Synthesising existing research on complicated grief in intellectual disability: findings from a systematic review

BACKGROUND

Complicated grief has been identified as a phenomenon in the general population, and there is an increasing body of research investigating complicated grief in people with intellectual disability. The aim of this study is to synthesise this existing knowledge from research published between 1999 and 2022.

METHODS

A structured systematic review using PRISMA guidelines was conducted, which searched three commonly used databases (Medline, PsycINFO and CINAHL) for research on the topic of bereavement and intellectual disability. The articles identified in this search were screened to identify those that addressed the issue of 'complicated grief', with all abstracts and subsequent full texts reviewed by two researchers.

RESULTS

In total, 179 abstracts were initially identified, with 34 articles eligible for full text screening and 18 papers reaching criteria for inclusion. Data relating to the studies' objectives were extracted under the headings of definition, defining principles, signs and symptoms, risk factors and treatments for complicated grief in intellectual disability. Thematic analysis of the extracted data was performed to identify key themes.

CONCLUSIONS

This review highlights that people with intellectual disability are likely to experience complicated grief reactions and that complicated grief is both underestimated and a clinically significant condition for people with intellectual disability. Future research should work to clarify diagnostic criteria and identify appropriate interventions.

Rapid, random-access, and quantification of hepatitis B virus using the Cepheid Xpert HBV viral load assay

BACKGROUND

Monitoring viral load (VL) is an essential part of the management of patients chronically infected with hepatitis B virus (HBV). The commercial HBV VL assays currently available are generally performed on high-throughput platforms for batch wise testing of plasma samples, with relatively long turn-around-times. Rapid VL testing could provide immediate input to clinical decision making.

METHODS

One hundred two stored plasma samples from 102 patients who were previously tested for HBV VL by the Cobas Ampliprep/Taqman or Cobas 4800 (Roche, Pleasanton, CA), were analyzed by the recently introduced Cepheid Xpert HBV Viral Load Assay. Thirty-one of the 102 samples were negative for HBV DNA and 71 out of 102 samples had a detectable VL. HBV DNA loads ranged from <20 to 5E8 IU/mL. HBV genotypes (A, B, C, D, E, and G) were known for 52 of the VL positive samples. Correlation of VL results between both assays was determined by the Pearson correlation coefficient (r2 ). The level of concordance was assessed using the Bland-Altman analysis.

RESULTS

HBV VLs correlated well between both assays, across all genotypes (Pearson correlation coefficient r2  = 0.987). Six samples exceeded a 0.5  log difference between assays. Bland-Altman analysis demonstrated a mean of the difference of -0.107 log and a standard deviation of 0.271 log.

CONCLUSION

High correlation was observed between the Roche Cobas HBV Viral Load tests and the Xpert HBV Viral Load Assay, thus enabling rapid, random access, and accurate HBV VL assessment.

Immune-escape mutations and stop-codons in HBsAg develop in a large proportion of patients with chronic HBV infection exposed to anti-HBV drugs in Europe

Background

HBsAg immune-escape mutations can favor HBV-transmission also in vaccinated individuals, promote immunosuppression-driven HBV-reactivation, and increase fitness of drug-resistant strains. Stop-codons can enhance HBV oncogenic-properties. Furthermore, as a consequence of the overlapping structure of HBV genome, some immune-escape mutations or stop-codons in HBsAg can derive from drug-resistance mutations in RT. This study is aimed at gaining insight in prevalence and characteristics of immune-associated escape mutations, and stop-codons in HBsAg in chronically HBV-infected patients experiencing nucleos(t)ide analogues (NA) in Europe.

Methods

This study analyzed 828 chronically HBV-infected European patients exposed to ≥ 1 NA, with detectable HBV-DNA and with an available HBsAg-sequence.

The immune-associated escape mutations and the NA-induced immune-escape mutations sI195M, sI196S, and sE164D (resulting from drug-resistance mutation rtM204 V, rtM204I, and rtV173L) were retrieved from literature and examined. Mutations were defined as an aminoacid substitution with respect to a genotype A or D reference sequence.

