Direct and possible indirect effects of vaccination on rotavirus hospitalisations among children in Malawi four years after programmatic introduction.

INTRODUCTION: Despite increased use of vaccine in routine immunisation, rotavirus remains a major cause of acute gastroenteritis (AGE) in low-income countries. We describe rotavirus prevalence and hospitalisation in Malawi pre and four years post vaccine introduction; provide updated vaccine effectiveness (VE) estimates; and assess rotavirus vaccine indirect effects. METHODS: Children under five years of age presenting to a referral hospital in Blantyre with AGE were recruited. Stool samples were tested for rotavirus using Enzyme Immunoassay. The change in rotavirus prevalence was evaluated using Poisson regression. Time series analysis was used to further investigate trends in prevalence over time. VE against rotavirus diarrhoea of any severity was estimated using logistic regression. Indirect effects were estimated by evaluating rotavirus prevalence in unvaccinated children over time, and by comparing observed reductions in incidence of rotavirus hospitalisation to those expected based on vaccine coverage and trial efficacy estimates. RESULTS: 2320 children were included. Prevalence of rotavirus in hospitalised infants (<12 months) with AGE decreased from 69/139(49.64%) prior to vaccine introduction to 197/607(32.45%) post-vaccine introduction (adjusted RR 0.67[95% CI 0.55, 0.82]). Prevalence in children aged 12-23 months demonstrated a less substantial decline: 15/37(40.54%) pre- and 122/352(34.66%) post-vaccine introduction (adjusted RR 0.85, 95% CI 0.57, 1.28). Adjusted VE was 61.89%(95% CI 28.04-79.82), but lower in children aged 12-23 months (31.69% [95% CI -139.03 to 80.48]). In hospitalised infants with rotavirus disease, the observed overall effect of the vaccine was 9% greater than expected according to vaccine coverage and efficacy estimates. Rotavirus prevalence among unvaccinated infants declined post-vaccine introduction (RR 0.70[95% CI 0.55-0.80]). CONCLUSIONS: Following rotavirus vaccine introduction in Malawi, prevalence of rotavirus in hospitalised children with AGE has declined significantly, with some evidence of an indirect effect in infants. Despite this, rotavirus remains an important cause of severe diarrhoea in Malawian children, particularly in the second year of life.

Management of persistent purulent pericarditis using streptokinase for intrapericardial fibrinolysis.

Purulent pericarditis (PP) is a very serious condition with almost 100% mortality if untreated. Intrapericardial fibrinolysis is a preferred alternative to pericardectomy in the treatment of persistent PP, but there are no consensus guidelines on the standard protocol for this procedure in children. A 9-year-old boy was referred to the Medical Research Council Unit in The Gambia (MRC). He had been unwell for 18 days with a high continuous fever, cough, fast breathing, and dyspnoea on exertion. Prior to referral he had been treated for malaria and pneumonia with no improvement. At the MRC, he was diagnosed with purulent pericarditis caused by Staphylococcus aureus and after admission he was managed for 4 weeks with intravenous antibiotics, pericardial aspirations followed by saline lavage of the pericardium and intrapericardial antibiotic instillation. Despite these measures, massive re-accumulation of the purulent pericardial effusion continued. Once daily intrapericardial instillation of streptokinase at a dose of 18,000 i.u/kg diluted in 50 ml of normal saline, and saline washout of the pericardium after 2 hours was commenced on the 29th day of admission, in addition to the antibiotics. This technique of fibrinolysis employed for 2 days was effective in managing the persistent purulent pericarditis when pericardial aspiration and intravenous and intrapericardial antibiotics failed.

Experiences in providing training and education in aquatic animal health.

The Institute of Aquaculture brings together cross-disciplinary researchers to meet the wide range of training challenges faced as the global aquaculture industry grows. The Institute offers training in a range of academic levels from short courses, aimed at farm operatives, to BSc (Hons), MSc and PhD levels. The focus of training at the Institute is on promoting a holistic approach, emphasising the importance of understanding the aquatic production system as a whole as well as detailed knowledge of specific pathogens. To make training more accessible, the Institute has made the provision of Continuing Professional Development (CPD) a strategic objective and provides distance learning and flexible study options.

Problem-solving in suicide attempters.

BACKGROUND: Recent research studies on the psychological processes underlying suicidal behaviour have highlighted deficits in social problem-solving ability, and suggest that suicide attempters may, in addition, be passive problem-solvers. The aim of this study was to examine problem-solving in suicide attempters (including passivity) and to see whether the deficits are mood-dependent. METHOD: Two groups, a suicide attempter group and a non-suicidal psychiatric control group completed measures of depression, hopelessness, suicidal ideation and social problem-solving ability shortly after admission, and again 6 weeks later. In addition, a non-psychiatric control group provided baseline data at a single time point. RESULTS: The suicide attempter group displayed poorer problem-solving ability than matched psychiatric controls and this difference persisted despite change in mood. However, although suicidal patients were more passive in their problem-solving style than non-psychiatric controls, they were not significantly more passive than psychiatric controls. Problem-solving did not change with improving mood. CONCLUSIONS: Although passivity is not unique to suicidal patients, in combination with the smaller number and less effective alternatives generated, it may increase vulnerability.

