Outreach and screening following the 2005 London bombings: usage and outcomes

BACKGROUND

Little is known about how to remedy the unmet mental health needs associated with major terrorist attacks, or what outcomes are achievable with evidence-based treatment. This article reports the usage, diagnoses and outcomes associated with the 2-year Trauma Response Programme (TRP) for those affected by the 2005 London bombings.MethodFollowing a systematic and coordinated programme of outreach, the contact details of 910 people were obtained by the TRP. Of these, 596 completed a screening instrument that included the Trauma Screening Questionnaire (TSQ) and items assessing other negative responses. Those scoring ≥6 on the TSQ, or endorsing other negative responses, received a detailed clinical assessment. Individuals judged to need treatment (n=217) received trauma-focused cognitive-behaviour therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR). Symptom levels were assessed pre- and post-treatment with validated self-report measures of post-traumatic stress disorder (PTSD) and depression, and 66 were followed up at 1 year.

RESULTS

Case finding relied primarily on outreach rather than standard referral pathways such as primary care. The effect sizes achieved for treatment of DSM-IV PTSD exceeded those usually found in randomized controlled trials (RCTs) and gains were well maintained an average of 1 year later.

CONCLUSIONS

Outreach with screening, linked to the provision of evidence-based treatment, seems to be a viable method of identifying and meeting mental health needs following a terrorist attack. Given the failure of normal care pathways, it is a potentially important approach that merits further evaluation.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Improved outcomes in paediatric intestinal failure with aggressive prevention of liver disease

BACKGROUND/PURPOSE

A protocol-driven care algorithm for the care of intestinal failure (IF) centred on therapies to prevent Parenteral Nutrition Associated Cholestasis (PNAC) was instituted in 2006. We report our results from 2006-2009, and compare them to the outcomes of our previous cohort of patients (1998-2006).

METHODS

With regional ethics board approval, we have been prospectively gathering data on patient with IF cared for by our regional surgical unit. IF was defined as a residual bowel length of <40 cm or a requirement for PN for greater than 60 days. With the development of a multidisciplinary care team, a protocol-driven strategy to prevent PNAC was instituted in 2006, with aggressive introduction of enteral feeds, use of prophylactic antibiotics to prevent bacterial overgrowth, lipid reduction and use of a fish oil-derived lipid preparation for cholestasis and Serial Transverse Enteroplasty (STEP) if bowel dilation occurred.

RESULTS

In the era from 1998-2006, 33 patients were identified, with a 72% survival; the direct bilirubin averaged 112+/-34 microM/L after 3 months of PN. 8/33 (27%) of patients received prophylactic antibiotics, and none received fish oil-based lipids. The most common causes of IF were gastroschisis (30%) and atresia (21%); 31 of 33 patients were infants. Average time to intestinal rehabilitation/death was 4.5+/-3 months. All deaths were related to sepsis or PN/liver failure. In the era from 2006-2009, 22 patients have been followed, with 100% survival*. Average bilirubin after 3 months of PN was 8+/-2.2 microM/L*, 20/22 (90%)* received prophylactic antibiotics, and 6/22(27%)* received fish oil-based lipid PN. The common causes of IF were gastroschisis 15/22 (68%) and atresia (27%). 18/22 are weaned from PN, and the average time to intestinal rehabilitation was 2.7+/-1.3 months, 4 patients underwent STEP procedures. (*p<0.05 by Fischer's exact or Student's t-test, data mean+/-SD).

CONCLUSIONS

The institution of an aggressive protocol of advancing enteric feeds, oral antibiotic prophylaxis for bacterial overgrowth, fish oil-based lipid use, and the STEP procedure for dilated bowel has resulted in an apparent increase in survival and a remarkable improvement in liver function in a paediatric IF population. Further studies to define the relative importance of these therapies are recommended.

Locked inpatient units in modern mental health care: values and practice issues

Locked inpatient units are an increasing phenomenon, introduced in response to unforseen abscondences and suicides of patients. This paper identifies some value issues concerning the practice of locked psychiatric inpatient units. Broad strategies, practicalities and ethical matters that must be considered in inpatient mental health services are also explored. The authors draw on the published research and commentary to derive relevant information to provide to patients and staff regarding the aims and rationales of locked units. Further debate is warranted in relation to best practice. Inpatient staff need to be aware of their practice values, be able to access education and supervision and negotiate apparent contradictions. Further patient/clinician focused enquiry is necessary to mitigate the negative and stigmatising effects of locked mental health units.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

Actions and comparative efficacy of phosphatidylcholine formulation and isolated sodium deoxycholate for different cell types

BACKGROUND

Phosphatidylcholine formulation has been used to dissolve local fat deposits. This study aimed to evaluate and compare the effects of phosphatidylcholine formulation and its vehicle sodium deoxycholate alone on different cell lines to understand better its mechanism of action.

METHODS

Cells and media including 3T3-L1 preadipocytes, normal foreskin fibroblasts, neonatal human dermal microvascular endothelial cells (CADMEC), and fetal human skeletal muscle cells (HSkMC) were used. After 24 h, cells were exposed in 3-4, 5-dimethylthiazol-2-yl-2, 3-diphenyl tetrazolium bromide reagent (MTT assays) to increasing dosages of phosphatidylcholine formulation (0.0156-0.5 mg/ml) or an equivalent vehicle, sodium deoxycholate solution, pH 9.0 (0.0066-0.210 mg/ml). Viability was assessed after 1, 2, and 3 days of treatment. Fat tissue (4 x 4 cm) obtained ex vivo from the dorsal fat pads of five rabbits was injected with 2 ml of phosphatidylcholine formulation (50 mg/ml), sodium deoxycholate (21 mg/ml), or normal saline and incubated for 24 h. These were examined histologically to identify cell lysis and morphologic changes.

RESULTS

At 0.125- and 0.25-mg/ml doses of phosphatidylcholine solution, CADMEC and HSkMC were more sensitive (P < 0.001, one-way ANOVA) than adipocytes at all time points examined. Phosphatidylcholine formulation at a dose of 0.5 mg/ml and the equivalent vehicle, sodium deoxycholate, at a dose of 0.21-mg/ml both induced nearly 100% fat cell lysis after 24 h, and evidence of cell lysis as early as 6 h after exposure. After incubation of fat tissue for 24 h with phosphatidylcholine formulation, loss of intracellular lipid staining with an increase in extracellular lipids was seen.

CONCLUSIONS

Isolated sodium deoxycholate was almost as effective as the phosphatidylcholine formulation, at clinical concentrations, in reducing the viability of mature adipocytes over time. Similar cytotoxic effects of phosphatidylcholine formulation on normal foreskin fibroblasts, endothelial cells, and human skeletal muscle cells also were observed. The data prove that the formulation acts in a nonspecific manner and that its unintentional administration to other tissues causes cell death.