The impact of in-service physical injury or illness on the mental health of military veterans.

BACKGROUND: Each year approximately 2000 UK service personnel are medically discharged with physical and/or psychological injury or illness. While there is much research on both psychological injury and physical injury, the challenges of transition relating to the intersection between the two has received less attention. This article reports on the first phase of a 2-year funded study with the aim to understand the lived experiences of veterans who have been discharged from service with a physical injury or illness and the impacts of this on their mental health. METHODS: Using a qualitative methodology, 22 veterans who had been discharged from service within the last 8 years were interviewed to identify key aspects of their experience of the transition process. RESULTS: The article highlights two key themes: how some veterans adjusted to life with a physical injury or condition; and, the intersections that became apparent between physical injury and mental health. The challenges that veterans faced were shaped by the transition process and by the way in which the medical discharge process was conducted. CONCLUSIONS: Consideration of improvements to the medical discharge process could influence better outcomes for those who have left with a physical injury or illness and later find themselves struggling with mental health issues.

Determining the anatomical origin of canine hepatic masses by CT.

OBJECTIVES: To identify CT features of canine hepatic masses that could be used to determine their divisional or lobar origin. MATERIALS AND METHODS: Preoperative, postcontrast CT images of 57 surgically resected hepatic masses were reviewed with respect to their size, position relative to the midline, gallbladder and portal vein, nearest recognisable hepatic lobar vein or portal vein and point of contact with the diaphragm and displacement of adjacent organs. RESULTS: The most prevalent histological diagnoses were hepatocellular carcinoma (n=26; 46%) and adenoma (n=10; 18%). Based on surgical assessment, it was observed that masses originated in the left hepatic division in 30 (53%) instances, central division in seven (12%) and right division in 20 (35%). All masses to the left of midline were left divisional, but only 18/30 (60%) masses to the right of midline were right divisional. Most (26/31; 84%) masses to the left of the gallbladder were left divisional and 84% (16/19) masses to the right of the gallbladder were right divisional. Half (10/20; 50%) of the right-divisional masses were medial, lateral or dorsal to the portal vein, but all other hepatic masses were ventral to the portal vein. A hepatic lobar vein or portal vein branch adjacent to the mass was observed in 53 (93%) instances; this feature correlated with surgical assessment of the affected division in 53 (93%) hepatic masses and the affected lobe in 32 (56%). CLINICAL SIGNIFICANCE: Combining CT features of hepatic masses appears to be an accurate method for determining their divisional or lobar origin.

interRAI home care quality indicators.

BACKGROUND: This paper describe the development of interRAI's second-generation home care quality indicators (HC-QIs). They are derived from two of interRAI's widely used community assessments: the Community Health Assessment and the Home Care Assessment. In this work the form in which the quality problem is specified has been refined, the covariate structure updated, and two summary scales introduced. METHODS: Two data sets were used: at the client and home-care site levels. Client-level data were employed to identify HC-QI covariates. This sample consisted of 335,544 clients from Europe, Canada, and the United States. Program level analyses, where client level data were aggregated at the site level, were also based on the clients from the samples from Europe, Canada, and the United States. There were 1,654 program-based observations - 22% from Europe, 23% from the US, and 55% from Canada.The first task was to identify potential HC-QIs, including both change and prevalence measures. Next, they were reviewed by industry representatives and members of the interRAI network. A two-step process adjustment was followed to identify the most appropriate covariance structure for each HC-QI. Finally, a factor analytic strategy was used to identify HC-QIs that cluster together and thus are candidates for summary scales. RESULTS: The set of risk adjusted HC-QIs are multi-dimensional in scope, including measures of function, clinical complexity, social life, distress, and service use. Two factors were identified. The first includes a set of eleven measures that revolve around the absence of decline. This scale talks about functional independence and engagement. The second factor, anchored on nine functional improvement HC-QIs, referenced positively, this scale indicates a return to clinical balance. CONCLUSIONS: Twenty-three risk-adjusted, HC-QIs are described. Two new summary HC-QI scales, the "Independence Quality Scale" and the "Clinical Balance Quality Scale" are derived. In use at a site, these two scales can provide a macro view of local performance, offering a way for a home care agency to understand its performance. When scales perform less positively, the site then is able to review the HC-QI items that make up the scale, providing a roadmap for areas of greatest concern and in need of targeted interventions.

