'Granulitis': defining a common, biofilm-induced, hyperinflammatory wound pathology.

The hard-to-heal (chronic) wound condition, now believed to be inextricably linked to the presence of microbial biofilm, has posed challenges in translating scientific understanding to clinical practice in recent decades. During this time, multiple descriptive terms of the wound pathology have been described, including critical colonisation, biofilm infection and inflammatory stasis. However, the absence of naming this disease state as a specifically identified condition that is tangible to treat has led to some confusion and delay in possible therapeutic approaches. When there is clinical uncertainty of wound status, antibiotics are too often inappropriately administered as a precaution. We therefore propose that introducing the term 'granulitis' (inflamed, unhealthy granulation tissue) could be used to identify the biofilm-induced, persistent inflammatory wound condition. This will help to raise clinician and public awareness of the condition, guide appropriate and prompt local wound hygiene, and encourage allocation of adequate resources to improve wound healing outcomes globally.

Virtual monitoring of suicide risk in the general hospital and emergency department.

OBJECTIVE: To determine whether continuous virtual monitoring, an intervention that facilitates patient observation through video technology, can be used to monitor suicide risk in the general hospital and emergency department (ED). METHOD: This was a retrospective analysis of a protocol in which select patients on suicide precautions in the general hospital and ED received virtual monitoring between June 2017 and March 2018. The primary outcome was the number of adverse events among patients who received virtual monitoring for suicide risk. Secondary outcomes were the percentage of patients for whom virtual monitoring was discontinued for behavioral reasons and the preference for observation type among nurses. RESULTS: 39 patients on suicide precautions received virtual monitoring. There were 0 adverse events (95% confidence interval (CI) = 0.000-0.090). Virtual monitoring was discontinued for behavioral reasons in 4/38 cases for which the reason for terminating was recorded (0.105, 95%CI = 0.029-0.248). We were unable to draw conclusions regarding preference for observation type among nurses due to a low response rate to our survey. CONCLUSIONS: Suicide risk can feasibly be monitored virtually in the general hospital or ED when their providers carefully select patients for low impulsivity risk.

Nurse home visits improve maternal/infant interaction and decrease severity of postpartum depression.

OBJECTIVE: To test the efficacy of the relationship-focused behavioral coaching intervention Communicating and Relating Effectively (CARE) in increasing maternal/infant relational effectiveness between depressed mothers and their infants during the first 9 months postpartum. DESIGN: Randomized clinical trial (RCT) with three phases. METHODS: In this three-phase study, women were screened for postpartum depression (PPD) in Phase I at 6 weeks postpartum. In Phase II, women were randomly assigned to treatment or control conditions and maternal/infant interaction was video recorded at four intervals postpartum: 6 weeks, 3 months, 6 months, and 9 months. Phase III involved focus group and individual interviews with study participants. SETTING: Phase I mothers were recruited from obstetric units of two major medical centers. Phase II involved the RCT, a series of nurse-led home visits beginning at 6 weeks and ending at 9 months postpartum. Phase III focus groups were conducted at the university and personal interviews were conducted by telephone or in participants' homes. PARTICIPANTS: Postpartum mother/infant dyads (134) representative of southeastern New England, United States participated in the RCT. One hundred and twenty-five mother/infant dyads were fully retained in the 9-month protocol. RESULTS: Treatment and control groups had significant increases in quality of mother/infant interaction and decreases in depression severity. Qualitative findings indicated presence of the nurse, empathic listening, focused attention and self-reflection during data collection, directions for video-recorded interaction, and assistance with referrals likely contributed to improvements for both groups. CONCLUSIONS: Efficacy of the CARE intervention was only partially supported. Nurse attention given to the control group and the data collection process likely confounded results and constituted an unintentional treatment. Results suggest that nurse-led home visits had a positive effect on outcomes for all participants.

A community-based screening initiative to identify mothers at risk for postpartum depression.

OBJECTIVES: To conduct a community-based, postpartum depression (PPD) screening initiative, and recommend PPD screening practices. DESIGN: Descriptive correlational. SETTINGS: Two academic medical centers, a university research office, and participants' homes. PARTICIPANTS: Five thousand one hundred and sixty-nine postpartum women age 14 to 49 years. METHODS: The Agency for Healthcare Research and Quality (AHRQ) framework was implemented by identifying a cohort of mothers and conducting PPD screening followed by diagnostic evaluation of those with positive screens. Mothers in the postpartum period were recruited from two academic medical centers and screened for PPD at 4 to 6 weeks postpartum by telephone or mail using the Edinburgh Postnatal Depression Scale (EPDS). Mothers with EPDS scores ≥10 were invited to participate in the Structured Clinical Interview for DSM IV (SCID) to confirm PPD. RESULTS: Six hundred and seventy-four (13%) women had EPDS scores ≥10; 185 women with elevated EPDS scores agreed to have a SCID diagnostic interview, and 144 were diagnosed with minor or major depression. A significantly higher percentage of women who self-administered and mailed in the EPDS than women who were screened via telephone had scores ≥10. Elevated PPD scores were not associated with age or parity. Race/ethnicity identification other than White and having less than high school education were associated with higher PPD scores. CONCLUSIONS: The AHRQ framework was effective in guiding a large-scale PPD screening initiative by identifying mothers at risk for PPD. Results support previous findings regarding prevalence, selected risk factors, and continued use of the EPDS with SCID confirmation.

