The impact of mental health and psychosocial support programmes on children and young people's mental health in the context of humanitarian emergencies in low- and middle-income countries: A systematic review and meta-analysis

Humanitarian emergencies pose a significant global health challenge for children and young people's mental and psychological health. This systematic review investigates the effectiveness of mental health and psychosocial support (MHPSS) programmes delivered to children and young people affected by humanitarian emergencies in low- and middle-income countries (LMICs). Twelve electronic databases, key websites and citation checking were undertaken. Forty-three randomised controlled trials (RCTs) published in English between January 1980 and May 2023 were included in the review. Overall, the findings suggest that cognitive behavioural therapy may improve depression symptoms in children and young people affected by humanitarian emergencies. Narrative exposure therapy may reduce feelings of guilt. However, the impact of the other MHPSS modalities across outcomes is inconsistent. In some contexts, providing psychosocial programmes involving creative activities may increase the symptoms of depression in children and young people. These findings emphasise the need for the development of MHPSS programmes that can safely and effectively address the diverse needs of children and young people living in adversarial environments.

Indigenising systematic reviews with a collaborative model of 'training the trainers'

BACKGROUND

Developing a workforce with the skills to produce and make judicious use of evidence for policy and practice decisions requires trainers who can tailor evidence and training to policy and practice priorities.

AIM

To describe how a collaborative learning model adapted a systematic review course to suit Indian nurse educators and research scholars in the conduct and use of systematic reviews.

DISCUSSION

A collaborative learning team of academics and research scholars brought together expertise in nursing education in India, and evidence synthesis in India and the UK. Participants found the course was highly beneficial, enhanced independent and critical thinking, and instilled them with the confidence and skills to deliver such courses to Indian researchers, nurses and other healthcare professionals.

CONCLUSION

Contextualising materials and methods to participants' experiences made learning more relatable. The use of adult learning approaches enabled participants to apply the same approaches when leading training in their own institutions and underpinned long-term sustainable working relationships between facilitators and learners, leading to new studies and new resources to support evidence-informed decision-making.

IMPLICATIONS FOR PRACTICE

An educational intervention on 'indigenising systematic reviews' with online collaborative learning can produce improvements in the knowledge and skills of participants. Advantages of this educational approach include its flexibility, active involvement of participants and sustainable partnership building. The principles and methods used could be replicated in any setting to train trainers.

Academic contributions to the development of evidence and policy systems: an EPPI Centre collective autoethnography

BACKGROUND

Evidence for policy systems emerging around the world combine the fields of research synthesis, evidence-informed policy and public engagement with research. We conducted this retrospective collective autoethnography to understand the role of academics in developing such systems.

METHODS

We constructed a timeline of EPPI Centre work and associated events since 1990. We employed: Transition Theory to reveal emerging and influential innovations; and Transformative Social Innovation theory to track their increasing depth, reach and embeddedness in research and policy organisations.

FINDINGS

The EPPI Centre, alongside other small research units, collaborated with national and international organisations at the research-policy interface to incubate, spread and embed new ways of working with evidence and policy. Sustainable change arising from research-policy interactions was less about uptake and embedding of innovations, but more about co-developing and tailoring innovations with organisations to suit their missions and structures for creating new knowledge or using knowledge for decisions. Both spreading and embedding innovation relied on mutual learning that both accommodated and challenged established assumptions and values of collaborating organisations as they adapted to closer ways of working. The incubation, spread and embedding of innovations have been iterative, with new ways of working inspiring further innovation as they spread and embedded. Institutionalising evidence for policy required change in both institutions generating evidence and institutions developing policy.

CONCLUSIONS

Key mechanisms for academic contributions to advancing evidence for policy were: contract research focusing attention at the research-policy interface; a willingness to work in unfamiliar fields; inclusive ways of working to move from conflict to consensus; and incentives and opportunities for reflection and consolidating learning.

Impact of COVID-19 on Mental Health Among Healthcare Workers in India: A Mixed-methods Systematic Review

Healthcare workers (HCWs) experienced significant mental health challenges during the COVID-19 pandemic. This review aimed to comprehensively assess the impact of the COVID-19 pandemic on the mental health of HCWs in India. We conducted a mixed-methods systematic review, which adopts a results-based convergent approach that incorporates quantitative and qualitative data. A comprehensive literature search was conducted in relevant databases: PubMed-Medline, CINAHL, Web of Science, and ProQuest. All available full-text studies in the English language that assessed the mental health outcomes (anxiety, stress, and depression) of HCWs during the pandemic and published until 28 February 2022 were included. A total of 31 studies were included in this review (27 quantitative studies, three qualitative studies, and one mixed-method study). The pooled prevalence of depression, anxiety, and stress among HCWs in India was 32.96%, 29.49%, and 33.47%, respectively. Integration of quantitative and qualitative findings using social determinants of health framework resulted in various contributing factors and coping strategies. There is a need for a supportive work environment, mental health support, and mental health policies for HCWs in India.

Paper 3: Selecting rapid review methods for complex questions related to health policy and system issues

Approaches for rapid reviews that focus on streamlining systematic review methods are not always suitable for exploring complex policy questions, as developing and testing theories to explain these complexities requires configuring diverse qualitative, quantitative, and mixed methods studies. Our objective was therefore to provide a guide to selecting approaches for rapidly (i.e., within days to months) addressing complex questions related to health policy and system issues.We provide a two-stage, transdisciplinary collaborative process to select a rapid review approach to address complex policy questions, which consists of scoping the breadth and depth of the literature and then selecting an optimal approach to synthesis. The first stage (scoping the literature) begins with a discussion with the stakeholders requesting evidence to identify and refine the question for the review, which is then used to conduct preliminary searches and conceptually map the documents identified. In the second stage (selection of an optimal approach), further stakeholder consultation is required to refine and tailor the question and approach to identifying relevant documents to include. The approach to synthesizing the included documents is then guided by the final question, the breadth and depth of the literature, and the time available and can include a static or evolving conceptual framework to code and analyze a range of evidence. For areas already covered extensively by existing systematic reviews, the focus can be on summarizing and integrating the review findings, resynthesizing the primary studies, or updating the search and reanalyzing one or more of the systematic reviews.The choice of approaches for conducting rapid reviews is intertwined with decisions about how to manage projects, the amount of work to be done, and the knowledge already available, and our guide offers support to help make these strategic decisions.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a UK oncology and reconstructive surgery service - benchmarking the data

The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.