Results

At least one immune-associated escape mutation was detected in 22.1% of patients with rising temporal-trend. By multivariable-analysis, genotype-D correlated with higher selection of ≥ 1 immune-associated escape mutation (OR[95%CI]:2.20[1.32–3.67], P = 0.002). In genotype-D, the presence of ≥ 1 immune-associated escape mutations was significantly higher in drug-exposed patients with drug-resistant strains than with wild-type virus (29.5% vs 20.3% P = 0.012). Result confirmed by analysing drug-naïve patients (29.5% vs 21.2%, P = 0.032). Strong correlation was observed between sP120T and rtM204I/V (P < 0.001), and their co-presence determined an increased HBV-DNA.

At least one NA-induced immune-escape mutation occurred in 28.6% of patients, and their selection correlated with genotype-A (OR[95%CI]:2.03[1.32–3.10],P = 0.001).

Finally, stop-codons are present in 8.4% of patients also at HBsAg-positions 172 and 182, described to enhance viral oncogenic-properties.

Conclusions

Immune-escape mutations and stop-codons develop in a large fraction of NA-exposed patients from Europe. This may represent a potential threat for horizontal and vertical HBV transmission also to vaccinated persons, and fuel drug-resistance emergence.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3161-2) contains supplementary material, which is available to authorized users.

Immunity against measles, mumps, rubella, varicella, diphtheria, tetanus, polio, hepatitis A and hepatitis B among adult asylum seekers in the Netherlands, 2016

Asylum seekers are a vulnerable population for contracting infectious diseases. Outbreaks occur among children and adults. In the Netherlands, asylum seeker children are offered vaccination according to the National Immunization Program. Little is known about protection against vaccine-preventable diseases (VPD) in adult asylum seekers. In this 2016 study, we assessed the immunity of adult asylum seekers against nine VPD to identify groups that might benefit from additional vaccinations. We invited asylum seekers from Syria, Iran, Iraq, Afghanistan, Eritrea and Ethiopia to participate in a serosurvey. Participants provided informed consent and a blood sample, and completed a questionnaire. We measured prevalence of protective antibodies to measles, mumps, rubella, varicella, diphtheria, tetanus, polio type 1-3 and hepatitis A and B, stratified them by country of origin and age groups. The median age of the 622 participants was 28 years (interquartile range: 23-35), 81% were male and 48% originated from Syria. Overall, seroprotection was 88% for measles (range between countries: 83-93%), 91% for mumps (81-95%), 94% for rubella (84-98%), 96% for varicella (92-98%), 82% for diphtheria (65-88%), 98% for tetanus (86-100%), 91% (88-94%) for polio type 1, 95% (90-98%) for polio type 2, 82% (76-86%) for polio type 3, 84% (54-100%) for hepatitis A and 27% for hepatitis B (anti-HBs; 8-42%). Our results indicate insufficient protection against certain VPD in some subgroups. For all countries except Eritrea, measles seroprotection was below the 95% threshold required for elimination. Measles seroprevalence was lowest among adults younger than 25 years. In comparison, seroprevalence in the Dutch general population was 96% in 2006/07. The results of this study can help prioritizing vaccination of susceptible subgroups of adult asylum seekers, in general and in outbreak situations.

Combined Analysis of the Prevalence of Drug-Resistant Hepatitis B Virus in Antiviral Therapy-Experienced Patients in Europe (CAPRE)

BACKGROUND

European guidelines recommend treatment of chronic hepatitis B virus infection (CHB) with the nucleos(t)ide analogs (NAs) entecavir or tenofovir. However, many European CHB patients have been exposed to other NAs, which are associated with therapy failure and resistance. The CAPRE study was performed to gain insight in prevalence and characteristics of NA resistance in Europe.

METHODS

A survey was performed on genotypic resistance testing results acquired during routine monitoring of CHB patients with detectable serum hepatitis B virus DNA in European tertiary referral centers.

RESULTS

Data from 1568 patients were included. The majority (73.8%) were exposed to lamivudine monotherapy. Drug-resistant strains were detected in 52.7%. The most frequently encountered primary mutation was M204V/I (48.7%), followed by A181T/V (3.8%) and N236T (2.6%). In patients exposed to entecavir (n = 102), full resistance was present in 35.3%. Independent risk factors for resistance were age, viral load, and lamivudine exposure (P < .001).

