Gender- and Sexuality-Minoritised Adolescents in DBT: A Reflexive Thematic Analysis of Minority-Specific Treatment Targets and Experience

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared to their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using Reflexive Thematic Analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three overarching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included "identity confusion and acceptance"; the relationship-based themes included "cis-Heterosexism" and "community connectedness"; and the space within DBT themes included "negotiating focus and targeting in DBT" and "creating safety in DBT". Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

One or three intradermal injections within one week for rabies pre-exposure immunization

Pre-exposure rabies vaccination is recommended fortravellers to endemic countries and forselected populations in highly endemic regions. It consists of three injections administered over 3-4 weeks. Travellers often ignore or do not have enough time to receive a complete course prior to departure or leave with only one or two injections. In this study, the secondary antibody response in volunteers who received one or three injections within one week is evaluated. Results are compared to the recommended three injection regimen when administered with two booster vaccinations on days 0 and 3 one year later. Long-lasting immune memory in volunteers who received only one time vaccination of 0.1 ml (1 site) intradermally and then received two booster vaccinations of 0.1 ml (1 site) intradermally on days 0 and 3, one or three years later is also reported. All volunteers developed an accelerated and adequate neutralizing antibody response within seven days after they received two boosters. These data suggest that three injections within one week are as immunogenic as three injections within four weeks. One clinic visit with two-site 0.1 ml ID injections or a one-site single 0.1 ml pre-exposure rabies vaccination is enough to prime the host immune memory for at least one to three years.

Ten-day observation of live rabies suspected dogs

This study aimed at analyzing a ten-day observation period of rabies suspected dogs and cats according to six criteria. Dogs and cats suspected of being rabid were brought for observation when they had either bitten a person or another animal or when abnormal behaviour or unusual illness was observed. Between 1985 and 2005, retrospective and prospective data from 1,222 dogs and 303 cats was collected during the ten-day observation period. If an animal had died, brain examination using fluorescent antibody testing was routinely performed. If an animal had survived for > or =10 days, it was released to its owner or transferred to the municipal dog shelter. A total of 644 dogs and 58 cats found rabid died within 10 days of observation. In addition, for 208 dogs confirmed rabid with laboratory tests between 1997 and 2005, six criteria were analysed from the day of submission. This experience with the implemented 10-day observation period confirms the WHO recommendation on identifying suspected rabid dogs or cats under veterinary supervision following a human exposure.

Sex- and age-related differences in rabies immunoglobulin hypersensitivity

We retrospectively reviewed 72132 patients who had received rabies immunoglobulin between 1987 and 2005 at the Queen Saovabha Memorial Institute, Bangkok. Purified equine rabies immunoglobulin (ERIG) was given to 42965 (59.56%) patients and human rabies immunoglobulin (HRIG) to 29167 (40.44%) patients. A total of 812 patients from both groups (1.13%) reported adverse reactions; among those who had received ERIG, 43.13% were male and 56.87% were female, and among those who had received HRIG, 34.62% were male and 65.38% were female. Females were at higher risk of exhibiting ERIG or HRIG hypersensitivity than males (P<0.01). None of the reactions was life-threatening. Serum sickness-like reactions to ERIG and HRIG were rare under the age of 10 years (0.05 and 0.01% among recipients in that age group).

Survival of neutralizing antibody in previously rabies vaccinated subjects: A prospective study showing long lasting immunity

Physicians dealing with potential rabies exposures and travel medicine are frequently asked how long previous pre- or post-exposure rabies vaccination induced immunity persists. We therefore carried out a prospective study on 118 rabies vaccine recipients who had received pre- or post-exposure regimens with tissue culture rabies vaccines by intramuscular or intradermal schedules 5-21 years previously. Rabies neutralizing antibody was detectable in the sera of all subjects on day 0. They then received one intradermal 0.1 mL booster injection on days 0 and 3. Neutralizing antibody determination was carried out on days 5, 7 and 14. All except one subject showed an accelerated antibody response following the two booster injections. Vaccination with a WHO recognized tissue culture rabies vaccine evokes long lasting immunity. This study supports current recommendations that immunity is long lasting and that boosters without immunoglobulin are sufficient even when prior vaccination was longer than 5 years previously.

