Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal.

BACKGROUND: In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists. METHODS: We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of 'Yes' or 'No' questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback. RESULTS: For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components. CONCLUSION: Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Riparian shading controls instream spring phytoplankton and benthic algal growth.

Dissolved oxygen (DO) concentrations showed a striking pattern in a multi-year study of the River Enborne, a small river in SE England. In each of three years (2010-2012), maximum DO concentrations were attained in mid-April, preceded by a period of steadily increasing diurnal amplitudes, followed by a steady reduction in both amplitude and concentration. Flow events during the reduction period reduce DO to low concentrations until the following spring. Evidence is presented that this pattern is mainly due to benthic algal growth which is eventually suppressed by the growth of the riparian tree canopy. Nitrate and silicate concentrations are too high to inhibit the growth of either benthic algae or phytoplankton, but phosphate concentrations might have started to reduce growth if the tree canopy development had been delayed. This interpretation is supported by evidence from weekly flow cytometry measurements and analysis of the diurnal, seasonal and annual patterns of nutrient concentrations. As the tree canopy develops, the river switches from an autotrophic to a heterotrophic state. The results support the use of riparian shading to help control algal growth, and highlight the risks of reducing riparian shade.

Characterising phosphorus and nitrate inputs to a rural river using high-frequency concentration-flow relationships.

The total reactive phosphorus (TRP) and nitrate concentrations of the River Enborne, southern England, were monitored at hourly interval between January 2010 and December 2011. The relationships between these high-frequency nutrient concentration signals and flow were used to infer changes in nutrient source and dynamics through the annual cycle and each individual storm event, by studying hysteresis patterns. TRP concentrations exhibited strong dilution patterns with increasing flow, and predominantly clockwise hysteresis through storm events. Despite the Enborne catchment being relatively rural for southern England, TRP inputs were dominated by constant, non-rain-related inputs from sewage treatment works (STW) for the majority of the year, producing the highest phosphorus concentrations through the spring-summer growing season. At higher river flows, the majority of the TRP load was derived from within-channel remobilisation of phosphorus from the bed sediment, much of which was also derived from STW inputs. Therefore, future phosphorus mitigation measures should focus on STW improvements. Agricultural diffuse TRP inputs were only evident during storms in the May of each year, probably relating to manure application to land. The nitrate concentration-flow relationship produced a series of dilution curves, indicating major inputs from groundwater and to a lesser extent STW. Significant diffuse agricultural inputs with anticlockwise hysteresis trajectories were observed during the first major storms of the winter period. The simultaneous investigation of high-frequency time series data, concentration-flow relationships and hysteresis behaviour through multiple storms for both phosphorus and nitrate offers a simple and innovative approach for providing new insights into nutrient sources and dynamics.

Femoral nerve block for pain relief in hip fracture: a dose finding study.

Hip fracture is the most common orthopaedic emergency. We investigated the concentration of 30 ml levobupivacaine that provided analgesia to 50% and 95% of patients with a hip fracture when injected around the femoral nerve under ultrasound guidance. We defined analgesia as a ≥ 20-point decrease on a 100-point pain scale with reduced cold sensation in the middle third of the anterior thigh 30 min after the nerve block. We increased the concentration of levobupivacaine if the preceding dose had been ineffective and decreased it if the preceding dose had been effective. Probit regression modelling estimated the effective (95% CI) concentration of 30 ml levobupivacaine in 50% and 95% of patients with a fractured hip to be 0.026 (0.023-0.028)% w/v and 0.036 (0.027-0.047)% w/v, respectively.

EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases.

To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.

User and carer involvement in child and adolescent mental health services: a Norwegian staff perspective.

It has been suggested that user involvement in heath care leads to improved services. The aim of the study was to explore attitudes towards user involvement of staff employed in Norwegian Child and Adolescent Mental Health Services (CAMHS). Most of the investigated mental health service staff expressed the opinion that users should be involved in the planning of their own treatment and generally have a positive attitude towards user involvement. Skepticism was related to some aspects of involvement and does not contradict their generally positive attitude towards user involvement.

Data collection from very low birthweight infants in a geographical region: methods, costs, and trends in mortality, admission rates, and resource utilisation over a five-year period.

