Action to Improve Social Determinants of Health: Outcomes of Leadership and Advocacy Training for Community Residents

Racial and ethnic disparities remain a public health problem and are largely due to social determinants of health (SDOH). Using an adapted 36-hour community health worker (CHW) curriculum, we trained 42 lay community residents in New Orleans, Louisiana, neighborhoods experiencing disparities in leadership and advocacy skills to address SDOH. Six months posttraining, 29 participants completed a follow-up survey and interview. Participants described increases in knowledge, self-efficacy, and activities related to leadership and advocacy at all levels of the social ecological model. We also found a significant increase in communicating with Louisiana state senators or representatives (p < .0339). Our findings show that an adapted CHW training curriculum focused on SDOH, leadership, and advocacy can be used to train lay community residents in how to make changes in the community conditions that affect health and prompt new engagement to address SDOH at all levels of the social ecological model. Future efforts to increase lay community participation in addressing SDOH may benefit from providing ongoing support to participants such as organizing meetings with residents interested in similar topics, offering opportunities to “shadow” experienced CHWs, or hosting additional skills building workshops.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Engaging LGBTQ Communities in Community-Partnered Participatory Research: Lessons from the Resilience Against Depression Disparities Study

BACKGROUND

The Resilience Against Depression Disparities (RADD), a community partnered, randomized comparative effectiveness study, aimed to address mental health in Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) racial/ethnic populations in New Orleans and Los Angeles.

OBJECTIVES

To describe engagement methods, lessons learned, and recommendations in engaging LGBTQ individuals and agencies throughout the RADD study.

METHODS

RADD used a community partnered participatory research framework to engage LGBTQ community members and agencies. Observational and quantitative data were collected to describe engagement activities and study adaptations from October 2016 to May 2019.

RESULTS

Our partnered approach resulted in multiple study adaptations. The principles of cultural humility, coleadership, and addressing health determinants were important to successful engagement with LGBTQ community members and study participants. We recommend maintaining cultural humility as the tenant of all research activities.

CONCLUSIONS

This project's engagement plan demonstrates that community-academic partnerships can be forged to create and modify existing study models for LGBTQ communities.

Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography

Background: Housing is an important social determinant of health (SDOH). Transgender people face a unique blend of discrimination and compromised social services, putting them at risk for housing insecurity and associated public health concerns. Aims: This targeted ethnography explores housing insecurity as a SDOH among transgender people in the U.S. Methods: In-depth interviews were conducted with transgender people (n = 41) throughout the U.S.A., identified through purposive sampling. A semi-structured guide was used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes. Results: Responses revealed pervasive housing insecurity and inter-related challenges. Respondents discussed how intersecting identities create unique constellations of vulnerability, which "intersect like a star." Financial insecurity and interpersonal rejection were lead housing insecurity causes, often resulting in psychological strain, which was sometimes addressed with substances and sexual risk-taking. These factors were cyclically accompanied by financial and employment insecurity and a cascade of unmet social needs. Social support facilitated coping. Discussion: Findings support increasing transgender housing security intervention resources that address intersecting and cyclical discrimination, trauma, housing, employment, and health issues.

Early data on long-term efficacy and safety of inotersen in patients with hereditary transthyretin amyloidosis: a 2-year update from the open-label extension of the NEURO-TTR trial

BACKGROUND AND PURPOSE

Hereditary transthyretin (hATTR) amyloidosis causes progressive polyneuropathy resulting from transthyretin (TTR) amyloid deposition throughout the body, including the peripheral nerves. The efficacy and safety of inotersen, an antisense oligonucleotide inhibitor of TTR protein production, were demonstrated in the pivotal NEURO-TTR study in patients with hATTR polyneuropathy. Here, the long-term efficacy and safety of inotersen are assessed in an ongoing open-label extension (OLE) study.

METHODS

Patients who completed NEURO-TTR were eligible to enroll in the OLE (NCT02175004). Efficacy assessments included the modified Neuropathy Impairment Score plus seven neurophysiological tests composite score (mNIS + 7), the Norfolk Quality of Life - Diabetic Neuropathy (Norfolk QOL-DN) questionnaire total score and the Short-Form 36 Health Survey (SF-36) Physical Component Summary (PCS) score. Safety and tolerability were also assessed.

RESULTS

Overall, 97% (135/139) of patients who completed NEURO-TTR enrolled in the OLE. Patients who received inotersen for 39 cumulative months in NEURO-TTR and the OLE continued to show benefit; patients who switched from placebo to inotersen in the OLE demonstrated improvement or stabilization of neurological disease progression by mNIS + 7, Norfolk QOL-DN and SF-36 PCS. No new safety concerns were identified. There was no evidence of increased risk for grade 4 thrombocytopenia or severe renal events with increased duration of inotersen exposure.

CONCLUSION

Inotersen slowed disease progression and reduced deterioration of quality of life in patients with hATTR polyneuropathy. Early treatment with inotersen resulted in greater long-term disease stabilization than delayed initiation. Routine platelet and renal safety monitoring were effective; no new safety signals were observed.

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities

INTRODUCTION

Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.

METHODS AND ANALYSIS

The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.

ETHICS AND DISSEMINATION

The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT02986126.

