Observed Trajectories of Cannabis Use and Concurrent Longitudinal Outcomes in Youth and Young Adults Receiving Coordinated Specialty Care for Early Psychosis

Cannabis use is present and persistent in young adults with early psychosis receiving Coordinated Specialty Care (CSC) in the United States. While CSC programs are effective in improving quality of life, helping individuals reach goals, and promoting recovery, cannabis use may limit the extent of these improvements. This study extended upon previous findings to examine trajectories of cannabis use among individuals with early psychosis. The sample consisted of 1325 CSC participants enrolled for more than one year at OnTrackNY and followed up to two years, categorized into three groups: no use, reduced use, and persistent use. Baseline demographic and clinical differences were compared across groups and associations between clinical and psychosocial outcomes at 12 months and 24 months were examined across groups. Of the sample, 40 % remained persistent users over two years while 12.8 % reduced their use. At baseline, persistent users were younger (p = 0.011), more likely to be male (p < 0.001), had lower education levels (p = 0.019), and were more likely to have had past legal issues prior to admission (p < 0.001) than non-users. At 2 years, persistent users had significantly worse symptom scores than non-users (p = 0.0003) and reduced users (p = 0.0004). These findings highlight the presence of persistent cannabis use being common in this population and the need to improve substance use treatment offered to allow more CSC participants to achieve improved outcomes.

Validity of the DSM-5 craving criterion for alcohol, tobacco, cannabis, cocaine, heroin, and non-prescription use of prescription painkillers (opioids)

BACKGROUND

Although the DSM-5 was adopted in 2013, the validity of the new substance use disorder (SUD) diagnosis and craving criterion has not been investigated systematically across substances.

METHODS

Adults (N = 588) who engaged in binge drinking or illicit drug use and endorsed at least one DSM-5 SUD criterion were included. DSM-5 SUD criteria were assessed for alcohol, tobacco, cannabis, cocaine, heroin, and opioids. Craving was considered positive if "wanted to use so badly that could not think of anything else" (severe craving) or "felt a very strong desire or urge to use" (moderate craving) was endorsed. Baseline information on substance-related variables and psychopathology was collected, and electronic daily assessment queried substance use for the following 90 days. For each substance, logistic regression estimated the association between craving and validators, i.e. variables expected to be related to craving/SUD, and whether association with the validators differed for DSM-5 SUD diagnosed with craving as a criterion v. without.

RESULTS

Across substances, craving was associated with most baseline validators (p values<0.05); neither moderate nor severe craving consistently showed greater associations. Baseline craving predicted subsequent use [odds ratios (OR): 4.2 (alcohol) - 234.3 (heroin); p's ⩽ 0.0001], with stronger associations for moderate than severe craving (p's < 0.05). Baseline DSM-5 SUD showed stronger associations with subsequent use when diagnosed with craving than without (p's < 0.05).

CONCLUSION

The DSM-5 craving criterion as operationalized in this study is valid. Including craving improves the validity of DSM-5 SUD diagnoses, and clinical relevance, since craving may cause impaired control over use and development and maintenance of SUD.

Consultant psychiatrists' experience of the impact of the COVID-19 pandemic on mental health services

OBJECTIVES

The novel coronavirus 2019 (COVID-19) has spread worldwide threatening human health. To reduce transmission, a 'lockdown' was introduced in Ireland between March and May 2020. The aim of this study is to capture the experiences of consultant psychiatrists during lockdown and their perception of it's impact on mental health services.

METHODS

A questionnaire designed by the Royal College of Psychiatrists was adapted and circulated to consultant members of the College of Psychiatrists of Ireland following the easing of restrictions. The questionnaire assessed the perceived impact on referral rates, mental health act provision, availability of information technology (IT), consultant well-being and availability of personal protective equipment (PPE). Thematic analysis was employed to analyse free-text sections.

RESULTS

Response rate was 32% (n = 197/623). Consultants reported an initial decrease/significant decrease in referrals in the first month of lockdown (68%, n = 95/140) followed by an increase/significant increase in the second month for both new (83%, n = 100/137) and previously attending patients (65%, n = 88/136). Social isolation and reduced face-to-face mental health supports were among the main reasons identified. The needs of children and older adults were highlighted. Most consultants (76%, n = 98/129) felt their working day was affected and their well-being reduced (52%, n = 61/119). The majority felt IT equipment availability was inadequate (67%, n = 88/132). Main themes identified from free-text sections were service management, relationship between patients and healthcare service and effects on consultants' lives.

CONCLUSIONS

The COVID-19 pandemic has placed increased pressure on service provision and consultant wellness. This further supports the longstanding need to increase mental health service investment.

440 Training in Microbiological Sampling for Toe Amputations in Diabetic Foot Disease: A Survey of UK Vascular Trainees

Aim

To determine usual practice and extent of training received by United Kingdom (UK) vascular surgery trainees in microbiological sampling for toe amputations in diabetic patients.

Method

A prospective online survey was distributed via social media networks and trainee organisations. All vascular surgery trainees in the UK were invited to participate. A total of 29 responses were included in the analysis.

Results

86% of respondents have been trained in toe amputations during registrar training. 66% have not been taught which samples to send for microbiological analysis. 10% receive regular training reviews in toe amputations. There is significant variability in the types of samples sent by trainees for microbiological analysis and the majority of trainees did not know how their samples are processed in the laboratory.

Conclusions

Toe amputations appear to be a neglected aspect of training for UK vascular surgery registrars. Lack of consistency in microbiological sampling techniques may prevent optimum antimicrobial stewardship and therefore increase the risk of further complications including major amputation. Inclusion of diabetic foot sepsis as a critical condition in the new vascular surgery curriculum may help to address this issue. A national consensus needs to be reached on how microbiological samples should be taken and processed in order for trainees to be taught in a consistent manner.

