A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents

BACKGROUND

Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN.

METHOD

We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12-18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT).

RESULTS

The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group.

CONCLUSIONS

Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Access to post-exposure prophylaxis following sexual exposure for men who have sex with men in an Irish healthcare setting

Men who have sex with men experience disproportionate rates of HIV acquisition. Post-exposure prophylaxis following unprotected sexual exposure reduces HIV transmission. Our aim was to assess access to post-exposure prophylaxis for men who have sex with men in Irish emergency departments. We contacted all national 24-hour adult emergency departments describing two scenarios; a seronegative man who has sex with men receiving unprotected insertive anal intercourse from a seropositive partner and secondly a woman sustaining a needle-stick injury from an unknown source. We recorded and compared responses regarding post-exposure prophylaxis advice in each situation. High proportions of emergency departments offered post-exposure prophylaxis for both situations despite minimal evidence to support use in needle-stick injury. Men who have sex with men were less likely to be asked to attend emergency departments for post-exposure prophylaxis administration than a person experiencing needle-stick injury. Men who have sex with men were less likely to be offered baseline serological testing for blood borne infections. Men who have sex with men were as likely as needle-stick injury to receive advice from healthcare workers in emergency departments and consultation durations were similar. This study identifies a need to educate healthcare workers in emergency departments on appropriate use of post-exposure prophylaxis following sexual exposure for men who have sex with men. Health care workers must appreciate the importance of post-exposure prophylaxis presentations as opportunities for intervention and HIV screening.

Prevalence of human papillomavirus in men who have sex with men in the era of an effective vaccine; a call to act

OBJECTIVES

The incidence of human papillomavirus (HPV)-associated anal cancer is increasing. Men who have sex with men (MSM), particularly those coinfected with HIV, are disproportionately affected. Documenting the molecular epidemiology of HPV infection is important in guiding policy makers in formulating universal and/or targeted vaccine guidelines.

METHODS

A prospective cohort study was conducted. HIV-positive and HIV-negative MSM > 18 years old were invited to participate. Provider-performed anal swabs were collected and anal HPV infection was detected using consensus primer solution phase polymerase chain reaction (PCR) followed by type-specific PCR for high-risk (HR)-HPV types 16, 18 and 31. Between-group differences were analysed using χ(2) tests and Wilcoxon rank tests.

RESULTS

One hundred and ninety-four MSM [mean (standard deviation (SD)) age 36 (10) years; 51% HIV-positive) were recruited. The median number of sexual contacts in the preceding 12 months was 4 (interquartile range 2-10). HIV-positive subjects had a mean (SD) CD4 count of 557 (217) cells/μL, and 84% were on highly active antiretroviral therapy (HAART). Thirty-one samples were B-globin negative and thus excluded from further analysis. A total of 113 subjects (69%) had detectable HPV DNA. Sixty-eight subjects (42%) had an HR-HPV type detected. HR HPV type 16 was detected in 44 samples (27%), HR-HPV type 18 in 26 samples (16%) and HR-HPV type 31 in 14 samples (23%). Twenty-eight subjects (17%) had more than one type of HR-HPV type detected. When HPV and HR-HPV were stratified by age, those > 35 years had a higher prevalence (P = 0.001 and P = 0.028, respectively). HIV-positive subjects were more likely than HIV-negative subjects to have any detectable HPV (77% vs. 61%, respectively; P = 0.04), to have HR-HPV type 18 or 31 (P = 0.05 and P = 0.006, respectively) and to be infected with more than one HR-HPV type (31% vs. 3%, respectively; P < 0.001). Within the HIV-positive group, the prevalence of HPV was higher in those not on HAART (P = 0.041), although it did not differ when stratified by CD4 count.

CONCLUSIONS

The identified prevalence of anal HPV infection was high. Emerging patterns of HPV-related disease strengthen the call for universal vaccination of boys and girls with consideration of catch-up and targeted vaccination of high-risk groups such as MSM and those with HIV infection.

Adverse tumor biology associated with mesenterico-portal vein resection influences survival in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

PATIENTS AND METHODS

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD-VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

RESULTS

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD-VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD-VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD-VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

CONCLUSIONS

PD with VR has similar morbidity but worse OS compared with a PD-VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.

Patterns of care for malignant pleural mesothelioma patients compensated by the Dust Diseases Board in New South Wales, Australia

BACKGROUND

The silent epidemic of mesothelioma in Australia is steadily increasing, and 30% of cases occur in New South Wales (NSW).

AIM

To describe the patterns of care and outcomes of patients with malignant pleural mesothelioma (MPM) in NSW.

METHODS

MPM patients in NSW applying for compensation at the NSW Dust Diseases Board from 2007 to 2009 were included. Survival from time of diagnosis was determined by the Kaplan-Meier method. The Chi-squared test was used to determine if there was an association between utilisation of treatment and geographical location.

RESULTS

A total of 138 patients was included: median age was 72.5; 91.3% male; 60.1% epithelial subtype; and 65.2% lived in major cities. All patients had at least one chest X-ray and computed tomography scan, and 21% had a positron emission tomography scan; 93.5% and 4.3% had histological or cytological confirmation respectively. Thoracoscopy (59.4%) was the most commonly used diagnostic procedure. Treatment utilisation: 53.6% chemotherapy; 35.5% radiotherapy; 9.4% extrapleural pneumonectomy (EPP); and 72.5% had palliative care involvement. There were no major differences in treatment utilisation between patients living in major cities and those in regional NSW (chemotherapy P = 0.42; radiotherapy P = 0.13 and palliative care P = 0.60), except for a higher rate of EPP in regional patients (16.7% vs 5.6%; P = 0.03). Median survival was 9.7 versus 12.3 months for city and regional patients respectively (P = 0.22).

