'Empowering our people' to address depression, violence, and sexual risk among Native Americans with recent binge alcohol use

Background: This study was launched in response to an American Indian (AI) community's concern regarding the comorbid occurrence of substance use, poor mental health, and other risk factors on sexual health. The purpose of this manuscript was to assess the relationship between alcohol use, violence, depression and STI/HIV risk behaviors on the frequency of unprotected sex acts and number of sexual partners among AI adults.Methods: Specifically, this analysis examines sociodemographic characteristics, experience of sexual and physical violence, binge drinking, depression, and sexual risk taking among n = 281 AI adults ages 18-55. Regression models examine associations between the aforementioned risk factors, number of sex partners and number of unprotected sex acts, by depression status and sex, among participants.Results: Frequent binge drinking predicted frequency of unprotected sex for both males and females; ever experiencing physical violence was a powerful predictor of unprotected sex for females, but not males. Ever experiencing physical violence strongly predicted having multiple sexual partners for females but was related to decreased number of sexual partners for males. Females ever experiencing sexual violence had more sexual partners; this was not observed for males. Binge drinking predicted frequency of unprotected sex acts, regardless of depression status.Discussion: Interventions for AI adults seeking to reduce sexual health risk should reflect past violence victimization in sexual decision making, primarily among women. The significant role of binge alcohol use for modifying sexual decisions should be of prime focus and interventions should be personalized to address individuals' own alcohol use patterns. Additional research should explore how binge alcohol use moderates the relationship between depression and sexual risk.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

Community Perspectives on Social Influences on Suicide Within a Native American Reservation

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Entrepreneurial, Economic, and Social Well-Being Outcomes from an RCT of a Youth Entrepreneurship Education Intervention among Native American Adolescents

Background: Entrepreneurship education has demonstrated positive impacts in low-resource contexts. However, there is limited evidence of such programs evaluated among Native American (NA) youth in a rural reservation. Methods: A 2:1 randomized controlled trial evaluated the impact of the Arrowhead Business Group (ABG) entrepreneurship education program on entrepreneurship knowledge, economic empowerment, and social well-being among 394 NA youth. An intent to treat analysis using mixed effects regression models examined within and between study group differences from baseline to 24 months. An interaction term measured change in the intervention relative to change in the control. ABG participants were purposively sampled to conduct focus groups and in-depth interviews. Results: Significant intervention vs. control group improvements were sustained at 12 months for entrepreneurship knowledge and economic confidence/security. Significant within-group improvements were sustained for ABG participants at 24 months for connectedness to parents, school, and awareness of connectedness. Qualitative data endorses positive impacts on social well-being among ABG participants. Conclusion: Observed effects on entrepreneurship knowledge, economic empowerment, and connectedness, supplemented by the experiences and changes as described by the youth themselves, demonstrates how a strength-based youth entrepreneurship intervention focused on developing assets and resources may be an innovative approach to dually address health and economic disparities endured in Native American communities.

Robust estimation of quantitative perfusion from multi-phase pseudo-continuous arterial spin labeling

PURPOSE

Multi-phase PCASL has been proposed as a means to achieve accurate perfusion quantification that is robust to imperfect shim in the labeling plane. However, there exists a bias in the estimation process that is a function of noise in the data. In this work, this bias is characterized and then addressed in animal and human data.

METHODS

The proposed algorithm to overcome bias uses the initial biased voxel-wise estimate of phase tracking error to cluster regions with different off-resonance phase shifts, from which a high-SNR estimate of regional phase offset is derived. Simulations were used to predict the bias expected at typical SNR. Multi-phase PCASL in 3 rat strains (n = 21) at 9.4 T was considered, along with 20 human subjects previously imaged using ASL at 3 T. The algorithm was extended to include estimation of arterial blood flow velocity.

RESULTS

Based on simulations, a perfusion estimation bias of 6-8% was expected using 8-phase data at typical SNR. This bias was eliminated when a high-precision estimate of phase error was available. In the preclinical data, the bias-corrected measure of perfusion (107 ± 14 mL/100g/min) was lower than the standard analysis (116 ± 14 mL/100g/min), corresponding to a mean observed bias across strains of 8.0%. In the human data, bias correction resulted in a 15% decrease in the estimate of perfusion.

CONCLUSIONS

Using a retrospective algorithmic approach, it was possible to exploit common information found in multiple voxels within a whole region of the brain, offering superior SNR and thus overcoming the bias in perfusion quantification from multi-phase PCASL.

