Comparative effectiveness of psychological interventions for treating the psychological consequences of sexual abuse in children and adolescents: a network meta-analysis

BACKGROUND

Following sexual abuse, children and young people may develop a range of psychological problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and a range of behaviour problems. Those working with children and young people experiencing these problems may use one or more of a range of psychological approaches.

OBJECTIVES

To assess the relative effectiveness of psychological interventions compared to other treatments or no treatment controls, to overcome psychological consequences of sexual abuse in children and young people up to 18 years of age. Secondary objectives To rank psychotherapies according to their effectiveness. To compare different 'doses' of the same intervention.

SEARCH METHODS

In November 2022 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and two trials registers. We reviewed the reference lists of included studies, alongside other work in the field, and communicated with the authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing psychological interventions for sexually abused children and young people up to 18 years old with other treatments or no treatments. Interventions included: cognitive behavioural therapy (CBT), psychodynamic therapy, family therapy, child centred therapy (CCT), and eye movement desensitisation and reprocessing (EMDR). We included both individual and group formats.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias for our primary outcomes (psychological distress/mental health, behaviour, social functioning, relationships with family and others) and secondary outcomes (substance misuse, delinquency, resilience, carer distress and efficacy). We considered the effects of the interventions on all outcomes at post-treatment, six months follow-up and 12 months follow-up. For each outcome and time point with sufficient data, we performed random-effects network and pairwise meta-analyses to determine an overall effect estimate for each possible pair of therapies. Where meta-analysis was not possible, we report the summaries from single studies. Due to the low number of studies in each network, we did not attempt to determine the probabilities of each treatment being the most effective relative to the others for each outcome at each time point. We rated the certainty of evidence with GRADE for each outcome.

MAIN RESULTS

We included 22 studies (1478 participants) in this review. Most of the participants were female (range: 52% to 100%), and were mainly white. Limited information was provided on socioeconomic status of participants. Seventeen studies were conducted in North America, with the remaining studies conducted in the UK (N = 2), Iran (N = 1), Australia (N = 1) and Democratic Republic of Congo (N = 1). CBT was explored in 14 studies and CCT in eight studies; psychodynamic therapy, family therapy and EMDR were each explored in two studies. Management as usual (MAU) was the comparator in three studies and a waiting list was the comparator in five studies. For all outcomes, comparisons were informed by low numbers of studies (one to three per comparison), sample sizes were small (median = 52, range 11 to 229) and networks were poorly connected. Our estimates were all imprecise and uncertain. Primary outcomes At post-treatment, network meta-analysis (NMA) was possible for measures of psychological distress and behaviour, but not for social functioning. Relative to MAU, there was very low certainty evidence that CCT involving parent and child reduced PTSD (standardised mean difference (SMD) -0.87, 95% confidence intervals (CI) -1.64 to -0.10), and CBT with only the child reduced PTSD symptoms (SMD -0.96, 95% CI -1.72 to -0.20). There was no clear evidence of an effect of any therapy relative to MAU for other primary outcomes or at any other time point. Secondary outcomes Compared to MAU, there was very low certainty evidence that, at post-treatment, CBT delivered to the child and the carer might reduce parents' emotional reactions (SMD -6.95, 95% CI -10.11 to -3.80), and that CCT might reduce parents' stress. However, there is high uncertainty in these effect estimates and both comparisons were informed only by one study. There was no evidence that the other therapies improved any other secondary outcome. We attributed very low levels of confidence for all NMA and pairwise estimates for the following reasons. Reporting limitations resulted in judgements of 'unclear' to 'high' risk of bias in relation to selection, detection, performance, attrition and reporting bias; the effect estimates we derived were imprecise, and small or close to no change; our networks were underpowered due to the low number of studies informing them; and whilst studies were broadly comparable with regard to settings, the use of a manual, the training of the therapists, the duration of treatment and number of sessions offered, there was considerable variability in the age of participants and the format in which the interventions were delivered (individual or group).

