Point-of-care ultrasound assessment of a swollen limb following snakebite envenomation - an adjunct to avoid fasciotomy

SUMMARY

Acute limb compartment syndrome can occur with cytotoxic snake envenomation. Ultrasound (US) assessment of the affected limb has been suggested as an adjunct to the administration of snakebite polyvalent antivenom to ameliorate the systemic and local effects. US may also aid in the diagnosis of compartment syndrome and the need for fasciotomy to prevent limb loss. This report presents an adult male who had severe soft tissue swelling from a puff adder bite to the wrist and highlights the use of US in assessing and monitoring the degree of swelling in subcutaneous and fascial compartments of the arm. This US monitoring in conjunction with frequent physical examination avoided the need for a fasciotomy and its attendant morbidity, resulting in complete resolution of the swelling and full recovery of limb function.

POS1343 TREATMENT OF RESISTANT RAYNAUD’S PHENOMENON WITH SINGLE-PORT THORACOSCOPIC SYMPATHICOTOMY: ONE-YEAR FOLLOW-UP

Background

Raynaud’s phenomenon (RP) usually results in discoloration of the extremities when provoked by cold or emotional stress [1]. Some patients do not respond to conventional therapies, such as lifestyle interventions and vasodilatory medication. These patients are confronted with limited options for treatment. In a previous study we have shown that minimally invasive Single-Port Thoracoscopic Sympathicotomy (SPTS) objectively and subjectively improves treatment-resistant RP, after one month [2]. This procedure for treatment-resistant RP is minimally invasive and potentially highly effective, because it specifically targets the sympathetic nerve at the third rib (R3), while leaving the ganglia untouched [3]. The procedure was only performed on the left side in the pilot study, which objectively resulted in improvement of left-hand perfusion in all patients after one month, when compared to the right hand. Furthermore, patient satisfaction after surgery was high and RP attacks of the left hand were less frequent and of shorter duration. Previous studies have shown that long-term effects of conventional sympathectomy is stable in the long run in the majority of patients [4, 5]. We have previously published the one-month results of SPTS for treatment-resistant RP in a concise report [2]. In the current study we sought to report the one-year follow-up results of SPTS for treatment-resistant RP in the same cohort of patients.

Objectives

Follow-up of patients with treatment-resistant Raynaud’s phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS).

Methods

Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillaroscopy were performed. In addition, questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period.

Results

One year after SPTS the duration of the attacks of was reduced with 1.9 hours in the left hand versus 0.9 hours in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p=0.017), pain (p=0.027) and physical functioning (p=0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75–140) at baseline versus 118 (95–190) one year post-operatively, p=0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1–41) at baseline versus 38 (24–43) one year post-operatively, p=0.028).

Conclusion

One year after unilateral R3 SPTS there is clear benefit with regard to the majority of outcome variables, though some effects seem to attenuate. Long-term effects and five-year follow-up results will be investigated in an on-going study.

References

[1]Herrick AL. The pathogenesis, diagnosis and treatment of Raynaud phenomenon. Nat Rev Rheumatol. 2012;8(8):469-79.

[2]van Roon AM, Kuijpers M, van de Zande SC, Abdulle AE, van Roon AM, Bos R, et al. Treatment of resistant Raynaud’s phenomenon with single-port thoracoscopic sympathicotomy: a novel minimally invasive endoscopic technique. Rheumatology (Oxford). 2020;59(5):1021-5.

[3]Kuijpers M, Klinkenberg TJ, Bouma W, DeJongste MJ, Mariani MA. Single-port one-stage bilateral thoracoscopic sympathicotomy for severe hyperhidrosis: prospective analysis of a standardized approach. J Cardiothorac Surg. 2013;8:216.

[4]Coveliers HM, Hoexum F, Nederhoed JH, Wisselink W, Rauwerda JA. Thoracic sympathectomy for digital ischemia: a summary of evidence. J Vasc Surg. 2011;54(1):273-7.

[5]Sayers RD, Jenner RE, Barrie WW. Transthoracic endoscopic sympathectomy for hyperhidrosis and Raynaud’s phenomenon. Eur J Vasc Surg. 1994;8(5):627-31.

