A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

Background

Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo.

Methods

A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score.

Results

Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance.

Conclusions

The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability.

Trial registration

Clinicaltrials.gov (NCT01696578).

     

Preferences for in-person disclosure: Patients declining telephone disclosure characteristics and outcomes in the multicenter Communication Of GENetic Test Results by Telephone study

Telephone disclosure of cancer genetic test results is noninferior to in-person disclosure. However, how patients who prefer in-person communication of results differ from those who agree to telephone disclosure is unclear but important when considering delivery models for genetic medicine. Patients undergoing cancer genetic testing were recruited to a multicenter, randomized, noninferiority trial (NCT01736345) comparing telephone to in-person disclosure of genetic test results. We evaluated preferences for in-person disclosure, factors associated with this preference and outcomes compared to those who agreed to randomization. Among 1178 enrolled patients, 208 (18%) declined randomization, largely given a preference for in-person disclosure. These patients were more likely to be older (P = 0.007) and to have had multigene panel testing (P < 0.001). General anxiety (P = 0.007), state anxiety (P = 0.008), depression (P = 0.011), cancer-specific distress (P = 0.021) and uncertainty (P = 0.03) were higher after pretest counseling. After disclosure of results, they also had higher general anxiety (P = 0.003), depression (P = 0.002) and cancer-specific distress (P = 0.043). While telephone disclosure is a reasonable alternative to in-person disclosure in most patients, some patients have a strong preference for in-person communication. Patient age, distress and complexity of testing are important factors to consider and requests for in-person disclosure should be honored when possible.     

Personal ultrasound imager: abdominal aortic aneurysm screening.

BACKGROUND: Miniaturized ultrasonographic machines (2.5-MHz curved-array transducer connected to a compact 2.6-kg console), termed personal ultrasound imagers (PUIs), may enable detection of occult abdominal aortic aneurysms (AAAs). OBJECTIVES: Our goals were to determine whether a PUI is capable of screening for AAAs and to compare the results with an established screening examination with standard echocardiography (SE). METHODS: One hundred twenty-five patients (aged >70 years) with hypertension who were referred for transthoracic echocardiography were enrolled. After SE, a focused screening with a PUI examination was performed by a blinded sonographer. An AAA was defined as a focal enlargement of the aorta >30 mm. Results and the length of time to image the aorta were compared for both tests. RESULTS: We studied 64 men and 61 women (aged 76.8 +/- 5 years; mean blood pressures: systolic 145.7 +/- 18 and diastolic 78.6 +/- 10; body surface area 1.9 +/- 0.2 m(2)). The mean time for SE was 2.9 +/- 1.5 minutes and for the PUI examination was 4.6 +/- 2.3 minutes. By using SE as the gold standard, the sensitivity and specificity of the PUI were 91% and 96%, respectively. The positive predictive value of the PUI was 71%, and the negative predictive value was 99%. CONCLUSION: A PUI can be used to screen for occult AAAs as an extension of the physical examination. Results are comparable to an established screening strategy that uses more expensive, nonportable echocardiographic equipment.     

Qualitative mapping of Barrett’s metaplasia: a prerequisite for intervention trials

Background: Barrett’s esophagus may present as a cellular mosaic with irregular longitudinal extensions of intestinal epithelium, spotty areas of dysplasia and other intermediate markers for cancer risk. It may not be possible to detect and reproducibly localize these findings with routine endoscopic biopsies. A more systematic biopsy protocol is necessary for chemopreventive studies to be feasible. Methods: Utilizing an adapted upper endoscope that allows accurate evaluation of distance from the incisors and rotatory position, chromoendoscopy with toluidine blue and systematic mapping (4 quadrant jumbo biopsies at 1 cm intervals) were performed twice on 18 patients with Barrett’s esophagus (second procedure 1 to 3 months after baseline study). All biopsy specimens were subjected to routine and immunohistochemical staining and flow cytometry to create baseline and follow-up maps for each patient. Eight of the 18 patients also underwent standard surveillance biopsies within 6 months of the systematic mapping procedures. Results: Epithelium type was reproducibly identified with 94% accuracy on second endoscopic maps. Ploidy, p53, and Ki-67 status were also reproducibly identified on second endoscopic maps (97%, 89%, and 85%, respectively). Dysplasia was found in 7 of 18 patients at similar sites at each mapping procedure (3 patients with high-grade dysplasia, 4 with low-grade dysplasia). Five of the patients who had dysplasia on mapping had also undergone standard surveillance. Low-grade dysplasia was missed in 2 of 3 patients and 1 patient with high-grade dysplasia had only low-grade dysplasia detected with standard biopsies. Conclusions: Utilizing a modified gastroscope and this methodology, we reliably located sites of dysplasia and other biomarkers within a field of Barrett’s esophagus. Patients had variable areas of dysplasia that were missed on standard endoscopic surveillance. (Gastrointest Endosc 1999;50:814-8.)     