AUTHORS' CONCLUSIONS

There was weak evidence that both CCT (delivered to child and carer) and CBT (delivered to the child) might reduce PTSD symptoms at post-treatment. However, the effect estimates are uncertain and imprecise. For the remaining outcomes examined, none of the estimates suggested that any of the interventions reduced symptoms compared to management as usual. Weaknesses in the evidence base include the dearth of evidence from low- and middle-income countries. Further, not all interventions have been evaluated to the same extent, and there is little evidence regarding the effectiveness of interventions for male participants or those from different ethnicities. In 18 studies, the age ranges of participants ranged from 4 to 16 years old or 5 to 17 years old. This may have influenced the way in which the interventions were delivered, received, and consequently influenced outcomes. Many of the included studies evaluated interventions that were developed by members of the research team. In others, developers were involved in monitoring the delivery of the treatment. It remains the case that evaluations conducted by independent research teams are needed to reduce the potential for investigator bias. Studies addressing these gaps would help to establish the relative effectiveness of interventions currently used with this vulnerable population.

[Proximal tibiofibular joint dislocation diagnosis and treatment]

INTRODUCTION

Proximal tibiofibular joint dislocations (PTFJD) are uncommon and underdiagnosed injuries. Urgent reduction is mandatory to avoid chronic disfunction. The scarcely available literature does not present a unified management guideline. An acute PTFJD case report with spontaneous reduction and a review of the literature is presented, aiming to assist the diagnosis and management of this pathology.

CASE REPORT

A 22-years old male presented to the emergency department with high intensity right knee pain after falling in a four-wheel motorcycle. The physical exam revealed a prominent painful mass on the lateral aspect of his knee and proximal leg. His range of motion and knee stability were unremarkable. X-rays were informed negative for musculoskeletal injuries. According to a sustained suspicion of PTFJD, the study was continued with a magnetic resonance imaging (MRI), which suggested PTFJD. During the following 24 hours, the patient referred he was entirely asymptomatic after feeling a loud "clank". He has been followed for three months with MRI, and remains asymptomatic with full functions.

CONCLUSION

PTFJD diagnosis requires appropriate images. Urgent close reduction is mandatory; if unsuccessful, open reduction, primary repair and internal fixation are indicated. The prognosis of spontaneous reduction remains uncertain and requires a serial clinical evaluation. In the case of recurrence, the appropriate surgical management is indicated according to the elapsed time from the injury.

Socio-economic inequalities in dietary intake in Chile: a systematic review

OBJECTIVE

Understanding the socio-economic inequalities in dietary intake is crucial when addressing the socio-economic gradient in obesity rates and non-communicable diseases. We aimed to systematically assess the association between socio-economic position (SEP) and dietary intake in Chile.

DESIGN

We searched for peer-reviewed and grey literature from inception until 31 December 2019 in PubMed, Scopus, PsycINFO, Web of Sciences and LILACS databases. Observational studies published in English and Spanish, reporting the comparison of at least one dietary factor between at least two groups of different SEP in the general Chilean population, were selected. Two researchers independently conducted data searches, screening and extraction and assessed study quality using an adaptation of the Newcastle Ottawa Quality Assessment Scale.

RESULTS

Twenty-one articles (from eighteen studies) were included. Study quality was considered low, medium and high for 24, 52 and 24 % of articles, respectively. Moderate-to-large associations indicated lower intake of fruit and vegetables, dairy products and fish/seafood and higher pulses consumption among adults of lower SEP. Variable evidence of association was found for energy intake and macronutrients, in both children and adults.

CONCLUSIONS

Our findings highlight some socio-economic inequalities in diets in Chile, evidencing an overall less healthy food consumption among the lower SEP groups. New policies to reduce these inequalities should tackle the unequal distribution of factors affecting healthy eating among the lower SEP groups. These findings also provide important insights for developing strategies to reduce dietary inequalities in Chile and other countries that have undergone similar nutritional transitions.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

School-based interventions to prevent anxiety and depression in children and young people: a systematic review and network meta-analysis

BACKGROUND

Rates of anxiety and depression are increasing among children and young people. Recent policies have focused on primary prevention of mental disorders in children and young people, with schools at the forefront of implementation. There is limited information for the comparative effectiveness of the multiple interventions available.

