Improving access to mental healthcare for displaced Syrians: case studies from Syria, Iraq and Turkey.

The conflict in Syria has led to an unprecedented humanitarian crisis that extends across multiple countries in the area. Mental health services were undeveloped before and now face huge strain and unmet need. The World Health Organization and others have developed a programme to build capacity in the delivery of mental health services in an integrated healthcare package to refugees and displaced people. The tool used for this is the mhGAP Intervention Guide and complementary materials. In this paper we refer to training in Turkey, Iraq and Syria where health professionals were trained to roll out this community-based integrated approach through primary healthcare. We describe field case examples that show the complexity of situations that face refugees, displaced people and those caught in active conflict. Training improved the knowledge and skills for managing mental health disorders in primary healthcare. Further work needs to be done to demonstrate greater access to and utilisation of services, client outcomes and organisational change with this approach.

Views and experiences of using integrated care pathways (ICPs) for caring for people in the last days to hours of life: results from a cross-sectional survey of UK professionals.

OBJECTIVES: To determine the views and experiences of health and social care professionals on using integrated care pathways (ICPs)for caring for people in the last days to hours of life. METHODS: Online cross-sectional questionnaire survey of UK professionals working in UK primary and secondary care settings. RESULTS: 1331 professionals returned completed questionnaires. Ninety-three per cent (1138/1228) of respondents used the Liverpool Care Pathway (LCP) or local variant. Eighty-eight (1089/1234) felt ICPs enabled professionals to provide better care for individuals and their families/carers. ICPs were viewed as promoting patient-centred holistic care, improving pain and symptom control, providing guidance and standards and improving communication with patients/families. Sixty-two per cent (770/1234) had no concerns regarding the use of ICPs. Areas of concern included incorrect use and implementation of the ICP, poor communication with families, junior level staff making decisions and insufficient education and support. CONCLUSIONS: There was strong support for using ICPs for caring for people in the last days to hours of life. ICPs were viewed as supporting high-quality patient-centred holistic care. Given the recommendations of the More Care Less Pathway report, those that develop the guidance and support that replace the LCP need to incorporate the aspects of this that have resulted in the benefits seen by professionals within this survey, but also learn from the instances where ICPs have failed to prevent poor care, or worse, have contributed to it.

Supplementing sow gestation diets with betaine during summer increases litter size of sows with greater numbers of parities.

Conducted during the Australian summer, this experiment evaluated the reproductive performance of sows receiving a diet supplemented with betaine, a potent organic osmolyte and methyl donor. Large White/Landrace/Duroc sows (n=450) ranging in parity from 1 to 7 (parity 2.9 ± 0.10, mean ± SEM), and mated between the 11th of January and 11th February were used. The treatments compared the effects of two gestation diets (standard (Stand) compared to betaine (Bet) supplemented) and two parity groups (parities one and two (P1/2) versus parity three and greater (P3+) on pregnancy outcomes and litter size. The betaine diet was fed from d 3 ± 1 post-mating until farrowing, with betaine content of the diet altered during gestation to ensure a daily intake of 7.6-9.0 g/sow. Liveweight (LW) and LW gain were unaffected by gestation diet; however, on d 1 of lactation P2 backfat (P2) tended (P=0.07) to be greater for standard compared to betaine fed sows (22.5 ± 0.42 compared to 21.5 ± 0.42 mm). P2, LW and LW gain were greater (P<0.05) for P3+ compared to P1/2 sows. Sow farrowing rate (0.79) was unaffected by gestation diet. Total litter size was greater (P<0.05) for Bet3+ (13.6 ± 0.35) sows compared to Stand3+ (12.1 ± 0.34), BetP1/2 (12.1 ± 0.36) and StandP1/2 (12.3 ± 0.38) sows. In conclusion, this is the first study to demonstrate that gestational betaine supplementation during summer increased litter size of sows with greater numbers of parities.

Septicaemia in a population-based HIV clinical cohort in rural Uganda, 1996-2007: incidence, aetiology, antimicrobial drug resistance and impact of antiretroviral therapy.

