An evaluation of a collaborative course for child and adolescent mental health professionals

There is a considerable gap between the offer and the demand for mental health treatment of children and adolescents, especially in low- and middle-income countries (LMICs). Permanent education in these countries is a promising and needed strategy to reduce this gap. This study was designed to evaluate the perceived impact of an educational intervention for child and adolescent mental health professionals in Brazil, the Child and Adolescent Mental Health Specialization Course (CESMIA). The intervention consisted of a 360-hour interprofessional postgraduation course. The CESMIA offered lectures and small-group case discussions for exchanging their experiences in dealing with the patients. The students were placed in these groups according to their professions in order to ensure a proportional distribution of healthcare professionals in each group. The evaluation employed a quasi-experimental design by the use of a knowledge, attitude, and practice (KAP) survey. The 39 participants reported significant improvement in all KAP dimensions. More specifically, the data indicated a 17% improvement for attitudes, a 9.4% increase for knowledge, and a 14% improvement for the practice dimensions. The CESMIA appeared to improve the level of knowledge of participants and their attitudes and actions towards patients, which reinforces the relevance of similar courses.     

blaCTX-M-2 is located in an unusual class 1 integron (In35) which includes Orf513

Examination of the bla(CTX-M-2) gene in plasmid pMAR-12 by sequencing and PCR analysis revealed that the bla gene and the surrounding DNA, which is closely related (99% homology) to the Kluyvera ascorbata chromosomal DNA that contains the bla(KLUA-1) gene, are located in a complex sul1-type integron, termed In35, that includes Orf513. It is possible that bla(CTX-M-2) was acquired by plasmid pMAR-12 through an uncharacterized recombinational event in which Orf513 could be involved.     

Why 4 years when 3 will do? Enhanced knowledge for rural nursing practice

In Australia, debates over the appropriate length of undergraduate nursing programs have a long history. Submissions from both universities and industry to key government reports have consistently argued that the current minimum entry level of practice, a three-year program, is too short to enable students to gain the knowledge and skills necessary for the contemporary nursing role. Despite these submissions, the established entry level for nursing practice in Australia remains a three-year undergraduate bachelor degree. However, there is a small group of high-achieving students who will begin practice at the end of a four-year program. Little is known about these programs, or the students who are currently enrolled in them. Designed as a collaborative endeavour, based on co-operative inquiry, the study discussed in this article aimed to provide an insight into aspects of a four-year undergraduate nursing program. Potentially, the broader theoretical and clinical preparation that is possible in a four-year program provides students with enhanced learning opportunities that will enable them to graduate with more confidence and greater ability. In this study a four-year program provided an opportunity for a regional university to prepare students for the demanding realities of a complex area of practice, rural nursing.     

Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast

OBJECTIVES: Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes. METHODS: A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina. RESULTS: Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness. CONCLUSIONS: In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HIV/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed.     

Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis

OBJECTIVES: We sought to evaluate the impact of dobutamine stress echocardiography (DSE) in patients with known rheumatic mitral stenosis (MS) in order to assess its safety, feasibility, and prognostic correlation to well-known clinical outcomes. BACKGROUND: Noninvasive prognostic assessment of MS still represents an unresolved task in patients with clinically challenging disease. METHODS: Dobutamine stress echocardiography was performed in 53 patients with MS (8 males; age 37.4 +/- 11.3 years) with no major complications. RESULTS: During follow-up (60.5 +/- 11.0 months), 29 patients presented with clinical events: 16 hospitalizations, seven cases of acute pulmonary edema, and six symptomatic supraventricular arrhythmias. On multivariate analysis, the diastolic mitral valve mean gradient at peak DSE (DSE-MG) was the best predictor of clinical events (p < 0.008), especially in patients with moderate disease (p < 0.001). The best performance of DSE for the detection of clinical events was obtained at a cut-off value of 18 mm Hg DSE-MG (sensitivity 90%, specificity 87%, and accuracy 90%). The addition of DSE to the conventional cardiology work-up would allow a 17% increment for the detection of high-risk patients in the entire population and a 40% increment in patients with presumed moderate disease. CONCLUSIONS: In patients with MS, DSE is a safe and highly feasible stress test. A DSE-MG > or =18 mm Hg identifies a subgroup of high-risk patients in whom a more aggressive approach may be warranted; on the other hand, patients with a DSE-MG <18 mm Hg predicts an uneventful clinical course and may justify a more conservative strategy.     

Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis

Endoscopic therapy, involving either injection sclerosis or band ligation, is considered the intervention of first choice for acute variceal bleeding (AVB). Pharmacologic agents have also been shown to be highly effective in the control of the bleeding episode. The purpose of this meta-analysis was to assess whether vasoactive drugs may improve the efficacy of endoscopic therapy (injection sclerosis or band ligation) in the control of AVB and thus increase survival rates. Computer databases and scientific meeting abstracts from 1994 to 2001 were used to search for randomized trials that compared the combined use of endoscopic and drug therapy with endoscopic therapy alone in the control of AVB. Eight trials involving 939 patients fulfilled the selection criteria and the following evaluated by standard meta-analysis methods: initial hemostasis, 5-day hemostasis, 5-day mortality, and adverse events. Combined treatment improved initial control of bleeding (relative risk [RR], 1.12; 95% confidence interval (CI), 1.02-1.23), and 5-day hemostasis (RR, 1.28; 95% CI, 1.18-1.39), with numbers of patients needed to treat (NNT) of 8 and 5, respectively. The difference in favor of combined treatment remained significant when trials that used drugs other than octreotide or that included a low proportion of alcoholic patients (<40%) or high-risk cirrhotic patients (<35%) were excluded. Mortality was not significantly decreased by combined therapy (RR, 0.73; 95% CI, 0.45-1.18). Severe adverse events were similar in both groups. In conclusion, in patients with AVB, pharmacologic agents improve the efficacy of endoscopic therapy to achieve initial control of bleeding and 5-day hemostasis, yet fail to affect mortality.     

Melphalan-prednisone versus alternating combination VAD/MP or VND/MP as primary therapy for multiple myeloma: final analysis of a randomized clinical study

BACKGROUND AND OBJECTIVES: In the absence of a cure for multiple myeloma (MM) with standard-dose therapy, any strategy that can be expected to increase tumor reduction and to extend survival duration is likely to be of clinical relevance. The primary end-point of the present study was to investigate whether the alternating combination of vincristine-doxorubicin-dexamethasone (VAD) and melphalan-prednisone (MP) or vincristine-mitoxantrone-dexamethasone (VND) and MP could improve the clinical outcome of MM patients thus treated in comparison with those receiving MP alone. DESIGN AND METHODS: Between November 1990 and April 1994, 527 previously untreated, stage I-III, MM patients from 29 Italian institutions were randomized to receive one of three remission induction chemotherapy regimens consisting of 8-monthly courses of either MP alone or alternating VAD/MP or VND/MP. RESULTS: On an intent-to-treat basis, the objective response rates were 53% with MP (objective + minor: 67%), 47% with VAD/MP (objective + minor: 61%) and 49% with VND/MP (objective + minor: 61%). Median survival duration was 36.5 months with MP, 29 months with VAD/MP and 32.5 months with VND/MP. The difference among these groups was not statistically significant, even after stratifying patients into high-risk and low-risk subgroups, as assessed by a multifactor proportional hazard analysis. In both younger and elderly patients, severe granulocytopenia and related infections were significantly more frequent with VND/MP compared to the remaining arms of treatment (p < 0.001 and p = 0.009, respectively). Similarly, the frequency of WHO grade III-IV cardiovascular events was significantly higher for patients receiving anthracycline-containing regimens (VND/MP and VAD/MP) than for those treated with MP alone (p = 0.04). INTERPRETATION AND CONCLUSIONS: Alternating VAD/MP and VND/MP failed to improve the clinical outcome for MM patients, at the cost of increased toxicity and morbidity. Resistance to standard-dose chemotherapy remains a significant obstacle to the treatment of MM.     

Association of the epsilon 2 allele of APOE gene to hypertriglyceridemia and to early-onset alcoholic cirrhosis