White biotechnology for green chemistry: fermentative 2-oxocarboxylic acids as novel building blocks for subsequent chemical syntheses

Functionalized compounds, which are difficult to produce by classical chemical synthesis, are of special interest as biotechnologically available targets. They represent useful building blocks for subsequent organic syntheses, wherein they can undergo stereoselective or regioselective reactions. "White Biotechnology" (as defined by the European Chemical Industry [ http://www.europabio.org/white_biotech.htm ], as part of a sustainable "Green Chemistry,") supports new applications of chemicals produced via biotechnology. Environmental aspects of this interdisciplinary combination include: Use of renewable feedstock Optimization of biotechnological processes by means of: New "high performance" microorganisms On-line measurement of substrates and products in bioreactors Alternative product isolation, resulting in higher yields, and lower energy demand In this overview we describe biotechnologically produced pyruvic, 2-oxopentaric and 2-oxohexaric acids as promising new building blocks for synthetic chemistry. In the first part, the microbial formation of 2-oxocarboxylic acids (2-OCAs) in general, and optimization of the fermentation steps required to form pyruvic acid, 2-oxoglutaric acid, and 2-oxo-D-gluconic acid are described, highlighting the fundamental advantages in comparison to chemical syntheses. In the second part, a set of chemical formula schemes demonstrate that 2-OCAs are applicable as building blocks in the chemical synthesis of, e.g., hydrophilic triazines, spiro-connected heterocycles, benzotriazines, and pyranoic amino acids. Finally, some perspectives are discussed.

Rabies exposures in thai children

OBJECTIVE

To determine the epidemiology of potential rabies exposures in Thai children.

METHODS

The study was carried out at the Queen Saovabha Memorial Institute of the Thai Red Cross Society during I calendar year. All charts of victims aged 0 to 14 years with possible rabies exposures were retrospectively reviewed.

RESULTS

Subjects were 2622 children, with a male to female ratio of 1.6:1 and a mean age of 6.7 years (range, 2 months to 14 years). Most exposures (86.3%) were related to dogs. The most common site of exposure was the lower extremity. The majority of exposures occurred in or around the home and as the consequence of unprovoked attacks rather than provoked attacks. Antirabies vaccines were given in all cases: 68.4% using the Thai Red Cross intradermal route, and 31.6% using the intramuscular route. Rabies immunoglobulin (RIG) was prescribed in 57.5% of children; 35.2% received human RIG (HRIG), and 22.3% received purified equine RIG (ERIG).

CONCLUSIONS

This study confirms that rabies exposures, especially in children, are an important public health problem in Thailand. The reduced-dose, multiple-site intradermal rabies vaccine method and ERIG in place of HRIG reduce the cost of treatment.

Failure of pre- and postexposure rabies vaccinations in a child infected with HIV

We report the case of a 6-y-old HIV-infected girl with severe immune deficiency who failed to respond to intramuscular pre-exposure rabies vaccination using human diploid cell rabies vaccine on days 0, 7 and 28. She also failed to respond to an intradermal postexposure rabies regimen using purified verocell rabies vaccine at 4 sites on days 0, 3 and 7 and at 2 sites on days 30 and 90 (double the usual regimen). Sequentially monitored rabies neutralizing antibody titers were below the WHO minimum acceptable level (> 0.15 IU/ml) in all specimens. Rabies prevention in HIV-infected persons with severe immune suppression requires further study.