Cyberbullying and Children and Young People's Mental Health: A Systematic Map of Systematic Reviews

Cyberbullying is associated with considerable negative mental and psychosocial consequences in children and young people, making it a serious public health concern. To review the highest level of available evidence, a systematic mapping review was conducted to identify systematic reviews that investigated the relationship between cyberbullying and mental and psychological outcomes in young people. Topic-relevant bibliographic databases and online resources were searched to identify reviews published since 2007. Data were extracted using a coding tool developed for this study. Methodological quality of included reviews was assessed using AMSTAR criteria. Nineteen systematic reviews satisfied the inclusion criteria and they reported a strong negative association between cyberbullying and mental health outcomes in young people. Meta-analysis was performed in 11 reviews and narrative synthesis in 8 reviews. Data were derived from predominantly cross-sectional studies and a clear causal relationship between cyberbullying and mental outcomes cannot be established. Two-third of the included reviews were classified to be of low or unclear quality, due to the lack of quality assessment of the primary studies included in individual reviews. This systematic map consolidates available evidence at review level and confirms the existing gaps in longitudinal and qualitative evidence synthesis. Closer examination of the moderating factors influencing cyberbullying behaviors in future research can advance our understanding and inform the development of tailored programs of intervention to mitigate the negative impact of this phenomenon.

Mental health and psychosocial support programmes for adults in humanitarian emergencies: a systematic review and meta-analysis in low and middle-income countries

Background

Humanitarian emergencies are a major global health challenge with the potential to have a profound impact on people’s mental and psychological health. Effective interventions in humanitarian settings are needed to support the mental health and psychosocial needs of affected populations. To fill this gap, this systematic review synthesises evidence on the effectiveness of a wide range of mental health and psychosocial support (MHPSS) programmes delivered to adults affected by humanitarian emergencies in low and middle-income countries (LMICs).

Methods

A comprehensive search of 12 electronic databases, key websites and citation checking was undertaken in 2015 and updated in May 2018. We included controlled trials published in English from 1980. We extracted data and assessed risk of bias prior to performing a meta-analysis using random effects models. When meta-analysis was not used, we narratively described individual trial effect sizes using forest plots.

Results

Thirty-five studies were included. Overall, MHPSS programmes show benefits in improved functioning and reducing post-traumatic stress disorder. There are also indications from a limited pool of evidence that cognitive–behavioural therapy and narrative exposure therapy may improve mental health conditions. Other psychotherapy modalities also showed a positive trend in favour of MHPSS programmes for improving several mental health outcomes.

Conclusion

In addition to MHPSS programme for improving mental health outcomes in adults affected by humanitarian emergencies in LMICs, there is also a need to generate robust evidence to identify potential impact on broader social dimensions. Doing so could aid the future development of MHPSS programmes and ensure their effective implementation across different humanitarian contexts in LMICs. Future research on MHPSS programmes which focus on basic services and security, community and family programmes, their cost-effectiveness and mechanisms of impact could also strengthen the MHPSS evidence base to better inform policy and practice decision-making in humanitarian settings.

Protocol registration number

CRD42016033578.

Abstract P3-10-13: Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer

Background

There are limited treatments for triple negative breast cancer (TNBC) patients and an unmet need for targeted approaches in these patients. In the last 4-5 years, the prevalence of high androgen receptor (AR) expression in TNBCs has been noted in up to 50% of tumors suggesting it has clinical relevance. The non-canonical NF-kB pathway is also upregulated in this patient group and it has been reported that that there is crosstalk between these pathways. Therefore the aim of this study was to examine the expression of IKKα and AR in breast cancer tissue samples, to assess if combining these markers increased prognostic power.

Methods

Immunohistochemistry was performed on tissue microarray of 410 patients to assess proteins level of IKK alpha and AR. Protein expression levels were assessed using the weighted histoscore (WHS) method. The median was employed as the cut off for IKK alpha and 1% as cut off for AR. Expression was analyzed for associations with cancer-specific survival (CSS) and recurrence-free survival (RFS).

Results

In a cohort of 370 breast cancers nether AR nor IKK alpha alone or combined were associated with CSS or RFS. Stratifying patients by ER status did not impact CSS or RFS. However, in TNBC patients (n=82) high expression of AR was associated with shorter CSS (HR 2.55 95 CI 1.61-5.59, p=0.013). To assess if combining AR and IKK alpha increased prognostic power, AR and IKK alpha were combined into a single score: 0= low expression of both or high expression of one and 1= high expression of both. In the full cohort or when stratified by ER status the score was not associated with CSS or RFS, however in TNBC the combined score potentiated the effect observed with AR alone, (HR 1.68 95 CI 1.20-2.33, p=0.001). Patient CSS was stratified from 11.5 years to 4.6 years and was independently associated with CSS when compared with common clinicopathological factors (HR 1.56 95CI 1.11-2.21, p=0.011). In addition, the combined score was associated with decrease radiotherapy use (p=0.032), increased recurrence rate (p=0.014), decreased cytotoxic T cells (p=0.007), B cells (p=0.043) and macrophages (p=0.037).

Conclusions

A combined AR and IKK alpha score is an independent prognostic classification for patients with TNBC. Patients with high expression of both AR and IKK alpha a significantly reduced survival and were immune cell cold. This study suggests that this patient group will not benefit from immunotherapy but dual targeting with anti-androgens and IKK alpha selective inhibitors could offer a novel therapeutic strategy for this patient group.

Citation Format: Roseweir AK, Khongthong P, Dickson K, Bennett L, Edwards J. Dual targeting of androgen receptor and IKK alpha is a potential therapeutic strategy for triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-13.

Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review

BACKGROUND

Chronic peripheral joint pain due to osteoarthritis (OA) is extremely prevalent and a major cause of physical dysfunction and psychosocial distress. Exercise is recommended to reduce joint pain and improve physical function, but the effect of exercise on psychosocial function (health beliefs, depression, anxiety and quality of life) in this population is unknown.

OBJECTIVES

To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.

SEARCH METHODS

Review authors searched 23 clinical, public health, psychology and social care databases and 25 other relevant resources including trials registers up to March 2016. We checked reference lists of included studies for relevant studies. We contacted key experts about unpublished studies.

SELECTION CRITERIA

To be included in the quantitative synthesis, studies had to be randomised controlled trials of land- or water-based exercise programmes compared with a control group consisting of no treatment or non-exercise intervention (such as medication, patient education) that measured either pain or function and at least one psychosocial outcome (self-efficacy, depression, anxiety, quality of life). Participants had to be aged 45 years or older, with a clinical diagnosis of OA (as defined by the study) or self-reported chronic hip or knee (or both) pain (defined as more than six months' duration).To be included in the qualitative synthesis, studies had to have reported people's opinions and experiences of exercise-based programmes (e.g. their views, understanding, experiences and beliefs about the utility of exercise in the management of chronic pain/OA).

DATA COLLECTION AND ANALYSIS

We used standard methodology recommended by Cochrane for the quantitative analysis. For the qualitative analysis, we extracted verbatim quotes from study participants and synthesised studies of patients' views using framework synthesis. We then conducted an integrative review, synthesising the quantitative and qualitative data together.

