Testing the effectiveness and acceptability of online supportive supervision for mental health practitioners in humanitarian settings: a study protocol for the caring for carers project

BACKGROUND

Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project.

METHOD

A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention.

DISCUSSION

There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.

Abolition of endocrine dimorphism in hyperthyroid males? An argument for the positive feedback effect of hyperoestrogenaemia on LH secretion

Our aim was (i) to investigate the hypothalamo-hypophyseal-gonadal axis in hyperthyroid Indian males, (ii) to rule out the modulatory role of adrenal steroids on it and (iii) to determine if the simultaneous rise in oestradiol and luteinising hormone (LH) in hyperthyroid males is due to a positive feedback action of oestradiol on pituitary LH release. Age- and BMI-matched men were divided into two groups, I, euthyroid subjects (n = 17) and II, hyperthyroid patients (n = 12) on the basis of their thyroid hormone levels. Serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, LH, follicle-stimulating hormone (FSH), prolactin, E(2), T, P(4), sex hormone binding globulin and dehydroepiandrosterone sulphate (DHEAS) were assayed. Mean levels of T and E(2) were approximately two times higher in group II in comparison with group I. DHEAS levels were similar in both groups ruling out any adrenal involvement. Mean serum LH level was 2.6 folds higher in group II in comparison with group I. Mean serum levels of FSH were higher in group II, it was marginally nonsignificant. On the basis of these and previous observations, we hypothesise that endocrinological dimorphism in human male and female is not rigid; a sustained rise in serum oestradiol probably induces a positive feedback action on pituitary leading to elevated gonadotrophin levels.

Assessment of quality of life among HIV positive people attending tertiary hospital of Delhi, India

As per global HIV/AIDS estimates, a total of 33 million [30.3 - 36.1 million] People were living with HIV in 2007. The world's second-most populous country, India, is experiencing a highly varied HIV epidemic, which appears to be stable or diminishing in some parts while growing at a modest rate in others. Quality of life (QOL) of HIV/AIDS patients is becoming an important component of overall assessment of health care and management in health care settings. It is one of the indicators effectiveness of management of PLHAS. The objective of this study was to determine the QOL of patients with HIV/AIDS in New Delhi. Purposive sampling was used to identify subjects from the antiretroviral therapy clinic (ART) in Lok Nayak hospital. 180 patients were interviewed with the WHOQOL-HIV instrument. This questionnaire included demographic data, multi-item scales and six domains namely physical, psychological, level of independence, social relationships, environment and spirituality religion. Study subjects were aged between 20-56 years. Mean age of all study subjects was 33.85 +/- 7.01 years, comprising of 34.4 females. More than 50% of the total subjects had received less than secondary school education. All domains have higher scores for women than men except the psychological domain. Correlation of scores of six domains with overall QOL score and among individual domains was statistically significant. Younger people showed poorer QOL and level of education correlated positively with all domains of QOL Overall results indicate that quality of life of AIDS attending Lok Nayak hospital is satisfactory.

Correlation between baseline CD4 + T-Lymphocyte count and plasma viral load in AIDS patients and their early clinical and immunological response to HAART: a preliminary study

The aim of this study was to determine the clinical, immunological and virological status of newly diagnosed AIDS cases and to monitor their clinical and immunological response to HAART after a minimum period of three months. Forty three drug naive AIDS patients were enrolled. The most common presenting complaints were weight loss (74.4%), cough (72.1%) and diarrhoea (67.4%). Mean baseline CD4 cell count was 112 +/- 60 cells/microL and mean baseline plasma viral load of 31 patients studied was 192,686 copies/mL. Baseline plasma viral load was higher among patients with lower baseline CD4 cell count. During follow-up, 80.8% patients showed clinical improvement, while a CD4 cell count increased by > or =50 cells/microL in 84.6% cases. Mean CD4 cell count increased from 126 +/- 16.6 cells/microL at baseline to 278 +/- 196.7 cells/microL.

