A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

Tolerability and acceptability of real-time continuous glucose monitoring and its impact on diabetes management behaviours in individuals with Type 2 Diabetes - A pilot study

INTRODUCTION

Emerging evidence suggests us of real-time continuous glucose monitoring systems (RT-CGM), can assist to improve glucose control in Type 2 Diabetes (T2D) treatment, however the impact of these devices on patients' stress levels and behaviour is poorly understood. This study aimed to examine the effects of RT-CGM on tolerance and acceptability of device wear, stress and diabetes management and motivation to change.

METHODS

Twenty adults (10 men, 10 women) with T2D (aged 60.6 ± 8.4 years, BMI 34.2 ± 4.7 kg/m²), were randomised to a low-carbohydrate lifestyle plan whilst wearing a RT-CGM or an 'offline-blinded' (Blinded-CGM) monitoring system continuously for 12 weeks. Outcomes were glycaemic control (HbA1c), weight (kg) perceived stress scale (PSS), CGM device intolerance, acceptability, motivation to change and diabetes management behaviour questionnaires.

RESULTS

Both groups experienced significant reductions in body weight (RT-CGM -7.4 ± 4.5 kg vs. Blinded-CGM -5.5 ± 4.0 kg) and HbA1c (-0.67 ± 0.82% vs. -0.68 ± 0.74%). There were no differences between groups for perceived stress (P = 0.47) or device intolerance at week 6 or 12 (both P > 0.30). However, there was evidence of greater acceptance of CGM in the RT-CGM group at week 12 (P = 0.03), improved blood glucose monitoring behaviour in the RT-CGM group at week 6 and week 12 (P ≤ 0.01), and a significant time x group interaction (P = 0.03) demonstrating improved diabetes self-management behaviours in RT-CGM.

CONCLUSION

This study provides preliminary evidence of improved behaviours that accompany RT-CGM in the context of diabetes management and glucose self-monitoring. RT-CGM may provide an alternative approach to glucose management in individuals with T2D without resulting in increased disease distress.

Forensic psychiatry training in Europe

Europe wide it is acknowledged that when mental disorder leads to dangerous criminal actions, as it occasionally does, the criminal courts may require expert clinical opinions. Provision of such expertise in itself requires training, but it also leads to a need for further response in the form of appropriate service provision for offenders found to have mental disorder in this context. In most countries some specialist training is required to meet these needs and, in a few, extended training has led to development of a recognised speciality of forensic psychiatry. We consider what it means to be a forensic psychiatrist in the European Union context. Defined by common ground in the medical model, full specialty recognition and training follows from three years of specialist teaching and experience in relationships between mental disorder and antisocial behaviour, assessment, care and treatment of offenders with mental disorder, risk assessment and management and prevention of victimisation. Consideration of such issues is important because the European Union (EU) considers that people who are recognised as specialists in one member country stand as specialists in any other. Furthermore, patients may also move between countries. International training collaboration within the EU appears to achieve more than simple knowledge transfer.

Weak-link Josephson Junctions Made from Topological Crystalline Insulators

We report on the fabrication of Josephson junctions using the topological crystalline insulator Pb_{0.5}Sn_{0.5}Te as the weak link. The properties of these junctions are characterized and compared to those fabricated with weak links of PbTe, a similar material yet topologically trivial. Most striking is the difference in the ac Josephson effect: junctions made with Pb_{0.5}Sn_{0.5}Te exhibit a rich subharmonic structure consistent with a skewed current-phase relation. This structure is absent in junctions fabricated from PbTe. A discussion is given on the origin of this effect as an indication of novel behavior arising from the topologically nontrivial surface state.

Gender Differences in Mathematics: Trends in Performance

Longitudinal entry and performance data for the Australian Mathematics Competition, which in 1992 attracted over 500,000 entries from secondary school students, are presented in this paper. Male and female patterns are of particular interest. Examination of data over the 10-yr. period from 1983 to 1992 showed that the number of females in the postcompulsory years of education electing to enter the competition increasingly approaches entry figures for males. Performance differences between females and males are also decreasing for most of the categories of questions found in the paper. However, the opposite effect was observed in questions categorized as algebraic. The implications of the findings are discussed.

Psychotic experiences and PTSD: exploring associations in a population survey

BACKGROUND

Extensive evidence has shown that experiencing a traumatic event and post-traumatic stress disorder (PTSD) are associated with experiences of psychosis. However, less is known about specific PTSD symptoms and their relationship with psychotic experiences. This study aimed to examine the relationship between symptoms of PTSD with paranoia and auditory hallucinations in a large-scale sample.

METHOD

The Adult Psychiatric Morbidity Survey (APMS) was utilized to examine the prevalence of lifetime trauma, symptoms of PTSD, and experiences of paranoia and auditory hallucinations (n = 7403).

RESULTS

There were significant bivariate associations between symptoms of PTSD and psychotic experiences. Multiple logistic regression analyses indicated that reliving and arousal symptoms were significant predictors for paranoia while reliving, but not arousal symptoms, also significantly predicted auditory hallucinations. A dose-response relationship was found, the greater the number of PTSD symptoms, the greater the odds were of experiencing both paranoia and hallucinations.

