagnosis (1.74 [1.05-2.88], P = 0.03), sensitization to animal dander (1.93 [1.21-3.09], P = 0.006) or pollen (1.16 [1.03-1.30], P = 0.012) and cluster regimens (vs rush) (4.18 [1.21-14.37], P = 0.023). A previous episode of anaphylaxis increased the risk for anaphylaxis in SCIT (OR [95% CI] = 17.35 [1.91-157.28], P = 0.01).

CONCLUSION

AIT for respiratory allergy is safe, with a low number of SRs observed in real-life clinical practice. A personalized analysis of risk factors could be used to minimize SRs.

Allergy immunotherapy across the life cycle to promote active and healthy ageing: from research to policies: An AIRWAYS Integrated Care Pathways (ICPs) programme item (Action Plan B3 of the European Innovation Partnership on active and healthy ageing) and the Global Alliance against Chronic Respiratory Diseases (GARD), a World Health Organization GARD research demonstration project

Allergic diseases often occur early in life and persist throughout life. This life-course perspective should be considered in allergen immunotherapy. In particular it is essential to understand whether this al treatment may be used in old age adults. The current paper was developed by a working group of AIRWAYS integrated care pathways for airways diseases, the model of chronic respiratory diseases of the European Innovation Partnership on active and healthy ageing (DG CONNECT and DG Santé). It considered (1) the political background, (2) the rationale for allergen immunotherapy across the life cycle, (3) the unmet needs for the treatment, in particular in preschool children and old age adults, (4) the strategic framework and the practical approach to synergize current initiatives in allergen immunotherapy, its mechanisms and the concept of active and healthy ageing.

Unusual case of paediatric septic arthritis of the lumbar facet joints due to Kingella kingae

A 32-month-old boy presented with febrile limping that had developed over 6days, associated with right lumbosacral inflammatory swelling. Magnetic resonance imaging (MRI) showed joint effusion of the right L5-S1 zygapophyseal joint, complicated by destructive osteomyelitis of the L5 articular process and paraspinal abscess. Surgery was decided to evacuate the fluid accumulation and rule out differential diagnoses. The diagnosis of septic arthritis of the facet joint was confirmed intraoperatively; real-time quantitative PCR analysis identified Kingella kingae. This is the first substantiated paediatric case of zygapophyseal joint septic arthritis due to K. kingae. K. kingae is the most common pathogen responsible for invasive osteoarticular infection in children under 4years of age. Since empiric antibiotics are effective in early stages, physicians should consider the possibility of spinal infections due to K. kingae when a limping child under 4years of age presents with a fever.

Association Between Asthma and Sensitization to Allergens of Dermatophagoides pteronyssinus

BACKGROUND AND OBJECTIVE

Little is known about the role of molecular diagnosis in house dust mite (HDM) allergy. In this study, we investigated the association between the sensitization profile of adolescent and adult HDM-allergic patients and asthma in a region with high rates of exposure to HDM.

METHODS

We conducted a cross-sectional study of 384 HDM-allergic patients (38.5%, males; median age, 28 years). A total of 368 patients (95.8%) had rhinitis, and 175 (45.6%) had asthma. Specific IgE (sIgE) to Dermatophagoides pteronyssinus, nDer p 1, rDer p 2, and rPen a 1 was measured in all patients. sIgE to Lepidoglyphus destructor was measured in patients (n=301) with a positive skin test result.

RESULTS

Significantly higher concentrations of sIgE to Der p 1 and sIgE to Der p 2 were observed in patients with asthma than in those without asthma. The proportion of asthmatic patients was higher among individuals who reacted (≥0.35 kUA/L) to both Der p 1 and Der p 2 (147/291, 50.5%) than among those who reacted to only 1 allergen (either Der p 1 or Der p 2, 18/55, 32.7%) or neither allergen (10/38, 26.3%, P=.002). Reactivity to both allergens was associated with asthma after adjusting for age and sex (OR, 2.87; 95%CI, 1.32-6.20). Higher concentrations of sIgE to L destructor were observed in patients with asthma than in patients without asthma. Tropomyosin sIgE ≥0.35 kUA/L was detected in only 6 individuals (1.6%).