Disclosure of Interests

None declared

Individual-specific changes in circadian rest-activity rhythm and sleep in symptom-free patients tapering their antidepressant medication

Introduction

Group-level studies showed cross-sectional and prospective between-person associations between circadian rest-activity rhythms (RAR), physical activity (PA), sleep, and depressive symptoms. However, whether these associations replicate at the within-person level remains unclear. Therefore, it is clinically relevant to investigate these associations within persons and study whether changes in depressive symptoms are related to changes in circadian rhythm and sleep variables.

Objectives

To identify changes in circadian rhythm elements in proximity to a transition in depressive symptoms, whether changes are less frequent in individuals without compared to those with transitions, and whether there are individual differences in the direction of change of circadian rhythm variables.

Methods

Data of remitted individuals tapering antidepressants were used: 12 with and 14 without a transition in depressive symptoms. RAR, PA, and sleep variables were calculated as predictors from four months of actigraphy data. Transitions in depressive symptoms were based on weekly SCL-90 scores and evaluation interviews. Kernel Change Point analyses were used to detect change points (CPs) and CP timing in circadian rhythm variables for each individual separately.

Results

In 67% of individuals with depressive symptoms transitions, CPs were identified in proximity to symptom transitions. CPs were detected less frequently in the no-transition group with 7 CPs in 14 individuals, compared to transition groups with 10 CPs in 12 individuals. For several RAR and sleep variables, consistent changes were detected in expected directions.

Conclusions

Circadian rhythm variables provide potentially clinically relevant information although their patterns around transitions are highly person-specific. Future research is needed to disentangle which variables are predictive for which patients.

Disclosure

No significant relationships.

Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects.

METHOD

We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747.

RESULTS

We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I², 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]).

CONCLUSION

Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.

Anticipating transitions in mental health in at-risk youth: A large-scale diary study into early warning signals

Introduction

Transitions in mental health, such as the onset or sudden progression of psychopathology, are difficult to foresee. If mental health behaves like other complex systems, drops in mental health may be anticipated by early warning signals (EWS), which manifest in the dynamics of time series data.

Objectives

This study aimed to establish the sensitivity and specificity of EWS as personalized risk markers for sudden drops mental health.

Methods

Individuals (N=122, mean age 23.6 ±0.7 years, 57% males) at increased risk for psychopathology completed daily questionnaires on mental states for six consecutive months. Transitions in mental health were identified by change point analyses. EWS, operationalized as rising trends in the autoregressive coefficient of 36 negative mental states, were identified using generalized additive models.

Results

EWS were found for 59% of individuals with a drop in mental health, and for 47% without such a drop (sensitivity: 0-.12; specificity: .88-1). There were considerable individual differences in the prevalence, strength, and timing of EWS.

Conclusions

EWS might be informative of impeding transitions, yet they are also highly conservative. Present findings may inspire future research into the prerequisites for detecting EWS in the context of mental health, for instance with respect to the stability of pre- and post-transition phases, the magnitude of transitions, and the timescale at which EWS manifest. An improved understanding of the dynamics that govern psychopathology could ultimately allow us to determine whether a specific individual at a specific moment in time is at risk for a sudden onset or progression of mental health problems.

Theta/SMR Neurofeedback Training Works Well for Some Forensic Psychiatric Patients, But Not for Others: A Sham-Controlled Clinical Case Series

Electroencephalographic (EEG) neurofeedback could be a promising treatment for forensic psychiatric patients. Increasing evidence shows some patients are unable to regulate cortical activity. Before neurofeedback can be applied successfully, research is needed to investigate the interpersonal mechanisms responsible for patients' ability to respond to neurofeedback. A single-case experimental design allows for close monitoring of individual patients, providing valuable information about patients' response to the intervention and the time frame in which changes in clinical symptoms can be observed. Four patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) substance use disorder and various comorbidities participated in a sham-controlled clinical case study. Self-report level of impulsivity and craving were assessed. Results indicate that one patient showed more improvements on behavioral measures after the neurofeedback training than did the others. This patient reported less impulsivity and reduced levels of self-reported craving. However, these findings could not be attributed to the neurofeedback intervention. The findings suggest that there is insufficient evidence for the beneficial effects of a theta/sensorimotor rhythm (SMR) neurofeedback intervention on measures of impulsivity and craving, and that there may be great interindividual differences in patients' ability to regulate cortical activity.

Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?

International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004-2007), the project phase (2008-2010) and the consolidation phase (2011-2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (-73%) and duration (-80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.

