Utility of viscoelastography with TEG 6s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study.

BACKGROUND: The TEG 6s is an automated cartridge-based device with limited description of use in obstetric haemorrhage. The aim of this analysis was to describe the utility of TEG 6s in identifying abnormal laboratory results of coagulation and platelet count, and inform an interventional treatment algorithm for postpartum haemorrhage. METHODS: A prospective observational cohort study of 521 women with moderate to severe obstetric haemorrhage (>1000 mL blood loss), including 372 women with at least one TEG 6s test. A non-pregnant control group was used for reference. TEG 6s test parameters Citrated Functional Fibrinogen (CFF), Citrated Kaolin TEG (CK) and Citrated Rapid TEG (CRT) were compared with paired laboratory tests of fibrinogen, PT/aPTT and platelet count, obtained during haemorrhage. RESULTS: Among 456 TEG 6s tests, 389 were matched with laboratory coagulation results. The receiver operator characteristic area-under-the-curve (95% CI) for CFF amplitude by 10 min to detect Clauss fibrinogen ≤2 g/L was 0.95 (0.91 to 0.99) (P<0.0001, sensitivity 0.74 and specificity 0.97 at ≤17 mm). False positives had median (IQR) Clauss fibrinogen of 2.4 (2.3-2.7) g/L. The CK-R time had some utility for detecting prolonged PT/aPTT, however a threshold for fresh frozen plasma transfusion was not established. A CRT maximum amplitude <57 mm, when CFF was ≥15 mm, identified four of eight samples with platelet count <75 × 109/L. CONCLUSION: The TEG 6s CFF can be used to identify low fibrinogen during obstetric haemorrhage. A value to identify transfusion thresholds for PT/aPTT and platelets was not established, and laboratory results should continue to be used.

Protocol for an HTA report: Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic modelling.

INTRODUCTION: Long-term medical conditions (LTCs) cause reduced health-related quality of life and considerable health service expenditure. Writing therapy has potential to improve physical and mental health in people with LTCs, but its effectiveness is not established. This project aims to establish the clinical and cost-effectiveness of therapeutic writing in LTCs by systematic review and economic evaluation, and to evaluate context and mechanisms by which it might work, through realist synthesis. METHODS: Included are any comparative study of therapeutic writing compared with no writing, waiting list, attention control or placebo writing in patients with any diagnosed LTCs that report at least one of the following: relevant clinical outcomes; quality of life; health service use; psychological, behavioural or social functioning; adherence or adverse events. Searches will be conducted in the main medical databases including MEDLINE, EMBASE, PsycINFO, The Cochrane Library and Science Citation Index. For the realist review, further purposive and iterative searches through snowballing techniques will be undertaken. Inclusions, data extraction and quality assessment will be in duplicate with disagreements resolved through discussion. Quality assessment will include using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data synthesis will be narrative and tabular with meta-analysis where appropriate. De novo economic modelling will be attempted in one clinical area if sufficient evidence is available and performed according to the National Institute for Health and Care Excellence (NICE) reference case.

Infectious diseases among travellers and migrants in Europe, EuroTravNet 2010.

To investigate trends in travel-associated morbidity with particular emphasis on emerging infections with the potential for introduction into Europe, diagnoses of 7,408 returning travellers presenting to 16 EuroTravNet sites in 2010 were compared with 2008 and 2009. A significant increase in reported Plasmodium falciparum malaria (n=361 (6% of all travel-related morbidity) vs. n=254 (4%) and 260 (5%); p<0.001), P. vivax malaria (n=51 (1%) vs. n=31 (0.5%) and 38 (1%); p=0.027) and dengue fever (n=299 (5%) vs. n=127 (2%) and 127 (2%); p<0.001) was observed. Giardia lamblia was identified in 16% of patients with acute diarrhoea, with no significant annual variation. The proportion of acute diarrhoea due to Campylobacter increased from 7% in 2008 to 12% in 2010 (p=0.001). We recorded 121 patients with pulmonary tuberculosis in 2010, a threefold increase in the proportionate morbidity from 2008 to 2010. In 2010, 60 (0.8%) cases of chronic Chagas disease, 151 (2%) cases of schistosomiasis and 112 (2%) cases of cutaneous larva migrans were reported. Illness patterns in sentinel travellers, captured by EuroTravnet, continue to highlight the potential role of travellers in the emergence of infectious diseases of public health concern in Europe and the relevance of offering medical travel advice and enforcing specific and adequate prophylaxis.

Recommendations for the practice of travel medicine.

Travel Medicine has emerged as a distinct entity over the last two decades in response to a very substantial increase in international travel and is now forging its own identity, remit and objectives for care of the traveller. Crucial to the formation of any speciality is the definition of recommendations for its practice. This is particularly important and needed for travel medicine as it overlaps with and forms part of day-to-day work in a number of different medical specialities. This document defines a set of recommendations for the practice of travel medicine from the Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow. Their objective is to help raise standards of practice and achieve greater uniformity in provision of services, better to protect those who travel. As travel medicine moves towards applying for speciality status, these standards will also contribute to that process.

Travel-related imported infections in Europe, EuroTravNet 2009.