CONCLUSIONS

These findings illustrate that symptoms of PTSD are associated with increased odds of experiencing auditory hallucinations and paranoia. Overlaps appear to be present between the symptoms of PTSD and psychotic experiences. Increasing awareness of this association may advance work in clinical practice.

Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis

BACKGROUND

Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.

METHOD

A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.

RESULTS

Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.

CONCLUSIONS

Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.

The influence of different force and pressure measuring transducers on lower extremity kinematics measured during walking

The examination of synchronous three dimensional (3-D) kinetics and kinematics of walking in laboratory based analyses typically requires participants/patients to make foot contact with a force or pressure measuring device. However, it has been proposed that this may lead to targeting whereby participants modify their natural gait pattern in order to ensure contact with the device. This study aimed to determine the extent to which an embedded force plate (EFP) and two different pressure mats (PMs) affect natural gait kinematics. Male participants (n = 12, age 24.23 SD 4.22 years, height 1.74 m SD 0.10, mass 75.78 SD 6.90 kg) walked at a velocity of 1.25 ms(-1) along a 22 m walkway in four different conditions. (1) EFP, (2) FootScan (FS) PM, (3) MatScan (MS) PM, (4) no device (ND). 3-D angular kinematic parameters were collected using an eight camera motion analysis system. Differences in kinematics were examined using repeated measures ANOVAs. Significant differences were observed in hip abduction, knee flexion/extension and knee abduction between various conditions and may warrant consideration in future research. No significant differences were reported at the ankle joint in any conditions. Comparing the PMs, no significant differences were observed, however, significant differences between the MS and the EFP and ND conditions were identified. The research supports the efficacy of collecting gait kinematics at the ankle joint and in most variables measured at the knee and hip joints.

Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis

BACKGROUND

Clinical equipoise regarding preventative treatments for psychosis has encouraged the development and evaluation of psychosocial treatments, such as cognitive behavioural therapy (CBT).

METHOD

A systematic review and meta-analysis was conducted, examining the evidence for the effectiveness of CBT-informed treatment for preventing psychosis in people who are not taking antipsychotic medication, when compared to usual or non-specific control treatment. Included studies had to meet basic quality criteria, such as concealed and random allocation to treatment groups.

RESULTS

Our search produced 1940 titles, out of which we found seven completed trials (six published). The relative risk (RR) of developing psychosis was reduced by more than 50% for those receiving CBT at every time point [RR at 6 months 0.47, 95% confidence interval (CI) 0.27-0.82, p = 0.008 (fixed-effects only: six randomized controlled trials (RCTs), n = 800); RR at 12 months 0.45, 95% CI 0.28-0.73, p = 0.001 (six RCTs, n = 800); RR at 18-24 months 0.41, 95% CI 0.23-0.72, p = 0.002 (four RCTs, n = 452)]. Heterogeneity was low in every analysis and the results were largely robust to the risk of an unpublished 12-month study having unfavourable results. CBT was also associated with reduced subthreshold symptoms at 12 months, but not at 6 or 18-24 months. No effects on functioning, symptom-related distress or quality of life were observed. CBT was not associated with increased rates of clinical depression or social anxiety (two studies).

CONCLUSIONS

CBT-informed treatment is associated with a reduced risk of transition to psychosis at 6, 12 and 18-24 months, and reduced symptoms at 12 months. Methodological limitations and recommendations for trial reporting are discussed.

Perceived social support buffers the impact of PTSD symptoms on suicidal behavior: implications into suicide resilience research

BACKGROUND

A growing body of research has highlighted the importance of identifying resilience factors against suicidal behavior. However, no previous study has investigated potential resilience factors among individuals with Posttraumatic Stress Disorder (PTSD). The aim of this study was to examine whether perceived social support buffered the impact of PTSD symptoms on suicidal behavior.

METHODS

Fifty-six individuals who had previously been exposed to a traumatic event and reported PTSD symptoms in the past month (n = 34, 60.7% participants met the full criteria for a current PTSD diagnosis) completed a range of self-report measures assessing PTSD symptoms, perceived social support and suicidal behavior. Hierarchical regression analyses were conducted to examine whether perceived social support moderates the effects of PTSD symptoms on suicidal behavior.

RESULTS

The results showed that perceived social support moderated the impact of the number and severity of PTSD symptoms on suicidal behavior. For those who perceived themselves as having high levels of social support, an increased number and severity of PTSD symptoms were less likely to lead to suicidal behavior.

CONCLUSIONS

The current findings suggest that perceived social support might confer resilience to individuals with PTSD and counter the development of suicidal thoughts and behaviors. The milieu of social support potentially provides an area of further research and an important aspect to incorporate into clinical interventions for suicidal behavior in PTSD or trauma populations.

Does unstable mood increase risk of suicide? Theory, research and practice

BACKGROUND

Suicide represents a substantial problem, with significant societal and personal impact. The identification of factors influencing suicide risk is an important step in preventing self-harming behaviour. In this article the authors explore whether emotional instability increases risk of suicide, beyond that of mood intensity.

