Using Group‐Based Parent Training Interventions with Parents of Children with Disabilities: A Description of Process,Content and Outcomes in Clinical Practice

Background: There is a need for further development and evaluation of group‐based parent‐ training interventions for parents of children with disabilities. This paper describes interventions delivered in two areas of Greater Manchester. Method: The process and content of an approach designed for parents of children with learning disabilities and autistic spectrum disorders is described. Results: Clinical outcome data for 22 parents/carers are presented. Client feedback about the course is also reported. Conclusions: The data suggest that this intervention is effective in reducing the frequency and impact of children’s challenging behaviours, and improving parental psychological well‐being. More rigorous and extensive evaluation is required.     

Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration

AIM: To evaluate pretreatment hepatitis B virus(HBV) testing, vaccination, and antiviral treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement.METHODS: We performed a retrospective cohort study using a national repository of Veterans Health Administration(VHA) electronic health record data. We identified all patients receiving anti-CD20 Ab treatment(2002-2014). We ascertained patient demographics, laboratory results, HBV vaccination status(from vaccination records), pharmacy data, and vital status. The high risk period for HBV reactivation is during antiCD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment serologic tests were used to categorize chronic HBV(hepatitis B surface antigen positive or HBs Ag+), past HBV(HBs Ag-, hepatitis B core antibody positive or HBc Ab+), resolved HBV(HBs Ag-, HBc Ab+, hepatitis B surface antibody positive or HBs Ab+), likely prior vaccination(isolated HBs Ab+), HBV negative(HBs Ag-, HBc Ab-), or unknown. Acute hepatitis B was defined by the appearance of HBs Ag+ in the high risk period in patients who were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis, liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease categories and differences compared using the χ2 test. Mean time to hepatitis peak alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration and follow-up were also compared by HBV disease group.RESULTS: Among 19304 VHA patients who received anti-CD20 Ab, 10224(53%) had pretreatment HBs Ag testing during the study period, with 49% and 43% tested for HBs Ag and HBc Ab, respectively within 6 mo pretreatment in 2014. Of those tested, 2%(167/10224) had chronic HBV, 4%(326/7903) past HBV, 5%(427/8110) resolved HBV, 8%(628/8110) likely prior HBV vaccination, and 76%(6022/7903) were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral treatment during the high risk period while 21% to 23% of those with past or resolved HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20 Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative(P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31% in hepatitis B negative. In those pretreatment HBV negative, 16(0.3%) developed acute hepatitis B of 4947 tested during anti-CD20 Ab treatment and followup. CONCLUSION: While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients received HBV antivirals, suggesting electronic health record algorithms may enhance health outcomes.     

Insulin Resistance Predicts Mortality in Nondiabetic Individuals in the U.S.

OBJECTIVE

Insulin resistance is a suspected causative factor in a wide variety of diseases. We aimed to determine whether insulin resistance, estimated by the homeostasis model assessment for insulin resistance (HOMA-IR), is associated with all-cause or disease-specific mortality among nondiabetic persons in the U.S.

RESEARCH DESIGN AND METHODS

We determined the association between HOMA-IR and death certificate–based mortality among 5,511 nondiabetic, adult participants of the third U.S. National Health and Nutrition Examination Survey (1988–1994) during up to 12 years of follow-up, after adjustment for potential confounders (age, sex, BMI, waist-to-hip ratio, alcohol consumption, race/ethnicity, educational attainment, smoking status, physical activity, C-reactive protein, systolic and diastolic blood pressure, plasma total and HDL cholesterol, and triglycerides).

RESULTS

HOMA-IR was significantly associated with all-cause mortality (adjusted hazard ratio 1.16 [95% CI 1.01–1.3], comparing successive quartiles of HOMA-IR in a linear model and 1.64 [1.1–2.5], comparing the top [HOMA-IR >2.8] to the bottom [HOMA-IR ≤1.4] quartile). HOMA-IR was significantly associated with all-cause mortality only in subjects with BMI <25.2 kg/m² (the median value) but not in subjects with BMI ≥25.2 kg/m². Subjects in the second, third, and fourth quartile of HOMA-IR appeared to have higher cardiovascular mortality than subjects in the lowest quartile of HOMA-IR. HOMA-IR was not associated with cancer-related mortality.