Evidence for Laryngeal Paralysis in Cricoarytenoid Joint Arthritis

Objective/Hypothesis: To demonstrate denervation atrophy of laryngeal muscles in a case of gout involving the cricoarytenoid joint. Methods: The posterior cricoarytenoid (PCA) and arytenoideus (A) muscles from a 72-year-old man with extensive gout were compared with those from a normal adult larynx (age and sex unknown) using stereologic techniques for changes in muscle composition and fiber diameter. Results: The PCA and A muscles in the gout specimen contained changes Indicative of muscle degeneration. In the PCA the volume fraction (VF) of intact muscle was 0.30, of degenerating muscle 0.13, and of fat 0.16. A normal PCA had a VF for intact muscle of 0.64 and 0 for degenerating muscle and fat. Similar changes were seen in the gout A muscle but were not measured. Muscle fiber diameters in the gout PCA (1,024 fibers) showed a significantly higher atrophy and hypertrophy factor than the normal PCA (1,255 fibers). The variability coefficient in the gout PCA (487) was almost double that in the normal PCA (290). Although muscle fiber diameters were not measured in the A muscle in gout, variability in fiber size was seen. Conclusions: The pattern and magnitude of muscle fiber degeneration in the PCA and A muscles from a larynx with gout fixation of the cricoarytenoid joint indicate neural degeneration. Since similar changes were not found in the thyroarytenoid (TA) and lateral cricoarytenoid (LCA), the neuropathy is selective for the posterior branch of the recurrent laryngeal nerve. This neuropathy is likely responsible for vocal cord adduction (stridor) and incomplete closure of the posterior commissure (aspiration) associated with acute cricoarytenoid arthritis. In chronic cricoarytenoid joint arthritis, ankylosis of the joint space maintains the adducted cord position.     

Pronuclear orientation, polar body placement, and embryo quality after intracytoplasmic sperm injection and in-vitro fertilization: further evidence for polarity in human oocytes?

Three hypotheses were tested: (i) the distance between first and second polar bodies (PB) may relate to embryo morphology, (ii) that the orientation of pronuclei (PN) relative to PB may relate to embryo morphology, (iii) that the placement of a spermatozoon in a fixed plane relative to the first PB [intracytoplasmic sperm injection (ICSI)] may alter PN/PB orientation relative to in-vitro fertilization (IVF). A total of 251 two pronuclear (2PN) embryos (124 ICSI, 127 IVF) from 64 patients was studied. Angles were measured between the PN axis and the nearest PB (alpha), the furthest PB (beta), and between the two PB (gamma). On day 2, the morphological grades of embryos were recorded. gamma ranged from 0 to 150 degrees and was not significantly different for ICSI or IVF embryos of different grades; however, an unusual distribution of gamma suggested different populations of oocytes. The first hypothesis was rejected. alpha and beta ranged from 0 to 90 degrees : alpha did not relate significantly to embryo grade, but beta increased significantly with decreasing quality of ICSI embryos (P < 0.05) and the total group (P < 0.01), supporting hypothesis (ii). The difference in beta between ICSI and IVF embryos was not significant, so hypothesis (iii) was unproven. Significant differences between ICSI and IVF embryos in PN positions, irregular cleavage, and cleavage failure were noted.     

Smoking history is related to free-living daily physical activity in claudicants.

PURPOSE: To determine whether smoking history was related to free-living daily physical activity in peripheral arterial occlusive disease (PAOD) patients with intermittent claudication, and whether the effect of smoking history on physical activity level persisted after controlling for group differences in ambulatory function, peripheral circulation, and body composition. METHODS: Patients were separated into three groups: those who never smoked (N = 35), those who had a lower pack-year history of smoking (< or =40 pack-yr; N = 33), and those who had a higher pack-year history (>40 pack-yr; N = 30). Free-living daily physical activity was assessed by activity monitors (an accelerometer and a pedometer) worn on each hip over 2 consecutive weekdays. Patients also were characterized on ambulatory function, peripheral circulation, and body composition because of their relationship with physical activity. RESULTS: A progressive decline (P < 0.001) in free-living daily physical activity with increasing smoking exposure was obtained from the accelerometer in the nonsmokers (482 +/- 36 kcal x d(-1); mean +/- SE), smokers with a lower pack-year history (361 +/- 37 kcal x d(-1)), and smokers with a higher pack-year history (227 +/- 23 kcal x d(-1)). A similar decline was found with the pedometer data (P < 0.001). After controlling for group differences in 6-min walk distance and in calf transcutaneous heating power, group differences in free-living daily physical activity were no longer significant. CONCLUSION: Progressive decrements in free-living daily physical activity with greater levels of smoking exposure in PAOD patients are primarily due to smoking-related impairments in ambulatory function and peripheral circulation.