An international perspective on psychotherapy

This commentary reviews the contributions made in each of the other articles in this issue in the context of the author's international experience. I discuss the tremendous diversity in education, training, experience, and legal status of psychologists around with world, using examples from Argentina, Australia, Brunei, Iran, Japan, Mexico, South Africa, and Spain--the eight countries represented in this issue of Journal of Clinical Psychology: In Session.     

Regular physical activity and insomnia: An international perspective

Both very low and very high levels of regular physical activity have been associated with degraded sleep quality. Cross‐national variations in habitual physical activity levels, therefore, may contribute to cross‐national differences in insomnia prevalence. The present study assesses and compares the extent to which weekly durations of moderate‐intensity physical activity contribute to insomnia risk. Demographic, sleep, physical activity and general health profiles were obtained from a convenience sample of 9,238 adults drawn from five countries (South Africa, Australia, China, South Korea and the UK) using social media. Insomnia prevalence, using DSM‐5 criteria, ranged from 4.1% (China) to 14.8% (UK). Evaluating risk using logistic regression adjusted only for age and gender, the lowest level of activity (<10 continuous min per week) was associated with significant insomnia risk (odds ratio = 1.37; 95% confidence interval = 1.05–1.79; p < 0.05). However, when adjusted for all covariates except country, only the highest level of physical activity (>300 min per week) was associated with significantly increased insomnia risk (odds ratio = 1.30; 95% confidence interval = 1.03–2.51; p < 0.05). Risk associated with high activity remained after the addition of “country” to the model (odds ratio = 1.31; 95% confidence interval = 1.02–1.69; p < 0.05). Across all models, female gender, low‐rated health, low education and older age consistently increased insomnia risk. These cross‐national data indicate that extremes of inactivity/activity can significantly influence insomnia risk independent of country. Insomnia risk associated with very low levels of activity may be mediated by poorer health and disadvantageous social status. However, while very high levels of activity increase insomnia risk independent of health and demographic factors, they may also confound with personally and occupationally demanding lifestyles.     

Interventions in fetal alcohol spectrum disorders: An international perspective

Fetal alcohol spectrum disorders (FASD) are present across countries and cultures, with prevalence rates threatening to rise in the coming years. In order to support children and families with FASD around the world, researchers must work to disseminate and implement evidence-based interventions. However, each cultural context presents unique elements and barriers to the implementation process. This review considers the challenges of addressing FASD in an international context. It summarizes existing FASD interventions that have empirical support in the domains of parenting and education, attention and self-regulation, adaptive functioning, and nutrition and medication. It then outlines cultural barriers pertaining to FASD that may impede the implementation process and makes suggestions for using purveyors as cultural liaisons between researchers and local stakeholders. The review concludes with recommendations for moving forward with international dissemination and implementation of FASD interventions.     

Venous thromboembolism and its prophylaxis in elective knee arthroplasty: An international perspective

IntroductionPatients undergoing knee arthroplasty are at high risk of developing post-operative deep vein thrombosis (DVT) or a pulmonary embolus (PE). Despite best efforts, the best prophylaxis for thromboembolic disease remains controversial. This article aims to update the reader on the newest guidelines concerning venous thromboembolism (VTE) prophylaxis for elective knee arthroplasty, highlighting their inconsistencies and why variations in recommendations exist.MethodsThe Medline database and the Internet were searched for VTE prophylaxis guidelines in English. 12 guidelines were found and compared. The comparison looked at the recommendations made, the grade of recommendation, the level of evidence available for these recommendations and any inconsistencies between the guidelines.ResultsNearly all the guidelines advocate the use of low molecular weight heparin (LMWH) and Fondaparinux. There is little consensus in terms of other recommended drugs, the doses, duration and their recommendation grades. There are marked differences in the methodologies adopted by the different guideline working-groups.ConclusionThere is still uncertainty about the optimal methods of thromboprophylaxis in elective knee arthroplasty. Although there are always going to be disagreements about the endpoints amongst guideline makers, guidelines should achieve uniformity in their reporting of end-points, criteria for levels of evidence and recommendation grades, facilitating the clinician's decision-making process.Level of evidenceIIa.     