Evaluation of an Entrepreneurship Education Intervention for American Indian Adolescents: Trial Design and Baseline Sample Characteristics

Entrepreneurship education is a strength-based approach and holds promise for promoting health equity for American Indian youth. Arrowhead Business Group (ABG) was developed by a tribal-academic research partnership and is being rigorously evaluated for impacts on psychosocial, behavioral, educational, and economic outcomes. This article describes: 1) the trial design and conceptual model under-girding the ABG program; 2) the sociodemographic, sociocultural, and family/household characteristics of participants at baseline; and 3) the baseline differences in key outcome indicators between study groups. Results demonstrate participants have baseline characteristics appropriate for study aims and are compared and contrasted with other youth from the participating tribal community and state in which the tribe resides. Findings inform future analyses to explore how baseline characteristics are associated with primary and secondary outcomes of the evaluation.

Characteristics of Substance Abuse and Self-Injury among American Indian Adolescents Who Have Engaged in Binge Drinking

Binge drinking appears to be a risk factor, facilitator, and method of suicidal and non-suicidal self-injury for some American Indian (AI) youth. We examined characteristics, patterns, and motivations for binge use among AI adolescents (N = 69; 10-19 years-old) who recently engaged in binge drinking. The majority used alcohol alone (53.7%) or a combination of alcohol and marijuana (31.3%) for their binge event. Gender differences emerged with boys more severely affected than girls. Forty-seven percent reported lifetime suicidal thoughts. This study represents one of the first in-depth examinations of substance use and related behaviors among AI adolescents who have engaged in recent binge use.

Towards Quantitative Systems Pharmacology Models of Chemotherapy-Induced Neutropenia

Neutropenia is a serious toxic complication of chemotherapeutic treatment. For years, mathematical models have been developed to better predict hematological outcomes during chemotherapy in both the traditional pharmaceutical sciences and mathematical biology disciplines. An increasing number of quantitative systems pharmacology (QSP) models that combine systems approaches, physiology, and pharmacokinetics/pharmacodynamics have been successfully developed. Here, I detail the shift towards QSP efforts, emphasizing the importance of incorporating systems-level physiological considerations in pharmacometrics.

A Mathematical Model of Granulopoiesis Incorporating the Negative Feedback Dynamics and Kinetics of G-CSF/Neutrophil Binding and Internalization

We develop a physiological model of granulopoiesis which includes explicit modelling of the kinetics of the cytokine granulocyte colony-stimulating factor (G-CSF) incorporating both the freely circulating concentration and the concentration of the cytokine bound to mature neutrophils. G-CSF concentrations are used to directly regulate neutrophil production, with the rate of differentiation of stem cells to neutrophil precursors, the effective proliferation rate in mitosis, the maturation time, and the release rate from the mature marrow reservoir into circulation all dependent on the level of G-CSF in the system. The dependence of the maturation time on the cytokine concentration introduces a state-dependent delay into our differential equation model, and we show how this is derived from an age-structured partial differential equation model of the mitosis and maturation and also detail the derivation of the rest of our model. The model and its estimated parameters are shown to successfully predict the neutrophil and G-CSF responses to a variety of treatment scenarios, including the combined administration of chemotherapy and exogenous G-CSF. This concomitant treatment was reproduced without any additional fitting to characterize drug-drug interactions.

Approaching Pharmacometrics as a Paleontologist Would: Recovering the Links Between Drugs and the Body Through Reconstruction

Our knowledge of dinosaurs comes primarily from the fossil record. Notwithstanding the condition of these vestiges, paleontologists reconstruct early reptilian life by comparison to previously discovered specimens. When relics are missing, reasonable deductions are used to fill in the gaps.

Exploring risk and protective factors with a community sample of American Indian adolescents who attempted suicide

American Indian adolescents are at disproportionate risk for suicide, and community-based studies of this population, which allow a deeper understanding of risks and resilience to inform interventions, are rare. This is a cross-sectional study of N = 71 Apache adolescents. Strengths include the role of the community and American Indian paraprofessionals in the design, implementation, and interpretation of findings. Participants were M = 16.0 years old, 65% female, and 69% multiple attempters. Risks included suicidal behavior among peers and family (68%), caregivers with substance problems (62%), and participant substance use history, namely alcohol (91%) and marijuana (88%). Areas of resiliency included lower depression scores (M = 23.1) and cultural activity participation. A multi-tiered intervention at individual, family, and community levels is needed.

Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression.

Community-based surveillance and case management for suicide prevention: an American Indian tribally initiated system

The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and self-injurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.

