Listen protect connect for traumatized schoolchildren: a pilot study of psychological first aid

Background

Listen Protect Connect (LPC), a school-based program of Psychological First Aid delivered by non-mental health professionals, is intended to support trauma-exposed children. Our objective was to implement LPC in a school setting and assess the effectiveness of LPC on improving psychosocial outcomes associated with trauma.

Methods

A pilot quasi-experiment was conducted with middle school children self-identified or referred to the school nurse as potentially exposed to stressful life experiences. LPC was provided to students by the school nurse, and questionnaires were administered at baseline, 2-, 4- and 8-weeks to assess life stressors, symptoms of post-traumatic stress disorder and depression, social support, and school connectedness. A total of 71 measurements were collected from 20 children in all. Although a small sample size, multiple measurements allowed for multivariable mixed effects models to analyze changes in the repeated outcomes over time.

Results

Students who received the intervention had reduced depressive and posttraumatic stress symptoms from baseline throughout follow-up period. Total social support also increased significantly from baseline through 8-weeks, and school connectedness increased up to 4-weeks post-intervention.

Conclusions

This study demonstrates the potential of LPC as a school-based intervention of Psychological First Aid. Future randomized trials of LPC are needed, however.

Decreased functional T lymphocyte-mediated cytokine responses in patients with chemotherapy-induced neutropenia

OBJECTIVES

The degree of immunosuppression in patients with haematological malignancies treated with chemotherapy is routinely measured as number of circulating cells (preferable neutrophils) in peripheral blood. A parallel decline in the number of T cells is expected, but a possible alteration in their functionality has been less well explored. The ability of T cells to secrete more than one cytokine simultaneously is known to indicate protective immunity. The aim of this study was to determine whether the function of circulating T cells is altered in patients with chemotherapy-induced neutropenia.

DESIGN, SETTING AND SUBJECTS

In this cross-sectional study, we used the FluoroSpot assay to investigate the proportion of T cells secreting either interferon-γ or interleukin-2, or both cytokines simultaneously, after anti-CD3 stimulation. Peripheral blood mononuclear cells from 53 adult patients with chemotherapy-induced neutropenia and 20 healthy individuals were investigated.

RESULTS

There were significantly fewer T cells secreting interferon-γ in patients with neutropenia compared with healthy control subjects (P = 0.02), but the difference was greatest for dual cytokine-secreting T cells (P = 0.001). Furthermore, the amount of secreted cytokine per T cell appeared to be reduced in patients, compared with control subjects.

CONCLUSION

Our results suggest that the functionality of T cells is altered in patients with haematological malignancies with chemotherapy-induced neutropenia. In parallel with a decline in T cell count, this may further increase the risk of severe infections.

Allergic bronchopulmonary aspergillosis in garden waste (compost) collectors--occupational implications

The separation of rotting garden material from general domestic waste and its collection for processing in industrial composting sites is a relatively new industry in the UK. Two cases of allergic bronchopulmonary aspergillosis and the results of health surveillance are described in a team of 28 garden waste (compost) collectors. A few cases of extrinsic allergic alveolitis due to Aspergillus fumigatus have previously been reported in compost workers. In the absence of any guidance from research and to prevent similar cases of a potentially serious illness, we advise that new starters to the job of collecting or processing compost are screened for asthma and aspergillus sensitivity, cystic fibrosis, bronchiectasis and immunodeficiency if their exposure to high levels of Aspergillus sp cannot be controlled. Annual health surveillance for these workers is also recommended.

Trends in ischaemic heart disease hospitalisation and case fatality in the Hong Kong Chinese population 2000-2009: a secondary analysis

OBJECTIVES

This study examines the recent trends in ischaemic heart disease (IHD) incidence and case fatality in Hong Kong and explores the possible risk factors.

DESIGN

Retrospective observational study.

SETTING

All public hospitals in Hong Kong.

OUTCOME MEASURES

Incidence rate was defined as the number of IHD inpatient episodes divided by the size of the corresponding population. Short-term and long-term case fatality rate was defined as deaths from all causes occurring within 30 and 31-365 days, respectively, divided by the number of IHD inpatient episodes among the corresponding population.

METHODS

Poisson and logistic regression models were used to examine the IHD incidence and short-term/long-term case fatality trends, respectively, for different age and sex groups.