METHODS

We did a systematic review and network meta-analysis, searching MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled trials for published and unpublished, passive and active-controlled randomised and quasi-randomised trials. We included educational setting-based, universal, or targeted interventions in which the primary aim was the prevention of anxiety and depression in children and young people aged 4-18 years. Primary outcomes were post-intervention self-report anxiety and depression, wellbeing, suicidal ideation, or self-harm. We assessed risk of bias following the Cochrane Handbook for Systematic Reviews of Interventions. We estimated standardised mean differences (SMD) using random effects network meta-analysis in a Bayesian framework. The study is registered with PROPSERO, number CRD42016048184.

FINDINGS

1512 full-text articles were independently screened for inclusion by two reviewers, from which 137 studies of 56 620 participants were included. 20 studies were assessed as being at low risk of bias for both random sequence generation and allocation concealment. There was weak evidence to suggest that cognitive behavioural interventions might reduce anxiety in primary and secondary settings. In universal secondary settings, mindfulness and relaxation-based interventions showed a reduction in anxiety symptoms relative to usual curriculum (SMD -0·65, 95% credible interval -1·14 to -0·19). There was a lack of evidence to support any one type of intervention being effective to prevent depression in universal or targeted primary or secondary settings. Comparison-adjusted funnel plots suggest the presence of small-study effects for the universal secondary anxiety analysis. Network meta-analysis was not feasible for wellbeing or suicidal ideation or self-harm outcomes, and results are reported narratively.

INTERPRETATION

Considering unclear risk of bias and probable small study effects for anxiety, we conclude there is little evidence that educational setting-based interventions focused solely on the prevention of depression or anxiety are effective. Future research could consider multilevel, systems-based interventions as an alternative to the downstream interventions considered here.

FUNDING

UK National Institute for Health Research.

Corneal densitometry after photorefractive keratectomy, laser-assisted in situ keratomileusis, and small-incision lenticule extraction

PurposeThe aim of this study was to gain greater insight into the corneal densitometry changes occurring as a result of refractive surgery and to compare these changes across three widely used surgical techniques, namely, photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis with a femtosecond laser (LASIK-FS), or ReLEx small-incision lenticule extraction (ReLEx SMILE).Patients and methodsThree hundred and thirty-six patients (184 male and 152 female patients) participated in this study. They were split into three groups according to the refractive surgery technique they had undergone: LASIK-FS (74 patients), PRK (153 patients), and ReLEx SMILE (109 patients). All participants underwent an exhaustive eye examination both before and after surgery. Pre- and postoperative corneal densitometry was measured using an Oculus Pentacam system.ResultsThe mean postoperative total corneal densitometry values were 16.53±1.94 for the LASIK-FS group, 15.53±1.65 for PRK, and 16.10±1.54 for ReLEx SMILE. When corneal densitometry was analyzed for specific corneal areas, the values corresponding to the 0-2, 2-6, and 6-10 mm annuli were similar across the three surgical techniques. The only region in which differences were found was the peripheral area (P<0.05), but these variations across techniques were not statistically significant.ConclusionsCorneal densitometry can be used as an objective metric to assess corneal response to refractive surgery, and to monitor patients over time. Corneal densitometry was not negatively affected by any of the refractive surgical procedures under evaluation.

Single molecule PCR in mtDNA mutational analysis: Genuine mutations vs. damage bypass-derived artifacts

The area of somatic mtDNA mutation measurement is in a crisis because the methods used to quantify mtDNA mutations produce results varying by multiple orders of magnitude. The reason for these discrepancies is not clear, but given that most methods involve PCR, the prime suspect is PCR artifacts (e.g. spontaneous errors by the DNA polymerases used). In addition to simple misincorporation, another important source of artificial mutations is the conversion of chemically modified (e.g. damaged) nucleotides into mutations when bypassed by a thermostable DNA polymerase. These latter mutations are particularly difficult to account for because appropriate controls are not available. Here, we argue that single molecule PCR (smPCR) is uniquely positioned to account for these bypass-related artificial mutations and discuss the methodology involved in employing this technique.