Sex and congenital malformations: an international perspective

The study evaluated the sex distribution of major isolated malformations and common trisomies among a large and geographically varied sample. Eighteen registries from 24 countries contributed cases, which were centrally reviewed and classified in three clinical types as isolated, associated, or syndromic. We selected cases of 26 major defects (n = 108,534); trisomy 21, 18, and 13 (n = 30,114); other syndromes (n = 2,898); and multiple congenital anomalies (n = 24,197), for a total of 165,743 cases. We observed a significant deviation of sex distribution (compared to a sex ratio of 1.06 or male proportion of 51.4%) for 24 of the 29 groups (a male excess in 16, a female excess in 8), and in 8 of such groups these estimates varied significantly across registries. A male excess was noted for two left obstructive cardiac defects (hypoplastic left heart and coarctation of the aorta) and a female excess for all the main types of neural tube defects. A male excess was seen for omphalocele but not gastroschisis. For neural tube defects the female excess tended to be stronger in areas with historically high prevalence for these defects. For 15 of the 26 birth defects the sex distribution differed among isolated, associated, and syndromic cases. Some of these epidemiologic commonalities are consistent with known or putative developmental processes. Further, the geographic variation for some defects may reflect local prevalence rates and risk factors. Finally, the findings underscore the need for clinical classification (e.g., into isolated, multiple, syndromes) in studies of birth defects.     

AIDS and older persons: an international perspective

The impact of the worldwide AIDS epidemic on persons aged 50 years or older has received relatively little consideration except in the United States, where interest has focused almost exclusively on older persons living with AIDS or at risk for infection. The place of older persons in the epidemic deserves international attention because their lives are being significantly affected in a variety of ways. Because most of the epidemic occurs in the developing regions of the world, especially in Africa and Asia, efforts to understand and deal with the concerns of older persons in relation to AIDS in those settings need expansion. Although older persons represent a non-negligible minority of the reported global caseload, a far larger number of older persons are affected through the illness and death of their adult children and younger generation relatives who contract AIDS. From a global perspective, a broader concern encompassing those who are affected through the infection of others rather than a narrow concern with those who are at risk or infected themselves is called for if the needs of the large majority of older persons adversely affected by the epidemic are to be addressed.     

Medicolegal liability in pathology: an international perspective

An inevitable outcome of modern Medicine in any country is that some patients will experience adverse events, some of which would have been preventable. Different nations have developed various approaches to such cases; their legal efficacies are probably dissimilar and dependent on a number of disparate variables. An international "snapshot" of the results of the interacting forces can be obtained by asking physicians in several countries how they view selected subjective facets of their tort systems. In the U.S., many physicians view the structure of malpractice torts as unfair, and that belief is shared by at least some pathologists. The American Medical Association has declared that a multiregional malpractice "crisis" exists which raises medical costs and threatens access to care. Furthermore, malpractice tort decisions are often flawed scientifically because lay jurors and judges cannot properly evaluate the quality of "expert" testimony given by adversarial witnesses. Despite these factors, there has been little effort to investigate the views of pathologists on malpractice actions outside the U.S. In this paper, the authors have collected the responses of an international group of pathologists to a questionnaire on that topic. The respondents practice in academic centers in 15 countries outside the U.S. As expected, a range of views was represented, with some pathologists reporting that malpractice litigation was uncommon and others noting a worrisome trend toward its growth. Interestingly, so-called "defensive medicine" was found to be relatively common in pathology in many countries.     

2020 international consensus on ANCA testing beyond systemic vasculitis

This document follows up on a 2017 revised international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in granulomatosis with polyangiitis and microscopic polyangiitis and focuses on the clinical and diagnostic value of ANCA detection in patients with connective tissue diseases, idiopathic interstitial pneumonia, autoimmune liver diseases, inflammatory bowel diseases, anti-glomerular basement membrane (GBM) disease, infections, malignancy, and during drug treatment. Current evidence suggests that in certain settings beyond systemic vasculitis, ANCA may have clinical, pathogenic and/or diagnostic relevance. Antigen-specific ANCA targeting proteinase-3 and myeloperoxidase should be tested by solid phase immunoassays in any patient with clinical features suggesting ANCA-associated vasculitis and in all patients with anti-GBM disease, idiopathic interstitial pneumonia, and infective endocarditis associated with nephritis, whereas in patients with other aforementioned disorders routine ANCA testing is not recommended. Among patients with autoimmune liver diseases or inflammatory bowel diseases, ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1 who do not have conventional autoantibodies or in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn’s disease. In these cases, ANCA should be tested by indirect immunofluorescence as the target antigens are not yet well characterized. Many questions concerning the optimal use of ANCA testing in patients without ANCA-associated vasculitis remain to be answered.     