RESULTS

IHD incidence was stable in most age groups. However, the incidence in men aged 15-24, 35-44 and ≥85 years showed increasing trends, whereas the incidence in men aged 55-64 years and women aged 35-74 years showed decreasing trends. Overall, the short-term/long-term case fatality rates were unchanged over time for both sexes. Short-term case fatality showed increasing trends in women aged 65-74 and ≥85 years, while long-term case fatality in men aged 55-64 and 75-84 years and women aged ≥75 years showed increasing trends.

CONCLUSIONS

Hong Kong trends resembled those in the USA, England and Wales, showing stable or slow decline in the IHD rates, while increasing trends were observed for some age groups, particularly young adults. Public health promotion efforts should focus on reducing cardiovascular risk factors, such as hypertension prevalence.

A descriptive cost analysis study of cases of right iliac fossa pain

Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M = 33, F = 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were €1857, €6252, €3517, €184,191 and €152,706 respectively. The total estimated cost was €348,525 (€3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures.

Systemic lupus erythematosus due to C1q deficiency with progressive encephalopathy, intracranial calcification and acquired moyamoya cerebral vasculopathy

We report a female with infantile onset of systemic lupus erythematosus secondary to C1q deficiency, in whom we identified a novel homozygous mutation in C1qB. The patient developed a progressive encephalopathy associated with spasticity, and suffered several arterial ischaemic strokes. Cerebral imaging demonstrated acquired intracranial calcification and a cerebral vasculopathy reminiscent of moyamoya. This case demonstrates overlap with some features of Aicardi-Goutières syndrome which, like C1q deficiency, is a monogenic cause of inflammation involving dysregulation of the innate immune system and stimulation of a type I interferon response.

Sexual function and laparoscopic ventral rectopexy for complex rectocoele

AIM

Laparoscopic ventral rectopexy (LVR) has recently been shown to be feasible, safe and efficient in restoring anatomy and improving rectal emptying in female patients presenting with a posterior pelvic floor prolapse. However, little is known about the sexual function of these patients. This study aimed to assess sexual activity in a group of patients referred for complex rectocoele and the consequences on sexual comfort of their treatment after LVR.

METHOD

We prospectively assessed 41 consecutive patients who underwent LVR (either laparoscopic or robotic-assisted) for symptomatic complex rectocoele from January 2009 to January 2010. We first identified sexually active patients in the cohort using a nonvalidated simplified questionnaire. The Brief Index Sexual Functioning for Women (BISF-W) questionnaire was used postoperatively to assess the impact of LVR on sexual function. Acceptability of the assessment of sexuality was also tested. The postoperative outcome of the sexually active patients was compared with data obtained from the French general population.

RESULTS

Among 38 patients in whom a successful LVR had been performed (three conversions), 22 (57.9%) were sexually active preoperatively and 18 (47.4%) were sexually active postoperatively at a mean of 7±4.2months of follow-up (P=0.44). No de novo dyspareunia was reported. At baseline, 13 patients experienced dyspareunia compared with six after LVR (P=0.02). A significant improvement in dyspareunia was observed (seven patients vs two patients; P=0.03). 19 (86%) of the 22 patients responded to the BISF-W questionnaire. The mean composite score was 26.7±8.2, with 63.2% of patients estimating sexual activity as important or very important. Compared with a reference population, sexual comfort was similar in LVR patients (32.2±12.6 vs 26.7±8.2; P=0.14).

CONCLUSION

Assessment of sexual function is accepted by the majority of patients suffering from pelvic floor disorders. In addition to the benefit on anatomical restoration and bowel function, LVR improves sexual function and dyspareunia in patients operated on for complex rectocoele.