An integrated pressure and pathway approach to the spatial analysis of groundwater nitrate: a case study from the southeast of Ireland

Excess nitrogen in soil, aquatic and atmospheric environments is an escalating global problem. Eutrophication is the principal threat to surface water quality in the Republic of Ireland. European Union Water Framework Directive (2000/60/EC) water quality status assessments found that 16% of Irish groundwater bodies were 'at risk' of poor status due to the potential deterioration of associated estuarine and coastal water quality by nitrate from groundwater. This paper presents a methodology for evaluating pressure and pathway parameters affecting the spatial distribution of groundwater nitrate, investigated at a regional scale using existing national spatial datasets. The potential for nitrate transfer to groundwater was rated based on the introduced concepts of Pressure Loading and Pathway Connectivity Rating, each based on a combination of selected pressure and pathway parameters respectively. In the region studied, the South Eastern River Basin District of Ireland, this methodology identified that pathway parameters were more important than pressure parameters in understanding the spatial distribution of groundwater nitrate. Statistical analyses supported these findings and further demonstrated that the proportion of poorly drained soils, arable land, karstic flow regimes, regionally important bedrock aquifers and high vulnerability groundwater within the zones of contribution of the monitoring points are statistically significantly related to groundwater nitrate concentrations. Soil type was found to be the most important parameter. Analysis of variance showed that a number of the pressure and pathway parameters are interrelated. The parameters identified by the presented methodology may provide useful insights into the best way to manage and mitigate the influence of nitrate contamination of groundwater in this region. It is suggested that the identification of critical source areas based on the identified parameters would be an appropriate management tool, enabling planning and enforcement resources to be focussed on areas which will yield most benefit.

Extended follow-up of an antibiotic cycling program for the management of febrile neutropenia in a hematologic malignancy and hematopoietic cell transplantation unit

BACKGROUND

Febrile neutropenia is a common complication during treatment of hematological malignancies and hematopoietic cell transplantation. Empiric antibiotic therapy in this setting, while standard of care, commonly leads to microbial resistance. We have previously shown that cycling antibiotics in this patient population is feasible. This report provides long-term follow-up of cycling antibiotics in this patient population.

METHODS

In a prospective cohort of hematological malignancy patients with neutropenic fever, we sought to evaluate the role of empiric antibiotic cycling in preventing antibiotic resistance. Antibiotic cycling was initiated in March 2002 and, until June 2005, antibiotics were cycled every 8 months (Cycling Period A). From July 2005 to December 2009, antibiotics were cycled every 3 months (Cycling Period B). The rates of bacteremia, resistance, and complications were compared to a retrospective cohort (Pre-cycling Period).

RESULTS

The rate of gram-negative bacteremia decreased when compared to Cycling Periods A and B (5.3 vs. 2.1 and 3.3 episodes/1000 patient-days, respectively, P < 0.0001), most likely owing to implementation of quinolone prophylaxis. The resistance profile of the gram-negative organisms isolated remained stable over the 3 time periods, with the exception of an increase in quinolone resistance during the cycling periods. Gram-positive bacteremia rates remained stable, but vancomycin-resistant Enterococcus (VRE) increased significantly (0.1 vs. 1.0 and 1.6 episodes/1000 patient-days, respectively, P = 0.005) during cycling periods. Mortality rates were comparable.

CONCLUSIONS

Antibiotic cycling for neutropenic fever was effectively implemented and followed over an extended time period. Gram-negative resistance remained stable, but there is some concern for selection of resistant gram-positive bacteria, specifically VRE. Although antibiotic cycling did not seem to cause resistance in our study, further study is necessary to clarify the effect of cycling on antibiotic resistance, patient outcomes, and hospital cost.

Onset and complications of varicella zoster reactivation in the autologous hematopoietic cell transplant population

BACKGROUND

Varicella zoster virus (VZV) infections are a common complication in patients receiving autologous or allogeneic hematopoietic cell transplant (HCT). Recent guideline revisions suggest extending VZV prophylaxis to 1 year after autologous HCT. We retrospectively evaluated reactivation at our center, before implementation of extended acyclovir prophylaxis, to determine onset and outcome in the autologous HCT population.

METHODS

Inclusion criteria consisted of adult patients who received an autologous HCT with documentation for at least 1 year post transplant. Those excluded from review were patients who received acyclovir prophylaxis for >30 days post transplant or subsequently received an allogeneic transplant within 1 year. For patients in whom reactivation occurred, the severity of infection, the timing of onset, treatment of the reactivation, and any complications were recorded.