MAIN RESULTS

Twenty-one trials (2372 participants) met the inclusion criteria for quantitative synthesis. There were large variations in the exercise programme's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Comparator groups were varied and included normal care; education; and attention controls such as home visits, sham gel and wait list controls. Risk of bias was high in one and unclear risk in five studies regarding the randomisation process, high for 11 studies regarding allocation concealment, high for all 21 studies regarding blinding, and high for three studies and unclear for five studies regarding attrition. Studies did not provide information on adverse effects.There was moderate quality evidence that exercise reduced pain by an absolute percent reduction of 6% (95% confidence interval (CI) -9% to -4%, (9 studies, 1058 participants), equivalent to reducing (improving) pain by 1.25 points from 6.5 to 5.3 on a 0 to 20 scale and moderate quality evidence that exercise improved physical function by an absolute percent of 5.6% (95% CI -7.6% to 2.0%; standardised mean difference (SMD) -0.27, 95% CI -0.37 to -0.17, equivalent to reducing (improving) WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function on a 0 to 100 scale from 49.9 to 44.3) (13 studies, 1599 participants)). Self-efficacy was increased by an absolute percent of 1.66% (95% CI 1.08% to 2.20%), although evidence was low quality (SMD 0.46, 95% CI 0.34 to 0.58, equivalent to improving the ExBeliefs score on a 17 to 85 scale from 64.3 to 65.4), with small benefits for depression from moderate quality evidence indicating an absolute percent reduction of 2.4% (95% CI -0.47% to 0.5%) (SMD -0.16, 95% CI -0.29 to -0.02, equivalent to improving depression measured using HADS (Hospital Anxiety and Depression Scale) on a 0 to 21 scale from 3.5 to 3.0) but no clinically or statistically significant effect on anxiety (SMD -0.11, 95% CI -0.26 to 0.05, 2% absolute improvement, 95% CI -5% to 1% equivalent to improving HADS anxiety on a 0 to 21 scale from 5.8 to 5.4; moderate quality evidence). Five studies measured the effect of exercise on health-related quality of life using the 36-item Short Form (SF-36) with statistically significant benefits for social function, increasing it by an absolute percent of 7.9% (95% CI 4.1% to 11.6%), equivalent to increasing SF-36 social function on a 0 to 100 scale from 73.6 to 81.5, although the evidence was low quality. Evidence was downgraded due to heterogeneity of measures, limitations with blinding and lack of detail regarding interventions. For 20/21 studies, there was a high risk of bias with blinding as participants self-reported and were not blinded to their participation in an exercise intervention.Twelve studies (with 6 to 29 participants) met inclusion criteria for qualitative synthesis. Their methodological rigour and quality was generally good. From the patients' perspectives, ways to improve the delivery of exercise interventions included: provide better information and advice about the safety and value of exercise; provide exercise tailored to individual's preferences, abilities and needs; challenge inappropriate health beliefs and provide better support.An integrative review, which compared the findings from quantitative trials with low risk of bias and the implications derived from the high-quality studies in the qualitative synthesis, confirmed the importance of these implications.

AUTHORS' CONCLUSIONS

Chronic hip and knee pain affects all domains of people's lives. People's beliefs about chronic pain shape their attitudes and behaviours about how to manage their pain. People are confused about the cause of their pain, and bewildered by its variability and randomness. Without adequate information and advice from healthcare professionals, people do not know what they should and should not do, and, as a consequence, avoid activity for fear of causing harm. Participation in exercise programmes may slightly improve physical function, depression and pain. It may slightly improve self-efficacy and social function, although there is probably little or no difference in anxiety. Providing reassurance and clear advice about the value of exercise in controlling symptoms, and opportunities to participate in exercise programmes that people regard as enjoyable and relevant, may encourage greater exercise participation, which brings a range of health benefits to a large population of people.

Gaps in the evidence on improving social care outcomes: findings from a meta-review of systematic reviews

Adult social care continues to be a central policy concern in the UK. The Adult Social Care Outcomes Framework (ASCOF) is a range of measures nationally available to drive forward improvement on outcomes and quality in local councils. While there is an emphasis on improving transparency, quality and outcomes, drawing on research evidence to achieve these aims is often difficult because the evidence is not easily identifiable, is disparate or of variable quality. We conducted a meta-review to analyse and summarise systematic review-level evidence on the impact of interventions on the four outcomes set out in the ASCOF: quality of life, delaying and reducing the need for services, satisfaction with services and safeguarding of vulnerable adults. This paper focuses on the availability of review-level evidence and the presence of significant gaps in this evidence base. A range of health and social care databases were searched, including MEDLINE, ASSIA and The Cochrane Library in January and February 2012. All systematic reviews evaluating the efficacy of social care interventions for improving ASCOF outcomes for older people, people with long-term conditions, mental health problems or physical and/or learning disabilities were eligible. Two reviewers independently screened systematic reviews for quality and relevance and extracted data; 43 systematic reviews were included, the majority of which examined the impact of interventions on quality of life (n = 34) and delaying and reducing the need for support (n = 25). Limited systematic review-level evidence was found regarding satisfaction with services and safeguarding. There were also significant gaps in relation to key social care interventions and population groups. Research priorities include addressing these gaps and the collation of data on interventions, outcomes and populations more closely related to social care. Overall, a more relevant, comprehensive and robust evidence base is required to support improvement of outcomes for recipients of adult social care.

Exploring issues in the conduct of website searching and other online sources for systematic reviews: how can we be systematic?

Websites and online resources outside academic bibliographic databases can be significant sources for identifying literature, though there are challenges in searching and managing the results. These are pertinent to systematic reviews that are underpinned by principles of transparency, accountability and reproducibility. We consider how the conduct of searching these resources can be compatible with the principles of a systematic search. We present an approach to address some of the challenges. This is particularly relevant when websites are relied upon to identify important literature for a review. We recommend considering the process as three stages and having a considered rationale and sufficient recordkeeping at each stage that balances transparency with practicality of purpose. Advances in technology and recommendations for website providers are briefly discussed.

How Do Contextual Factors Influence Implementation and Receipt of Positive Youth Development Programs Addressing Substance Use and Violence? A Qualitative Meta-Synthesis of Process Evaluations

OBJECTIVE

Positive youth development (PYD) often aims to prevent tobacco, alcohol, and drugs use and violence. We systematically reviewed PYD interventions, synthesizing process, and outcomes evidence. Synthesis of outcomes, published elsewhere, found no overall evidence of reducing substance use or violence but notable variability of fidelity. Our synthesis of process evaluations examined how implementation varied and was influenced by context.

DATA SOURCE

Process evaluations of PYD aiming to reduce substance use and violence. Study Inclusion Criteria: Overall review published since 1985; written in English; focused on youth aged 11 to 18 years; focused on interventions addressing multiple positive assets; reported on theory, process, or outcomes; and concerned with reducing substance use or violence. Synthesis of process evaluations examined how implementation varies with or is influenced by context.

