Responding to mental health statutory drivers: experience of a low intensity cognitive behavioural therapy programme.

OBJECTIVES: Stress control (SC), a brief psycho-education course, was implemented to increase access to psychological therapies in line with Northern Irish mental health service statutory drivers. The first aim of this study was to gauge the efficacy of SC in a robust manner with clinical significance testing. The second aim was to assess whether demographics traditionally 'hard-to-reach' - males, younger adults and those from deprived areas - accessed SC. The third aim was to elucidate what prompted their access and the experiences of attendees at SC. METHODS: Attendees at SC were 170 adults over six iterations of the course. Pre- and post-questionnaires included the Depression Anxiety Stress Scales - 21, captured demographic details and qualitative feedback, which was subject to a mixed-methods analysis. RESULTS: SC attendees reported significant decreases on depression, anxiety and stress sub-scales post-intervention. Moreover, 38.71% (n=36) of attendees who completed SC exhibited clinically significant improvement afterwards on one or more sub-scale. Attendance figures for males, younger adults and those classified as socioeconomically deprived were modest. Patterns within the data suggested prospective success for targeting these cohorts. CONCLUSIONS: SC attracted people in need of mental healthcare input and affected quantifiable change within those people's lives, while satisfying statutory demands for service delivery in an accessible community context. Recommendations to increase engagement with those traditionally 'hard-to-reach' for psychological services are provided, which, if implemented, have the potential to achieve further compliance with Northern Irish mental health statutory drivers.

Advancing the defensive explanation for anxiety disorders: lorazepam effects on human defense are systematically modulated by personality and threat-type.

Clinically effective drugs against human anxiety and fear systematically alter the innate defensive behavior of rodents, suggesting that in humans these emotions reflect defensive adaptations. Compelling experimental human evidence for this theory is yet to be obtained. We report the clearest test to date by investigating the effects of 1 and 2 mg of the anti-anxiety drug lorazepam on the intensity of threat-avoidance behavior in 40 healthy adult volunteers (20 females). We found lorazepam modulated the intensity of participants' threat-avoidance behavior in a dose-dependent manner. However, the pattern of effects depended upon two factors: type of threat-avoidance behavior and theoretically relevant measures of personality. In the case of flight behavior (one-way active avoidance), lorazepam increased intensity in low scorers on the Fear Survey Schedule tissue-damage fear but reduced it in high scorers. Conversely, in the case of risk-assessment behavior (two-way active avoidance), lorazepam reduced intensity in low scorers on the Spielberger trait anxiety but increased it in high scorers. Anti-anxiety drugs do not systematically affect rodent flight behavior; therefore, we interpret this new finding as suggesting that lorazepam has a broader effect on defense in humans than in rodents, perhaps by modulating general perceptions of threat intensity. The different patterning of lorazepam effects on the two behaviors implies that human perceptions of threat intensity are nevertheless distributed across two different neural streams, which influence effects observed on one-way or two-way active avoidance demanded by the situation.

Hyperferritinemia in a woman with systemic lupus erythematosus, severe nephritis and an iron-rich intraspinal schwannoma mimicking lupus myelopathy.

We describe a lupus flare in a 59-year-old woman who presented with pancytopenia, nephritis, severe renal dysfunction and marked hyperferritinemia. The course of the disease was further complicated by an iron-laden, intraspinal ancient schwannoma that compressed the cervical cord mimicking a lupus-related myelopathy and was removed surgically. Treatment with mycophenolate mofetil (MMF) and prednisone induced a gradual decline in levels of serum ferritin with a concomitant improvement in renal function and reduction of proteinuria. Serum ferritin may be a useful marker of the response to treatment with MMF in renal lupus.

Cirsoid aneurysm of the scalp.

A 29-year-old man with a pulsatile scalp swelling is presented. The clinical diagnosis of a cirsoid aneurysm was confirmed on computed tomography of the brain and selective cerebral angiography. It is important to detect veins draining from the aneurysm into the intracerebral venous system, as percutaneous occlusion of the aneurysm may be possible in their absence.

Impact of HIV-1 status on the radiological presentation and clinical outcome of children with WHO defined community-acquired severe pneumonia.