OBJECTIVES: To describe the incidence and aetiology of septicaemia, and antimicrobial drug resistance in HIV-infected and uninfected individuals, and the impact of antiretroviral therapy (ART) on septicaemia. METHODS: Between 1996 and 2007, we followed up a rural population-based cohort of HIV-infected and uninfected participants. The aetiology and incidence of septicaemia, and antimicrobial drug resistances were determined. ART became available in 2004, and its impact on the incidence of septicaemia was examined. RESULTS: The overall septicaemia incidence (per 1000 pyrs) was 32.4 (95% CI 26.2-40.6) but was only 2.6 (95% CI 1.3-6.2) in HIV-negative patients and 67.1 (95% CI 53.4-85.4) in HIV-positive patients not on ART. Among those on ART, the overall incidence was 71.5 (95% CI 47.1-114.3), although it was 121.4 (95%CI 77.9-200.4) in the first year on ART and 37.4 (95%CI 18.9-85.2) in the subsequent period. Septicaemia incidence was significantly associated with lower CD4 counts. The commonest isolates were Streptococcus pneumoniae (SPN, n = 68) and Non-typhi salmonellae (NTS, n = 42). Most SPN isolates were susceptible to ceftriaxone and erythromycin, while resistance to cotrimoxazole and penicillin was common. All NTS isolates were susceptible to ciprofloxacin, but resistance to cotrimoxazole and chloramphenicol was common. CONCLUSIONS: Septicaemia incidence was higher in HIV-infected than in HIV-uninfected participants, and it remained high for some time among those who started ART. Starting ART earlier at higher CD4 counts is likely to lead to lower septicaemia incidence. Both SPN and NTS, the commonest isolates, were resistant to most commonly available antimicrobials. Blood culture laboratory surveillance systems to monitor antibiotic susceptibility and inform treatment guidelines are needed in Africa.

Evaluation of blood donor deferral causes in the Trinidad and Tobago National Blood Transfusion Service.

The majority of blood donations in Trinidad and Tobago are made as replacement by family members or friends. National Blood Transfusion Policy was drafted in 2007 to promote voluntary, repeated donation. The objective of this study is to assess the current rate and reasons for donor deferral, and the aim is to guide the proposed donor education and recruitment programme. A retrospective study of pre-donation deferral of prospective blood donors at the National Blood Transfusion Centre, Port of Spain, Trinidad and Tobago, was conducted. Records of all pre-donation deferrals over a 12-month period were studied. As many as 11,346 pre-donation screening interviews were conducted. There were 4043 (35.6%) deferrals. The most common reasons for donor deferral were exposure to high-risk sexual activity (27.6%), low haemoglobin 22.2% and hypertension 17.5%. Other reasons such as medication, chronic medical illness, tattoos, travel history, recent pregnancy, surgery or presentation outside the accepted age limit caused 33.8% of all deferrals and the majority (34.7%) of male deferrals. Low haemoglobin (44.5%) was the most common reason among females. The rate of deferral of voluntary donors was not significantly different from that for replacement donors (31.7 vs. 35.4%, P = 0.25). This study exposed a lack of public awareness as the principal reason for an unacceptably high rate of donor deferral. Donor education about selection criteria needs to be urgently addressed as an objective of the National Policy. Monitoring and evaluation of deferral rates and reasons could be used as one indicator of the effectiveness of the Policy.

Electro-sensitisation of mammalian cells and tissues to ultrasound: a novel tumour treatment modality.

This study demonstrates that mammalian cell targets (erythrocytes and tumour cells) may be sensitised to ultrasound using electric pulses and this combination treatment results in destruction of those cells in vitro. It further demonstrates that when a tumour mass is treated in vivo using combined electric field and ultrasound therapy, significant retardation of tumour growth has been observed using a mouse tumour model. We suggest that combined electric field and ultrasound (CEFUS) therapy may provide a novel, drug-free treatment modality for cancer.

Phytoestrogens are potent inhibitors of estrogen sulfation: implications for breast cancer risk and treatment.