CONCLUSIONS

These findings support resistance testing in cases of apparent NA therapy failure. This survey highlights the impact of exposure to lamivudine and adefovir on development of drug resistance and cross-resistance. Continued use of these NAs needs to be reconsidered at a pan-European level.

Persistent and transient hepatitis B virus (HBV) infections in children born to HBV-infected mothers despite active and passive vaccination

Combined passive and active immunization for newborns very effectively prevents perinatal hepatitis B virus (HBV) infections. In the Netherlands, babies born to hepatitis B surface antigen (HBsAg)-positive women receive passive immunization with hepatitis B and at least three active HBsAg vaccinations. Serological testing for the presence of HBV markers was offered for all infants born to HBsAg-positive mothers between January 2003 and July 2007, after completion of their vaccination schedule. About 75% of the infants (n = 1743) completed their HB-vaccination schedule and participated in the serologic evaluation. Twelve of them (0.7%) were found to be HBV infected. Furthermore, we identified three older children with high levels of anti-HBc, anti-HBs and anti-HBe, while they were HBsAg and HBV DNA negative. This serologic profile is evidence for a resolved HBV infection. In the group of older children (1.5-5 years of age, n = 728), about half of the HBV-infected children (3 of 7) had already cleared their infection at the time of sampling. For a proper evaluation of the efficacy of a new intervention programme to prevent vertical HBV transmission, it is also important to analyse the HBV markers in serum collected when the children are older than 1.5 years. In a programmatic setting, all children born to HBV-infected mothers should be tested not only for the level of anti-HBs but also for the absence of HBsAg, because 2 of the 12 HBV-infected children (17%) had a high level of anti-HBs.

Comparative immunogenicity of a PreS/S hepatitis B vaccine in non- and low responders to conventional vaccine

Conventional hepatitis B vaccines do not elicit adequate antibody production in 5-10% vaccinees. This trial tests the ability of a third-generation vaccine, containing PreS1 and PreS2 antigens in addition to the S antigen, to elicit seroprotective titres in documented non- and low-responders, compared with those to a conventional vaccine. In the primary population of non-responders (<10 IU/l anti-HBs antibodies after > or = 4 previous injections of conventional vaccine) an enhanced antibody response was seen to additional injections of the third-generation vaccine compared with a conventional vaccine (absolute difference 14.9%; P = 0.006). Enhanced antibody responses were also found in a population that included low responders.

Safety and immunogenicity profile of an experimental hepatitis B vaccine adjuvanted with AS04

The reactogenicity and safety of an experimental hepatitis B (HB) vaccine containing adjuvant system (AS04) was compared with a licensed vaccine in a phase III, single-blind, randomised study in healthy volunteers >or=15 years of age. A total of 1303 subjects were enrolled to receive either two doses of HB-AS04 (0, 6 months) or three doses of the comparator vaccine (0, 1, 6 months). Two doses of HB-AS04 elicited seroprotection rates close to 100% and two-fold higher GMTs than the comparator vaccine. Results showed that both vaccines were well tolerated and the general safety profile of HB-AS04 was similar to that of the comparator vaccine.

Sweet liking, novelty seeking, and gender predict alcoholic status

BACKGROUND

The relationship between a hedonic response to sweet taste and a propensity to excessive alcohol drinking is supported by both animal and human studies. There is evidence indicating that the tendency to rate more concentrated sweet solutions as the most pleasurable (i.e., sweet liking) is associated with the genetic vulnerability to alcoholism. However, sweet liking by itself is insufficient to predict the alcoholic status of the individual. Our previous study indicated that alcoholic status can be predicted by a combination of hedonic response to sweet taste and personality profile as measured by the Tridimensional Personality Questionnaire (TPQ). This study was designed to further test this hypothesis.

METHODS

Participants were 165 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence and/or interpersonal problems secondary to substance-abusing family members. In addition to a routine medical examination, on the 24th day after admission, patients completed the TPQ, the standard sweet taste test was conducted, and paternal family history of alcoholism was evaluated.

