Relational Health in Transitions: Female Adolescents in Chemical Dependency Treatment

BACKGROUND

Adolescent substance use (SU) remains a serious problem. Inpatient, primary care, and self-treatment models for chemical dependency (CD) yield varying degrees of success impacting the sequelae of chronic or episodic SU. Relational engagement among adolescent substance users is a long known influential factor in the development, maintenance and transformation of addictive behaviors.

OBJECTIVES

Following tenets of Relational-Cultural Theory and using the Relational Health Indices for Youth (RHI-Y), a validated survey tool for adolescents, we sought to measure relational health (RH) during times of transitions during CD treatment. This article addresses use of the tool and its potential for improving addictions research and practice.

METHODS

During 2015-2017 we explored differences in RH scores in adolescent girls entering inpatient CD treatment at three points: 51 at admission, 39 at discharge, and 13 at 3 months post-discharge. Data were analyzed using a generalized linear mixed model to compare changes in domain scores of RH.

RESULTS

Changes in RH scores were significant in the friend domain, but not the mentor and community domains. The RHI-Y shows promise in discerning RH change during transitions in CD treatment.

Double-Blind, Placebo-Controlled, Randomized Phase I/IIa Study (Safety and Efficacy) with Buspirone/Levodopa/Carbidopa (SpinalonTM) in Subjects with Complete AIS A or Motor-Complete AIS B Spinal Cord Injury

BACKGROUND

No drug treatment capable of restoring locomotor capabilities in patients suffering a motor-complete spinal cord injury (SCI) has ever been developed. We assessed the safety and efficacy of an activator of spinal locomotor neurons in humans, which were shown in paraplegic animals to elicit temporary episodes of involuntary walking.

METHODS

Single administration of buspirone/levodopa/carbidopa (SpinalonTM), levodopa/carbidopa (ratio 4: 1), and buspirone or placebo was performed using a dose-escalation design in 45 subjects placed in supine position who had had an SCI classified as complete (AIS A) or motor-complete/sensory incomplete (AIS B) for at least 3 months. Blood samples before and at regular intervals (15, 30, 60, 120, 240 min) after treatment were collected for hematological and pharmacokinetic (PK) analyses. Electromyographic (EMG) activity of eight muscles (four per leg) was monitored prior to and at several time points after drug administration.

RESULTS

SpinalonTM (10-35 mg buspirone/100-350 mg levodopa/25-85 mg carbidopa) displayed no sign of safety concerns - only mild nausea was found in 3 cases. At higher doses, 50 mg/500 mg/125 mg SpinalonTM was considered to have reached maximum tolerated dose (MTD) since 3 out of 4 subjects experienced related adverse events including vomiting. PK analyses showed comparable data between groups suggesting no significant drugdrug interaction with SpinalonTM. Only the SpinalonTM-treated groups displayed significant EMG activity accompanied by locomotor-like characteristics - that is with rhythmic and bilaterally alternating bursts.

CONCLUSION

Therefore, this study provides evidence of safety and preliminary efficacy following a single administration of SpinalonTM in subjects with SCI.

Abstract 23: Lower Heart Rate Variability Associated With Incident Coronary Heart Disease and Death in Post-Menopausal Women

Rationale: Lower heart rate variability (HRV) has been associated with increased all-cause mortality and adverse cardiovascular events including sudden death. The role of HRV in post-menopausal women is understudied. Therefore, we tested the hypothesis of a significant association between HRV and incident coronary heart disease (CHD) and CHD death in post-menopausal women.

Methods: This is an analysis of prospective data collected during the Women’s Health Initiative (WHI) clinical trials. A total of 57,061 post-menopausal women were included. HRV was quantified using two variables; standard deviation of all normal-to-normal RR intervals (SDNN, milliseconds), and the root mean square of successive differences in normal-to-normal RR intervals (RMSSD, milliseconds). We used Cox proportional hazards models to test the association between HRV and incident CHD, hard CHD (including myocardial infarction and fatal CHD), and total CHD death. We controlled for age, race, alcohol use, physical activity, depression, BMI, smoking, diabetes, hypertension, lipid disorders, and family history of CHD.

Results: The results are as highlighted for incident and hard CHD in table 1 and for CHD death in table 2. There were statistically significant associations between lower HRV (as a continuous variable and as quartiles) and higher levels of incident CHD.

