Design and challenges for a randomized, multi-site clinical trial comparing the use of service dogs and emotional support dogs in Veterans with post-traumatic stress disorder (PTSD)

Posttraumatic stress disorder (PTSD) is a leading cause of impairments in quality of life and functioning among Veterans. Service dogs have been promoted as an effective adjunctive intervention for PTSD, however published research is limited and design and implementation flaws in published studies limit validated conclusions. This paper describes the rationale for the study design, a detailed methodological description, and implementation challenges of a multisite randomized clinical trial examining the impact of service dogs on the on the functioning and quality of life of Veterans with PTSD. Trial design considerations prioritized participant and intervention (dog) safety, selection of an intervention comparison group that would optimize enrollment in all treatment arms, pragmatic methods to ensure healthy well-trained dogs, and the selection of outcomes for achieving scientific and clinical validity in a Veteran PTSD population. Since there is no blueprint for conducting a randomized clinical trial examining the impact of dogs on PTSD of this size and scope, it is our primary intent that the successful completion of this trial will set a benchmark for future trial design and scientific rigor, as well as guiding researchers aiming to better understand the role that dogs can have in the management of Veterans experiencing mental health conditions such as PTSD.

An audit of parents'/guardians' wishes recorded after coronial autopsies in cases of sudden unexpected death in infancy: issues raised and future directions

In the U.K., cases of sudden unexpected death in infancy are under the jurisdiction of the Coroner and consent for a post-mortem is not required. Prior to the Human Tissue Act 2006 (HTA) there was also no requirement to request retention of tissue (blocks and slides). The HTA stipulates that parental/ guardian consent is mandatory to retain or dispose of all tissues after the Coroners' purposes have been fulfilled. In 2007, in order to avoid confusion with the consent needed for hospital post-mortems, a new form was introduced by Sheffield Children's Hospital NHS Foundation Trust (SCH) called Record of parents'/guardians'wishes regarding samples taken at a Coroner's post mortem. This version specifically asks if blocks and slides may be retained as part of the medical record, or are to be disposed of, and for parental agreement (or not) for the frozen tissue, blocks and slides to be used for education, audit, quality control and medical research. One hundred and nineteen Coroners' postmortems covering the years 2006-2007 were reviewed. All parents/guardians (P/G) were contacted and the outcomes of P/G wishes recorded by SCH staff, Coroners' Officers (CO) and Police Family Liaison Officers (PFLO) were analysed and compared (44% from CO were outstanding at the time of audit). Any delay in recording P/G wishes by these three groups was also compared. In 2006, parental agreement to the use of blocks and slides for education, audit, quality control and medical research was 94%, 77% and 75% for SCH, CO and PFLO, respectively. In 2007 it was 84%, 37% and 100% for the same groups. Permission for the retention of frozen tissue given to SCH, CO and PFLO was 90%, 62% and 100% in 2006 and 90%, 44% and 100% in 2007, respectively. Cases where parents did not wish for the retention or use of tissue (including blocks and slides) were 3%, 15% and 0% in 2006 for SCH, CO and PFLO respectively, and 0% for all groups in 2007. Training of staff in all aspects of post-mortem and bereavement care is essential for ascertaining parental wishes. Families should be provided with the knowledge that allows them to make informed choices. The analysis of the results of the audit supports this view.

Gonioscopy findings and prevalence of occludable angles in a Burmese population: the Meiktila Eye Study

AIM

To determine the prevalence of preglaucomatous angle-closure disease in central Myanmar.

METHODS

A population-based survey of inhabitants >or=40 years in the Meiktila District was carried out; 2481 subjects were identified, 2076 participated and 2060 underwent gonioscopy of at least one eye. Eyes with angles traditionally described as "occludable" were recorded as primary angle-closure suspects (PACS); eyes with PACS and peripheral anterior synechiae (PAS), or an increased intraocular pressure but without primary angle-closure glaucoma, were recorded as primary angle closure (PAC).