[Multidetector row CT in assessment of coronary artery calcification on hemodialisis]

Vascular calcification is a strong predictor of cardiovascular and all-cause mortality. Coronary artery calcification is more frequent, more extensive and progresses more rapidly in CKD than in general population. They are also considered a marker of coronary heart disease, with high prevalence and functional significance. It suggests that detection and surveillance may be worthwhile in general clinical practice. New non-invasive image techniques, like Multi-detector row CT, a type of spiral scanner, assess density and volume of calcification at multiple sites and allow quantitative scoring of vascular calcification using calcium scores analogous to those from electron-beam CT. We have assessed and quantified coronary artery calcification with 16 multidetector row CT in 44 patients on hemodialysis and their relationship with several cardiovascular risk factors. Coronary artery calcification prevalence was of 84 % with mean calcium score of 1580 +/- 2010 ( r 0-9844) with calcium score > 400 in 66% of patients. It was usually multiple, affecting more than two vessels in more than 50%. In all but one patient, left anterior descending artery was involved with higher calcium score level at right coronary artery. Advanced age, male, diabetes, smoking, more morbidity, cerebrovascular disease previous, and calcium-binders phosphate and analogous vitamin D treatment would seem to be associated with coronary artery calcification. Coronary artery calcification is very frequent and extensive, usually multiple and associated to modifiable risk factors in hemodialysis patients. Multi-detector-row CT seems an effective, suitable, readily applicable method to assess and quantify coronary artery calcification.

[Good virological response to pegylated interferon alfa monotherapy of chronic hepatitis C infection in hemodialysis patient]

Liver disease caused by hepatitis C virus infection is associated to significant morbidity and mortality among patient with end stage renal disease on maintenance hemodialysis (HD). Therapy in these patients consists of Interferon, preferably pegylated Interferon (pIFN), thus Ribavirin (RBV) is not recommended for patients with impaired renal function, outside its use in controlled trials. We report a case of 35 years young woman on HD treatment, renal transplantation candidate with chronic hepatitis C virus infection, HCV RNA positive (by PCR), genotype 3a, moderate viral load, light increase of aminotransferases. Pegylated Interferon alfa-2a (135 mcg/weekly/SC) was initiated. She achieved HVC RNA negative within 12 weeks, following with pINF as monotherapy to complete 24 weeks (6 months). Sustained virologic response persisted to 24 and 48 weeks. Most important side effects were light detriment of anemia, moderate neutropenia and thombocytopenia, transitory elevation of transaminases and "flu-like" syndrome. Adverse events were well tolerated with total compliance with pIFN dose, no requiring reduce or stop the treatment. These findings confirm that hemodialysis patients with chronic hepatitis C respond well to pegylated IFN monotherapy and a long-term sustained virologic response is achieved, appears to be better tolerated with less side effects, so combination therapy with pINF plus ribavirin is not necessary in all cases.

Carbohydrate restriction does not change mitochondrial free radical generation and oxidative DNA damage

Many previous investigations have consistently reported that caloric restriction (40%), which increases maximum longevity, decreases mitochondrial reactive species (ROS) generation and oxidative damage to mitochondrial DNA (mtDNA) in laboratory rodents. These decreases take place in rat liver after only seven weeks of caloric restriction. Moreover, it has been found that seven weeks of 40% protein restriction, independently of caloric restriction, also decrease these two parameters, whereas they are not changed after seven weeks of 40% lipid restriction. This is interesting since it is known that protein restriction can extend longevity in rodents, whereas lipid restriction does not have such effect. However, before concluding that the ameliorating effects of caloric restriction on mitochondrial oxidative stress are due to restriction in protein intake, studies on the third energetic component of the diet, carbohydrates, are needed. In the present study, using semipurified diets, the carbohydrate ingestion of male Wistar rats was decreased by 40% below controls without changing the level of intake of the other dietary components. After seven weeks of treatment the liver mitochondria of the carbohydrate restricted animals did not show changes in the rate of mitochondrial ROS production, mitochondrial oxygen consumption or percent free radical leak with any substrate (complex I- or complex II-linked) studied. In agreement with this, the levels of oxidative damage in hepatic mtDNA and nuclear DNA were not modified in carbohydrate restricted animals. Oxidative damage in mtDNA was one order of magnitude higher than that in nuclear DNA in both dietary groups. These results, together with previous ones, discard lipids and carbohydrates, and indicate that the lowered ingestion of dietary proteins is responsible for the decrease in mitochondrial ROS production and oxidative damage in mtDNA that occurs during caloric restriction.