AIMS: 1. To determine the survival and morbidity of infants at discharge with a birthweight of less than 1500 g in the geographically defined population of East Anglia. 2. To demonstrate a cost-effective method of regional data collection. 3. To determine whether there were any changes in the demand for neonatal care. STUDY DESIGN AND SUBJECTS: A prospective cohort analysis using a single database to collect data on 1244 very low birthweight infants from eight neonatal units in one Region from 1993 to 1997. RESULTS: Estimated ascertainment of VLBW infants to the study was 96%. Over the 5 years survival rates were stable (75-79%). 52% of deaths in infants admitted for neonatal care occurred on day 1, with just 15% of deaths occurring after 28 days of life. Mortality risk significantly decreased with increasing gestational age at birth. Compared to 22-25-week old infants, the mortality risk decreased by 65% for 26-27-week old infants (OR 0.35 95% CI (0.21, 0.59)) and by 92% for 32-39-week old infants (OR 0.08 95% CI (0.03, 0.21)) with intermediate odds ratios of 0.22 (0.12, 0.42) and 0.13 (0.06, 0.28) for the 28-29 and 30-39 weeks gestation, respectively. Higher birthweight, after adjusting for gestation also decreased the mortality risk (OR 0.78 per 100 g difference, 95% CI (0.71, 0.86)). No change was seen in the number of extremely preterm infants admitted for intensive care or resource utilisation, although a significant increase was seen in the number of infants dying in delivery rooms. There was a reduction in the reported incidence of pulmonary interstitial emphysema (10-4%) but no change in the number of ventilation days or the rate of chronic lung disease. The mean maternal age increased from 27.7 years to 28.9 years during the study. Maternal steroid administration increased (30% to 59%) and was associated with a decreased risk of mortality (OR 0.44, 95% CI: 0.31-0.62). CONCLUSIONS: It is possible to collect useful data from the neonatal period at a reasonable cost from a geographically defined population. This information was used for informing clinicians, counselling parents and in the era of managed clinical networks will be useful in guiding the provision of effective health care resources.

Outcome at 2 years for very low birthweight infants in a geographical population: risk factors, cost, and impact of congenital anomalies.

AIM: To determine the type and rate of disability at 2 years of age in infants born in the geographically defined population of East Anglia with a birthweight less than 1500 g and to assess the risk factors for disability. STUDY DESIGN: A prospective cohort analysis from all eight neonatal units in East Anglia from 1993-1997 using a single database. METHODS: Local paediatricians assessed children at 2 years using the Health Status Questionnaire and data collection was centrally coordinated. RESULTS: Outcomes for 947 children, 99% of survivors, were available, 74 (7.8%) had severe disability and this was significantly associated with gestational age (p<0.0005), birthweight (p<0.0005) and sex (p=0.046). Major congenital abnormality contributed 27% of all severe disability. The overall cerebral palsy rate was 6.2%, nine children were blind and five had sensorineural hearing loss requiring aids. These children had a high level of use of community services with 19% of the cohort being referred to one or more community service. ELBW infants or those born <30 weeks gestation were 1.5 times and twice as likely to have moderate or severe disability and 2.3 and 5.4 times as likely to have cerebral palsy as those weighing 1000 to 1500 g or >30 weeks gestation. Boys were at higher risk of adverse outcome. CONCLUSIONS: The study was able to define the increased risk associated with being born at lower gestational age or lower birthweight and demonstrates successful ascertainment of outcomes for large local populations at a reasonable cost.

Expression of PrPC on cellular components of sheep blood.

PrP(C), a glycosylphosphatidylinositol-linked glycoprotein, plays a central role in the pathogenesis of transmissible spongiform encephalopathies (TSEs), undergoing a conformational alteration to the disease-associated isoform, commonly designated PrP(Sc). PrP(C) is expressed in many tissues other than the nervous system, although its precise function(s) remains unclear. It has previously been demonstrated that TSEs can be transmitted by blood transfusion in sheep. The aim of this work was to identify which components of blood carried the infection. As an initial step, the distribution of PrP(C) on cellular components of sheep blood was examined to identify potential targets for infection. Cell-surface expression of PrP(C) was found only on peripheral blood mononuclear cells (PBMCs); however, platelets also contained significant amounts of intracellular PrP(C). The level of PrP(C) expressed on the cell surface of PBMCs was influenced by PrP genotype, with the highest levels found in scrapie-susceptible VRQ/VRQ sheep and the lowest levels in scrapie-resistant ARR/ARR sheep. In susceptible sheep, PrP(C) was expressed at varying levels on all major subsets of PBMCs, with the highest levels on the CD21(+) subset of B cells, and PrP expression was upregulated dramatically on CD21(+) B cells in some scrapie-infected sheep.

Decision-making at the end-of-life and the incompetent patient: a comparative approach.