"Housing Insecurity Seems to Almost Go Hand in Hand with Being Trans": Housing Stress among Transgender and Gender Non-conforming Individuals in New Orleans

Housing is an important social determinant of physical and mental health. Transgender and gender non-conforming individuals (T/GNCI) face a unique constellation of discrimination and compromised social services, putting them at risk for housing insecurity, homelessness, and its associated public health concerns. This study explores housing insecurity among T/GNCI in New Orleans, LA, where the infrastructural landscape is marked by an underinvestment in housing stock and disaster capitalism. In-depth interviews were conducted with T/GNCI (n = 17) living in New Orleans, identified through purposive sampling. Semi-structured guides were used to elicit personal stories and peer accounts of insecure housing experiences and coping strategies. Interviews were audio recorded and transcribed. Data was coded, sorted, and analyzed for key themes using NVIVO 11. Respondents discussed an array of circumstances that contribute to housing insecurity, including intersectional stigma and discrimination coupled with gentrification and a changing housing landscape in the city. Housing was intricately intertwined with employment and other structural issues; vulnerability in one realm was closely tied to insecurity in the others. Social support and queer family structures emerged as a key source of resilience, coping, and survival. The study supports an increase of resources for T/GNC housing access and interventions that address the cyclical discrimination, housing, and employment issues this population faces with a consideration of the historical and current structural barriers impeding their access to safe, stable, long-term housing.

Training Community Residents to Address Social Determinants of Health in Underresourced Communities

Disparities in chronic disease and life expectancy remain a significant public health problem and are largely attributable to social determinants of health. Community health workers (CHWs) promote health equity through individual- and community-level activities, and leadership and advocacy skills training make CHWs more likely to catalyze structural change. CHWs are increasingly being integrated into clinical practices to support care management, creating a need for new grassroots community-level advocates. We adapted for community residents an existing CHW training curriculum focused on social determinants of health and effecting community change. We offered 36 hours of training at community-based locations in New Orleans, Louisiana. We assessed baseline civic and community participation and pre- and postknowledge for each lesson. Among 43 enrollees, 42 completed the program. The majority were Black (92.7%), female (92.7%), and retired or unemployed (77.5%), with a median age of 61.5 years. In the past year, 85% of participants had volunteered, 57.1% had been involved with a community organization, and 32.4% had contacted the city council. Participants demonstrated statistically significant increases in knowledge in 5 of 6 lessons. Our success in increasing knowledge of advocacy among a civically engaged group suggests that trainees may become community leaders in addressing social determinants of health.

Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.

Differences in structural geometrical outcomes at the neck of the proximal femur using two-dimensional DXA-derived projection (APEX) and three-dimensional QCT-derived (BIT QCT) techniques

Structural geometric parameters at neck of the proximal femur were obtained using DXA-derived hip structural analysis (APEX 3) and quantitative computed tomography-derived (BIT QCT) techniques in 237 elderly females. Linear correlations for parameters ranged from 0.45 to 0.90. The average value of the subperiosteal width, as determined by the two techniques, was the same; variables dependent on mass measurements were different.

INTRODUCTION

There has been increasing interest in using bone structural geometry to assess bone fragility to complement bone mineral mass. The objective of this study is to compare structural geometrical differences between "2D" DXA-derived and "3D" QCT-derived techniques in unselected clinical cases.

METHODS

All 237 females had both DXA and QCT assessments of femoral neck structural geometry. Variables compared were areal bone mineral density, cross-sectional area (CSA), cross-sectional moment of inertia (CSMI), section modulus (Z), averaged cortical thickness (Ct), endosteal width (ESW), subperiosteal width (W), and buckling ratio (BR).

RESULTS

Correlation of femoral neck variables ranged from 0.45 for ESW to 0.90 for CSA. APEX 3 and BIT QCT-derived femoral neck W values were numerically similar. However CSA, CSMI, Z and Ct values measured by APEX 3 were higher and ESW and BR values were lower than corresponding BIT QCT.

CONCLUSIONS

2D DXA structural analysis of neck of femur is related to but different from same parameters calculated from true 3D images obtained by CT. Femoral neck size values are similar for DXA and QCT, but structural geometrical variables dependent on mass calibration standards, location of neck ROI and mathematical derivation techniques are different.

Introduction of electronic referral from community associated with more timely review by secondary services

BACKGROUND

Electronic referral (eReferral) from community into public secondary healthcare services was introduced to 30 referring general medical practices and 28 hospital based services in late 2007.

OBJECTIVES

To measure the extent of uptake of eReferral and its association with changes in referral processing.

METHODS

Analysis of transactional data from the eReferral message service and the patient information management system of the affected hospital; interview of clinical, operational and management stakeholders.

RESULTS

eReferral use rose steadily to 1000 transactions per month in 2008, thereafter showing moderate growth to 1200 per month in 2010. Rate of eReferral from the community in 2010 is estimated at 56% of total referrals to the hospital from general practice, and as 71% of referrals from those having done at least one referral electronically. Referral latency from letter date to hospital triage improves significantly from 2007 to 2009 (p<0.001), from a paper referral median of 8 days (inter-quartile range, IQR: 4-14) in 2007 to an eReferral median of 5 days (IQR: 2-9) and paper referral median of 6 days (IQR: 2-12) in 2009. Specialists upgrade the referrer-assigned eReferral priority in 19.2% of cases and downgrade it 18.6% of the time. Clinical users appreciate improvement of referral visibility (status and content access); however, both general practitioners and specialists point out system usability issues.

DISCUSSION

With eReferrals, a referral's status can be checked, and its content read, by any authorized user at any time. The period of eReferral uptake was associated with significant speed-up in referral processing without changes in staffing levels. The eReferral system provides a foundation for further innovation in the community-secondary interface, such as electronic decision support and shared care planning systems.

CONCLUSIONS

We observed substantial rapid voluntary uptake of eReferrals associated with faster, more reliable and more transparent referral processing.

