1207 EXPLORING AUDIO-RECORDING IN TERMINAL ILLNESS - THE HOSPICE BIOGRAPHERS MODEL

Introduction

The therapeutic benefits of narrative in terminally ill patients is widely studied and evidenced in the research literature. The Hospice Biographers are a charity offering a professional free service for end-of-life patients the opportunity to audio-record their life story in a memory stick and to keep copies for themselves and for their families. The objective of this qualitative study is to explore the experience of a group of people either recording or listening to an audio-biography.

Methods

Five semi-structured in-depth interviews with terminally ill adults who recorded an audio-biography and another interview with a family member were conducted virtually. Transcripts of the zoom interviews were coded using thematic analysis.

Results

Our findings showed that patients found talking to a trained audio-biographer provided a neutral, non-judgemental interlocutor. The biographer helped them reminisce in a guided conversation navigating their life stories in chronological order. The experience of planning for the recording varied from preparing a mind-map, to writing down some guide notes or no preparation at all. Patients reported a feeling of catharsis while telling their stories as well as being able to reflect on and analyse significant life events. However, it was challenging to convey difficult emotions whilst being mindful of how patients’ life stories might be perceived by families. Although there was a degree of uncertainty about impact of the recording upon listeners, it was felt that leaving a voice-recorded account would still be informative and beneficial. A personal narrative could also provide a wider historical account of the relevant time period. Some individuals fed back that they would have valued the opportunity to edit their recording after listening and include a visual element.

Conclusions

Recording an audio-biography in terminal illness allows patients a space for reflection and provides a valued connection with immediate family members and future generations.

A Synopsis of Proteins and Their Purification

The goal of protein purification is to separate a specific protein from all other biomolecules. Classical chromatographic procedures have been designed to exploit particular distinguishing features of individual target proteins, such as size, shape, physicochemical properties, and binding affinity. Advances in molecular biology and bioinformatics have positively contributed at every level to the challenge of purifying individual proteins and more recently have led to the development of high-throughput proteomic platforms. In this chapter, a synopsis of advancements in the field of protein chromatography is presented, with reference to the principal tools and resources that are available to assist with protein purification strategies.

Mentalising skills in generic mental healthcare settings: can we make our day-to-day interactions more therapeutic?

Aims and methodCaring for patients with personality disorder is one of the biggest challenges in psychiatric work. We investigated whether mentalisation-based treatment skills (MBT-S) teaching improves clinicians' understanding of mentalising and attitudes towards personality disorder. Self-report questionnaires (Knowledge and Application of MBT (KAMQ) and Attitudes to Personality Disorder (APDQ)) were completed at baseline and after a 2-day MBT-S workshop.

RESULTS

Ninety-two healthcare professionals completed questionnaires before and after training. The mean within-participant increase in scores from baseline to end-of-programme was 11.6 points (95% CI 10.0-13.3) for the KAMQ and 4.0 points (1.8-6.2) for the APDQ.Clinical implicationsMBT-S is a short intervention that is effective in improving clinicians' knowledge of personality disorder and mentalisation. That attitudes to personality disorder improved overall is encouraging in relation to the possibility of deeper learning in staff and, ultimately, improved care for patients with personality disorder.Declaration of interestNone.

Baclofen and the Alcohol Withdrawal Syndrome-A Short Review

The Alcohol Withdrawal Syndrome (AWS), which may occur with or without delirium, is a frequent consequence of sudden alcohol cessation in patients with moderate to severe Alcohol Dependence Syndrome (ADS). Withdrawal as a result of habituation to alcohol is part of the definition of the Alcohol Dependence Syndrome (ICD10). Since the recognition of Delirium Tremens, in the early nineteenth century, the management of the syndrome, an acute medical emergency, has proven controversial. The barbiturates, chlormethiazole, and recently the safer benzodiazepines transformed the management of these conditions. The benzodiazepines, particularly diazepam and chlordiazepoxide, are now the most used first line agents in the treatment of AWS. In addition, a number of other agents, including baclofen, a GABA-B receptor agonist, have the potential to suppress the alcohol withdrawal syndrome. In this review we review the potential use of baclofen in its role to treat AWS. We summarize initial case reports as well as more recent randomized trials of AWS treatment with baclofen. We conclude that currently there is not enough evidence to support the use of baclofen as a first line treatment for AWS. More research will be needed to determine where baclofen might have a role in second-line management of the Alcohol Withdrawal Syndrome on its own or in combination with benzodiazepines or other agents.