RESULTS

In the final analysis, 56 patients were assessed. Reactivation of zoster occurred in 16% of recipients with a median onset of 4.5 months post transplant. Complications that were observed include postherpetic neuralgia, severe pain, scarring, and motor weakness. Two patients required hospitalization for treatment, with 1 patient requiring 6 months of rehabilitation for motor weakness following the infection.

CONCLUSIONS

Our study revealed a 16% incidence of VZV reactivation in our autologous HCT population. The onset of these occurrences ranged from 2 to 10 months post transplant, with significant VZV-associated complications. We consider VZV reactivation a serious concern in the autologous transplant setting, requiring extended prophylaxis.

How we approach patient evaluation for hematopoietic stem cell transplantation

The evaluation of patients for hematopoietic stem cell transplantation is a complex process. The decision to recommend transplantation is not simply dependent on patient diagnosis; instead it is a specialized analytic decision process intricately dependent on a number of variables including patient age, performance status, medical comorbidities, family support structure, socioeconomic viability and motivation to participate in self-care, to name a few. The process of pre-transplant patient evaluation has substantial variability across different transplant centers, owing to lack of formal published guidelines. This review summarizes the process of pre-transplant patient evaluation and workup, and aims to describe components of a well-organized and evidenced-based patient selection process for SCT.

Toward understanding suicide among youths: results from the White Mountain Apache tribally mandated suicide surveillance system, 2001-2006

OBJECTIVES

We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions.

METHODS

Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations.

RESULTS

Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict.

CONCLUSIONS

An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.

The clinical impact of antibacterial prophylaxis and cycling antibiotics for febrile neutropenia in a hematological malignancy and transplantation unit

Febrile neutropenia is an expected complication during treatment of aggressive hematological malignancies and hematopoietic cell transplantation. We conducted a prospective cohort trial to determine the effects and safety of prophylactic fluoroquinolone administration, and rotation of empiric antibiotics for neutropenic fever in this patient population. From March 2002 through 2004, patients were treated with prophylactic levofloxacin during prolonged neutropenia, and a cycling schedule of empiric antibiotic therapy for neutropenic fever was initiated. The rates of bacteremia, resistance and complications were compared to a retrospective cohort of previously treated patients. The rate of gram-negative bacteremia decreased after the initiation of prophylactic levofloxacin (4.7 vs 1.8 episodes/1000 patient days, P<0.05). Gram-positive bacteremia rates remained unchanged, but more isolates of Enterococcus faecium were resistant to vancomycin after the intervention began. Resistance to the antibiotic agents used in the rotation did not emerge. There was no change in mortality during the intervention period. A prophylactic and cycling antibiotic schedule was successfully implemented on a hematological malignancy and hematopoietic cell transplant unit. gram-negative bacteremia was significantly decreased, without emergence of resistance. Concerns with Gram-positive resistance will require further observation.

Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease

BACKGROUND

Angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor antagonists (AIIRA) are considered to be equally effective for patients with diabetic kidney disease (DKD), but renal and not mortality outcomes have usually been considered.

OBJECTIVES

To evaluate the benefits and harms ACEi and AIIRA in patients with DKD.

SEARCH STRATEGY

We searched MEDLINE (1966 to December 2005), EMBASE (1980 to December 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 4 2005) and contacted known investigators.

SELECTION CRITERIA

Studies comparing ACEi or AIIRA with placebo or each other in patients with DKD were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI). Heterogeneity among studies was explored using the Cochran Q statistic and the I(2) test, subgroup analyses and random effects metaregression.

MAIN RESULTS

Fifty studies (13,215 patients) were identified. Thirty eight compared ACEi with placebo, five compared AIIRA with placebo and seven compared ACEi and AIIRA directly. There was no significant difference in the risk of all-cause mortality for ACEi versus placebo (RR 0.91, 95% CI 0.71 to 1.17) and AIIRA versus placebo (RR 0.99, 95% CI 0.85 to 1.17). A subgroup analysis of studies using full-dose ACEi versus studies using half or less than half the maximum tolerable dose of ACEi showed a significant reduction in the risk of all-cause mortality with the use of full-dose ACEi (RR 0.78, 95% CI 0.61 to 0.98). Baseline mortality rates were similar in the ACEi and AIIRA studies. The effects of ACEi and AIIRA on renal outcomes (ESKD, doubling of creatinine, prevention of progression of micro- to macroalbuminuria, remission of micro- to normoalbuminuria) were similarly beneficial. Reliable estimates of effect of ACEi versus AIIRA could not be obtained from the three studies in which they were compared directly because of their small sample size.