In contrast to the situation in the Netherlands and Belgium, the legislatures in both England & Wales and Germany have not recognised that active euthanasia may be lawful in any circumstance. Nevertheless, the courts in both jurisdictions have held that passive euthanasia, that is the withdrawal or withholding of life-prolonging treatment, is perfectly lawful; indeed it will often constitute good medical practice. This article adopts a comparative approach to assessing the manner in which decisions to withdraw or withhold life-prolonging treatment are made in relation to previously competent patients without a legally effective advance directive or a proxy decision-maker, considering the approaches adopted by the courts in England & Wales and Germany: the best interests and 'presumed will' approaches respectively. Due to the inherent drawbacks associated with each approach it is concluded that the best way forward would be for both jurisdictions to adopt a mixed approach, allowing the autonomy model to temper the best interests approach, recognising that the patient is an individual rather than simply an object of concern.

New Zealand sheep with scrapie-susceptible PrP genotypes succumb to experimental challenge with a sheep-passaged scrapie isolate (SSBP/1).

Scrapie does not occur in New Zealand (NZ), although PrP gene alleles associated with susceptibility to the disease are found at relatively high frequencies in NZ sheep. The hypothesis that scrapie is a genetic disease of sheep is thus unlikely to be true. To confirm that NZ sheep are actually susceptible to scrapie infection, NZ sheep of various PrP genotypes were challenged by subcutaneous inoculation with a sheep-passaged scrapie isolate (SSBP/1). Showing similar PrP genetics to that seen in UK sheep, all NZ sheep carrying the VRQ PrP allele developed clinical signs typical of scrapie, with characteristic neurodegenerative changes and PrP(Sc) evident on histopathological examination of their brains and lymphoid tissues. The incubation periods recorded in NZ sheep were generally shorter than those found in UK sheep. The results confirm that New Zealand sheep are as susceptible as their UK counterparts to experimental scrapie infection by subcutaneous inoculation.

Gait and function after intra-articular arthrodesis of the hip in adolescents.

BACKGROUND: Patients who have had a hip arthrodesis have been reported to have pain in the back and the knee due to an altered gait. There is little information about the specific compensatory mechanisms that are adopted when walking. The purpose of this study was to objectively define gait adaptations after an arthrodesis of the hip and to correlate the kinematic findings with pain and other patient outcomes. METHODS: Nine patients who had had an arthrodesis of the hip at an average age of thirteen years and five months (range, ten years and nine months to sixteen years and eleven months) were evaluated with gait analysis and muscle strength-testing and completed a questionnaire related to pain and function. The average duration of follow-up was eight years and ten months (range, two years and one month to thirteen years and ten months). The frequency of the postoperative visits varied. Seven patients were adults at the time of the study and were called back specifically for the study. RESULTS: All patients had decreased cadence and step lengths. The kinematic findings included decreased dorsiflexion of the ipsilateral ankle, hyperextension of the ipsilateral knee during the stance phase, and a tendency toward increased genu valgum during gait. In normal gait, there is no genu varum or valgum during the stance phase. The patients had an average (and standard deviation) of 7 +/- 4 degrees of genu valgum. Pelvic and lumbar motion in the sagittal plane was excessive in all patients. Strength-testing revealed clinically relevant weakness in the ipsilateral quadriceps in all patients, with a difference of more than 20 percent between the two extremities in six patients. The gastrocnemius. soleus muscle was stronger on the side with the fused hip in six patients. The questionnaire, designed by Harris in 1969 and completed by the patients at the time of the gait analysis, revealed back pain in seven patients. The questionnaire was administered only once. The functional outcome as measured with use of the same questionnaire worsened as the duration of follow-up increased. CONCLUSIONS: The gait analysis showed excessive motion in the lumbar spine and the ipsilateral knee in all nine patients. This abnormal motion led to pain as the duration of follow-up increased, and all patients who had been followed for four or more years after the arthrodesis complained of back pain. We hypothesized that excessive motion for an extended duration can lead to back pain. The preferred position of the hip for the arthrodesis was 20 to 25 degrees of flexion, neutral abduction-adduction, and neutral rotation.

PMTI, a broadly active unusual single-stranded polyribonucleotide, inhibits human immunodeficiency virus replication by multiple mechanisms.