Novel outreach settings to enhance sexually transmitted infection/HIV awareness, diagnosis and treatment in hard-to-reach populations

Despite recent rises in the number of cases of sexually transmitted infections (STIs) such as syphilis and gonorrhoea in England and increasing rates of HIV diagnosis among several men who have sex with men populations, many individuals are still not engaging with sexual health services. The John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital, London set up outreach clinics at the two world's largest adult lifestyle exhibitions in 2013 and 2015. This was the first time that a sexual health screening and promotion service was available at these large-scale (over 10,000 attendees at each) adult lifestyle events. A total of 381 individuals underwent STI screening across the two events. Nineteen (5.0%) patients were diagnosed with an infection. Twelve (3.1%) patients with Chlamydia trachomatis, three (0.8%) patients with syphilis, one (0.3%) patient with Neisseria gonorrhoeae, one (0.3%) patient with HIV, one (0.3%) patient with hepatitis B and one (0.3%) patient with hepatitis C. All 19 patients were promptly contacted with their results and had arrangements made for treatment or were referred for specialist follow up. Where possible, contact tracing was also performed. Implementing such outreach-based projects is challenged by lack of on-site laboratory support, high staffing demands and potentially high costs. However, we achieved a total HIV screening uptake rate of 94.5% amongst our outreach clinic attendees (versus 67% nationally in conventional sexual health clinic attendees) with an HIV positivity rate of 0.3% (versus 0.2% nationally in high HIV prevalence band populations). Additionally, 30.7% had never been tested for HIV previously (versus 20.7% nationally). Our work demonstrates that these strategies can help to address issues related to lack of STI/HIV screening in hard-to-reach populations and promote risk reduction behaviour.

Structural behaviour and gene delivery in complexes formed between DNA and arginine-containing peptide amphiphiles

We describe in depth the structure of complexes formed between DNA and two classes of arginine-containing peptide amphiphiles, namely, the lipopeptide PRW-C₁₆ (P = proline, R = arginine, W = tryptophan, C₁₆ = C16 : 0 alkyl chain) and the bolaamphiphile RFL₄FR (R = arginine, F = phenylalanine, L = leucine). A combination of X-ray and neutron scattering provided unprecedented insights into the local structure of these complexes. Lipopeptide-based complexes self-assembled into layered structures with large-scale fractal features, hosting DNA in the interstices. Bola-amphiphile scaffolds were characterized by planar structures with DNA strands presumably sandwiched in-between peptide nanotapes. Importantly, complexation did not affect the structural integrity of DNA in either of the two complexes. The bolaamphiphile conjugates displayed high levels of molecular ordering in contrast to the liquid-crystalline features observed in lipopeptide assemblies. Peptide-DNA complexes were assessed for their potential as a means to deliver the reporter vector pEGFP-N1 into SW480 human colon carcinoma cells. Successfully transfected cells expressed green fluorescent protein. The potentiating effect of PRW-C₁₆ on the cellular uptake of ectopic DNA was found to be much greater than that observed with RFL₄FR. In contrast to the bolaamphiphile-based conjugate, the liquid-crystalline nature of the lipopeptide complex is likely to play a key role in DNA release and transfection efficiency since these weakly bound structures require lower energy expenditure during disassembly and load release.

Exercise for depression

CLINICAL QUESTION

Is exercise an effective treatment for depression?

BOTTOM LINE

Exercise is associated with a greater reduction in depression symptoms compared with no treatment, placebo, or active control interventions, such as relaxation or meditation. However, analysis of high-quality studies alone suggests only small benefits.

Young people with intellectual disabilities attending mainstream and segregated schooling: perceived stigma, social comparison and future aspirations

BACKGROUND

Mainstream schooling is a key policy in the promotion of social inclusion of young people with learning disabilities. Yet there is limited evidence about the school experience of young people about to leave mainstream as compared with segregated education, and how it impacts on their relative view of self and future aspirations.