Family quality of life in 25 Belgian families: quantitative and qualitative exploration of social and professional support domains.

BACKGROUND: This article reports on the results of a study conducted in Belgium on family quality of life situated within a larger project focusing on the development of support strategies for young and adolescent siblings of persons with intellectual disabilities. The objectives of this article are twofold: (1) to present the results of the measures contained in the nine domains of the Family Quality of Life Survey-2006 (FQOLS-2006) from the perspective of parents (quantitative analysis); and (2) to come to a more in-depth understanding of two important domains of the FQOLS-2006 by exploring and comparing the quantitative and qualitative data from open-ended interviews with parents. METHOD: The FQOLS-2006 was completed by the main caregivers of 25 families living in one typical Belgian province. Subsequently, semi-structured interviews with one or both parents were conducted within the same families. Content analysis was carried out on the transcribed interviews using the qualitative software package MaxQDA. RESULTS: A detailed analysis of the quantitative data together with data from the content analysis of the interviews revealed important issues with regard to two family quality of life domains, support from others and support from services. In general, parents were satisfied with the professional support they received, whereas they were more critical of support from others. CONCLUSIONS: The quantitative data from the FQOLS-2006 were supported and further explained by the qualitative data. These findings highlight the importance of adequate professional support, which is a flexible and capable answer to each family's individual needs. The authors warn of the dangers of 'handicapism' and plea for a family-centred support approach that takes the whole family into account. Finally, they indicate the benefits of increased practical-pedagogical support.

Factitious disorder (Munchausen's syndrome).

Factitious disorder, often referred to as Munchausen's syndrome, is a condition in which sufferers present to healthcare professionals seeking investigation and treatment for signs and symptoms that they have consciously fabricated for no obvious reason. Factitious presentations have been described all over the world, in every medical specialty and in every age group, yet by its very nature factitious disorder is difficult to study. There is therefore a dearth of evidence in the literature relating to epidemiology, aetiology and therapeutics. The disorder is notoriously difficult to recognise in clinical practice and there are as yet no definitive treatment options available. This article provides a brief overview of the literature before offering guidance on the diagnosis and management of factitious disorder presenting in the general hospital. It also considers fabricated or induced illness, also known as Munchausen's syndrome by proxy.

Single microbubble response using pulse sequences: initial results.

The study of acoustic scattering by single microbubbles has the potential to offer improved signal processing techniques. A microacoustic system that employs a hydrodynamically-focused flow was used to detect radiofrequency (RF) backscatter from single microbubbles. RF data were collected using a commercial scanner. Results are presented for two agents, namely Definity (Lantheus Medical Imaging, N. Billerica, MA, USA) and biSphere (Point Biomedical Corp, San Carlos, CA, USA). The agents were insonified with amplitude-modulated pulses, and it was observed in both agents that a subpopulation of microbubbles did not produce a measurable echo from the first-half amplitude pulse, but did produce a response from the full amplitude pulse and from a subsequent half amplitude pulse. The number of microbubbles in this subpopulation was seen to increase with increasing transmit amplitude. These results do not bear out the simple theory of microbubble-pulse sequence interaction and invite a reassessment of signal processing approaches.

Bridging circuit for the resection of retroperitoneal sarcoma involving the aorta and the IVC- veno-venous to veno-arterial perfusion.

A 50-year-old female underwent surgery for removal of a massive retroperitoneal sarcoma (RPS) involving the right hepatic lobe and the inferior vena cava (IVC), abdominal aorta, right lung, right hemi-diaphragm and pericardium. Resection of the RPS necessitated cross-clamping of the abdominal aorta, IVC and the hepatic artery. Cross-clamp time cannot be predicted prior to tumour resection and vascular re-construction. To prevent complications of prolonged cross-clamp time and distal hypo-perfusion, circulatory support was sought to facilitate the procedure. A perfusion circuit was designed to accommodate an easy and immediate redirection of blood flow from venovenous bypass (VVB) to veno-arterial bypass (VAB) without requiring a change of circuit and with minimum heparin administration. Furthermore, this circuit provides the added safety of an oxygenator and a heat-exchanger. Utilising the circuit enabled successful resection of the RPS. The patient was discharged from the intensive care unit (ICU) seven days later without any post-operative complications. This case report of a design of a perfusion circuit for the resection of RPS made use of a perfusion approach that had not previously been described and allowed for a reduction in the duration of ischaemic time and retroperitoneal bleeding.