CONCLUSION

Survival and treatment utilisation was not significantly different between MPM patients living in major cities and regional NSW, except for a higher rate of EPP in patients in regional NSW.

Work engagement supports nurse workforce stability and quality of care: nursing team-level analysis in psychiatric hospitals

Research in healthcare settings reveals important links between work environment factors, burnout and organizational outcomes. Recently, research focuses on work engagement, the opposite (positive) pole from burnout. The current study investigated the relationship of nurse practice environment aspects and work engagement (vigour, dedication and absorption) to job outcomes and nurse-reported quality of care variables within teams using a multilevel design in psychiatric inpatient settings. Validated survey instruments were used in a cross-sectional design. Team-level analyses were performed with staff members (n = 357) from 32 clinical units in two psychiatric hospitals in Belgium. Favourable nurse practice environment aspects were associated with work engagement dimensions, and in turn work engagement was associated with job satisfaction, intention to stay in the profession and favourable nurse-reported quality of care variables. The strongest multivariate models suggested that dedication predicted positive job outcomes whereas nurse management predicted perceptions of quality of care. In addition, reports of quality of care by the interdisciplinary team were predicted by dedication, absorption, nurse-physician relations and nurse management. The study findings suggest that differences in vigour, dedication and absorption across teams associated with practice environment characteristics impact nurse job satisfaction, intention to stay and perceptions of quality of care.

A diagnostic dilemma: drug-induced aseptic meningitis in a 45-year-old HIV-positive man

We describe a case of aseptic meningitis following the administration of moxifloxacin in a 45-year-old man with human immunodeficiency virus (HIV). At presentation he was receiving tuberculosis treatment on a modified regimen following severe hepatotoxicity; this included moxifloxacin, started 8 days previously. Initial cerebrospinal fluid (CSF) analysis was grossly abnormal. Anti-viral and -bacterial treatments were started. All microbiological tests proved negative and his moxifloxacin was withheld resulting in a complete normalisation of CSF. Drug-induced aseptic meningitis is a diagnosis of exclusion and presents a serious diagnostic dilemma. The decision to withhold medication cannot be taken lightly.

MeV-energy x rays from inverse compton scattering with laser-wakefield accelerated electrons

We report the generation of MeV x rays using an undulator and accelerator that are both driven by the same 100-terawatt laser system. The laser pulse driving the accelerator and the scattering laser pulse are independently optimized to generate a high energy electron beam (>200  MeV) and maximize the output x-ray brightness. The total x-ray photon number was measured to be ∼1×10(7), the source size was 5  μm, and the beam divergence angle was ∼10  mrad. The x-ray photon energy, peaked at 1 MeV (reaching up to 4 MeV), exceeds the thresholds of fundamental nuclear processes (e.g., pair production and photodisintegration).

Quantum dots as phototoxic drugs and sensors of specific metabolic processes in living cells

When conjugated to CdSe/ZnS nanocrystals (quantum dots), the nucleobase adenine and the neurotransmitter dopamine quench fluorescence emission from in a manner strongly dependent upon the size of the quantum dot. The degree of quenching serves to predict the efficiency with which the conjugates are able to enter living cells. Along with quenching, the presence of specific receptors on the cells is necessary for QD binding, entry, and phototoxicity. Toxicity is manifested by opening of large membrane pores and by oxidative DNA damage, and does not require the release of Cd⁺². In bacterial cells, light exposure is necessary for uptake, and procedures to reduce toxicity eliminate labeling. In mammalian cells, antioxidants prevent toxicity but not QD uptake, leading to QD-loaded cells that are nonfluorescent before light exposure. These findings provide a general procedure for rational design of nanoparticle-based photosensitizing drugs and for "off-on" fluorescent labels.

Nineteenth century research on cell death

This paper reviews research on cell death in the 19th C. The first report of cell death was by Vogt in 1842, which was remarkably soon after the establishment of the cell theory by Schleiden and Schwann between 1838 and 1842. Initial studies on cell death, including that of Vogt, focused on its occurrence in metamorphosis (Vogt, 1842; Prévost and Lebert, 1844; Weismann, 1863-1866) or in blatant pathology (Virchow, 1858), but as histological techniques improved it was found to be involved in more subtle roles in numerous situations including endochondral ossification (Stieda, 1872), ovarian follicle atresia (Flemming, 1885), cell turnover (Nissen, 1886), the wholesale loss of a population of sensory neurons in fish (Beard, 1889), and the naturally occurring histogenetic death of myocytes (Felix, 1889) and neurons (Collin, 1906). The current categorization of cell death into about three main morphological types has 19th century roots in that apoptosis was well described by Flemming (1885), who called it chromatolysis, and various authors including Noetzel (1895) proposed a threefold classification. This article is part of a Special Issue entitled "Apoptosis: Four Decades Later".

Long-term neurological follow-up of HIV-positive patients diagnosed with syphilis

No cerebrospinal fluid (CSF) abnormalities are found in HIV-positive patients in long-term follow-up after standard syphilis treatment. Syphilis has been reported to have immunological effects on HIV infection and HIV is known to modulate both the manifestations of syphilis and the serological response to therapy. HIV-positive patients who had been diagnosed with and treated for syphilis prior to 2007 were identified. Patients were consented for lumbar puncture. Serum HIV viral load, CD4 count and CSF were recorded. Thirty-five patients with previously diagnosed and treated syphilis underwent lumbar puncture. Thirty-four patients had a normal neurological exam. Only one patient had an abnormal mean white cell count (10.7 cells per high-power field). The finding that those with previously diagnosed syphilis had normal CSF and clinical findings is reassuring and supports the practice of using standard syphilis therapy in HIV-positive patients.