The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis.

INTRODUCTION: More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance. OBJECTIVES: To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. METHODS: We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology. RESULTS: The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. CONCLUSIONS: The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population. KEY WORDS: Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Adherence to antipsychotic medication among homeless adults in Vancouver, Canada: a 15-year retrospective cohort study.

PURPOSE: The purpose of this study was to investigate the level of adherence to antipsychotic prescription medication in a well-defined homeless cohort over a 15-year period. We hypothesized that adherence would be well below the recommended threshold for clinical effectiveness (80 %), and that it would be strongly associated with modifiable risk factors in the social environment in which homeless people live. METHOD: Linked baseline data (including comprehensive population-level administrative prescription records) were examined in a subpopulation of participants from two pragmatic-randomized trials that investigated Housing First for homeless and mentally ill adults. Adherence to antipsychotic medication was operationalized using the medication possession ratio. Multivariable logistic regression was used to estimate effect sizes between socio-demographic, homelessness-related and illness factors, and medication possession ratio. RESULTS: Among the 290 participants who met inclusion criteria for the current analysis, adherence to antipsychotic prescription was significantly associated with: history of psychiatric hospitalization; receipt of primary medical services; long-acting injectable antipsychotic formulations; and duration of homelessness. Mean medication possession ratio in the pre-randomization period was 0.41. Socio-demographic characteristics previously correlated with antipsychotic non-adherence were not significantly related to medication possession ratio. CONCLUSIONS: This is the first study to quantify the very low level of adherence to antipsychotic medication among homeless people over an extended observation period of 15 years. Each of the four factors found to be significantly associated with adherence presents opportunities for intervention. Strategies to end homelessness for this population may represent the greatest opportunity to improve adherence to antipsychotic medication.

The prevalence and geographic distribution of complex co-occurring disorders: a population study.

AIMS: A subset of people with co-occurring substance use and mental disorders require coordinated support from health, social welfare and justice agencies to achieve diversion from homelessness, criminal recidivism and further health and social harms. Integrated models of care are typically concentrated in large urban centres. The present study aimed to empirically measure the prevalence and distribution of complex co-occurring disorders (CCD) in a large geographic region that includes urban as well as rural and remote settings. METHODS: Linked data were examined in a population of roughly 3.7 million adults. Inclusion criteria for the CCD subpopulation were: physician diagnosed substance use and mental disorders; psychiatric hospitalisation; shelter assistance; and criminal convictions. Prevalence per 100 000 was calculated in 91 small areas representing urban, rural and remote settings. RESULTS: 2202 individuals met our inclusion criteria for CCD. Participants had high rates of hospitalisation (8.2 admissions), criminal convictions (8.6 sentences) and social assistance payments (over $36 000 CDN) in the past 5 years. There was wide variability in the geographic distribution of people with CCD, with high prevalence rates in rural and remote settings. CONCLUSIONS: People with CCD are not restricted to areas with large populations or to urban settings. The highest per capita rates of CCD were observed in relatively remote locations, where mental health and substance use services are typically in limited supply. Empirically supported interventions must be adapted to meet the needs of people living outside of urban settings with high rates of CCD.

Dating fractures in infants.

AIM: To document the timing of the appearance of the radiological features of fracture healing in a group of infants in which the date of injury was known and to assess the degree of interobserver agreement. MATERIALS AND METHODS: Three paediatric radiologists independently assessed 161 images of 37 long bone fractures in 31 patients aged 0-44 months. The following features were assessed: soft-tissue swelling, subperiosteal new bone formation (SPNBF), definition of fracture line, presence or absence of callus, whether callus was well or ill defined, and the presence of endosteal callus. RESULTS: Agreement between observers was only moderate for all discriminators except SPNBF. SPNBF was invariably seen after 11 days but was uncommon before this time even in the very young. In one case SPNBF was seen at 4 days. CONCLUSION: With the exception of SPNBF, the criteria relied on to date fractures are either not reproducible or are poor discriminators of fracture age.

Radiological features of Meckel's diverticulum and its complications.

Meckel's diverticulum is the most common congenital abnormality of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications may occur, including obstruction, intussusception, perforation, diverticulitis, and gastrointestinal haemorrhage. These complications may produce a variety of different clinical features and radiological appearances. The purpose of this article is to review the potential imaging manifestations of Meckel's diverticulum and its complications and discuss the advantages and disadvantages of the imaging techniques available.

Cervical spine injuries to children under 11: should we use radiography more selectively in their initial assessment?

OBJECTIVES: To assess the effectiveness of cervical spine radiography in injured children under 11 years old, and suggest improvements. METHODS: Retrospective survey of radiographs and accident and emergency records for children examined during a one year period in a large teaching hospital. RESULTS: No cervical spine fractures occurred in this age group during the year. The recorded clinical findings did not always justify radiography. CONCLUSIONS: Clinical examination appears undervalued by those assessing injured children and is poorly recorded. Radiography can be used more selectively. Initial assessment using a single lateral projection can be followed in doubtful cases by cross sectional imaging.