RESULTS

Sweet liking was strongly associated with a paternal history of alcoholism. The odds of receiving an alcohol dependence diagnosis were shown to increase, on the average, by 11% for every one-point increase in the TPQ novelty-seeking score in sweet-liking but not in sweet-disliking subjects. Gender contributed independently to the probability of alcohol dependence, with males exhibiting higher rates of alcoholism than females.

CONCLUSIONS

These findings support the hypothesis that a hedonic response to sweet taste is associated with a genetic risk for alcoholism. Alcoholic status may be predicted by a combination of sweet liking, the TPQ novelty-seeking score, and gender in a mixed group of alcoholic, polysubstance-dependent, and psychiatric patients.

Association Between Sweet Preference and Paternal History of Alcoholism in Psychiatric and Substance Abuse Patients

BACKGROUND

The relationship between preference for stronger sweet solutions and propensity to excessive alcohol drinking is supported by both animal and human studies. This study was designed to test the hypothesis that sweet preference is associated with the genetic risk of alcoholism as measured by a paternal history of alcoholism.

METHODS

Participants were 180 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence, or psychiatric conditions. In addition to a routine medical examination, patients completed the standard sweet preference test twice (on the 9th and 24th days after admission), and the family history of alcoholism was evaluated.

RESULTS

Sweet preference was shown to be stable over time. It was strongly associated with a paternal history of alcoholism, with family history-positive patients approximately 5 times more likely to prefer stronger sweet solutions than family history-negative subjects. Such factors as dependence on alcohol, cocaine, opiates, cannabis, other drugs (including prescription drugs), and tobacco smoking, as well as demographics (gender and age), did not significantly interfere with association between sweet preference and paternal history of alcoholism.

CONCLUSIONS

These findings provide some support for the hypothesis that preference for stronger sweet solutions is associated with a genetic predisposition to alcoholism as measured by a paternal history of alcoholism.

Is a low dose of hepatitis B vaccine enough for a rapid vaccination scheme?

AIM: To determine whether or not a low dose of HB vaccine can be effectively used in the rapid vaccination.

METHODS: Rapid vaccination (0, 1, 2 months) with low dose (5 μg) or routine dose (10 μg) HB vaccine was studied in 250 subjects (130 school children and 120 university students). Serum from all the participants was tested for HBsAg, anti-HBs and anti-HBc at 1, 3 and 7 months after the first dose of vaccination and all subjects were serum HBV marks negative before the vaccination. Non-responders to a complete initial vaccination from university students were given an additional vaccination with 10 μg of HB vaccine and their serum anti-HBs was tested again one month later.

RESULTS: One month after the third dose of vaccination (third month) sero-conversion rates and geometric mean titer (GMTs) were significantly (P < 0.01) higher in the routine dose (resp. 89% and 106.8) than in the low dose group (resp. 72% and 59.5). Sero-conversion rates and GMTs were maintained stable for another 4 months in both groups. After an additional vaccination to non-responders with 10 μg HB vaccine, 17/23 subjects (13/15 from those vaccinated with 5 μg vaccine and 4/8 from those vaccinated with 10 μg vaccine) became anti-HBs positive, yielding similar sero-conversion rates for both dose groups.

CONCLUSION: Higher sero-conversion rates and GMTs were reached in those vaccinated with 10 μg HB vaccine than in those vaccinated with 5 μg HB vaccine after a complete vaccination with a 0, 1, 2 month scheme. But the subjects vaccinated with 5 μg vaccine can also reach the similar sero-conversion rate after an additional vaccination.

Behavioural, hyperthermic and neurotoxic effects of 3,4-methylenedioxymethamphetamine analogues in the Wistar rat