Liver transplant outcomes in HIV+ haemophilic men

Hepatitis C virus infection is the major cause of end-stage liver disease and the major indication for transplantation (OLTX), including among HIV-HCV co-infected individuals. The age of HCV acquisition differs between haemophilic and non-haemophilic candidates, which may affect liver disease outcomes. The purpose of the study was to compare rates of pre- and post-OLTX mortality between co-infected haemophilic and non-haemophilic subjects without hepatocellular cancer participating in the Solid Organ Transplantation in HIV Study (HIV-TR). Clinical variables included age, gender, race, liver disease aetiology, BMI, antiretroviral therapy, MELD score, CD4 + cell count, HIV RNA PCR and HCV RNA PCR. Time to transplant, rejection and death were determined. Of 104 HIV-HCV positive subjects enrolled, 34 (32.7%) underwent liver transplantation, including 7 of 15 (46.7%) haemophilic and 27 of 89 (30.3%) non-haemophilic candidates. Although haemophilic subjects were younger, median 41 vs. 47 years, P = 0.01, they were more likely than non-haemophilic subjects to die pre-OLTX, 5 (33.3%) vs. 13 (14.6%), P = 0.03, and reached MELD = 25 marginally faster, 0.01 vs. 0.7 years, P = 0.06. The groups did not differ in baseline BMI, CD4, detectable HIV RNA, detectable HCV RNA, time to post-OLTX death (P = 0.64), graft loss (P = 0.80), or treated rejection (P = 0.77). The rate of rejection was 14% vs. 36% at 1-year and 36% vs. 43% at 3-year, haemophilic vs. non-haemophilic subjects, respectively, and post-OLTX survival, 71% vs. 66% at 1-year and 38% vs. 53% at 3-year. Despite similar transplant outcomes, pretransplant mortality is higher among co-infected haemophilic than non-haemophilic candidates.

Adipocytokine zinc α2 glycoprotein (ZAG) as a novel urinary biomarker for normo-albuminuric diabetic nephropathy

OBJECTIVE

A substantial proportion of diabetic nephropathy individuals are non-albuminuric. Using a proteomic approach, we searched for novel urinary biomarkers.

METHODS

We studied three groups (n = 6 per group) of males with Type 2 diabetes: (1) normal renal function; (2) classical diabetic nephropathy (urinary albumin-creatinine ratio > 1000 mg/g and glomerular filtration rate < 60 ml/min.1.73 m(2) ) and (3) non-albuminuric diabetic nephropathy (glomerular filtration rate < 60 ml/min.1.73 m(2) and urinary albumin-creatinine ratio < 30 mg/g). We used two-dimensional fluorescence differential gel electrophoresis, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry peptide identification and western blot validation in the study.

RESULTS

Sixty protein spots were differentially abundant between the non-albuminuric and macro-albuminuric subjects (> 2.5-fold, P < 0.05). In the non-albuminuric subjects, in addition to previously reported α(1) -microglobulin, the next most interesting spot (upregulated 3.44-fold, P = 0.0026) was human zinc-α(2) -glycoprotein, a novel adipose-cytokine associated with glomerular injury. This was confirmed by western blot and replicated in female diabetic nephropathy subjects.

CONCLUSIONS

From our preliminary results, human zinc-α(2) -glycoprotein may be a novel urinary biomarker for non-albuminuric diabetic nephropathy.

Gender differences for initiating teriparatide therapy: baseline data from the Direct Assessment of Nonvertebral Fracture in the Community Experience (DANCE) study

The prospective, observational Direct Assessment of Nonvertebral Fracture in the Community Experience (DANCE) study shows that, among patients with risk factors for osteoporosis, women are more likely to be screened and to receive appropriate treatment than men. There needs to be greater awareness that osteoporosis affects both men and women.

INTRODUCTION

The prospective, observational DANCE study evaluated teriparatide use in the mainland USA and Puerto Rico in patients with osteoporosis in a community setting. This analysis compares baseline characteristics of women and men that may contribute to differences in initiation of teriparatide therapy.

METHODS

Investigators prescribed teriparatide 20 μg/day subcutaneous injection for ≤24 months to 3,698 patients (3,342 women, 356 men) whom they considered appropriate candidates for therapy. Study entry was guided by product labeling. Specific timing and frequency of office visits were not mandated. Treatment decisions were based on the clinical judgment of study investigators and local standards of care.

RESULTS

At baseline, similar proportions of women and men had prior fragility fractures (57% and 59%, respectively) and comorbid conditions that increase fracture risk (83% and 84%, respectively). Women were older than men (mean age 68 vs. 65 year; P < 0.0001) and more likely to have received prior osteoporosis therapy (88% vs. 62%; P < 0.0001). Investigators prescribed teriparatide more often for women than men based on general frailty (21% vs. 16%; P = 0.0151), low body mass index (17% vs. 10%; P = 0.0005), and an inadequate response (58% vs. 36%; P < 0.0001) or intolerance to previous therapy (23% vs. 12%; P < 0.0001). Chronic glucocorticoid therapy was the reason investigators cited most frequently for initiating therapy more often in men than in women (17% vs. 10%; P < 0.0001)

CONCLUSIONS

These results suggest that patients' gender may influence the reasons physicians initiate teriparatide therapy in a community setting.

