Culturally adapted psychosocial interventions (CaPSI) for early psychosis in a low-resource setting: study protocol for a large multi-center RCT

BACKGROUND

Psychosis treatment guidelines recommend cognitive behaviour therapy (CBT) and family intervention (FI), for all patients with first episode psychosis (FEP), though guidance borrows heavily from literature in adults from high income countries. To our knowledge, there are few randomized controlled trials (RCTs) examining the comparative effect of these commonly endorsed psychosocial interventions in individuals with early psychosis from high-income countries and no such trials from low and middle-income countries (LMICs). The present study aims to confirm the clinical-efficacy and cost-effectiveness of delivering culturally adapted CBT (CaCBT) and culturally adapted FI (CulFI) to individuals with FEP in Pakistan.

METHOD

A multi-centre, three-arm RCT of CaCBT, CulFI, and treatment as usual (TAU) for individuals with FEP (n = 390), recruited from major centres across Pakistan. Reducing overall symptoms of FEP will be the primary outcome. Additional aims will include improving patient and carer outcomes and estimating the economic impact of delivering culturally appropriate psychosocial interventions in low-resource settings. This trial will assess the clinical-efficacy and cost-effectiveness of CaCBT and CulFI compared with TAU in improving patient (positive and negative symptoms of psychosis, general psychopathology, depressive symptoms, quality of life, cognition, general functioning, and insight) and carer related outcomes (carer experience, wellbeing, illness attitudes and symptoms of depression and anxiety).

CONCLUSIONS

A successful trial may inform the rapid scale up of these interventions not only in Pakistan but other low-resource settings, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority groups with FEP.

TRIAL REGISTRATION

NCT05814913.

154 ‘You’ve Lost Your Tuning Form’ – Don't Worry I Have the Solution…

Background

Patients are frequently referred to ENT emergency services with sudden hearing loss. Differentiating sensorineural from conductive losses is paramount in establishing the urgency of review and when to commence urgent steroid therapy. Tuning fork tests are useful for this, but they are not always readily available in primary care or the emergency room.

Aim

To identify and evaluate an alternative method to Weber's test for differentiating conductive from sensorineural hearing loss.

Method

A pilot prospective diagnostic accuracy study was designed to include 10 individuals with unilateral conductive and 10 with asymmetrical sensorineural hearing loss. Each individual was subjected to a pure tone audiogram (PTA), Weber's test and the new index test.

Results

The new index test showed 100% correlation (r=1) with Weber's test and 90% sensitivity, specificity and overall accuracy when compared to Weber's test for diagnosing conductive and sensorineural hearing loss.

Conclusion

This new test may be used as an alternative to Weber's test when a tuning fork is not available. It might even replace the need for Weber's test when PTA testing is readily available. This test could be used to triage referrals and differentiate conductive from sensorineural hearing loss.

Conflicts

There are no conflicts to declare.

Highly efficient CRISPR-Cas9-mediated editing identifies novel mechanosensitive microRNA-140 targets in primary human articular chondrocytes

OBJECTIVE

MicroRNA 140 (miR-140) is a chondrocyte-specific endogenous gene regulator implicated in osteoarthritis (OA). As mechanical injury is a primary aetiological factor in OA, we investigated miR-140-dependent mechanosensitive gene regulation using a novel CRISPR-Cas9 methodology in primary human chondrocytes.

METHOD

Primary (passage 1/2) human OA chondrocytes were isolated from arthroplasty samples (six donors) and transfected with ribonuclear protein complexes or plasmids using single guide RNAs (sgRNAs) targeting miR-140, in combination with Cas9 endonuclease. Combinations of sgRNAs and single/double transfections were tested. Gene editing was measured by T7 endonuclease 1 (T7E1) assay. miRNA levels were confirmed by qPCR in chondrocytes and in wild type murine femoral head cartilage after acute injury. Predicted close match off-targets were examined. Mechanosensitive miR-140 target validation was assessed in 42 injury-associated genes using TaqMan Microfluidic cards in targeted and donor-matched control chondrocytes. Identified targets were examined in RNAseq data from costal chondrocytes from miR-140^-/- mice.

RESULTS

High efficiency gene editing of miR-140 (90-98%) was obtained when two sgRNAs were combined with double RNP-mediated CRISPR-Cas9 transfection. miR-140 levels fell rapidly after femoral cartilage injury. Of the top eight miR-140 gene targets identified (P < 0.01), we validated three previously identified ones (septin 2, bone morphogenetic protein 2 and fibroblast growth factor 2). Novel targets included Agrin, a newly recognised pro-regenerative cartilage agent, and proteins associated with retinoic acid signalling and the primary cilium.