AIMS: We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa. METHODS: Of 425 children aged between 3 and 59 months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48 h after enrolment or deterioration within 14 days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status. RESULTS: 82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12 months of age was significantly worse in HIV-1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p = 0.002), while HIV-1 infected and uninfected children aged > or =12 months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher "other consolidates/infiltrates" than "endpoints for consolidation" in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<0.036). CONCLUSIONS: The WHO standard treatment guideline for severe pneumonia is inadequate for HIV-1 infected infants. The increased prevalence of "other consolidates/infiltrates" among HIV-1 infected children who failed standard treatment supports the addition of co-trimoxazole to WHO standard treatment.

Usefulness of different imaging modalities in the assessment of scapular fractures caused by blunt trauma.

PURPOSE: To analyze the usefulness of chest and scapular trauma radiographs, axial computed tomography (CT), and two- and three-dimensional (2D and 3D) reconstruction CT in detecting fractures of the six anatomical regions of the scapula. MATERIAL AND METHODS: Forty-four patients, with a median age (range) of 34 (16-60) years, with scapular fractures caused by blunt trauma were prospectively collected between January 2003 and December 2005. Their chest and scapula radiographs, and axial, 2D, and 3D CTs were reviewed blindly and independently by two observers. Each modality was compared with a gold standard to determine its diagnostic usefulness. Our gold standard was consensus reached by all authors together examining all modalities at the same time. We also compared 3D CTs reconstructed from chest and scapula axial views. RESULTS: Axial and 3D reconstruction tomographic studies were the only useful modalities in assessing fractures in all six anatomical scapular regions. Three-dimensional CTs reconstructed from chest and scapula axial views were equally sensitive and specific. CONCLUSION: CT scanning with 3D reconstructions is the most useful imaging modality to detect and define the extent of scapular injury, and this can be done as part of a chest trauma computed tomography protocol.

The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy.

AIM: To determine the value of magnetic resonance imaging (MRI) in the detection of the location of the placenta and placental adherence in patients with extra-uterine or abdominal pregnancy. METHODS: A retrospective study of patients with a suspected diagnosis of extra-uterine pregnancy was performed over a 12-month period. MRI images on hard and soft copy were reviewed by two radiologists blinded to the clinical and operative findings. RESULTS: Nine patients with 10 foetuses were imaged. Nine foetuses were in an extra-uterine position; three were delivered dead, one from intrauterine growth retardation and one from a fatal congenital anomaly. The placenta was located correctly in all nine patients with placental adherence demonstrated in four patients. The placenta was safely delivered in six patients and left in situ in three in which there was MRI evidence of placental adherence. CONCLUSIONS: MRI is valuable in accurately demonstrating the location of the placenta within the abdomen and the presence of placental adherence, which directly affects the decision whether to remove or leave the placenta in situ.

Imaging techniques to identify morbidly adherent placenta praevia: a prospective study.

The objective of this study was to assess the sensitivity and specificity of Gray scale ultrasonography, magnetic resonance (MRI) and colour flow Doppler imaging in the diagnosis of morbidly adherent placenta praevia. We collected prospectively 30 cases of placenta praevia diagnosed by Gray scale ultrasound, colour flow Doppler and MRI. Delivery by elective caesarean section was carried out at the 38th week, before the onset of labour, unless obstetric complications supervened. Data regarding maternal outcome and newborn status were collected. Three patients had a morbid adherence of the placenta at delivery, two of whom required caesarean hysterectomy, and the other an internal iliac artery ligation. One patient was delivered at 33 weeks' gestation due to uncontrollable bleeding and the remainder were delivered at 38 weeks. All mothers and infants were well at the time of discharge. Colour flow Doppler was shown to be more specific in the diagnosis of the morbidly adherent placenta praevia than MRI. Doppler had a negative predictive value of 95%.

Imaging of acquired immunodeficiency syndrome (AIDS).

Imaging plays an important role in the detection and characterisation of opportunistic infections and malignancies in patients with the acquired immunodeficiency syndrome (AIDS). The imaging features of opportunistic infections are often non-specific, but when examined in the context of CD4 levels will often allow a correct diagnosis to be made. It is important to be aware of specific syndromes such as lymphoproliferative disease and AIDS nephropathy. The radiologist is often the first clinician to suspect the possibility of human immunodeficiency virus (HIV) or AIDS in a patient's diagnostic work-up and it is, therefore, important that radiologists are familiar with the imaging features of this disease and its complications.

An investigation into the production of intra-articular gas bubbles and increase in joint space in the zygapophyseal joints of the cervical spine in asymptomatic subjects after spinal manipulation.