1. The ability of N-ethyl (MDEA) and N-butyl (MDBA) analogues of 3,4-methylenedioxymethamphetamine (MDMA, 'Ecstasy') to induce acute behavioural changes and increases in body temperature, and to cause serotonergic neurotoxicity, was assessed in young adult male Wistar rats. The in vitro ability of MDMA analogues to evoke presynaptic monoamine release from crude rat forebrain synaptosomal preparations pre-labelled with [3H]5-HT or [3H]DA was also measured. 2. In behavioural experiments, acute MDMA and MDEA (20 mg/kg, i.p.) significantly increased rat open-field locomotion scores, decreased open-field rearing, and induced stereotypy, Straub tail and head weaving. MDBA did not produce any of these behaviours. 3. After repeated dosing (8 x 20 mg/kg, i.p., twice daily for 4 days), MDMA > MDEA >> MDBA > or = saline at decreasing forebrain [3H]paroxetine binding levels and concentrations of 5-HT and 5-HIAA at 14 days post-treatment. None of the analogues caused any long-term changes in dopamine or noradrenaline concentrations in the forebrain. 4. Acute MDMA and MDEA (20 mg/kg, i.p.) produced significant acute increases in rat aural temperature compared with saline-treated animals, while 20 mg/kg MDBA caused no significant effects. 5. MDA, MDMA and MDEA were equipotent at inducing [3H]5-HT release from frontal cortex/hippocampal synaptosomes, while MDBA only evoked a significant release at 100 microM concentrations. The potency order for inducing [3H]DA release from striatal synaptosomes was MDA > MDMA > MDEA = MDBA. 6. This study shows that large N-alkyl substitution decreases the ability of MDMA analogues to evoke presynaptic 5-HT and DA release, induce acute hyperthermia, hyperlocomotion and behavioural changes, and cause long-term serotonergic neurotoxicity. 7. The structure-activity relationship data presented here indicate that the neurotoxic damage caused by substituted amphetamines requires a combination of acute hyperthermia and increased neurotransmitter release. Induction of one of these effects in isolation is not sufficient to cause serotonergic nerve terminal degradation.

GB virus type C viremia and envelope antibodies among population subsets in The Netherlands

BACKGROUND AND OBJECTIVES

Two new flaviviruses, hepatitis G virus and GB virus type C (GBV-C), are possible causative agents for non-A-E hepatitis. In this study we established the prevalence of GBV-C markers in various population subsets in The Netherlands by assays for GBV-C antibodies and GBV-C nucleic acid.

MATERIALS AND METHODS

We tested specimens from groups of patients with hepatitis of various causes, intravenous drug users (IVDUs), and blood donors for GBV-C RNA (LCx(R) GBV-C assay, Abbott Laboratories), and for antibodies to the GBV-C envelope E2 protein (GBV-C anti-E2) with an enzyme immunoassay (Abbott Laboratories). Patients and donors were represented in one group only.

RESULTS

GBV-C RNA and GBV-C anti-E2 prevalence were, respectively, 2/34 (6%) and 3/34 (9%) among patients with non-A-E hepatitis, 2/10 (20%) and 0/10 (0%) among hepatitis B virus patients, 10/40 (25%) and 19/40 (48%) among hepatitis C virus (HCV) patients, 1/8 (13%) and 0/8 (0%) among patients with autoimmune hepatitis (AIH), 24/102 (24%) and 72/102 (71%) among IVDUs, 1/34 (3%) and 2/34 (6%) among blood donors with indeterminate anti-HCV recombinant immunoblot assay reactivity, and 3/250 (1.2%) and 8/250 (3.2%) among first-time blood donors. The profile of simultaneous GBV-C RNA positivity plus GBV-C anti-E2 positivity was found in 2/40 (5%) HCV patients, 4/102 (4%) IVDUs, and 1/250 (0.4%) first time blood donors.

CONCLUSION

GBV-C infection appears not to be a major cause of non-A-E hepatitis and AIH, but is associated with parenteral risk. The prevalence of GBV-C viremia in first time blood donors is higher than that of HCV (1.2 vs. 0.04%), but GBV-C viremia in IVDUs is lower than HCV (24 vs. 59%). Most IVDUs have probably previously been exposed to GBV-C given the very high prevalence of GBV-C anti-E2 (71%). Most persons with GBV-C markers are GBV-C RNA-negative and anti-E2-confirmed positive, suggesting that GBV-C infection is transient.

Do picture archiving and communication systems improve report turnaround times?