CONCLUSION

We describe a highly efficient CRISPR-Cas9-mediated strategy for gene editing in primary human chondrocytes and identify several novel mechanosensitive miR-140 targets of disease relevance.

Demographic and psychosocial characteristics of self-harm: The Pakistan perspective

Self-harm is a major public health issue in Pakistan, yet the characteristics of those who self-harm are under-explored. This is a secondary analysis from a large randomized control trial on the prevention of self-harm, exploring demographic, clinical and psychological characteristics of people who self-harm in Pakistan. A total of 221 participants with a history of self-harm were recruited from medical wards of three major hospitals in Karachi. The Beck Scale for Suicidal Ideation (BSI), Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Suicide Attempt Self Injury Interview (SASII) assessment scales were completed. The sample consisted predominantly of females (68.8%) in their 20's. Interpersonal difficulties were most commonly reported as the main antecedent to the self-harm, followed by financial difficulties. Participants had high severity scores on BSI, BDI and BHS. Pesticide and insecticide use were (n = 167, 75.6%) the most common methods of self-harm. The findings indicate that some characteristics of those who self-harm in Pakistan are comparable to other populations. This may raise the possibility of common causal mechanisms and processes. Future research needs to examine the efficacy of interventions targeting these risk factors in reducing rates of self-harm and thus suicide.

Suicidal ideation during pregnancy in British Pakistani women

Introduction

Suicide is a major public health problem and one of the common causes of maternal mortality. Rates of suicide and self-harm are higher in British South Asian women compared to the majority white population. Suicidal Ideation (SI) is a significant risk factor associated with self-harm and suicide.

Objective

To explore the prevalence and risk factors of SI in British Pakistani women.

Aim

To identify risk factors associated with SI, in order to inform future preventive strategies.

Method

This is a secondary analysis of a larger study which looked at depression during pregnancy and infant outcomes. Participants who consented (women aged 18 or over, in their third pregnancy trimester) were initially assessed for maternal depression using the Edinburgh Post-Natal Depression Scale (EPDS), with one of the questions on the EPDS being on SI. Participants who met the study criteria, were further assessed regarding socio-demographic factors, perceived social support, social adversity and isolation.

Results

The rate of SI in this group of women was 8.1%, with baseline interview results suggesting that women with SI being significantly more likely to be aged 20 or less, have experience of severe life events and being less likely to have social support.

Conclusion

This area of research is key to understanding SI in British Pakistani women, to better develop culturally sensitive interventions for use within this group.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Exploratory randomized controlled trial of a group psychological intervention for postnatal depression in British mothers of South Asian origin

Introduction

The rates of postnatal depression (PND) in British South Asian (BSA) women are higher than the general population. PND is known to cause disability and suffering in women and negative consequences for their infants and their family with huge costs to society. Due to linguistic and cultural barriers, BSA women do not access health care services.

Objectives

To conduct an exploratory trial to test the feasibility and acceptability of a culturally adapted group Cognitive Behavioural Therapy (CBT) intervention (Positive Health Programme (PHP).

Aim

We aimed to determine if depressed BSA women receiving the PHP intervention will show significant improvements in terms of severity of depression, marital support, and social support as compared to the control group.

Methods

We used a two-arm pragmatic single-blind randomised controlled design. Women meeting the inclusion criteria were randomised either to the experimental group receiving PHP or treatment as usual (TAU) that is standard care usually provided by the GP.

Results

A total of 615 mothers were screened for participation in the trial, of these 137 were assessed further to determine eligibility. Eighty-three mothers were randomized to receive either PHP (n = 42) or treatment as usual (TAU) (n = 41). Mothers found the intervention to be acceptable and felt an overall positive change in their attitudes, behaviour and confidence level.

Conclusion

The recruitment and retention figures (70%) highlight the ability of the research team to engage with the population. The findings suggest the acceptability of the culturally adapted PHP intervention for British South Asian women with postnatal depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A prospective study of social difficulties, acculturation and persistent depression in Pakistani women living in the UK

BACKGROUND

The reasons for the high prevalence of depressive disorders in women of Pakistani origin living in the UK are not clear. The aim of this study was to determine the relative importance of life events, chronic social difficulties and acculturation in a population-based sample of British Pakistani women.

METHOD

A cross-sectional and prospective cohort study of 18- to 65-year-old Pakistani women in UK was carried out. The Schedule for Clinical Assessment in Neuropsychiatry for diagnosis, the Life Events and Difficulties Schedule for social stress and an acculturation questionnaire were used.