CONCLUSIONS

L destructor may be a relevant allergen in high-exposure areas. Dual sensitization (ie, IgE to both Der p 1 and Der p 2) may help to identify HDM-allergic patients who are at risk of asthma.

[Pretibial pseudocyst after anterior cruciate ligament reconstruction with a biocomposite screw]

We report the case of a patient who presented a pretibial extra-articular cyst two years after an arthroscopically assisted ACL reconstruction using an autologous bone-patellar tendon-bone graft. The tibial fixation was achieved with a bioabsorbable screw made of poly-L, D-lactic and -tricalcium phosphate (-TCP). A subcutaneous pseudocystic lesion was excised. It consisted of a capsular fibrous tissue with minimal milky fluid (1 ml) centrally. It penetrated into the tibial tunnel but did not communicate with the knee joint space. The histopathological analysis demonstrated fibrous tissue with multinucleated giant cells and refractile particles which suggested a foreign body reaction. After the surgery, the patient recovered perfectly well and he returned to his pre-injury level of physical activity in two months. To the best of our knowledge, this is the first report of this complication in a patient with a biocomposite screw made of poly-L, D-lactic and -tricalcium phosphate (-TCP).

Understanding Discrepancies in the Prediction of Mental Health, Substance Use and Dual Disorders. Implications From a Multi-Site International Study

Introduction

The use of valid and practical screening scales might ease the burden for greatly needed universal testing for mental health, substance use and dual disorders, but do they work well with all populations? Do they miss correct identification of certain groups?

Objective

To understand discrepancies in diagnostic prediction using the AC-OK screen in conjunction with other standardized assessment scales.

Methods

Two hundred and twenty-six Latino participants were recruited from primary care and community clinics in Madrid, Barcelona and Boston and assessed with standardized mental health and substance abuse measures including the AC-OK screen and with a Computerized adaptive test for mental health (CAT-MH). A measure of frequency of discrepancies and an adjusted and unadjusted comparison of results and demographic characteristics or respondents were made for mental health, substance abuse or for discrepancies in both categories.

Results

35.4% of cases were discrepant in mental health (AC-OK-Mental Health vs. Patient Health Questionnaire-9, Generalized Anxiety Disorder 7 or PTSD Checklist) and 14.2% in substance abuse (AC-OK-substance abuse vs. drug abuse screening test or Alcohol use disorders identification test). When CAT-MH scale was incorporated, discrepant results were found in 24.3% and 14.2%, respectively. No association was found between substance abuse discrepancies and patient demographics. In logit regressions being from Barcelona, of younger age and male were significant predictors of discrepancies.

Conclusions

Discrepancies were observed in the diagnostic prediction, with differences detected for site and sociodemographic characteristics of participants suggesting the importance of testing screeners for site and population differences. Evidence for the misclassification of young males is discussed. Caution is warranted in the implementation of screeners for at risk populations.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Sensitization pattern of crustacean-allergic individuals can indicate allergy to molluscs

This study investigated the sensitization pattern of crustacean-allergic patients according to tolerance to molluscs. Thirty-one patients with anaphylaxis to crustaceans (14 with mollusc allergy and 17 with mollusc tolerance) were studied using skin prick tests (SPTs), specific IgEs (sIgEs) and SDS-PAGE immunoblotting. IgE-reactive shrimp proteins were identified by proteomic analyses. Patients with mollusc allergy presented more frequently SPTs positive to molluscs and higher sIgE titres in response to both molluscs and crustaceans. Shrimp-sIgE and rPen a1-sIgE values of 1.57 kUA /l and 4.38 kUA /l, respectively, showed positive likelihood ratios of 4.3 and 10.9 for the identification of mollusc allergy. Patients with mollusc allergy reacted more frequently to tropomyosin in immunoblots than did patients without it (93% vs 35%, respectively, P = 0.004). Reactivity to proteins other than tropomyosin (n = 14) was not different between the two groups. Among patients with crustacean anaphylaxis, patients with mollusc allergy and mollusc tolerance show a different pattern of sensitization, something that may help identify them.