Reviewing essential public health functions in the Eastern Mediterranean Region post COVID-19 pandemic: a foundation for system resilience

The COVID-19 pandemic exposed vulnerabilities in many health systems worldwide with profound implications for health and society. The public health challenges experienced during the pandemic have highlighted the importance of resilient health systems, that can adapt and transform to meet the population's evolving health needs. Essential public health functions (EPHFs) offer a holistic, integrated and sustainable approach to public health by contributing to achieving several health priorities and goals. In recent years, there has been a focused effort to conceptualise and define the EPHFs. In this paper, we describe the collaborative approach undertaken by the WHO Eastern Mediterranean Region (EMR) and UK Health Security Agency and present the findings and results of the revised EPHFs, in view of lessons learnt from the COVID-19 pandemic and the current priorities for countries across the EMR. This included conducting a desktop review, a gap and bottleneck analysis and stakeholder consultation to arrive at the revised EPHF model including four enablers and nine core functions, including a new function: public health services. The EPHFs will offer countries a complementary and synergistic approach to strengthen health systems and public health capacities and contribute to the region's ability to effectively respond to future health challenges and emergencies. By focusing on the EPHFs, countries can work towards ensuring health security as an integral goal for the health system besides universal health coverage, thus strengthening and building more resilient and equitable health systems.

Feasibility, acceptability and clinical benefit of a trauma-focused stabilisation group for post-traumatic stress disorder patients with complex presentations on primary care waitlists

BACKGROUND

Large numbers of people showing complex presentations of post-traumatic stress disorder (PTSD) in the NHS Talking Therapies services routinely require multi-faceted and extended one-to-one National Institute of Clinical Excellence (NICE) recommended treatment approaches. This can lead to longer waits for therapy and prolong patient suffering. We therefore evaluated whether a group stabilisation intervention delivered to patients on the waitlist for individual trauma-focused psychological treatment could help address this burden.

AIMS

The study aimed to ascertain a trauma-focused stabilisation group's acceptability, feasibility, and preliminary clinical benefit.

METHOD AND RESULTS

Fifty-eight patients with PTSD waiting for trauma-focused individual treatment were included in the study. Two therapists delivered six 5-session groups. The stabilisation group was found to be feasible and acceptable. Overall, PTSD symptom reduction was medium to large, with a Cohen's d of .77 for intent-to-treat and 1.05 for per protocol analyses. Additionally, for depression and anxiety, there was minimal symptom deterioration.

CONCLUSIONS

The study provided preliminary evidence for the acceptability, feasibility and clinical benefit of attending a psychoeducational group therapy whilst waiting for one-to-one trauma therapy.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

Evaluating Augmented Depression Therapy (ADepT): study protocol for a pilot randomised controlled trial

BACKGROUND

While existing psychological treatments for depression are effective for many, a significant proportion of depressed individuals do not respond to current approaches and few remain well over the long-term. Anhedonia (a loss of interest or pleasure) is a core symptom of depression which predicts a poor prognosis but has been neglected by existing treatments. Augmented Depression Therapy (ADepT) has been co-designed with service users to better target anhedonia alongside other features of depression. This mixed methods pilot trial aims to establish proof of concept for ADepT and to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost-effectiveness of ADepT, compared to an evidence-based mainstream therapy (Cognitive Behavioural Therapy; CBT) in the acute treatment of depression, the prevention of subsequent depressive relapse, and the enhancement of wellbeing.

METHODS

We aim to recruit 80 depressed participants and randomise them 1:1 to receive ADepT (15 weekly acute and 5 booster sessions in following year) or CBT (20 weekly acute sessions). Clinical and health economic assessments will take place at intake and at 6-, 12-, and 18-month follow-up. Reductions in PHQ-9 depression severity and increases in WEMWBS wellbeing at 6-month assessment (when acute treatment should be completed) are the co-primary outcomes. Quantitative and qualitative process evaluation will assess mechanism of action, implementation issues, and contextual moderating factors. To evaluate proof of concept, intake-post effect sizes and the proportion of individuals showing reliable and clinically significant change on outcome measures in each arm at each follow-up will be reported. To evaluate feasibility and acceptability, we will examine recruitment, retention, treatment completion, and data completeness rates and feedback from patients and therapists about their experience of study participation and therapy. Additionally, we will establish the cost of delivery of ADepT.