New-world and transcultural impact on Thai medical practices and professional behaviour

Thailand, which is barely recovering from the 1997 economic collapse, has passed a new constitution, has a new government and all of this will have a profound effect on the way doctors practice and interact with their patients. Some of the factors that have been responsible for this are 1) Passage of a patient's rights bill 2) Legal definition of what is a proper consent form 3) The public's demand for openness, better communication and transparency in medicine These concepts, which now have a legal as well as moral basis, will impact directly on doctors and nurses as their practices will be subject to increasingly intense scrutiny and criticism. Doctors and nurses in past generations were among the most respected members of Thai society. They were trusted almost without exception and their judgment was not questioned. Only rare cases of malfeasance and malpractice came to public notice though, no doubt, they existed but to a much lesser degree. A physicians' life was much simpler for our teachers, fathers and grandfathers. Life was inexpensive, families were less demanding and the doctor did not have to surround himself with expensive foreign-made apparatus which can bankrupt the doctor as well as the patients who have to pay the bills. Medical decisions were made mostly on the basis of observation, past experience at the bedside and not in the laboratory or imaging rooms. Honest errors in diagnosis were common, treatment was limited and simple and this was all tolerated or expected by the public. Few if any disappointments on the part of patients ended up before a judge.

Invasive group A Streptococcal infections at Chulalongkorn University Hospital

To determine whether the incidence and pattern of group A Streptococcal (GAS) infections in Thailand have paralleled those in the United States and Europe, we conducted a retrospective study of invasive GAS infections at Chulalongkorn University Hospital from 1995 to 1999. A total of 42 cases were identified. There were 18 males and 24 females (median age of 59 and 46 years, respectively). Most patients were in two age groups: 20-39 (33%) and 60-79 (38%). Underlying conditions were present in 34 patients (81%), including mostly chronic system diseases (50%), alcohol abuse (19%), diabetes mellitus (14%), connective tissue diseases (12%), immunosuppressive illnesses (12%), and human immunodeficiency virus infection (10%). The most common clinical presentations were skin and soft-tissue infections (31%), primary bacteremia (29%), and arthritis (14%). Of these, 24 (57%) presented with toxic shock syndrome (TSS). Overall mortality rate was 33 per cent. All GAS but one isolate were susceptible to penicillin.

Presumably entomophthoramycosis in an HIV-infected patient: the first in Thailand

The authors reported the case of a symptomatic HIV-infected woman with a slowly progressive infiltrative lesion which invaded in and around the nasal cavity over a 6-month period. Physical examination showed erythematous to violaceous plaques at the nasal and malar areas. Swelling of the inferior turbinate was noted in the right nare. Skin biopsy of the involved area revealed multiple nonseptate, broad, thin-walled hyphae within giant cells and granulomata. Entomophthoramycosis was diagnosed based on clinical features and histopathology. She was treated with intravenous amphotericin B for two weeks, followed by oral itraconazole 400 mg daily. At six months there was complete resolution of all lesions.

Seroprevalence of hepatitis A virus antibody among children and young adults in Bangkok

OBJECTIVE

To determine the prevalence of hepatitis A virus (HAV) antibodies in various age groups of healthy children and young adults who have not received the hepatitis A vaccine.

METHOD

Blood samples were collected from 825 volunteers aged 1-30 years from a well baby clinic and five academic institutions in the Don Mueang area from 1998 to 1999. Serum samples were assayed for specific HAV IgG antibodies using a commercial enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

The seropositivity rate (12.4% overall) in each age group was as follows: 1-3 years, 7.7 per cent; 4-7 years, 6.6 per cent; 8-11 years, 12.4 per cent; 12-15 years, 10.7 per cent and 16-30 years, 25.9 per cent.

CONCLUSIONS

In the Don Mueang area of Bangkok, the majority of children (< 16 years) do not have natural immunity against HAV. The use of hepatitis A vaccine for this population should be considered. Pre-vaccination serologic screening for HAV IgG in children may not be worthwhile.

What are today's orphaned vaccines?