Establishment of Pertussis toxin BRP batch 2 for CHO clustering assay

Recently, the Chinese hamster ovary (CHO) cell-based clustering assay replaced the in vivo Histamine Sensitisation Test (HIST) in mice in European Pharmacopoeia (Ph. Eur.) general chapter 2.6.33. ‘Residual pertussis toxin’ as the recommended method to test for residual pertussis toxin in acellular pertussis vaccine intermediates. To support the standardised CHO clustering assay, availability of a reference standard is critical. Ph. Eur. pertussis toxin Biological Reference Preparation (BRP) batch 1 was first calibrated in International Units in 2008 for the HIST and subsequently also calibrated for the CHO clustering assay in 2017. However, its stocks were dwindling and needed to be replaced. In an effort to maintain adequate supply, a project (BSP141) was initiated by the European Directorate for the Quality of Medicines & HealthCare (EDQM), under the aegis of the Biological Standardisation Programme, to establish a second pertussis toxin BRP (BRP2). Candidate material was manufactured ad hoc by an acellular pertussis vaccine manufacturer and an optimal formulation for long-term stability was defined. Exhaustive in-process and post-production controls demonstrated that the material was fit for its intended purpose and therefore a collaborative study for calibration and stability assessment of the candidate material was organised, which included 10 laboratories worldwide. As a result of the study, the candidate material was established as Ph. Eur. Pertussis toxin BRP batch 2 with a potency of 130 IU/vial for the CHO clustering assay. Unopened vials must be stored at −20°C. The BRP may be used for up to two weeks after reconstitution if appropriately handled and stored at 2–8°C.

Current level of technology use, health and eHealth literacy in older Canadians with a recent fracture-a survey in orthopedic clinics

Among older adults who have recently sustained a fracture, there is substantial adoption of mobile technology. Furthermore, health and eHealth literacy level reported by participants supports the development of interactive eHealth interventions toward fostering better patient engagement in skeletal health management.

INTRODUCTION

Electronic health resources are increasingly used in the self-management of medical conditions. We aimed to identify the current level of technology adoption, health, and eHealth literacy among older adults with a recent fracture, to determine if the use of electronic interventions would be feasible and acceptable in this population.

METHODS

Adults ≥ 50 years with recent fractures were invited to complete a self-administered survey composed of 21 questions, including an 8-item perceived eHealth literacy scale.

RESULTS

A total of 401 participants completed the survey (women, 64%; ≥ 65 years, 59%; university education, 32%). Most participants reported no difficulty in reading printed health material (67%) and felt confident in filling out medical forms (65%). Younger age and higher levels of education were associated with higher health literacy. Most respondents (81%) owned at least one mobile device (smartphone, 49%; tablet, 45%). eHEALS scores were similar among men (29, IQR 24-32) and women (29, IQR 25-33), and between younger age group categories (50-64 years, 30; IQR 26-33; and 65-74 years, 29; IQR 25-32), but lower in the oldest age group (≥ 75 years, 24; IQR 21-29; p < 0.05). Compared with the youngest group, those ≥ 75 years had higher odds of an eHEALS < 26 (odds ratio, 4.2; 95% confidence interval 2.0-8.9) after adjusting for sex and education level.

CONCLUSION

There is significant adoption of mobile technology among older adults. Health and eHealth literacy reported by this study population supports the development of interactive eHealth interventions toward fostering better patient engagement in skeletal health management.

Pilot study on the use of infrared thermal imaging to predict infrainguinal bypass outcome in the immediate post-operative period

Objectives

Early bedside post-operative monitoring of infrainguinal bypass surgery is currently based on subjective clinical findings and handheld Doppler signals. Infrared thermal imaging is an objective and reproducible technique that has been proven to be a reliable and accurate method to measure skin temperature. The aim of this prospective study was to assess infrared thermal imaging as a predicting tool of bypass graft outcome in the immediate post-operative period and assess the angiosome concept.

Methods

This was a prospective cohort study of 25 patients undergoing infrainguinal bypass. Demographic and clinical data were prospectively collected and included gender, age, co-morbidities, pre- and post-operative ankle brachial pressure indices, surgery undertaken and patency of run-off vessels. Infrared thermal imaging was undertaken pre- and post-operatively to assess thermal changes to the feet following revascularisation.

Results

We found that an increase in temperature from pre- to post-operative was significantly associated with bypass patency. An increase in temperature was found to have a positive predictive value of 75%, a negative predictive value of 100%, a sensitivity of 100% and specificity of 89% for predicting graft patency.

Conclusions

Infrared thermal imaging can be used to measure temperature related changes of the microcirculation post-operatively and predict bypass outcomes in the immediate post-operative period.

"Reversible" myelodysplastic syndrome or ineffectual clonal haematopoiesis? - add(6p) myeloid neoplasm with a spontaneous cytogenetic remission

Cytotoxic chemotherapy has inherent mutagenic potential and alters the bone marrow microenvironment after therapy. In some cases, this potentiates expansion of an aberrant clone and may lead to a therapy-related myeloid neoplasm if the clone overcomes selective pressure. We present the case of a 43-year-old woman diagnosed with an indolent, therapy-related myeloid neoplasm with an isolated chromosome 6p abnormality following treatment for de novo Acute Myeloid Leukaemia (AML), who manifest a sustained spontaneous cytogenetic remission two years later, possibly due to an ineffectual or non-dominant founding clone. This case reminds us to be mindful of the possibility that clonal haematopoiesis may not always equate to clinically relevant disease, even in the setting of an abnormal clonal karyotype.