DATA EXTRACTION

Two reviewers in parallel.

DATA SYNTHESIS

Thematic synthesis.

RESULTS

We identified 12 reports. Community engagement enhanced program appeal. Collaboration with other agencies could broaden the activities offered. Calm but authoritative staff increased acceptability. Staff continuity underpinned diverse activities and durable relationships. Empowering participants were sometimes in tension with requiring them to engage in diverse activities.

CONCLUSION

Our systematic review identified factors that might help improve the fidelity and acceptability of PYD interventions. Addressing these might enable PYD to fulfill its potential as a means of promoting health.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Prevalence of Frailty in Patients Receiving Occupational Therapy Services in Skilled Nursing Facilities

Date Presented 4/8/2016

The prevalence of frailty was measured by the Survey of Health, Ageing, and Retirement in Europe Frailty Instrument (SHARE–FI) among older adults (N = 170) receiving occupational therapy services in a skilled nursing facility. Of these, 72.9% (n = 124) were frail upon evaluation. The results support occupational therapists’ use of the SHARE–FI to distinguish frailty from other clinical conditions to provide effective services.

Primary Author and Speaker: Kelly Dickson

Contributing Author: Pamela Toto

Systematic review and meta-analysis of effects of community-delivered positive youth development interventions on violence outcomes

BACKGROUND

We systematically reviewed and meta-analysed evaluations testing the effectiveness of positive youth development (PYD) interventions for reducing violence in young people.

METHODS

Two reviewers working independently screened records, assessed full-text studies for inclusion and extracted data. Outcomes were transformed to Cohen's d. Quality assessment of included evaluations was undertaken using the Cochrane risk of bias tool. Effect sizes were combined using multilevel meta-analysis. We searched 21 databases, including MEDLINE, PsycINFO, CINAHL and CENTRAL, and hand-searched key journals and websites. We included studies where the majority of participants were aged 11-18 years and where interventions were delivered in community (not clinical or judicial) settings outside of normal school hours. We excluded studies targeting predefined physical and mental health conditions or parents/carers alongside young people. We defined violence as perpetration or victimisation of physical violence including violent crime.

RESULTS

Three randomised trials were included in this systematic review. Included evaluations each had design flaws. Meta-analyses suggested that PYD interventions did not have a statistically significant effect on violence outcomes across all time points (d=0.021, 95% CI -0.050 to 0.093), though interventions did have a statistically significant short-term effect (d=0.076, 95% CI 0.013 to 0.140).

CONCLUSIONS

Our meta-analyses do not offer evidence of PYD interventions in general having effects of public health significance in reducing violence among young people. Evaluations did not consistently report theories of change or implementation fidelity, so it is unclear if our meta-analyses provide evidence that the PYD theory of change is ineffective in reducing violence among young people.

The effects of Positive Youth Development interventions on substance use, violence and inequalities: systematic review of theories of change, processes and outcomes

Background

Positive Youth Development (PYD) delivered outside school aims to enable young people to develop positive assets such as relationships and confidence, rather than to merely address risk. Existing reviews of PYD effects on substance use or violence are old and unsystematic.

Objectives

To systematically review evidence to answer the following questions: what theories of change inform PYD interventions addressing substance use and violence? What characteristics of participants and contexts are identified as barriers to and facilitators of implementation and receipt in process evaluations of PYD? What is the effectiveness and cost-effectiveness of PYD in reducing substance use and violence? What characteristics of participants and contexts appear to moderate, or are necessary and sufficient for, PYD effectiveness?

Data sources

A total of 21 bibliographic databases; 35 websites and contacting authors.

Review methods

We included reports published in English since 1985 and reporting on theories of change, as well as process, outcome and economic evaluations of PYD targeting 11- to 18-year-olds and addressing substance use or violence. References were screened on title/abstract and, where appropriate, on full report. Data extraction and quality assessment used Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Theories of change and process evaluations were qualitatively metasynthesised. Outcome evaluations were synthesised narratively and meta-analytically.

Results

32,394 unique references were identified and 48 were included. A total of 16 reports described theories, 13 (10 studies) evaluated processes and 25 (10 studies) evaluated outcomes.

Theories of change

PYD interventions aim to offer opportunities for young people to develop positive ‘assets’ such as skills and confidence. These are theorised to promote and be promoted by young people’s ‘intentional self-regulation’, which involves reflecting on behaviour; determining goals; using existing resources to pursue these; and redirecting effort when thwarted. This enables ‘developmental regulation’, namely individuals capitalising on other opportunities to promote personal development. Positive assets thus accrued reduce health risks by reducing the impact on individuals of environmental risk or by ameliorating the impact of such risks. The literature offers limited insights beyond these general ideas.

Process evaluations

Community engagement ensured that programmes were accessible and appealing. Staff capacity and continuity were crucial factors but often challenging when programmes could not offer full-time jobs. Tensions arose between a desire to empower participants to choose activities and a requirement for them to undertake a breadth of activities.

Outcome evaluations

Meta-analyses of all combined outcomes and of short-term alcohol use, illicit drug use and smoking found no significant effects. There were small, statistically significant, short-term effects for an omnibus measure of substance use and for violence. We could not undertake metaregression to assess sociodemographic moderators but narrative synthesis suggested no clear pattern of effects by sex. We found no economic evaluations.

Limitations

Insufficient studies precluded qualitative comparative analyses.

Conclusions

How PYD might promote health is currently undertheorised. Implementation can be challenging. We found little evidence that current PYD interventions delivered outside school reduce substance use or violence. However, these may not constitute a test of the effectiveness of the PYD model, as some included interventions that, although meeting our inclusion criteria, were not exemplars of PYD.

Future work

Further evaluations should assess interventions employing PYD theory of change.

Study registration

This study is registered as PROSPERO CRD42013005439.

Funding

The National Institute for Health Research Public Health Research programme.

Systematic review of reviews of observational studies of school-level effects on sexual health, violence and substance use

For three decades there have been reports that the quality of schools affects student health. The literature is diverse and reviews have addressed different aspects of how the school environment may affect health. This paper is the first to synthesise this evidence using a review of reviews focusing on substance-use, violence and sexual-health. Twelve databases were searched. Eleven included reviews were quality-assessed and synthesised narratively. There is strong evidence that schools' success in engaging students is associated with reduced substance use. There is little evidence that tobacco-control policies and school sexual-health clinics on their own are associated with better outcomes.

What is positive youth development and how might it reduce substance use and violence? A systematic review and synthesis of theoretical literature

Background

Preventing adolescent substance use and youth violence are public health priorities. Positive youth development interventions are widely deployed often with the aim of preventing both. However, the theorised mechanisms by which PYD is intended to reduce substance use and violence are not clear and existing evaluated interventions are under-theorised. Using innovative methods, we systematically searched for and synthesised published theoretical literature describing what is meant by positive youth development and how it might reduce substance use and violence, as part of a broader systematic review examining process and outcomes of PYD interventions.

