Adverse psychological effects and costs associated with waiting for radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is undertaken as a potentially curative treatment for a variety of heart rhythm disturbances. Previous studies have demonstrated improved quality of life and reduced symptoms after ablation. In many health care environments waiting lists exist for scheduling of procedures. However, the psychological effects of waiting for radiofrequency ablation have not previously been assessed. We hypothesized that waiting for this intervention may be associated with increased psychological morbidity and health care costs. METHODS: Ninety-two patients scheduled for elective RFA completed repeated questionnaires comprising the Medical Outcomes Short Form 36, Hospital Anxiety and Depression Scale, and an in-house questionnaire designed to assess the burden of symptoms related to arrhythmia (arrhythmia-related burden score). Mean scores were generated and compared at time points while waiting, before and after the procedure. Regression analyses were carried out to identify predictors of increased psychological morbidity while waiting and immediately prior to the procedure. Health care costs during the waiting period as a consequence of arrhythmia were quantified. RESULTS: Mean scores for parameters of psychological morbidity worsened during the period of waiting and improved after the procedure. Predictors of adverse effects within the cohort varied according to the time point assessed for each of the measures of psychological morbidity. A conservative estimate of the health care cost incurred while waiting exceeds £ 181 per patient. CONCLUSIONS: Waiting for radiofrequency ablation appears to be associated with adverse psychological effects and health care costs. These results may support strategies to reduce waiting times and prioritize resource allocation.

How do partners find out about the risk of Huntington's disease in couple relationships?

Whilst a growing body of work has explored family communication about Huntington's disease and how at-risk individuals learn about their risk, the experience of telling a partner and partners' experiences of finding out about this potentially devastating hereditary illness have received little attention. This study describes the experiences of partners in finding out about Huntington's disease and any impact on couple's relationships/marriages. We undertook a thematic analysis of qualitative interviews which explored the dynamics of partners' marriages after predictive testing and partners' views of genetic counseling. A main theme from partners' accounts was how they found out about their spouse's risk of Huntington's disease and the impact this had on marital relations. The analysis revealed four types of disclosure experiences: (1) marital secrets; (2) alerting, but not telling; (3) knowing and seeing; (4) marital ignorance. Our findings demonstrate that partners' experiences of (non)disclosure about the risk of HD within marriages is an important factor which contributes to couples' coping or marital problems. Exploring how spouses found out about their partner's risk of HD will illuminate issues about a couple's past and future patterns of communication and their coping strategies. A practical and ethical implication is the extent to which genetic counselors should inform partners about the course and nature of Huntington's disease when a partner is the support person for the individual being tested.

The costs of conflict: meeting the mental health needs of serving personnel and service veterans.

Military mental health has, until recently, been a neglected and marginalized area of interest and although both World Wars saw important advances, in peacetime we typically forget lessons learned in earlier conflicts. Since 2003 however, with high intensity war-fighting on two fronts involving the service personnel of many nations, attention has, once again focused on the immediate and long-term emotional and psychological impact of combat. Whilst we know a lot about posttraumatic stress disorder (PTSD), much less attention has been paid to a variety of other equally, if not more salient yet superficially less dramatic problems facing service personnel deployed on operations, but which are much more likely to lead to mental disorder than traumatic events and the 'horrors of war'. This article describes some of these broader yet less tangible and under-researched issues and discusses the provision of services for the burgeoning veteran community. The mental health of service personnel and veterans is politically sensitive and attracts significant public and media interest. Understanding and responding appropriately to the needs of this group should be of concern to all mental health professionals and it has important consequences, not only for affected individuals but, for the public perception of mental health services as a whole.

First responders after disasters: a review of stress reactions, at-risk, vulnerability, and resilience factors.

Disasters are widely reported, commonplace events that characteristically leave an enormous legacy of human suffering through death, injury, extensive infrastructural damage, and disorganization to systems and communities. The economic costs may be almost incalculable. Professional and civilian first responders play a vital role in mitigating these effects. However, to maximize their potential with the minimum health and welfare costs to first responders, it is important to have a good understanding of the demands of such work on them, how they cope, and what enables them to fulfill their roles. This review will explore these themes by highlighting important findings and areas of uncertainty.

Proinflammatory markers in prediction of posttraumatic psychological symptoms: a prospective cohort study.