Hippocampal dysfunction in the pathophysiology of schizophrenia: a selective review and hypothesis for early detection and intervention

Scientists have long sought to characterize the pathophysiologic basis of schizophrenia and develop biomarkers that could identify the illness. Extensive postmortem and in vivo neuroimaging research has described the early involvement of the hippocampus in the pathophysiology of schizophrenia. In this context, we have developed a hypothesis that describes the evolution of schizophrenia-from the premorbid through the prodromal stages to syndromal psychosis-and posits dysregulation of glutamate neurotransmission beginning in the CA1 region of the hippocampus as inducing attenuated psychotic symptoms and initiating the transition to syndromal psychosis. As the illness progresses, this pathological process expands to other regions of the hippocampal circuit and projection fields in other anatomic areas including the frontal cortex, and induces an atrophic process in which hippocampal neuropil is reduced and interneurons are lost. This paper will describe the studies of our group and other investigators supporting this pathophysiological hypothesis, as well as its implications for early detection and therapeutic intervention.

Atypical femur fractures: a survey of current practices in orthopedic surgery

The results of a self-administered online survey demonstrate that orthopedic surgeons' management practices for AFF are variable. These data will inform the development of clinical practice guidelines.

INTRODUCTION

We aimed to determine current AFF treatment practices of orthopedic surgeons to inform clinical practice guideline development.

METHODS

A self-administered online survey was developed and sequentially posted on the Orthopaedic Trauma Association (OTA) website from July to August 2015 and the Canadian Orthopaedic Association (COA) website from December 2015 to January 2016. Level of confidence in diagnosis and treatment as well as treatment preferences between respondents who self-identified as trauma surgeons vs. non-trauma surgeons were compared.

RESULTS

A total of 172 completed surveys were obtained (OTA, N = 100, 58%; COA, N = 72, 8%). Seventy-eight percent of respondents had treated ≥1 AFF in the previous 6 months. Seventy-six percent reported feeling extremely or very confident in diagnosing AFF (trauma 84% vs. non-trauma surgeons 70%, p = 0.04), and 63% reported feeling extremely or very confident in treating AFF (trauma 82%, non-trauma surgeons 50%, p < 0.01). Preferred management for complete and symptomatic incomplete AFFs was surgical fixation with a cephalomedullary nail (CMN) by 88 and 79%, respectively, while close follow-up was preferred for asymptomatic incomplete AFFs in 72% of respondents. Trauma surgeons used the CMN more frequently than non-trauma surgeons (90 vs. 76% p = 0.03). In patients with bilateral AFFs, with one side surgically treated, 56% were extremely likely to surgically treat the contralateral side, if symptomatic. Most felt guidelines (81%) and educational resources (73%) would be valuable.

CONCLUSIONS

Current orthopedic treatment practices for AFFs are variable. The results of this survey will inform the development of practice guidelines and educational resources.

Examining heterotypic continuity of psychopathology: a prospective national study

BACKGROUND

Individuals with one psychiatric disorder are at increased risk for incidence and recurrence of other disorders. We characterize whether the magnitude of such heterotypic continuity varies based on whether the first disorder remits or persists over time.

METHOD

Cohorts were selected from participants in the National Epidemiologic Survey on Alcohol and Related Conditions wave 1 (2001-2002) and wave 2 (2004-2005) surveys with ⩾1 mood, anxiety, or substance use disorder at wave 1. Among respondents remitting (n = 6719) or not remitting (n = 3435) from ⩾1 of disorder at wave 2, the analyses compared the odds of developing new disorders.

RESULTS

As compared with adults whose disorders persisted from wave 1 to wave 2, those with ⩾1 remission had lower odds of incidence or recurrence of another disorder. Remission from alcohol dependence [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3-0.5] and drug dependence (OR 0.4, 95% CI 0.3-0.6) were associated with the lowest odds of incidence of another disorder. Social anxiety disorder was associated with the lowest adjusted odds of recurrence (adjusted OR = 0.2, 95% CI 0.1-0.6). Remission of disorders within one class (mood, anxiety, substance use) was consistently associated with lower odds of incidence or recurrence of disorders from the same class than with developing disorders from the other classes.

CONCLUSIONS

Remission from common psychiatric disorders tends to decrease the risk for incidence or recurrence of disorders and this effect is stronger within than across disorder classes. These results do not support the concept of heterotypic continuity as a substitution of one disorder for another.

Role of vitamin A metabolism in IIH: Results from the idiopathic intracranial hypertension treatment trial

INTRODUCTION

Vitamin A and its metabolites (called retinoids) have been thought to play a role in the development of idiopathic intracranial hypertension (IIH). The IIH Treatment Trial (IIHTT) showed the efficacy of acetazolamide (ACZ) in improving visual field function, papilledema grade, quality of life and cerebrospinal fluid (CSF) pressure. We postulated that IIH patients would demonstrate elevated measures of vitamin A metabolites in the serum and CSF.

METHODS

Comprehensive measures of serum vitamin A and its metabolites were obtained from 96 IIHTT subjects, randomly assigned to treatment with ACZ or placebo, and 25 controls with similar gender, age and body mass index (BMI). These included retinol, retinol binding protein, all-trans retinoic acid (ATRA), alpha- and beta-carotenes, and beta-cryptoxanthin. The IIHTT subjects also had CSF and serum vitamin A and metabolite measurements obtained at study entry and at six months.

RESULTS

At study entry, of the vitamin A metabolites only serum ATRA was significantly different in IIHTT subjects (median 4.33nM) and controls (median 5.04nM, p=0.02). The BMI of IIHTT subjects showed mild significant negative correlations with serum ATRA, alpha- and beta-carotene, and beta-cryptoxanthin. In contrast, the control subject BMI correlated only with serum ATRA. At six months, the serum retinol, alpha-carotene, beta-carotene, and CSF retinol were increased from baseline in the ACZ treated group, but only increases in alpha-carotene (p=0.02) and CSF ATRA (p=0.04) were significantly greater in the ACZ group compared with the placebo group. No other vitamin A measures were significantly altered over the six months in either treatment group. Weight loss correlated with only with the change in serum beta-carotene (r=-0.44, p=0.006) and the change in CSF retinol (r=-0.61, p=0.02).