Methods

We searched 19 electronic databases, review topic websites, and contacted experts between October 2013 and January 2014. We included studies written in English, published since 1985 that reported a theory of change for positive youth development focused on prevention of smoking, alcohol consumption, drug use or violence in out-of-school settings. Studies were independently coded and quality-assessed by two reviewers.

Results

We identified 16 studies that met our inclusion criteria. Our synthesis suggests that positive youth development aims to provide youth with affective relationships and diverse experiences which enable their development of intentional self-regulation and multiple positive assets. These in turn buffer against or compensate for involvement in substance use and violence. Existing literature is not clear on how intentional self-regulation is developed and which specific positive assets buffer against substance use or violence.

Conclusions

Our synthesis provides: an example of a rigorous systematic synthesis of theory literature innovatively applying methods of qualitative synthesis to theoretical literature; a clearer understanding of how PYD might reduce substance use and violence to inform future interventions and empirical evaluations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2817-3) contains supplementary material, which is available to authorized users.

'It's on your conscience all the time': a systematic review of qualitative studies examining views on obesity among young people aged 12-18 years in the UK

OBJECTIVE

To explore the perspectives of young people in the UK on obesity, body size, shape and weight.

DESIGN

Systematic review of qualitative studies using thematic synthesis.

DATA SOURCES

Sensitive searches of 18 electronic databases from 1997 to February 2010 supplemented by grey literature searches.

STUDY SELECTION

Studies produced since 1997 using qualitative methods to collect perspectives of people aged 12-18 years in the UK, reporting methods for data collection or analysis. Studies of people with eating disorders and those rated low in reliability and usefulness were excluded.

RESULTS

Searches identified 30 studies involving over 1400 young people from a range of contexts. Young people of all sizes placed considerable emphasis on personal responsibility, and on the social, rather than health implications of being overweight. Young people with experience of obesity described severe, unrelenting, size-related abuse and isolation. Regardless of their own size, young people were judgemental of individuals who were overweight, but those with experience of obesity described an environment that contained multiple barriers to weight loss. Only one study asked young people directly what might support them to have a healthy body size. Study findings were configured under three main themes, labelled with quotes from included studies: general perceptions of size and society's responses ('It's on your conscience all the time'); the experiences of young people who were overweight ('If I had the choice I wouldn't be this size') and these larger young people's experiences of trying to loose weight and suggestions for action ('Make sure, even when it's hard, you've got people there').

CONCLUSIONS

The perspectives of young people in the UK, when synthesised across the spectrum of body sizes, paint a picture of a stigmatising and abusive social world. Research and policy need to engage young people actively so as to address the social implications of obesity.

Occupational health purchasing behaviour by SMEs--a new theoretical model

BACKGROUND

Factors influencing corporate decisions to purchase occupational health (OH) are unknown.

AIMS

To assist the marketing of OH services to small- and medium-sized enterprises (SMEs) by characterizing purchasing behaviour.

METHODS

We developed a 2×2 model, based on published studies, to describe OH purchasing behaviour by SMEs. We tested the model by analysis of responses to a cross-sectional market research survey carried out in November 2007. The companies surveyed were SMEs employing 30-250 employees, within the localities of five UK National Health Service OH services: West London, Buckinghamshire, Cambridge, Portsmouth and York. We chose a sample representative of all SMEs for each location. The survey explored knowledge of OH and the perceived importance of a variety of services.

RESULTS

We obtained responses from 387 companies (19%); 81% indicated that they knew about OH and 24% had purchased OH services. OH was rated 'very important' by 35%, and 65% rated it as 'quite' or 'very important'. Sickness absence and its business impact were monitored by 89%. Enterprises claiming OH understanding were significantly more likely to purchase OH services (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6-8.0). Companies employing fewer than 90 employees were significantly less likely to purchase such services than larger ones (OR 0.17, 95% CI 0.09-0.3).

CONCLUSIONS

OH knowledge and company size are key determinants of SME purchasing behaviour. Our findings support our proposed theoretical model. However, more research could explore claimed knowledge of OH with respect to the proposed purchaser types and business benefits.

How explicable are differences between reviews that appear to address a similar research question? A review of reviews of physical activity interventions

BACKGROUND

Systematic reviews are promoted as being important to inform decision-making. However, when presented with a set of reviews in a complex area, how easy is it to understand how and why they may differ from one another?

METHODS

An analysis of eight reviews reporting evidence on effectiveness of community interventions to promote physical activity. We assessed review quality and investigated overlap of included studies, citation of relevant reviews, consistency in reporting, and reasons why specific studies may be excluded.

RESULTS

There were 28 included studies. The majority (n = 22; 79%) were included only in one review. There was little cross-citation between reviews (n = 4/28 possible citations; 14%). Where studies appeared in multiple reviews, results were consistently reported except for complex studies with multiple publications. Review conclusions were similar. For most reviews (n = 6/8; 75%), we could explain why primary data were not included; this was usually due to the scope of the reviews. Most reviews tended to be narrow in focus, making it difficult to gain an understanding of the field as a whole.

CONCLUSIONS

In areas where evaluating impact is known to be difficult, review findings often relate to uncertainty of data and methodologies, rather than providing substantive findings for policy and practice. Systematic 'maps' of research can help identify where existing research is robust enough for multiple in-depth syntheses and also show where new reviews are needed. To ensure quality and fidelity, review authors should systematically search for all publications from complex studies. Other relevant reviews should be searched for and cited to facilitate knowledge-building.

Ten year performance evaluation of a field-scale zero-valent iron permeable reactive barrier installed to remediate trichloroethene contaminated groundwater

The Monkstown zero-valent iron permeable reactive barrier (ZVI PRB), Europe's oldest commercially-installed ZVI PRB, had been treating trichloroethene (TCE) contaminated groundwater for about 10 years on the Nortel Network site in Northern Ireland when cores from the reactive zone were collected in December, 2006. Groundwater data from 2001-2006 indicated that TCE is still being remediated to below detection limits as the contaminated groundwater flows through the PRB. Ca and Fe carbonates, crystalline and amorphous Fe sulfides, and Fe (hydr)oxides have precipitated in the granular ZVI material in the PRB. The greatest variety of minerals is associated with a approximately 1-2 cm thick, slightly cemented crust on top (up-gradient influent entrance) of the ZVI section of the PRB and also with the discontinuous cemented ZVI material ( approximately 23 cm thick) directly below it. The greatest presence of microbial communities also occurred in the up-gradient influent portion of the PRB compared to its down-gradient effluent section, with the latter possibly due to less favorable conditions (i.e., high pH, low oxygen) for microbial growth. The ZVI filings in the down-gradient effluent section of the PRB have a projected life span of >10 years compared with ZVI filings from the continuous to discontinuous cemented up-gradient ZVI section (upper approximately 25 cm) of the PRB, which may have a life span of only approximately 2-5 more years. Supporting Information from applied, multi-tracer testing indicated that restricted groundwater flow is occurring in the upper approximately 25 cm of the ZVI section and preferential pathways have also formed in this PRB over its 10 years of operation.

Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial

OBJECTIVE

To compare the efficacy of 100 mg and 200 mg of mifepristone and 24- and 48-hour intervals to administration of 800 microg vaginal misoprostol for termination of early pregnancy.

DESIGN

Placebo-controlled, randomized, equivalence trial, stratified by centre.

SETTING

13 departments of obstetrics and gynecology in nine countries.

POPULATION

2,181 women with 63 days or less gestation requesting medical abortion.

METHODS

Two-sided 95% CI for the risk differences of failure to complete abortion were calculated and compared with 5% equivalence margin between two doses of mifepristone and two intervals to misoprostol administration. Proportions of women with adverse effects were compared between the regimens using standard testes for proportions.

OUTCOME MEASURES

Rates of complete abortion without surgical intervention and adverse effects associated with the regimens.

RESULTS

Efficacy outcome was analysed for 2,126 women (97.5%) excluding 55 lost to follow up. Both mifepristone doses were found to be similar in efficacy. The rate of complete abortion was 92.0% for women assigned 100 mg of mifepristone and 93.2% for women assigned 200 mg of mifepristone (difference 1.2%, 95% CI: -1.0 to 3.5). Equivalence was also evident for the two intervals of administration: the rate of complete abortion was 93.5% for 24-hour interval and 91.7% for the 48-hour interval (difference -1.8%, 95% CI: -4.0 to 0.5). Interaction between doses and interval to misoprostol administration was not significant (P = 0.92). Adverse effects related to treatments did not differ between the groups.

CONCLUSIONS

Both the 100 and 200 mg doses of mifepristone and the 24- and 48-hour intervals have a similar efficacy to achieve complete abortion in early pregnancy when mifepristone is followed by 800 micrograms of vaginally administered misoprostol.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

OBJECTIVE

To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.

DESIGN

Cross-sectional study.

SETTING

Public termination of pregnancy (TOP) services in three provinces.

SAMPLE

A total of 673 women attending the above services for TOP.

METHODS

Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound).

MAIN OUTCOME MEASURES

Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.

RESULTS

Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.

CONCLUSIONS

Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.

Will the law come running? The potential role of "brain fingerprinting" in crime investigation and adjudication in Australia

A major feature of the Australian criminal justice system is that jurors assess witness credibility and are the ultimate finders of fact. Recognising the occasional fallibility of humans in detecting truth and deception, the jury's function may be assisted by highly regulated expert evidence about a variety of scientific techniques. A recent scientific development has been the invention of "brain fingerprinting" (BF) by Dr Larry Farwell in the United States. Brain fingerprinting measures brainwave functioning to detect awareness of crime-relevant information in order to distinguish between guilty and innocent suspects. This article considers whether BF could be used for crime investigation and adjudication in Australia. By examining the rules of expert evidence and the principles relating to "novel scientific evidence", the admissibility of BF in the various Australian jurisdictions is evaluated. The utility of BF in criminal investigations and counter-terrorism initiatives is also canvassed. The authors conclude that, at the present time, it is unlikely that expert testimony on BF will be admitted in Australian criminal trials. However, the technique potentially offers other benefits to the criminal justice system, thereby warranting its consideration as a "criminal and investigative tool of the future".

Self-reported anti-social behaviour: prevalence and risk factors amongst adolescents with and without intellectual disability

BACKGROUND

Research has suggested increased risk of anti-social behaviour amongst individuals with intellectual disability (ID).

METHODS

This study reports the results of a secondary analysis of data relating to self-reported anti-social behaviour, obtained from the 1999 Office for National Statistics (ONS) study of the mental health of children and adolescents in Great Britain. Self-report data from 4174 adolescents was available. Within this group, a sub-group of 98 adolescents with ID was identified. Data covered a variety of sub-types of anti-social behaviour.

RESULTS

Comparisons of individuals with ID and those without ID indicated a significantly higher prevalence of a number of types of self-reported anti-social behaviour in the ID sample. Further analyses indicated however, that these between group differences were accounted for by the higher rates of social deprivation and child mental health problems among the ID sample.

CONCLUSIONS

Rather than ID per se being associated with increased rates of anti-social behaviour, adolescents with ID may be more likely to experience risk factors (lower socio-economic status and mental health problems) known to be associated with anti-social behaviour. The clinical implications of this and possible future directions for research are discussed.

Comparative studies of high performance swimming in sharks II. Metabolic biochemistry of locomotor and myocardial muscle in endothermic and ectothermic sharks

Metabolic enzyme activities in red (RM) and white (WM) myotomal muscle and in the heart ventricle (HV) were compared in two lamnid sharks (shortfin mako and salmon shark), the common thresher shark and several other actively swimming shark species. The metabolic enzymes measured were citrate synthase (CS), an index of aerobic capacity, and lactate dehydrogenase (LDH), an index of anaerobic capacity. WM creatine phosphokinase (CPK) activity, an index of rapid ATP production during burst swimming, was also quantified. Enzyme activities in RM, WM and HV were similar in the two lamnid species. Interspecific comparisons of enzyme activities at a common reference temperature (20 degrees C) show no significant differences in RM CS activity but higher CS activity in the WM and HV of the lamnid sharks compared with the other species. For the other enzymes, activities in lamnids overlapped with those of other shark species. Comparison of the HV spongy and compact myocardial layers in mako, salmon and thresher sharks reveals a significantly greater spongy CS activity in all three species but no differences in LDH activity. Adjustment of enzyme activities to in vivo RM and WM temperatures in the endothermic lamnids elevates CS and LDH in both tissues relative to the ectothermic sharks. Thus, through its enhancement of both RM and WM enzyme activity, endothermy may be an important determinant of energy supply for sustained and burst swimming in the lamnids. Although lamnid WM is differentially warmed as a result of RM endothermy, regional differences in WM CS and LDH activities and thermal sensitivities (Q(10) values) were not found. The general pattern of the endothermic myotomal and ectothermic HV muscle metabolic enzyme activities in the endothermic lamnids relative to other active, ectothermic sharks parallels the general pattern demonstrated for the endothermic tunas relative to their ectothermic sister species. However, the activities of all enzymes measured are lower in lamnids than in tunas. Relative to lamnids, the presence of lower WM enzyme activities in the thresher shark (which is in the same order as the lamnids, has an RM morphology similar to that of the mako and salmon sharks and may be endothermic) suggests that other factors, such as behavior and swimming pattern, also affect shark myotomal organization and metabolic function.

