Early Intervention for Trauma: Current Status and Future Directions

Although psychological debriefing (PD) represents the most common form of early intervention for recently traumatized people, there is little evidence supporting its continued use with individuals who experience severe trauma. This review identifies the core issues in early intervention that need to be addressed in resolving the debate over PD. It critiques the available evidence for PD and the early provision of cognitive-behavioral therapy (CBT). Based on available evidence, we propose that psychological first aid is an appropriate initial intervention, but that it does not serve a therapeutic or preventive function. When feasible, initial screening is required so that preventive interventions can be used for those individuals who may have difficulty recovering on their own. Evidence-based CBT approaches are indicated for people who are at risk of developing posttraumatic psychopathology. Guidelines for managing acutely traumatized people are suggested and standards are proposed to direct future research that may advance our understanding of the role of early intervention in facilitating adaptation to trauma.     

Adeno-associated virus vector-mediated systemic delivery of IFN-beta combined with low-dose cyclophosphamide affects tumor regression in murine neuroblastoma models.

PURPOSE: Type I IFNs (IFN-alpha/beta) have shown significant antitumor activity in preclinical models but limited efficacy and significant toxicity in clinical trials. We hypothesized that the antitumor activity of type I IFNs could be enhanced by chronic, low-dose systemic delivery and sought to test this in murine neuroblastoma models. EXPERIMENTAL DESIGN: Continuous liver-generated expression of human IFN-beta (hINF-beta) was achieved through a gene therapy-mediated approach using adeno-associated virus vectors encoding hIFN-beta (AAV hINF-beta). Orthotopic localized retroperitoneal and disseminated models of neuroblastoma were established using three different xenografts. Immunohistochemical analysis and ELISA were used to evaluate the antiangiogenic effect of therapy. RESULTS: The development of both localized orthotopic (retroperitoneal) and disseminated neuroblastoma was prevented in all mice expressing hINF-beta. Continued growth of established retroperitoneal tumors, treated with AAV hINF-beta as monotherapy, was significantly restricted, and survival for mice with established, disseminated disease was significantly prolonged following administration of AAV hINF-beta. Analysis of treated tumors revealed a significant antiangiogenic effect. Mean intratumoral vessel density was diminished and expression of the angiogenic factors vascular endothelial growth factor and basic fibroblast growth factor were both decreased. Finally, combination therapy in which AAV hIFN-beta was used together with low-dose cyclophosphamide resulted in regression of both established retroperitoneal and disseminated disease. CONCLUSIONS: AAV-mediated delivery of hIFN-beta when used as monotherapy was able to restrict neuroblastoma growth due in part to inhibition of angiogenesis. When used in combination with conventional chemotherapy, AAV hIFN-beta was able to effect complete tumor regression.     

Designing new substance abuse treatment services for a competitive environment.

A multivariate analysis of the relationships between service attributes and physician perceptions was conducted as an approach to marketing substance abuse treatment services. The results of this attribute-perceptive-preference study indicate: the physician(s) on staff attribute makes the greatest contribution to perceived quality and efficiency; easy referral admission makes the largest contribution to accessibility perceptions; and providing feedback produces the greatest contribution to perceived continuity. The JCAH attributes neither adds to nor subtracts from the perceptions of any of the four perceptual attributes. Other findings indicate that perceived efficiency produces the greatest contribution to overall consumer preference. Quality perceptions make the second largest contribution to overall preference, followed by continuity and accessibility perceptions.     

Some observations on the faecal carriage of mesophilic Aeromonas species in cows and pigs

Replicate faecal samples from healthy individual pigs and cows were examined for the presence of Aeromonas sp. over a 12-month period. Aeromonads were found to be minor components of the faecal flora, only 8.8% of 520 samples from pigs and 4.6% of 481 samples from cows proving positive. Isolation rates in both groups of animals were seasonal. A hydrophila (62% of the isolates) was the predominant species in cows, followed by A. caviae (32%) and A. sobria (15%). This pattern was also recorded in the natural waters that the animals drank from during the period when the faecal carriage rate was at its highest. In pigs, A. caviae (59%) was more common than A. hydrophila (41%). A. sobria was not found in any of the pig-associated samples. It seems that cattle acquire their faecal aeromonads from drinking water. The source of the organisms in pigs is less clear.     