CONCLUSION

Vitamin A toxicity is unlikely a contributory factor in the causation of IIH. Our findings differ from those of prior reports in part because of our use of more accurate quantitative methods and measuring vitamin A metabolites in both serum and CSF. ACZ may alter retinoid metabolism in IIH patients.

The clinical utility of genetic testing of tissues from pregnancy losses

OBJECTIVE

To map the current testing being undertaken following pregnancy loss across the UK and to examine the clinical utility in terms of identifying a cause for the loss and in identifying couples at risk of an unbalanced liveborn child.

DESIGN

Retrospective audit.

SETTING

UK, for the year 2014.

POPULATION

An audit of 6465 referrals for genetic testing of tissue samples following pregnancy loss.

METHODS

Data were obtained by questionnaire from 15 UK regional genetics laboratories.

MAIN OUTCOME MEASURES

Data were analysed with respect to gestational age, the presence of identified fetal anomalies, methodologies used, abnormality rates and the presence of a parental balanced rearrangement.

RESULTS

Of 6465 referrals a genetic cause was identified in 22% of cases (before 12 weeks' gestation, in 47%; at 12-24 weeks, in 14%; after 24 weeks, in 6%). In 0.4% of cases a balanced parental rearrangement was identified where there was a risk of an affected liveborn child in a future pregnancy. Eighty percent of genetic imbalances identified were aneuploidy or triploidy and could be identified by quantitative fluorescence polymerase chain reaction alone. There was significant variation across the UK in acceptance criteria, testing strategies and thus level of resolution of testing.

CONCLUSIONS

Genetic testing of tissues following pregnancy loss identifies a probable cause of fetal demise in 22% of cases, but it is of low clinical utility in identifying couples at risk of a future unbalanced liveborn child. A comprehensive multidisciplinary review is needed to develop proposals for an affordable and equitable service.

TWEETABLE ABSTRACT

UK audit of genetic testing of fetal loss shows variation in access to and resolution of analysis.

Mental disorders and risk of suicide attempt: a national prospective study

Most mental disorders, when examined independently, are associated with an elevated risk for suicide attempt. However, mental disorders often co-occur, and that co-occurrence is well explained by models where specific mental disorders are understood as manifestations of latent dimensions of psychopathology. To date, it remains unclear whether the risk of suicide attempt is due to specific mental disorders, to specific dimensions of psychopathology (that is, internalizing and externalizing dimensions), to a general psychopathology factor or to a combination of these explanations. In a large nationally representative prospective survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we used structural equation modeling to examine the shared and specific effects of Axis I and Axis II disorders on the occurrence of suicide attempts in the general population and among individuals with a lifetime history of suicidal ideation. Effects of mental disorders on the risk of suicide attempt were exerted almost exclusively through a general psychopathology factor representing the shared effect across all mental disorders. Effects of remitted psychiatric disorders on the risk of suicide attempt were fully mediated by current mental disorders. Similar patterns of associations were found in individuals with suicidal ideation. These results held when using different approaches to modeling psychiatric comorbidity. Our findings underscore the importance of adopting dimensional approaches to comorbidity in the study of suicidal behavior. Because mental disorders increase the risk of suicide attempt through a general psychopathology liability, this dimension should be considered as an important therapeutic target to substantially advance suicide prevention.

Mediators involved in the relation between depressive symptoms and weight status in female adolescents and young adults

Depression may be a risk factor for overweight status, but mechanisms involved in this relationship are unclear. This study explored behavioral factors involved in the relationship between adolescent depression symptoms and adult overweight status. A population-based cohort of female participants in Project EAT (n=1,035) was followed over 10 years and reported on psychological functioning, weight status, and eating and activity patterns in early/middle adolescence (1999=Time 1; T1), middle adolescence/early young adulthood (2004=Time 2; T2), and early/middle young adulthood (2009=Time 3; T3). Structural equation models were fit which included T1 depression scores predicting overweight status at T3, with T2 fruit and vegetable consumption, moderate-to-vigorous physical activity, and binge eating examined as mediators. There were small but significant effects of T1 depression scores predicting an increased likelihood of T3 overweight status (standardized estimate=0.038; p=.007), and of T2 binge eating mediating the relation between T1 depression and T3 overweight status (standardized indirect effect estimate=.036; p=.009). Binge eating may be one pathway to overweight among depressed females, suggesting that recognition and treatment of eating pathology in individuals with depression may help prevent overweight. Examination of other behavioral (and non-behavioral) factors explaining the relationship between depression and overweight is warranted.

Large-amplitude internal waves benefit corals during thermal stress

Tropical scleractinian corals are particularly vulnerable to global warming as elevated sea surface temperatures (SSTs) disrupt the delicate balance between the coral host and their algal endosymbionts, leading to symbiont expulsion, mass bleaching and mortality. While satellite sensing of SST has proved a reliable predictor of coral bleaching at the regional scale, there are large deviations in bleaching severity and mortality on the local scale that are poorly understood. Here, we show that internal waves play a major role in explaining local coral bleaching and mortality patterns in the Andaman Sea. Despite a severe region-wide SST anomaly in May 2010, frequent upslope intrusions of cold sub-pycnocline waters due to breaking large-amplitude internal waves (LAIW) mitigated coral bleaching and mortality in shallow waters. In LAIW-sheltered waters, by contrast, bleaching-susceptible species suffered severe bleaching and total mortality. These findings suggest that LAIW benefit coral reefs during thermal stress and provide local refugia for bleaching-susceptible corals. LAIW are ubiquitous in tropical stratified waters and their swash zones may thus be important conservation areas for the maintenance of coral diversity in a warming climate. Taking LAIW into account can significantly improve coral bleaching predictions and provide a valuable tool for coral reef conservation and management.

Transport of very preterm infants with respiratory distress syndrome using nasal continuous positive airway pressure

AIM

To audit clinical practice during transport of very preterm infants (<32 weeks) with acute respiratory distress syndrome (RDS) receiving nasal continuous positive airway pressure (NCPAP).