The aim of this study was to investigate travel-associated morbidity in European travellers in 2009 in comparison with 2008, with a particular emphasis on emerging infectious diseases with the potential for introduction into Europe. Diagnoses with demographic, clinical and travel-related predictors of disease from ill returning travelers presenting to 12 core EuroTravNet sites from January to December 2009 were analysed. A total of 6392 patients were seen at EuroTravNet core sites in 2009, as compared with 6957 in 2008. As compared with 2008, there was a marked increase in the number of travellers exposed in North America and western Europe. Respiratory illnesses, in particular pandemic A(H1N1) influenza, influenza-like syndromes, and tuberculosis, were also observed more frequently. A significant increase in reported dengue cases in 2009 as compared with 2008 was observed (n = 172, 2.7% vs. n = 131, 1.90%) (p 0.002). The numbers of malaria and chikungunya cases were also increasing, although not significantly. Two deaths were recorded: visceral leishmaniasis and sepsis in a Sudanese migrant, and Acinetobacter sp. pneumonia in a patient who had visited Spain. This is the most comprehensive study of travel-related illness in Europe in 2009 as compared with 2008. A significant increase in travel-related respiratory and vector-borne infections was observed, highlighting the potential risk for introduction of these diseases into Europe, where competent vectors are present. The number of traveller deaths is probably underestimated. The possible role of the travellers in the emergence of infectious diseases of public health concern is highlighted.

The impact of AIDS education among elementary school students.

We report the results of a controlled prospective study designed to assess the impact of education on AIDS among elementary school students. 1,825 students from 3 school boards participated; 848 students were assigned to the trial group and 778 to the comparison group. Overall, the results showed a significant increase in students' level of knowledge of AIDS following their classroom lessons on AIDS. The students exposed to AIDS education expressed more accurate and appropriate beliefs about the transmission of AIDS. The students' reports indicated that television and magazines were their main outside sources of information about AIDS. Generally, the students demonstrated a positive attitude toward the AIDS curriculum. We conclude that classroom education on AIDS is effective in imparting knowledge and changing students' beliefs about AIDS. Further periodic assessments of AIDS education programs would be required at a variety of educational levels to determine if this change will lead to alteration in behaviour. Such assessments would help in the development of more comprehensive and cohesive programs in AIDS education.

The AIDS dilemma: worry and concern over AIDS.

Information was collected from 148 homosexual men to examine their current sexual practices, knowledge of acquired immunodeficiency syndrome (AIDS), perception of risk for this disease and change in sexual behaviour. The data were analyzed to investigate the relationship of these variables to the degree of worry and concern about AIDS expressed by most respondents. Overall, a decline in high-risk sexual behaviour was reported. Measures of worry and concern were significantly related to the subjects' perception of risk for AIDS and reduction in risk behaviours. However, the measures of Health Locus of Control, knowledge about AIDS and sociodemographic characteristics did not significantly predict the degree of worry and concern. The data are discussed in light of the current AIDS epidemic.

PIP: 224 Canadian homosexual men were asked to complete self-report questionnaires on sexual behavior for 1) subjective assessment of the risk of aids, 2) concern about AIDS, 3) subjective perception of risk, 4) knowledge of AIDS, and 5) Multidimensional Health Locus of Control (MHLC). The final sample consisted of 148 men aged 19-66: 30% had a university degree, 27% were professionals, and 45% were blue collar workers. Only collar workers. Only 7 (5%) were HIV positive. Although 40% had more than 1 partner a month, the rest had either 1 partner or no partners. Receptive hand-anus with receptive anal intercourse was assigned a value of 3; receptive anal intercourse with no receptive hand-anus a value of 2; active oral and/or anilingus a value of 1; having more than 11 partners a month were assigned a value of 4. The scores of 119 respondents (80.5%) ranged from 0 to 3, while 29 men (19.6%) scored 4 to 7. 77% stated that they changed their sexual behavior to mitigate risks; 38% used the condom more frequently; 39% reduced the incidence of receptive anal intercourse; and 48% had fewer partners. 80% were occasionally or often thinking about AIDS; 70% were concerned about getting AIDS; and 36% were preoccupied with this concern. 59% deemed their risk greater than that of heterosexuals, and 87% thought that the combined risk of gays was also greater when compared to heterosexuals. Increased worry was significantly associated with the reduction of risk behavior, but only 1 of the 3 indicators of subjective assessment of risk were statistically significant set against concern about AIDS. Findings indicate that behavior was modified as a consequence of an affective response to the threat of this disease.

A prospective study of psychosocial aspects of gastric stapling surgery.

Sixteen patients who underwent gastric stapling procedure for morbid obesity were assessed pre- and post-operatively on several psychosocial dimensions using a number of self-report questionnaires including the Eating Disorders Inventory, Locus of Control, and Millon's Clinical Multi-Axial Inventory. Subjects' responses to questions regarding their socialization, lifestyle and sexual relations were also compared for the two periods. The mean interval between surgery and completion of follow-up questionnaires was 13.6 months. Eighty-one percent of the patients showed an improvement in their psychosocial profile as measured by the MCMI. Although some residual difficulties were reported, generally patients were pleased with their physical appearance and experienced an improvement in current relationships and sexual functioning. Overall, the results indicate a favorable psychosocial outcome following gastric stapling surgery.

AIDS epidemic, emotional strain, coping and psychological distress in homosexual men.

This study examined the process by which emotional strain imposed by the threat of AIDS may manifest itself as psychological distress, assessed by depressive symptomatology, in a sample of homosexual men. Specifically, the study examined the extent to which the perceived threat of AIDS is related to depression, and how coping resources, such as locus of control and social support, influence this process. Results highlight the role of social support and locus of control. These factors were found to be the strongest correlates of depression, and appear to exert a considerable influence on the associations between strain measures and depressive symptomatology.