RESULTS

Depressive disorder at baseline was associated with older age, social isolation and marked difficulties involving health and close relationships. Depressive disorder at follow-up was associated with severity of depression at baseline, difficulties in close relationships and two aspects of acculturation, especially less acculturation in relation to use of the English language.

CONCLUSIONS

Lack of acculturation, especially less familiarity with the English language, is an independent predictor of persistence of depression in Pakistani women in UK. This needs to be taken into consideration when planning treatment, which also needs to address the personal difficulties associated with persistent depression. The implication of this work is that women of Pakistani origin with depression should be encouraged to receive help in the use of English as one part of treatment that may prevent relapse.

Smoking behavior among 14-17 year old students: a comparison between Pakistan and the UK

Smoking is a major public problem concern the world over. It is one of the major preventable causes of premature death and disease in the world. Fourteen to seventeen year olds are among a vulnerable group of individuals in society and susceptible to cigarette smoking. Older students act as role models to younger pupils and could influence smoking behavior. In a cross-sectional study we compared the differences in smoking between high school students in Pakistan and the United Kingdom. A self-administered anonymous questionnaire, adapted from a WHO questionnaire about tobacco smoking, was distributed to the students. In the UK, 235 participants were recruited; 16% (n = 38) were regular smokers. In Pakistan, 350 participants were recruited; 17% (n = 58) were regular smokers. In both countries males were significantly more likely to smoke. Reasons for smoking varied between the UK and Pakistan. In the UK, the majority smoked for recreational or social purposes and in Pakistan peer pressure played the major role. Beliefs regarding smoking were similar between the two countries. The lifetime prevalence of smoking was higher in the UK, but more students in Pakistan smoked daily. There were important differences in the smoking patterns between the two countries, which have potential public health implications.

Appropriate length of epidural catheter in the epidural space for postoperative analgesia: evaluation by epidurography

In current practice, the length of epidural catheter that should be left in the epidural space is not standardised for effective postoperative analgesia. This prospective, randomised, double-blinded study aimed to determine the most appropriate length of epidural catheter that should be inserted into the epidural space for postoperative analgesia. We recruited 102 women and assigned them into three study groups (3, 5 and 7 cm insertion). An epidural catheter was inserted and epidurography was performed. Postoperatively, mean pain scores, motor and sensory levels, and any complications associated with the epidural catheter were recorded. No statistically significant difference for mean postoperative pain score was found at all study timings. Motor and sensory blockade was also statistically insignificant. Unilateral sensory analgesia developed in one patient in the 7 cm group and epidural catheter dislodgement was observed in four patients in the 3 cm group. In order to minimise catheter-related complications for postoperative analgesia, the most appropriate length that an epidural catheter should be left in the epidural space is 5 cm. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Comparison Between Prevalence and Patterns of Cigarette Smoking Amongst Sixth form Students in the United Kingdom and Pakistan

Background:

Tobacco smoking is one of the major preventable causes of premature death and disease in the world. Adolescents are amongst the most vulnerable group of individuals in society and are highly susceptible to cigarette smoking. Sixth Formers being the most senior members of the school act as role models to younger pupils and could influence smoking behaviour.

Objective:

In a cross sectional and comparative study we aimed to determine the differences in smoking prevalence and patterns between Sixth Form students in Pakistan (a developing country) and the United Kingdom (a developed country).

Method:

A self-administered questionnaire, adapted from the WHO questionnaire, about tobacco smoking for health professionals was distributed amongst the students. The responses were anonymised to encourage truthful answers; there was no pressure to respond.

Of the 235 participants in the UK, 38 (16%) were regular smokers. Of the 297 participants in Pakistan, 20 (7%) of participants were regular smokers. In both countries there was a significant difference between the genders, with males being more likely to smoke. In Pakistan it was identified that the main reason for smoking was due to peer pressure, where as in the UK it was for recreational and social purposes.

Conclusions:

The prevalence of smoking was higher in UK compared to Pakistan. There was a significant difference in the smoking behaviour patterns in the two countries.

N-hexane neuropathy in screen printers

BACKGROUND

To study the clinical and electrophysiological profile of n-hexane neuropathy in a tertiary care center of India.

METHODS

Twenty five screen printers from five different factories, with peripheral neuropathy were included in the study. A detailed general physical, systemic and neurological examination was conducted Visual acuity, color vision and field charting was done in all the subjects. All patients were subjected to Folstein mini mental scale examination. Electrophysiological evaluation included motor and sensory conduction studies of the conventionally studied nerves of upper and lower limbs, Needle EMG of various distal and proximal muscles and patterned visual evoked responses. The electrophysiological profile was repeated every three months till one year. Sural nerve biopsy was studied in six patients. The patients were followed for a maximum of 4 years.