Outpatient management of low-velocity gunshot-induced fractures

This prospective study evaluated the efficacy of an outpatient management protocol for patients with a gunshot-induced fracture with a stable, nonoperative configuration. Forty-one patients (44 fractures) with a grade I or II open, nonoperative fracture secondary to a low-velocity missile comprised the study population. Patients were treated by a standard protocol, which included 1 g of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. Follow-up visits were performed until complete wound and fracture healing were achieved. Thirty-two (78%) of 41 patients underwent full follow-up. Average follow-up was 5.2 months. One (2.8%) fracture (distal fibula) developed a superficial infection, which responded to an additional week of oral antibiotics, and no patient developed a deep infection. There was 1 delayed union and 2 patients with painful retained shrapnel. These results demonstrate that patients with stable, low-velocity, gunshot-induced fractures can be managed effectively and safely on an outpatient basis using this protocol.

Axonal sprouting following lesions of the rat substantia nigra

Parkinson's disease is characterized by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta. Symptoms do not appear until most nigral neurons are lost, implying that compensatory mechanisms are present. Sprouting has been proposed as one of these mechanisms. This study quantified the extent of compensatory axonal sprouting following injury of dopaminergic neurons within the substantia nigra pars compacta. Specifically, the extent of the axonal arbour and axonal varicosity morphology was measured after partial destruction (with 6-hydroxydopamine) of the substantia nigra of the adult male rat. Four months later, the substantia nigra was injected with the anterograde neuronal tracer dextran-biotin to trace the full extent of individual axons. An unbiased estimate of neuron number was performed in each animal. This demonstrated nigral neuronal loss ranging from 10 to 90% on the side that received the injection whilst a 7% reduction was observed in the side contralateral to the lesion. Coincident with this loss, some nigral neurons lose tyrosine hydroxylase expression. Vigorous axonal sprouting was observed in the terminal arbours of lesioned animals and was associated with an increased axonal varicosity size. Axonal varicosities and branching points were primarily confined to the dorsal 1.5mm of the caudate-putamen, an area predominantly innervated by nigral neurons. It appears that dopaminergic neurons were responsible for this sprouting because the density of dopamine transporter immunoreactive varicosities in the caudate-putamen was maintained until about a 70% loss of neurons. It was concluded that substantial compensation in the form of sprouting and new dopaminergic synapse formation occurs following lesions of the substantia nigra pars compacta.

The anatomy and cell biology of peripheral myelin protein-22

The gain of function phenotypes exhibited by the heterozygous Tr, Tr-J, and CMT1A mutations indicate that these mutations interfere with more than the function of a single PMP22 allele. The identification of proteins that interact with PMP22 and that are sensitive both to stoichiometry and the effects of the mutations could provide important leads to a unified hypothesis to explain the riddle of the PMP22-related neuropathies.

Biological hazards

This article outlines the biological hazards that nurses may face in their workplace. It hopes to inform nurses how they can reduce such hazards at work and contribute to a safer working environment.

Physiological evidence for arteriovenous anastomoses in the uterine circulation of late-pregnant ewes

1. The objective of the present study was to determine whether arteriovenous anastomoses (AVA) are present in the uterine circulation of conscious, late-pregnant ewes. 2. Twenty late-pregnant ewes were assigned to two groups. In group 1, 15 microm coloured microspheres were injected into the uterine artery of the pregnant horn and the relative proportion of microspheres trapped in the uterus and lungs was determined. The percentage shunting of blood measured by this method was 17+/-3%, representing a blood flow of 164+/-39 mL/min (n = 12). Any contribution of ovarian, cervical, rectal and other vascular beds was specifically excluded in this group. 3. In group 2, total uterine capillary flow was measured using the reference blood flow method, by injecting 15 microm microspheres into the heart. Calibrated flow probes, placed on both main uterine arteries, concurrently measured total uterine blood flow. Total blood flow to the uterus (flow probe) was significantly greater (t = 3.415; P = 0.027) than uterine capillary flow (microspheres), indicating AVA shunting in the uterine circulation. Mean total blood flow to the uterus was 1749+/-160 mL/min, of which an average 25+/-5% (n = 5 sheep) was shunted. 4. The percentage AVA shunting for groups 1 and 2 was not significantly different (t = 1.219; P = 0.24) and, when combined, the mean percentage of uterine blood flow passing through AVA in the late-pregnant sheep was determined to be 19+/-3%. 5. The present study shows that AVA are present and patent in the uterine circulation of late-pregnant ewes and that they account for the shunting of approximately 20% of the uterine blood flow into the maternal venous circulation.

Unrecognized pregnancy in the overdosed or poisoned patient

A 22-year-old woman was found in bed unresponsive and hypotensive after an apparent overdose. Subsequent workup in the emergency department identified a ruptured ectopic pregnancy and extensive hemoperitoneum. A significant delay occurred when emergency physicians excluded the possibility of pregnancy because of the patient's normal menstrual history. A qualitative serum or urine pregnancy test is recommended in all women of child-bearing age who present with poisoning or drug overdose.

[Collaboration between non-governmental organizations and governments for health sector reform]

One of the most prominent current trends is the vital and increasingly visible role played by nongovernmental organizations (NGOs) in the world in general and in the activities and conferences sponsored by the United Nations (UN). Given these circumstances, part of the mission of PAHO is to strengthen the ties between governments and NGOs through provision of technical cooperation and support in priority program areas, such as health care, and facilitation of the exchange of information and experiences. This report examines different lines of action designed to improve collaboration between NGOs and governments in the area of health sector reform.

[The United Nations confronts the challenges of a changing world: the 49th Annual DPI/NGO Conference]

The United Nations (UN), previously considered a forum exclusively for sovereign governments, has changed over time in tune with various political, economic, social, and cultural phenomena. One of these is the growing presence of nongovernmental organizations (NGOs) in international agencies and activities. The 49th Annual Conference of the Department of Public Information and NGOs, held at UN headquarters on 10 September 1996, analyzed the extent to which the UN is allowing NGOs to participate in its discussions of policy, institutional reform, and field operations. The issues discussed at the Conference and the challenges that face the UN in a changing world from the subject of this report.