One-tube-PCR technique for CCL2, CCL3, CCL4 and CCL5 applied to fine needle aspiration biopsies shows different profiles in autoimmune and non-autoimmune thyroid disorders

Autoimmune thyroid diseases are characterized by lymphocytic infiltration of the thyroid gland. Chemokines are crucial in the recruitment of lymphocytes and might play an important role in the pathogenesis of autoimmune thyroid disease. The aim of this study was to test the feasibility of analysing by one-tube reverse-transcriptase polymerase chain reaction (RT-PCR) technique CC chemokine profiles in samples obtained by fine needle aspiration biopsy (FNAB). In 27 out of 35 (77%) samples, the material was sufficient for analysis and in 16 (59%) chemokines were detected, thus demonstrating the potential of this technique. Moreover, even in this small group, a statistically significant increase of CCL3 and CCL4 was found in samples from patients with autoimmune thyroid disease as compared to those with multinodular goiter. Chemokine profile measured by improved multiamplification techniques in FNAB thyroid samples may become a useful complementary tool for the management of thyroid autoimmune disease as it constitutes a source of data for research of their pathogenesis.

[Measurement of cardiac output after cardiac surgery: validation of a partial carbon dioxide rebreathing (NICO) system in comparison with continuous thermodilution with a pulmonary artery catheter]

Cardiac output is usually monitored with a pulmonary artery catheter. However, because that method is not free of risk, devices have been designed in recent years to measure cardiac output in a way that is minimally invasive or fully noninvasive. Among such devices is the NICO monitor, which is based on a modified Fick equation (partial CO2 rebreathing).

OBJECTIVE

To compare the accuracy of cardiac output measurements from the NICO monitor to measurements obtained by continuous thermodilution with a pulmonary artery catheter.

MATERIAL AND METHODS

A nonprobabilistic, consecutive sample of 20 patients was enrolled in the early postoperative period after elective cardiac surgery (coronary or valve procedures) in the recovery ward. Seven measurements of cardiac output were taken simultaneously with each method in each patient.

RESULTS AND CONCLUSIONS

Cardiac output estimated by the partial CO2 rebreathing method was lower than the measurement obtained by the pulmonary artery catheter. The percentage error between the 2 methods was 37%, indicating that the NICO monitor can not substitute for the traditional method. The better correlation found between normal-to-low cardiac output values and the absence of side effects of using the NICO method suggest that it might be indicated for detecting low cardiac output after cardiac surgery, especially when the risk-benefit ratio does not favor using a pulmonary artery catheter.

[Utility of intra-access pressure]

Monitoring of vascular access is essential for clinical evaluation on hemodialysis patients, detects early disfunction of access, allows adequate dialysis and decreases the morbidity associated. Although is demonstrated that intra-access pressure (IAP) is a good method of screening to evaluate arterial-venous (AV) fistulas, its utility is uncommon because its measurement requires a complex system. We would like to validate the utility of IAP monitoring using a simplified measure of IAP and its relation with other methods of screening in detecting stenoses prior to thromboses of AV grafts. We studied 24 AV grafts of 24 patients during 18 months we measured arterial pressure, mean arterial pressure (MAP), dynamic venous pressure, IAP, Kt/v, URR, recirculation index (RI), access flow and color Doppler flow, dividing the patients in two groups, with stenoses or not, if IAP/MAP > 0.5 and stenoses > 0.50 by Doppler we performed arteriography and percutaneous transluminal angioplasty with stent if stenoses exits. The values of IAP, MAP, RI were higher significantly in the stenoses group with increase of vascular access in grafts were dilation by angioplasty was made. All stenoses detected with IAP were confirmed by Doppler and arteriography but one. We conclude that IAP is an early, useful, easy, effective method in detecting stenoses of AV grafts prior to thrombosis.