RESULTS

Twenty three [92%] patients had sensory- motor neuropathy, while pure sensory neuropathy was seen in two. The sensory conductions were affected almost equally in upper as well as the lower limbs, while the motor conductions were affected more in the lower limbs than the upper limbs. The sensory conductions were not recordable in both the upper and the lower limbs in 18 [72%] patients. Motor conduction studies revealed an asymmetric and patchy involvement. Proximal conduction block was seen in 3 patients [12%]. On needle EMG features of denervation were seen in all patients. P100 latency was normal in all. Sural nerve biopsy showed a selective decrease in large myelinated axons with demyelination. Axonal swelling with focal areas of demyelination was observed in two patients.

CONCLUSIONS

The electrophysiological patterns as well as the histopathology reflect the pathophysiology of n-hexane neuropathy.

Down beat nystagmus in vitamin B 12 deficiency syndrome

A 34 years old male, presenting with progressive proximal weakness, with a neurogenic pattern on needle EMG, and a family history suggestive of an autosomal recessive disorder, was found to have additional features of myeloneuropathy and a down beat nystagmus. A low serum vitamin B12 level was found, and on vitamin B12 supplementation there was a partial clinical as well as electrophysiological recovery.

Vitamin B12 deficiency: a clinical and electrophysiological profile

OBJECTIVE

The present study was conducted to evaluate the clinical and electrophysiological profile of vitamin B12 deficiency syndrome and whether a correlation exists between the disease process and the various electrophysiological parameters.

METHODS

40 patients with vitamin B12 deficiency neurological syndromes with low serum vitamin B12 and high homocysteine levels were subjected to a detailed motor and sensory nerve conduction studies and pattern reversal VER (P100), SSEP (P37) after stimulation of the posterior tibial nerve and median nerve (N 20) were obtained bilaterally. MR cervical spine was done in all the patients and MR brain in those who presented with neuro-psychiatric symptoms. The patients were followed up at three months, six months and one year after treatment.

RESULTS

On the basis of clinico-electrophysiological profile, 31 patients had myeloneuropathy, 5 isolated myelopathy, 4 isolated neuropathy. Four of the patients with myeloneuropathy, had concomitant dementia. MR imaging revealed abnormality in 12.5% of cases. Prolongation of P37 latency was observed in 39 (97.5%) patients, N 20 latency in 22 (55%), and P100 latency in 19 (47.5%) patients. Peripheral neuropathy was seen in 18 patients; optic neuropathy in 8; and combination of peripheral and optic neuropathy in 9 patients. The peripheral neuropathy was axonal in 19, and demyelinating in 6 patients. There was a significant correlation of the duration of the disease with N 20 latency (P < 0.04). Serum vitamin B12 level correlated well with the latencies of P37 (P < 0.005) and sural SNAP (P < 0.006). On treatment, normalization of P100, MRI signal, N 20 and partial recovery of P37 latencies was seen at 6 months, 9 months and one year respectively.

CONCLUSION

Differential recovery of central and peripheral syndromes was seen. This correlated with the underlying demyelinating and axonal processes, which was well reflected by the electrophysiological studies, and has an important bearing on the outcome.

Azithromycin in bronchiolitis obliterans complicating bone marrow transplantation: a preliminary study

Bronchiolitis obliterans (BO) is a serious noninfectious pulmonary complication following allogeneic bone marrow transplantation (BMT). Azithromycin, a macrolide antibiotic, may have a beneficial effect in BO through its anti-inflammatory effect. The aim of the current study was to investigate the potential effect of azithromycin on pulmonary function tests (PFTs) in BO complicating BMT. PFTs of 153 post-BMT patients were followed; eight patients out of 153 (12%) developed obstructive airway disease on their PFTs, along with characteristic findings of BO on high-resolution computed tomography of the chest. These patients were given azithromycin 500 mg q.d. for 3 days, followed by 250 mg three times a week for 12 weeks. Clinically significant improvements were achieved both in forced vital capacity, where the mean (95% confidence interval) increase reported was 410 mL (0.16-0.65), which was an average improvement of 21.57%, and in the forced expiratory volume in one second, where the mean increase noticed was 280 mL (0.10-0.44), which was an average improvement of 20.58%. In conclusion, the potential role of azithromycin in the treatment of bronchiolitis obliterans is intriguing and it warrants further testing.

