Secondary vaginoplasty for disorders for sexual differentiation: is there a right time? Challenges with compliance and follow-up at a multidisciplinary center.

PURPOSE: We present the experience of a multidisciplinary center for disorders of sexual differentiation (DSD) in treating females requiring vaginoplasty. Specifically, we evaluate outcomes and compliance with follow-up protocols in patients undergoing secondary vaginoplasties. MATERIALS/METHODS: We retrospectively reviewed consecutive DSD patients who underwent feminizing genitoplasties in 2006-2010. A subset of patients were instructed in vaginal self-dilation at time of secondary vaginoplasty. Through follow-up visits and administered questionnaires we assessed outcomes, compliance and overall satisfaction. RESULTS: Twenty-two feminizing genitoplasties were completed during the study interval. There were no postoperative complications; average blood loss was 74 ml and mean length of stay was 3 days. Ten females underwent secondary vaginoplasty. The response rate to questionnaires was 5 of 9. Age of initiation for self-dilation ranged from 8 to 24 years. Initial compliance two months postoperatively was good, but diminished 12-24 months after surgery. Responses to the quality-of-life questionnaire were diverse, reflecting a range of patient ages and varied experiences. CONCLUSION: A multidisciplinary, comprehensive approach is necessary to care for patients with DSD due to psychosexual, medical and reconstructive concerns. A secondary vaginoplasty to facilitate menarche and psychosocial concerns is feasible with minimal complications, though compliance and toleration with regard to post-surgical dilation regimens is variable.

Can individualized health care plans help increase continence in children with dysfunctional elimination syndrome?

School-age children with dysfunctional elimination syndrome (DES) do not always have school support for their treatment plans, including an every 2-hr voiding schedule. The objective of this study was to increase school support of treatment plans by allowing access to bathrooms, thereby improving continence. An eight-question survey about bathroom access at schools was given to parents at baseline. The author contacted school nurses requesting that treatment plans be incorporated into individual health plans (IHPs) with teacher support of the IHP. Six weeks later, school nurses were contacted and parents completed a postintervention survey to determine whether IHPs were supported by teachers. Voiding diaries were used to document continence. Seventeen parents completed the survey at baseline, and 13 children were enrolled in the intervention. After the intervention, 100% of the children had IHPs and teacher support of treatment plans. Ninety-two percent had increased continence. IHPs improved teacher support of children's treatment plans and improved their continence.

Involving carers in mental health service development.

OBJECTIVE: A project designed to enhance carer participation in a mental health service is described. METHOD: Carers of people with a mental illness were involved in reviewing and developing policies, and developing a carer rights and responsibilities booklet. RESULTS: Policies relevant to carers of people with a mental illness were reviewed and updated, and new policies developed to cover existing gaps. Carer and staff awareness of policies was increased. A carer rights and responsibilities booklet was developed. CONCLUSIONS: Involving carers at this level of service development enhances carer awareness and understanding of the processes involved in a mental health service, and improves staff understanding of carer issues and viewpoints. This process is valuable for mental health services, resulting in positive outcomes.

An integrated approach to general practice mental health training: the importance of context.

OBJECTIVE: The high prevalence of mental disorders and the barriers to detection and treatment of these in general practice are well recognized. As such, the government has placed great emphasis on training general practitioners (GPs) in primary care mental health and on the provision of support for GPs in the delivery of such services. The current paper aims to evaluate a local, rural training program in mental health for GPs. We hypothesized that local 'context-driven' training would lead to increased knowledge and reported change in practice by GPs with mental health patients. METHOD: Locally developed and delivered 'Level 1' training was offered to GPs through the Better Outcomes in Mental Health Care initiative. The training was provided with 6-hour workshops covering mental health assessment and management planning. The training was evaluated through pre- and 6-week post-questionnaires assessing attitudes and practice with respect to treatment of patients with mental health problems. RESULTS: Forty-nine GPs from the Loddon Campaspe Southern Mallee region of Victoria participated in the training. Following the 6-hour workshop, there was an increase in reported use of psychoeducation for patients with depression, use of cognitive behavioural therapy for patients with anxiety, and ease in obtaining advice to assist with the management of psychosis. CONCLUSIONS: GP mental health education should take into consideration the local context, cover systems issues as well as skills development, and aim to develop personal relationships between mental health clinicians and GPs to enhance outcomes.

Impaired bone marrow homing of cytokine-activated CD34+ cells in the NOD/SCID model.