The role of the plain radiograph and renal tract ultrasound in the management of children with renal tract calculi.

AIMS: The aim of this retrospective study was to assess the relative efficacy of plain abdominal radiographs and detailed renal tract ultrasound (US) examination in the diagnosis and follow-up of children with renal tract calculi. METHODS: The records and imaging studies of 28 paediatric patients who had presented with proven renal tract calculi over a period of 5 years were examined. RESULTS: In 23 (82%) patients, US was the first investigation. All these patients also had plain radiographs. Plain radiographs were the first investigation in five (18%) patients. All renal calculi (100%) visible on plain films were demonstrated on US. Furthermore, detailed US often provided other clinically significant findings that were not apparent on plain films. CONCLUSION: As a result of this study it is recommend that detailed US should be the investigation of choice in children with suspected renal tract calculi.

Improved ultrasound detection of renal scarring in children following urinary tract infection.

A system for defining renal scarring on ultrasound is proposed and compared with DMSA scintigraphy. Renal scarring was assessed with ultrasound in children following urinary tract infection (UTI) using the following criteria: (1) proximity of sinus echoes to cortical surface; (2) loss of pyramids; (3) irregularity of outline; (4) loss of definition of capsular echo; and (5) calyceal dilatation. Three hundred and thirty-nine consecutive ultrasound scans (US) and DMSA scintigrams, comprising 648 kidneys, were performed and reported blindly and the results were compared. Using DMSA scintigraphy as the gold standard, ultrasound had a positive predictive value of 93% and a negative predictive value of 95%. Ultrasound disagreed with DMSA scintigraphy in 5.2% of kidneys. On review of the cases of disagreement where arbitration was possible by comparison with other imaging, ultrasound was incorrect in 10 kidneys and DMSA was incorrect in 13. We conclude that the sensitivity in the ultrasound detection of renal scarring can be greatly improved using this method. If no scars were detected at ultrasound an alternative explanation for an abnormal DMSA scintigram should be sought.

Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.

This randomized controlled trial evaluated the efficacy of a brief intervention designed to reduce the harmful consequences of heavy drinking among high-risk college students. Students screened for risk while in their senior year of high school (188 women and 160 men) were randomly assigned to receive an individualized motivational brief intervention in their freshman year of college or to a no-treatment control condition. A normative group selected from the entire screening pool provided a natural history comparison. Follow-up assessments over a 2-year period showed significant reductions in both drinking rates and harmful consequences, favoring students receiving the intervention. Although high-risk students continued to experience more alcohol problems than the natural history comparison group over the 2-year period, most showed a decline in problems over time, suggesting a developmental maturational effect.

fimA and tctC based DNA diagnostics for Salmonella.

Immunochemical analyses of 85 isolates of 17 Salmonella serovars using polyclonal antiserum to SEF21, the type 1 fimbriae of Salmonella enteritidis, demonstrated antigenic relatedness among both type 1 and type 2 fimbriae of Salmonella. However, anti-SEF21 antiserum was not entirely suitable as a Salmonella diagnostic probe due either to a variability of, or a rare deficiency of, detectable fimbriae. Partial amino acid sequence analyses of the SEF21 structural fimbrin protein revealed 99% homology to Salmonella typhimurium FimA. Therefore, oligonucleotide probes for Salmonella detection were designed following sequencing of S. enteritidis fimA and comparison to the corresponding genes of S. typhimurium, Escherichia coli, Klebsiella pneumoniae and Serratia marcescens. One oligonucleotide probe hybridized to all 612 Salmonella isolates of 89 serovars tested while two other probes detected 97.5% and 99.7% of the isolates. Three consistently weak positive reactions were obtained, therefore, inclusivity was optimized by identification of a Salmonella-specific tctC DNA probe that detected 609 of 612 Salmonella isolates. No hybridization of these Salmonella probes was detected to 250 other Enterobacteriaceae isolates or to 14 other eubacterial species. Therefore, in combination, DNA probes to fimA and tctC proved to be highly reliable diagnostics for Salmonella bacteria. Accordingly, PCR assays targeting fimA and tctC were developed.

Radiologically-guided cutting needle biopsy for suspected malignancy in childhood.

Twenty-seven cutting needle biopsies were performed on 25 children with suspected malignancy using computed tomographic (CT, 22) or ultrasound (US, 5) guidance. Anatomical sites were: retroperitoneum 6, liver 4, kidney 4, abdomen/pelvis 4, thorax 4, bowel 2, neck 1. Sixteen patients (64%) underwent subsequent open biopsy (5), marrow biopsy (2) or resection (9). There was complete concordance between the histological findings from the open or marrow biopsy and the previous needle biopsy in 12 of these 16 patients; in two patients the needle biopsy was misleading, causing inappropriate initial treatment in one. In two other patients needle biopsy was correct but lacked specific diagnostic features. Needle biopsies were performed under general, local or Ketamine anaesthesia. There were no apparent complications related to these procedures. We believe that radiologically-guided cutting needle biopsy should replace open biopsy in most children with solid malignant lesions. It can easily be performed during a single anaesthetic episode which allows radiological evaluation, biopsy, bone marrow and cerebrospinal fluid sampling. However, the potential for sampling error and histological variation within these tumours needs to be borne in mind.