METHODS

Retrospective cohort study.

RESULTS

Twenty-seven infants were receiving NCPAP before transport team's arrival, and 23 were commenced on NCPAP after team's arrival. Six infants (12%) failed NCPAP before transfer, 2 infants (4.5%) failed NCPAP less than 24 hours, and 5 infants (11.3%) failed more than 24 hours - 7 days following admission. None died or developed pneumothorax during, or 7 days after admission. We did not observe NCPAP failure during transfer. There was a statistically significant difference between the NCPAP success and NCPAP failure groups for FiO2 at admission (p < 0.05), and the duration of NCPAP (p < 0.05).

CONCLUSION

NCPAP is a potentially safe and effective mode of respiratory support for very preterm infants during ground, and air transports.

Latent structure of social fears and social anxiety disorders

BACKGROUND

Despite its high prevalence and associated levels of impairment, the latent structure of social anxiety disorder (SAD) is not well understood, with published studies reporting inconsistent results. Furthermore, it is unknown whether the latent structure of social fears in individuals with and without SAD is the same.

METHOD

Exploratory factor analysis (EFA) and confirmatory factor analysis followed by multiple indicators multiple causes (MIMIC) analysis were conducted on 13 commonly feared social situations assessed in a nationally representative sample including individuals with SAD and those with social fears but who did not meet DSM-IV criteria for SAD.

RESULTS

An EFA conducted in the full sample, including individuals with no social fears (88% of the sample), yielded only one factor. When the sample was restricted to those with at least one social fear, the EFA yielded three factors, in both the subsample with at least one social fear but no SAD and the subsample with SAD. The three factors represented feared situations related to public performance, close scrutiny and social interaction. The MIMIC analyses further indicated that the three-factor structure was able to explain differences in prevalence of social fears across a broad range of sociodemographic covariates.

CONCLUSIONS

Among individuals with at least one social fear and those with DSM-IV SAD the latent structure of social fears appears to be best described by three factors, although this may partially depend on how the sample is specified. These results may help reconcile the findings of different numbers of factors identified in previous studies.

Imperfect informed consent for prenatal screening: Lessons from the Quad screen

Objective

The study evaluated patient informed consent (IC) for the Quad screen and examined differences in IC between test acceptors and test refusers. A multidimensional model of IC was used.

Methods

Women seeking prenatal care at nine obstetrics clinics in a large Midwestern city completed surveys between February and December 2006. Surveys contained measures for three dimensions of IC: intention, understanding and controlling influence.

Results

56.2% of women did not meet criteria for all three of our dimensions of IC and therefore failed to give it. The failure rate was higher among women who choose to screen (72.6%) than women who choose not screen (50%) (p < 0.001). Women who met all criteria for IC were over three times less likley to choose to screen (or = 0.32, CI 0.17–0.62 ( p < 0.01)) than women who did not meet criteria for IC.

Conclusion

The decision to screen for fetal anomalies is less of a deliberated action than the decision not to screen. Women who lack a fundamental understanding of the purpose and nature of the screen may be operating on the belief that the screen is part of standard care and presents no need to deliberate.

Home/family, peer, school, and neighborhood correlates of obesity in adolescents

OBJECTIVE

This study was designed to (1) identify the most important home/family, peer, school, and neighborhood environmental characteristics associated with weight status and (2) determine the overall contribution of these contexts to explaining weight status among an ethnically/racially diverse sample of adolescents.

DESIGN AND METHODS

Surveys and anthropometric measures were completed in 2009-2010 by 2,793 adolescents (53.2% girls, mean age = 14.4 ± 2.0, 81.1% non-white) in Minneapolis/St. Paul, Minnesota schools. Data representing characteristics of adolescents' environments were collected from parents/caregivers, friends, school personnel, and Geographic Information System sources. Multiple regression models controlled for adolescent age, ethnicity/race, and socioeconomic status.

RESULTS

The variance in body mass index (BMI) z-scores explained by 51 multicontextual characteristics was 24% for boys and 22% for girls. Across models, several characteristics of home/family (e.g., infrequent family meals) and peer environments (e.g., higher proportion of male friends who were overweight) were consistently associated with higher BMI z-scores among both boys and girls. Among girls, additional peer (e.g., lower physical activity among female friends) and neighborhood (e.g., perceived lack of safety) characteristics were consistently associated with higher BMI z-scores.

CONCLUSIONS

Results underscore the importance of addressing the home/family and peer environments in future research and intervention efforts designed to reduce adolescent obesity.

Modeling and treating internalizing psychopathology in a clinical trial: a latent variable structural equation modeling approach

BACKGROUND

Clinical trials are typically designed to test the effect of a specific treatment on a single diagnostic entity. However, because common internalizing disorders are highly correlated ('co-morbid'), we sought to establish a practical and parsimonious method to characterize and quantify changes in a broad spectrum of internalizing psychopathology targeted for treatment in a clinical trial contrasting two transdiagnostic psychosocial interventions.

METHOD

Alcohol dependence treatment patients who had any of several common internalizing disorders were randomized to a six-session cognitive-behavioral therapy (CBT) experimental treatment condition or a progressive muscle relaxation training (PMRT) comparison treatment condition. Internalizing psychopathology was characterized at baseline and 4 months following treatment in terms of the latent structure of six distinct internalizing symptom domain surveys.

RESULTS

Exploratory structural equation modeling (ESEM) identified a two-factor solution at both baseline and the 4-month follow-up: Distress (measures of depression, trait anxiety and worry) and Fear (measures of panic anxiety, social anxiety and agoraphobia). Although confirmatory factor analysis (CFA) demonstrated measurement invariance between the time-points, structural models showed that the latent means of Fear and Distress decreased substantially from baseline to follow-up for both groups, with a small but statistically significant advantage for the CBT group in terms of Distress (but not Fear) reduction.