Silent myocardial ischaemia in patients with type II diabetes mellitus and its relation with autonomic dysfunction

Accelerated coronary and peripheral vascular atherosclerosis is one of the most common and chronic complications of diabetes mellitus. A relatively recently analysed aspect of coronary artery disease in this condition is its silent or asymptomatic nature. We studied silent/asymptomatic myocardial ischaemia in unselected consecutive middle aged asymptomatic diabetics and controls by 24-hour ambulatory electrocardiographic monitoring, treadmill test and coronary angiography. Also, a relationship was sought between silent myocardial ischaemia and autonomic dysfunction. Thirty asymptomatic diabetics between the ages 35-60 without any documented evidence of coronary artery disease and as many controls (matched for age, sex, smoking habits, blood pressure, serum cholesterol and body mass index) were studied. All the diabetics and controls were subjected to treadmill test and 24-hour ambulatory electrocardiographic monitoring. Coronary angiography was done in those who were positive in treadmill test or 24-hour ambulatory electrocardiographic monitoring. Also five simple bedside tests for autonomic dysfuncton i.e. heart rate response to valsalva, deep breathing and orthostatic variation and blood pressure response to orthostatic variation and sustained handgrip were done in all the subjects. Those with two or more abnormal tests were diagnosed as having autonomic dysfunction. ST segment depression indicating silent myocardial ischaemia was seen in 14 (46.7%) out of 30 diabetics and in 3 (10.0%) out of 30 controls on both Holter and treadmill test (p=0.002). Also, diabetics had higher heart rate and greater number of supraventricular and ventricular ectopics than controls. Coronary angiography done in patients with silent ischaemia revealed higher prevalence of multivessel involvement and diffuse disease in diabetics as compared to controls. Half the diabetics (50%) and none of the control had autonomic dysfunction. Autonomic dysfunction was present in 85.7 percent of diabetics with silent ischaemia compared to 18.7 percent diabetics without silent ischaemia (p=0.001).

The frequency and influence of gallbladder varices on gallbladder functions in patients with portal hypertension

Gallbladder varices have been reported in patients with portal hypertension. The exact frequency and significance of these collaterals in patients with cirrhotic and noncirrhotic portal hypertension is not known. One hundred and two patients with portal hypertension [38 with cirrhosis, 29 with noncirrhotic portal fibrosis (NCPF) and 35 with extrahepatic portal vein obstruction (EHPVO)] and 25 healthy controls were studied. Gallbladder varices were seen at ultrasound as tortuous, dilated vessels in the wall or in the bed of the gallbladder. In 35 patients (19 patients with and 16 without gallbladder varices) and in 10 healthy controls, gallbladder functions were studied by determining fasting volume (FV) and then residual volume (RV) every 10 min over 1 h after giving a liquid meal of 420 k.cal. Ejection fraction (EF) was computed as a percentage by the formula: FV--RV/FV x 100. Twenty four (24%) patients had gallbladder varices: Five (13%) with cirrhosis, seven (24%) with NCPF, and 12 (34%) with EHPVO. FV in EHPVO patients was seen significantly more than in cirrhotics (31.6 +/- 15.4 vs 19.3 +/- 6.0 ml, p < 0.05). The RV and EF were not different in the three groups of patients compared with the controls. The EF was similar in patients with or without gallbladder varices (63.3 +/- 10.2% vs 64.6 +/- 10.4%). Gallbladder varices are often seen in portal hypertension, more often in EHPVO patients, and these collaterals cause some gallbladder stasis but do not impede gallbladder function and hence seem unlikely to contribute to gallstone formation.

High familial prevalence of gallstones in the first-degree relatives of gallstone patients

Limited information is available on the prevalence of gallstones in the first-degree relatives of gallstone patients. Three groups of subjects were studied by real-time ultrasound examination: group A, 105 index gallstone patients (male/female; 20:85); group B, 330 first-degree relatives of index patients; group C, matched controls for group A (n = 105) and group B (n = 330) subjects. Dietary, anthropometric, and biochemical investigations were carried out. In 39 of 105 (37%) index cases, one or more additional family members had gallstones (positive-index case). The positive-index cases were younger than the remaining index cases (mean age, 33.1 +/- 14 vs. 44.5 +/- 13.1 years; P < .05). Fifty-one of 330 (15.5%) first-degree relatives had gallstones, nearly four and a half times (95% confidence interval [CI], 2.4 to 8.5) more often than in the matched control population (12 of 330 [3.6%]). Thirty-three of 51 (65%) positive relatives were women; mother (37.3%), sister (17.6%) or daughters (10%) to the index patients. There was no difference in the diet, physical activity, and serum lipid profile between the positive index patients and the remaining gallstone patients and positive relatives and their controls. Our results show that there is a strong familial predisposition for gallstone formation. Female relatives of young gallstone patients should be routinely screened for gallstones.