Brachial plexopathy: a clinical and electrophysiological study

BACKGROUND

A retrospective study to evaluate the clinical and electrophysiological profile of brachial plexus lesions in a tertiary care center of India.

METHODS

Thirty eight patients with brachial plexopathy (idiopathic or traumatic) with detailed electrophysiological studies were sampled. This included detailed motor and sensory nerve conduction studies of the conventional median, ulnar and radial nerves of the upper limbs, CMAP from deltoid, biceps and triceps on stimulating the ERB's point, needle EMG in the appropriate muscles and paraspinal muscles. The electrophysiological studies were performed on both sides irrespective of the clinical involvement and were recorded within 1.61 +/- 2.89 months in idiopathic group and 2.11 +/- 2.65 months in traumatic plexopathy group. The severity of involvement was assessed on MRC scale. ADL scale was used to assess the disability at presentation and subsequent follow up.

RESULTS

12 patients (11 male and 01 female) had idiopathic brachial plexopathy and 26 patients (all male) had traumatic brachial plexopathy. In the idiopathic group the lesion was localized to upper trunk in 58.3% of patients and middle trunk (posterior cord) in 41.66% and none had lower trunk or diffuse involvement. 25% had bilateral involvement. Two patients (16.6%) with idiopathic plexitis had recurrence involving the opposite side during the follow up. In the traumatic group the lesion was localized to the upper trunk in 11.53%, middle trunk (posterior cord) in 57.69% and 30.76% of patients had diffuse involvement. All the patients in traumatic plexopathy group had severe disability while in idiopathic group 91.66% had severe disability and 8.33% had moderate disability. Low amplitude CMAP and F wave abnormality were seen in 16.6% of patients in idiopathic group. On needle EMG 83.3% had fasciculation or fibrillations while none had paraspinal EMG abnormality. In traumatic group low to absent CMAP was seen in 69.2% and 76.92% had F wave abnormality. SNAPs were not recordable in 53.8%. On Needle EMG all the patients showed fasciculation or fibrillations and only 6 (23.0%) had paraspinal muscle fibrillations. Root avulsion could be documented in only four of these cases on MR imaging.

CONCLUSIONS

Recovery in the traumatic group correlated well with the electrophysiological abnormalities while no such correlation was evident in the idiopathic group.

Paroxysmal kinesigenic dyskinesia manifestation of hyperthyroidism

Sporadic paroxysmal kinesigenic dyskinesia (PKD) secondary to thyrotoxicosis is an extremely rare entity. A 36-year-old female presented with the features of PKD. Her investigations revealed thyrotoxicosis. Her dyskinesia did not respond to carbamazepine but remitted with the anti-thyroid drug, neomercazole. Perhaps hyperthyroidism-related PKD is a result of a metabolic disturbance of the basal ganglia circuits rather than a permanent and irreversible change.

Pre-collisional anastomosing shear zones in the Kohistan arc, NW Pakistan

Ductile strain localization commonly forms a pattern of shear zones anastomosing around lenses of less deformed rock. Initiation and development of anastomosing shear zones are studied through description of the structures and deformation history of plutonic rocks that form the lower crust of the Kohistan arc. Structures and textures developed in these rocks result from primary magmatic to solid state regional strain, overprinted by anastomosing shear zones. The primary strain was mainly acquired during magmatic emplacement at 100-90 Ma. Strain localization took place continuously from magmatic emplacement to solid state deformation during cooling of the plutons and formed three successive sets of shear zones. Set 1 is composed of associated discrete Riedel and thrust shear zones developed above solidus conditions during southwestward thrusting. Continuous deformation from solidus to amphibolite facies conditions between 100 and 83 Ma formed the second set of shear zones. The lower amphibolite facies set 3 shear zones are diffeentiated by larger strains recorded in the thicker mylonitic zones and enlargement of the spacing between shear zones during cooling. The anastomosing pattern of shear zones described here probably represents arc-related deformation during subduction of the Tethys oceanic lithosphere below the Kohistan arc.

Familial history of opium use and reported problems among opium addicts in Pakistan

One-hundred and twenty-nine opiate addicts on a monthly maintenance regimen were studied. Subjects with a positive family history of opium use had an earlier age of onset than the subjects without a family history of opium use. Self-reported psychosocial problems resulting from opium use were documented in only seven subjects. Individuals who began opium use after 1979, when it became illegal to use the drug, had a significantly later age of onset than subjects who began before 1979, suggesting that negative legal sanctions can delay initiation of opium consumption.