CONCLUSIONS

The approach demonstrated in this study provides a practical solution to modeling co-morbidity in a clinical trial and is consistent with converging evidence pointing to the dimensional structure of internalizing psychopathology.

Thought disorder in the meta-structure of psychopathology

BACKGROUND

Dimensional models of co-morbidity have the potential to improve the conceptualization of mental disorders in research and clinical work, yet little is known about how relatively uncommon disorders may fit with more common disorders. The present study estimated the meta-structure of psychopathology in the US general population focusing on the placement of five under-studied disorders sharing features of thought disorder: paranoid, schizoid, avoidant and schizotypal personality disorders, and manic episodes as well as bipolar disorder.

METHOD

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a face-to-face interview of 34 653 non-institutionalized adults in the US general population. The meta-structure of 16 DSM-IV Axis I and Axis II psychiatric disorders, as assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version (AUDADIS-IV), was examined using exploratory and confirmatory factor analysis.

RESULTS

We document an empirically derived thought disorder factor that is a subdomain of the internalizing dimension, characterized by schizoid, paranoid, schizotypal and avoidant personality disorders as well as manic episodes. Manic episodes exhibit notable associations with both the distress subdomain of the internalizing dimension as well as the thought disorder subdomain. The structure was replicated for bipolar disorder (I or II) in place of manic episodes.

CONCLUSIONS

As our understanding of psychopathological meta-structure expands, incorporation of disorders characterized by detachment and psychoticism grows increasingly important. Disorders characterized by detachment and psychoticism may be well conceptualized, organized and measured as a subdimension of the internalizing spectrum of disorders. Manic episodes and bipolar disorder exhibit substantial co-morbidity across both distress and thought disorder domains of the internalizing dimension. Clinically, these results underscore the potential utility of conceptualizing patient treatment needs using an approach targeting psychopathological systems underlying meta-structural classification rubrics.

A GIS-based methodology for selecting stormwater disconnection opportunities

The purpose of this paper is to introduce a geographic information system (GIS)-based decision support tool that assists the user to select not only areas where (retrofit) sustainable drainage systems (SuDS) could be implemented within a large catchment (>100 ha), but also to allow discrimination between suitable SuDS techniques based on their likely feasibility and effectiveness. The tool is applied to a case study catchment within London, UK, with the aim of increasing receiving water quality by reducing combined sewer overflow (CSO) spill frequency and volume. The key benefit of the tool presented is to allow rapid assessment of the retrofit SuDS potential of large catchments. It is not intended to replace detailed site investigations, but may help to direct attention to sites that have the greatest potential for retrofit SuDS implementation. Preliminary InfoWorks CS modelling of 'global disconnections' within the case study catchment, e.g. the removal of 50% of the total impervious area, showed that CSO spill volume could be reduced by 55 to 78% during a typical year. Using the disconnection hierarchy developed by the authors, the feasibility of retrofit SuDS deployment within the case study catchment is assessed, and the implications discussed.

First Report of Association of Mucor circinelloides on Noni (Morinda citrifolia) in Hawaii

Noni (Morinda citrifolia) is a popular medicinal plant found in tropical or subtropical regions of the world. The fruit and juice extracts have properties that are reportedly therapeutic for diabetes, high blood pressure, and certain types of cancer (1,4). In our studies on noni juice produced from fruit collected from the Kohala and Puna districts of the island of Hawaii from 2008 to 2010, Mucor circinelloides f. sp. circinelloides was isolated from 85% of 157 juice samples and observed with up to 75% incidence on fruit surfaces during fermentation processing in glass jars. Fungal growth, appearing 14 to 21 days in storage at 22°C, was pale yellow to tan brown and was associated with wounded surfaces. Single-spore strains, KN 06-2 (2006; ripe fruit puree) and KN 08-08 (2008; fermented juice; CBS 124110), identified by Centraalbureau voor Schimmelcultures by molecular methods were 97.3% similar in internal transcribed spacer sequence to the type strain (CBS 195.68). M. circinelloides f. sp. circinelloides strains (KN 08-08, KN 09-06, or KN 10-02) (2008 to 2010; fermented juice) were inoculated by pipetting an aliquot of 100 μl of fungus strain spore suspension (1 × 10⁵ to 1.33 × 10⁶ spores/ml) onto firm, yellow maturity noni fruit that were washed, surface disinfected, and either wounded (surface cuts) or nonwounded. Controls consisted of no inoculation and sterile distilled water (SDW) inoculation treatments. Ten to twenty each of wounded and nonwounded fruit comprised each inoculation treatment. Fruit were incubated in acrylic bins with a layer of distilled water at the bottom, and sealed with snap-on lids. The bins were incubated on a lab bench at 22 to 23°C under fluorescent lights. Fruits were evaluated for presence of fungal growth and severity of symptoms. To determine viability of spores on inoculated fruit without symptoms, surfaces were swabbed with sterile cotton swabs dipped in SDW, streaked on potato dextrose agar (PDA) plates, and incubated at 22°C under fluorescent lights. The inoculation experiment was conducted twice. Nonwounded fruit inoculated with M. circinelloides f. sp. circinelloides strains did not result in infections (KN 09-06 and KN 10-02) or produced slight mycelial growth (0 to 20%; KN 08-08). Wounded fruit inoculated with any of the three strains resulted in 85 to 100% infection of moderate severity. There were no infections in noninoculated or SDW treatments of nonwounded or wounded fruit. Koch's postulates were fulfilled with the reisolation of M. circinelloides f. sp. circinelloides from selected fruit exhibiting soft tissue, discoloration, and sporulating yellowish green mycelial growth. Swab washes from asymptomatic surfaces of inoculated nonwounded fruit resulted in the growth of M. circinelloides f. sp. circinelloides on PDA, proving viability of the spores and confirmed that the fungus is primarily pathogenic only on wounded fruit surfaces. To our knowledge, this is the first report of M. circinelloides as a wound pathogen of noni fruit. The quality of fermented noni juice may be affected by the presence of M. circinelloides f. sp. circinelloides but can be remedied by pasteurization that does not affect antitumor properties (unpublished data). This fungus is also a reported pathogen of mango (2) and peach (3). References: (1) J. Li et al. Oncol. Rep. 20:1505, 2008. (2) K. Pernezny and G. W. Simone. Phytopathol. News 34:25, 2000. (3) C. Restuccia et al. J. Food Prot. 69:2465, 2006. (4) M. Y. Wang et al. Acta Pharmacol. Sin. 23:1127, 2002.