Sacral nerve stimulation enhances epithelial barrier of the rectum: results from a porcine model

BACKGROUND

The mechanism of action of sacral nerve stimulation (SNS) remains largely elusive. The aims of this study were to develop a clinically relevant animal model for percutaneous SNS and to describe its effect on the epithelial barrier of the rectum.

METHODS

Under general anesthesia and after percutaneous electrode placement for S3 nerve root stimulation, six pigs underwent unilateral stimulation and six bilateral stimulation. Animals were stimulated for 3 h using an external pulse generator (1-2.5 V; 14 Hz; 210 μs). Six animals underwent electrode implantation without stimulation and served as controls. Full-thickness rectal biopsies were performed prior to and after stimulation. Paracellular permeability was evaluated by measuring sulfonic acid flux across the rectal mucosa in Ussing chambers. Histological assessment of mucosal thickness, epithelial desquamation, and mucus expression were performed.

KEY RESULTS

Percutaneous stimulation resulted in successful anal contractions whose amplitude and uniformity was enhanced following bilateral compared with unilateral stimulation. In controls, paracellular permeability significantly increased during the stimulation period whereas it remained unchanged following unilateral stimulation. In contrast, permeability was significantly reduced by bilateral stimulation. This effect was associated with a concomitant reduction in mucosal thickness and a trend toward increased amount of mucus on surface epithelium compared with controls.

CONCLUSIONS & INFERENCES

The development of a porcine model of percutaneous SNS revealed the ability of neuromodulation to reinforce rectal epithelial barrier. Furthermore, our results suggest that SNS could be used for treatment of gastrointestinal pathologies with reduced rectal mucosal barrier functions.

Spot urine potassium as a potential screening test for aldosterone breakthrough

BACKGROUND AND AIMS

Treatment with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may suppress aldosterone production only in the initial phase of treatment and subsequently lead to a rising level of aldosterone to baseline or higher. This phenomenon is described as aldosterone breakthrough. Apart from serial plasma aldosterone levels, there are no other test to identify this condition. The purpose of this study was to evaluate the role of spot urine potassium as a potential screening test for aldosterone breakthrough.

MATERIALS AND METHODS

This was a cross sectional study involving 94 patients who were on an ACEI or ARB for a minimum duration of 40 weeks. An aldosterone cut off value of 102 pg/ml was used to define aldosterone breakthrough based on a previous study. Patients with primary hyperaldosteronism, conditions giving rise to secondary hyperaldosteronism and those who were on drugs which could interfere with the renin-angiotensin-aldosterone system were excluded. The study patients had their blood sample analysed for renal profile, renin, aldosterone and urine sample analysed for urine potassium.

RESULTS

Incidence of aldosterone breakthrough in this study was 23.4%. The median urine potassium was 62.0 mmol/L in the aldosterone breakthrough group compared to the non-breakthrough group which was 38.5 mmol/L. The urine potassium showed statistically significant difference between both groups (p=0.016). The correlation coefficient was 0.284; statistically significant (p=0.006) as the sample size was large (n=94).

CONCLUSION

A raised urinary potassium after initiating treatment ith ACEI or ARB is a potential screening test for aldosterone breakthrough.

Responding to students with posttraumatic stress disorder in schools

The prevalence of trauma exposure among youth is a major public health concern. Students who have experienced a traumatic event are at increased risk for academic, social, and emotional problems. School can be an ideal setting for mental health professionals to intervene with traumatized students, school staff, and parents both immediately following a traumatic event and when symptoms of posttraumatic stress disorder and other trauma-related mental health problems develop. This article describes evidence-based treatments for posttraumatic stress disorder and outlines practical approaches to use in schools.

Use of a rapid test of pneumococcal colonization density to diagnose pneumococcal pneumonia

BACKGROUND

There is major need for a more sensitive assay for the diagnosis of pneumococcal community-acquired pneumonia (CAP). We hypothesized that pneumococcal nasopharyngeal (NP) proliferation may lead to microaspiration followed by pneumonia. We therefore tested a quantitative lytA real-time polymerase chain reaction (rtPCR) on NP swab samples from patients with pneumonia and controls.

METHODS

In the absence of a sensitive reference standard, a composite diagnostic standard for pneumococcal pneumonia was considered positive in South African human immunodeficiency virus (HIV)-infected adults hospitalized with radiographically confirmed CAP, if blood culture, induced good-quality sputum culture, Gram stain, or urinary Binax demonstrated pneumococci. Results of quantitative lytA rtPCR in NP swab samples were compared with quantitative colony counts in patients with CAP and 300 HIV-infected asymptomatic controls.

