The Effectiveness of Cannabinoids in the Treatment of Posttraumatic Stress Disorder (PTSD): A Systematic Review

Objectives: Posttraumatic stress disorder (PTSD) is a potentially debilitating mental health problem. There has been a recent surge of interest regarding the use of cannabinoids in the treatment of PTSD. We therefore sought to systematically review and assess the quality of the clinical evidence of the effectiveness of cannabinoids for the treatment of PTSD. Method: We included all studies published until December 2018 where a patient has had PTSD diagnosed and had been prescribed or were using a cannabinoid for the purpose of reducing PTSD symptoms. Our primary outcome measure was the reduction in PTSD symptoms using a validated instrument. In the absence of randomized controlled trials, we included the next best available levels of evidence including observational and retrospective studies and case reports. We assessed risk of bias and quality using validated tools appropriate for the study design. Results: We included 10 studies in this review, of which only one study was a pilot randomized, double-blind, placebo-controlled, crossover clinical trial. Every identified study had medium to high risk of bias and was of low quality. We found that cannabinoids may decrease PTSD symptomology, in particular sleep disturbances and nightmares. Conclusions: Most studies to date are small and of low quality, with significant limitations to the study designs precluding any clinical recommendations about its use in routine clinical practice. Evidence that cannabinoids may help reduce global PTSD symptoms, sleep disturbances, and nightmares indicates that future well-controlled, randomized, double-blind clinical trials are highly warranted.PROSPERO registration number: 121646.

Platelet GPIbα is a mediator and potential interventional target for NASH and subsequent liver cancer

Non-alcoholic fatty liver disease ranges from steatosis to non-alcoholic steatohepatitis (NASH), potentially progressing to cirrhosis and hepatocellular carcinoma (HCC). Here, we show that platelet number, platelet activation and platelet aggregation are increased in NASH but not in steatosis or insulin resistance. Antiplatelet therapy (APT; aspirin/clopidogrel, ticagrelor) but not nonsteroidal anti-inflammatory drug (NSAID) treatment with sulindac prevented NASH and subsequent HCC development. Intravital microscopy showed that liver colonization by platelets depended primarily on Kupffer cells at early and late stages of NASH, involving hyaluronan-CD44 binding. APT reduced intrahepatic platelet accumulation and the frequency of platelet-immune cell interaction, thereby limiting hepatic immune cell trafficking. Consequently, intrahepatic cytokine and chemokine release, macrovesicular steatosis and liver damage were attenuated. Platelet cargo, platelet adhesion and platelet activation but not platelet aggregation were identified as pivotal for NASH and subsequent hepatocarcinogenesis. In particular, platelet-derived GPIbα proved critical for development of NASH and subsequent HCC, independent of its reported cognate ligands vWF, P-selectin or Mac-1, offering a potential target against NASH.

Base excision repair proteins couple activation-induced cytidine deaminase and endonuclease G during replication stress-induced MLL destabilization

The breakpoint cluster region of the MLL gene (MLLbcr) is frequently rearranged in therapy-related and infant acute leukaemia, but the destabilizing mechanism is poorly understood. We recently proposed that DNA replication stress results in MLLbcr cleavage via endonuclease G (EndoG) and represents the common denominator of genotoxic therapy-induced MLL destabilization. Here we performed a siRNA screen for new factors involved in replication stress-induced MLL rearrangements employing an enhanced green fluorescent protein-based reporter system. We identified 10 factors acting in line with EndoG in MLLbcr breakage or further downstream in the repair of the MLLbcr breaks, including activation-induced cytidine deaminase (AID), previously proposed to initiate MLLbcr rearrangements in an RNA transcription-dependent mechanism. Further analysis connected AID and EndoG in MLLbcr destabilization via base excision repair (BER) components. We show that replication stress-induced recruitment of EndoG to the MLLbcr and cleavage are AID/BER dependent. Notably, inhibition of the core BER factor Apurinic-apyrimidinic endonuclease 1 protects against MLLbcr cleavage in tumour and human cord blood-derived haematopoietic stem/progenitor cells, harbouring the cells of origin of leukaemia. We propose that off-target binding of AID to the MLLbcr initiates BER-mediated single-stranded DNA cleavage, which causes derailed EndoG activity ultimately resulting in leukaemogenic MLLbcr rearrangements.