METHODS

Sixty young people with mild to moderate intellectual disabilities in their final year of secondary school participated in this study. Twenty-eight individuals came from mainstream schools and 32 attended segregated school. They completed a series of self-report measures on perceptions of stigma, social comparison to a more disabled and non-disabled peer and the likelihood involved in attaining their future goals.

RESULTS

The majority of participants from both groups reported experiencing stigmatized treatment in the local area where they lived. The mainstream group reported significant additional stigma at school. In terms of social comparisons, both groups compared themselves positively with a more disabled peer and with a non-disabled peer. While the mainstream pupils had more ambitious work-related aspirations, both groups felt it equally likely that they would attain their future goals. Although the participants from segregated schools came from significantly more deprived areas and had lower scores on tests of cognitive functioning, neither of these factors appeared to have an impact on their experience of stigma, social comparisons or future aspirations.

CONCLUSIONS

Irrespective of schooling environment, the young people appeared to be able to cope with the threats to their identities and retained a sense of optimism about their future. Nevertheless, negative treatment reported by the children was a serious source of concern and there is a need for schools to promote the emotional well-being of pupils with intellectual disabilities.

Adrenalectomy reduces neuropeptide Y-induced insulin release and NPY receptor expression in the rat ventromedial hypothalamus

Chronic central administration of neuropeptide Y (NPY) causes hyperphagia, hyperinsulinemia, and obesity, a response that is prevented by prior adrenalectomy (ADX) in rats. The basis of NPY's effect and how the acute responses to this peptide are affected by ADX remain unknown. This study investigates the role of glucocorticoids in acute NPY-stimulated food intake, acute NPY-induced insulin release, and hypothalamic NPY-receptor mRNA expression levels. NPY-induced food intake was similar in ADX and control rats after acute intracerebroventricular injection of NPY. Injection of NPY caused a significant increase in plasma insulin in control rats, but this effect was completely absent in ADX rats in which basal plasma insulin levels were also lower than controls. In addition, ADX significantly reduced the number of neurons expressing NPY receptor Y(1) and Y(5) mRNAs in the ventromedial hypothalamus (VMH), without affecting Y(1)- or Y(5)-mRNA expression in the paraventricular hypothalamus or the arcuate nucleus. These data indicate that glucocorticoids are necessary for acute NPY-mediated insulin release and suggest that the mechanisms involve glucocorticoid regulation of Y(1) and Y(5) receptors specifically within the VMH nucleus.

Profiles of time perspective and personality: developmental considerations

Time perspective is an important but subtle cognitive construct underlying personality, decision making, and goal setting. This study identified 3 temporal dimensions--temporal extension, temporal attitude, and temporal structure--and reviewed the associations among them. T. J. Cottle's (1969, 1977) work on temporal profiles was briefly reviewed; it suggested that 3 types of temporal profiles can be isolated and that 3 broad personality dimensions--human agency, mood, and temperament--from characteristic associations with each of the temporal profiles. The authors expected the profiles to reflect developmental sensitivities as a person moves from adolescence into early adulthood. Two samples (159 high school students and 236 university students) participated in the study. The results provided some limited support for the actualizer and atomist profiles; somewhat surprisingly, the role of temporal extension appeared to be insignificant. No evidence was found for a developmental transition of time perspective between middle adolescence (15-17 years) and early adulthood (18-25 years).

Short-term metabolic and haemodynamic effects of GR79236 in normal and fructose-fed rats