Pictorial review: benign and malignant enlargement of the pterygo-masseteric muscle complex.

Seven cases of unilateral enlargement of the pterygoid and/or masseter muscles due to haemangioma (1), benign masseteric hypertrophy (2), rhabdomyosarcoma (2), leukaemic infiltration (1) and non-Hodgkin's lymphoma (1) are presented. The differential diagnosis of pterygo-masseteric muscle enlargement is outlined and the usefulness of computed tomography (CT) discussed.

Lethal skeletal dysplasia owing to double heterozygosity for achondroplasia and spondyloepiphyseal dysplasia congenita.

A male infant with lethal short limbed dwarfism is described. His father had spondyloepiphyseal dysplasia congenita and his mother had achondroplasia. It is believed that the infant inherited both of these disorders and that their combined effects resulted in early death owing primarily to severe pulmonary hypoplasia.

Coronary cameral fistulae following heart transplantation.

Coronary cameral fistulae in 208 orthotopic heart transplants performed at Papworth Hospital were examined. Sixteen fistulae in 208 heart transplants were identified (7.7%). This compares with a reported incidence of 0.2% or less in native hearts. Seven (3.4%) were similar to previously described fistulae to the right ventricle and were secondary to endomyocardial biopsy. Four (1.9%) arose from right or left coronary artery atrial branches and drained into the right atrium. We have called these 'suture line fistulae'. Five (2.4%) arose from left coronary branches at the apex; four of these drained into the left ventricle and one into the right ventricle. We believe these to be secondary to cutting needle biopsy of the apex of the donor heart before transplant and have designated them 'harvest biopsy fistulae'. One patient with a large fistula angiographically had no oximetric evidence of shunt at cardiac catheterization. Coronary cameral fistulae are an uncommon complication of heart transplantation and follow-up biopsy, and appear to be of no haemodynamic significance.

The recognition of previous abdominal surgery by computed tomography.

Knowledge regarding previous surgery is important when reporting abdominopelvic CT. We have examined 50 consecutive patients undergoing abdominopelvic CT to establish whether careful scrutiny of the images can reliably reveal evidence of previous surgery. The radiologist performing the CT study inspected the patient's abdomen for scars and established their nature by discussion with the patient. A second radiologist, unaware of the patient's clinical details, reviewed the CT images and predicted whether there had been any previous surgery. These predictions proved inaccurate: Only 51% of scars were recognised at this initial assessment (63% following retrospective review). Although the absence of major organs was reliably reported, even large paramedian scars were missed. Old scars were missed more frequently than recent ones. Accurate details of previous surgery are necessary when interpreting abdominopelvic CT.

Rupture of the right hemidiaphragm following blunt trauma: the use of ultrasound in diagnosis.

Diaphragmatic rupture occurs in approximately 5% of patients who sustain multiple trauma and post-mortem studies suggest that right-sided rupture is more common than generally realized. Four cases of rupture of the right hemidiaphragm secondary to blunt trauma are presented. The chest radiographs were all similar, demonstrating a right sided fluid collection and right lower lobe consolidation in all patients. No patient had a pneumothorax. CT was useful only in retrospect, demonstrating a posterior eventration of the liver into the thorax in two patients. Ultrasound proved diagnostic in all cases demonstrating either the free edge of the diaphragm as a flap within the pleural fluid or the liver herniating into the thorax. The value of ultrasound as a simple, non-invasive and direct means of imaging the diaphragm is emphasized.

Genetic regulation of the tricarboxylate transport operon (tctI) of Salmonella typhimurium.

Tricarboxylates are transported into Salmonella typhimurium by a binding protein-dependent transport system known as TctI. Genetically, it comprises three structural genes, tctCBA, as well as a fourth gene of unknown function (tctD), which is transcribed divergently from tctC (K. A. Widenhorn, J. M. Somers, and W. W. Kay, J. Bacteriol. 170:3223-3227, 1988). Deletions in tctD strongly reduced expression of tctC or of tctC-lacZ transcriptional fusions; however, expression was restored when tctD was present in trans. Expression of tctD-lacZ transcriptional fusions was strongly repressed in the presence of D-glucose but could be alleviated by the addition of cyclic AMP. Furthermore, transcription of tctD was found not to be autogenously regulated. Thus, tctD is considered to be regulated by catabolite repression and encodes a transcriptional activator of tctCBA expression. From the DNA sequence of tctD, the predicted gene product was hydrophilic and shared distinct homologies with other globally regulated transcriptional activators such as OmpR and NtrC.