Temporary inhibition of the plasminogen activator inhibits periosteal chondrogenesis and promotes periosteal osteogenesis during appendicular bone fracture healing

INTRODUCTION

Aminocaproic acid is approved as an anti-fibrinolytic for use in joint replacement and spinal fusion surgeries to limit perioperative blood loss. Previous animal studies have demonstrated a pro-osteogenic effect of aminocaproic acid in spine fusion models. Here, we tested if aminocaproic acid enhances appendicular bone healing and we sought to uncover the effect of aminocaproic acid on osteoprogenitor cells (OPCs) during bone regeneration.

METHODS

We employed a well-established murine femur fracture model in adult C57BL/6J mice after receiving two peri-operative injections of aminocaproic acid. Routine histological assays, biomechanical testing and micro-CT analyses were utilized to assess callus volume, and strength, progenitor cell proliferation, differentiation, and remodeling in vivo. Two disparate ectopic transplantation models were used to study the effect of the growth factor milieu within the early fracture hematoma on osteoprogenitor cell fate decisions.

RESULTS

Aminocaproic acid treated femur fractures healed with a significantly smaller cartilaginous callus, and this effect was also observed in the ectopic transplantation assays. We hypothesized that aminocaproic acid treatment resulted in a stabilization of the early fracture hematoma, leading to a change in the growth factor milieu created by the early hematoma. Gene and protein expression analysis confirmed that aminocaproic acid treatment resulted in an increase in Wnt and BMP signaling and a decrease in TGF-β-signaling, resulting in a shift from chondrogenic to osteogenic differentiation in this model of endochondral bone formation.

CONCLUSION

These experiments demonstrate for the first time that inhibition of the plasminogen activator during fracture healing using aminocaproic acid leads to a change in cell fate decision of periosteal osteoprogenitor cells, with a predominance of osteogenic differentiation, resulting in a larger and stronger bony callus. These findings may offer a promising new use of aminocaproic acid, which is already FDA-approved and offers a very safe risk profile.

The integration of individual therapy and family therapy in the treatment of child and adolescent psychiatric disorders

Children influence families and families influence children. Individuals create a family, and a family is more than a sum of its individuals. These dialectic views are at the heart of the clinical application of the integration of individual and family therapy. Any attempt to treat the mental disorders of children and adolescents must consider both views and their treatment implications. The use of combined therapeutic modalities can offer more flexibility, specificity, and precision for the treatment process.

Parent management training

As the estimates of prevalence and cost of mental health problems in our children continue to rise, it is incumbent on our society to have an effective and cost-efficient means to address this health crisis. Consistently, the research literature indicates that PMT offers great promise as an efficacious treatment of conduct-disordered children. There are recent studies of PMT's benefits as a preventive intervention that not only improves children's conduct but also positively affects parent-child relationships, mood, social competence, and school adjustment or performance. Although relatively untested, there are indications that PMT also could play an important adjunctive role in the treatment of internalizing disorders. As a curriculum-driven and didactic form of treatment, PMT is highly adaptable to various treatment and prevention contexts, and from a managed care perspective, PMT's structure allows its costs to be well defined and managed. Despite these positive attributes, however, few clinics systematically offer PMT as a treatment option, and third-party payers have been reluctant to cover its costs. Although it is conceded that much needs to be learned about the scope of PMT's effectiveness and the modifications that are necessary to improve its adaptability to high-risk families, it is proposed that PMT should join the mainstream of broadly available health care provisions for children and their families. This broad inclusion of PMT requires mental health educators to include PMT training as a standard part of provider training, requires that third-party payers include PMT as a covered service, and requires that local and federal governments support the proliferation of PMT in treatment and prevention initiatives.

Assessment of the family. Systemic and developmental perspectives

Why was Elizabeth the symptomatic family member? This challenging question is informed by the family assessment, which examines family process patterns, family structure, family history, and developmental challenges of individual family members and the family as a whole. Although the answer to this question may never be explained completely, the family assessment does contribute to the biopsychosocial formulation on which rational therapeutic intervention is based. The family assessment does not replace a clinical assessment of the identified patient. Rather, the use of the family assessment provides a greater breadth from which to view children and adolescents presenting complaints.

Family therapy for eating disorders

It is a perpetual source of debate whether dysfunctional family communication and relationship patterns cause eating disorders or the stress associated with raising a child with an eating disorder elicits such problems. Regardless, family therapy is a necessary component of any comprehensive biopsychosocial approach to the treatment of eating disorders. A careful assessment of the entire family, including the identified patient; his or her parents and siblings; the parents' marriage and families of origin; the child's emotional, social, and physical development; parental regulation of developmental stages; and communication patterns is mandatory. Family therapy for eating-disordered patients attempts to facilitate the elimination of potentially life-threatening symptoms and begin a therapeutic process of change within the entire family. Research has shown significant support for the use of family therapy in this population, but well-controlled treatment outcome research remains somewhat limited.

Data-gathering tools for "real world" clinical settings: a multisite feasibility study

OBJECTIVE

To determine the mental health needs and optimal treatments for children and families in "real world" settings, data-gathering strategies are needed that can be easily implemented across a variety of clinical settings. To address this need, the authors developed and piloted a "clinician-friendly" questionnaire that includes demographic, psychosocial, medical, and family history variables, such as those routinely gathered in standard clinical evaluations.