Conclusion: In post-menopausal women, lower HRV was associated with a modestly higher, but statistically significant, risk for incident cardiovascular events, including fatal and non-fatal myocardial infarction. Factors associated with lower HRV and cardiac autonomic impairment may be candidates for reducing CHD risk, such as better glycemic control and improved physical activity.

Errors in Fluid Balance with Pump Control of Continuous Hemodialysis

The use of pumps both proximal and distal to the dialyzer during continuous hemodialysis provides control of dialysate and ultrafiltration flow rates, thereby reducing nursing time. However, we had noted unexpected severe extracellular fluid depletion suggesting that errors in pump delivery may be responsible. We measured in vitro the operation of various pumps under conditions similar to continuous hemodialysis. Fluid delivery of peristaltic and roller pumps varied with how the tubing set was inserted in the pump. Piston and peristaltic pumps with dedicated pump segments were more accurate. Pumps should be calibrated and tested under conditions simulating continuous hemodialysis prior to in vivo use.

Accuracy of intravenous and enteral preparations involving small volumes for paediatric use: a review

BACKGROUND

Children often need to be administered very small volumes of medicines that are authorised for use in adults. Neonatal drug delivery is particularly challenging, and doses are often immeasurable with the equipment currently available.

AIM

To summarise research to date on the accuracy of intravenous and enteral medicine preparation requiring small volumes (<0.1 mL), with a focus on paediatric use and to identify areas for further work.

METHOD

Twenty-three publications were identified for the narrative review via: Web of Science (1950-2016), Cumulative Index to Nursing and Allied Health Literature (1976-2016), Excerpta Medica Database (1974-2016) and International Pharmaceutical Abstracts (1970-2016) searches. Nine additional papers were identified through backward citation tracking and a further 17 were included from the personal knowledge of the review team.

RESULTS

Measurement of volumes (<0.1 mL), for enteral and intravenous dosing, accounts for 25% of medicine manipulations within paediatric hospitals. Inaccuracies are described throughout the literature with dose administration errors attributed to technique, calculation, dilution and problems associated with equipment. While standardised concentrations for intravenous infusion and drug concentrations that avoid measurement of small volumes would ameliorate problems, further work is needed to establish accurate methods for handling small volumes during the administration of medicines to children and risk minimisation strategies to support staff involved are also necessary.

CONCLUSIONS

This review has revealed a paucity of information on the clinical outcomes from problems in measuring small volumes for children and highlighted the need for further work to eliminate this source of inaccurate dosing and potential for medication error.

Changing practices: The addition of a novel surgical approach to gynecomastia

INTRODUCTION

Gynecomastia can be a significant impediment to quality of life for men who suffer from this affliction. Numerous surgical techniques have been described in the literature ranging from minimally invasive options such as liposuction to incision based reductions. The standard for the general surgeons at our institution has been subcutaneous mastectomy through a circumareolar incision, which often proved inadequate for patients with grade II or III gynecomastia. In November 2013 we adopted a new technique, the "double donut", that offers the post-operative appearance of a limited incision, with the additional benefits of mastopexy, skin reduction, and mastectomy through an enlarged incision which is not superficially evident at the completion of the procedure.

METHODS

We reviewed our surgical database for all cases performed for gynecomastia in the period from May 2005 to August 2016. Basic demographic information, diagnostic modality, symptoms, indication for procedure, operation performed, and final pathology were collected and analyzed.

RESULTS

There were 70 mastectomies performed on 52 subjects. All subjects were male; 14 were African American and 38 were Caucasian. The average age was 47 (23-73) years old. The majority of the patients were evaluated with mammogram and/or ultrasound. All but one patient presented with pain as the chief complaint. There were 41 mastectomies done prior to initiation of this technique and 29 were performed after. The average total volume of breast tissue excised via the previous technique was 97.4 cm³, this increased to 186.5 cm³ with the new technique. No necrosis of the NAC was seen and no wound infections resulted in complication. Cosmetic satisfaction was seen in 98% of patients.

CONCLUSION

The "double donut" technique is particularly useful for males with grades II or III gynecomastia. It provides good wound results, with acceptable patient satisfaction and cosmetic outcomes. Although initially developed for patients with higher grade gynecomastia, the improved visibility and increased patient satisfaction allowed this to become the preferred technique at our institution.

European consensus for starting and stopping enzyme replacement therapy in adult patients with Pompe disease: a 10-year experience

BACKGROUND AND PURPOSE

Pompe disease is a rare inheritable muscle disorder for which enzyme replacement therapy (ERT) has been available since 2006. Uniform criteria for starting and stopping ERT in adult patients were developed and reported here.