INTRODUCTION: Posttraumatic psychopathology (PTP) describes the spectrum of conditions that can complicate the recovery from commonly occurring musculoskeletal trauma. There is a clear association with the activation of the hypothalamic-pituitary-adrenal axis (HPAA), and we wished to examine the predictive value of proinflammatory markers of the HPAA and of the GABA, which acts as an inhibitory regulator. METHODS: Levels of proinflammatory markers and GABA were measured in 84 patients who had suffered musculoskeletal injuries requiring hospitalisation. PTP was assessed by the use of the General Health Questionnaire (GHQ) at presentation and again at two- and six-month reviews. RESULTS: Significant psychological disturbance was noted in 39% of patients at two months and falling back to 18% by six months. There was no correlation between any of the markers tested at presentation and PTP at follow-up. DISCUSSION: The HPAA response to trauma and the development of PTP are extremely complex. It is unlikely that a simple blood assay will provide significant predictive information, while incident specific information and patient perception are of more practical use.

The psychiatric consequences of trauma.

Trauma can have marked and sustained psychological effects. Those at high risk thereof can be identified, and effective treatments are available. This review provides guidelines for the effective management of the psychiatric sequelae of trauma.

The mind continues to matter: psychologic and physical recovery 5 years after musculoskeletal trauma.

OBJECTIVES: Posttraumatic psychopathology may complicate recovery from musculoskeletal injury. This article details the 5-year follow-up of a cohort study examining the relationship between posttraumatic psychopathology and recovery after musculoskeletal trauma. DESIGN: A prospective cohort study of patients with musculoskeletal injuries (Grampian Trauma Outcomes Study) assessed 5 years after their injury. SETTING: Orthopaedic trauma unit, Level I equivalent. PATIENTS: One hundred four of the initial group of 200 patients with musculoskeletal injuries. INTERVENTION: Trauma care and prospective evaluation of physical and psychologic recovery. MAIN OUTCOME MEASURES: Development of psychopathology (measured by the General Health Questionnaire [GHQ]) and functional outcome (measured by Short Form-36 [SF-36] and Musculoskeletal Function Assessment [MFA]). RESULTS: Follow-up at 5 years was 104 patients (52%). GHQ caseness was predictive of physical dysfunction (SF-36, MFA), which had not returned to baseline levels by 5 years. Although injury severity was strongly predictive of psychological disturbance (GHQ caseness) at 5 years, linear regression analysis demonstrated that GHQ score was an important predictor of outcome, whereas Injury Severity Score contributed very little. CONCLUSIONS: Psychologic disturbance after musculoskeletal trauma is related to adverse functional outcome. This is not influenced by preinjury state, but constitutes a sustained posttraumatic effect that is only weakly related to severity of injury.

Children, resilience and disasters: recent evidence that should influence a model of psychosocial care.

PURPOSE OF REVIEW: This paper draws on articles and chapters published mainly in 2006 and 2007 to identify implications for designing sustainable programmes of psychosocial care for children and young people who are affected by disasters and terrorism. RECENT FINDINGS: Recent research confirms previous knowledge that most children and young people are resilient, but also very vulnerable to the psychosocial effects of disasters. Most children are distressed in the immediate aftermath when they gain their sense of safety from adults, predictable routines and consistent support systems. Others may develop serious mental disorders though post-traumatic mental disorders may not develop until weeks, months or years later. Research instruments may be sensitive to cultural variability; simply translating measures into other languages is insufficient. SUMMARY: International experience of different types of disaster and terrorist incidents suggests that the broad principles of good service design include integrating responses to the psychosocial needs of children and adolescents into general disaster preparedness and recovery plans; working with families rather than individual children to address their needs; identifying professionals who specialize in responding to disasters and are skilled in working with children prior to events; and focusing resources on increasing the capabilities of staff of community facilities to recognize and respond to children's common reactions to trauma and provide assistance.

The psychological and psychosocial impact of the Pakistan Kashmir earthquake after 8 months: a preliminary evaluation by PACTT.

Natural disasters are complex events that challenge the coping abilities of individuals and communities (Alexander, 2005). They are characterised by substantial loss, physical injury and economic hardship, as well as by extensive internal displacement and damage to the infrastructure, as exemplified by the Pakistan Kashmir earthquake of 8 October 2005. Measuring 7.6 on the Richter scale, it affected an area of 30 000 square miles and a population of 3.6 million. Approximately 90 000 were killed, 200 000 were injured and 3.5 million were left homeless (Khan, 2006). Based on a literature review and estimates from the World Health Organization (WHO), the National Plan of Action for Mental Health and Psychosocial Relief of Earthquake Survivors anticipated high levels of trauma-related psychopathology (Rana et al, 2006).

The mind does matter: Psychological and physical recovery after musculoskeletal trauma.