DISCUSSION

We will proceed to definitive trial if any concerns about the safety, acceptability, feasibility, and proof of concept of ADepT and trial procedures can be rectified, and we recruit, retain, and collect follow-up data on at least 60% of the target sample.

TRIAL REGISTRATION

ISCRTN85278228, registered 27/03/2017.

A unified theory of bone healing and nonunion

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft.

Cite this article: Bone Joint J 2016;98-B:884–91.

Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of outcome in a consecutive sample

Objective

Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area.

Method

A consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects.

Results

CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience.

Conclusions

The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas.

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Cognitive Therapy for PTSD can be effectively implemented in routine clinical care.

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The intent-to-treat analysis showed very large treatment effects.

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Patients found the treatment acceptable, and the majority showed clinically significant change.

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Few patient characteristics moderated treatment outcome.

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Inexperienced therapists had more dropouts.

Reducing unwanted trauma memories by imaginal exposure or autobiographical memory elaboration: an analogue study of memory processes

Unwanted memories of traumatic events are a core symptom of post-traumatic stress disorder. A range of interventions including imaginal exposure and elaboration of the trauma memory in its autobiographical context are effective in reducing such unwanted memories. This study explored whether priming for stimuli that occur in the context of trauma and evaluative conditioning may play a role in the therapeutic effects of these procedures. Healthy volunteers (N = 122) watched analogue traumatic and neutral picture stories. They were then randomly allocated to 20 min of either imaginal exposure, autobiographical memory elaboration, or a control condition designed to prevent further processing of the picture stories. A blurred picture identification task showed that neutral objects that preceded traumatic pictures in the stories were subsequently more readily identified than those that had preceded neutral stories, indicating enhanced priming. There was also an evaluative conditioning effect in that participants disliked neutral objects that had preceded traumatic pictures more. Autobiographical memory elaboration reduced the enhanced priming effect. Both interventions reduced the evaluative conditioning effect. Imaginal exposure and autobiographical memory elaboration both reduced the frequency of subsequent unwanted memories of the picture stories.

Weekend Arthroplasty: A Longer Inpatient Stay?

As pressures mount on efficiency, hip and knee arthroplasty surgery is increasingly being performed during weekends. Despite the growing trend for weekend orthopaedic surgery, there are virtually no published data on the effect of weekend operating on the length of hospital stay (LOS).

Abnormal cortisol awakening response predicts worse cognitive function in patients with first-episode psychosis

BACKGROUND

Cognitive impairment, particularly in memory and executive function, is a core feature of psychosis. Moreover, psychosis is characterized by a more prominent history of stress exposure, and by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In turn, stress exposure and abnormal levels of the main HPA axis hormone cortisol are associated with cognitive impairments in a variety of clinical and experimental samples; however, this association has never been examined in first-episode psychosis (FEP).

METHOD

In this study, 30 FEP patients and 26 controls completed assessment of the HPA axis (cortisol awakening response and cortisol levels during the day), perceived stress, recent life events, history of childhood trauma, and cognitive function. The neuropsychological battery comprised general cognitive function, verbal and non-verbal memory, executive function, perception, visuospatial abilities, processing speed, and general knowledge.

RESULTS

Patients performed significantly worse on all cognitive domains compared to controls. In patients only, a more blunted cortisol awakening response (that is, more abnormal) was associated with a more severe deficit in verbal memory and processing speed. In controls only, higher levels of perceived stress and more recent life events were associated with a worse performance in executive function and perception and visuospatial abilities.

CONCLUSIONS

These data support a role for the HPA axis, as measured by cortisol awakening response, in modulating cognitive function in patients with psychosis; however, this association does not seem to be related to the increased exposure to psychosocial stressors described in these patients.

Skunk and psychosis in South East London

Background:

Epidemiological studies have reported that the increased risk of developing psychosis in cannabis users is dose related. In addition, experimental research has shown that the active constituent of cannabis responsible for its psychotogenic effect is Delta-9-Tetrahydrocannabinol (THC) (Murray et al, 2007). Recent evidence has suggested an increased in potency (% TCH) in the cannabis seized in the UK (Potter et al, 2007).

Hypothesis:

We predicted that first episode psychosis patients are more likely to use higher potency cannabis and more frequently than controls.