[Adequacy of treatment for chronic anxiety or depression; an exploratory study of treatment practice]

Many patients with anxiety or depression receiving specialised outpatient treatment at mental health centres do not fully recover. Relapse and chronic course are common. This raises questions about the adequacy of the treatment they receive.<br/> AIM: To obtain insight into the type and length of the treatment given to patients with chronic anxiety or depression.<br/> METHOD: We collected data as part of a national study involving 12 mental health trusts. To be included in the study, patients had to satisfy certain criteria: they had to have received specialised treatment for anxiety or depression for at least two years and there had to be concerns whether these patients would benefit from further treatment in this setting. We gathered information about patient characteristics, diagnosis and treatment history.<br/> RESULTS: On the basis of our selection criteria, 268 patients participated in our study; 65% of the patients were female. Patients were grouped in three categories: 67% were suffering from major depression, 25% from anxiety disorder and 8% from comorbid anxiety and depression. On average, patients had been treated for six years. More than one third of patients had received poor-quality treatment: treatment in the form of psychotherapy and/or pharmacotherapy had not been carried out in accordance with treatment guidelines.<br/> CONCLUSION: In practice, much current treatment falls short of expectations. In particular, pharmacotherapy for depression needs to be improved. Longer periods of treatment should be evaluated at least once every six months.

Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?

OBJECTIVE

In 2006, a goal of reducing seclusion in Dutch hospitals by at least 10% each year was set. More than 100 reduction projects in 55 hospitals have been conducted, with €35 million in funding. This study evaluated the results.

METHODS

Data (2008 to 2013) were from a national register. Multilevel logistic regression examined determinants of seclusion.

RESULTS

Hospital participation in the register ranged from eight in 2008 to 66 in 2013, and admissions ranged from 11,300 to 113,290. The average yearly nationwide reduction of secluded patients was about 9%. Reduction was achieved in half of the hospitals. Some hospitals saw increased rates. In some hospitals where seclusion decreased, use of forced medication increased. Higher seclusion rates were associated with psychotic and bipolar disorders, male gender, and several ward types.

CONCLUSIONS

Seclusion decreased significantly, and forced medication increased. Rates varied widely between hospitals. For many hospitals, more efforts to reduce seclusion are needed.

[Tailored pharmacotherapy. Consultations about medication in a care programme for depression]

BACKGROUND

Despite the increasing rationalisation of mental health care, there are no specific recommendations regarding the number of contacts between a patient and a psychiatrist for the pharmacotherapy that forms part of the combined outpatient treatment (antidepressants and psychotherapy) of depression.

AIM

To consider the possibility of drawing up an advisory document regarding frequency, number and duration of consultations about medication in combined treatment for depression.

METHOD

We reviewed the literature and had qualitative interviews with psychiatrists and trainees in psychiatric residency.

RESULTS

The literature focuses predominantly on diagnostics and patient characteristics that determine the amount of care required. Advice on medication and pharmacotherapy is provided only by experts. According to the interviews, in psychiatric practice many factors influence the number and duration of consultations. Nevertheless, a distinctive pattern emerged.

CONCLUSION

Regarding medication in the acute treatment phase, five or six visits to a psychiatrist are sufficient for most patients. Extra consultations have to be arranged for smaller groups of less stable patients and for crisis-prone patients.

Seclusion as a necessary vs. an appropriate intervention: a vignette study among mental health nurses

In a vignette study, mental health nurses were asked to score vignettes on necessity and appropriateness using a Likert scale. Sixty-nine clinical nurses from four mental health institutes scored 64 vignettes on necessity (there is no alternative) and appropriateness (seclusion supports patients' treatment) of seclusion simultaneously. Data analysis focused on the differences between both scores, and included general linear model analysis, t-test statistics and Kendall's tau. The t-test resulted in a significantly higher score on necessity than on appropriateness. Differences between both scores could be explained for 32% by a combination of nurse characteristics and vignette variables. Necessity and appropriateness were found to be strongly associated with each other, showing that underpinning patterns were largely the same. This research enhances the understanding of underlying factors that influence the decision of nurses to use seclusion. This is essential for the development of interventions aimed at the reduction of seclusion use in mental health practice.

Effect of a cognitive behavioral self-help intervention on depression, anxiety, and coping self-efficacy in people with rheumatic disease

OBJECTIVE

The aim of this study was to investigate whether a new cognitive-behavioral self-help program with minimal coaching could improve psychological well-being (depression, anxiety, and coping self-efficacy) in people with rheumatic disease and depressive symptoms.