OBJECTIVES: To analyze the size and density of cervical zygapophyseal joint spaces in asymptomatic subjects using computed tomography (CT) and plain film radiography. The joint spaces were analyzed before manipulation without traction, before manipulation with manual traction, after manipulation without traction, and after manipulation with manual traction. The data obtained before the manipulation were compared with data obtained after the manipulation to determine if significant alterations occurred. DESIGN: Twenty-two asymptomatic subjects were placed into 1 or more of 6 possible experimental groups. In all experimental groups, except for experiment 1, the subjects underwent: (step 1) a premanipulation radiograph and/or CT scan, (step 2) a premanipulation plus traction radiograph and/or CT scan, (step 3) a postmanipulation radiograph and/or CT scan, and (step 4) a postmanipulation plus traction radiograph and/or CT scan. RESULTS: Except for experiment 2, there was no significant change in the width, area, and density values of the zygapophyseal joint spaces immediately after the manipulation in either the traction or traction-free positions of the neck, and no visible radiolucent cavities were demonstrated in any view. CONCLUSION: No evidence of gas in the joint space or obvious increase in zygapophyseal joint space width immediately after the manipulation was found. This was evident in both the traction and traction-free postmanipulation scans and plain film images. This is not consistent with the current understanding of cavitation in joints, in particular, the refractory period.

Telemedicine and neurosurgery: experience of a regional unit based in South Africa.

We carried out a retrospective analysis of all emergency referrals to the neurosurgery department of the Wentworth Hospital from 1996 to 1999. The hospital provided a service to seven peripheral hospitals with computerized tomography (CT) scanners and 46 hospitals without, in the province of KwaZulu Natal. By the end of the study, six of the hospitals with CT scanners had facilities for teleradiology and the mean patient return rate had fallen to 17%. In comparison, almost half the patients seen from the hospitals with no CT scanners were returned to hospital after assessment at the Wentworth Hospital. We also carried out a prospective analysis of 100 consecutive teleradiology-assisted consultations from January to March 2000. Of the 57 patients (79%) who remained at their referral hospitals, 45 had a good outcome, while the other 12 (21%) patients had a poor outcome. The implementation of teleradiology-assisted consultation decreased the number of inappropriate inter-hospital transfers while maintaining appropriate patient care and improving outcome.

Amoebic liver abscess--results of a conservative management policy.

OBJECTIVE: To evaluate the safety and efficacy of conservative management of amoebic liver abscesses. DESIGN: A prospective study carried out over a 1-year period. SETTING: Inpatients and outpatients in a tertiary referral institution. SUBJECTS: Amoebic liver abscess was diagnosed on clinical, ultrasonographic, and serological features. All patients were treated with metronidazole. The indication for ultrasound-guided aspiration of the abscess was failure to improve clinically within 48-72 hours. MAIN OUTCOME MEASURES: Clinical improvement, clinical deterioration and failure of clinical improvement (persistent pain). RESULTS: In total 178 patients (male-to-female ratio 5:1) with 203 abscesses were treated during this period. Of these, 23 patients required percutaneous aspiration and 150 patients were managed without intervention and clinically resolved spontaneously. Abscesses requiring aspiration tended to be larger than those managed without aspiration (10.7 cm v. 8.2 cm) (p = 0.003). There were no complications following aspiration. Mean hospital stay was longer (12.3 days) for patients who underwent aspiration compared with those who did not (6.7 days) (p = 0.031). Only 5 patients presented with ruptured abscesses, 1 cutaneously and 4 intraperitoneally, with the only death in this latter category. CONCLUSION: Conservative medical management of amoebic liver abscess is safe. Percutaneous ultrasound-guided aspiration is indicated only in patients who fail to improve clinically after 48-72 hours rather than on rigid criteria.

Paravertebral arteriovenous malformation supplied by branches of the iliac arteries.

SUMMARY: Arteriovenous malformations of the spine and spinal cord can be classified into spinal cord arteriovenous malformations (AVMs) and fistulas (AVFs) and dural AVM and AVF occurring outside the dura but draining into the epidural veins called paravertebral AVM and AVF 1. Paravertebral malformations are rare arteriovenous communications outside the dura but draining into the epidural veins. These malformations produce symptoms from either venous congestion of the cord or cord compression from dilated epidural veins resulting in a myelopathy.We present a case of a patient with a lumbar paravertebral malformation treated successfully by endovascular occlusion of the feeders.