Person first: what people with enduring mental disorders value about community psychiatric nurses and CPN services.

Based on a Scottish study, this article presents findings from qualitative analysis of interview data, on views of people with enduring mental disorders (people) regarding services provided by community psychiatric nurses (CPNs) and what these people value in working with CPNs. Thirteen people took part in semi-structured interviews, and data were analysed using strategies including thematic analysis. The main finding was that people value their interpersonal relationship with CPNs. This relationship has a specific function in the individual's overall social network. The CPN-person relationship forms the context of 'purposeful talk', and is shaped and developed through the talk. It provides comfort and a greater sense of confidence with which people can cope with daily life. A valued feature of the personalized relationship with CPNs is continuity, associated with regularity of contact with CPNs, accessibility (both physical and emotional) and respect for and commitment to people as individuals. We interpret CPNs, as they appear in these accounts given by people with enduring mental disorders, as 'beings-in-between', bridging symbolically the worlds of hospital and community. They are figures between 'friends' and professionals, to whom people who have been ill can relate and show feelings which would, if otherwise expressed, compromise participation in community. CPNs help sustain people experiencing 'illness in the context of life' and enhance their potential for participation in the community. In doing so they contribute to public health. Viability of sustaining relationships and personal care, valued at the micro-level of interaction, depends on support at the meso-level by managers, and at the macro-level by policy makers and funders. Health service managers who play a key role in instigating and managing service changes should engage in regular dialogue with CPNs about the impact of change on the ability of CPNs to maintain sustaining relationships with people. The adaptability of CPNs to the situation and the person-in-the-situation needs to be facilitated, not compromised, by the requirements of record-keeping and accounting systems. Practice described in this study indicates the possibility of CPNs relating to the person in ways consistent with a 'community development approach'. Limitations of the study are noted. Our findings are highly contextualized and based on a small sample. Nonetheless, they are consistent with findings from other studies also based on listening to service users' accounts of problems of living with enduring mental disorder. Implications of the analysis of peoples' perceptions of the role of CPNs are considered, with attention to service providers, policy makers and future research.

Effective problem solving in suicide attempters depends on specific autobiographical recall.

The relationship between over-general autobiographical memory and interpersonal problem solving was investigated by comparing a group of suicide attempters with a nonsuicidal psychiatric control group and a normal control group. Results showed that suicide attempters were more over-general in memory and displayed significantly poorer problem solving than the other two groups. Furthermore, suicide attempters who were more over-general displayed greater deficits in problem solving. It was concluded that effective problem solving in suicide attempters depends on specific autobiographical recall.

Nonconvulsive status epilepticus causing acute confusion.

PRESENTATION: an elderly patient presented with acute confusion and was found to have nonconvulsive status epilepticus. She responded to treatment with anti-epileptic drugs. OUTCOME: this case illustrates an important, under-recognized and reversible cause of acute prolonged confusion.

Progress's Pilgrim: a critical narrative of research in progress.

There is increasing interest in the use of stories to develop nursing and health care practice. This paper reports on how we used story to understand and develop research on nursing practice. Story (or narrative) and science can be seen as distinct but complementary paradigms. We have found that a story framework can help researchers to reflect on a process of social scientific investigation, and to consider how to 'go on' in that process. In a study on 'Community psychiatric nurses' empowerment of people with enduring mental disorders in the community: involving users to develop services' we have encountered a number of interesting and challenging issues related to design and use of methods. We present these issues within a framework of story analysis, focusing on issues related to empowerment. This analysis draws on Burke's 'pentad' of story elements as a framework for narrative analysis. We present the elements of the 'story of the study-as-funded' and as it was carried out through the pilot stage, and outline the story of developments in the main study. 'Trouble' in a story centres on a problematic 'ratio' of story elements. The 'trouble' at this stage in the progress of our study relates to lack of fit between some parts of the instruments (the methods) and the goal (empowerment), and to the status of the CPNs as actors or agents. Narrative analysis sensitizes us to these issues of 'trouble' and provides a means of addressing them. Like John Bunyan's Pilgrim, we have learned through our progress; unlike Pilgrim, we know not our end.

Discourses on empowerment.

The discourse community of British psychiatric and mental health nursing is a contested realm. The 'Big Stories' of policy and planning of services are clearly articulated in disputes in journals, but the 'Little Stories' of nurses' work and patients' or users' experiences may be ignored or under-valued. This paper illustrates how the Big Story of a central theme in current policy--empowerment--is articulated in the realm of research funding and design, and how it is articulated by practitioners. The paper focuses attention on the responsibilities faced by researchers, in relating the Little Stories of practice and the Big Story of policy. It reports early and tentative findings from a study of community psychiatric nurses' empowerment of people with enduring mental disorders. The paper suggests ways in which strategies for analysis of qualitative data from interviews with CPNs may be informed by ideas drawn from the field of discourse analysis; reflexively examining how researchers' discourses relate to those of policy makers and mental health nursing practitioners. This paper is based on a presentation at the Network for Psychiatric Nursing Research Conference, Napier University, Edinburgh, 17 September 1997.