METHOD

This article provides a summary of existing theory and indirect evidence in support of an association between emotional instability and suicidality. A systematic literature search (Embase, Medline, PsychInfo) was carried out on literature conducted up to October, 2011. Meta-analysis was used to assess the strength of the proposed association.

RESULTS

The systematic search identified 20 journal articles meeting the inclusion criteria, including retrospective questionnaire design studies and research conducted across several time-points. Meta-analysis revealed a moderate association, which remained statistically significant even when only including studies conducted over multiple time-points. This effect was attenuated, but remained significant, when controlling for study selection bias.

LIMITATIONS

Retrospective questionnaire studies failed to adequately control for mood level. Little is still currently understood about the types of emotional instability (e.g., dysoria, anxiety) most associated with suicidality.

CONCLUSIONS

Future avenues of investigation include micro- to macro-longitudinal research and the differentiation of emotion subtypes and instability metrics. Momentary assessment techniques may help to detect subtle fluctuations in mood leading to more effective and immediate intervention. Psychosocial intervention strategies for treating unstable emotions are discussed.

Effects of drop-out on efficacy estimates in five Cochrane reviews of popular antipsychotics for schizophrenia

OBJECTIVE

Our aim was to find out how Cochrane reviews of five popular or frequently prescribed second-generation antipsychotics in the UK (olanzapine, risperidone, quetiapine, amisulpride and aripiprazole) approached the problem of high drop-out in placebo-controlled trials.

METHOD

We examined the following: (i) whether reviews included data from studies with a level of drop-out exceeding their stated exclusion criterion; (ii) the level of missing data each efficacy outcome in each review relied upon; and (iii) impact of excluding studies with high drop-out.

RESULTS

All reviews included data they stated they would exclude because of unacceptable levels of attrition, four (risperidone, olanzapine, amisulpride, aripiprazole) without clear acknowledgement or justification. Several reviews also excluded data from a number of relatively low-attrition studies because of missing standard deviations.

CONCLUSION

Cochrane reviews of five popular antipsychotics for schizophrenia misrepresented the available evidence on their efficacy. The impact of including high-attrition studies was difficult to quantify because of the exclusion of relevant low-attrition studies. Further analysis of the efficacy of these drugs in studies with acceptable rates of attrition is required. To reduce the problem of high attrition, trialists should gather follow-up data from people who leave the double-blind process early.

Factors affecting the aldosterone/renin ratio

Although the aldosterone/renin ratio (ARR) is the most reliable screening test for primary aldo-steronism, false positives and negatives occur. Dietary salt restriction, concomitant malignant or renovascular hypertension, pregnancy and treatment with diuretics (including spironolactone), dihydropyridine calcium blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor antagonists can produce false negatives by stimulating renin. We recently reported selective serotonin reuptake inhibitors lower the ratio. Because potassium regulates aldosterone, uncorrected hypokalemia can lead to false negatives. Beta-blockers, alpha-methyldopa, clonidine, and nonsteroidal anti-inflammatory drugs suppress renin, raising the ARR with potential for false positives. False positives may occur in patients with renal dysfunction or advancing age. We recently showed that (1) females have higher ratios than males, and (2) false positive ratios can occur during the luteal menstrual phase and while taking an oral ethynylestradiol/drospirenone (but not implanted subdermal etonogestrel) contraceptive, but only if calculated using direct renin concentration and not plasma renin activity. Where feasible, diuretics should be ceased at least 6 weeks and other interfering medications at least 2 before ARR measurement, substituting noninterfering agents (e. g., verapamil slow-release±hydralazine and prazosin or doxazosin) were required. Hypokalemia should be corrected and a liberal salt diet encouraged. Collecting blood midmorning from seated patients following 2-4 h upright posture improves sensitivity. The ARR is a screening test only and should be repeated once or more before deciding whether to proceed to confirmatory suppression testing. Liquid chromatography-tandem mass spectrometry aldosterone assays represent a major advance towards addressing inaccuracies inherent in other available methods.

Affective variability predicts suicidal ideation in individuals at ultra-high risk of developing psychosis: an experience sampling study

OBJECTIVE

There is a suggestion in the literature that more variable affect increases suicidal ideation through the repeated re-activation of latent suicidal cognitions. The hypothesis that affective variability would be a better predictor of suicidal ideation and related behaviour than affect level was tested in individuals at ultra-high risk of developing psychosis. This study also examined the prediction that affective variability is a suicide-specific mechanism and would not predict levels of attenuated psychotic phenomena.

METHOD

Twenty-seven ultra-high risk individuals were required to complete ambulant ratings of their affect when prompted by an electronic wristwatch for six days (the experience sampling method). In the debriefing session, participants were assessed with a semi-structured interview (the Comprehensive Assessment of At-Risk Mental State), which assessed the severity and frequency of suicidality and psychosis-related phenomena.

RESULTS

The variability of negative and positive affect was predictive of the frequency of suicidal thoughts and behaviour. More variable negative, but not positive affect, was also associated with more severe suicidal ideation and related behaviour. Affect variability was not significantly related to the severity of attenuated psychotic phenomena.

CONCLUSION

Affective variability appears to be a specific risk factor for suicidal ideation in individuals at ultra-high risk of developing psychosis. Early intervention should focus on providing individuals with skills for regulating their own affect.