AUTHORS' CONCLUSIONS

Although the survival benefits of ACEi are known for patients with DKD, the relative effects on survival of ACEi with AIIRA are unknown due to the lack of adequate direct comparison studies. In placebo controlled studies, only ACEi (at the maximum tolerable dose, but not lower so-called renal doses) were found to significantly reduce the risk of all-cause mortality. Renal and toxicity profiles of these two classes of agents were not significantly different.

Efaproxiral red blood cell concentration predicts efficacy in patients with brain metastases

Efaproxiral (Efaproxyn™, RSR13), a synthetic allosteric modifier of haemoglobin (Hb), decreases Hb-oxygen (O₂) binding affinity and enhances oxygenation of hypoxic tumours during radiation therapy. This analysis evaluated the Phase 3, Radiation Enhancing Allosteric Compound for Hypoxic Brain Metastases; RT-009 (REACH) study efficacy results in relation to efaproxiral exposure (efaproxiral red blood cell concentration (E-RBC) and number of doses). Recursive partitioning analysis Class I or II patients with brain metastases from solid tumours received standard whole-brain radiation therapy (3 Gy/fraction × 10 days), plus supplemental O₂ (4 l/min), either with efaproxiral (75 or 100 mg/kg daily) or without (control). Efaproxiral red blood cell concentrations were linearly extrapolated to all efaproxiral doses received. Three patient populations were analysed: (1) all eligible, (2) non-small-cell lung cancer (NSCLC) as primary cancer, and (3) breast cancer primary. Efficacy endpoints were survival and response rate. Brain metastases patients achieving sufficient E-RBC (⩾483 μg/ml) and receiving at least seven of 10 efaproxiral doses were most likely to experience survival and response benefits. Patients with breast cancer primary tumours generally achieved the target efaproxiral exposure and therefore gained greater benefit from efaproxiral treatment than NSCLC patients. This analysis defined the efaproxiral concentration-dependence in survival and response rate improvement, and provided a clearer understanding of efaproxiral dosing requirements.

Emergency department organisation of critical care transfers in the UK

OBJECTIVES

Transport of the critically ill patient to or from the emergency department (ED) is a frequent occurrence. This study was designed to determine whether UK EDs currently have appropriate equipment, monitoring, staff training systems, and processes of care for transportation of the critically ill patient.

METHODS

A postal questionnaire regarding ED transfer patients was sent to 247 UK EDs, followed by repeat mailing and telephone follow up of non-responders.

RESULTS

In total, 139 EDs (56%) responded. An estimated 20-30 critically ill patients are transferred from and <20 are received by each ED annually. Processes of care are poorly developed; only 79 EDs (56%) have transfer guidelines available. Audit of transfers is ongoing in 59 EDs (42%), and critical incident reporting is ongoing in 122 (88%). There is a lack of immediately available transport equipment; for example, 17 EDs (12%) have no transport ventilator, 9 (6%) have no transport monitor, and 9 (6%) have no syringe pump. Transport equipment is invariably not standardised. Anaesthetic staff of specialist registrar (74 doctors; 53%) or senior house officer (36 doctors; 26%) grades carry out the majority of ED transfers accompanied by a D or E grade nurse. Both invariably have no formal transfer training.

CONCLUSIONS

This study highlights inadequacies in provision of equipment and monitoring during interhospital transfer from the ED. Training and processes of care for transport of the critically ill are also suboptimum. Many departments are currently reviewing these processes to formalize and improve transfer training procedures and protocols.

Antihypertensive agents for preventing diabetic kidney disease

BACKGROUND

Twenty to sixty percent of diabetic patients are affected by hypertension and antihypertensive agents are used to treat this condition. These agents are also used to prevent the onset of kidney disease both in normotensive and hypertensive diabetics.

OBJECTIVES

To evaluate the comparative effects of antihypertensive agents in patients with diabetes and normoalbuminuria.

SEARCH STRATEGY

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, conference proceedings, and contact with investigators were used to identify relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antihypertensive agent with placebo or another agent in hypertensive or normotensive patients with diabetes and no kidney disease (albumin excretion rate < 30 mg/d) were included.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data on renal outcomes and other patient relevant outcomes (all-cause mortality, serious cardiovascular events), and assessed quality of trials. Analysis was by a random effects model and results expressed as relative risk (RR) and 95% confidence intervals (CI).