Radiology departments are beginning to embrace new technologies to decrease operating budgets and improve services. One of these technologies is the picture archiving and communication system (PACS). PACS, through immediate availability of images to the radiologist, promises to decrease turnaround times of reports to the clinician. The purpose of this study was to determine if this technology actually decreases the time for referring clinicians to receive reports generated by the radiologist. The time to provide a preliminary report by a resident and time to finalize this report by a board-certified radiologist was retrospectively obtained for 6,022 abdominal and pelvic computed tomography (CT) scans over two 1-year periods from March 1, 1997 to March 1, 1998 and from March 1, 1998 to March 1, 1999. During the first year, interpretation was conducted using hard-copy film and during the second using PACS. In both 1-year periods, MedSpeak voice recognition software (IBM, White Plains, NY) was employed for dictation. The average time for a preliminary report for a abdominal and pelvic CT, dictated by a resident or fellow, to be available in alphanumeric form on the hospital information system using hard-copy film was 3.73 days. The installation of a PACS system decreased this turnaround time to 0.56 days, representing an 85.0% improvement. The time to availability of final reports, ie, signed by board-certified staff radiologists, was 5.49 days in the hard-copy interpretation subset and 5.97 days in the PACS subset. The addition of PACS into an academic gastrointestinal radiology division improves availability of alphanumeric preliminary reports of abdominal and pelvic CTs on the hospital information system (HIS), dictated by a resident or fellow, by 85.0%. There was no impact with a PACS on the time to final sign reports by a staff board certified radiologist as signing patterns remained relatively constant over the two interpretation formats.

Telemedicine in practice

Telemedicine is defined as the "delivery of health care and sharing of medical knowledge over a distance using telecommunication systems." The concept of telemedicine is not new. Beyond the use of the telephone, there were numerous attempts to develop telemedicine programs in the 1960s mostly based on interactive television. The early experience was conceptionally encouraging but suffered inadequate technology. With a few notable exceptions such as the telemetry of medical data in the space program, there was very little advancement of telemedicine in the 1970s and 1980s. Interest in telemedicine has exploded in the 1990s with the development of medical devices suited to capturing images and other data in digital electronic form and the development and installation of high speed, high bandwidth telecommunication systems around the world. Clinical applications of telemedicine are now found in virtually every specialty. Teleradiology is the most common application followed by cardiology, dermatology, psychiatry, emergency medicine, home health care, pathology, and oncology. The technological basis and the practical issues are highly variable from one clinical application to another. Teleradiology, including telenuclear medicine, is one of the more well-defined telemedicine services. Techniques have been developed for the acquisition and digitization of images, image compression, image transmission, and image interpretation. The American College of Radiology has promulgated standards for teleradiology, including the requirement for the use of high resolution 2000 x 2000 pixel workstations for the interpretation of plain films. Other elements of the standard address image annotation, patient confidentiality, workstation functionality, cathode ray tube brightness, and image compression. Teleradiology systems are now widely deployed in clinical practice. Applications include providing service from larger to smaller institutions, coverage of outpatient clinics, imaging centers, and nursing homes. Teleradiology is also being used in international applications. Unresolved issues in telemedicine include licensure, the development of standards, reimbursement for services, patient confidentiality, and telecommunications infrastructure and cost. A number of states and medical boards have instituted policies and regulations to prevent physicians who are not licensed in the respective state to provide telemedicine services. This is a major impediment to the delivery of telemedicine between states. Telemedicine, including teleradiology, is here to stay and is changing the practice of medicine dramatically. National and international communications networks are being created that enable the sharing of information and knowledge at a distance. Technological barriers are being overcome leaving organizational, legal, financial, and special interest issues as the major impediments to the further development of telemedicine and realization of its benefits.

Acute cholecystitis in the intensive care unit

The development of acute cholecystitis in the ICU is now a well-recognized complication of many acute illnesses that precipitate ICU admission and may also result as a complication of the subsequent treatment. The etiology of the disease remains obscure and, unlike acute cholecystitis outside the ICU setting, most cases are acalculous and not associated with gallstones. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Clinical examination is often unhelpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. Biochemical markers are nonspecific and contribute to the delay in diagnosis and treatment. Early diagnosis is essential to avoid the high rates of associated morbidity and mortality. The diagnosis is usually made by radiologic tests, most often by sonographic examination of the gallbladder, which can be performed at the bedside. However, radiologic findings may also be nonspecific. The treatment involves gallbladder drainage by percutaneous cholecystostomy, which is usually curative in acalculous cholecystitis. Interval cholecystectomy is indicated for the remaining patients with gallstone-associated cholecystitis.