Evidence of expression of endotoxin receptors CD14, toll-like receptors TLR4 and TLR2 and associated molecule MD-2 and of sensitivity to endotoxin (LPS) in islet beta cells

CD14, a GPI-linked membrane protein, is a component of the lipopolysaccharide (LPS) receptor complex, one of the pattern-recognizing receptors (PRR) expressed by myeloid lineage cells. Here we report that CD14, the functionally linked toll-like receptor molecules, TLR2 and TLR4, and the associated molecule MD-2 are expressed in endocrine cells of the human pancreatic islets. CD14 expression in human pancreatic islets was determined by immunofluorescence staining of tissue sections and primary cultures, and confirmed by flow cytometry of dispersed normal islets and SV40-transformed islet cells (HP62). The latter cells synthesized and secreted CD14 in response to lipopolysaccharide (LPS) in a time- and dose-dependent manner. Reverse transcription polymerase chain reaction (RT-PCR)-Southern was positive for CD14, TLR2, TLR4 and MD-2 in human pancreas, purified islets and HP62 cells. In vitro experiments using rat islets (also positive for CD14 by RT-PCR) and HP62 cells showed that LPS regulates glucose-dependent insulin secretion and induces inflammatory cytokines [interleukin (IL)-1alpha, IL-6 and tumour necrosis factor (TNF)-alpha]. The functional expression of CD14 and associated molecules in islet beta cells adds a new pathway that islet cells may follow to adjust their function to endotoxaemia situations and become vulnerable to the inflammatory events that occur during diabetogenic insulitis.

[Migraine and MIDAS (MIDASELA) in Colombian hospital workers]

AIMS

The aim of this study was to determine the prevalence of migraine and its implications in the occupational and outside employment/daily activities of the workers at a regional hospital in the Cundiboyacense Plateau in Colombia.

PATIENTS AND METHODS

The available members of the house staff at this institution were interviewed by applying the neuroepidemiological protocol drawn up by the World Health Organization (WHO); general doctors performed the initial screening and the determination of neurological disease was carried out by a clinical neurologist, both in patients who were positive and negative for neurological disease. Quality of life was evaluated by means of the MIDAS (Migraine Disability Assessment) survey, MIDASELA (in Spanish for Latin America); the analysis was performed using the EPI 6.04 software application.

RESULTS

A total of 238 people were studied: 188 females and 50 males; the prevalence of migraine was 22.5% (15.5% by the WHO protocol and 7% false negatives), with predominance in females (OR: 5.49; p< 0.005). In the MIDASELA questionnaire, 47.2% of the patients had a 50% alteration in their productivity, with regard to their occupational and outside employment/daily activities. A minimum number of patients (3.8%) were unable to work because of migraine, as compared to the figures for outside employment/daily activities (29.7%) or those involving leisure/family (66.4%). The average work, outside employment/daily and family time lost per patient because of migraine was 0.3, 2 and 5.2 days, respectively.

CONCLUSION

A sub register in the prevalence of migraine could be reported in places where the WHO protocol is used. This pathology will have to be taken well into account in Colombian hospital workers due to its individual, occupational, family, social and economic impact. It is necessary to introduce health policies and programmes aimed at evaluating, controlling and treating this type of pathology in an appropriate manner, in order to improve the quality of life of those whose job it is to look after and improve that of the other Colombians.

Comparison of amplicor, in-house polymerase chain reaction, and conventional culture for the diagnosis of tuberculosis in children

A total of 251 clinical specimens (235 gastric aspirates and 16 bronchoalveolar lavages) from 88 children were prospectively tested in a blinded manner for the presence of Mycobacterium tuberculosis complex, by use of the Amplicor M. tuberculosis test and by means of in-house polymerase chain reaction (PCR). The results were compared with those obtained by conventional culture and by direct microscopy. All of the children underwent extended follow-up to verify or exclude the clinical diagnosis of tuberculosis. The results of the different tests, when compared to the final clinical diagnosis, were a sensitivity of 60% and a specificity of 96.8% for in-house PCR, 44% and 93.7% respectively for the Amplicor test, 44% and 100% for mycobacterial culture and 12% and 100% for microscopy. Amplicor tests presented false-positive findings in children without tuberculous infection. We conclude that both in-house PCR and the Amplicor test are rapid methods that can be helpful for difficult or urgent diagnosis of tuberculosis in children. However, efforts should be aimed toward improvement of the sensitivity and specificity of an easy-to-use PCR kit.