Chromosomal polymorphisms in African vlei rats, Otomys irroratus (Muridae: Otomyini), detected by banding techniques and chromosome painting: inversions, centromeric shifts and diploid number variation

Pericentric inversions are important for evolutionary biology because of their potential role in speciation. They may result in reproductive isolation due to illegitimate pairing of homologues at meiosis which leads to the production of aneuploid gametes (containing deletions or duplications of chromosomal segments), and consequently mediate chromosomal divergence. In this study, we describe the prevalence of pericentric inversions in the African vlei rat, Otomys irroratus (OIR). The species is characterized by intraspecific chromosomal variation (2n = 23-32) across its distribution in southern Africa. Here, we analyzed 55 individuals collected from 7 localities in South Africa by G- and C-banding and chromosome painting with flow sorts of Myotomys unisulcatus. Of the 55 specimens that were analyzed, 47% contained inversions or centromeric shifts on 4 autosomes (OIR1, 4, 6 and 10) which were present singly in specimens (i.e. none of the specimens contained all 4 inversions concurrently). These inversions were found in both homozygous and heterozygous state over a wide geographic range suggesting that they are floating polymorphisms. Given the potential role of inversions in post-mating isolation (through production of aneuploid gametes), the prevalence of inversions as floating polymorphisms in the vlei rats suggests that they are probably retained in the population through suppression of recombination in the inverted regions of the chromosomes.

Genetic parameters for visually assessed traits and their relationships to wool production and liveweight in Australian Merino sheep

Heritability was estimated for a range of visually assessed traits recorded on Merino sheep, together with the phenotypic and genetic correlations among the visually assessed traits and correlations of the visually assessed traits with measured wool production traits and liveweight. Data were derived from four research resource flocks, with a range of 12 958 to 57 128 records from animals with 478 to 1491 sires for the various traits. The estimates of heritability were high for the wool quality traits of handle, wool character and wool colour (0.33–0.34) and the conformation traits of face cover, neck wrinkle and body wrinkle (0.42–0.45), moderate for front leg structure (0.18) and low for back leg structure (0.13). Fleece rot score had low heritability (0.14), while classer grade was moderately heritable (0.20). Estimates of genetic correlations among the visually assessed wool quality traits were low to moderate in size and positive (0.17–0.47). Genetic correlation estimates among the assessed conformation traits were generally very low, except for the genetic correlations between scores for neck and body wrinkle (0.92 ± 0.01) and front and back leg structure (0.31 ± 0.09). Fleece rot score had low positive genetic correlations with neck and body wrinkle scores (0.18 ± 0.05 and 0.15 ± 0.05, respectively) and classer grade (0.26 ± 0.06). Classer grade was slightly positively correlated with the wool quality traits (0.17–0.45) and leg structure traits (0.21–0.25). The genetic correlations among the visually assessed traits were generally neutral to favourable. The visually assessed wool quality traits had low to moderate favourable genetic correlations with mean and coefficient of variation of fibre diameter (0.19 –0.47), but negative correlations with clean wool yield (–0.26 to –0.37). Face cover was unfavourably correlated with staple length (–0.27 ± 0.04) and liveweight (–0.23 ± 0.02). Neck and body wrinkle scores were genetically associated with higher greasy (0.33–0.39) and clean fleece weights (0.19–0.22), greater coefficient of variation of fibre diameter (0.24–0.26) and fibre curvature (0.27–0.28), but with reduced yield (–0.26 to –0.28) and staple length (–0.34 to –0.41). Fleece rot score was genetically correlated with clean fleece weight (0.26 ± 0.05) and coefficient of variation of fibre diameter (0.27 ± 0.04). Classer grade was favourably correlated with greasy and clean fleece weights (–0.41 to –0.43), staple length (–0.29 ± 0.04), liveweight (–0.36 ± 0.03) and coefficient of variation of fibre diameter (0.27 ± 0.03). Most genetic correlations between the visually assessed traits and the measured production traits and liveweight were close to zero and less than 0.2 in magnitude. This study provides accurate values for the parameter matrix required to incorporate visually assessed traits into breeding objectives and the genetic evaluation programs used in the Australian sheep industry, allowing the development of breeding objectives and indexes that optimally combine visually assessed performance and measured production in Merino sheep.

In vitro production of llama (Lama glama) embryos by intracytoplasmic sperm injection: Effect of chemical activation treatments and culture conditions