Psychometric properties of the modified Symptom Severity Index (SSI)

The psychometric properties of the modified Symptom Severity Index were investigated to assess the relationships among dimensions of pain in temporomandibular disorders (TMD). The 15-item instrument is composed of ordinal scales assessing five pain dimensions (intensity, frequency, duration, unpleasantness and difficulty to endure) as experienced in three locations (temple, temporomandibular joint (TMJ), masseter). In 108 closed-lock subjects, Cronbach's alpha was used to measure internal consistency resulting in 31 of the 105 pair-wise comparisons >or=0.71. Multilevel exploratory factor analysis was used to assess dimensionality between items. Two factors emerged, termed temple pain and jaw pain. The jaw pain factor comprised the TMJ and masseter locations, indicating that subjects did not differentiate between these two locations. With further analysis, the jaw pain factor could be separated into temporal aspects of pain (frequency, duration) and affective dimensions (intensity, unpleasantness, endurability). Temple pain could not be further reduced; this may have been influenced by concurrent orofacial pains such as headache. Internal consistency was high, with alphas >or=0.92 for scales associated with all factors. Excellent test-retest reliability was found for repeat testing at 2-48 h in 55 subjects (Intra-class correlation coefficients = 0.97, 95%CI 0.96-0.99). In conclusion, the modified Symptom Severity Index has excellent psychometric properties for use as an instrument to measure pain in subjects with TMD. The most important characteristic of this pain is location, while the temporal dimensions are important for jaw pain. Further research is needed to confirm these findings and assess relationships between dimensions of pain as experienced in other chronic pain disorders.

Distal revascularisation with interval ligation (DRIL): an experience

INTRODUCTION

The global increase of chronic renal failure has resulted in a growing number of patients on haemodialysis using arteriovenous fistulas (AVFs). By virtue of their very function, AVFs at times shunt blood away from regions distally, resulting in an ischaemic steal syndrome. Distal revascularisation with interval ligation (DRIL) has been described as a procedure to treat symptomatic ischaemic steal. We present our experience in the management of this complication.

PATIENTS AND METHODS

Six patients with severe ischaemic steal were treated using a DRIL procedure between May 2004 and June 2007. There were three males and three females, all with elbow brachiocephalic AVFs. Symptoms ranged from severe rest pain to digital gangrene. Published results from international studies of 135 DRIL procedures were also reviewed.

RESULTS

Vascular access was maintained along with the elimination of ischaemic symptoms in the six patients using an ipsilateral reversed basilic vein graft. Interval ligation of the distal brachial artery was performed at the same time. All patients showed immediate and sustained clinical improvement of symptoms with a demonstrable increase in digital pulse oximetry.

CONCLUSIONS

DRIL is a beneficial treatment option that has proven successful at alleviating ischemic steal symptoms and preserving vascular access. This avoids placement of central lines, its associated risks, and the need to create an alternative sited fistula.

Long-term follow-up of idiopathic intracranial hypertension: the Iowa experience

OBJECTIVE

To evaluate recurrent or delayed worsening of papilledema and visual function in patients with idiopathic intracranial hypertension (IIH) followed for more than 10 years.

METHODS

This is an Institutional Review Board approved retrospective chart review of 410 patients with the diagnosis of IIH evaluated at the University of Iowa Hospitals and Clinics from January 1984 to January 1996. Of the 410 patients, 20 patients with IIH who were followed over 10 years at the neuro-ophthalmology clinic met the inclusion criteria. Three neuro-ophthalmologists independently evaluated and graded the visual field examinations and optic disc stereo-photographs for each follow-up visit (median = 15).

RESULTS

Of the 20 patients, 11 demonstrated a stable course of disease without worsening in papilledema or visual field, and 9 patients worsened after a stable course. Of these 9 patients, 6 patients experienced delayed worsening (range: 28 to 135 months from presentation) and 3 patients had recurrence after resolution of papilledema 12 to 78 months from initial resolution of the IIH.

CONCLUSION

Idiopathic intracranial hypertension is a chronic condition that may worsen after a period of stability, warranting long-term follow-up.

Major phenolic acids and total antioxidant activity in Mamaki leaves, Pipturus albidus

Three phenolic acids, (+)catechins, chlorogenic acid, and rutin, were identified and quantified in Mamaki leaves using a liquid chromatograph-mass spectrometer technique. Concentrations of (+)catechins, chlorogenic acid, and rutin varied from 1.1 to 5.0 mg/g of Mamaki leaves as determined in the extract using 0.5% acetic acid in 90% aqueous methanol. This study also quantified total antioxidant capacity using the photochemiluminescence method, which was expressed in equivalents to ascorbic acid (AA). Mamaki teas brewed for 30 min contained total antioxidant activity (TAA) between 238 and 259 mg AA/g of tea. Mamaki teas brewed for 1 h and stored at 4 h, 1 d, and 3 d at 4 degrees C had available TAA 293, 271, 172, and 163 mg AA/g of tea leaves, respectively. The concentrations of (+)catechins and rutin in Mamaki leaves are compared to other types of popular teas. Mamaki teas contained relatively low amounts of TAA compared to green teas and Lipton teas.