BACKGROUND: Posttraumatic psychopathology (PTP) is important to the orthopedic surgeon because it appears to be much more common than might have been suspected and may complicate the recovery from musculoskeletal injury. We have investigated the relationship between physical and psychological recovery in victims of musculoskeletal trauma. METHODS: A prospective cohort of 200 patients with musculoskeletal injuries were studied, correlating development of psychopathology (measured by the General Health Questionnaire) and functional outcome (measured by Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment) 2 and 6 months after their injuries. RESULTS: Pre-existing psychological disturbance was found in 11% of our patients; this figure rose to 46% of patients at 2 months but fell to 22% at 6 months. The posttraumatic disturbance correlated strongly with impaired functional outcome as measured by all three outcomes measures (total and category scores) (p < 0.05). CONCLUSIONS: The strong correlation of PTP with impaired functional outcome after musculoskeletal trauma stresses that it is a significant problem. Further research is required to determine whether an approach that combines physical and psychological treatment can improve patient outcomes.

Recovery after musculoskeletal trauma in men and women.

BACKGROUND: Recent work has suggested that women are more at risk of impaired outcome after traumatic injuries. This would suggest that resources should be targeted at female trauma patients to optimize their outcomes. We wished to explore the physical and psychological outcomes of women treated in our trauma unit. METHODS: The Grampian Trauma Outcomes Study recruited patients aged 16 to 70 years with musculoskeletal injuries. Patients with significant head injuries, alcohol intoxication, or low-energy osteoporotic fractures were excluded. Of 227 patients approached, 200 were recruited to the study. Patients were asked to complete physical and psychosocial (Short Form-36 and Musculoskeletal Function Assessment) and psychological (General Health Questionnaire) outcomes measures at initial assessment and at 2- and 6-month follow-up. RESULTS: Of the 200 patients, 79% completed 2-month follow-up and 75% completed 6-month follow-up. There were no significant differences in the outcomes scores between male and female patients at either of the follow-up points. CONCLUSION: From our study, women do not appear to have impaired recovery after trauma as compared with men. Larger scale studies are required to assess the need to target specific resources toward the treatment of female trauma victims.

Enterovirus 70 binds to different glycoconjugates containing alpha2,3-linked sialic acid on different cell lines.

Enterovirus 70 (EV70), the causative agent of acute hemorrhagic conjunctivitis, exhibits a restricted tropism for conjunctival and corneal cells in vivo but infects a wide spectrum of mammalian cells in culture. Previously, we demonstrated that human CD55 is a receptor for EV70 on HeLa cells but that EV70 also binds to sialic acid-containing receptors on a variety of other human cell lines. Virus recognition of sialic acid attached to underlying glycans by a particular glycosidic linkage may contribute to host range, tissue tropism, and pathogenesis. Therefore, we tested the possibility that EV70 binds to alpha2,3-linked sialic acid, like other viruses associated with ocular infections. Through the use of linkage-specific sialidases, sialyltransferases, and lectins, we show that EV70 recognizes alpha2,3-linked sialic acid on human corneal epithelial cells and on U-937 cells. Virus attachment to both cell lines is CD55 independent and sensitive to benzyl N-acetyl-alpha-D-galactosaminide, an inhibitor of O-linked glycosylation. Virus binding to corneal cells, but not U-937 cells, is inhibited by proteinase K, but not by phosphatidylinositol-specific phospholipase C treatment. These results are consistent with the idea that a major EV70 receptor on corneal epithelial cells is an O-glycosylated, non-glycosyl phosphatidylinositol-anchored membrane glycoprotein containing alpha2,3-linked sialic acid, while sialylated receptors on U-937 cells are not proteinaceous.

Sialic acid functions in enterovirus 70 binding and infection.

The interaction of viruses with host cell receptors is the initial step in viral infection and is an important determinant of virus host range, tissue tropism, and pathogenesis. The complement regulatory protein decay-accelerating factor (DAF/CD55) is an attachment receptor for enterovirus 70 (EV70), a member of the Picornaviridae, commonly associated with an eye infection in humans known as acute hemorrhagic conjunctivitis. In early work, the EV70 receptor on erythrocytes, responsible for its hemagglutinating activity, was shown to be sensitive to neuraminidase, implying an essential role for sialic acid in virus attachment. Here, we extend these results to show that cell surface sialic acid is required for EV70 binding to nucleated cells susceptible to virus infection and that sialic acid binding is important in productive infection. Through the use of site-directed mutagenesis to eliminate the single N-linked glycosylation site of DAF and of a chimeric receptor protein in which the O-glycosylated domain of DAF was replaced by a region of the HLA-B44 molecule, a role in EV70 binding for the sialic acid residues of DAF was excluded, suggesting the existence of at least one additional, sialylated EV70-binding factor at the cell surface. Treatment of cells with metabolic inhibitors of glycosylation excluded a role for the N-linked oligosaccharides of glycoproteins but suggested that O-linked glycosylation is important for EV70 binding.

Survivors of the Piper Alpha oil platform disaster: long-term follow-up study.