Detection of herpes viruses in respiratory secretions of patients undergoing artificial ventilation

The significance of detection of herpes viruses in respiratory secretions of critically ill patients is controversial. The study aim was to determine the prevalence of herpes virus DNA in respiratory secretions in patients on artificial ventilation. Respiratory secretions taken thrice weekly from 174 patients in a tertiary center intensive therapy unit (ITU) were tested for herpes simplex virus (HSV) by nested PCR. Samples from 61 patients in ITU for 4 days or more were also tested for Epstein Barr Virus (EBV) and cytomegalovirus (CMV) using real-time PCR. HSV positivity increased with ITU stay with 18.6% admission samples positive, 32.5% day 2-5 samples, and 65.9% day 6-39 samples. Being HSV positive on admission did not influence mortality (9/27, 33.3% vs. 38/118, 32.2%) however, subsequently, mortality of those negative but becoming positive was higher than in those remaining negative (10/35, 29% vs. 5/24 21%). At least one sample was EBV positive in 61% and CMV positive in 19% of patients tested. Of 63 patients tested for all three viruses, 4 were positive for three viruses, 23 patients for two viruses, 24 for one virus and 12 were negative for all the above viruses. Detection of HSV, EBV and CMV is common in ITU patients. Becoming HSV positive while in ITU may increase mortality.

South Africa’s Socio-Techno divide: a critical discourse analysis of government speeches

This paper aims at contributing to the debate about the digital divide. We first focus on what to us constitutes the root problem: the typical approaches to the development of people through and by the use of information and communication technologies (ICT). In contrast to governmental, political and technological attempts that focus almost exclusively on providing access to digital communication technologies, and expect “development” naturally to flow from that, we argue for a focus on “development” which is based on our notion of sustainable socio-economic development. We refer to “technocentric approaches” when the approaches propose and pursue technological interventions and show little regard for the actual needs of the people involved. At the other end of the scale, where the focus is on people and their developmental needs, we will speak of “sociocentric approaches”. This presents us with a different divide, which we will refer to as the “socio-techno divide”. We argue that it is this divide that has to be addressed – not the digital divide – and then present an analysis of the socio-techno divide. This analysis takes the form of two types of Critical Discourse Analysis (CDA), namely Foucauldian and Habermassian. The analysis of the South African government’s rhetoric illuminates the issues that need our attention and indicates an agenda for constructive engagement about the use of ICT for development in the Third and Fourth worlds.

Choice of antenatal testing significantly effects a patient's work obligations

OBJECTIVE

We sought to compare two approaches to antenatal testing for their impact on the workforce.

STUDY DESIGN

This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. chi2- and Student's t-tests were performed where appropriate. A P-value of <0.05 was considered significant.

RESULT

A total of 195 women were surveyed. Among them, 94 women had an NST and 101 had a BPP. Overall, 59.2% were multiparous, 33.1% had to arrange for child care and 97.2% felt reassured by the testing. There were no differences in demographic characteristics, education, type of insurance or employment status between the groups. Women who had NSTs were more likely to lose time from work than those who had BPPs (218.4 versus 68.9 min; P<0.001). Of the women who had semiweekly NSTs, 80.6% would have preferred weekly testing. If the 94 women who received semiweekly testing had weekly testing, a total of 534.4 h would have been available for the workforce.

CONCLUSION

Twice-weekly NST results in a significant increase in time lost from the workforce compared with weekly BPP.

Anterior perirhinal cortex kindling produces long-lasting effects on anxiety and object recognition memory

Temporal lobe epilepsy (TLE) is frequently accompanied by memory impairments and, although their bases are unknown, most research has focused on the hippocampus. The present study investigated the importance of another medial temporal lobe structure, the perirhinal cortex (Prh), in changes in memory in TLE using kindling as a model. Rats were kindled twice daily with anterior Prh stimulation until three fully generalized seizures were evoked. Beginning 7 days later and on successive days, rats were tested in an elevated plus maze, a large circular open field, an open field object exploration task and a delayed-match-to-place task in a water maze in order to assess anxiety-related and exploratory behaviour, object recognition memory and spatial cognition. Kindling increased anxiety-related behaviour in both the elevated plus and open field mazes and disrupted spontaneous object recognition but spared all other behaviours tested. These results are consistent with other findings indicating a greater role for the Prh in object memory and emotional behaviour than in spatial memory and contrast with the selective disruption of spatial memory produced by dorsal hippocampal kindling. The site-selectivity of the behavioural disruptions produced by kindling indicates that such effects are probably mediated by changes particular to the site of seizure initiation rather than to changes in the characteristic circuitry activated by limbic seizure generalization. Further investigation of the behavioural effects of Prh kindling may be useful for studying the mechanisms of mnemonic and affective dysfunction associated with TLE and offer insights into bases for variability in such dysfunction across patients.

The relation between extent of dorsal hippocampal kindling and delayed-match-to-place performance in the Morris water maze

Dorsal hippocampal kindling impairs subsequent performance on spatial tasks. The relation between this effect and the extent of kindling achieved prior to testing has not been clearly established. Thus, the present study investigated the effects of dorsal hippocampal kindling on performance of a delayed-match-to-place (DMTP) task in the Morris water maze by assessing performance after each of series of different points in the kindling process including 1, 6, 11, and 16 afterdischarges, 1 stage 1 seizure, and 1 stage 5 seizure. We found that kindling produced a deficit that was apparent very early into kindling in terms of both direct swim (by 1 AD) and escape distance (by 6 ADs) measures but that did not clearly change in severity with further kindling. These results illustrate that kindling of even a few localized hippocampal seizures can disrupt spatial cognition and suggest that the mechanisms mediating memory disruption either do not change substantially as kindling progresses or that compensatory processes are engaged across training that mitigate any further kindling-related deteriorations in performance.

[Relationship between learning ability and memory and free radical in hippocampus of old rats]

OBJECTIVE

To study the relationship between the amount of free radical in hippocampus and the learning ability and memory in old rats.