The adenosine (A1) receptor agonist, GR79236 (N-[(1S,trans)-2-hydroxycyclopentyl]adenosine), inhibits catecholamine-induced lipolysis in vitro, but the short-term metabolic and haemodynamic effects have not been previously reported in the fructose fed model of insulin resistance, dyslipidaemia and hypertension. This study reports the effects of GR79236 (1 mg/kg/day for 8 days) on nonesterified free fatty acid and triglyceride metabolism, oral and i.v. glucose tolerance, blood pressure and heart rate, and insulin sensitivity, in normal rats and rats fed a fructose-enriched diet. In normal rats, GR79236 significantly reduced fasting glucose (25%), free fatty acid (50%) and triglyceride (55%) concentrations, and improved glucose tolerance (AUC[glu] 21.2 +/- 1.3 vs. 16.5 +/- 1.1 mmol h/l, p < 0.05). Fructose feeding induced a state of insulin resistance and dyslipidaemia, as shown by an increase in steady-state plasma glucose levels (7.1 vs. 6.1 mmol/l), impaired i.v. glucose tolerance and a 3-fold rise in fasting triglyceride levels; fructose-fed rats also developed a significant increase in blood pressure. GR79236 ameliorated the effects of fructose feeding on fatty acid and triglyceride levels, and blood pressure, and improved i.v. glucose tolerance in fructose-fed rats. The hypotriglyceridaemic effect was due to a reduction in triglyceride secretion rate (17.3 +/- 1.7 vs. 30.2 +/- 1.1). Thus, in normal rats and in a dietary-induced rodent model of insulin resistance, dyslipidaemia and hypertension, GR79236 has lipid-lowering and glucose-lowering activity, as well as haemodynamic effects, which are potentially useful for treating both the metabolic and haemodynamic features of insulin resistance and NIDDM in humans.

Pharmacokinetics of an oral solution of the microemulsion formulation of cyclosporine in maintenance pediatric liver transplant recipients

BACKGROUND

A comparison of the oral bioavailability of cyclosporine from the original formulation (CsA) and from the new formulation, cyclosporine for microemulsion (CsA-ME), was made in pediatric maintenance liver transplant patients within two age groups (group 1, ages 1-5 years; group 2, ages 6-17 years) in an open-label, multicenter, randomized crossover trial. All patients were at least 6 months past transplantation and were receiving CsA maintenance therapy.

METHODS

In study period 1 (days 1 through 14), patients were administered either CsA or CsA-ME at the same b.i.d. dosage as their maintenance therapy. Upon entry into period 2 (days 15 through 28), patients were converted to the alternate formulation at a 1:1 mg dose ratio. On day 29, all patients returned to the CsA treatment administered at study entry, with follow-up on day 35. Dosage adjustments were not allowed with either CsA or CsA-ME. Twelve-hour pharmacokinetic profiling was performed at the end of periods 1 and 2.

RESULTS

Both the mean area under the concentration-versus-time curve and the mean maximum blood concentration of cyclosporine-both normalized for dose-were significantly increased: by 66% and 109%, respectively, in patients receiving CsA-ME compared with those receiving CsA in group 1 and by 39% and 75%, respectively, in group 2. During this study, liver function remained stable, and serum creatinine and blood pressure did not differ significantly between treatment groups.

CONCLUSIONS

This study shows increased bioavailability in all patients converted to CsA-ME, with the greatest increase seen in patients with the lowest initial cyclosporine bioavailability. The tolerability was similar between the two formulations during this study.

Cardiovascular effects of different infusion rates of sufentanil in patients undergoing coronary surgery

OBJECTIVE

Pharmacokinetics and haemodynamic effects of a total dose of 15 micrograms.kg-1 sufentanil, an opioid anaesthetic agent, were studied in patients undergoing aortocoronary bypass surgery at three infusion rates of 30 (group I), 5 (group II), and 2 (group III) micrograms.kg-1.min-1, respectively.

RESULTS

Plasma concentrations of sufentanil could be optimally characterized by a linear biexponential pharmacokinetic model. Non-compartmental analyses indicated that there was no significant difference in the values of clearance (11.6, 13.3, 14.3 ml.min-1.kg-1), steady-state volume of distribution (0.220, 0.255 and 0.331 l.kg-1) and mean residence time (18.8, 13.3 and 14.3 min) among the groups. The observed mean Cmax values of 421 (group I), 125 (group II), and 53 (group III) ng.ml-1 and observed mean AUC values from 0 to 3 min were all consistent with the dosing regimens. There were large inter-individual variations in haemo-dynamic response. Compared to plasma data, a delay in haemodynamic effects was found. Times to reach peak haemodynamic effect ranged from 4.3 to 4.9 min for group I, from 4.6 to 6.1 min for group II, and from 9.9 to 11.3 for group III. Except heart rate, peak haemodynamic effects in these study patients generally ranged from 20.9% to 35.2%. Significant reductions in the area under the effect-time profiles of mean arterial blood pressure and systemic vascular resistance were observed in group II and group III, but not in group I. Significant reductions in the area under the effect-time profiles of left ventricular stroke work index were observed in group III only. No effect on heart rate was found in any group.