CONCLUSIONS

HOMA-IR is associated with all-cause mortality in the nondiabetic U.S. population but only among persons with normal BMI. HOMA-IR is a readily available measure that can be used in the future to predict mortality in clinical or epidemiological settings.Insulin resistance is a condition in which normal amounts of insulin are not adequate to produce the expected biologic response in target tissues, including adipose tissue, muscle, and liver. Insulin resistance has been associated with a wide variety of adverse health outcomes, including type 2 diabetes (1), hypertension (2), cardiovascular disease (1), cerebrovascular disease (3), peripheral vascular disease (4), congestive heart failure (5), nonalcoholic fatty liver disease (6), dyslipidemia (low HDL cholesterol and high triglycerides) (7), and a variety of malignancies (8). Using a mathematical simulation model, Eddy et al. (9) recently estimated that insulin resistance was responsible for 42% of myocardial infarctions in the U.S. and was the most important single cause of coronary artery disease.Obesity is known to be a strong risk factor for insulin resistance, in particular ectopic as opposed to subcutaneous adiposity (10). In addition, factors unrelated to obesity are important contributors to insulin resistance, such as race, sex, physical activity, and genetic factors, while as-yet-unknown causes of insulin resistance also likely exist.The homeostasis model assessment for insulin resistance (HOMA-IR) estimates insulin resistance from fasting plasma glucose and serum insulin levels (11). There is good correlation between values of insulin resistance obtained using HOMA-IR and the euglycemic-hyperinsulinemic clamp method (12), the gold-standard test that is too costly and technically demanding to be used in epidemiologic studies or clinical practice. Given the combination of accuracy and ease of testing, HOMA-IR is considered an appropriate method for measurement of insulin resistance in epidemiologic studies (12).Our aim was to determine the association between HOMA-IR and mortality in nondiabetic people in the U.S. independently of other important predictors of mortality. This finding would be important in incorporating HOMA-IR into future models predicting mortality for clinical or epidemiological purposes, especially since HOMA-IR is readily available.     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Immunohistochemical Evaluation of 95 Bone Marrow Reactive Plasmacytoses

We histologically and immunohistochemically studied 95 bone marrow (BM) reactive plasmacytoses. Ten biopsies from plasma cell myeloma (PCM) patients served as a control group. In addition, we studied 10 monoclonal gammopathy of undetermined significance (MGUS) cases. Histologically, plasmacytosis varied between 5% and 25% with an interstitial pattern of plasma cell (PC) distribution being characteristically displayed. Immunohistochemically, we did not find any CD56/NCAM nor cyclin D1 expression in all biopsies (95 of 95, 100%), not even a weak, doubtful one; PCs were all polyclonal and CD138 positive. On the contrary, myeloma-associated PCs showed monoclonality for κ- or λ- light chain and strong CD56/NCAM immunoreactivity (8 of 10, 80%); four of them were cyclin D1 positive. Osteoblasts exhibited similar CD56/NCAM expression in both groups. Our data confirm the diagnostic utility of CD56/NCAM in the phenotypic characterization of polyclonal plasma cells, suggesting an important role of this particular immunomarker in the BM trephine study of polyclonal versus neoplastic plasmacytic infiltrations.     

Non-Hodgkin lymphoma response evaluation with MRI texture classification

Background

Liver cancer is a common malignancy with a high mortality rate. Given the poor prognosis associated with this cancer, many patients seek additional therapies that may improve quality of life or survival. Several Traditional Chinese Medicines (TCM) have been evaluated in clinical trials, but little is known about them outside of China.

Methods

We searched independently and in duplicate 8 electronic databases, including 2 Chinese language databases, until February 2009. We included any randomized clinical trials (RCT) evaluating a TCM oral preparation for the treatment of hepatocellular cancers. We abstracted data on survival, tumor response, and performance scores. We conducted a random-effects meta-analysis and applied a meta-regression analysis.