METHODS

Morris water maze was used for 10 days to examine the learning scores, latency scores, and the loci of movement in the maze among 46 old rats (aged 20 months), 36 young rats (aged 6 months), and 34 adult rats (aged 12 months). Salicylate was injected intraperitoneally and hippocampus dialysis was performed. Chromatography was used to measure the basic values of 2,3DHBA and 2,5DHBA in dialysis fluid chemiluminometry was used to measure the superoxide dismutrase (SOD) in the sample. The rats were killed and their brains were taken out. Histological examination was conducted to calculate the number of neurons in CA1, CA4, and PM regions in hippocampus.

RESULTS

The learning scores on the first, fifth, and tenth days were 36.5 +/- 5.9 sec, 38.6 +/- 5.9 sec, and 39.4 +/- 6.9 sec (P > 0.05) in the old rats; 60.2 +/- 5.4 sec, 156.8 +/- 5.8 sec, and 165.1 +/- 6.8 sec in the young rats; and 61.7 +/- 5.8 sec, 152.3 +/- 6.9 sec, and 168.7 +/- 6.5 sec in adult rats. The learning scores at any time point of old rats were significantly lower than those of the young and adults rats (all P < 0.01). The latency scores of the first, fifth, and tenth days were 25.7 +/- 1.2 sec, 27.5 +/- 1.9 sec, and 27.7 +/- 1.9 sec in the old rats without significant difference between any two of these values (P > 0.05), however, the 3 latency scores of the old rats were all significantly larger than those of the young and adult rats (21.8 +/- 1.7 sec, 5.9 +/- 1.0 sec, and 3.6 +/- 0.6 sec, and 21.8 +/- 1.6 sec, 5.0 +/- 0.9 sec, and 4.8 +/- 0.7 sec respectively, all P < 0.01). The basic value of 2,3DHBA after intraperitoneal injection of salicylate was 20.7 +/- 0.3 pmol/ml in the old rats, 5 times that of the young rats and 6 times that of the adult rats (P < 0.01). The basic value of 2,5DHBA after intraperitoneal injection of salicylate was 60.12 pmol/ml in the old rats, 6 times that of the young rats and 5.8 times that of the adult rats (P < 0.01). The SOD activity was 410 U x g(-1) x min(-1) +/- 50 U x g(-1) x min(-1), significantly lower than those in the young and adult rats (880 U x g(-1) x min(-1) +/- 62 U x g(-1) x min(-1) and 860 U x g(-1) x min(-1) +/- 60 U x g(-1) x min(-1) (both P < 0.01). The values of neuron density in CA1, CA4, and PM regions of the old rats were all significantly lower than those of the young and adult rats (all P < 0.01).

CONCLUSION

The decrease of learning ability in old rat is positively correlated with the increase of free radicals and loss of neurons in hippocampus.

Mast cells differentially express and release active high molecular weight neurotrophins

Nerve growth factor (NGF), a target-derived factor for survival and maintenance of peripheral and central neurons, has been implicated in inflammatory processes. Mast cells are the principal effector cells in IgE-dependent hypersensitivity reactions, and also play a role in diseases characterised by inflammation, including those of the nervous system like multiple sclerosis. Mast cells are capable of synthesising and responding to NGF, although the occurrence of other members of the NGF family of neurotrophins and their protein forms have not been described. Immunoblot analysis with highly selective neurotrophin antibodies has now been used to show that rat peritoneal mast cells express a higher molecular weight form (73 kDa) of NGF, but not the monomeric (13 kDa) NGF polypeptide. Mast cells also expressed 73 kDa forms of neurotrophin-4 and neurotrophin-3; brain-derived neurotrophic factor was not detected. Medium conditioned by degranulating peritoneal mast cells contained similar high molecular weight forms of NGF and neurotrophin-4 on Western blots, but no neurotrophin-3. Mast cell-derived neurotrophin immunoreactivities were inhibited by the respective peptide antigen, further demonstrating the specificity of the mast cell-derived neurotrophic protein. Mast cell-released proteins supported the survival of cultured chicken embryonic neural crest- and placode-derived sensory neurons; neurotrophic activities were inhibited by neutralising antibodies for NGF and neurotrophin-4, respectively. High molecular isoforms of neurotrophins have been reported to occur in experimental colitis and in the inflamed gut of patients with Crohn's disease and ulcerative colitis, tissue sites rich in mast cells. The data suggest an important role for neurotrophins in the pathophysiology of inflammatory disease.

Transcervical Foley catheter for preinduction cervical ripening in an outpatient versus inpatient setting

OBJECTIVE

To compare use of the Foley catheter for preinduction cervical ripening in an inpatient versus outpatient setting.

METHODS

A randomized trial was conducted from May 1998 to December 1999. Women with a term gestation in the vertex presentation, a reactive nonstress test, an amniotic fluid index above the fifth percentile, and a Bishop score of no more than 5 were included. The primary outcome variable was a change in Bishop score. A Foley catheter with a 30-mL balloon was placed through the cervix on gentle traction in each group. The outpatient group was then discharged home with written instructions and returned in the morning for induction. The inpatient group was admitted to labor and delivery, with induction started upon extrusion of the Foley.

RESULTS

Sixty-one women were randomized into the outpatient group, and 50 women into the inpatient group. Maternal age, gravidity, previous cesarean delivery, and gestational age did not differ between the groups. The median Bishop score at entry was 3.0 for each group (P =.97). The mean change in Bishop scores after catheter placement was not different between the inpatient and outpatient groups (3.0 versus 3.0; P =.74). The maximum dose of oxytocin, time of oxytocin, epidural rate, induction time, 1-minute and 5-minute Apgar scores, and cord pH were not significantly different. The outpatient group on average avoided 9.6 hours of hospitalization. There were no adverse events or maternal morbidity in either group.