Development costs for new biological agents are increasing, and the time span from laboratory research to introduction of a product on the world market is becoming ever longer. Complex regulatory requirements add barriers and additional costs to early introduction abroad. This results in reluctance by manufacturers to undertake development of a vaccine that will be used for a tropical disease in only the public sector of a poor country. The chances of recovery of huge investment costs before patents expire are not good, unless such a new vaccine can also be sold at high cost in North America and Europe. These are some of the reasons that we still do not have a modern Japanese encephalitis vaccine or products against malaria and dengue fever. Many tropical countries must find a way to develop their own vaccine production facilities. Innovative help for technology transfer will have to be forthcoming, or many new life-saving products will never bridge the gap between research unit and production.

Venomous snake husbandry in Thailand

A captive breeding program for venomous Thai snakes was established at the Queen Saovabha Memorial Institute at Bangkok, Thailand. This was necessary to secure a stable, healthy, and species-confirmed source of snake venom for antivenom production. In 1994, wild-caught specimens were collected, sexed, quarantined, and housed appropriately. All data in this report, with the exclusion of Table 6, were collected from 1994 to 1997. Two species were bred successfully in captivity to date during this study period. Although captive breeding has not yet been achieved with all species and subspecies, our early success was encouraging.

Non-serogroup O:1 Vibrio cholerae bacteremia and cerebritis

We describe a case of non-serogroup O:1 Vibrio cholerae bacteremia and cerebritis in a 41-year-old Thai man with alcoholism who presented with fever and cellulitis of the right ankle. He was successfully treated with parenteral cefotaxime and then was switched to treatment with oral ciprofloxacin.

A comparison of mutations induced by accelerated iron particles versus those induced by low earth orbit space radiation in the FEM-3 gene of Caenorhabditis elegans

The fem-3 gene of Caenorhabditis elegans was employed to determine the mutation frequency as well as the nature of mutations induced by low earth orbit space radiation ambient to Space Shuttle flight STS-76. Recovered mutations were compared to those induced by accelerated iron ions generated by the AGS synchrotron accelerator at Brookhaven National Laboratory. For logistical reasons, dauer larvae were prepared at TCU, transported to either Kennedy Space Center or Brookhaven National Laboratory, flown in space or irradiated, returned to TCU and screened for mutants. A total of 25 fem-3 mutants were recovered after the shuttle flight and yielded a mutation frequency of 2.1x10(-5), roughly 3.3-fold higher than the spontaneous rate of 6.3x10(-6). Four of the mutations were homozygous inviable, suggesting that they were large deletions encompassing fem-3 as well as neighboring, essential genes. Southern blot analyses revealed that one of the 25 contained a polymorphism in fem-3, further evidence that space radiation can induce deletions. While no polymorphisms were detected among the iron ion-induced mutations, three of the 15 mutants were homozygous inviable, which is in keeping with previous observations that high LET iron particles generate deficiencies. These data provide evidence, albeit indirect, that an important mutagenic component of ambient space radiation is high LET charged particles such as iron ions.

Immunologic and virologic evaluation of HIV-1-infected children after rabies vaccination

BACKGROUND

One-third of Thai children experience a dog bite by the time they are 15 years old, and HIV-1 infection in children is also not uncommon. Previous study has shown that rabies vaccination of HIV-1-infected children may not result in a satisfactory antibody response when CD4+ T cells are less than 15%. The objective of this prospective clinical study is to evaluate the immunologic response and effect on viral load after rabies vaccination in HIV-infected children.

METHODS

Thirteen HIV-1-infected children were vaccinated with the intramuscular rabies pre-exposure regimen using human diploid cell rabies vaccine (HDCV) on days 0, 7 and 28. CD4+ and CD8+ lymphocyte counts were performed on days 0, 7 and 28. Plasma viral loads were determined on days 0, 7, 14, 60, 90, 180 and 360.

RESULTS

There were no significant change in serial measurements of CD4+/CD8+ lymphocytes during a period of 1 month and in plasma viral load during 1 year. There was no associated clinical deterioration or any adverse reactions attributable to vaccine.

CONCLUSIONS

Rabies vaccination in HIV-1-infected children appears to be safe but did not significantly change the levels of plasma HIV RNA, CD4+ and CD8+ cell counts.