METHODS

In total, 82 persons with a rheumatic disease enrolled in a randomized controlled trial were allocated to either a group receiving the self-help program or a waiting list control condition group. For both groups, measurements were done at baseline, posttest, and followup. The outcome measures were the depression and anxiety scales of the Hospital Anxiety and Depression Scale and an adaptation of the Generalized Self-Efficacy Scale. Repeated-measures analyses of covariance were performed to evaluate changes in outcome measures from pretest to posttest and from posttest to followup.

RESULTS

The results showed that the self-help program was effective in reducing symptoms of depression and anxiety and in strengthening coping self-efficacy. The positive effects remained after a followup period of 2 months.

CONCLUSION

This cost-effective program could very well be used as a first step in a stepped care approach or as one of the treatment possibilities in a matched care approach.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

Methodological issues in monitoring the use of coercive measures

PURPOSE

In many European countries, initiatives have emerged to reduce the use of seclusion and restraint in psychiatric institutions. To study the effects of these initiatives at a national and international level, consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required. The aim of this article is to identify problems in defining and recording coercive measures. The study contributes to the development of consistent comparable measurements definitions and provides recommendations for meaningful data-analyses illustrating the relevance of the proposed framework.

METHODS

Relevant literature was reviewed to identify various definitions and calculation modalities used to measure coercive measures in psychiatric inpatient care. Figures on the coercive measures and epidemiological ratios were calculated in a standardized way. To illustrate how research in clinical practice on coercive measures can be conducted, data from a large multicenter study on seclusion patterns in the Netherlands were used.

RESULTS

Twelve Dutch mental health institutes serving a population of 6.57 million inhabitants provided their comprehensive coercion measure data sets. In total 37 hospitals and 227 wards containing 6812 beds were included in the study. Overall seclusion and restraint data in a sample of 31,594 admissions in 20,934 patients were analyzed. Considerable variation in ward and patient characteristics was identified in this study. The chance to be exposed to seclusion per capita inhabitants of the institute's catchment areas varied between 0.31 and 1.6 per 100.000. Between mental health institutions, the duration in seclusion hours per 1000 inpatient hours varied from less than 1 up to 18h. The number of seclusion incidents per 1000 admissions varied between 79 up to 745. The mean duration of seclusion incidents of nearly 184h may be seen as high in an international perspective.

CONCLUSION

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates. The study contributes to the development of international standards on gathering coercion related data and the consistent calculation of relevant outcome parameters.

Factors contributing to mental health professionals' decision to use seclusion

OBJECTIVE

The authors constructed an explanatory model of factors contributing to the decision to use seclusion.

METHODS

Experts helped develop 64 vignettes that manipulated multiple patient and environmental variables. Eighty-two mental health professionals working on inpatient wards in four institutes in the Netherlands rated the vignettes. A univariate general linear model examined vignette variables and rater characteristics influencing the decision to use seclusion.

RESULTS

Almost half of the decision to seclude (46%) could be explained by a combination of rater characteristics and vignette variables. Rater characteristics explained 31.7%, and vignette variables explained 27.9% (with a 13.6% interaction effect). Rater characteristics, in order of explanatory influence, were type of care provided by the professional (such as on a crisis-intensive care or an observation-diagnostic unit), current frequency of participation in seclusion, the specific institute where the professional was employed (of the four participating institutes), experience using seclusion (number of years), and being in training to be a psychiatrist or a community mental health nurse. The primary vignette variables, in order of influence, were the approachability of the patient, seriousness of danger, availability of patient rooms and space, primary diagnosis, the professional's perceived trust in colleagues, staff-patient ratio during the shift, and voluntary or involuntary status.

CONCLUSIONS

The model explained nearly half of the decision by mental health professionals to seclude vignette patients. Rater characteristics were at least as important as patient variables, including problem behaviors and diagnosis, and ward features. Because perceived approachability of the patient was a key factor, seclusion reduction policies should focus on supporting professionals in their efforts to manage inpatients with problem behaviors in an appropriate way.

Cost-effectiveness of a psychoeducational relapse prevention program for depression in primary care

BACKGROUND

Major depression is a prevalent mental disorder with a high risk of relapses and recurrences, which are associated with considerable burden for patients and high costs for society. Despite these negative consequences, only few studies have focused on interventions aimed at the prevention of recurrences in primary care patients with depression.