CONCLUSION

Our findings suggested that a slower infusion rate of sufentanil at a dose of 15 micrograms.kg-1 tends to give a greater reduction in mean arterial blood pressure, systemic vascular resistance, and left ventricular stroke work index than does a faster infusion rate.

Pharmacokinetics of cyclosporine after renal transplant in children

The pharmacokinetics of cyclosporine and the relationship between blood levels and average drug concentration were prospectively evaluated in 18 children 1 month after renal transplantation. All children had normal renal function and no hepatic or gastrointestinal dysfunction. Cyclosporine was administered after an overnight fast, and serial blood samples were drawn over a 24-hour period. Analysis of cyclosporine levels was performed by means of monoclonal radio immunoassay on whole blood. Children were divided into three age groups for comparison: 2-5 years, 5-10 years, and > 10 years. There were no differences between age groups in serum protein, serum lipids, or hemoglobin levels, or in the pharmacokinetic parameters of cyclosporine except as follows: significant differences were noted in cyclosporine dose based on body weight, apparent steady-state volume of distribution, and apparent blood clearance, with the youngest children (2-5) requiring higher doses, a relative greater distribution, and exhibiting more rapid drug clearance than those > 10 years of age. In addition, we observed diurnal variation in trough levels, with morning levels (0 hr) significantly higher than those obtained in the evening (12 hours after administration of cyclosporine). Trough levels demonstrated a fair correlation with area under the concentration-time curve (AUC) and average concentration (Cav), but an abbreviated kinetic profile using cyclosporine levels 1 and 3.5 hours after administration accurately predicted AUC.

Significant others' contribution to early adolescents' perceptions of their competence

This study measures perceptions of competence in the scholastic and athletic domains and also examines gender differences in these areas. It explores the relative contributions of significant others (namely, parents, teachers, classmates and close friends) for an Australian cohort of early adolescents. A total of 264 children (average age, 11.7 years; 40% female) in Grade 6, their parents and their classroom teachers were surveyed using six modified Harter scales. Analyses supported the notion that the sources related to early adolescents' perceptions were different and that the relative predictive utility of the five sources varied as a function of gender and the domain type. Scholastic competence for males is related to external (father and teacher) perceptions as well as internal (child's) perceptions whereas for females, scholastic competence is related entirely to internal (child's) perceptions. In contrast, athletic competence for males is related only to external (teacher) perceptions, whereas for females athletic competence is related to external (mother) perceptions as well as internal (child's) perceptions. The findings are discussed in terms of their theoretical and practical implications in educational practice.

Self esteem, depression, behaviour and family functioning in sexually abused children

Eighty-four sexually abused children and their families, were compared with controls to look at short-term effects of sexual abuse. The abuse group had more marital breakdown, unemployment, communication problems within the family and poor marital mental health. The abused children had more depression, low self-esteem and behaviour disorder. There was no relationship between intrafamilial abuse and depression, self-esteem or behaviour disorder. More severe abuse was related to low self-esteem and children's negative perceptions of their mothers. In planning treatment the child's relationship to the perpetrator may need less emphasis, with more on self-esteem, depression, family functioning and the child's perceptions of the family.

The criminal justice system and the sexually abused child. Help or hindrance?

OBJECTIVE

To assess the progress of 59 sexually abused children in the criminal justice system to see whether they testified, whether there were any effects on their self-esteem or behaviour, whether it resulted in depression and what their parents' perceptions of the process were.

DESIGN

A prospective study of sexually abused children, with data from interviews with the parents and psychological testing of the children.