We investigated the ability of 37 flavonoids and flavonoid sulfoconjugates, including some abundant dietary constituents, to act as substrates and/or inhibitors of the sulfotransferase and sulfatase enzymes that interconvert active estrogens and inactive estrogen sulfates in human tissues. The enzymes studied include estrogen sulfotransferase, the thermostable phenolsulfotransferase that acts on a range of substrates including estrogens; steroid sulfatase; and two related enzymes, monoamine phenolsulfotransferase and arylsulfatase A. Several dietary flavonoids, including the soy isoflavones genistein and daidzein, were sulfated by these human sulfotransferases. Many flavonoids were potent inhibitors of thermostable phenolsulfotransferase. Genistein and equol were potent mixed inhibitors of hepatic estrogen sulfotransferase, with inhibitory constant values of 500 nM and 400 nM, respectively. Monoamine phenolsulfotransferase activity was relatively unaffected by flavonoids, but this enzyme was mainly responsible for the sulfation of flavonoids at concentrations greater than 1 micro M. Of the compounds tested, only daidzein 4,7-bisulfate, a trace metabolite in humans, significantly inhibited steroid sulfatase in the micromolar concentration range. Hence, dietary flavonoids may be able to influence the bioavailability of endogenous estrogens, and disrupt endocrine balance, by increasing the ratio of active estrogens to inactive estrogen sulfates in human tissues.

Do dietary phytoestrogens influence susceptibility to hormone-dependent cancer by disrupting the metabolism of endogenous oestrogens?

Phytoestrogens are natural constituents of our diets that have been suggested to protect against hormone-dependent breast cancer. Some of the diverse effects of these compounds may be attributed to ligand-dependent differences in their interaction with oestrogen receptor sub-classes. However, phytoestrogens can also inhibit enzymes that are involved in the generation and removal of endogenous steroid hormones. Among the most potent effects of dietary phytoestrogens is their ability to inhibit the sulphotransferases that sulphate both oestrogenic steroids and a variety of environmental chemicals, including dietary pro-carcinogens. Circulating steroid sulphates are thought to be the major source of oestradiol in post-menopausal breast tumours and sulphation is a key step in the activation of some dietary pro-carcinogens. Hence the inhibition of sulphotransferases by dietary phytoestrogens may have complex effects upon human susceptibility to breast cancer.

Provider attitudes and use of alternative medicine in a midwestern medical practice in 2001.

OBJECTIVE: To determine the current level of use, referral and desire for service of different complementary and alternative (CAM) therapies among Gundersen Lutheran Medical Center providers. METHODS: A survey was conducted in January of 2001 of all medical and associate staff. RESULTS: The response rate was 79%; 55% reported using 1 or more of 18 therapies for themselves. Over 25% of providers used nutritional supplements, herbal medicines, or hydrotherapy with a patient. Over half of providers had referred a patient for biofeedback or chiropractic care. Over half of providers would like to offer acupuncture, biofeedback, chiropractic care, hydrotherapy, nutritional supplements, or massage to patients in the future. Associate staff, female staff, primary care providers, and those who had personally used CAM therapies were more likely to have used, referred, or wish to offer more therapies in the future. There was little support for aromatherapy, magnetic field therapy, naturopathic medicine, or ethnic healing methods. CONCLUSIONS: Use of and desire for complementary therapies at Gundersen Lutheran was higher than expected by the Integrative Medicine Oversight Committee. Health care organizations should consider having a process in place to manage the increasing demands for complementary and alternative therapies.

Repetitive transcranial magnetic stimulation: perspectives for application in the treatment of bipolar and unipolar disorders.