MAIN RESULTS

Sixteen trials (7603 patients) were identified, six of angiotensin converting enzyme inhibitors (ACEi) versus placebo, six of ACEi versus calcium channel blockers (CCBs), one of ACEi versus CCBs or combined ACEi and CCBs and three of ACEi versus other agents. Compared to placebo, ACEi significantly reduced the development of microalbuminuria (six trials, 3840 patients: RR 0.60, 95% CI 0.43 to 0.84) but not doubling of creatinine (three trials, 2683 patients: RR 0.81, 95% CI 0.24 to 2.71) or all-cause mortality (four trials, 3284 patients: RR 0.81, 95% CI 0.64 to 1.03). Compared to CCBs, ACEi significantly reduced progression to microalbuminuria (four trials, 1210 patients: RR 0.58, 95% CI 0.40 to 0.84).

AUTHORS' CONCLUSIONS

A significant reduction in the risk of developing microalbuminuria in normoalbuminuric patients with diabetes has been demonstrated for ACEi only. It appears that the effect of ACEi is independent of baseline blood pressure, renal function and type of diabetes, but data is too sparse to be confident that these are not important effect modifiers and an individual patient data meta-analysis is required.

Towards empirical description of malaria seasonality in southern Africa: the example of Zimbabwe

BACKGROUND

Quantitative description and mapping of malaria seasonality is important for timely spatial targeting of interventions and for modelling malaria risk. There is a need for seasonality models that predict quantitative variation in transmission between months.

METHODS

We use Zimbabwe as an example for developing an empirical map of malaria seasonality. We describe the relationship between seasonality in malaria and environmental covariates for the period 1988--1999, by fitting a spatial-temporal regression model within a Bayesian framework to provide smoothed maps of the seasonal trend. We adapt a seasonality concentration index used previously for rainfall to quantify malaria case load during the peak transmission season based on monthly values.

RESULTS

Combinations of mean monthly temperature (range 28--32 degrees C), maximum temperature (24--28 degrees C) and high rainfall provide suitable conditions for seasonal transmission. High monthly maximum and mean monthly minimum temperatures limit months of high transmission. The intensity of seasonal transmission was highest in the north western part of the country from February to May with the peak in April and lowest in the whole country from July to December. The north western lowlands had the highest concentration of malaria cases (>25%) followed by some districts in the north central and eastern part with a moderate concentration of cases (20-25%). The central highlands and south eastern part of the country had the lowest concentration of malaria cases (<20%). This pattern was closely associated to the geographic variation in the seasonality of climatic covariates particularly rainfall and temperature. Conclusions Our modelling approach quantifies the geographical variation in seasonal trend and the concentration of cases during the peak transmission season and therefore has potential application in malaria control. The use of a covariate adjusted empirical model may prove useful for predicting the seasonal risk pattern across southern Africa.

Temperature-suitability maps for schistosomiasis in South Africa

The results of parasitological surveys have shown that both urinary and intestinal schistosomiasis occur widely among the human residents of South Africa. The national data on both diseases have now been incorporated into a geographical information system, to develop new maps based on defined temperature constraints. The disease data, obtained from a 'hard-copy' atlas of schistosomiasis, were used as a template to select temperature regimes that were (1) suitable and (2) unsuitable for the transmission of schistosomes to humans in South Africa. The regimes were derived from the published results of investigations in which the biology of larval schistosomes (i.e. schistosome transmission) was related to temperature in South Africa. Those regimes that were based on the estimated temperature minima for transmission corresponded more closely to the disease-distribution data than those based on the corresponding maxima. An estimate of the number of children living in the climate-suitable areas was made but, within the context of the spatial methodology used and the limitations of the available disease data, it was not possible to predict the prevalences of schistosomiasis.

CCR5 genotyping in an Australian and New Zealand type 1 diabetes cohort

Infiltration of pancreatic tissue by autoreactive T-cells involves secretion of multiple cytokines and chemokine receptor expression. Genetically determined variation in cell surface expression of the chemokine receptor CCR5 may result in differences in inflammatory cell migration in response to relevant chemokines. Adolescents with type 1 diabetes (T1D) from Australia and New Zealand were genotyped for CCR5-delta32 (n = 626). The allele frequency was compared with that of 253 non-diabetic Australian adolescents and with that of 92 adults with systemic lupus erythematosus. A reduced allele frequency was seen in T1D compared with controls (0.092 vs. 0.123, p = 0.05). This difference was not seen for the cohort of patients with SLE (freq = 0.114). A reduction in the number of CCR5-delta32/delta32 homozygotes, who lack CCR5, in the T1D cohort was also seen and while not statistically significant (2 observed compared to 5.25 expected; p = 0.12) is interesting. These results suggest a partial protection from T1D for CCR5-delta32 homozygous individuals is possible and that CCR5 has a potential role in the pathogenesis of T1D.