Epidemiologic links between drug use and HIV epidemics: an international perspective

Injecting use of heroin has been the highest risk substance use behavior for HIV since the beginning of the pandemic. These risks extend beyond individual levels to networks of drugs users and to wider social contexts that have been referred to collectively as the risk environment. Investigations of individual, network, and risk environment level associations with heroin availability, use, and subsequent spread among injecting drug users (IDUs) have been conducted in multiple settings, but much less is known about the world's center of illicit opium production and heroin exports-Afghanistan. Recent outbreaks of injecting drug use and of HIV infection attributed to IDUs in several African countries suggest that heroin use is expanding into new regions. This article explores the epidemiology of HIV among drug users in several risk environments, the epidemiology of heroin and its associations with HIV outbreaks among IDUs in Central Asia and the Commonwealth of Independent States, and the drug use and IDUs outbreaks now emerging in Africa. The dearth of targeted, evidence-and human rights-based responses to these epidemics is explored as a structural driver of HIV spread in these settings.     

Information technology and patient safety in nursing practice: an international perspective

When people become patients, they place their trust in their health care providers. As providers assume responsibility for their diagnosis and treatment, patients have a right to expect that this will include responsibility for their safety during all aspects of care. However, increasing epidemiological data make it clear that patient safety is a global problem. Improved nursing care may prevent many adverse events, and nursing must take a stronger leadership role in this area. Although errors are almost inevitable, safety can be improved, and health care institutions are increasingly making safety a top priority. Information technology provides safety benefits by enhancing communication and delivering decision-support; its use will likely be a cornerstone for improving safety. This paper will discuss the status of patient safety from an international viewpoint, provide case studies from different countries, and discuss information technology solutions from a nursing perspective.     

Outcomes beyond hospital discharge in infants and children with viral meningitis: A systematic review

Viruses are the commonest cause of childhood meningitis, but outcomes beyond hospital discharge are poorly described. We undertook a systematic literature review of long‐term outcomes following paediatric viral meningitis. A search was carried out using MEDLINE, Embase, and Cochrane Review for studies from 1 January 1990 to 31 December 2018. Studies were included where specific outcome measures were available beyond hospital discharge for children <16 years old with viral meningitis. In total, 3588 papers were identified of which 14 were eligible for inclusion. Four studies reported outcomes in children with nonenterovirus 71 meningitis. A US study of 16 cases demonstrated subtle language difficulties at 3‐year follow‐up in infants in contrast to an Australian study, which revealed no impairment in language. A Fijian study showed that two out of eight cases had sensorineural hearing loss compared with none in a UK cohort of 668 infants. Three studies evaluated outcomes of enterovirus 71 meningitis in China and Taiwan, two showed cases recovered without sequelae, while one demonstrated an increased risk of attention deficit hyperactivity disorder. Two studies including 141 cases of human parechovirus revealed no evidence of neurodevelopmental sequelae. Conversely, an Australian study demonstrated neurodevelopmental sequelae in 11 out of 77 infants with parechovirus meningitis. Most studies identified in this review demonstrated a high proportion of good clinical outcomes following viral meningitis. However, the data are limited, so robustly conducted neurodevelopmental studies are warranted to inform the evidence‐based management of viral meningitis beyond hospital discharge.     

Innate immune memory: An evolutionary perspective

Over the last decades, there was increasing evidence for the presence of innate immune memory in living organisms. In this review, we compare the innate immune memory of various organisms with a focus on phylogenetics. We discuss the acquisition and molecular basis of immune memory and we describe the innate immune memory paradigm and its role in host defense during evolution. The molecular characterization of innate immunological memory in diverse organisms and host-parasite systems reconciles mechanisms with phenomena and paves the way to molecular comprehension of innate immune memory. We also revise the traditional classification of innate and adaptive immunity in jawed vertebrates. We emphasize that innate immune responses have the capacity to be “primed” or “trained”, thereby exerting a yet unknown type of immunological memory upon re-infection.