OBJECTIVES: Transcranial magnetic stimulation (TMS) affects the brain by non-invasively stimulating the cerebral cortex and inducing electrical currents in neurons. The powerful magnetic field acts as a vector that passes across the scalp and the skull, and then converts into an electrical energy within the brain. Originally used in neurophysiology, TMS has since been applied in a variety of neuropsychiatric conditions, including mood disorders. Imaging studies in mood-disordered patients have pointed to dysfunctional limbic and prefrontal cortex activity. TMS researchers have thus postulated that dorsolateral prefrontal cortex (DLPFC) stimulation might change brain activity both locally and in paralimbic areas through transynaptic connections, and alter mood. METHODS: We will describe the technology of TMS, its applications to date, and explore its mechanisms of action. RESULTS: Several clinical trials have demonstrated TMS effects on mood in health and disease. There is a growing consensus that TMS has antidepressant effects, although little is known about the role played by a variety of stimulation parameters such as the intensity or frequency of stimulation. One study has found an antimanic effect of right prefrontal TMS. CONCLUSION: TMS is relatively safe; however, much more research is needed before TMS can be integrated into routine clinical practice.

The effect of repeated boar exposure on cortisol secretion and reproduction in gilts.

It has been proposed that short-term activation of the hypothalamo-pituitary adrenal axis, with a consequent increase in the secretion of cortisol, amy disrupt the endocrine events prior to ovulation and thereby impair reproduction in females. We investigated this concept in gilts in which oestrus was detected by introduction to boars, where intense physical contact is possible, or by applying pressure to the back of gilts (back-pressure test) during fence-line exposure to boars, where intense physical contact is prohibited. We expected that there would be a greater release of cortisol and that reproduction would be inhibited in gilts introduced to boars compared to gilts in which the back-pressure test was used. As expected, introduction of gilts to boars resulted in a significant transient increase in plasma concentrations of cortisol while there was no significant effect of using the back-pressure test on plasma cortisol. Nevertheless, introduction of gilts to boars did not impair reproduction and there was no effect of method of detecting oestrus on duration of oestrus, sexual receptivity, fertility or fecundity. The length of the oestrous cycle was decreased and ovulation rate increased in gilts that were introduced to boars compared to gilts that underwent the back-pressure test, indicating that introduction of gilts to boars may have stimulated these aspects of reproduction. These stimulatory effects may have been due to an increased exposure of gilts to sexual behaviour and stimuli from boars when introduced to boars and/or to stimulatory effects of the hypothalamo-pituitary adrenal axis on some aspects of reproduction.

The effect of three finishing systems on four esthetic restorative materials.

Previous studies have investigated the finishing and smoothness of composite and traditional glass-ionomer restorations, but few have included resin-modified glass-ionomer cements or more recent finishing systems. The results of using three different finishing systems (Sof-Lex, Enhance, finishing burs) on two composites (Silux, Prisma TPH), a traditional glass ionomer (Ketac-Fil), and a resin-modified glass ionomer (Fuji II LC) were studied. Sixty samples were condensed into sectioned acrylic tubes, covered with a Mylar matrix plus a glass slide at each surface, then cured as per the manufacturers' instructions. Samples were randomized to three groups of five for each material and testing with a Surfanalyzer 4000 of unfinished samples (cured with Mylar matrix) was done to obtain baseline average surface roughness (Ra). Samples were then finished as per the manufacturers' instructions using polishing disks, abrasive impregnated disks, and finishing burs before further surface testing. Samples finished with burs and with abrasive impregnated disks were further polished using polishing paste (Prisma Gloss) and again tested. Data were analyzed with ANOVA testing and Tukey's HSD pairwise comparison. Initial testing after randomization to groups showed no significant difference in surface roughness (P = 0.24). Two-factor analysis revealed no significant difference between materials (P = 0.34), a significant difference in method of finish (P < or = 0.00), with no significant interaction between type of material and method of finish (P = 0.11). Aluminum oxide disk and impregnated disk systems provided the best finish for microfilled composite and both glass-ionomer materials (P < or = 0.00). No significant difference in method of finish existed with the hybrid composite (P = 0.07). Overall, esthetic restorative material finishing is best accomplished using abrasive impregnated disks or aluminum oxide disks. Finishing burs gave a significantly rougher surface than the former methods.

Axotomized septal cholinergic neurons rescued by nerve growth factor or neurotrophin-4/5 fail to express the inducible transcription factor c-Jun.