RESULTS

The prevalence of PACS in at least one eye was 5.7% (95% CI 4.72 to 6.62); prevalence increased with age and was more common in women (p<0.001). The prevalence of PAC in at least one eye was 1.50% (95% CI 1.47 to 1.53). All participants with PAS had at least 90 degrees of closure (range 90-360 degrees).

CONCLUSION

The prevalence of preglaucomatous angle-closure disease (PACS and PAC) in this population was 5.7% and 1.5%, respectively. PACS was more common in women, and its prevalence increased with age.

Prevalence of glaucoma in rural Myanmar: the Meiktila Eye Study

AIM

To determine the prevalence of glaucoma in the Meiktila district of central, rural Myanmar.

METHODS

A cross-sectional, population-based survey of inhabitants > or =40 years of age from villages in Meiktila district, Myanmar, was performed; 2481 eligible participants were identified and 2076 participated in the study. The ophthalmic examination included Snellen visual acuity, slit-lamp examination, tonometry, gonioscopy, dilated stereoscopic fundus examination and full-threshold perimetry. Glaucoma was classified into clinical subtypes and categorised into three levels according to diagnostic evidence.

RESULTS

Glaucoma was diagnosed in 1997 (80.5%) participants. The prevalence of glaucoma of any category in at least one eye was 4.9% (95% CI 4.1 to 5.7; n = 101). The overall prevalence of primary angle-closure glaucoma (PACG) was 2.5% (95% CI 1.5 to 3.5) and of primary open-angle glaucoma (POAG) was 2.0% (95% CI 0.9 to 3.1). PACG accounted for 84% of all blindness due to glaucoma, with the majority due to acute angle-closure glaucoma (AACG).

CONCLUSION

The prevalence of glaucoma in the population aged > or =40 years in rural, central Myanmar was 4.9%. The ratio of PACG to POAG was approximately 1.25:1. PACG has a high visual morbidity and AACG is visually devastating in this community. Screening programmes should be directed at PACG, and further study of the underlying mechanisms of PACG is needed in this population.

Prevalence and causes of visual impairment in rural myanmar: the Meiktila Eye Study

OBJECTIVE

To determine the prevalence and causes of visual impairment in the Meiktila district of central, rural Myanmar.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Random, stratified, cluster sampling of the inhabitants 40 years of age and older from villages in the Meiktila district was performed; 2481 eligible participants were identified and 2076 participated in the study.

METHODS

The ophthalmic examination included presenting and pinhole Snellen visual acuity with an illiterate E chart, slit-lamp examination of the anterior segment, and dilated stereoscopic fundus examination. The principal cause of visual impairment was recorded.

MAIN OUTCOME MEASURES

Visual impairment and blindness were defined by both presenting and corrected visual acuity according to World Health Organization criteria: better eye < 6/18 and < 3/60, respectively.

RESULTS

Comprehensive examinations, including Snellen visual acuity, were performed on 2073 participants (83.6%) The prevalence estimate of presenting visual impairment was 40.4% (95% confidence interval [CI], 36.1-44.7) and of presenting blindness was 8.1% (95% CI, 6.5-9.9). After pinhole correction, the corresponding prevalences were 26.8% (95% CI, 23.5-30.1) and 5.3% (95% CI, 4.0-6.6). Cataract, uncorrected refractive error, and glaucoma were the most common causes of visual impairment.

CONCLUSIONS

Visual impairment and blindness remain major public health problems in rural Myanmar. Specific programs directed toward reducing the cataract burden need to be implemented.

The right place in the right space? Awareness of site for needle thoracocentesis

BACKGROUND

Invasive practical procedures require identification of surface anatomical landmarks to reduce risk of damage to other structures. Needle thoracocentesis has specific complications, which have been previously documented. An observational study was performed among emergency physicians to name the landmark for needle thoracocentesis and identify this point on a human volunteer as per Advanced Trauma and Life Support (ATLS) guidelines.