Assisted reproductive technologies in the llama (Lama glama) are needed to provide alternative methods for the propagation, selection and genetic improvement; however, recovery of adequate quantity and quality of spermatozoa for conventional IVF is problematic. Therefore, an effort was made to adapt the intracytoplasmic sperm injection (ICSI) procedure for the in vitro production of llama embryos. The specific objectives of this study were: (1) to determine in vitro maturation rates of oocytes recovered by transvaginal ultrasound-guided oocyte aspiration (TUGA) or flank laparotomy; (2) to evaluate the effects of activation treatments following ICSI; (3) to evaluate the development of llama ICSI embryos in CR1aa medium or in an oviduct cell co-culture system. Llamas were superstimulated by double dominant follicle reduction followed by oFSH administered in daily descending doses over a 3-day interval. Oocytes were harvested by flank laparotomy or TUGA and matured in vitro for 30 h. Mature oocytes were subjected to ICSI followed by no chemical activation (Treatment A), ionomycin only (Treatment B) or ionomycin/DMAP activation (Treatment C). More oocytes were recovered by flank laparotomy procedure compared with TUGA (94% versus 61%, P<0.05) and a greater number of oocytes harvested by flank laparotomy reached the metaphase-II stage (77% versus 44%, P<0.05). After ICSI, the proportion of cleaved and 4-8-cell stages embryos was significantly greater when injected oocytes were activated with ionomycin/DMAP combination (63% and 38%, respectively, P<0.05). The co-culture of ICSI embryos with llama oviduct epithelial cells resulted in progression to morula (25%) and blastocyst (12%) stages; whereas, all embryos cultured in CR1aa medium arrested at the 8-16-cell developmental stage.

Self-fertilization in mosses: a comparison of heterozygote deficiency between species with combined versus separate sexes

Self-fertilization is a key difference of adaptive significance between species with combined versus separate sexes. In haploid-dominant species such as mosses and ferns, species with either combined or separate sexes (monoicous and dioicous, respectively) have the potential to self-fertilize (intergametophytic selfing), but being monoicous allows an additional mode of selfing (intragametophytic selfing). We used allozyme electrophoresis to estimate deviations from expected levels of heterozygosity under Hardy-Weinberg equilibrium to infer selfing rates in 10 moss species from 36 New Zealand populations. We found that while there were deficiencies of heterozygotes compared to expectation in both monoicous and dioicous mosses, monoicous species had significantly higher levels of heterozygote deficiency than dioicous species (F(IS)=0.89+/-0.12 and 0.41+/-0.11, respectively). Estimated selfing rates suggest that selfing occurs frequently in monoicous populations, and rarely in dioicous populations. However, in two dioicous species (Polytrichadelphus magellanicus and Breutelia pendula), we found significant indications of mixed mating or biparental inbreeding in a handful of populations. These data provide the first analysis of heterozygote deficiency and selfing among haploid-dominant species with breeding system variation, and we discuss our results with respect to the consequences of inbreeding depression and the evolution of breeding systems.

Relationships of tacrolimus pharmacokinetic measures and adverse outcomes in stable adult liver transplant recipients

BACKGROUND AND OBJECTIVES

Alternative measures to trough concentrations [non-trough concentrations and limited area under the concentration-time curve (AUC)] have been shown to better predict tacrolimus AUC. The aim of this study was to determine if these are also better predictors of adverse outcomes in long term liver transplant recipients.

METHODS

The associations between tacrolimus trough concentrations (C(0)), non-trough concentrations (C(1), C(2), C(4), C(6/8)), and AUC(0-12) and the occurrence of hypertension, hyperkalaemia, hyperglycaemia and nephrotoxicity were assessed in 34 clinically stable liver transplant patients.

RESULTS AND DISCUSSION

The most common adverse outcome was hypertension, prevalence of 36%. Hyperkalaemia and hyperglycaemia had a prevalence of 21% and 13%, respectively. A sequential population pharmacokinetic/pharmacodynamic approach was implemented. No significant association between predicted C(0), C(1), C(2), C(4), C(6/8) or AUC(0-12) and adverse effects could be found. Tacrolimus concentrations and AUC measures were in the same range in patients with and without adverse effects.

CONCLUSIONS

Measures reported to provide benefit, preventing graft rejection and minimizing acute adverse effects in the early post-transplant period, were not able to predict adverse effects in stable adult liver recipients whose trough concentrations were maintained in the notional target range.

Evaluating the costs of mosquito resistance to malaria parasites

Costly resistance mechanisms have been cited as an explanation for the widespread occurrence of parasitic infections, yet few studies have examined these costs in detail. A malaria-mosquito model has been used to test this concept by making a comparison of the fitness of highly susceptible lines of mosquitoes with lines that are resistant to infection. Malaria infection is known to cause a decrease in fecundity and fertility of mosquitoes; resistant mosquitoes were thus predicted to be fitter than susceptible ones. Anopheles gambiae were selected for refractoriness/resistance or for increased susceptibility to infection by Plasmodium yoelii nigeriensis. Additional lines that acted as controls for inbreeding depression were raised in parallel but not exposed to selection pressure. Selections were made in triplicate so that founder effects could be detected. Resistance mechanisms that were selected included melanotic encapsulation of parasites within 24 h postinfection and the complete disappearance of parasites from the gut. Costs of immune surveillance were assessed after an uninfected feed, and costs of immune deployment were assessed after exposure to infection and to infection and additional stresses. Mosquito survivorship was unaffected by either resistance to infection or by an increased burden of infection when compared with low levels of infection. In most cases reproductive fitness was equally affected by refractoriness or by infection. Resistant mosquitoes did not gain a fitness advantage by eliminating the parasites. Costs were consistently associated with larval production and egg hatch rate but rarely attributed to changes in blood feeding and never to changes in mosquito size. No advantages appeared to be gained by the offspring of resistant mosquitoes. Furthermore, we were unable to select for refractoriness in groups of mosquitoes in which 100% or 50% of the population were exposed to infection every generation for 22 generations. Under these selection pressures, no population had become completely refractory and only one became more resistant. Variations in fitness relative to control lines in different groups were attributed to founder effects. Our conclusion from these findings is that refractoriness to malaria is as costly as tolerance of infection.