AIMS OF THE STUDY

To assess the cost-effectiveness of a psychoeducational prevention program (PEP) aimed at improving the long-term outcome of depression in primary care.

METHODS

Recruitment took place in the northern part of the Netherlands, patients were referred by general practitioners. In total 267 patients were included in the study and randomly assigned to usual care (UC) or UC with one of three forms of PEP; PEP alone, psychiatric consultation followed by PEP (psychiatrist-enhanced PEP), and cognitive behavioral therapy followed by PEP (CBT-enhanced PEP). Costs and health outcomes were registered at three month intervals during the 36 months follow-up of the study. Primary outcome measure was the proportion of depression-free time.

RESULTS

Mean total costs during the 36 months of the study were 8200 euros in the UC group, 9816 euros in the PEP group, 9844 euros in the psychiatrist-enhanced PEP group, and 9254 euros in the CBT-enhanced PEP group. Costs of productivity losses, hospital admissions, contacts with regional institutions for mental healthcare, and medication use contributed substantially to the total costs in each group. Results of the primary outcome measure were less positive for PEP than for UC, but slightly better in the enhanced PEP groups. If decision-makers are willing to pay up to 300 euros for an additional proportion of depression-free time, UC is most likely to be the optimal intervention. For higher willingness to pay, CBT-enhanced PEP seems most efficient.

DISCUSSION

The basic PEP intervention was not cost-effective in comparison with UC. The economic impact of productivity losses associated with depression, and the importance of including these costs in economic studies, was illustrated by the findings of this study. Due to the drop-out of patients during the 36 months follow-up period, economic analyses had to account for missing data, which may complicate the interpretation of the results. Although Quality-Adjusted Life Years (QALYs) could not be assessed for all the patients, the results of analyses focusing on QALYs supported the overall conclusion that PEP is not cost-effective. IMPLICATIONS FOR HEALTH CARE PROVISION AND POLICIES: Results indicated that PEP should not be implemented in the Dutch healthcare system. Furthermore, is seems highly unlikely that PEP could be cost-effective in other (comparable) European healthcare systems.

IMPLICATIONS FOR FURTHER RESEARCH

The relatively positive economic results for CBT-enhanced PEP imply that UC enriched with CBT (but without PEP) might be cost-effective in preventing relapses in primary care patients with depression. The actual consequences of CBT for relapse prevention will have to be studied in further detail, both from a clinical and economic point of view.

Skin autofluorescence is increased in systemic lupus erythematosus but is not reflected by elevated plasma levels of advanced glycation endproducts

OBJECTIVES

To examine whether skin advanced glycation endproducts (AGEs) accumulation, plasma levels of AGEs-N(epsilon)-carboxymethyllysine (CML) and N(epsilon)-carboxyethyllysine (CEL)-and serum levels of soluble receptor for AGEs (sRAGE) are elevated in SLE patients compared with controls, and whether these parameters are related to disease activity and endothelial cell (EC) activation.

METHODS

Ten SLE patients (9 women, age 34 +/- 13 yrs, mean +/- s.d.) and 10 age- and sex-matched controls were included. Patients were analysed during inactive as well as active disease. Skin AGE accumulation was estimated using ultraviolet-A (UV-A) light for measurement of autofluorescence obtained by Excitation-Emission matrix Scanner (AF-EEMS). Levels of CML and CEL were determined by tandem mass spectrometry. Levels of sRAGE and of soluble vascular cell adhesion molecule-1 (sVCAM-1) were determined by ELISAs.

RESULTS

Skin AF-EEMS was increased in SLE patients compared with controls (P < 0.05). Levels of CML and CEL were comparable between patients and controls and were not influenced by disease activity. sRAGE and sVCAM-1 levels were higher in quiescent SLE patients compared with controls (P < 0.05) and increased further during active disease (P < 0.05). In patients with quiescent disease and controls, sRAGE levels correlated to sVCAM-1 levels (r = 0.579, P = 0.007).

CONCLUSIONS

Skin AGEs and levels of sRAGE and sVCAM-1 were elevated in SLE patients, whereas levels of CML and CEL were comparable with controls. As sRAGE even further increased during endothelial activation, it might be hypothesized that sRAGE acts as a decoy receptor. Why this proposed mechanism is insufficient to prevent increased AGE accumulation in the skin of SLE patients has to be established.