CONCLUSIONS

The Foley bulb is as effective in the outpatient as the inpatient setting for preinduction cervical ripening.

Dorsal hippocampal kindling produces a selective and enduring disruption of hippocampally mediated behavior

Kindling produces enduring neural changes that are subsequently manifest in enhanced susceptibility to seizure-evoking stimuli and alterations in some types of behavior. The present study investigated the effects of dorsal hippocampal (dHPC) kindling on a variety of behaviors to clarify the nature of previously reported effects on spatial task performance. Rats were kindled twice daily with dHPC stimulation until three fully generalized seizures were evoked. Beginning 7 d later and on successive days, rats were tested in an elevated plus maze, a large circular open field, an open field object exploration task, and a delayed-match-to-place (DMTP) task in a water maze to assess anxiety-related and activity-related behavior (tasks 1 and 2), object recognition memory (task 3), and spatial cognition (task 4). Kindling disrupted performance on the DMTP task in a manner that was not delay dependent and produced a mild enhancement of activity-related behaviors in the open field task but not the elevated plus maze. All other aspects of testing were spared. These findings indicate that dHPC kindling produces enduring and selective effects on behavior that are consistent with a restricted disruption of hippocampally mediated functions. Possible bases for these effects are changes in local NMDA receptor function and/or changes in local inhibition, which might alter the optimal conditions for experience-dependent induction of intrahippocampal plasticity. This preparation may be useful for studying the mechanisms of mnemonic dysfunction associated with temporal lobe epilepsy and may offer unique insights into the mechanisms underlying normal hippocampal function.

Early transvaginal ultrasonography versus early cerclage in women with an unclear history of incompetent cervix

OBJECTIVE

Our aim was to compare outcomes in women with a questionable history of incompetent cervix, followed up with early transvaginal ultrasonography, with outcomes in women who had early cerclage.

STUDY DESIGN

Charts were reviewed and patients identified for incompetent cervix from our obstetric database from 1995 through 1997. We included women who had an unclear history of incompetent cervix as follows: second-trimester loss or termination, > or =3 first-trimester terminations, cone biopsy or loop electrosurgical excision, or exposure to diethylstilbestrol. The primary outcome variable was gestational age at delivery.

RESULTS

A total of 106 women were included, 45 in the early cerclage group and 61 in the early transvaginal ultrasonography group. The mean gestational age at delivery was 35.1 weeks for the early cerclage group versus 36.1 weeks for the early transvaginal ultrasonography group.

CONCLUSION

In women with an unclear history of incompetent cervix, early cerclage does not appear to offer significant benefit over early transvaginal ultrasonography.

A randomized comparison of transcervical Foley catheter to intravaginal misoprostol for preinduction cervical ripening

OBJECTIVE

To compare the efficacy of intravaginal misoprostol tablets with transcervical Foley catheter for preinduction cervical ripening.

METHODS

Pregnant women who presented for induction of labor with unfavorable cervices (Bishop score less than 6) were assigned randomly to intravaginal misoprostol (50 microg tablet every 4 hours for a maximum of six doses) or 30-mL Foley catheter placed transcervically with maintenance of traction.

RESULTS

Among 111 women, 53 were allocated to misoprostol and 58 to Foley bulb. Contractile abnormalities were more frequent in the misoprostol group (20.4%) than the Foley group (0%) (P <.001). No statistically significant differences were noted between groups in change in Bishop score, preinduction cervical ripening times, and total induction times. There were no statistically significant differences in mode of delivery or adverse neonatal outcomes. Uterine rupture occurred in one woman with two previous cesarean deliveries in the misoprostol group.

CONCLUSION

Intravaginal misoprostol and transcervical Foley catheter are equivalent for cervical ripening. Uterine contractile abnormalities and meconium passage are more common with misoprostol.

Intracervical fibrin sealants: a potential treatment for early preterm premature rupture of the membranes

OBJECTIVE

We report our experience with a transvaginally applied intracervical fibrin sealant at <24 weeks' gestation.

STUDY DESIGN

This is an observational study of a referred patient population, with preterm premature rupture of the membranes at <24 weeks' gestation.

RESULTS

Twelve women consented to our protocol. The mean gestational age at preterm premature rupture of membranes was 19 weeks 4 days (range, 13-23 weeks); the mean gestational age at treatment was 20 weeks 5 days (range, 17-23 weeks). All women had a diminution in the amount of amniotic fluid leakage with an increase in amniotic fluid index. Among the 12 pregnancies (13 fetuses), there were 7 surviving neonates. Two women had apparent "resealing" of the membranes.

CONCLUSION

Fibrin sealants in midtrimester rupture of the membranes may lead to improved outcomes and now warrant formal evaluation.

Treatment of rats with experimental allergic neuritis using high dose immunoglobulin

OBJECTIVE

To investigate the therapeutic potential of high-dose immunoglobulin (HIG) in experimental allergic neuritis (EAN) to provide a theoretical basis of its clinical use in the treatment of human inflammatory demyelinating neuropathies.

METHODS

Female Lewis rats were induced to EAN, and divided into experimental and control groups. The rats were treated with either 0.3 g/kg.day-1 of IgG or an equivalent volume of 0.15 mol/L glycine. Clinical, electrophysiologic, and histologic evaluations were carried out in a blind fashion.

RESULTS

Clinically, rats treated with IgG had significantly less severe symptoms (P < 0.001) and slower progression (P < 0.001) than controls. Electrophysiologically, the mean conduction latency of the experimental group was significantly shorter than controls (P < 0.05). Histologically, rats treated with IgG prepared from normal Lewis rats had a significantly lower percentage of demyelinated fibers (P = 0.01) and total abnormal fibers (P < 0.001) than controls. Statistically, clinical, electrophysiologic and morphologic data were all significantly correlated.