Characterization of the Human Cytochrome P450 Forms Involved in Metabolism of Tamoxifen to Its α-Hydroxy and α,4-Dihydroxy Derivatives

Tamoxifen is a known hepatocarcinogen in rats and is associated with an increased incidence of endometrial cancer in patients. One mechanism for these actions is via bioactivation, where reactive metabolites are generated that are capable of binding to DNA or protein. Several metabolites of tamoxifen have been identified that appear to predispose to adduct formation. These include alpha-hydroxytamoxifen, alpha,4-dihydroxytamoxifen, and alpha-hydroxy-N-desmethyltamoxifen. Previous studies have shown that cytochrome P450 (P450) enzymes play an important role in the biotransformation of tamoxifen. The aim of our work was to determine which P450 enzymes were capable of producing alpha-hydroxylated metabolites from tamoxifen. When tamoxifen (18 or 250 microM) was used as the substrate, P450 3A4, and to a lesser extent, P450 2D6, P450 2B6, P450 3A5, P450 2C9, and P450 2C19 all produced a metabolite with the same HPLC retention time as alpha-hydroxytamoxifen at either substrate concentration tested. This peak was well-separated from 4-hydroxy-N-desmethyltamoxifen, which eluted substantially later under the chromatographic conditions used. No alpha,4-dihydroxytamoxifen was detected in incubations with any of the forms with tamoxifen as substrate. However, when 4-hydroxytamoxifen (100 microM) was used as the substrate, P450 2B6, P450 3A4, P450 3A5, P450 1B1, P450 1A1, and P450 2D6 all produced detectable concentrations of alpha,4-dihydroxytamoxifen. These studies demonstrate that multiple human P450s, including forms found in the endometrium, may generate reactive metabolites in women undergoing tamoxifen therapy, which could subsequently play a role in the development of endometrial cancer.

Isolation of Mycobacterium avium subsp paratuberculosis from environmental samples collected from farms before and after destocking sheep with paratuberculosis

OBJECTIVE

To determine whether Mycobacterium avium subsp paratuberculosis could be isolated from soil-pasture, faecal, water and sediment samples on farms before and after removal of sheep with paratuberculosis. A feasibility study and subsequent field survey.

PROCEDURE

First the analytical sensitivity of radiometric culture of the organism from two types of soil was determined relative to faeces. Then soil-pasture, faecal, water and sediment samples were collected for culture from a range of sites from 6 farms with paratuberculosis affected sheep and goats. Similar samples were collected from 20 farms at least 9 months after removal of infected stock.

RESULTS

The analytical sensitivity of culture of M a paratuberculosis from soil samples was 2 orders of magnitude less than that from faeces, and environmental samples required longer incubation periods to yield significant growth in radiometric culture (BACTEC) medium. However, the organism was recovered from approximately 20% of 163 soil-pasture, water and sediment samples from 6 properties with clinically-affected animals with paratuberculosis. The positive samples were from a range of topographic sites, including open exposed and dry areas, however, low lying areas tended to have larger numbers of organisms. When the same sites were sampled again about 5 months later, only 1 was culture positive, and none were culture positive > 12 months later. Of 17 water and dam sediment samples collected from farm 6, which had long-standing high prevalence OJD infection, only one water sample and one sediment from the same dam were culture positive. None of the 5 water samples from the other farms were culture positive. Of 96 water samples, 90 sediment samples and 93 soil samples from farms that had been destocked of infected sheep/goats for 9 to 24 months, one sediment sample from a farm in Victoria (destocked for 12 months) and two sediment samples from a farm in New South Wales (10, 19 months) were culture positive. Recontamination from cattle or water could not be excluded as a cause of the positive cultures from the second farm.

CONCLUSION

M a paratuberculosis can be detected by radiometric culture in environmental samples from farms grazed by sheep or goats with paratuberculosis. There is a relatively low likelihood of recovery of the organism from water samples from such farms, and at 5 or more months after removing stock with paratuberculosis the likelihood of positive cultures from environmental samples is very low. Although the analytical sensitivity of culture from environmental samples is less than that from faeces, surveys of environmental sites are nevertheless feasible. However, improved culture methods are needed for critical surveys and to study the movement and fate of the organism in the environment.

A comparison of ovulation suppression and ovulation stimulation in the treatment of endometriosis-associated infertility

This study compares ovulation stimulation or suppression with the pregnancy rate among infertile couples with endometriosis. The design is a nonrandomized, prospective, multicentered cohort analytic study. Two hundred and ninety-seven couples with laparoscopy-proven endometriosis were analyzed: 68 received no therapy, 42 received clomiphene and 74 received danazol. Forty patients (22%) conceived and pregnancy rates were similar in each treatment group. The relative likelihood of pregnancy associated with clomiphene was 2.9 (95% confidence limits 1.2-7.1); the relative likelihood of pregnancy with danazol was 1.02 (95% confidence limits 0.5-2.3). This study suggests that pregnancy rates during clomiphene treatment could be superior to expectant therapy, while pregnancy rate after danazol is similar to no treatment.