Methods:

We collected information concerning socio-demographic, clinical characteristics and cannabis use (age at first use, frequency, length of use, type of cannabis used) from a sample of 191 first-episode psychosis patients and 120 matched healthy volunteers. All were recruited as part of the Genetic and Psychosis (GAP) study which studied all patients who presented to the South London and Maudsley Trust.

Results:

There was no significant difference in the life-time prevalence of cannabis use or age at first use between cases and controls. However, cases were more likely to be regular users (p=0.05), to be current users (p=0.04) and to have smoked cannabis for longer (p=0.01). Among cannabis users, 86.8% of 1st Episode Psychosis Patients preferentially used Skunk/Sinsemilla compared to 27.7% of Controls. Only 13.2 % of 1st Episode psychosis Patients chose to use Resin/Hash compared to 76.3% of controls. The concentration of TCH in these in South East London, ranges between 8.5 and 14 % (Potter et al, 2007). Controls (47%) were more likely to use Hash (Resin) whose average TCH concentration is 3.4% (Potter et al, 2007).

Conclusions:

Patients with first episode psychosis have smoked higher potency cannabis, for longer and with greater frequency, than healthy controls.

The use of interlocked 'customised' blade plates in the treatment of metaphyseal fractures in patients with poor bone stock

Balanced and stable fixation in metaphyseal fractures and nonunion can be difficult because of osteoporosis, disuse osteopenia, comminution, joint proximity or malignant infiltration. Five patients with nonunion and four with comminuted or pathological acute fractures of metaphyseal areas of the tibia or humerus were treated with a 'customized' interlocked blade plate. The plates are standard AO dynamic compression plates of a suitable length that are bent to an acute angle in an industrial vice and 'interlocked'. The nine patients with a mean age of 62.2 years (range 30-91) were followed up for a mean of 7.2 months. At follow-up all fractures had healed with a single complication of subacromial impingement in a patient with a proximal humeral fracture.

'Clearance' of cervical spine injury in the obtunded patient

The need to exclude cervical spine injury ('clearance') in an obtunded patient poses a dilemma. The purpose of this study was to find out the current practices for tackling this situation around the country. A questionnaire was sent to all Intensive Care Units who accept injured patients. There is a great diversity in the management and investigation of these patients. There is clearly a need for a recognised protocol for dealing with this difficult situation. Such a protocol is suggested.

Deferred treatment for prostate cancer

The clinical outcome of 278 prostate cancer patients managed by a deferred treatment policy was analysed retrospectively. Following TURP or biopsy, all patients were asymptomatic and deemed suitable for management by a deferred treatment policy, i.e. hormone therapy or other forms of treatment were only initiated if and when symptomatic progression occurred. The overall 5-year survival rate was 30%; 18% of patients died from other causes without needing treatment for their prostate cancer; 11% were alive and untreated after 5 years' follow-up; 17% died from prostate cancer without further treatment. Poor tumour grade, anaemia, metastatic disease, a short history, presentation with retention, and a raised serum creatinine at presentation were associated with a poor prognosis.

Expressed emotion: from predictive index to clinical construct

Expressed emotion, a measure of family attitudes toward psychiatric patients that is predictive of relapse, has attracted renewed attention recently as interest in the chronic psychiatric patient has widened. The authors review the development of the concept and the limits of its meaning. In seeking the core clinical construct underlying the expressed emotion variable, the authors also review recent studies of the relationship of expressed emotion to family interaction patterns, physiological arousal states, precipitants of relapse, and parental personality style. While family intervention studies are necessary to demonstrate that expressed emotion influences outcome in psychiatric patients, methodological limitations in currently available studies leave this issue unresolved.

The development and in vitro evaluation of acrylic strips and dialysis tubing for local drug delivery

This study reports on the development of drug containing acrylic strips for delivering antimicrobial agents and compares the in vitro release pattern with dialysis tubing. Polyethylmethacrylic strips of suitable dimensions containing 10 to 50% chlorhexidine acetate, 40% metronidazole and 40% tetracycline were prepared. Daily release of the incorporated drugs into 1 ml aliquots was measured spectrophotometrically over a 14 day period. Similarly the release of chlorhexidine gluconate from various lengths of patent and heat sealed dialysis tubing was recorded for 4 days. At 30%, 40% and 50% admixtures the acrylic strips released chlorhexidine up to the 14 day period and a parallel bioassay confirmed the maintenance of antibacterial activity to this time. At the same admixture the release of metronidazole was greater than chlorhexidine and tetracycline. All drugs were released at high levels on day 1 followed by a marked fall in release by day 2 and progressive fall thereafter. The release from tubing was almost total within 24 hours and was independent of sealing the ends. The strips appear to have potential for prolonged drug delivery to periodontal pockets. Preliminary clinical use revealed no patient acceptability problems and alterations in subgingival flora were produced.