The inducible transcription factor c-Jun increases in neurons in response to axotomy by unknown mechanisms, and it has been postulated that c-Jun may regulate genes involved in promoting either degeneration or regeneration of axotomized neurons. In this report, we investigated the effect of daily or twice daily intraventricular administration of the neurotrophins nerve growth factor or neurotrophin-4/5 on the decrease in choline acetyltransferase expression and the increase in c-Jun expression in rat medial septum/diagonal band neurons three, seven and 14 days following unilateral, complete, fornix fimbria lesion. We also examined whether medial septum/diagonal band neurons might die by apoptosis within two weeks of fornix fimbria lesion using terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end labelling. Our results show that both nerve growth factor and neurotrophin-4/5 maintain the phenotype of basal forebrain cholinergic neurons following axotomy. Furthermore, using double-labelling immunofluorescence, we found that while c-Jun was expressed in cholinergic neurons in control-treated rats seven days following fornix fimbria lesion, cholinergic neurons rescued by either nerve growth factor or neurotrophin-4/5 in neurotrophin-treated rats failed to express c-Jun. At no time-point (three, seven or 14 days post-axotomy) did any neurons in the medial septum/diagonal band stain positive for terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labelling, suggesting that medial septum/diagonal band neurons do not undergo apoptosis within the first two weeks following axotomy at the time-points observed by us. Therefore, these results show that both nerve growth factor and neurotrophin-4/5 rescue the phenotype of axotomized cholinergic neurons and that these rescued neurons fail to express c-Jun in response to axotomy. In addition, since neither nerve growth factor nor neurotrophin-4/5 induced c-Jun in medial septum/diagonal band cholinergic neurons, it seems unlikely that the neurotrophic effects of nerve growth factor and neurotrophin-4/5 on cholinergic neurons are mediated via c-Jun expression. Furthermore, since axotomy failed to increase terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end labelling in septal neurons, it appears unlikely that c-Jun expression in these axotomized neurons is related to neuronal degeneration via apoptosis.

Suppression of integrin activation: a novel function of a Ras/Raf-initiated MAP kinase pathway.

Rapid modulation of ligand binding affinity ("activation") is a central property of the integrin cell adhesion receptors. Using a screen for suppressors of integrin activation, we identified the small GTP-binding protein, H-Ras, and its effector kinase, Raf-1, as negative regulators of integrin activation. H-Ras inhibited the activation of integrins with three distinct alpha and beta subunit cytoplasmic domains. Suppression was not associated with integrin phosphorylation and was independent of both mRNA transcription and protein synthesis. Furthermore, suppression correlated with activation of the ERK MAP kinase pathway. Thus, regulation of integrin affinity state is a novel, transcription-independent function of a Ras-linked MAP kinase pathway that may mediate a negative feedback loop in integrin function.

Candida albicans arthritis one year after successful treatment of fungemia in a healthy infant.

Fungal arthritis in pediatric patients is rare and is most often associated with hematogenous spread to the affected joint. It is generally seen concomitant with, or shortly after, fungemia. We report a case of an immunocompetent patient in whom candidal arthritis developed 1 year after initial fungemia. The initial candidiasis was considered to be adequately treated with amphotericin B. The Candida isolates from the neonatal fungemia and subsequent arthritis were the some as identified by electrophoretic karyotype, restriction fragment length polymorphism analysis, and antifungal susceptibility testing. Pediatric candidal fungemia, arthritis, and their treatments are discussed.

Therapeutic touch with adolescent psychiatric patients.

Seven hospitalized, adolescent psychiatric patients who received a total of 31 Therapeutic Touch treatments over two 2-week periods were interviewed about their experience. Findings from the interviews were categorized within 2 overarching themes-the therapeutic relationship and the body/mind connection. The study participants enjoyed the Therapeutic Touch, and in fact, they wanted more of it. This research shows the possibility of Therapeutic Touch as a nursing intervention with adolescent psychiatric patients if all care is taken to obtain their consent and to provide them with a safe environment for touch therapy.