Young male prisoners in a Young Offenders' Institution: their contact with suicidal behaviour by others

Prison suicide rates are increasing. The impact of witnessing a suicide or how many people do so is unknown. The aim of this study was to find how many young people detained in a Young Offenders' Institution (YOI) have had contact with another's suicide attempt and to test for association between this and own self-harming behaviour. A questionnaire, developed for the project, was distributed within a YOI. 74% (355/480) responded. One hundred and fifty-one (43%) of the young men reported that they knew someone who had attempted suicide, 48 of them knowing someone who had thereby died. The contact with a non-fatal suicide attempted by others was associated with own self-harm (OR 1.73, CI 1.39-21.4, p<0.01); contact with completed suicide had no such association. The most important factor that increased the chance of knowing a suicide attempter was actual length of time spent in prison up to the time of the study; 95 (63%) of the young men with such contact had it in prison. No other significant vulnerability factors were identified. It seems likely that imprisonment is a specific vulnerability factor for self-harm, one explanation being that it increases the risk of exposure to a contact with suicidal behaviour by others. Further work is called for to test relationships between such exposure and own behaviour over time, and to gather first hand accounts from the young men in such circumstances in order to understand the meaning for them of the contact with suicidal behaviour by others. This would inform appropriate intervention strategies, and could save much morbidity, and even mortality.

Population pharmacokinetic analysis of mycophenolic acid in renal transplant recipients following oral administration of mycophenolate mofetil

AIM

To develop a population pharmacokinetic model for mycophenolic acid in adult kidney transplant recipients, quantifying average population pharmacokinetic parameter values, and between- and within-subject variability and to evaluate the influence of covariates on the pharmacokinetic variability.

METHODS

Pharmacokinetic data for mycophenolic acid and covariate information were previously available from 22 patients who underwent kidney transplantation at the Princess Alexandra Hospital. All patients received mycophenolate mofetil 1 g orally twice daily. A total of 557 concentration-time points were available. Data were analysed using the first-order method in NONMEM (version 5 level 1.1) using the G77 FORTRAN compiler.

RESULTS

The best base model was a two-compartment model with a lag time (apparent oral clearance was 27 l h(-1), and apparent volume of the central compartment 98 l). There was visual evidence of complex absorption and time-dependent clearance processes, but they could not be successfully modelled in this study. Weight was investigated as a covariate, but no significant relationship was determined.

CONCLUSIONS

The complexity in determining the pharmacokinetics of mycophenolic acid is currently underestimated. More complex pharmacokinetic models, though not supported by the limited data collected for this study, may prove useful in the future. The large between-subject and between-occasion variability and the possibility of nonlinear processes associated with the pharmacokinetics of mycophenolic acid raise questions about the value of the use of therapeutic monitoring and limited sampling strategies.

Does 'like predict like' when patients discharged from high secure hospitals re-offend? An instrument to describe serious offences

BACKGROUND

The statement that past behaviour is the best predictor of future behaviour has empirical support in respect of whether an individual will, or will not, commit a criminal offence. People who have offended in the past are more likely to offend in the future. The aims of this study were to develop an instrument and to examine whether the same statement applies in respect of the nature and circumstances of successive offences committed by the same person.

METHOD

A rating instrument to describe seven variables relating to the nature and circumstances of a serious offence, the SODI, was developed by the authors. Inter-rater reliability was measured when the instrument was applied to 80 offences committed by 40 patients leaving high secure hospitals. The data were examined for evidence of similarity in the nature and circumstances of successive offences.

RESULTS

For five of the seven items of the instrument the kappa coefficients for inter-rater reliability were > 0.65. No significant associations, in terms of SODI ratings, were found between the offence that led to hospital admission and that which was committed after discharge.

CONCLUSIONS

The SODI is a reliable instrument for the description of serious offences committed by this group. Risk assessments in psychiatry should be informed by an awareness that in only a proportion of cases will the nature and circumstances of any serious re-offence resemble the nature and circumstances of the offence which contributed to a patient's admission to hospital.

Vascular training in the U.K.: femorodistal bypass, an index procedure?

OBJECTIVES

femorodistal bypass operation is one of three index procedures for vascular training in the U.K. Our aim is to determine the suitability of femorodistal bypass to be considered as an index procedure in the era of increasing utilisation of percutaneous transluminal angioplasty (PTA).

DESIGN

a retrospective analysis of prospectively collected data.

PATIENTS AND METHODS

a total of 526 patients with 608 chronic critically ischaemic limbs admitted to the vascular unit, at the Royal United Hospital, Bath, between January 1994 and December 1999 was included in the study.

RESULTS

revascularisation either by PTA, bypass surgery or a combination of both was attempted in 524 limbs (86%). Crural procedures were carried out on 71 limbs (14% of revascularised limbs). Primary crural procedures included 34 PTAs as a sole treatment (48%), and 37 femorodistal bypass operations (52%).