RESULTS

Thirty-three cases were committed for trial or sentencing, resulting in 20 convictions. Twenty-two children testified at the committal hearing and eight at trials. Although 55% of parents expressed dissatisfaction with the legal system, thinking it was stressful to their children, a comparison of children who did not testify with those who did showed no significant differences on indices of depression, self-esteem or behaviour. As most children were involved in court-preparation programs and most mothers were supportive of their children, these may have been ameliorating factors.

CONCLUSIONS

Even though the initial stressful effects of children appearing in court appear to be transient, there should be increased use of screens, closed-circuit television and preparation-for-court programs to make court appearances less intimidating.

Stability and change in outcomes for sexually abused children

OBJECTIVE

To evaluate sexually abused children and their families at intake and 18 months later, in comparison with a control group.

METHODS

Eighty-four sexually abused children aged 5 to 15 years were assessed at intake, with 64 being able to be reassessed at 18 months, the assessment using measures of self-esteem relevant to their age; the Children's Depression Inventory, and the Achenbach Child Behavior Checklist. Parents were assessed with the McMaster Family Assessment Device and the General Health Questionnaire. Control children and families were similarly assessed. Additional measures at follow-up were a structured interview with the parents, the Indices of Coping Responses, and the Newcastle Child and Family Life Events Schedule. Therapists were contacted to obtain information on type and duration of therapy.

RESULTS

While the control children's self-esteem, depression, and behavior scores showed little change over time, the abused children's scores were more likely to move toward the normal range although 56% remained in the dysfunctional range for self-esteem, 48% for behavior, and 35% for depression. Improvement in child behavior was related to improvement in family function. While there was no direct relationship between child outcome and the relationship of the abuser to the child, family dysfunction, which was related to child outcome, did correlate with the closeness of the abuser to the child. Sixty-five percent of abused children had received therapy for an average of 9 months. No relationship was found between therapy and outcome.

CONCLUSIONS

The major variable relating to improvement in sexually abused children appears to be adequacy of family functioning. There is a need for increased emphasis on the evaluation of treatment.

The effects of dietary n - 3 fatty acid in animal models of type 1 and type 2 diabetes

We studied the incorporation of dietary n - 3 fatty acids from marine oils into red cell membranes, using animal models of type 1 diabetes (streptozotocin-treated Wistar rats) and type 2 diabetes (gold-thioglucose-injected CBA/T6 mice). In type 1 diabetic rats, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were higher following marine oil supplementation, and the increase in EPA was significantly greater than in non-diabetic animals (3.4 +/- 1.4% vs. 0.8 +/- 1.6%). Marine oil supplementation also resulted in higher levels of EPA and DHA in mice, but the increases were quantitatively similar with and without type 2 diabetes. Improvement in glycosylated haemoglobin following n - 3 fatty acid feeding was only found in type 2 diabetes (6.5 +/- 2.9% vs. 9.5 +/- 1.2%). This was associated with a higher plasma insulin concentration (170 +/- 40 vs. 136 +/- 41 mU/ml). The theory that n - 3 fatty acids improve insulin sensitivity would have predicted a decrease in plasma insulin levels. Our results suggest that n - 3 fatty acids may modify insulin secretion.

Activities of some key enzymes of carbohydrate, ketone body, adenosine and glutamine metabolism in liver, and brown and white adipose tissues of the rat

In general, the activities of enzymes in brown adipose tissue (BAT) are more similar to those in white adipose tissue than those in liver. Thus the activities of the glycolytic enzymes hexokinase and 6-phosphofructokinase are high but those of glucose 6-phosphatase and fructose bisphosphatase are non-detectable in the two adipose tissues. The activity of HMG-CoA synthase was non-detectable in BAT indicating that this tissue, unlike liver, cannot produce ketone bodies from fatty acid oxidation but, since the tissue possesses a high activity of HMG-CoA lyase, it might produce ketone bodies from leucine catabolism. The findings suggest that 'metabolically' brown adipose tissue can be classified better as an adipose tissue than as a peripheral liver. A high activity of 3-oxoacid CoA transferase but a non-detectable activity of 3-hydroxybutyrate dehydrogenase suggests that BAT can utilise acetoacetate but not 3-hydroxybutyrate for heat generation during cold exposure plus starvation.