Primary tumour expression of the cysteine cathepsin inhibitor Stefin A inhibits distant metastasis in breast cancer.

Using the clinically relevant 4T1-derived syngeneic murine model of spontaneous mammary metastasis to bone, we have identified the cysteine cathepsin inhibitor Stefin A as a gene differentially expressed in primary and metastatic mammary tumours. In primary tumours, Stefin A expression correlated inversely with metastatic potential in 4T1-derived lines and was not detected in tumour cells in culture, indicating induction only within the tumour microenvironment. Enforced expression of Stefin A in the highly metastatic 4T1.2 cell line significantly reduced spontaneous bone metastasis following orthotopic injection into the mammary gland. Consistent with the mouse data, Stefin A expression correlated with disease-free survival (absence of distant metastasis) in a cohort of 142 primary tumours from breast cancer patients. This was most significant for patients with invasive ductal carcinoma expressing Stefin A, who were less likely to develop distant metastases (log rank test, p = 0.0075). In a multivariate disease-free survival analysis (Cox proportional hazards model), Stefin A expression remained a significant independent prognostic factor in patients with invasive ductal carcinoma (p = 0.0014), along with grade and progesterone receptor (PR) status. In human lung and bone metastases, we detected irregular Stefin A staining patterns, with expression often localizing to micrometastases (<0.2 mm) in direct contact with the stroma. We propose that Stefin A, as a cysteine cathepsin inhibitor, may be a marker of increased cathepsin activity in metastases. Using immunohistology, the cathepsin inhibitor was detected co-expressed with cathepsin B in lung and bone metastases in both the murine model and human tissues. We conclude that Stefin A expression reduces distant metastasis in breast cancer and propose that this may be due to the inhibition of cysteine cathepsins, such as cathepsin B.

Predictors of influenza immunization among home care clients in Ontario.

BACKGROUND: This study examined factors associated with the receipt of influenza vaccination among Ontario home care clients. METHODS: Home care clients were assessed, as part of a routine home visit, during a pilot study of the Resident Assessment Instrument - Home Care (RAI-HC) in 12 Ontario Community Care Access Centres (CCACs). The RAI-HC is a multidimensional assessment that identifies clients' needs and level of functional ability. Multiple logistic regression was used to identify factors associated with influenza immunization in the two years prior to assessment. RESULTS: The overall rate of immunization reached about 80% by 2002. Factors such as age, respiratory problems, diabetes and congestive heart failure were associated with greater uptake, but overall rates of influenza immunization were lower than expected. Low education, smoking and poor medication adherence were negatively associated with influenza immunization. In addition, there was considerable variation in uptake among CCACs after adjusting for other significant individual-level independent variables. INTERPRETATION: Comprehensive assessments like the RAI-HC can be used to help identify and respond to health promotion and disease prevention issues in this population, and to compare rates across Canada.

Structural MRI of the brain in presumed carriers of genes for schizophrenia, their affected and unaffected siblings.

BACKGROUND: Schizophrenia is a highly heritable disorder associated with structural brain abnormalities. The aim of this study was to establish if the gene(s) for schizophrenia are associated with specific abnormalities of brain structure. SUBJECTS: Six sibships from multiple affected families were recruited. Each sibship consisted of one patient with schizophrenia, one "obligate carrier" without the disorder but with an affected child, and one "non-affected non-carrier". Such sibships are very rare, but present a powerful opportunity to separate the associations of genotype and phenotype. Obligates presumably have the gene(s) but not the disorder, affected siblings have both, whereas non-affected non-carrier siblings have neither. METHOD: Brain MRI was conducted with a semiautomated region of interest analysis. The risk of false positive findings was reduced by collapsing brain regions and sides into five regions and comparing groups by repeated measures analysis of variance. RESULTS: In terms of whole brain volumes and volumes of cortical structures, obligates resembled their non-affected non-carrier siblings, both groups having significantly greater volumes than their schizophrenic siblings (p=0.01 and p=0.04). Obligates also had significantly smaller ventricles than their schizophrenic siblings (p=0.03). However, with respect to the amygdalohippocampal complex, the obligates' brains resembled those of their schizophrenic siblings, both groups showing a significant reduction in volume when compared with their non-affected non-carrier siblings (p=0.001). CONCLUSIONS: In the families studied, reductions in volumes of cortical structures and reductions in whole brain volume seem to be associated with the phenotype of schizophrenia. By contrast, reduced volume of the amygdalohippocampal complex seems to be associated with genetic risk for the disorder even in the absence of disease.