BACKGROUND: The long-term psychological effects of surviving a major disaster are poorly understood. We undertook a survey of survivors of the Piper Alpha oil platform disaster (1988). AIMS: To examine the role of factors relating to the trauma, the survivors and the survivors' circumstances. METHOD: Ten years after the disaster, 78% (46/59) of the survivors were located, of whom 72% (33/46) agreed to be interviewed. A further three individuals completed postal measures. RESULTS: The most stringent diagnostic criteria for post-traumatic stress disorder (PTSD) were met by 21% (7/33) of the survivors over 10 years after the disaster. Features such as physical injury, personal experience and survivor guilt were associated with significantly higher levels of post-traumatic symptoms. CONCLUSIONS: A narrow definition of factors affecting outcome will limit the potential for improving survivor well-being in the long-term after major disasters. Specific symptoms that are not included in the criteria for the diagnosis of PTSD, together with issues such as re-employment, need to be addressed.

An evaluation of patient satisfaction with an information leaflet for trauma survivors.

A new leaflet that provided information about posttraumatic reactions and how to deal with them was distributed within 14 days of attendance at the Accident and Emergency Department (ED), Aberdeen Royal Infirmary, to a heterogeneous sample of trauma patients (N = 222). An evaluation form to assess satisfaction with the leaflet was also mailed with the leaflet. A sample of 98 (44%) of the initial patient group responded, and 96% of them reported the leaflet as either very helpful or helpful. Satisfaction with the leaflet was not affected by age, by gender, or by the type of trauma encountered. Overall, the findings confirmed that such a leaflet is well received by trauma patients attending an ED.

Dealing with violent and aggressive patients: at what cost to nurses?

OBJECTIVES: To determine the attitudes and experiences of nursing staff in relation to violent and aggressive patients. METHOD: A self-administered questionnaire booklet was distributed to 289 nursing staff working in 'high-risk' units within two NHS Trusts. In addition to assessing the frequency of violent incidents, the degree of burnout and post-traumatic symptoms experienced were assessed by the inclusion of two standardised measures in the survey, viz, the Maslach Burnout Inventory and the Impact of Event Scale-Revised respectively. RESULTS: One hundred and fifty six (54%) nurses responded to this survey. Over two-thirds of nurses (72%) had been physically assaulted during the previous two years. The longterm psychological impact of these incidents was not related to whether or not a physical injury was sustained. A positive correlation between burnout and exposure to verbal abuse, threatened assault and violence was demonstrated. CONCLUSIONS: Nurses in these Trusts are exposed to an unacceptable level of violence or aggression from patients, potential implications of which include post-traumatic reactions and burnout. However, nurses are reluctant to report incidents of verbal abuse or threats formally, and they rely upon the support of their colleagues following 'distressing' incidents. To protect the wellbeing of their staff, hospital management needs to consider preventative measures, such as training and personal alarms, and improved reporting systems to ensure all incidents are accurately recorded.

Binding to decay-accelerating factor is not required for infection of human leukocyte cell lines by enterovirus 70.

Enterovirus 70 (EV70) is one of several human enteroviruses that exhibit a propensity for infecting the central nervous system (CNS). The mechanisms by which neurotropic enteroviruses gain access to and invade the CNS are poorly understood. One possibility is that circulating leukocytes become infected and carry neurotropic enteroviruses to the CNS. We examined the ability of EV70 to infect cell lines derived from lymphoid, myeloid, and monocytic lineages. Most leukocyte cell lines tested bound radiolabeled EV70 and were permissive for EV70 replication, suggesting that EV70, in contrast to other enteroviruses, has an in vitro tropism that includes lymphoid, monocytic, and myeloid cell lines. For some of the cell lines, virus binding and infection correlated with surface expression of decay-accelerating factor (DAF), an attachment protein for EV70 on HeLa cells. However, EV70 also adsorbed to and infected cell lines that expressed little or no DAF. In contrast to what was observed for HeLa cells, neither DAF-specific monoclonal antibodies nor phosphatidylinositol-specific phospholipase C treatment inhibited EV70 binding to permissive leukocyte cell lines, and antibody blockade of DAF had little or no effect on EV70 replication. We also found that neither the human coxsackievirus-adenovirus receptor nor intercellular cell adhesion molecule 1, which mediate the entry of coxsackie B viruses and coxsackievirus A21, respectively, functions as a receptor for EV70. EV70 binding to all cell lines was sensitive to sialidase treatment and to inhibition of O glycosylation by benzyl N-acetyl-alpha-D-galactosaminide. Taken together, these results suggest that a sialylated molecule(s) other than DAF serves as a receptor for EV70 on permissive human leukocyte cell lines.