Dog-bite injuries at the Animal Bite Clinic of the Thai Red Cross Society in Bangkok

Canine rabies remains a public health problem in Thailand and other developing countries. This study of animal bites at the Animal Bite Clinic at the Queen Saovabha Memorial Institute revealed that: (1) The majority of patients were bitten by dogs and the time of the attack was mostly during the day. (2) School-aged children are at the highest risk for animal bites. (3) The most common site of injury are the legs and foot (64.2%), with the second most common site being the hands and fingers (21.2%). (4) Only 48 per cent of patients received rabies vaccine 1-2 days after being exposed. There was considerable delay before the rest received treatment. Solving Thailand' s rabies problem depends on control of canine rabies and educational campaigns. Public education must be an integral part of efforts to decrease the incidence of animal bites and assurance that they are managed properly.

N-Glycosidation of D-arabino-hex-2-ulosonic acid

Two approaches to N-functionalized D-arabino-hex-2-ulosonic acid derivatives were established by nucleophilic substitution of methyl (3,4,5-tri-O-acetyl-beta-D-arabino-hex-2-ulopyranosyl)onate bromide (1). Reaction of 1 with amino compounds in the presence of mercury(II) cyanide led to the 2,3-cis configured beta-D-arabino N-glycosides. On the other hand, the reaction of bromide 1 with azide, followed by catalytic hydrogenation led to 2,3-trans alpha-D-arabino glycosyl amine methyl 3,4,5-tri-O-acetyl-2-amino-alpha-D-arabino-hex-2-ulopyranosonate, which was easily rearranged to the thermodynamically more stable beta-D-arabino N-acetyl derivative methyl 4,5-di-O-acetyl-2-acetylamino-3-hydroxy-beta-D-arabino-hex-2-ulopyranosonate. The assignment of configuration of the tertiary anomeric centre and conformation of all products was based on 1H NMR H,H coupling constants and NOE difference experiments.

Diffusion and fate of intramuscularly injected human rabies immune globulin

The importance of rabies immune globulin (RIG) in postexposure rabies treatment is well known and it has been emphasized that the local injection into the animal bite sites is crucial. This preliminary study used a radioisotope tracer that allows following the fate of human rabies immune globulin (HRIG) injected intramuscularly. There was significant retention and local diffusion of the immune globulin at the injection site and significant radiotracer could still be detected at the site 24 h later.

Humanistic learning in medical curriculum

This paper argues for more attention and exposure to humanistic learning in the Thai medical curriculum. Humanistic learning traditionally consists of literature, history and philosophy, and is advantageous for medical education in that it tends to foster sensitivities to feelings, awareness of social traditions, and creating of skills in deliberating complex, ethical issues. These dispositions are necessary for a doctor in the world where there is an ever increasing public demand for communication, accountability and transparency on the part of doctors. It is proposed that the Thai medical curriculum should include more humanistic learning, and that medical students should be given opportunities to interact more with students from other disciplines throughout their studies and later professional life.

Neutralizing antibodies to rabies following injection of rabies immune globulin into gluteal fat or deltoid muscle

BACKGROUND

This experiment was carried out to determine whether there is any difference in circulating rabies antibody when rabies immune globulin is administered into fat or muscle tissue.

METHODS

Blood samples were taken at 24 and 48 hours after administering 40 IU/kg body weight of purified equine rabies immune globulin (ERIG) into deltoid muscle, or fatty gluteal tissue of grossly obese subjects.

RESULTS

Both groups revealed barely detectable antibody levels.

CONCLUSIONS

No conclusion was possible concerning the absorption kinetics of immune globulin from fat or muscle. However, it was evident that circulating antibody levels, using the recommended 40 IU/kg dose of ERIG, were extremely low and probably less than the required protective level at the possible bite site. This study supports current recommendations for local infiltration of virus inoculation sites with human or equine rabies immune globulin.