Mucus altering agents as adjuncts for nonviral gene transfer to airway epithelium.

Nonviral vectors have been shown to be a safe and valid alternative to recombinant viruses for gene therapy of cystic fibrosis (CF). Nevertheless, gene transfer efficiency needs to be increased before clinical efficacy is likely in man. One barrier to increased efficacy is normal airway mucus. Using an ex vivo model of sheep tracheal epithelium, we show that this barrier can, in part, be overcome by treatment with the mucolytic agents, Nacystelyn or N-acetylcysteine using either a cationic lipid or a cationic polymer as the gene transfer agent. Further, in vivo application of either Nacystelyn or the anticholinergic glycopyrrolate, both clinically used agents, resulted in increased reporter gene expression in the mouse lung, but no significant correction of the bioelectric defect in CF null mice. These results, whilst unlikely to be sufficient in themselves to achieve clinically relevant gene therapy, may be a further useful step in the attainment of this goal.

Diffusion tensor imaging (DTI) and proton magnetic resonance spectroscopy (1H MRS) in schizophrenic subjects and normal controls.

Several proton magnetic resonance spectroscopy (1H MRS) studies in schizophrenia have found reduced N-acetyl aspartate (NAA) concentrations in pre-frontal and temporal regions of the brain. Reductions in NAA may reflect abnormalities of neuronal structure (e.g. reduced neuronal density or viability) or abnormalities of neuronal function. Diffusion tensor imaging (DTI) measures diffusion anisotropy, an indicator of the structural integrity of a neuronal tract. Both techniques were used to examine the anatomical basis of pre-frontal dysfunction in schizophrenia. Ten patients with DSM-IV schizophrenia were compared with 10 healthy controls. 1H MRS and DTI were performed on a clinical MR system and analysed with a region of interest approach. NAA concentrations and diffusion anisotropy were measured in the same pre-frontal white matter region. Diffusion anisotropy was also measured in a control region (occipital white matter). 1H MRS revealed non-significant but consistently reduced NAA concentrations (by 10-15%) in the pre-frontal white matter in schizophrenic subjects. Diffusion anisotropy measures revealed no such differences between schizophrenics and controls. It is concluded that the abnormalities of 'connectivity' reported in brain-imaging studies of schizophrenia may not be attributable to structural abnormalities of white matter and that reduced NAA in the pre-frontal white matter may reflect abnormal function of structurally intact neurons.

Should the treatment of schizophrenia include old antipsychotic drugs?

Clozapine, although not suitable as a first-line drug, is superior to all other antipsychotics in terms of minimizing positive symptoms, reducing side effects, and treating treatment-resistant patients. There is little evidence that other newer drugs share these benefits. For certain patients it is not difficult to justify, on clinical grounds, the additional cost of prescribing clozapine. The case for prescribing one of the other newer drugs in preference to a traditional antipsychotic is often less clear-cut. Traditional antipsychotics clearly still have a role in the treatment of schizophrenia and they remain the authors' preferred choice of first-line therapy.

Efficient gene transfer to airway epithelium using recombinant Sendai virus.

Clinical studies of gene therapy for cystic fibrosis (CF) suggest that the key problem is the efficiency of gene transfer to the airway epithelium. The availability of relevant vector receptors, the transient contact time between vector and epithelium, and the barrier function of airway mucus contribute significantly to this problem. We have recently developed recombinant Sendai virus (SeV) as a new gene transfer agent. Here we show that SeV produces efficient transfection throughout the respiratory tract of both mice and ferrets in vivo, as well as in freshly obtained human nasal epithelial cells in vitro. Gene transfer efficiency was several log orders greater than with cationic liposomes or adenovirus. Even very brief contact time was sufficient to produce this effect, and levels of expression were not significantly reduced by airway mucus. Our investigations suggest that SeV may provide a useful new vector for airway gene transfer.