Locked in grief: a qualitative study of grief among family members of missing persons in southern Sri Lanka.

INTRODUCTION: The psychological and social issues experienced by family members of missing persons are different from normal grief following the death of a loved one. The term "Ambiguous loss" describes this psychological phenomenon. Ambiguous loss acts as a barrier to adjusting to grief, leading to symptoms of depression and intra and interpersonal relational conflicts. An in-depth phenomenological understanding of this subjective experience is important. METHOD: A qualitative study was conducted among close family members of persons who had gone missing during the civil conflict and the 2004 tsunami in southern Sri Lanka following formal ethical approval from an university ethics review committee. Purposive and snowballing sampling methods were used to recruit the participants. Theoretical sample saturation was achieved with 24 family members of missing persons. Responders were mothers, fathers, wives, husbands, and siblings of missing individuals. In-depth interviews were recorded with the help of a semi-structured guide, after informed consent. The recordings were transcribed and coded by three independent investigators. The investigators through consensus arrived at the phenomenological themes and grounded them through reflexivity. The triangulation process involved cross-checking observational notes made by the interviewers and consulting the interviewees. RESULTS: We interviewed 24 first degree relatives of missing individuals. Twenty-one of the interviewees were unsure about the fate of the missing individual, while three of them believed the missing individual to be dead. Of the 24 missing individuals, 20 were males and 18 had gone missing in civil conflicts and 6 in the Indian Ocean Tsunami. Six predominant phenomenological themes were identified. Those were lack of closure, hope, guilt, helplessness, perpetual suffering, and an emotional vacuum. These phenomenological experiences are highlighted by the interviewees through a range of utterances that hold profound cultural, social and emotional significance of unresolved and vacillating grief. CONCLUSION: The highlighted phenomenology of grief in surviving family members of those who go missing following traumatic events demands a response from health and social services in every country that experiences disaster. The surviving loved one is 'locked in grief' indefinitely and future research on evidence-based interventions to overcome this predicament is warranted.

Unconfirmed death as a predictor of psychological morbidity in family members of disappeared persons.

BACKGROUND: The 2004 tsunami, the civil conflict until 2009 and the youth insurrection in the late 1980s in Sri Lanka resulted in many persons being classified as 'missing' as they disappeared and were unaccounted for. Our aim was to compare the prevalence of major depressive disorder (MDD) and prolonged grief disorder (PGD) in families of disappeared individuals, who eventually received the mortal remains and those who did not. METHOD: An ethically approved cross sectional study was conducted in a purposively selected sample after informed consent. Information on the circumstances of the family member going missing was gathered. Culturally adapted versions of the General Health Questionnaire and the Beck Depression Scale were administered. Those who screened positive were assessed by a psychiatrist on Diagnostic and Statistical Manual of Mental Disorders-5 criteria to arrive at a diagnosis. RESULTS: Of 391 cases of disappearances studied, MDD (17.5% v. 6%) and PGD (22% v. 7%) were significantly higher in those who did not eventually receive the mortal remains of the disappeared person. Among those who did not receive the mortal remains, being unsure whether the disappeared person was dead or alive was highly predictive of MDD and PGD. Mothers and wives, older family members and those with a family history of mental illness were more vulnerable. CONCLUSIONS: Family members of missing individuals unsure whether their loved one was alive or dead have higher psychological morbidity in the form of MDD and PGD.

Psychological morbidity and illness perception among patients receiving treatment for tuberculosis in a tertiary care centre in Sri Lanka.

A descriptive cross sectional study was carried out to determine prevalence of depression and anxiety and to describe disease perception among patients with tuberculosis (TB) at National Hospital for Respiratory Diseases (NHRD), Welisara. Consecutive patients on anti-TB therapy admitted to wards and attending clinic were recruited until the estimated sample of 430 was reached. They were assessed using Hospital Anxiety and Depression Scale (HADS) and Brief Illness Perception Questionnaire (BIPQ). A total of 254 in-ward patients and 176 clinic patients were included. Of the inward patients, 25.2% had depression and 12.6% had anxiety. Of the clinic patients, 17.6% screened were positive for anxiety and 8.5% screened were positive for depression. Mean BIPQ score was 27.44 for the whole population. Prevalence of depression was significantly higher among in-ward patients (25.2%, p<0.0001), elderly age groups (20.5%, p=0.007), patients with lower education levels (20.6%, p= 0.012) and previously treated patients (32.3%, p=0.004). In-ward group (50.8%, p=0.002), lower education group (48.7%, p<0.0001), previously treated group (60%, p=0.005) and patients with depression (60.8%, p=0.001) and anxiety (68.3%, p<0.0001) showed significanly higher BIPQ scores. Our study shows that depression and anxiety are common among patients receiving treatment for TB.