Results

We included 45 RCTs (n = 3,236). All studies employed an active control group. In general, the reporting of methodological issues was poor. We analyzed data from 37 trials reporting on complete response effects score (Relative Risk [RR] of 1.26 (95 CI, 1.04–1.52, P = 0.01, I² = 0%, P = 0.99). Products containing ginseng, astragalus and mylabris had a larger treatment effect (OR 1.34, 95% CI, 1.04–1.71, P = 0.01) than the pooled broad estimate, also the case for astragalus-based treatments (OR 1.35, 95% CI, 1.001–1.80. P = 0.048). We examined survival rates and pooled 15 studies reporting on 6 month outcomes (RR 1.10, 95% CI, 1.04–1.15, P = < 0.0001, I² = 0%, P = 0.60). This effect was consistent at other prospective dates, including 12 months (22 trials, RR 1.26, 95% CI, 1.17–1.36, P = < 0.0001, I² = 7%, P = 0.36), 24 months (15 trials, 1.72, 95% CI, 1.40–2.03, P = < 0.0001, I² = 0%, P = 0.75); and, at 36 months (8 trials, RR 2.40, 95% CI, 1.65–3.49, P = < 0.0001, I² = 0%, P = 0.62).

Limitations

All included trials were conducted in China where emerging evidence suggests many RCTs are not, in fact, randomized. Publication bias may exist, favouring positive reports.

Conclusion

Our meta-analysis displays compelling evidence of effectiveness for hepatocellular cancers that should be evaluated in high-quality and transparent clinical trials.     

2,6-Dichloro-p-phenylenediamine: comparative disposition in male and female rats and mice

2,6-Dichloro-p-phenylenediamine (DPA) was recently reported to induce hepatocellular adenomas and carcinomas in male and female B6C3F1 mice but not in F344 rats. The present investigation of comparative disposition in both sexes of each species was designed to detect species-related variations in DPA disposition that might explain variations in toxicity. Mouse tissues retained higher concentrations of radioactivity at the early time points (15 min and 2 h) than the corresponding rat tissues but were readily cleared at later time points. Elimination of DPA-derived radioactivity by each species was primarily in urine (56-63% of an intravenous dose of 600 mumol/kg body weight) and secondarily in feces (23-31%). Metabolites were qualitatively similar, but varied quantitatively with species. Rats excreted three major and eight minor metabolites in urine, while mice excreted one major and nine minor metabolites. The major metabolite present in mouse urine (61-78% of radioactivity) was approximately two-fold higher than the corresponding major metabolite in rat urine. Efforts to detect covalent binding of DPA and/or metabolites with hepatic DNA indicated no detectable binding in either species. The present study indicates that quantitative variations in disposition and metabolism exist between the two species but does not identify a likely source of species variation in susceptibility to DPA toxicity.     

Murine typhus in Cyprus: 21 paediatric cases

The aim of this article is to present the manifestations of Rickettsia typhi infection in childhood. Twenty-one children under 15 years of age were hospitalised in the Department of Paediatrics of the Archbishop Makarios Hospital in Nicosia, Cyprus, from 2000 to 2006 with Rickettsia typhi infection. Ten of them were boys and 11 were girls. The median age was eight years (range four to 13 years). The most common clinical features were fever (100%) and rash (57%). Lymphadenopathy, usually cervical, was also a frequent finding (37%). Severe headache was rather infrequent (29%). Splenomegaly or hepatomegaly were less frequent findings (24% and 10%, respectively). Mild elevation of liver enzymes (AST and ALT elevated >1-fold in 81% and 75%, respectively) was the most frequent laboratory finding. Thrombocytopenia (28%) and leucopenia (17%) were less frequent. Nearly half of the patients (10/21) came from four neighbouring villages, where most residents work in agriculture. All of the children were treated with appropriate antibiotic regimens and had complete recovery. Rickettsia typhi infection should be considered in the differential diagnosis of children who present during the summer or early autumn months with prolonged fever and rash with or without lymphadenopathy.