METHODS

Three consensus meetings were organized through the European Pompe Consortium, a network of experts from 11 European countries in the field of Pompe disease. A systematic review of the literature was undertaken to determine the effectiveness of ERT in adult patients on a range of clinical outcome measures and quality of life. A narrative synthesis is presented.

RESULTS

Consensus was reached on how the diagnosis of Pompe disease should be confirmed, when treatment should be started, reasons for stopping treatment and the use of ERT during pregnancy. This was based on expert opinion and supported by the literature. One clinical trial and 43 observational studies, covering a total of 586 individual adult patients, provided evidence of a beneficial effect of ERT at group level. At individual patient level, the response to treatment varied, but factors associated with a patient's response to ERT were not described in many studies. Eleven observational studies focused on more severely affected patients, suggesting that ERT can also be beneficial in these patients. There are no studies on the effects of ERT in pre-symptomatic patients.

CONCLUSIONS

This is the first European consensus recommendation for starting and stopping ERT in adult patients with Pompe disease, based on the extensive experience of experts from different countries.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

BACKGROUND AND OBJECTIVE

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.

METHODS

The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts.

RESULTS

The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary.

CONCLUSION

The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Medical students help bridge the gap in sexual health education among middle school youth

BACKGROUND

School-based programs are important in addressing risky teenage sexual behavior. We implemented a sex education program using trained medical student volunteers.

METHODS

Medical students (n=30) implemented a seven-session curriculum, designed by medical students and faculty, to 7th and 8th grade students (n=310) at a local school. Middle school students completed pre- and post-assessments. Teachers and medical students completed questionnaires relating their perceptions of students' attitudes and understanding of sexual health.

RESULTS

Students completing the curriculum scored 5% higher on post- versus pre-assessment (84% vs 78.7%, p<0.001). Statistically significant gains were noted in knowledge of reproductive system anatomy, community resources, and sexual decision making. Sixty percent of middle school teachers compared to only 16.7% of medical student volunteers reported discomfort teaching sexual health.

DISCUSSION

Sexual education delivered by trained medical student volunteers may improve middle schoolers' understanding of sexual health. [Full article available at http://rimed.org/rimedicaljournal-2017-01.asp].

Evaluation of the pilot TAPUAKI Pacific pregnancy and parenting education programme

<p><strong>Background</strong>: The TAPUAKI programme aimed to improve Pacific women’s, their partners and families’ knowledge and confidence about pregnancy and parenting so they can make informed choices about their health and that of their infants. The programme consisted of six two-hour blocks of antenatal classes run over six consecutive weeks.</p><p><strong>Aim</strong>: To evaluate the TAPUAKI programme for the effectiveness and delivery of its curriculum to pregnant mothers.</p><p><strong>Methods</strong>: Both paper survey questionnaires and focus group interviews (talanoa) were used for the evaluation. Out of 32 participants who attended the TAPUAKI programme, 13 agreed to take part in the evaluation (a response rate of 41%). There were 3 sites (from 2013-2014) where the programme was piloted: Henderson, Onehunga and Otara. The 13 participants were Samoan, Cook Islands Māori or Tongan ethnicity, all aged between 17 and 40 years old.  In addition, there were 2 female facilitators at each site who delivered the curriculum. All six facilitators agreed to take part in the evaluation.  </p><p><strong>Findings</strong>: Participants reported that their knowledge about pregnancy and parenting had increased as a result of the programme. Specifically, these topics were nutrition, giving birth, breastfeeding and safe sleeping practices. The programme helped to change some incorrect practices and beliefs that were held by those participants who already had children.</p><p><strong>Conclusion</strong>: The TAPUAKI programme increased the women’s knowledge and confidence about pregnancy and parenting. </p>

The Use of the BBC Microcomputer with Psychiatric Conditions

In 1983 a scheme was run by the DHSS and the DTI whereby BBC microcomputers were placed in occupational therapy departments around Britain to see whether they would be a useful therapeutic tool. As part of this project Battle Hospital, Reading, was given two computers, one of which was intended to be peripatetic in the West Berkshire District. From December 1983 to date one of the computers has been used at Fair Mile Hospital, Wallingford. This is a resulting report to show the possible uses of the BBC computer in psychiatry. It describes how the computer has helped to treat specific psychiatric symptoms and illustrates this with case observations to show the responses of various patients.