The Thr505 and Ser557 residues of the AGT1-encoded alpha-glucoside transporter are critical for maltotriose transport in Saccharomyces cerevisiae

AIMS

The main objective of this study was to identify amino acid residues in the AGT1-encoded alpha-glucoside transporter (Agt1p) that are critical for efficient transport of maltotriose in the yeast Saccharomyces cerevisiae.

METHODS AND RESULTS

The sequences of two AGT1-encoded alpha-glucoside transporters with different efficiencies of maltotriose transport in two Saccharomyces strains (WH310 and WH314) were compared. The sequence variations and discrepancies between these two proteins (Agt1p(WH310) and Agt1p(WH314)) were investigated for potential effects on the functionality and maltotriose transport efficiency of these two AGT1-encoded alpha-glucoside transporters. A 23-amino-acid C-terminal truncation proved not to be critical for maltotriose affinity. The identification of three amino acid differences, which potentially could have been instrumental in the transportation of maltotriose, were further investigated. Single mutations were created to restore the point mutations I505T, V549A and T557S one by one. The single site mutant V549A showed a decrease in maltotriose transport ability, and the I505T and T557S mutants showed complete reduction in maltotriose transport.

CONCLUSIONS

The amino acids Thr(505) and Ser(557), which are respectively located in the transmembrane (TM) segment TM(11) and on the intracellular segment after TM(12) of the AGT1-encoded alpha-glucoside transporters, are critical for efficient transport of maltotriose in S. cerevisiae.

SIGNIFICANCE AND IMPACT OF THE STUDY

Improved fermentation of starch and its dextrin products, such as maltotriose and maltose, would benefit the brewing and whisky industries. This study could facilitate the development of engineered maltotriose transporters adapted to starch-efficient fermentation systems, and offers prospects for the development of yeast strains with improved maltose and maltotriose uptake capabilities that, in turn, could increase the overall fermentation efficiencies in the beer and whisky industries.

A cost-efficiency analysis of a mobile dental clinic in the public services

During 1997, the Gauteng Oral Health Services implemented a Mobile Oral Health Care System (MOHCS) in the province. For the first year (1997/98) one mobile dental clinic was utilised in the West Rand region of the province and services were provided by dentists, dental therapists and oral hygienists. The purpose of the MOHCS is to provide an accessible and affordable comprehensive oral health care service of high quality and standard. The aim of this study was to determine the cost-efficiency of the mobile dental clinic utilised in the West Rand region over the first year of implementation. After consultation with all stakeholders, an operational plan was finalised. The plan included a traveling schedule, clinicians available for service delivery, and a management information system (MIS). Statistics on dental materials, consumables, treatment provided, etc. were collected and analysed. During the study period 2072 patients received dental treatment at 38 different sites in the region. At an average cost of R56.50 (+/- US$11) per patient, services to the value of R92.45 (+/- US$18) per patient were delivered during 104 working days. Of the 1477 patients treated by a dentist or dental therapist, 53% were treated by extracting 1026 teeth, and 27% by restoring 570 teeth. For oral hygiene patients, 67% received an oral hygiene procedure and 13% received fissure sealants. With a net margin ratio of 0,39 and a breakeven point of 1173,46 patients and 58,90 days, an accessible and cost-efficient service was provided to health districts in the West Rand region.

Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy

BACKGROUND

The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions.

METHOD

A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up.

RESULTS

Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9.6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2.07 (95% confidence interval (CI) 1.13-3.00) and 1.62 (95% CI 0.70-2.55) respectively] and PEP patients [2.37 (95% CI 1.35-3.39) and 1.93 (95% CI 0.92-2.94) respectively].

CONCLUSIONS

The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.

Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial

BACKGROUND

Depression is a highly prevalent, often recurring or persistent disorder. The majority of patients are initially seen and treated in primary care. Effective treatments are available, but possibilities for providing adequate follow-up care are often limited in this setting. This study assesses the effectiveness of primary-care-based enhanced treatment modalities on short-term patient outcomes.

METHOD

In a randomized controlled trial we evaluated a psycho-educational self-management intervention. We included 267 adult patients meeting criteria for a DSM-IV diagnosis of major depressive disorder, assessed by a structured psychiatric interview. Patients were randomly assigned to: the Depression Recurrence Prevention (DRP) program (n=112); a combination of the DRP program with psychiatric consultation (PC+DRP, n=39); a combination with brief cognitive behavior therapy (CBT+DRP, n=44); and care as usual (CAU, n=72). Follow-up assessments were made at 3 months (response 90%) and 6 months (85%).