Psychiatric morbidity among patients with recurrent miscarriage

In this study 81 women with recurrent miscarriages completed questionnaires designed to assess depression, anxiety and general health. This data was matched with data from their medical notes to ascertain demographic and reproductive variables. The results indicated that 33% of patients could be classified as depressed with 9.9% of women being moderately depressed and 7.4% suffering from severe depression. Twenty-one percent of patients had levels of anxiety that were equal or higher to a typical psychiatric outpatient population. Neither age, cigarette consumption, alcohol intake, previous live birth, number of miscarriages, lateness of miscarriage nor length of time since last miscarriage were found to affect the degree of psychiatric morbidity. These findings add to our understanding of the degree to which recurrent miscarriage can affect mental health.

Implant-related fractures of the femur following hip fracture surgery

BACKGROUND

Most hip fractures are treated surgically, with use of either internal fixation or prosthetic replacement of the femoral head. The presence of these implants increases the risk of a later femoral fracture in susceptible osteoporotic patients. The purpose of this study was to analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery.

METHODS

Over a ten-year period from January 1988 to December 1997, 6230 patients (median age, eighty-two years; male:female ratio, 1247:4983) who sustained a total of 6696 hip fractures were admitted to the Edinburgh Orthopaedic Trauma Unit. Demographic information on the patients and details of the original treatment of the hip fracture were prospectively coded and entered into a trauma database. All subsequent readmissions due to a femoral fracture related to the implant were prospectively audited and extracted for the purposes of this study.

RESULTS

One hundred and forty-one patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery. Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years. The median age and gender distribution of the patients who sustained a subsequent femoral fracture were similar to those of the hip fracture population as a whole. Two-thirds of the fractures propagated from the tip of the implant. Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence. The incidence was relatively high in the patients initially treated with a Gamma nail (18.74 fractures per 1000 person-years) or a cementless hemiarthroplasty (11.72 per 1000 person-years) and was relatively low in those treated with a compression hip screw (4.46 per 1000 person-years), cannulated screws (4.50 per 1000 person-years), or a primary arthroplasty with cement (6.2 per 1000 person-years). The highest incidence of fracture was seen in the patients who had required an arthroplasty with cement as a revision procedure following failure of a primary implant (22.39 per 1000 person-years).

CONCLUSIONS

Implant-related fractures following hip fracture surgery are more common than has previously been appreciated. The risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture.

Liver tumours due to endometriosis and endometrial stromal sarcoma

BACKGROUND

Endometriosis can occur in unusual sites, liver involvement being first described in 1986. Extra-uterine malignant transformation in endometriosis has been reported, occurring mainly in the ovary. Liver involvement with endometrial stromal sarcoma (ESS) has not been previously reported.

CASE OUTLINE

Two patients presenting with symptomatic liver masses related to endometriosis, who successfully underwent surgical intervention, are presented.

CASE 1

A 31-year-old woman previously had been treated with hysterectomy and bilateral salpingoophorectomy for severe pelvic endometriosis. Six years later, she presented with malaise from bilobar liver involvement with endometrial deposits. She proceeded acutely to hilar obstruction with obstructive jaundice and portal vein thrombosis.

CASE 2

A 59-year-old post-menopausal woman had earlier presented acutely from a ruptured mesenteric cyst, which showed features of endometrial stromal sarcoma (ESS). Two years later, she presented with symptoms from a large ESS occupying the right lobe.

DISCUSSION

Endometriosis per se, as well as malignant transformation into ESS can involve the liver.These should be considered in women with hepatic space occupying lesions of unknown etiology.

Drugs in pregnancy. Prescribing for psychiatric disorders in pregnancy and lactation

The most recent Confidential Enquiry into the causes of maternal deaths during the perinatal period in England and Wales (1994-1996) revealed that psychological illness was at least as important as hypertensive disorders. It is therefore important for obstetricians to be aware of a variety of psychiatric conditions as well as the psychotropic medication prescribed and sequelae of continuation or withdrawal of these drugs. Best management, of this particularly vulnerable group of women, requires close liaison with the psychiatric team. This chapter considers four groups of women most likely to be prescribed psychoactive drugs during the perinatal period: (i) women with mental illness wishing to conceive, (ii) women with mental illness who conceive while taking medication, (iii) those who become mentally ill while pregnant, and (iv) those who become unwell postnatally. Guidelines for treatment are discussed.