The effects of the incorporation of chlorhexidine acetate on some physical properties of polymerized and plasticized acrylics

The effects on the water uptake and weight loss of the incorporation of chlorhexidine acetate in heat cured acrylic and an acrylic gel soft liner was determined. Hardness and transverse bend measurement were similarly made for admixtures to heat and cold cured acrylics. Following soaking in water for 87 days the heat cured test specimens demonstrated an initial weight gain followed by a progressive loss, the soft liner test specimens however all showed weight gains. Drying back specimens to constant weight revealed significantly greater weight losses in test compared to control specimens for both the cured acrylic and gel liner. However these weight losses were less than the chlorhexidine content for 5 and 10% admixtures. Hardness and moduli of elasticity measurements were significantly reduced for heat and cold cured acrylics containing chlorhexidine. The property changes observed in the materials would be consistent with the pattern of incorporation of chlorhexidine into the matrix. However, these do not negate the carriage of medicaments in these materials for prolonged delivery within the oral cavity, if employed as rebase or reline materials in existing prostheses.

The effects of drug and water incorporation upon some physical properties of cold cured acrylic

The addition of drugs to the cold cured acrylics has been demonstrated to variably affect their mechanical properties. This study investigated the effects, to the mechanical properties of a cold cured denture base material, of the addition of drugs and water. Chlorhexidine acetate was incorporated into the denture reline material at 10% w/w in the polymer phase of the material. Specimens also contained 10, 20, or 30% water w/w in the monomer phase of the material with or without the drug. The hardness of the specimens decreased with the addition of water to drug containing or drug-free specimens. Furthermore, there was a significant reduction in the modulus of elasticity of the material with the addition of drugs and water or water alone, which was progressive as the amount of water increased. The load at fracture was similarly reduced as the water incorporation increased. The results demonstrated the considerable effects drug and water incorporation had upon the material. However, this would not negate the use of the material in the oral cavity in the reline or rebase situation employing existing prostheses. Moreover, the reduction in material strength may have the advantage of progressive loss of material with a resulting improved release pattern of the contained drug.

Uptake of Carrier-free Cs by Ramalina reticulata

The uptake of carrier-free (137)Cs by Ramalina reticulata Kremp. does not appear to be directly linked to metabolism. The results indicate the presence of a barrier to entry of (137)Cs. The barrier is stabilized by Ca ions. Removal of Ca by pretreatment of the tissue in monovalent salt solutions increases the uptake of (137)Cs. Uptake under anaerobiosis is also greater than normal, but in this case, Ca displaced from the barrier membrane is not lost from the tissue and normal permeability is rapidly re-established when aerobic conditions are restored. Under anaerobiosis Ca(2+) increases damage to the respiratory mechanism presumably by increasing retention of toxic products.

Potassium Loss and Changes in the Fine Structure of Corn Root Tips Induced by H-ion

The effects of H, Ca, and anaerobiosis upon loss of K to ambient solutions, upon changes in the fine structure, and upon the respiration of corn root tissue were studied. In the pH range 5.5 to 8.0 losses of K decreased with decreasing H concentration. Ca reduced K loss greatly in the lower part of the pH range but with increasing pH the effect of Ca declined. Losses of K under N(2) were much greater than those measured under air but the same effects of H and Ca were found. The effect of phosphate upon K loss was found to depend upon pH, temperature and the state of development of the tissue.In pure H(2)O or dilute HCl no obvious derangement of the fine structure of meristematic cells was found to occur in 3 hours above pH 4.4 except attenuation of the groundplasm. At pH 4.4 and below, serious injury was found. The presence of CaCl(2) or NaCl in the treatment solution greatly ameliorated the effect of H, CaCl(2) being effective at minute concentration (0.01 meq per liter). NaH(2)PO(4) was without any great effect. Anaerobiosis at neutral pH produced severe tissue damage.In contrast to anaerobic treatments, aerobic treatments (pH 5.8) resulting in large losses of K were not accompanied by any diminution of the respiratory rate.