RESULTS

Patient acceptance of enhanced care was good. The mean duration of the index episode was 11 weeks (S.D.=9.78) and similar in CAU and enhanced care. Recovery rate after 6 months was 67% overall; 17% of all participants remained depressed for the entire 6-month period.

CONCLUSION

Enhanced care did not result in better short-term outcomes. We found no evidence that the DRP program was more effective than CAU and no indications for added beneficial effects of either the psychiatric evaluation or the CBT treatment to the basic format of the DRP program. Observed depression treatment rates in CAU were high.

Elective hand surgery in patients taking warfarin

We reviewed 22 patients who had undergone either carpal tunnel decompression or release of Dupuytren's contractures while anticoagulated with warfarin. All patients continued with their usual anticoagulant regime over the period of operation, provided that the international normalized ratio (INR) was 3 or less. There was no abnormal intraoperative or postoperative bleeding in any patient. Journal of Hand Surgery (British and European volume, 2004).

Accelerated atherosclerosis in patients with Wegener's granulomatosis

BACKGROUND

Several autoimmune disorders are complicated by excess cardiovascular disease. In addition to traditional risk factors, non-traditional risk factors such as endothelial activation and excessive vascular remodelling might be determinants of the progression of atherosclerosis in patients with an autoimmune disease.

OBJECTIVE

To evaluate whether patients with Wegener's granulomatosis (WG) have an increased prevalence of atherosclerosis and to determine predisposing factors.

METHODS

29 WG patients (19 men; mean (SD) age, 53 (14) years) with inactive disease and 26 controls (16 men; age 53 (15) years) were studied. Common carotid intima-media thickness (IMT) was measured by ultrasound. In all individuals traditional risk factors for cardiovascular disease were determined. High sensitivity C reactive protein (hsCRP) was measured. Endothelial activation was assessed by measuring thrombomodulin, vascular cell adhesion molecule-1, and von Willebrand factor. As a marker of vascular remodelling matrix metalloproteinases (MMP-3 and MMP-9) and TIMP-1 were measured.

RESULTS

IMT was increased in WG patients compared with controls (p<0.05). No differences in traditional risk factors and endothelial activation markers between patients and controls were found. Levels of hsCRP, MMPs, and TIMP-1 were increased in WG patients (p<0.05).

CONCLUSIONS

Increased IMT found in WG patients cannot be explained by an increased prevalence of traditional risk factors. Although endothelial activation markers in WG patients with inactive disease were not increased, the raised levels of hsCRP, MMPs, and TIMP-1 suggest that enhanced inflammation and excessive vascular remodelling are contributing factors in the development of accelerated atherosclerosis in WG.

Predictability of the one-year course of depression and generalized anxiety in primary care

Several predictors of the course of depression and generalized anxiety have been identified. Whether these predictors provide a solid basis for primary care physicians (PCPs) to give an accurate prognosis remains unclear. A parallel study showed modest agreement between PCP prognosis and observed course (kappa< or = 0.21). It is the aim of the present study to establish the extent to which the one-year course of depression and generalized anxiety in primary care is in fact predictable. Predictability is operationalized as the combined predictive power of major prognostic factors identified in the literature. We identified 269 cases of ICD-10 depression and 134 of generalized anxiety among consecutive PCP attenders. For these patients a statistical model was built that provided optimal predictions of the one-year course of the disorder, based on the prognostic factors discerned. The predictions were compared with the actual course observed. Reasonable agreement (kappa = 0.37 for depression, kappa = 0.35 for anxiety) and good association (gamma = 0.66 for depression, gamma=0.67 for anxiety) were found between predicted and observed course. Nevertheless, the combined predictive power of the prognostic factors remains limited. A realistic evaluation of the accuracy of the PCP prognosis should take this limited predictability into account.

Comparison of immulite with vidas for detection of infection in a low-prevalence population of pregnant women in The Netherlands

A comparative evaluation of the Vidas system (bioMérieux, Marcy l'Etoile, France) and the Immulite System (Diagnostic Products Corporation) was performed using 500 prospectively collected serum samples. As part of a routine antenatal screening program, these samples were tested for hepatitis B surface antigen, and immunoglobulin G (IgG) and IgM antibodies to Toxoplasma gondii and rubella virus. The overall agreement between the two assay systems ranged from 98.0 to 99.8%. After discrepancy analysis the outcome in terms of relative sensitivity and specificity varied from 97.5 to 100%.