Astrocyte reactivity in neonatal mice: apparent dependence on the presence of reactive microglia/macrophages

In neonatal mice, an acute injury produced by a stab wound to the cortex results in minimal astrocyte reactivity, as has been observed by others. However, if the source of the stab wound, a piece of nitrocellulose (NC) membrane, were now implanted in the cortex for a period of time (chronic NC implant injury), then extensive astroglial reactivity in the neonatal brain ensues. The astrogliosis is manifested by increased mRNA, protein content, and immunoreactivity for GFAP, and by ultrastructural changes. Given the previous reports that inflammatory cytokines are possible mediators of astrocyte reactivity (e.g., Balasingam et al: J Neurosci 14:846, 1994), we examined the brain parenchyma of neonatal mice following an NC stab or implant injury, with minimal or extensive astrogliosis, respectively, for a possible differential representation of inflammatory cells. A significant correlation (r = 0.87, P < 0.05) was observed between the occurrence of astrogliosis and the presence of reactive microglia/macrophages; no other inflammatory cell type was detected in the brain parenchyma of neonatal mice following NC implant injury. We suggest that reactive microglia/macrophages are required for the evolution of cells into reactive astrocytes following insults to the neonatal brain.

Outcome of rotationally unstable pelvic ring injuries treated operatively

Twenty-nine patients with unstable rotational injuries treated operatively were observed for an average of 39 months. There were 24 associated orthopaedic injuries. Twenty-seven patients had symphysis disruption (4 with rami fractures) and 2 had rami fractures associated with an acetabular fracture. Followup evaluation of those who could be evaluated in each category revealed that 96% had no pain or pain only on strenuous activity, ambulated without assistance or limitations, and returned to work. Open reduction and internal fixation of rotationally unstable pelvic fractures results in a high functional success rate.

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.

Discriminative power of visual evoked potential characteristics in multiple sclerosis

To investigate the discriminative power of pattern-reversal visual evoked potential characteristics (peak latencies and amplitude) and to test whether the addition of visual evoked potential amplitude can increase the power of the visual evoked potential in the diagnosis of multiple sclerosis, we retrospectively studied visual evoked potentials in 59 patients with definite multiple sclerosis and 126 control subjects. Two check sizes (17' and 10') were used. Females had significantly higher amplitudes and shorter latencies than males. N80 latency showed a gradual increase and P100 amplitude a decrease with age. P100 latency was stable between the ages of 20 and 55 years but was increased in childhood and the elderly. The significance of visual evoked potential peak latencies and amplitude in separating the two groups was investigated by means of a (multivariate) discriminant analysis. The visual evoked potential with a pattern of 10' could be measured in 58% of patients with multiple sclerosis. The exclusive use of the P100 amplitude in the discriminant analysis resulted in a percentage of correctly classified cases of 84%, whereas for P100 and N80 latency it was 85% and 90%, respectively. With the 17' pattern, the N80 latency yielded also a higher correct percentage than did the P100 latency. Although N80 latency is, to a greater extent than P100 latency, influenced by age, sex and size of stimulus pattern, when these influences are accounted for, the N80 latency is a more sensitive measure than P100 latency in the classification of multiple sclerosis. Combined use of latency and amplitude for discriminant analysis yielded no significant improvement of the percentage of correctly classified cases.

Specific binding of endocrine transforming growth factor-beta 1 to vascular endothelium

The presentation of recombinant biologically active 125I-TGF-beta 1 via the bloodstream to potential target cells in mice and rats was evaluated by quantitative light and electron microscope radioautography. Specificity was evaluated by in vivo competition with excess unlabeled TGF-beta 1, and integrity of the ligand at the binding site was demonstrated by trichloroacetic acid precipitation after extraction from tissues. The distribution of radiolabel at 2.5, 15, 30, 45, and 60 min after 125I-TGF-beta 1 injection revealed radiolabel principally over microvasculature endothelium but at times > 2.5 min over endothelial endocytic components indicative of internalization. Nonspecific binding of 125I-TGF-beta 1 to the apex of the proximal convoluted tubule of the kidney indicated it as the likely site of rapid clearance of TGF-beta 1 from the circulation, while a comparison of the binding of 125I-TGF-beta 1 (endothelial) to that of 125I-TGF-beta 1 complexed with alpha 2-macroglobulin-methylamine (liver parenchyma) indicated that clearance of TGF-beta 1 complexed alpha 2-macroglobulin was likely via the hepatic alpha 2-macroglobulin receptor. The endothelial TGF-beta receptors uncovered here are likely involved in the local regulatory mechanism of leukocyte and monocyte adhesion and tissue infiltration regulated by endocrine TGF-beta 1.

TUNAS AS SMALL AS 207 mm FORK LENGTH CAN ELEVATE MUSCLE TEMPERATURES SIGNIFICANTLY ABOVE AMBIENT WATER TEMPERATURE

Tunas (family Scombridae) maintain muscle temperatures (Tm) elevated significantly above ambient water temperature (Ta) by using vascular counter-current heat exchangers (retia mirabilia) to conserve metabolic heat generated by continuous contraction of red muscle fibers. Previous work has documented endothermy and both behavioral and physiological thermoregulation in tunas, but only individuals greater than approximately 1 kg body mass had been studied. The purpose of this study was to measure Tm and to examine heat exchanger morphology in smaller fish in order to determine the minimum size at which tunas can elevate Tm significantly above Ta. Measurements of Tm made immediately after capture in field-caught and laboratory-raised tunas (Euthynnus lineatus, Auxis thazard, A. rochei and Thunnus albacares) spanning a size range of 15.5&shy;667 mm fork length (FL) show that tunas 207 mm FL (162.3 g) and larger can elevate red muscle temperature by at least 3.0&deg;C above Ta. E. lineatus, A. thazard and A. rochei of this size possess blood vessels serving the red muscle that are arranged as both lateral and central heat exchangers; the smallest tuna with evidence of a rete was a 108.5 mm FL E. lineatus. In the ectothermic scombrid Scomberomorus sierra (108.7&shy;132.0 mm FL), Tm was elevated 0.2&shy;0.5&deg;C above Ta, and the greatest Tm elevation reported in any ectothermic species is only 2.7&deg;C. Taken together, these data provide evidence that tunas greater than 207 mm FL are endothermic.

Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results

To investigate the importance of arterial integrity in tibial fracture healing, the authors retrospectively assessed prognosis as a function of arterial injury in a large series of tibial fracture patients. The records of 114 patients who were treated for an open fracture of the tibia at a San Francisco hospital between 1981 and 1991 were selected for review; in each case, the injury had been caused by a blunt trauma, and arteriography had been performed to evaluate a suspected arterial injury in the ipsilateral extremity. Sixty-two patients had had a normal arteriogram and 52 had demonstrated occlusion of one or two of the three arteries that supply the foot. The group of patients who had demonstrated arterial occlusion had a significantly greater incidence of delayed union or nonunion (24 of 52 compared with ten of 62) and notably more cases of osteomyelitis (nine of 52 compared with four of 62); when the patients with osteomyelitis are excluded, the difference between the groups is still significant. This study is the first that indicates that patients with open fractures of the tibia who demonstrate arterial occlusion in their ipsilateral extremity may be more prone to delayed union or nonunion. More vigilant follow-up evaluation may therefore be warranted in such patients to better anticipate the need for exchange rodding or bone grafting.