METHOD

Optical scanning technology was used to encode data from more than 1,900 children, including 1,458 consecutive referrals in four military child psychiatry clinics, 285 consecutive admissions to a civilian psychiatric state hospital, 71 pediatric patients, and a community sample of 113 children.

RESULTS

Despite geographic and logistic obstacles, clinical data were reliably obtained across multiple settings. Data analyses revealed meaningful differences across samples in subjects' presenting complaints, and a range of psychosocial, demographic, and background variables. Data were characterized by an apparently high degree of accuracy and completeness.

CONCLUSIONS

Findings illustrate the importance and feasibility of standardized data-gathering approaches in routine clinical settings and clarify the hazards as well as the opportunities afforded by these research approaches. Such data-gathering tools appear to have significant merit and deserve further implementation and testing across a range of clinical and research settings.

The reported prevalence of physical and sexual abuse among a sample of children and adolescents at a public psychiatric hospital

In this retrospective analysis of inpatient charts, a total of 298 children and adolescents admitted to a public psychiatric hospital over a 1-year period were examined for the prevalence of reported histories of physical or sexual abuse. Physical abuse was reported in 15% of the cases, while sexual abuse occurred in 13%. A variety of comparisons were made examining possible differences in gender, age, race, diagnosis, and personality trait disturbance among the abused and nonabused patients. Relative to known prevalence rates as reported to child protective agencies, physical or sexual abuse occurred much more frequently among our sample of patients, suggesting the need for careful assessment of such histories upon admission and during treatment.

Didactic modules for curricular development in child and adolescent psychiatry education

A group of child and adolescent psychiatry educators in the Association for Academic Psychiatry have developed didactic aids, termed modules,for curricular development in child psychiatry training programs. These modules consist of sets of references designed to communicate the essence of a subject area. The design is flexible, allowing the modules to be used by programs with varying amounts of time available for teaching the designated subject. The project has been endorsed by the major organizations representing education in child psychiatry. Eight modules are available for distribution, and a mechanism is in place for creating others. The authors believe this concept will be equally useful in adult psychiatry programs.

Self-harming behavior in incarcerated male delinquent adolescents

This report describes self-harming behavior in males in a juvenile incarceration center. Three groups of adolescents were examined: self-harmers, those referred for a psychiatric examination, and the incarcerated general population. Compared to the general population, the youth in the two mental health groups were younger, had greater family needs, had more educational problems, were more likely to have escaped from a previous placement, and committed more rule violations. The self-harming group, when compared with the psychiatrically referred group, had a greater number of prior offenses, were more disruptive in school, performed worse on a problem-solving task, and committed more rule violations. Issues of psychopathology and treatment are discussed.

Informed consent as a framework for treatment: ethical and therapeutic considerations

Significant changes in the nature of doctor-patient relationships have required more patient involvement in decision making and the therapeutic use of informed consent. Particularly in family therapy, open acknowledgment and discussion of potential hazards of psychotherapy not only establish trust, but also can deflect patients' resistance to therapy and strengthen their commitment to the therapeutic work. Three case reports of the successful use of "informed consent as a treatment strategy" are described.

Thyroid-induced mania in hypothyroid patients

This retrospective study, based on 18 case reports, describes an organic affective syndrome, manic type, occurring shortly after the initiation of thyroid replacement in hypothyroid patients. The symptomatology and homogeneity of the syndrome offers insight into the relationship between thyroid activity and affective disturbance. The patients experiencing mania showed concurrent psychopathology at the time of replacement therapy, frequently had a past history of personal or familial psychiatric disorder and were given dosages in the high range of normal. The potential morbidity of the manic state was considerable. These findings suggest that a group of hypothyroid patients at risk can be identified. In such a group, lower initial dosages and gradual increases in dosage may be indicated.

The in vivo survival of red blood cells stored in modified CPD with adenine: report of a multi-institutional cooperative effort

In order to provide data in support of licensure applications for citrate-phosphate-dextrose (CPD) supplemented with adenine, a multi-institutional cooperative effort was organized to determine survivability of red blood cells subjected to prolonged liquid storage. Two manufacturers supplied plastic multiple bag blood storage containers prefilled with modified CPD (glucose 25% greater than the normal concentration) supplemented with adenine (17.0 to 17.3 mg per 63 ml of anticoagulant; 0.25 millimolar approximate final concentration when diluted with 450 ml of whole blood for 35 days showed a mean survival of 80.53 +/- 6.44 per cent (1 SD). Both red blood cell and supernatant plasma biochemical characteristics were comparable to those reported for whole blood stored for 21 days in either acid-citrate-dextrose (ACD) or CPD. Red blood cells from 19 units stored as concentrates for 35 days (Hct 75.03 +/- 3.74%) had a mean survival of 71.38 +/- 10.3 per cent with considerable interdonor variation in survival and interlaboratory variation in some biochemical characteristics. Red blood cells from eight units stored as concentrates (Hct 75.38 +/- 4.30%) for 28 days showed a mean survival of 83.97 +/- 6.10 per cent and biochemical characteristics comparable to those reported for red blood cell concentrates stored in CPD or ACD for 21 days. Modified CPD with adenine as formulated offers an improved anticoagulant for blood banking by extending the permissible red blood cell storage period.