Elder abuse among outpatient department attendees in a tertiary care hospital in Sri Lanka.

OBJECTIVES: Abuse of older people is a hidden problem. Some believe that it is less in Asian societies as the extended family is a protective factor. The real extent of the problem however, is not researched adequately in Sri Lanka. METHODS: A cross sectional descriptive study was conducted at the North Colombo Teaching Hospital on 530 consecutive adults above 60 years of age attending the out-patient department. The Hwalek-Sengstock elder abuse screening test with modifications to address socio-cultural differences was administered. A brief demographic questionnaire and questions on past and present abuse were also included. RESULTS: Out of 530 elders studied, 32 (6%) were above 80 years of age and the mean age was 68.5 years. Male to female ratio was 1:2. Abuse, either physical, psychological, verbal or neglect was reported by 239 (45%) elders. Physical abuse was reported by 5.6%. The screening test revealed that the study population was vulnerable to psychological and financial abuse. Total overall rate of abuse was 38.5%. Loneliness was reported by 26%. Of the caregivers, 22% were financially dependent on the elders. Having more than three children was a risk factor for psychological and financial abuse and being single was a risk factor for psychological abuse. CONCLUSIONS: Physical, emotional and financial abuse of elders were reported in our study population. A limitation of this study was that it studied elders who sought treatment at a tertiary care hospital. Community studies will be needed to establish the true prevalence of elder abuse.

The knowledge and attitude of primary school teachers in Sri Lanka towards childhood attention deficit hyperactivity disorder.

OBJECTIVE: To assess the knowledge and attitudes towards attention deficit hyperactivity disorder (ADHD) among primary school teachers in the Gampaha District. METHODS: A descriptive cross sectional study was conducted in randomly selected schools of Gampaha district using a stratified sampling method. The knowledge and attitudes on ADHD were assessed by a self-administered questionnaire distributed among all the consenting primary school teachers in the selected schools. RESULTS: Total of 202 completed questionnaires of 210 distributed were returned. The majority showed good understanding about ill effects ofADHD, teachers' role in management and counterproductive effects of punishment. Three-fourths had a positive attitude towards behavioural therapy. However, only a minority had adequate knowledge about the presentation of ADHD and its treatment with medication. More than 80% of teachers believed that the parents were to be blamed for the child's ADHD. The majority of participating teachers also believed that behavioural disturbances caused by ADHD children were deliberate and malicious. Teachers who had training in child psychology recorded a significantly higher knowledge and had a more favourable attitude. CONCLUSIONS: The knowledge of ADHD and its treatment among primary school teachers needs to be improved. Particular focus should be on improving attitudes and disseminating the message that timely interventions can make a difference in the educational and social development of the child.

Mental health research trends in Sri Lanka.

OBJECTIVE: To review the number of research publications in the field of mental health in Sri Lanka from 1900 to 2009. METHODS: A search of all publications in psychiatry and mental health from Sri Lanka was conducted using Pubmed, all medical journals published in Sri Lanka and researchers. The identified papers were reviewed for their content and categorised as research in psychiatry and mental health, based on strict inclusion and exclusion criteria. RESULTS: A total of 207 papers were identified. The first mental health research publication from Sri Lanka is in 1964. The last decade (2000-2009) accounted for 62% of the publications with the majority of the papers being published in indexed journals. The Ceylon Medical Journal carried the most number of papers and the topic on which most of the research was conducted was suicide and deliberate self harm. CONCLUSIONS: There is an increasing trend towards research in to psychiatry and mental health in Sri Lanka.

Olfactory impairment is more marked in patients with mild dementia with Lewy bodies than those with mild Alzheimer disease.

BACKGROUND: Dementia patients with anosmia are more likely to have Lewy body pathology at postmortem, but clinicopathological studies have only assessed olfaction in moderate dementia or an average of 5 years before death. It is not known whether, in patients with mild dementia (MMSE score over 20), olfactory function is more impaired in Alzheimer disease (AD) than dementia with Lewy bodies (DLB). METHODS: Patients with mild DLB (n = 21), mild AD (n = 27), mild cognitive impairment (MCI) (n = 21) and controls (n = 47) were assessed using a 16-item olfactory identification test and an olfactory threshold test which used sticks impregnated with differing concentrations of butanol. RESULTS: Patients with mild DLB had impaired olfactory identification ability compared with those with mild AD or MCI, independent of age, cognitive function and sex. The sensitivity of a cutoff score of seven correct responses out of 16 was 0.81 for distinguishing mild DLB from mild AD (AUC 0.682). The specificity, positive predictive value and negative predictive value for the same cut-off score were 0.41, 0.48 and 0.73, respectively. The olfactory threshold was not different in the AD and DLB groups. CONCLUSIONS: Simple bedside tests of olfactory identification merit further examination for their potential to improve the identification of patients with DLB when used alongside existing criteria. They are insufficiently specific for use in screening.