[The basis for well-founded simulations]

In medical education, simulation is gaining increasing importance for teaching a variety of subjects. A well-founded educational approach is necessary for effective use. In addition to material aspects, simulation environment, curriculum, learning environment, and methods of debriefing have to be considered. The role of a competent instructor should be emphasized and the importance of an elaborate change management process to implement a good concept should not be underestimated.

[What Surgeons Should Know about Risk Management]

Background: The fact that medical treatment is associated with errors has long been recognized. Based on the principle of "first do no harm", numerous efforts have since been made to prevent such errors or limit their impact. However, recent statistics show that these measures do not sufficiently prevent grave mistakes with serious consequences. Preventable mistakes such as wrong patient or wrong site surgery still frequently occur in error statistics. Methods: Based on insight from research on human error, in due consideration of recent legislative regulations in Germany, the authors give an overview of the clinical risk management tools needed to identify risks in surgery, analyse their causes, and determine adequate measures to manage those risks depending on their relevance. The use and limitations of critical incident reporting systems (CIRS), safety checklists and crisis resource management (CRM) are highlighted. Also the rationale for IT systems to support the risk management process is addressed. Results/Conclusion: No single tool of risk management can be effective as a standalone instrument, but unfolds its effect only when embedded in a superordinate risk management system, which integrates tailor-made elements to increase patient safety into the workflows of each organisation. Competence in choosing adequate tools, effective IT systems to support the risk management process as well as leadership and commitment to constructive handling of human error are crucial components to establish a safety culture in surgery.

The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users

We describe how simulation and incident reporting can be used in combination to make the interaction between people, (medical) technology and organisation safer for patients and users. We provide the background rationale for our conceptual ideas and apply the concepts to the analysis of an actual incident report. Simulation can serve as a laboratory to analyse such cases and to create relevant and effective training scenarios based on such analyses. We will describe a methodological framework for analysing simulation scenarios in a way that allows discovering and discussing mismatches between conceptual models of the device design and mental models users hold about the device and its use. We further describe how incident reporting systems can be used as one source of data to conduct the necessary needs analyses - both for training and further needs for closer analysis of specific devices or some of their special features or modes during usability analyses.

The role of the registered nurse in the marketing of primary healthcare services, as part of health promotion

Existing literature on the marketing of primary healthcare services was reviewed to determine the role of registered nurses in this regard. The systematic review included “— five searches and ensured wide coverage of the results of available primary research studies on the topic. The results were summarised and the role of registered nurses in the marketing of primary healthcare services was identified. Primary research sources on the topic included textbooks on marketing by experts in the field and relevant journal articles by authorities on healthcare marketing. The data were analysed and four main categories identified. To ensure the trustworthiness of the research, Lincoln and Guba’s (1981:215-216) criteria, as explained by Krefting (1991:217), were applied. Because the population consisted of only literature, ethical considerations concerning human subjects were irrelevant. Results indicated that the basic commercial marketing principles (the so-called 4Ps - product, price, place, and promotion) could be adapted for the health sector. The conclusion was that registered nurses could contribute to the marketing of primary healthcare services by communicating with the community (promotion) and by ensuring effective service (product) delivery at the right price and place. Registered nurses could influence the community’s perceptions of health care and facilitate behaviour changes, thereby promote health. The implementation of the findings and recommendations of this research could create a new awareness among registered nurses of their role in the marketing of primary healthcare services in South Africa and improve their skills in this regard.

Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions

This study investigated failures of prospective memory (PM) as a relevant but neglected error type in medicine. A patient simulator was used to investigate PM failures. The influence of subjective importance (high, low) and type of intention (educational, internal, external) on the (missed) execution of intention was investigated in a 2 x 2 design. The effects on missed executions by importance (high < low) and type of intention (educational < external < internal) were hypothesized. Of 73 valid intentions in 40 prepared simulator scenarios 19 (26%) were missed overall. A total of 64% of unimportant and 80% of important intentions were executed 79% of educational 67% of external and 72% of internal intentions were executed. Neither difference was statistically significant using chi(2) tests. Interaction was significant for missed executions (p = 0.025; n = 19; df = 2; chi(2) = 7.41) and for executions (p = 0.002; n = 54; df = 2; chi(2) = 12.50). Despite low statistical support and some methodological limitations, it was possible to show that PM failures are relevant to patient safety and that patient simulators are a suitable but so far unused tool for their investigation.

[Innovative training for enhancing patient safety. Safety culture and integrated concepts]

INTRODUCTION

Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article.

METHOD

Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed.

RESULTS

The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising.

CONCLUSION

As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

[Patient safety and errors in medicine: development, prevention and analyses of incidents]

"Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: "Primum nihil nocere"--"First, do not harm".

The residual anthelmintic efficacy of moxidectin against selected nematodes affecting sheep

Determination of the residual anthelmintic efficacy in sheep of an oral formulation of moxidectin at a dosage rate of 0.2 mg kg-1 was evaluated 27-29 (mean: 28) d after dosing and that of the injectable formulation of moxidectin at a dosage rate of 0.2 mg kg-1 at 27-29 (mean: 28) and 34-36 (mean: 35) d post-treatment. The injectable formulation was more than 80% effective in more than 80% of treated sheep against a third larval stage challenge of Haemonchus contortus, Teladorsagia (Ostertagia) circumcincta, Gaigeria pachyscelis and Oesophagostomum columbianum at both 28 and 35 d post-treatment. The oral formulation on the other hand was equally effective against a third larval stage challenge of G. pachysce1is at 28 d post-treatment and more than 60% effective in more than 60% of treated sheep against a third larval stage challenge at 28 d post-treatment of H. contortus, T. circumcincta and O. columbianum.

[The value of a new IRMA for determining thyroglobulin]

A total of 277 patients suffering from differentiated thyroid carcinoma with individual follow-up periods of up to five years had been investigated. More than 1,000 sera were collected. The present paper reports on the results of the parallel serum Tg determinations by means of a recently introduced Tg-IRMA system in comparison with the previously used, well established Tg-RIA method. The intra- and the interassay variation of the IRMA were found at 37% and 46%, respectively, for 4 ng Tg/ml, and 3% and 6%, respectively, for Tg values above 40 ng/ml. Several effects that could interfere with the serum Tg determination (freezing or repeated freezing and thawing of sera, hemolysis or lipemia or dilution of sera, preanalytical use of serum separating tubes) were examined. Although statistically significant in some instances, at least, all of the above mentioned effects were without any practical relevance for the clinical routine use of the IRMA. In patients being in complete remission and on complete TSH suppressive thyroid hormone treatment but having no residual thyroid tissue (n = 70), the level of clinical significance was 1 ng Tg/ml for the IRMA system, resulting in a sensitivity of 99% and a specificity of 90%, respectively. For the RIA system, however, the level of clinical significance was found to be 10 ng Tg/ml with a sensitivity of 89% and a specificity of 95%. We could additionally define the grey-zone for the practical use of the IRMA (1-3 ng Tg/ml). The IRMA system is significantly more sensitive and detects more sera correctly positive than the Tg-RIA.(ABSTRACT TRUNCATED AT 250 WORDS)

Ekologiese waarnemings van 'n Bergskilpadpopulasie, Geochelone pardalis Bell, 1828, soos aangeteken in die Soetdoring-Natuurreser-vaat in die Oranje-Vrystaat

Hierdie studie poog om vas te stel of die bergskilpad Geochelone pardalis Bell, 1828, habitatsvoorkeure asook territoriale neigings toon. Geen territorialiteit bestaan nie maar wel loopgebiede waarbinne die skilpad meeste van sy aktiwiteite bedryf. Bewegingspatrone van 'n aantal individuele skilpaaie word bespreek. This study ascertains whether the mountain tortoise Geochelone pardalis Bell, 1828, shows habitat preferences and territorial tendencies. No territorialism was found but most activities took place within a certain range. Movement patterns of a number of individual tortoises are described.