CONCLUSIONS

The EAN animal model is reliable for observation of HIG effects, and useful to provide data for clinical work. HIG has a significant therapeutic effect in EAN when given soon after disease onset. It can reduce clinical disease severity and decrease the number of demyelinated fibers as well as the number of total abnormal fibers. For the current controversy over whether HIG is effective, the results of this research support the clinical use of HIG in human demyelinating neuropathy.

The synergistic enhancement of pathology in intermittently cooled nerve

OBJECTIVE

To explore how non-freezing cold nerve injury (NFCNI) is affected by fluctuating ambient temperatures.

METHODS

The sciatic nerves of Wistar rats were exposed to either intermittent cooling and rewarming or continuous cooling. The pathology was assessed neurophysiologically and morphologically.

RESULTS

More severe injury was observed when nerve was intermittently cooled, despite an identical duration and degree of cooling.

CONCLUSION

The observed pathology is a result of repeated reperfusion injury to nerves that are cooled intermittently.

Cold nerve injury is enhanced by intermittent cooling

Clinically nonfreezing cold nerve injury (NFCNI) is often preceded by fluctuating ambient temperatures. To simulate this we exposed the sciatic nerve of Wistar rats to intermittent cooling and rewarming. This paradigm was contrasted with one in which the sciatic nerve was continuously cooled. Despite an identical duration and degree of sciatic nerve cooling in both experiments, the pathology, as assessed neurophysiologically and morphologically, was much more severe when the nerve was intermittently cooled. It is likely that this exaggerated pathology is a result of repeated reperfusion injury. These experimental results suggest the need for a trial of free radical scavengers or antioxidants in models of NFCNI.

A prospective, randomized comparison of Foley catheter insertion versus intracervical prostaglandin E2 gel for preinduction cervical ripening

OBJECTIVE

The objective of this study was to compare intracervical prostaglandin E2 gel with insertion of a Foley bulb for efficacy in preinduction cervical ripening.

STUDY DESIGN

Women who came to the hospital for induction of labor with a Bishop score </=5 were randomly assigned to treatment with either prostaglandin E2 gel or a Foley bulb. Prostaglandin E2 gel was used according to the manufacturer's recommendation. The Foley group had a number 14 Foley catheter inserted, inflated, and placed on traction. Immediately after Foley bulb extrusion or 6 hours after prostaglandin E2 gel course completion, a dilute oxytocin solution was started if the patient was not in labor.

RESULTS

Seventy-seven women were entered into the Foley group and 72 were entered into the prostaglandin E2 gel group. Both the Bishop score after preinduction ripening (6.5 vs 5.1, P <.001) and the change in Bishop score (3.5 vs 2.7, P =.015) were significantly higher in the Foley group. There were no differences between the groups in mode of delivery, infant weight, rate of hyperstimulation, shoulder dystocia, patient discomfort, epidural use, oxytocin use, or nonreassuring fetal heart rate patterns. The preinduction time (9.9 vs 17.2 hours, P <.001) and the total induction time (22.4 vs 30.4 hours, P <.001) were significantly shorter in the Foley group. Patient charges were 31% lower in the Foley group (P <.001).

CONCLUSION

Use of the Foley catheter resulted in a higher postinduction Bishop score, a greater change in Bishop score, a shorter induction time, and lower patient charges than did intracervical prostaglandin E2 gel.

Nonmalignant hyperthermia on induction of anesthesia in a pediatric patient undergoing bidirectional Glenn procedure

We report a case of severe hyperthermia in a 6-month-old boy with a single ventricle, dextrocardia, asplenia, and transposition of the great arteries, during induction of anesthesia on three separate occasions. To our knowledge, this is the first case reported of repeated intraoperative hyperthermia not related to malignant hyperthermia, infection, neuroendocrine tumor, or iatrogenic causes (e.g., anticholinergic blockade or warming devices). The severe hyperthermia may be secondary to the medications given before and during induction and/or the stress of the induction. Among the induction medications given during the three episodes, fentanyl is the most likely contributing drug. Human data indicate that opioids increase the sweating threshold and decrease the vasoconstriction and shivering thresholds. The medications could cause a widening in the thermoregulation interthreshold and the stress could induce nonshivering thermogenesis.

Sources of variability in hospital costs of atrial septal defect repair

Sources of variability in the cost of atrial septal defect repair were assessed. Variations in practice style, inflation, and errors in data entry were found to be the 3 primary sources of cost variability.

Cold injury to nerves is not due to ischaemia alone

The effect of cold on nerve fibre populations may be quite selective. Thus it was possible in the present study, with precise timing of a non-freezing cold nerve injury, to destroy myelinated fibres, but leave unmyelinated fibres intact. The aetiology of this cold-induced selective peripheral nerve pathology remains controversial, but recent evidence suggests that ischaemia plays an important role. To investigate this matter further, we have sought to determine whether ischaemia alone might account for such discrete nerve pathology, in a series of non-freezing cold injury paradigms. Compared with previous 'pure' ischaemic peripheral nerve models, notable differences were found in the present paradigms (early post-ischaemic luxury perfusion and severe nerve pathology), suggesting a multifactorial aetiology. Nonetheless a tight correlation was evident, with increasing duration of cold injury resulting in a progressively more severe reduction in post-cold nerve blood flow. Given these findings, we would propose that the pathological basis of non-freezing cold nerve injury is one of ischaemia, accelerated and enhanced by direct cold injury.