Pseudolikelihood estimation of the Rasch model

An estimation method is proposed for the Rasch model on the basis of the pseudolikelihood theory of Arnold and Strauss (1988). A simulation study was conducted to compare the proposed maximum pseudolikelihood estimates with the well known conditional maximum likelihood and unconditional maximum likelihood estimates for the item parameters of the Rasch model. The results show great similarity between the methods.

Accuracy of general practitioner's prognosis of the 1-year course of depression and generalised anxiety

BACKGROUND

A prognosis serves important functions for the management of common mental disorders in primary care.

AIMS

To establish the accuracy of the general practitioner's (GP) prognosis.

METHOD

The agreement between GP prognosis and observed course was determined for 138 cases of ICD-10 depression and 65 of generalised anxiety disorder, identified among consecutive attenders of 18 GPs.

RESULTS

Modest agreement between GP prognosis and course was found, both for depression (kappa=0.21) and generalised anxiety (kappa=0.11). Better agreement (kappa=0.45 for depression, and kappa=0.33 for generalised anxiety) was observed between the course and predictions from a statistical model based on information potentially available to the GP at the time the prognosis was made. This model assesses attainable performance for GPs.

CONCLUSIONS

General practitioners do a fair job in predicting the 1-year course of depression and generalised anxiety. Even so, their performance falls significantly short of attainable performance.

Biosynthesis of isoprenoids via mevalonate in Archaea: the lost pathway

Isoprenoid compounds are ubiquitous in living species and diverse in biological function. Isoprenoid side chains of the membrane lipids are biochemical markers distinguishing archaea from the rest of living forms. The mevalonate pathway of isoprenoid biosynthesis has been defined completely in yeast, while the alternative, deoxy-D-xylulose phosphate synthase pathway is found in many bacteria. In archaea, some enzymes of the mevalonate pathway are found, but the orthologs of three yeast proteins, accounting for the route from phosphomevalonate to geranyl pyrophosphate, are missing, as are the enzymes from the alternative pathway. To understand the evolution of isoprenoid biosynthesis, as well as the mechanism of lipid biosynthesis in archaea, sequence motifs in the known enzymes of the two pathways of isoprenoid biosynthesis were analyzed. New sequence relationships were detected, including similarities between diphosphomevalonate decarboxylase and kinases of the galactokinase superfamily, between the metazoan phosphomevalonate kinase and the nucleoside monophosphate kinase superfamily, and between isopentenyl pyrophosphate isomerases and MutT pyrophosphohydrolases. Based on these findings, orphan members of the galactokinase, nucleoside monophosphate kinase, and pyrophosphohydrolase families in archaeal genomes were evaluated as candidate enzymes for the three missing steps. Alternative methods of finding these missing links were explored, including physical linkage of open reading frames and patterns of ortholog distribution in different species. Combining these approaches resulted in the generation of a short list of 13 candidate genes for the three missing functions in archaea, whose participation in isoprenoid biosynthesis is amenable to biochemical and genetic investigation.

PipMaker--a web server for aligning two genomic DNA sequences

PipMaker (http://bio.cse.psu.edu) is a World-Wide Web site for comparing two long DNA sequences to identify conserved segments and for producing informative, high-resolution displays of the resulting alignments. One display is a percent identity plot (pip), which shows both the position in one sequence and the degree of similarity for each aligning segment between the two sequences in a compact and easily understandable form. Positions along the horizontal axis can be labeled with features such as exons of genes and repetitive elements, and colors can be used to clarify and enhance the display. The web site also provides a plot of the locations of those segments in both species (similar to a dot plot). PipMaker is appropriate for comparing genomic sequences from any two related species, although the types of information that can be inferred (e.g., protein-coding regions and cis-regulatory elements) depend on the level of conservation and the time and divergence rate since the separation of the species. Gene regulatory elements are often detectable as similar, noncoding sequences in species that diverged as much as 100-300 million years ago, such as humans and mice, Caenorhabditis elegans and C. briggsae, or Escherichia coli and Salmonella spp. PipMaker supports analysis of unfinished or "working draft" sequences by permitting one of the two sequences to be in unoriented and unordered contigs.