RESULTS

A cohort of 25 emergency physicians was studied, 21 (84%) of which were ATLS certified. The correct landmark was named by 22 (88%). Only 15 (60%) correctly identified the second intercostal space on the human volunteer, all placing the needle medial to the midclavicular line, with a range of 3 cm. Two (8%) named and identified the site of needle pericardiocentesis; one (4%) named and identified the fifth intercostal space in the anterior axillary line.

DISCUSSION

These results demonstrate a low accuracy among emergency physicians in identifying correct landmarks for needle thoracocentesis under elective conditions. Should greater emphasis be placed on competency based training in ATLS?

Relationship between Trendelenburg tilt and internal jugular vein diameter

OBJECTIVES

To evaluate the relationship between Trendelenburg tilt and internal jugular vein (IJV) diameter, and to examine any cumulative effects of tilt on the IJV diameter.

METHODS

Using a tilt table, healthy volunteers were randomised to Trendelenburg tilts of 10 degrees, 15 degrees, 20 degrees, 25 degrees, and 30 degrees. Ultrasound was used to measure and record the lateral diameter of the right IJV at the level of the cricoid cartilage. Following each reading the table was returned to the supine position. Balanced randomisation was used to assess cumulative tilt effects.

RESULTS

A total of 20 healthy volunteers were recruited (10 men, 10 women). Mean supine IJV diameter was 13.5 mm (95% CI 12.8 to 14.1) and was significantly greater at 10 degrees (15.5 mm, 95% CI 14.9 to 16.1). There was no significant difference between 10 degrees and greater angles of tilt. The effect of the previous angle of tilt did not prove to be statistically significant.

CONCLUSION

Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10 degrees tilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25 degrees achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).

Functional dissection of YabA, a negative regulator of DNA replication initiation in Bacillus subtilis

The regulation of initiation of DNA replication is crucial to ensure that the genome is replicated only once per cell cycle. In the Gram-positive bacterium Bacillus subtilis, the function of the YabA protein in initiation control was assigned based on its interaction with the DnaA initiator and the DnaN sliding clamp in the yeast two-hybrid and on the overinitiation phenotype observed in a yabA null strain. However, YabA is unrelated to known regulators of initiation and interacts with several additional proteins that could also be involved directly or not in initiation control. Here, we investigated the specific role of YabA interactions with DnaA and DnaN in initiation control by identifying single amino acid changes in YabA that disrupted solely the interaction with DnaA or DnaN. These disruptive mutations delineated specific interacting surfaces involving a Zn2+-cluster structure in YabA. In B. subtilis, these YabA interaction mutations abolished both initiation control and the formation of YabA foci at the replication factory. Upon coexpression of deficient YabA mutants, mixed oligomers formed foci at the replisome and restored initiation control, indicating that YabA acts within a heterocomplex with DnaA and DnaN. In agreement, purified YabA oligomerized and formed complexes with DnaA and DnaN. These findings underscore the functional association of YabA with the replication machinery, indicating that YabA regulates initiation through coupling with the elongation of replication.

Survey of attitudes of senior emergency physicians towards the introduction of emergency department ultrasound

INTRODUCTION

Emergency department ultrasound (EDU) is widely practised in the USA, Australia, parts of Europe, and Asia. EDU has been used in the UK since the late 1990s but as yet, few areas have established a practice.

OBJECTIVES

To assess the current climate of opinion with respect to the practice, constraints, and establishment of EDU among emergency department (ED) consultants on the island of Ireland.

METHODS

A postal questionnaire was formulated, piloted, and assessed for ambiguity by a sample of ED consultants and an independent non-ED consultant, prior to being mailed to all ED consultants in Ireland.

RESULTS

Of the 58 consultants canvassed 46 (79%) responded. Of the respondents, 40 (87%) strongly agreed/agreed that EDU is appropriate and should be performed in the ED. Of these, 3 (7%) are currently performing EDU; 37 (80%) have not had formal training in EDU, however 42 (91%) support the establishment of national guidelines for training in focused ultrasound in the ED. Problems instituting EDU were often multifactorial. Commonly highlighted difficulties included financial issues (24 respondents, 52%) and radiology department support (16 respondents, 34%). Other cited problems include varying interdepartmental practices (15 respondents, 33%) and (for some EDs) low numbers of patients requiring EDU, with projected difficulties in skills maintenance.