CONCLUSIONS

during a 6-year period only 37 primary femorodistal bypass operations were performed in a unit which aggressively treats CLI. PTA is the initial step and increasingly the sole treatment for critical limb ischaemia (CLI), including distal lesions. We question the rationale of including an uncommon operation as a vascular training index procedure.

Genetic parameters for meat quality and carcass traits and their correlation with wool traits in Australian Merino sheep

Estimates of genetic parameters for carcass traits in Merino sheep are presented, including muscle pH and colour, which are indicators of meat quality. The inclusion of these in the parameter set for genetic evaluation will provide the basis for more accurate estimated breeding values and the design of better breeding programs for improving meat traits in straightbred Merino sheep and crossbred lamb production. Data from 1045, nineteen-month-old Merino rams, the progeny of 125 sires from 3 strains that are representative of the industry, were used. Heritability and genetic correlations were estimated by fitting an animal model using a REML procedure in univariate and multivariate analyses. The traits included fasted pre-slaughter liveweight; dressing %; carcass tissue depth at the GR site (FATGR); fat depth at the C site (FATC); eye muscle depth (EMD), width (EMW), and area (EMA); ultimate pH and colour (L*, a*, b*) of the eye muscle. Multivariate analyses were used to estimate genetic correlations among meat traits and between wool traits (clean wool weight and mean fibre diameter) and selected carcass and meat traits. Estimates of heritability were: liveweight 0.51 (±0.10), dressing % 0.39 (±0.10), FATGR 0.33 (±0.09), FATC 0.20 (±0.08), EMD 0.27 (±0.08), EMW 0.15 (±0.07), EMA 0.23 (±0.08), muscle pH 0.27 (±0.09), and 0.14 (±0.07), 0.02 (±0.06), and 0.04 (±0.06) for the meat colour measurements L*, a*, and b* respectively. There was a favourable genetic correlation between muscle pH and colour L* of –0.56 (±0.23). There were also significant genetic correlations between wool weight and FATGR (–0.34 ± 0.16) and between mean fibre diameter and muscle colour L* (–0.66 ± 0.27). The study indicates that there is genetic variation for carcass traits, including indicators of meat quality, with scope for selection to improve meat production and quality in Merino sheep.

Quantum dot superlattice thermoelectric materials and devices

PbSeTe-based quantum dot superlattice structures grown by molecular beam epitaxy have been investigated for applications in thermoelectrics. We demonstrate improved cooling values relative to the conventional bulk (Bi,Sb)2(Se,Te)3 thermoelectric materials using a n-type film in a one-leg thermoelectric device test setup, which cooled the cold junction 43.7 K below the room temperature hot junction temperature of 299.7 K. The typical device consists of a substrate-free, bulk-like (typically 0.1 millimeter in thickness, 10 millimeters in width, and 5 millimeters in length) slab of nanostructured PbSeTe/PbTe as the n-type leg and a metal wire as the p-type leg.

Total body irradiation using a modified standing technique: a single institution 7 year experience

We describe a simple standing technique for delivering total body irradiation (TBI) using large horizontal fields, made possible by the off-centre installation of a non-dedicated treatment unit in a pre-existing bunker. Patients are treated using anterior and posterior fields with customized lung compensators. This technique enables the dose to the lung to be accurately calculated and modified to avoid overdose and to minimize the risk of pneumonitis. From February 1991 to December 1997, 94 patients with a variety of haematological malignancies were given fractionated TBI using this technique prior to allogenic or autologous bone marrow transplantation. Patients received a total dose of 14.4 Gy given in eight fractions over 4 days, with at least 6 h between fractions. The prescribed dose to the lungs was reduced to 12 Gy in eight fractions. The technique was well tolerated, took less than 10 min to set up and did not disrupt the daily routine use of the machine. Doses to all measured points on the trunk and head were within +/-6% of the prescribed dose. Doses to the lungs were within +/-5% of the prescribed dose. There were no early respiratory deaths in the 37 autologous transplant patients. There were 10 (17%) respiratory deaths in the 57 allogeneic transplant patients, 3 of confirmed infectious aetiology.

Functional regulator treatment of Class II division 1 malocclusions

This controlled retrospective study aimed to identify the contribution of skeletal and dental changes in the correction of Class II division 1 malocclusions using Fränkel's functional regulator II (FRII), with reference to a concurrently recruited control group. One hundred and thirty-eight patients with Class II division 1 malocclusions were identified, those accepting treatment forming the study group and those declining treatment the control group. The study group (n = 70) were treated with a Fränkel appliance. Pre- and post-treatment observation cephalometric radiographs were analysed and compared. Mean values for both skeletal and dental variables in the control group were remarkably consistent throughout the study period; however, this masked individual variations in this group. The skeletal variables in the study group that showed statistically significant differences from the control group were SNB, ANB, BaNA and ANS-Me, but none of these was sufficiently large to be regarded as clinically significant. Dental variables showed clinically and statistically significant differences, including a 10 degree reduction in UI-Max and 3.1 degree increase in LI-Mand. The Fränkel appliance was thus found to be effective in producing desirable occlusal and dental changes in the majority of patients treated.