Immunogenicity of rabies postexposure booster injections in subjects who had previously received intradermal preexposure vaccination

BACKGROUND

Preexposure rabies vaccination is recommended using the full dose intramuscular or less expensive reduced dose intradermal method. The reliability of the reduced dose intradermal preexposure regimen is still controversial. The objective of this study was to determine whether it will mount a predictable accelerated immune response after a simulated rabies exposure.

METHOD

One hundred and thirty-eight veterinary students received intradermal or intramuscular preexposure vaccination using a potent batch of purified chick embryo rabies vaccine. They then received booster injections one year later.

RESULTS

Subjects who received intradermal rabies preexposure vaccination, using 0.1 mL of a potent tissue culture vaccine on days 0, 7, and 28, had a lower postexposure booster antibody response 1 year later than subjects given the preexposure series intramuscularly. A significant number showed an unsatisfactory early anamnestic response. Residual neutralizing antibodies, 1 year after the intramuscular preexposure series, were also significantly higher in the intramuscular than in the 0.1 mL dose intradermal group. However, all study subjects had antibody titers above the minimum recommended level of 0.5 IU/mL by day 14.

CONCLUSIONS

We conclude that not all subjects who received an intradermal preexposure vaccine series may be fully protected during the first 5 days after an exposure. Rabies immune globulin, injected into bite wounds and followed by a complete postexposure vaccine series, may be indicated if such a patient experiences a severe rabies exposure.

Economic issues in postexposure rabies treatment

Rabies remains a worldwide public health problem even though means to control this disease are known. Logistic problems and cultural barriers for effective dog control in many countries and the high cost of human postexposure treatment, account for much of the remaining worldwide human toll. Efforts to make vaccines, with effective and safe tissue or avian culture products and immune globulin, more affordable have been only marginally successful. Second generation rabies vaccines (purified Vero-, chick and duck embryo cell products) are effective, safe and less expensive than human diploid cell rabies vaccine. Reduced dose intradermal postexposure vaccination works, is affordable, and has helped abolish the use of dangerous and poorly immunogenic brain tissue-derived vaccines in Thailand, the Philippines, and Sri Lanka. The use of purified equine rabies immune globulin has been found to be safe and cost-effective. It is, unfortunately, in short supply worldwide. Preexposure rabies vaccination for travelers to endemic regions is recommended and should be administered by the intramuscular route whenever possible.

Acute acalculous cholecystitis in leptospirosis

The authors present three patients with acalculous cholecystitis seen at a tertiary care center in Bangkok. The first patient was explored surgically because peritonitis was suspected. The two other patients were treated conservatively with antibiotics and supportive care, and they recovered fully. The diagnosis of leptospirosis was confirmed by increasing antibody titers in three patients and by blood culture in one patient. Leptospira were not detected in the surgical specimen. Leptospirosis is a systemic disease that can present with a multitude of symptoms and signs including right upper quadrant pain mimicking cholecystitis. A high level of awareness and appropriate laboratory studies should allow early diagnosis and may prevent unnecessary surgical intervention.

Melioidosis, an environmental and occupational hazard in Thailand

Melioidosis is a tropical environmental hazard that causes acute and chronic pulmonary disease, abscesses of the skin and internal organs, meningitis, brain abscess and cerebritis, and acute fulminant rapidly fatal sepsis. It is more common among adults, individuals with diabetes, and individuals with chronic renal disease, but it can occur in normal hosts and children. Burkholderia pseudomellei is the most prevalent cause of community-acquired pneumonia, liver and splenic abscess, and sepsis in northeastern Thailand. Melioidosis can reactivate years after primary infection and result in chronic or acute life-threatening disease. With increasing worldwide travel and migration, patients may present in nonendemic countries with reactivation melioidosis decades after leaving an endemic region. We discuss seven selected patients presenting with this disease to a tertiary care facility in Bangkok between 1995 and 1997. Awareness should allow early diagnosis and treatment, which can lead to decreased morbidity and mortality.