Histological and biochemical changes in testis of zinc deficient BALB/c strain of mice

Zinc, protein, cholesterol, phospholipids, alkaline phosphatase (AlPase), acid phosphatase (AcPase), adenosine-5-triphosphatase(ATPase) and histology were studied in testis of zinc-deficient mice. Zinc and protein decreased in the 3-week experiment whereas they increased in the 6-week experiment. Zinc is involved in several functions of the cell and is regulated by hormones. Inhibition of spermatogenesis indicates for decreased zinc levels in 3-week whereas the increase in 6-week experiment indicates for accumulation of zinc in oedomatous fluid and uncontrolled diffusion of zinc across the blood testis barrier. Glycogen decreased in the 3-week as well as 6-week experiments due to blockage of androgen and spermatogenesis. Cholesterol and phospholipids increased in the 3-week experiment and decreased in 6-week experiment as both the parameters are related to steroidogenesis. Zinc deficiency leads to aspermatogenic condition and comparatively less injury to non-germinal cells. This could have blocked the transport of material across the testis barrier and therefore might have increased AlPase levels. Increased AcPase, probably represents lysosomal enzymes, as the cell debris of disorganised epithelium are to be digested and removed. ATPase increased in 3-week experiment and can be correlated to increased demands of energy of testicular cells to overcome the insults of zinc deficiency whereas the decrease in 6-week experiment could be as a result of inhibition of spermatogenesis.

Persistent or recurrent acromegaly. Long-term endocrinologic efficacy and neurologic safety of postsurgical radiation therapy

As in other clinics, pituitary surgery was definitive treatment in less than 50% of cases of acromegaly treated at one institution over several decades. From 1965 to 1989, 24 acromegalic patients who had noncurative pituitary surgery received radiation therapy at the National Institutes of Health, with a basal human growth hormone level of greater than 5 ng/ml as the criterion for active disease. Using megavoltage irradiation, more than 60% of these patients stabilized at a normal hormonal range, and the overwhelming majority had decreasing growth hormone levels with time. No major side effects of irradiation were encountered except panhypopituitarism of varying degrees. The authors evolved a policy of surgery as the first option, followed by irradiation for patients with postoperative growth hormone levels more than 5 ng/ml.

Splenic abscess

We report a splenic abscess in an elderly diabetic female. Awareness of the disease is emphasised.

Intensive combined modality therapy of small round cell and undifferentiated sarcomas in children and young adults: local control and patterns of failure

Seventy-five patients (ages 4-35 years) with the following small round cell tumors and undifferentiated sarcoma were treated at the National Cancer Institute: Ewing's sarcoma (n = 32), peripheral neuroepithelioma (n = 14), rhabdomyosarcoma (n = 24), undifferentiated sarcoma (n = 5). Most patients had poor prognostic features including 36 (48%) with metastatic disease, and 42 (56%) with central (truncal) tumors (22 in the pelvis). Treatment included 5 cycles of intensive induction chemotherapy with vincristine, cyclophosphamide and adriamycin, plus aggressive local radiation therapy using simulation and computerized treatment planning for all patients. Thereafter, complete clinical responses were consolidated with intensive chemotherapy, total body irradiation and autologous bone marrow transplantation. There were three local only failures, 10 local plus distant failures, 36 distant only failures, 3 treatment-related deaths, and one intercurrent death. Overall actuarial survival and event-free survival at 4 years are 49 and 29%, respectively. Actuarial freedom from local progression was seen in 74% of patients at 4 years, quite remarkable considering the bulk and location of most of these tumors. Without aggressive surgery, many of these high risk patients had satisfactory outcomes, but better systemic treatments are still needed.

Cranial nerve palsies in benign intracranial hypertension

Benign intracranial hypertension may occasionally be associated with various cranial nerve palsies. A case with multiple cranial nerve involvement is presented.