CONCLUSION

Despite the vast majority of ED consultants being in favour of EDU, very few actually perform it on a regular basis or have had any formal training. Highlighted difficulties in EDU implementation included financial constraints, lack of support from radiology departments, and lack of formal training.

Emergency department ultrasound (EDU): clinical adjunct or plaything?

BACKGROUND

Emergency department ultrasound (EDU) is a physician performed ultrasound service aimed at improving patient flow and diagnosis in the emergency department.

METHODS

This paper describes the initial phase of the introduction of EDU with three illustrative case reports and a discussion on the pitfalls and benefits of EDU.

RESULTS AND DISCUSSION

In three cases discussed here, the use of EDU facilitated treatment and reduced the need for formal radiological scanning. While there are drawbacks to EDU, we believe these are far outweighed by the advantages, and in a recent survey of emergency medicine consultants throughout Ireland, the vast majority were in favour of its introduction.

CONCLUSION

EDU has become a routine part of our clinical practice, and although we are still on a learning curve with regard to its use, we have experienced significant benefits in patient care. With technological advances (such as improved image resolution and teleradiology) the potential for EDU will continue to expand, but training, practice, accreditation, and audit are essential.

Early steps of Bacillus subtilis primosome assembly

Primosomes are nucleoprotein assemblies designed for the activation of DNA replication forks. Their primary role is to recruit the replicative helicase onto single-stranded DNA. The "replication restart" primosome, defined in Escherichia coli, is involved in the reactivation of arrested replication forks. Binding of the PriA protein to forked DNA triggers its assembly. PriA is conserved in bacteria, but its primosomal partners are not. In Bacillus subtilis, genetic analysis has revealed three primosomal proteins, DnaB, DnaD, and DnaI, that have no obvious homologues in E. coli. Interestingly, they are involved in primosome function both at arrested replication forks and at the chromosomal origin. Our biochemical analysis of the DnaB and DnaD proteins unravels their role in primosome assembly. They are both multimeric and bind individually to DNA. Furthermore, DnaD stimulates DnaB binding activities. DnaD alone and the DnaD/DnaB pair interact specifically with PriA of B. subtilis on several DNA substrates. This suggests that the nucleoprotein assembly is sequential in the PriA, DnaD, DnaB order. The preferred DNA substrate mimics an arrested DNA replication fork with unreplicated lagging strand, structurally identical to a product of recombinational repair of a stalled replication fork.

Psychological model for judicial decision making in emergency or temporary child placement

In emergencies, family court judges must often make rapid decisions, without benefit of thorough information, that have significant impact on people's lives. Action-oriented research was used to develop a model that would bring psychosocial factors to the legal system for the purpose of enhancing the judicial decision-making process in emergency and temporary child placement cases.

DnaB, DnaD and DnaI proteins are components of the Bacillus subtilis replication restart primosome

Phenotypes of Bacillus subtilis priA mutants suggest that they are deficient in the restart of stalled chromosomal replication forks. The presumed activity of PriA in the restart process is to promote the assembly of a multiprotein complex, the primosome, which functions to recruit the replication fork helicase onto the DNA. We have proposed previously that three proteins involved in the initiation of replication at oriC in B. subtilis, DnaB, DnaD and DnaI, are components of the PriA primosome in this bacterium. However, the involvement of these proteins in replication restart has not yet been studied. Here, we describe dnaB mutations that suppress the phenotypes of B. subtilis priA mutants. In a representative mutant, the DnaC helicase is loaded onto single-stranded DNA in a PriA-independent, DnaD- and DnaI-dependent manner. These observations confirm that DnaB, DnaD and DnaI are primosomal proteins in B. subtilis. Moreover, their involvement in the suppression of priA phenotypes shows that they participate in replication fork restart in B. subtilis.