Atypical Internal Yellowing of Papaya Fruit in Hawaii Caused by Enterobacter sakazakii

Internal yellowing (IY) caused by Enterobacter cloacae and characterized by yellow discolored tissue surrounding the papaya (Carica papaya L.) seed cavity, diffuse margins, and the presence of a distinctly rotten odor was first reported in 1987 (3). Here we report the formation of atypical internal yellowing (AIY) in ripe papaya caused by the bacterium Enterobacter sakazakii. In surveys conducted from 2006 to 2007, 'Kapoho Solo' papayas grown in the Puna District of Hawaii Island were obtained from various packinghouses. After incubation at 27°C, the papayas were bisected and examined for symptoms of IY. Among papayas that were asymptomatic for IY, a dull, greenish yellow discoloration of the flesh with a distinct margin extending from the seed cavity into the pericarp was noted, along with a pungent odor. These symptoms occurred in 5 of the 500 fruit surveyed and bacterial populations were 10² to 10³ CFU/g. Discolored tissue was aseptically excised, weighed, macerated, serially diluted in sterile distilled water (SDW), and plated onto modified peptone yeast extract medium (PT-M4) (4). The plates were incubated at 30°C for 24 to 48 h until single colonies were evident. After 48 h, colonies on PT-M4 were orange-red, convex and circular, and surrounded by a somewhat opaque 1-mm margin. After single colony purification, five strains were obtained. The strains, inoculated into oxidation/fermentation-glucose tubes and API 20E strips (bioMerieux, Inc., Durham, NC) incubated at 30°C, were shown to be facultative anaerobes and identified as E. sakazakii with a 98.4% certainty. Colonies plated onto tryptic soy agar (TSA) and incubated for 72 h at 25°C produced yellow pigmentation, indicative of E. sakazakii. Amplification by PCR with E. sakazakii-specific primers (2) yielded a 929-bp fragment, which was absent with E. cloacae and Pseudomonas aeruginosa template DNA. To confirm pathogenicity, cell suspensions at 10⁹ CFU/ml of putative E. sakazakii strains RK07-05, RK07-06, and RK07-07 and E. cloacae (3) were inoculated by injection (0.5 ml per site) into one-third-ripe 'Kapoho Solo' papayas (six fruit per strain, inoculated at duplicate sites) and incubated at 27°C for 4 days. Control sites were injected with 0.5 ml of SDW. Fruit inoculation experiments were repeated. E. cloacae-inoculated sites produced typical IY as previously described (3), while the sites inoculated with the three E. sakazakii strains produced greenish yellow tissue (26% mean incidence), symptomatic of AIY. Control sites did not produce IY or AIY. Koch's postulates were fulfilled, and the identification of reisolated bacterial strains was confirmed with API 20E, PCR, and pigment production on TSA. Although less prevalent (1% incidence) than the typical IY produced by E. cloacae (3), E. sakazakii has the potential to affect quality and food safety of fresh and processed papaya products. E. sakazakii has been implicated in a severe form of neonatal meningitis, sepsis, and necrotizing enterocolitis (1). Research into the transmission and infection of papaya of this cross-domain pathogen merits further study. References: (1) D. H. Adamson. Clin. Microbiol. Newsl. 3:19, 1981. (2) A. Lehner et al. BMC Microbiol. 4:43, 2004. (3) K. A. Nishijima et al. Plant Dis. 71:1029, 1987. (4) K. A. Nishijima et al. Plant Dis. 88:1318, 2004.

Long-term Results of Surgical Repair of Popliteal Artery Aneurysm

OBJECTIVE

To determine the long-term outcome of surgical repair of popliteal artery aneurysms (PAA).

METHODS

A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1988 and 2006 was performed. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan-Meier methods.

RESULTS

48 patients underwent repair of 63 PAAs (ligation and bypass=45, interposition grafting=18). The 5-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 75%, 95%, 98% and 81%, respectively. The 10-year primary graft patency rates were significantly lower for emergency cases (59%) compared with elective cases (66%) (p=0.0023). Thirteen patients (16 PAAs) required a total of 20 late re-interventions. Duplex ultrasound was available in 33 of 45 PAAs treated by ligation and bypass. Five (15%) PAAs demonstrated perfusion of the aneurysm sac at median (range) follow up of 75 (1-246) months after primary repair and two of these required emergency re-operation.

CONCLUSIONS

These data demonstrate that surgical PAA repair is associated with excellent long-term durability and provide an important benchmark with which to compare results of endovascular PAA repair. Patients treated using the ligation and bypass technique should be enrolled in an aneurysm sac surveillance program.

Demonstrating Pathogenicity of Enterobacter cloacae on Macadamia and Identifying Associated Volatiles of Gray Kernel of Macadamia in Hawaii

Gray kernel is an important disease of macadamia (Macadamia integrifolia) that affects the quality of kernels, causing gray discoloration and a permeating, foul odor. Gray kernel symptoms were produced in raw, in-shell kernels of three cultivars of macadamia that were inoculated with strains of Enterobacter cloacae. Koch's postulates were fulfilled for three strains, demonstrating that E. cloacae is a causal agent of gray kernel. An inoculation protocol was developed to consistently reproduce gray kernel symptoms. Among the E. cloacae strains studied, macadamia strain LK 0802-3 and ginger strain B193-3 produced the highest incidences of disease (65 and 40%, respectively). The other macadamia strain, KN 04-2, produced gray kernel in 21.7% of inoculated nuts. Control treatments had 1.7% gray kernel symptoms. Some abiotic and biotic factors that affected incidence of gray kernel in inoculated kernels were identified. Volatiles of gray and nongray kernel samples also were analyzed. Ethanol and acetic acid were present in nongray and gray kernel samples, whereas volatiles from gray kernel samples included the additional compounds, 3-hydroxy-2-butanone (acetoin), 2,3-butanediol, phenol, and 2-methoxyphenol (guaiacol). This is believed to be the first report of the identification of volatile compounds associated with gray kernel.