Diagnosis of tuberculosis in children using a polymerase chain reaction

We investigated the value of the polymerase chain reaction (PCR) in the diagnosis of active tuberculosis in children and evaluated the relationship between PCR results in children with tuberculous infections and mediastinal adenopathies detected by computerized tomography (CT-Scan). This was a controlled, blinded, prospective study comparing nested PCR, mycobacterial cultures and the clinical diagnosis based on 350 clinical specimens from 117 children referred for evaluation of suspected pulmonary tuberculosis. All children with tuberculous infection but without active disease underwent a chest CT-scan to detect the presence of mediastinal adenopathies not evident on chest x-ray. The sensitivity of PCR was 56.8% in children with clinically active disease (culture: 37.8%; smears: 13.5%). A major advantage of PCR over cultures was noted when there was no parenchymal involvement on chest radiograph and when the patient was undergoing anti-tuberculous treatment. There were nine specimens with false-negative PCR results due to the presence of amplification reaction inhibitors. PCR was positive in five children with tuberculous infection without active disease and these children presented mediastinal adenopathies on the CT-scan that were not evident on chest radiography. There were no false-positive PCR results in the control groups of children. We conclude that nested PCR is a rapid and sensitive method for the early diagnosis of tuberculosis in children. It is especially useful when the diagnosis of active tuberculosis is difficult. In our study children with tuberculous infection without apparent disease who have positive PCR results have mediastinal adenopathies on CT-scan.

Cloning of ARE-containing genes by AU-motif-directed display

A procedure suitable for cloning labile mRNAs that contain AU motifs is presented (AU-DD). These motifs are regulatory sequences within the so-called AU-rich elements (AREs) often found in 3' untranslated regions of genes such as cytokines, proto-oncogenes, and transcription factors. AU-DD is an AU-motif-directed differential display that permits the identification of ARE-containing genes differentially expressed after cell activation. It has been applied to peripheral blood monocytes and a T cell clone to isolate 59 cDNA fragments associated to activation. Fourteen percent of isolated fragments belong to already known genes that certainly are cytokines and transduction/transcription factors. The remaining 86% correspond to unknown genes of which 92% have been confirmed to be differentially expressed. These data demonstrate the efficiency of the system and support the notion that numerous genes falling into those categories remain unidentified and that they can be cloned by this method.

[Anesthesia paresthetica: contribution of a new case and evolutive study using magnetic resonance]

Patients with subclinical cobalamin deficiency may develop a subacute myeloneuropathy after nitrous oxide anesthesia. Frequently they have hematologic manifestations, however there is only a few reports of spinal lesions shown on MR and particularly of the effects of cobalamin replacement therapy on these lesions. We describe a patient with unsuspected cobalamin deficiency who developed subacute combined degeneration of the spinal cord after nitrous oxide anesthesia. MR showed high intensity in dorsal columns on T2-weighted image, and posterior resolution of abnormalities after therapy. We discuss the importance of preoperative hematologic manifestations for select high risk patients and prevent this complication. On the other hand, we consider MR as a useful tool to improve our knowledge in the pathophysiology of the neurologic manifestations of the process.

[Use of muscular flaps for the treatment of open fractures of limbs. Apropos of 42 cases]

PURPOSE OF THE STUDY

Since 1988, skin defect associated with upper (6 cases) or lower (34 cases) limb fractures were treated in our Orthopaedic Department with regional or free muscular flaps. The aim of this study was to demonstrate that muscular flaps represent a treatment of choice for infection prevention and consolidation.

MATERIAL AND METHODS

42 patients have been treated: 29 Cauchoix III or IV, 12 secondary exposed fractures, 1 amputation. A total of 42 flaps, including 28 regional flaps and 14 microvascular free-tissue transfers were performed. A first stage included thorough debridement, fixation with external fixator in 85 per cent, and revascularization (4 cases). A second look was necessary in all but 3 cases: flap coverage was performed at this stage. A bone graft was proposed in 17 cases after a mean time of 3 months and 20 days.

RESULTS

Bony healing was found in 37 cases (86.5 per cent) with a mean delay of 7 months 20 days. 5 patients required another method of treatment because of flap necrosis or non-union, with an average time to bony healing of 13 months. 42 tissue transfers were performed with an overall success rate of 95.3 per cent (2 necrosis of latissimus dorsi flaps). 3 partial necrosis involved 2 regional and 1 free flap. One of them needed another treatment. No infection was encountered in 40 cases (95 per cent) even if most of the patients were treated after initial treatment elsewhere.