RESULTS

Pneumococci were the leading pathogen identified in 76 of 280 patients with CAP (27.1%) using the composite diagnostic standard. NP colonization density measured by lytA rtPCR correlated with quantitative cultures (r = 0.67; P < .001). The mean lytA rtPCR copy number in patients with pneumococcal pneumonia was 6.0 log(10) copies/mL, compared with patients with CAP outside the composite standard (2.7 log(10) copies/mL; P < .001) and asymptomatic controls (0.8 log(10) copies/mL; P < .001). A lytA rtPCR density ≥8000 copies/mL had a sensitivity of 82.2% and a specificity of 92.0% for distinguishing pneumococcal CAP from asymptomatic colonization. The proportion of CAP cases attributable to pneumococcus increased from 27.1% to 52.5% using that cutoff.

CONCLUSIONS

A rapid molecular assay of NP pneumococcal density performed on an easily available specimen may significantly increase pneumococcal pneumonia diagnoses in adults.

Lupus, the current therapeutic approaches

The management of systemic lupus erythematosus (SLE) is challenging due to the heterogenous presentation and clinical manifestations of the disease. Standard therapies for SLE use immunosuppressive drugs with significant side effects. Advanced knowledge of the pathogenesis of SLE has led to new therapeutic approaches targeting specific molecules, pathways and cells. Factors intimately involved in the chronic inflammatory response to SLE have been studied in animal models of the disease and tested in clinical trials. Here we review the topic discussing the agents currently used in the induction and maintenance therapy of SLE. In addition, the emerging therapeutic modalities in SLE that use biologics such as monoclonal antibodies to immune cell surface molecules or cytokines, synthetic peptides, oligonucleotides and cell-based therapies are discussed here.

An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device

We report an unknown complication of peripherally inserted central venous catheter in a patient with Ventricular Assist Device. This rare complication led to the failure of the right ventricular assist device, which could be detrimental in patients with dilated cardiomyopathy.

Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele

AIM

Laparoscopic ventral mesh rectopexy, previously described for external rectal prolapse, was evaluated for symptomatic complex rectocoele.

METHOD

From January 2004 to December 2008, 84 (50.9%) patients (mean age 64 ± 5 years) underwent laparoscopic ventral mesh rectopexy for symptomatic complex rectocoele, confirmed preoperatively on dynamic defaecography, with 26 (31%) patients having a concurrent cystocoele. The operative technique was standardized, and those with cystocoele underwent bladder mesh suspension during the same procedure. Prospectively collected data were analysed for preoperative symptoms, operative and functional results [constipation, faecal incontinence (FI), dyspareunia and satisfaction score].

RESULTS

The conversion rate was 3.6% and perioperative morbidity 4.8% with no mortality. At a median follow up of 29 (4-59) months, there was a significant decrease in vaginal discomfort (86-20%) and obstructed defaecation symptoms (83-46%), P < 0.001. There was no significant change in FI (20-16%), no worsening of preoperative symptoms or new complaints of constipation, dyspareunia or FI. Overall, 88% of patients reported an improvement in overall well-being.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe and effective method for treating symptomatic complex rectocoele.

The antenatal detection rate of major congenital heart disease in Scotland

Ultrasonography has been used to detect fetal congenital heart disease since the 1980s, although there has been little uniformity in policy. In the UK, data published for 1993-1995 found an average detection rate of 23.4% with a Scottish rate of 9.6%. At the time of this study, 10 out of the 14 health boards in Scotland were implementing the 16-22-week fetal anomaly scan (FAS). The aims of this study were to determine the rate of antenatal diagnosis of major congenital heart disease (MCHD) throughout Scotland during 1 January to 31 December 2006, to document the regional differences in detection and to determine if implementation of a FAS significantly improved rates. Retrospective data were collected from the centralized Paediatric Cardiac Services in Edinburgh and Glasgow. The database contains information on all infants with cardiac disease in Scotland. All infants requiring cardiac intervention or dying in the first year of life were included. The results showed that the antenatal diagnosis rate for Scotland was 28% (95% CI 21.2%, 34.9%). The Scottish health boards that had implemented the FAS had a significantly higher antenatal detection rate (χ2 test P = 0.037). In conclusion, antenatal detection rate of MCHD varies widely throughout Scotland. Implementation of the FAS has made a significant difference to antenatal diagnosis