Appropriate neurological evaluation and multimodality magnetic resonance imaging in eclampsia.

HYPOTHESIS: Simultanagnosia is common in eclampsia and a visuospatial test may be the most appropriate method in assessing the degree and monitoring of neurological deficit. AIM: To determine a sensitive clinical test for the degree of neurological deficit in eclampsia and in monitoring neurological change. METHODS: Thirty women with eclampsia were evaluated by clinical neurological quantitative scales including the Canadian Neurological Scale, Glasgow Coma Scale, Mini-Mental State Examination, a validated Cookie Theft Picture Test (CTPT), magnetic resonance imaging (MRI) (T1/T2), diffusion weighted imaging (DWI) and magnetic resonance angiography (MRA). RESULTS: The CTPT, used to measure simultanagnosia, had a sensitivity of 100% (95% CI: 84.5-100), specificity of 33.3% (95% CI: 1.8-87.5) with positive predictive value of 93.1% (95% CI: 75.8-98.8) and negative predictive value of 100% (95% CI: 5.5-100). The degree of agreement between simultanagnosia as measured by CTPT and DWI was 93.3% (Kappa=0.474; P=0.001). Standard MRI compared with DWI had a sensitivity of 77.8% (95% CI: 57.3-90.6), specificity of 100% (95% CI: 31-100), positive predictive value of 100% (95% CI: 80.8-100) and negative predictive value of 33.3% (95% CI: 9-69.1). The degree of agreement between standard MRI and DWI was 90%, this was statistically significant (Kappa=0.412: P=0.001). CONCLUSIONS: The validated CTPT for simultanagnosia was abnormal in the majority (n=29; 96.7%) of eclamptic patients with other neurological scales normal. Standard MRI and DWI showed excellent correlation with this simple bedside clinimetric evaluation. The oedema in eclampsia is primarily of vasogenic origin.

Efficacy and cost-effectiveness of bronchial arterial embolisation in the treatment of major haemoptysis.

OBJECTIVE: To determine the efficacy and cost-effectiveness of bronchial artery embolisation (BAE) in the treatment of major and massive haemoptysis in HIV-positive and negative patients with pulmonary inflammatory disease. METHODS: A retrospective review of patients admitted over a period of 24 months to Wentworth Hospital with major haemoptysis treated using BAE. RESULTS: Eighty-seven patients were treated (77 males, 10 females). Bilateral disease was present in 50 patients (57%). Thirty-two patients were HIV-positive (37%). Embolisation was successfully performed in 77 patients (88.5%), and failed for technical reasons in 10 patients (11.5%). There was only one procedural complication. Fifty-seven patients had a successful outcome, with cessation of haemoptysis within 24 hours (66.5%). Haemoptysis continued in 30 patients (34%) (20 patients embolised and the 10 patients who had failed procedures). Fourteen of these patients (16%) required lobectomy or pneumonectomy as an emergency procedure. Five patients (5.7%) died from respiratory failure or pulmonary haemorrhage. Twenty-four HIV-positive patients were successfully embolised. Costing of BAE, including a 2-day ICU and 3-day ward stay, was R6,720; together with surgical resection the cost was R14,170. CONCLUSIONS: BAE is an effective treatment for major and/or massive haemoptysis in patients with pulmonary inflammatory disease who are not surgical candidates. Patients who are HIV-positive are able to tolerate the procedure well.

Vertebral artery injury in cervical spine trauma.

Forty-seven patients with cervical spine trauma were evaluated prospectively with magnetic resonance imaging (MRI) and angiography (MRA) to determine the incidence of vertebral artery injury. Twelve patients (25%) had vertebral artery injuries (one bilateral), and occlusion was identified in nine patients and dissection in four. The vertebral artery injury did not result in neurological dysfunction. No specific treatment was instituted for the vascular injury, and in four patients, MRA showed no evidence of recanalization at follow-up.

Arterial embolization for haemorrhage in the obstetric patient.

Arterial embolization is a safe and effective treatment for persistent post-partum haemorrhage that is unresponsive to conservative management. Embolization should be the treatment of choice in these patients provided that suitable radiological skills and equipment are available. Embolization is potentially useful in patients with antepartum haemorrhage in the last trimester or in patients at high risk for antepartum haemorrhage.