A controlled family history study of childhood-onset depressive disorder

BACKGROUND

We studied the family psychiatric history of 125 youths with childhood-onset depressive disorder (a portion of whom developed bipolar disorder) and 55 psychiatric controls with nonaffective disorder.

METHODS

Probands were classified according to prospectively observed clinical course in childhood. Family psychiatric history was determined by interviewers blind to probands' diagnosis, with mothers typically informing about themselves and about remaining first- and a all second-degree adult relatives.

RESULTS

Families of affectively ill juveniles had 5-fold greater odds of lifetime depressive disorder and 2-fold greater odds of recurrent unipolar depressive disorder than did families of psychiatric controls. The higher risk of depression was most evident in first-degree and female relatives. Mothers of affectively ill youths were younger at onset of depression than were mothers of controls. Alcoholism and substance use disorders were more prevalent in relatives of affectively ill probands than in controls and cosegregated with familial depression. However, other covariates were more important at predicting patterns of familial depression. Familial illness patterns also varied somewhat with proband characteristics.

CONCLUSIONS

Child probands with affective disorder identify families enriched with affective disorder (even compared with families of psychiatric controls), suggesting that juvenile- and adult-onset forms of this condition share the same diathesis. Rates of affective illness in the families of depressed youngsters also are notably higher than population-based estimates. The findings therefore indicate that very-early-onset affective disorder is familial and that pedigrees ascertained through affectively ill children are good candidates for family and genetic studies.

Arm training reduces the VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease

BACKGROUND

Patients with severe chronic obstructive pulmonary disease (COPD) may develop dyspnea with minimal arm activity, thoracoabdominal dyssynchrony with unsupported arm exercise (UAEX) and increased oxygen uptake (VO2), and minute ventilation (VE) with simple unsupported arm elevation (UAE) and UAEX. We investigated whether unsupported arm training, as the only form of exercise, could decrease the VO2 and VE cost (percentage increase from resting baseline) associated with unsupported arm elevation and exercise, respectively.

METHODS

Twenty-six patients with severe COPD were randomized to 21-24 sessions of unsupported arm (ARMT) or low-intensity resistive breathing (RBT) training as the only form of exercise. Patients were studied before and after training using a metabolic cart and esophageal and gastric pressures to evaluate metabolic and respiratory muscle function.

RESULTS

After ARMT, the VO2 (58% vs 38% increase, P < 0.05) and VE (41% v. 21% increase, P < 0.05) cost for UAEX at exercise isotime decreased and endurance time increased. Similarly the VO2 (25% vs 18% increase, P < 0.05) cost decreased and VE no longer increased in response to 2 minutes of UAE after ARMT. The RBT group showed no such change. No improvement in ventilatory load or respiratory muscle function could be identified to explain the physiologic changes observed. After ARMT, mean inspiratory flow (VT/TL), a measure of central respiratory drive, was reduced during UAEX and the expected increase during UAE did not occur.

CONCLUSION

We conclude that arm training reduces the VO2 and VE cost of UAE and UAEX, possibly through improved synchronization and coordination of accessory muscle action during unsupported arm activity.

The pathogenesis of non-freezing cold nerve injury. Observations in the rat

Non-freezing cold nerve injury is uncommon in civilian practice, but may reach epidemic proportions in war zones. Studied since the time of Hippocrates, its aetiology has remained elusive. We sought to replicate experimentally, a peripheral nerve cold temperature gradient, since this has been emphasized in clinical descriptions. Our observations, in the rat, of the vasa nervorum show that cold-induced intravascular aggregation is followed by a 'no-reflow' phenomenon which culminates in endothelial damage and delayed thrombotic occlusion.

Tamponade in patients undergoing cardiac surgery: a clinical-echocardiographic diagnosis

The purpose of this study was to evaluate the sensitivity of current echocardiographic criteria in detecting cardiac tamponade in the patient who has undergone cardiovascular surgery. Because the current echocardiographic criteria for tamponade were initially developed and studied predominantly in patients with medical problems, relatively less information is available in patients who have undergone cardiac surgery. Of 848 consecutive patients who underwent cardiovascular surgery, patients were selected for the study if they had clinical or hemodynamic deterioration and had undergone an echocardiogram just before a successful pericardiocentesis or a surgical evacuation of pericardial blood or clot. The echocardiograms were evaluated for evidence of chamber collapse, cardiac motion, Doppler flow variations, and the location and width of pericardial separation. Fourteen patients were identified who met the inclusion criteria (clinical or hemodynamic deterioration, recent echocardiogram, and successful intervention) for cardiac tamponade. The clinical and hemodynamic findings were hypotension (13 patients), low cardiac output (7), low urine output (3), cardiopulmonary arrest (1), elevated central venous pressure (1), and shortness of breath (1). In these patients current echocardiographic criteria were seen infrequently: chamber collapse in the right atrium (6 of 14 patients) and right ventricle (4 of 14); Doppler flow variation (2 of 5); and swinging heart (0 of 15), whereas increased pericardial separation (> or = 10 mm) was seen in all (14 of 14) the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma management and morbidity in Australian general practice: the relationship between patient and doctor estimates