Stress and recurrent miscarriage

Our current understanding into the role of stress in unexplained recurrent miscarriages comes from two different research strategies. The majority of research has examined the role of psychological support within this patient population. This support has been provided in a number of ways ranging from weekly interviews with a psychiatrist or gynaecologist and or visual re-assurance in the form of ultrasound scans. A comparison of psychological support with an absence of such intervention has found differences in successful pregnancy outcome varying from as great as 84 versus 26%, respectively. It has been assumed that psychological support reduces the miscarriage rate by reducing “stress”within this patient population. In addition it provides indirect support for a role of stress in the aetiology of unexplained recurrent miscarriage. Other studies have attempted to directly assess the effect of personality characteristics on miscarriage rate; these studies have yielded conflicting results.The mechanism by which stress may be causal in the aetiology of unexplained recurrent miscarriage has not been examined in humans. Animal studies, however, have found that psychological distress can alter immune parameters that may be intricately involved with implantation. These parameters include an elevation of the “abortive” cytokine TNF-a and a reduction in the “anti-abortive” cytokine TGF-P2. Cells that are involved in the release of TNF-a at the feto-maternal interface include T cells, macrophages and mast cells.Mechanisms through which stress may act on these cells are explored and an integrated model is postulated.

Extended daily dialysis: A new approach to renal replacement for acute renal failure in the intensive care unit

Continuous venovenous hemofiltration (CVVH) is an effective form of renal replacement therapy for acute renal failure (ARF) that offers greater hemodynamic stability and better volume control than conventional hemodialysis in the critically ill, hypotensive patient. However, the application of CVVH in the intensive care unit (ICU) has several disadvantages, including intensive nursing requirements, continuous anticoagulation, patient immobility, and expense. We describe a new approach to the treatment of ARF in the ICU, which we have termed extended daily dialysis (EDD). In this study, EDD was compared with CVVH in 42 patients: 25 patients were treated with EDD for a total of 367 treatment days, and 17 patients were treated with CVVH for a total of 113 days. Median treatment time per day was 7.5 hours for EDD (range, 6 to 8 hours, 25th to 75th percentile) versus 19.5 hours for CVVH (range, 13.4 to 24 hours; P < 0.001). Mean arterial blood pressures (MAPs) did not differ significantly for patients treated with EDD when measured predialysis (median MAP, 70 versus 67 mm Hg for CVVH; P = 0.078), midway through daily treatment (70 versus 68 mm Hg for CVVH; P = 0.083), or at the end of treatment (71 versus 69 mm Hg for CVVH; P = 0.07). Net daily ultrafiltration was similar for the two treatment modalities (EDD, median, 3,000 mL/d; range, 1,763 to 4,445 mL/d; CVVH, 3,028 mL/d; range, 1,785 to 4,707 mL/d; P = 0.514). Anticoagulation requirements were significantly less for patients treated with EDD (median dose of heparin, 4,000 U/d; range, 0 to 5,800 U/d versus 21,100 U/d; range, 8,825 to 31,275 U/d for patients treated with CVVH; P < 0.001). We found that EDD eliminated the need for constant supervision of the dialysis machine by a subspecialty dialysis nurse, allowing one nurse to manage more than one treatment. Overall, EDD was well tolerated by the majority of patients, offered many of the same benefits provided by CVVH, and was technically easier to perform.

A spatial statistical approach to malaria mapping

BACKGROUND

Good maps of malaria risk have long been recognized as an important tool for malaria control. The production of such maps relies on modelling to predict the risk for most of the map, with actual observations of malaria prevalence usually only known at a limited number of specific locations. Estimation is complicated by the fact that there is often local variation of risk that cannot be accounted for by the known covariates and because data points of measured malaria prevalence are not evenly or randomly spread across the area to be mapped.

METHOD

We describe, by way of an example, a simple two-stage procedure for producing maps of predicted risk: we use logistic regression modelling to determine approximate risk on a larger scale and we employ geo-statistical ('kriging') approaches to improve prediction at a local level. Malaria prevalence in children under 10 was modelled using climatic, population and topographic variables as potential predictors. After the regression analysis, spatial dependence of the model residuals was investigated. Kriging on the residuals was used to model local variation in malaria risk over and above that which is predicted by the regression model.

RESULTS

The method is illustrated by a map showing the improvement of risk prediction brought about by the second stage. The advantages and shortcomings of this approach are discussed in the context of the need for further development of methodology and software.