The use of spleen transplantation and cyclosporine treatment to induce unresponsiveness to pancreatic islet transplantation in rats

One way of achieving permanent survival of allografted islets in the rat has been to first transplant a kidney of the same strain as the islets and induce acceptance of the kidney using cyclosporin A treatment. Rats bearing long-surviving renal allografts will then accept islets of the same strain without further immunosuppression. Such an approach may be effective for combined renal and islet grafting, but transplantation of the kidney as well as islets may not always be desirable, and the question arises as to whether another organ could be used to achieve the same effect. Auxiliary spleen transplants were performed from LEW to DA rats, followed by cyclosporine 10 mg/kg for 14 days. Twelve rats with long-surviving grafts were then made diabetic with streptozotocin and given LEW islets placed under the kidney capsule, 6 rats being given a further course of cyclosporine 10 mg/kg for 7 days after islet transplantation. Rats that did not reject their islets then underwent removal of the spleen transplant, and if this did not result in rejection islet function was proven by removal of the kidney bearing the islets. The results show that spleen allograft rejection can be prevented by cyclosporine treatment and that 50% of animals with long-surviving spleen allografts will accept subsequent islet allografts from rats of the same donor strain. The acceptance of islet allografts can be increased to 100% by a further short course of cyclosporine treatment. It is concluded that spleen allografts can be used to produce unresponsiveness to islets in rats.     

A role for calcitonin gene-related peptide in protection against gastric ulceration.

OBJECTIVE: The goal of this investigation was to determine the role of calcitonin gene-related peptide (CGRP) in gastric mucosal resistance to ulceration. SUMMARY BACKGROUND DATA: CGRP is a 37-amino acid peptide found in the peripheral ends of afferent gastric neurons. CGRP is known to inhibit acid secretion, stimulate mucosal blood flow, and stimulate release of somatostatin. METHODS: The release of CGRP in response to intragastric and intra-arterial administration of capsaicin in the isolated, vascularly perfused rat stomach was measured by radioimmunoassay. The molecular forms of CGRP released were analyzed by gel filtration chromatography. The effect of intravenous CGRP or intragastric capsaicin on gastric ulceration induced by 100 mmol/L HCl and indomethacin was studied in intact and endogenous CGRP-depleted rats. RESULTS: Intra-arterial capsaicin (concentration range, 10(-7) to 10(-5) mol/L) stimulated a prompt and sustained release of immunoreactive CGRP, of which 84% coeluted with rat 1-37 CGRP I by gel filtration. Intragastric capsaicin (range, 10(-5) to 10(-4) mol/L) failed to release CGRP into the vascular perfusate. In intact rats, intragastric capsaicin (10(-6) mol/L) or intravenous CGRP I (10 micrograms/kg/hr) reduced the number and area of mucosal lesions caused by HCl and indomethacin compared with the findings in control rats. Rats depleted of endogenous CGRP were more susceptible to gastric ulceration than were normal rats. Intragastric capsaicin failed to protect the mucosa of CGRP-depleted rats, whereas exogenous intravenous CGRP was effective. CONCLUSIONS: These data support the hypothesis that CGRP released from gastric enteric neurons mediates gastric mucosal resistance to ulceration by noxious agents.     

Prevalence of total hip replacement: how much demand has been met?

OBJECTIVE--To determine the prevalence of completed elective total hip replacements in a defined elderly population. DESIGN--Cross sectional postal questionnaire survey with additional data and validation from general practice and hospital records. SETTING--Six general practices in the English counties of Avon, Somerset, and Oxfordshire. SUBJECTS--A total of 7806 patients aged 65 years and over (94.7% response). RESULTS--The overall prevalence (95% confidence intervals) of elective total hip replacement was 5.3 (4.8,5.8)% Age and sex specific prevalences were 2.7 (2.0,3.5)% in men and 4.1 (3.3,4.9)% in women aged 65-74 years, and 5.2 (4.0,6.5)% in men and 8.8 (7.6,10.0)% in women aged 75 years and over. Of the 415 patients who had received elective total hip replacement, 28.2% had required bilateral surgery, 20% had received at least one operation privately, and 13% had required revision surgery. CONCLUSION--Our results show an increased level of satisfied demand for total hip replacement in elderly people compared with earlier estimates. The increasing prevalence of hip replacement is an indicator of increasing potential demand for revision procedures. Population based surveys are required to establish the level of unmet demand for primary procedures. Differences in past surgical activity may be important in interpreting the wide variation in current surgical rates.     

RETROPERITONEAL SCHWANNOMA: A CASE SERIES AND REVIEW

Schwannomas account for only a small percentage of retroperitoneal tumours. Presentation is typically varied and non-specific and pre-operative diagnosis is difficult. Herein are described five cases of retroperitoneal schwannoma. Presentation was varied, ranging from abdominal pain, abdominal mass, obstructed labour or an incidental finding. All patients had either an abdominal computed tomography scan and/or ultrasound performed. Pre-operative biopsy either by fine needle aspiration (in one patient) or core biopsy in two patients was unhelpful. In four patients with smaller tumours, complete excision was possible with no apparent long-term morbidity and no clinical evidence of recurrent tumour with follow up from 3.5 months to 11 years. For the largest tumour, complete surgical excision was not attempted as it would have entailed significant morbidity.