Background: The diverse incidence of alcoholic cirrhosis around the world and the fact that not all alcoholic drinkers develop liver disease indicates that genetic and environmental factors play an important role in the development of liver cirrhosis. Lipids participate in early stages of alcoholic cirrhosis. Therefore variations in the plasma lipid profile due to primary (genetic) or secondary (environmental) dyslipidemia could affect the development of liver disease. The aim of this study was to analyze the lipid profile and apolipoprotein E (APOE) polymorphism in patients with alcoholic liver cirrhosis (AC) and determine the risk associated with genotype polymorphism with the onset of alcoholic cirrhosis. Methods: In a case and control study, 86 patients with AC divided into hyperlipidemic (H) and non‐hyperlipidemic (non‐H) groups, and 133 healthy individuals (C) matched by age and sex were studied. Lipid profile and liver function tests were measured by enzymatic methods. The APOE genotypes were identified by PCR‐RFLP′s. Results: A statistically significant increase of the APOE*2 allele and genotypes 2/2, 2/3, and 2/4 was present in AC patients compared to C group. A hyperlipidemic state characterized by increased levels of triglycerides and apolipoprotein B (APOB) and a decrease of high density lipoprotein‐cholesterol (HDL‐c) was detected in young‐aged patients (31.2 ± 6.2 years old vs. 46.3 ± 12.5 years old). In this group, hypertriglyceridemia was closely associated to APOE*2 allele and to an early onset of liver cirrhosis. By contrast, APOE*4 allele was associated with a longer duration of alcohol intake (>20 years) in the non‐H group. Conclusions: This study shows the association of hypertriglyceridemia and APOE allele with the early onset of alcoholic liver cirrhosis, and the interaction between environmental factors, such as duration of alcohol abuse and amount of alcohol intake, and genetic factors (APOE*2 allele) on the hypertriglyceridemic process.     

Leptin does not induce hypertrophy, cell cycle alterations, or production of MCP-1 in cultured rat and mouse cardiomyocytes

BACKGROUND: Leptin has been proposed as an important mediator in cardiovascular pathophysiology. Patients with congestive heart failure (CHF) present high plasma leptin levels. CHF is generally preceded by myocardial remodeling involving hypertrophy, necrosis, and apoptosis. AIM: To investigate whether leptin causes hypertrophy or cell cycle alterations, or induces MCP-1 synthesis in cardiomyocytes. MEHODS: Primary cultures of neonatal rat cardiomyocytes (PC) and murine cell line HL-1 were used. RT-PCR was used to identify Ob-Rb gene expression. Metabolic activity and proliferation of cardiomyocytes was studied using MTT and BrdU uptake, while apoptosis was assayed with Hoechst dye vital staining and flow cytometry. Measurement of the cell surface area was used to determine hypertrophy. MCP-1 levels were measured by ELISA. RESULTS: RT-PCR showed Ob-Rb mRNA expression in HL-1 cells. Exposure to leptin induced no changes in metabolic activity, proliferation, and apoptotic rates, and did not alter cell cycle in cardiomyocytes. Leptin did not increase cell size of cardiomyocytes, and MCP-1 synthesis was not detected in PC and HL-1 cells treated with leptin. CONCLUSION: This work shows that leptin does not induce changes in viability, proliferation, size or apoptosis of rat neonatal and HL-1 cardiomyocytes, and it does not induce MCP-1 secretion in these cells.     

Mitochondrial ferritin: a new player in iron metabolism

Mitochondrial ferritin (MtF) is a novel H-type ferritin encoded by an intronless gene on chromosome 5q23.1. The protein is synthesized as a precursor of about 30 kDa that is targeted to mitochondria by a leader sequence of 60 amino acids. This leader is proteolytically removed inside the mitochondria and the resulting 22 kDa subunit forms typical ferritin shells. These shells have ferroxidase activity and are therefore likely to sequester potentially harmful free iron. However, this may be a limited function since MtF has a very restricted tissue expression. High amounts are found in testis but only very low levels are found in iron storage organs. The levels of MtF appear to correlate more with mitochondrial abundance than with iron metabolism. MtF does not seem to be an obligatory intermediate in transfer of free iron to heme and other iron compounds in mitochondria. However, its level increases dramatically in sideroblastic anemia when heme synthesis is disrupted. This increased synthesis does not appear to involve the classical translational control since MtF mRNA lacks an apparent iron response element. In transfected HeLa cells added iron is incorporated as quickly into MtF as into cytosolic ferritin. In addition, increased levels of MtF cause a redistribution of iron from cytosol to mitochondria and this effect is enhanced by iron chelation. Thus high levels of MtF result in an iron deficient phenotype in cytosol with decreased expression of ferritin and increased expression of transferrin receptor. This avidity for iron may explain why MtF levels are maintained at low levels in most normal cells. The regulation of MtF expression and possible therapeutic applications of MtF in neurological disorders involving increased iron deposition are topics for future research.