PcrA is an essential DNA helicase of Bacillus subtilis fulfilling functions both in repair and rolling-circle replication

The only DNA helicase essential for Escherichia coli viability is DnaB, the chromosome replication for helicase. In contrast, in Bacillus subtilis, in addition to the DnaB counterpart called DnaC, we have found a second essential DNA helicase, called PcrA. It is 40% identical to the Rep and UvrD DNA helicases of E. coli and 61% identical to the PcrA helicase of Staphylococcus aureus. This gene is located at 55 degree on the chromosome and belongs to a putative operon together with a ligase gene (lig) and two unknown genes named pcrB and yerH. As PcrA was essential for cell viability, conditional mutants were constructed. In such mutants, chromosomal DNA synthesis was slightly decreased upon PcrA depletion, and rolling-circle replication of the plasmid pT181 was inhibited. Analysis of the replication intermediates showed that leading-strand synthesis of pT181 was prevented upon PcrA depletion. To compare PcrA with Rep and UvrD directly, the protein was produced in rep and uvrD mutants of E. coli. PcrA suppressed the UV sensitivity defect at a uvrD mutant but not its mutator phenotype. Furthermore, it conferred a Rep-phenotype on E. coli. Altogether, these results show that PcrA is an helicase used for plasmid rolling-circle replication and suggest that it is also involved in UV repair.

Replication terminus for DNA polymerase I during initiation of pAM beta 1 replication: role of the plasmid-encoded resolution system

Replication of plasmid pAM beta 1 is initiated by DNA polymerase I (Pol I) and completed by DNA polymerase III holoenzyme contained in the replisome machinery. In this study we report that initiation of DNA replication generates D-loop structures containing the nascent leading strand paired to its template, and that D-loop extension is arrested approximately 230 bp from the initiation site of DNA synthesis in the presence of the plasmid-encoded resolvase. In vitro and in vivo data suggest that this arrest is caused by a collision between Pol I and the resolvase bound to its target. As the arrested D-loop replication intermediates carry a single-stranded primosome-assembly site, we hypothesize that the biological role of the replication arrest is to limit the region replicated by Pol I and to promote the replacement of Pol I by the replisome in order to initiate concerted synthesis of the leading and lagging strands.

In vivo analysis of the plasmid pAM beta 1 resolution system

The promiscuous plasmid pAM beta 1 from Gram-positive bacteria encodes a resolution system which differs from that of Tn3 in that (i) it requires a histone-like protein and an unusual resolvase-DNA interaction to promote recombination and (ii) it mediates in vivo DNA inversion in plasmid substrates. In this in vivo analysis, the pAM beta 1 resolution site is narrowed down to a 99 bp segment, the strand exchange is mapped within 10 bp and the serine residue at position 10 of the resolvase is shown to be essential for enzyme activity. In addition, data showing that the resolution system does not promote DNA inversion in the Bacillus subtilis chromosome are presented. Implications of this observation are discussed.

Establishing ownership of the hospital bill in admissions: a key to protecting your facility's fiscal integrity

You have a plan and you have educated and documented that the patient is cognizant of his/her responsibility. Reality often dictates that problems surface after discharge. How can we prevent the patient from placing the bill on a shelf and forgetting it? As a part of your hospital's bottomline, you have a responsibility to ensure that its fiscal integrity is protected. Afterall, your hospital is also a business as well as a healing institution. Taking the lead in getting the right information at the admission or precertification stage is a vital element in the collection loop. Second, realize that not all, but a majority of patients, are beginning to investigate their benefits and coverage limitations. They may be doing so without a total understanding of insurance terminology or the difference in how much of the hospital/physician charges are paid or what percent rests with them. Last, in Pennsylvania at least, the state requires active participation by hospitals in healthcare cost containment by requiring submission rate and medical outcome information. Why not take this opportunity as an admitting professional to try some of the strategies mentioned. Informing the patient of their insurance benefits and providing an estimate of the bill will increase your department's contribution, and educate the patient about "consumerism". Consumerism is developing within the healthcare industry.(ABSTRACT TRUNCATED AT 250 WORDS)