Poly(1-methyl-6-thioinosinic acid), or PMTI, is a single-stranded polyribonucleotide and is the first homopolyribonucleotide devoid of Watson-Crick hydrogen bonding sites to show potent human immunodeficiency virus (HIV) inhibition. PMTI was found to be active when evaluated against a variety of low passage clinical HIV isolates in fresh human peripheral blood cells, including T cell-tropic and monocyte-macrophage-tropic viruses, syncytium-inducing and non-syncytium-inducing viruses and viruses representative of the various HIV-1 clades (A through F). The compound was active against HIV-2, all nucleoside and non-nucleoside reverse transcriptase (RT) inhibitor drug-resistant virus isolates tested and interacted with AZT or ddl to synergistically inhibit HIV infection. In biochemical inhibition assays, PMTI was determined to be a potent inhibitor of HIV-1 and HIV-2 RT, including RTs with mutations that engender resistance to nucleoside and non-nucleoside RT inhibitors. PMTI inhibited both the polymerase and RNase H activities of HIV RT. PMTI did not inhibit HIV-1 protease or integrase. Cell-based mechanism of action assays indicated that PMTI also interfered with early events in the entry of HIV into target cells. Furthermore, PMTI inhibited the fusion of gp120-expressing and CD4-expressing cells, but at concentrations approximately 1 log10 greater than those that inhibited virus entry. These results suggest that the homopolyribonucleotide PMTI blocks HIV replication in human cells at its earliest stages by multiple mechanisms, inhibition of virus entry and inhibition of RT.

Psychological interventions in self-injurious behaviour. Working with people with a learning disability.

BACKGROUND: Psychological approaches to working with people with learning disabilities who self-injury have developed over the past 30 years. METHOD: The major literature is reviewed and an ecological framework is described which emphasises the importance of environmental, interpersonal and intrapersonal dynamics to understanding the multi-factorial nature of self-injury. Case examples are given. RESULTS: Self-injury is seen as essentially communicative and functionally adaptive; it is the person's best attempt to deal with abusive, neglecting or traumatic environments or events. CONCLUSIONS: The persistence of self-injurious behaviour once established, requires an interdisciplinary approach which addresses comprehensively the variety of factors which have contributed to the development and maintenance of self-injury.

Isolation and characterization of adociavirin, a novel HIV-inhibitory protein from the sponge Adocia sp.

Aqueous extracts of the New Zealand sponge Adocia sp. (Haplosclerida) displayed potent anticytopathic activity in CEM-SS cells infected with HIV-1. Protein fractions of the extract bound both to the viral coat protein gp120 and to the cellular receptor CD4, but not to other tested proteins. The purified active protein, named adociavirin, was characterized by isoelectric focusing, amino acid analysis, MALDI-TOF mass spectrometry and N-terminal sequencing. Adociavirin, a disulfide-linked homodimer with a native molecular weight of 37 kDa, was active against diverse strains and isolates of HIV-1, as well as HIV-2, with EC50 values ranging from 0.4 nM to > 400 nM. The anti-HIV potency of adociavirin appears dependent on host cell type, with macrophage cultures being the most sensitive and peripheral blood lymphocytes the most resistant.

Gait analysis and muscle strength in children with congenital pseudarthrosis of the tibia: the effect of treatment.

Twelve patients with healed congenital pseudarthrosis of the tibia underwent gait analysis and muscle strength testing to determine the functional result of treatment. Six children younger than 4 years of age presented with pseudarthroses (early onset), and six children first fractured at older than 4 years of age (delayed onset). Four children with amputations as final treatment for congenital pseudarthrosis were studied for comparison. The early-onset group had undergone an average of 4.2 surgeries and all required transankle fixation. The delayed-onset group had undergone an average of 1.5 surgeries, with one child requiring fixation across the ankle. Lack of ankle push-off and foot drop occurred in the early-onset group. Terminal stance phase ankle power generation was greatly diminished in the early-onset group. Total mechanical work performed by the affected limb, when compared to the uninvolved contralateral limb, was symmetric in delayed-onset patients and reduced by 68% in early-onset patients and by 85% in amputees. Gastrocsoleus strength was reduced by 40%. Gait and muscle strength of patients with "healed" congenital pseudarthrosis of the tibia are markedly disturbed. Early onset of disease, early surgery, and transankle fixation lead to an inefficient gait comparable to that of amputees.

The effect of limb-length discrepancy on gait.

We evaluated the gait of thirty-five neurologically normal children who had a limb-length discrepancy of the lower extremities that ranged from 0.8 to 15.8 per cent of the length of the long extremity (0.6 to 11.1 centimeters). The twenty-two boys and thirteen girls had an average age of thirteen years (range, eight to seventeen years). No patient had a substantial angular or rotational deformity of the lower extremities. We found no correlation between the actual discrepancy or the per cent discrepancy and any of the dependent kinematic or kinetic variables, including pelvic obliquity. Discrepancies of less than 3 per cent of the length of the long extremity were not associated with compensatory strategies. When a discrepancy was 5.5 per cent or more, more mechanical work was performed by the long extremity and there was a greater vertical displacement of the center of body mass. Clinically, this degree of discrepancy was manifested by the use of toe-walking as a compensatory strategy. Children who had less of a discrepancy were able to use a combination of compensatory strategies to normalize the mechanical work performed by the lower extremities.