The reduced engraftment potential of hematopoietic stem/progenitor cells (HSPCs) after exposure to cytokines may be related to the impaired homing ability of actively cycling cells. We tested this hypothesis by quantifying the short-term homing of human adult CD34+ cells in nonobese diabetic/severe combined immunodeficient (NOD/SCID) animals. We show that the loss of engraftment ability of cytokine-activated CD34+ cells is associated with a reduction in homing of colony-forming cells (CFCs) to bone marrow (BM) at 24 hours after transplantation (from median 2.8% [range, 1.9%-6.1%] to 0.3% [0.0%-0.7%]; n = 3; P < .01), coincident with an increase in CFC accumulation in the lungs (P < .01). Impaired BM homing of cytokine-activated cells was not restored by using sorted cells in G0G1 or by inducing cell cycle arrest at the G1/S border. Blocking Fas ligation in vivo did not increase the BM homing of cultured cells. Finally, we tested cytokine combinations or culture conditions previously reported to restore the engraftment of cultured cells but did not find that any of these was able to reverse the changes in homing behavior of cytokine-exposed cells. We suggest that these changes in homing and, as a consequence, engraftment result from the increased migratory capacity of infused activated cells, leading to the loss of selectivity of the homing process.

First year of practice visits for the Rural Depression Anxiety Research and Treatment General Practice program.

OBJECTIVE: To describe the first 12 months activities of a key component of a General Practice Psychiatry program - the GP practice visit. DESIGN: Questionnaire to evaluate effects on participating general practitioners practice. SETTING: Rural group general practices. SUBJECTS: Thirty-two general practitioners in the Loddon Campaspe Southern Mallee region in Victoria. INTERVENTIONS: Practice visits involved a combination of each of three key activities: primary consultation, secondary consultation and/or case discussion and formal teaching. RESULTS: General practitioners reported a variety of changes in their practice as a result of the visits. CONCLUSION: Practice visits appear to be a useful means of influencing GP's practice. Further work is required to determine whether such changes are accompanied by demonstrable benefits in patient outcome. WHAT IS ALREADY KNOWN: Several models to assist GPs effectively manage mental health problems have been described. These models require regular contact and so have had limited utility in rural settings. WHAT THIS STUDY ADDS: This study suggests that infrequent contact or input, based on well established models, can alter GP's clinical behaviour.

Influence of cell cycling and cell division on transendothelial migration of CD34+ cells.

The migration of haemopoietic stem and progenitor cells across endothelium lining bone marrow sinuses is a critical first step in the homing and successful engraftment of these cells. We have previously shown that freshly isolated mobilized peripheral blood CD34+ cells adhere to the endothelial surface but do not transmigrate unless activated by growth factors. The aim of this work was to examine the relationship between cell cycle progression, cell division and migration across endothelium. We now show that the enhanced migration of cytokine-activated cells is selective for cells which are in G0G1 phase of the cell cycle. Thus, the transmigrated population of CD34+ cells was enriched for cells in G0G1 phase, and sorted cells in G0G1 migrated more efficiently than those in S+G2M. Conversely, cells in S+G2M were more adherent to endothelium, a finding that may explain their reduced migration. Using the cytoplasmic dye, carboxyfluorescein diacetate succinimidyl ester, to track the divisional kinetics of CD34+ cells, we found that migration occurred preferentially in non-divided cells. Thus, although CD34+ cells require cytokine activation in order to migrate, cell division is not required for transmigration, which occurs optimally before cells enter S phase. The superior migratory ability of CD34+ cells in G0G1 phase of the cell cycle may have important implications for the homing and engraftment of ex vivo expanded cells.

Fetal haemopoietic cells display enhanced migration across endothelium.

Fetal haemopoietic cells continually circulate and migrate into tissues, and thus may have specialized homing capabilities. In this study we investigated the in vitro features of haemopoietic cells in fetal blood and liver which are relevant to homing and engraftment. Fetal cells were examined for long-term culture-initiating cell (LTC-IC) and progenitor content, adhesion molecule expression, cell cycle behaviour and transendothelial migratory activity. The LTC-IC content of fetal CD34+ cells is similar to that of CD34+ cells from cord and adult mobilized blood. In contrast to adult and cord blood CD34+ cells, fetal CD34+ cells were actively cycling (11.0 +/- 1.7% and 28 +/- 1.1% of fetal blood and liver CD34+ cells, respectively, in S+G2M, P < 0.001, compared with cord and adult cells). The striking finding was that fetal haemopoietic cells (both LTC-ICs and committed progenitors) displayed significantly higher levels of migration across endothelium (P < 0.05 compared with cord, P < 0.01 compared with adult blood and bone marrow CD34+ cells), which were further increased by chemokines and growth factors. The superior migratory activity of fetal haemopoietic cells may underlie a more efficient homing ability, in keeping with their physiological role.