Predicting normal lung function in patients with childhood spinal cord injury.

STUDY DESIGN: A prospective observational study. OBJECTIVES: To compare the height and arm span measurements in childhood spinal cord injured (SCI) people and examine the subsequent effect on calculating the predicted lung function using standard formulae and to discuss which of the two measurements is the most appropriate to use in these formulae. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHOD: A total of 12 children had lung function tests performed and at the same time had height and armspan measured. The predicted lung function was calculated twice; once using height and then using arm span and compared. The actual lung function test results were expressed as percentage of the two predicted values, respectively, and compared. RESULTS: The difference between the mean height (1499 mm) and arm span (1649 mm) measurements was significant (P<0.001). In all cases, the arm span measurement was greater than the height. The two predicted lung function values (one calculated using height and the other armspan) were significantly different (P<0.001). When lung function test results were expressed as percentage of the two predicted values they gave a very different interpretation of the results. The actual performance was much lower than the predicted values if arm span, rather than height, was used in prediction equations. CONCLUSION: In childhood SCI, the difference in height and arm span is significant. This affects the predicted lung function values significantly and thus changes the interpretation of the lung function test results. The most appropriate measurement to use in prediction equations (height or arm span) in these subjects is yet to be decided.

Psychological distress among students from five universities in Sri Lanka.

OBJECTIVE: To determine the proportion of university students that are psychologically distressed when compared to an age and sex matched population sample and to describe the factors that may contribute to their distress. DESIGN: A cross-sectional comparison study. METHODS: The general health questionnaire (GHQ 30), previously validated in Sinhala, was administered as a screening test to random samples of undergraduates in 5 universities. Age and sex matched controls from the respective communities were also administered the screening test. The undergraduates also filled in a pre-tested questionnaire with personal details. Chi-square tests were used to determine statistical significance between groups. RESULTS: Among the undergraduates, 104 (39.8%) had scores for psychological distress whereas only 67 (25.7%) from the community sample had scores for similar distress. This difference was significant (p = 0.0007). A significantly greater proportion (p = 0.009) of those entering from rural schools were psychologically distressed than those from suburban and urban schools, and a greater proportion living in rented rooms and hostels were (p = 0.001) distressed than those travelling from their homes. CONCLUSIONS: The psychological distress among undergraduates was significantly greater than among the general population. More students who enter from rural schools seem to be distressed than those who enter from suburban and urban schools.

Decreased CD44 standard form expression correlates with prognostic variables in ovarian carcinomas.

Expression of CD44 standard form (CD44s) was evaluated by automated immunohistochemical analysis using the anti-CD44 A3D8 clone in 101 ovarian epithelial neoplasms including 82 primary tumors (64 carcinomas and 18 tumors of low malignant potential [LMP]), 9 lymph node metastases, 8 malignant ascites, and 2 peritoneal implants. Immunostaining was scored semiquantitatively. Tumors were graded according to the FIGO (International Federation of Gynecology and Obstetrics) classification system. Tumor stage and patient survival were determined from the patient records. While 9 of 18 LMP tumors expressed CD44s, only 15 of 64 carcinomas expressed it. In the carcinomas, univariate analysis revealed that decreased CD44s expression correlated with high tumor grade, advanced stage, and shortened survival. Loss of CD44s expression also was noted in the tumor cells in 8 of 9 lymph node metastases, 7 of 8 malignant ascites, and 1 of 2 implants. Multivariate analysis revealed that only tumor stage independently correlated with patient survival. Loss of CD44s expression determined by immunohistochemical analysis is more common in ovarian carcinomas than in LMP tumors; correlates with prognostic variables including tumor grade, stage, and survival; and may have an important role in the dissemination of ovarian cancer.

Human inflammatory cells within the tumor microenvironment of lung tumor xenografts mediate tumor growth suppression in situ that depends on and is augmented by interleukin-12.