The aims of this study were to describe asthma management and morbidity in patients attending general practitioners in Australia, and to assess the relationship between patient reports and those of their general practitioner (GP). The sample comprised consecutive patients attending 46 general practitioners chosen at random in five regions of New South Wales, Australia. A total of 4538 patients were screened, 607 (13.4%) reported ever having diagnosed asthma, and the 501 who reported asthma in the previous 12 months completed a detailed questionnaire. Three hundred and thirty-four patients also had information about their asthma management recorded by their GP. The patient questionnaire asked about asthma symptoms, therapy, lung function measurement, and asthma-related morbidity. The GP questionnaire asked the doctor to record similar information about the patients. Two-thirds of the patients used regular inhaled beta 2-agonist medication, and one-half reported using preventive therapy. Only 24% owned a peak flow meter and 9% had a written plan of action for asthma attacks. Although preventive therapy and airway function assessment were more common in those with frequent symptoms (> 2-3 times per week), this group were still sub-optimally managed. In the matched sample (n = 334), doctors reported prescribing bronchodilator and preventive medication, measuring airway function and recommending peak flow meter use more often than suggested by patient-reported data. The study concludes that many patients do not attend for regular review, and that management remains sub-optimal, particularly in young adults. Data from patient surveys may underestimate clinical practice, as assessed from doctors' records. This should lead to patient-derived estimates of management being interpreted with caution in epidemiological studies. Further attention to patient understanding and compliance with prescribed asthma management advice is needed in order to better manage asthma in the community.

Nerve regeneration

The regeneration of nerve is a brilliant example of plasticity within the nervous system. Axonal sprouts form within a few hours of nerve injury and grow vigorously over long distances. Nonetheless, recovery from nerve injury, such as that seen after laceration of distal motor-sensory nerve, is often incomplete. A variety of approaches to enhance peripheral nerve regeneration are currently being pursued. They include the use of electric fields, treatment with neurotrophic factors and Schwann cell manipulation.

Bipolar disorder and comorbid conduct disorder in childhood and adolescence

OBJECTIVE

To report on the rate and associated features of comorbid conduct disorder (CD) in 26 bipolar (BP) youths and examine whether comorbidity affects clinical course.

METHOD

The clinically referred subjects, 8 to 13 years old at study entry, were participating in a longitudinal investigation of childhood-onset psychiatric disorders. They were repeatedly examined during an interval of up to 12 years, and diagnosed by DSM-III criteria.

RESULTS

There was a 69% rate of lifetime comorbidity and 54% rate of episode comorbidity with CD. CD predated the first BP episode for 11 youths and postdated it for 7. Only 12% of the 26 children had primary uncomplicated affective illness. Youngsters without CD comorbidity had a higher rate of primary affective illness, a somewhat greater number of BP episodes, but slightly better overall clinical course. They also had a greatly elevated rate of maternal mania, whereas BP youths with CD were notable for the rate of paternal substance abuse.

CONCLUSIONS

Comorbid CD may exist in a large portion of young patients with BP disorder, confusing its clinical presentation and possibly accounting for some of the documented failure to detect BP disorder. Comorbid CD in bipolar youths appears to be associated with a somewhat worse clinical course. The overall indications are that comorbid CD may identify a subtype of very early onset BP disorder.

Eating disorders and maladaptive dietary/insulin management among youths with childhood-onset insulin-dependent diabetes mellitus

OBJECTIVE

To determine the prevalence of DSM-III eating disorder and the conjoint symptoms of maladaptive dietary/insulin management (irrespective of eating disorder) and their psychiatric and biomedical correlates among youths with childhood-onset insulin-dependent diabetes mellitus (IDDM).

METHOD

Forty-four girls and 35 boys, 8 to 13 years old at IDDM onset, were repeatedly interviewed during an interval of up to 14 years (mean = 9 years) to ascertain psychiatric disorders and behaviors related to diabetes care. Metabolic control and IDDM-related hospitalizations also were monitored.

RESULTS

By the mean age of approximately 21 years, 3.8% of the sample had DSM-III eating disorders and 11.4% had "eating problems," defined as the conjoint symptoms of severe dietary indiscretion and repeated insulin omission (irrespective of eating disorders). Youths with "eating problems" were nine times more likely to have had a psychiatric disorder than the rest of the patients, and they had a significantly higher rate of pervasive noncompliance with medical treatment. No between-group differences were found in metabolic control and rates of multiple hospitalizations.

CONCLUSIONS

The diabetes-specific symptom-pair of serious dietary indiscretion and repeated insulin omission appears to identify youths who have had other problems as well. The association of eating problems with psychiatric disorders (other than eating disorders) suggests that a subgroup of diabetic youths have various difficulties in coping with the medical illness and require close monitoring and psychosocial intervention.

A controlled prospective study of DSM-III adjustment disorder in childhood. Short-term prognosis and long-term predictive validity

OBJECTIVES

Using DSM-III criteria for adjustment disorder (AD), further operationalized by requiring at least three clinically significant symptoms, we sought to characterize this diagnosis in terms of presenting features, recovery, and predictive validity among juveniles.

DESIGN

The samples included clinically referred, 8- to 13-year-old patients with the research diagnosis of AD (N = 30) and a high rate of comorbid disorders and age-and comorbid disorder-matched psychopathologic controls (N = 26). As part of a naturalistic, longitudinal, nosologic study, patients were repeatedly examined during an average follow-up interval of 7 to 8 years.

RESULTS

Adjustment disorder was associated with six symptoms, on average, and 60% of the patients had other, specific psychiatric disorders. Adjustment disorder had a median episode length of 7 months and a 97% recovery rate. Comorbidity had no appreciable effect on recovery. Patients with adjustment disorder and controls had similar rates of new psychiatric disorders and other dysfunctional outcomes during the follow-up.

CONCLUSIONS

Among psychiatrically referred youths, the diagnosis of AD has clinical information value and identifies a syndromatic presentation that can be the focus of concern or treatment. It has a reasonably good short-term prognosis, in spite of the fact that patients with this diagnosis typically present with comorbid specific psychiatric disorders. Controlling for the effects of comorbidity, AD does not predict later dysfunction. To achieve a convergence of findings from research and clinical practice, it would be important to ensure a uniform application of specific, operational diagnostic criteria for AD.