DISCUSSION

Experience with regional muscle transfer has advocated the gastrocnemius and proximal pedicle medial soleus as reliable and excellent choice for reconstruction of the proximal and middle third of the leg. Latissimus dorsi transfer, which can be used totally, partially, or as a "vascular graft flap" represent the treatment choice for extensive upper or lower limb exposed fracture especially for distal lower limb fracture (exposure of the tibia). Muscle flap coverage in the acute period (within 48 or 72 hours) remains for us the best treatment.

[Therapeutic possibilities of the lateral supra-malleolar flap and its variations. Apropos of 6 clinical cases]

The distally based lateral supramalleolaire flap with a retrograde blood flow on the perforating branch of the peroneal artery is a good flap to treat loss of skin involving the ankle, the region behind the Achilles tendon, and the foot. Based on the results of an anatomical study, the authors describe a modification of this flap which can be raised on the infero-lateral collateral artery, with an anterograde blood flow. In fact, clinical experience of six cases shows that vascular pedicle component (perforating branch of the peroneal artery, infero-lateral collateral artery) and blood flow (anterograde, retrograde) can be calculated according to the regional vascular network, arc of rotation and the type of flap. Because of the many possible combinations, it can be considered to be a flap with variable vascular pedicle raised "à la carte". However, according to our clinical cases, the anterograde blood flow does not seem to have resolved the problems of venous congestion of this flap.

Use of a posterior calf fasciocutaneous flap with distal pedicle to reconstruct a huge ankle defect

A distally based posterior calf fasciocutaneous flap was successfully used to reconstruct a major ankle defect with exposed bones and joints. The flap, which reaches easily this region, can also be used as a free flap for coverage of heel and ankle when the forefoot is not involved in the injury.

Juvenile xanthogranuloma: non-X histiocytosis with systemic involvement

Two patients with different patterns of soft tissue and bone involvement demonstrate the variability of extracutaneous manifestations of juvenile xanthogranuloma, a non-X histiocytosis, better known to dermatologists than to radiologists.

Nucleotide sequence and genetic map of the 16-kb vaccinia virus HindIII D fragment

We have determined the nucleotide sequence of the 16,059-bp HindIII D fragment from vaccinia virus strain WR. Translation in all 6 reading frames reveals a set of 22 open reading frames (ORFs), which are capable of encoding proteins ranging from 61 to 844 amino acids in length. With one exception, ORF 12, we have divided them into two primary sets according to their size. The minor group contains eight members ranging in length from 61 to 84 amino acids. The major group has thirteen members varying from 146 to 844 amino acids in length, and, in addition, due to its location on the DNA, one small ORF, 61 amino acids long. The neighboring major ORFs are closely packed along the DNA, being separated by 42 or fewer base pairs. In several instances the ends of adjoining ORFs overlap for up to 11 triplet codons. In three cases, 1 or 2 bases are shared between translation start and stop signals in adjacent ORFs. Regions of both strands of the DNA are transcribed. Two sets of temperature-sensitive mutations, totaling 17, which map to the HindIII D fragment, have been combined into eight complementation groups. The results of marker rescue analysis map one or more member of each group to a site in the HindIII D fragment within a defined open reading frame.

Pharmacokinetics of furosemide in patients with hepatic cirrhosis

The pharmacokinetics of furosemide was studied in 7 patients with diagnosed liver cirrhosis and in 7 healthy subjects. Furosemide in plasma and ascitic fluid was analyzed spectrofluorometrically. After a single intravenous dose, the cirrhotic patients showed lower initial plasma concentrations of furosemide because of the larger volume of distribution. The mean half-life in cirrhotic patients was significantly greater than in healthy volunteers. The longer half-life was associated with a reduction in the serum clearance of furosemide. Ascitic fluid volume in the patients ranged from 4.6 to 7.71. There was no significant amount of furosemide in the fluid. The diuretic interchange between this fluid and plasma was slow, as peak concentrations ranged from 0.3 to 0.5 microgram/ml within 3 to 5 h after bolus administration of furosemide. Diuresis and urinary sodium excretion, 5 h after furosemide injection, were similar in both groups; larger potassium excretion was found in the cirrhotic patients.