The human tumor microenvironment includes a mixture of tumor cells, inflammatory cells, fibroblasts, and endothelial cells, all of which are tethered to an extracellular matrix. It has been difficult to study the dynamic interactions of these cells in human tumors in situ for obvious ethical and logistical considerations that prohibit experimental manipulations of tumors while still in patients. Fresh tissue from human lung tumor biopsy implanted into SCID mice was shown to remain viable, and the histologic appearance of the tumor microenvironment was maintained in the tumor xenografts for at least 3 months. In this study, the authors established that the inflammatory cells within human tumor xenografts can suppress tumor growth, and that this suppression is a result, in part, of endogenously produced interleukin-12 (IL-12) because IL-12 neutralizing antibodies enhance the growth of the tumor xenografts. The tumor-inhibitory activity of the inflammatory leukocytes is also enhanced by the local and sustained release of human recombinant IL-12 into the tumor microenvironment from cytokine-loaded biodegradable microspheres. Neither the anti-IL-12 neutralizing antibody nor the delivery of exogenous IL-12 from microspheres had any effect on tumor xenografts in the absence of the inflammatory leukocytes. In conclusion, the inflammatory cells within the tumor microenvironment of human lung tumor xenografts are functional and can suppress tumor growth, and the dynamic effects of the inflammatory cells can be modulated by exogenous cytokines.

Bcl-2 overexpression results in enhanced capacitative calcium entry and resistance to SKF-96365-induced apoptosis.

Although there is evidence that changes in cellular ionic concentrations are important early events in apoptosis, the regulation of ion fluxes across the plasma membrane during this process is poorly understood. We report here that Bcl-2 overexpression results in up-regulation of capacitative Ca2+ entry (CCE) and that SKF-96365, an inhibitor of CCE, is a potent inducer of apoptosis. Cells that overexpress Bcl-2 are resistant to SKF-96365-mediated apoptosis and to its inhibition of CCE. Enhanced CCE can be reversed with ouabain, suggesting that Bcl-2-associated plasma membrane hyperpolarization plays a role in up-regulating CCE and may partially explain the antiapoptotic effect of Bcl-2.

Breast-conserving radiation therapy using combined electron and intensity-modulated radiotherapy technique.

BACKGROUND AND PURPOSE: To explore the feasibility of a multi-modality breast-conserving radiation therapy treatment technique to reduce high dose to the ipsilateral lung and the heart when compared with the conventional treatment technique using two tangential fields. MATERIALS AND METHODS: An electron beam with appropriate energy was combined with four intensity modulated photon beams. The direction of the electron beam was chosen to be tilted 10-20 degrees laterally from the anteroposterior direction. Two of the intensity-modulated photon beams had the same gantry angles as the conventional tangential fields, whereas the other two beams were rotated 15-25 degrees toward the anteroposterior directions from the first two photon beams. An iterative algorithm was developed which optimizes the weight of the electron beam as well as the fluence profiles of the photon beams for a given patient. Two breast cancer patients with early-stage breast tumors were planned with the new technique and the results were compared with those from 3D planning using tangential fields as well as 9-field intensity-modulated radiotherapy (IMRT) techniques. RESULTS: The combined electron and IMRT plans showed better dose conformity to the target with significantly reduced dose to the ipsilateral lung and, in the case of the left-breast patient, reduced dose to the heart, than the tangential field plans. In both the right-sided and left-sided breast plans, the dose to other normal structures was similar to that from conventional plans and was much smaller than that from the 9-field IMRT plans. The optimized electron beam provided between 70 to 80% of the prescribed dose at the depth of maximum dose of the electron beam. CONCLUSIONS: The combined electron and IMRT technique showed improvement over the conventional treatment technique using tangential fields with reduced dose to the ipsilateral lung and the heart. The customized beam directions of the four IMRT fields also kept the dose to other critical structures to a minimum.

VH and VL gene complexes encoding an anti-spectrin antibody are defined by nucleotide sequencing of cDNA from a hybridoma generated from Hu-PBL-SCID mouse.

Previously we reported that human imunocompetent cells engrafted into scid mice mount a sustained and vigorous humoral immune response to murine erythrocytes. One of the dominant and consistently observed reactivity pattern of these antibodies in immunoblot analysis is with the alpha and beta isoforms of spectrin. In order to define the human xenoreactive response more completely, a hybridoma was generated (from a hu-PBL-scid mouse) whose antibody reacted with two high molecular weight species 225 to 250 kDa. We report here that this conserved antibody species reacts with both the murine and human erythrocyte proteins and cDNA nucleotide sequence analysis of the light and heavy chain genes encoding this antibody reveals that the light chain variable region gene has been previously observed in association with an autoreactive antibody. In addition to characterizing a conserved human B cell clonotype this is the first report of a human monoclonal antibody being generated from the hu-PBL-scid model using the standard hybridoma technology.