Best practices: community-based postpartum depression screening: results from the CARE study.

This column describes findings and best-practice recommendations from CARE (Communicating and Relating Effectively), a prospective randomized study in which 5,169 mothers were screened for postpartum depression. The prevalence rate was 13%. Results support use of the Edinburgh Postnatal Depression Screening Scale and a diagnostic assessment for those who screen positive. Of the 674 mothers with positive screens, 26% were not asked about their emotional state by clinicians. Screening must be linked to treatment options via referral and follow-up. Best-practice strategies for implementing screening include educating clinicians and postpartum women.

Peer-mentoring for first-time mothers from areas of socio-economic disadvantage: a qualitative study within a randomised controlled trial.

BACKGROUND: Non-professional involvement in delivering health and social care support in areas of socio-economic deprivation is considered important in attempting to reduce health inequalities. However, trials of peer mentoring programmes have yielded inconsistent evidence of benefit: difficulties in implementation have contributed to uncertainty regarding their efficacy. We aimed to explore difficulties encountered in conducting a randomised controlled trial of a peer-mentoring programme for first-time mothers in socially disadvantaged areas, in order to provide information relevant to future research and practice. This paper describes the experiences of lay-workers, women and health professionals involved in the trial. METHODS: Thematic analysis of semi-structured interviews with women (n = 11) who were offered peer mentor support, lay-workers (n = 11) who provided mentoring and midwives (n = 2) who supervised the programme, which provided support, from first hospital antenatal visit to one year postnatal. Planned frequency of contact was two-weekly (telephone or home visit) but was tailored to individuals' needs. RESULTS: Despite lay-workers living in the same locality, they experienced difficulty initiating contact with women and this affected their morale adversely. Despite researchers' attempts to ensure that the role of the mentor was understood clearly it appeared that this was not achieved for all participants. Mentors attempted to develop peer-mentor relationships by offering friendship and sharing personal experiences, which was appreciated by women. Mentors reported difficulties developing relationships with those who lacked interest in the programme. External influences, including family and friends, could prevent or facilitate mentoring. Time constraints in reconciling flexible mentoring arrangements with demands of other commitments posed major personal difficulties for lay-workers. CONCLUSION: Difficulties in initiating contact, developing peer-mentor relationships and time constraints pose challenges to delivering lay-worker peer support. In developing such programmes, awareness of potential difficulties and of how professional support may help resolve these should improve uptake and optimise evaluation of their effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN55055030.

Food intake and electrolyte status of ultramarathoners competing in extreme heat.

OBJECTIVE: To relate changes in laboratory indices to dietary intake during extremely prolonged running and to determine if dietary intake influences the ability of runners to finish an 160 km trail race. METHODS: We monitored intake and serum chemistries of 26 runners competing in an 160 km foot race in temperatures which peaked at 38 degrees C. Blood was drawn pre-, mid- and post-race. Dietary intake and incidence of gastrointestinal distress or changes in mental status were determined by interview with runners approximately every 13 km. Twenty-three runners completed at least 88 kms and, of these 23 runners, 13 finished 160 km in a mean time of 26.2 +/- 3.6 hours. RESULTS: Finishers ingested nearly 30,000 J, 19.4 +/- 8.1 L of fluid and 16.4 +/- 9.5 g of sodium (Na). Sodium and fluid intake per hour was estimated to be 0.6 g/hour and 0.7 L/hour, respectively. Electrolyte intake during the first half of the race was similar between those that finished the race and those that did not. Finishers ingested fluid at a greater rate than non-finishers (p = 0.01) and tended to meet their caloric needs more closely than did non-finishers (p = 0.09). Body weight was unchanged over time (ANOVA, p = 0.52). Serum Na concentration tended to fall from 143 to 140 mEq/L during the race (p = 0.06), and was inversely correlated with weight loss (p = 0.009). Serum Na concentration was lower mid-race in runners experiencing changes in mental status than in runners without changes (p = 0.04). Fluid intake was inversely correlated with serum Na concentrations (p = 0.04). Most of the runners experienced nausea or vomiting; these symptoms were not related to serum sodium concentration. Hyponatremia (<135 mEq/L) was seen in one runner at 88 kms, but resolved by 160 km. Urinary sodium excretion decreased (p = 0.002) as serum aldosterone concentration increased pre- to post-race (p < 0.001). From start to finish of the race plasma volume increased by 12%. CONCLUSIONS: Food and fluid was ingested at a greater rate than described previously. Runners consumed adequate fluid to maintain body weight although dietary sodium fell far short of the recommended 1 g/hour. The rate of fluid intake was greater in finishers than in non-finishers, and finishers tended to more nearly meet their energy needs. Maintenance of body mass despite large exercise energy expenditures in extreme heat is consistent with fluid overload during a running event lasting more than 24 hours in hot and humid conditions.

Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease.

Patients with chronic hepatitis C virus (HCV) infection frequently report fatigue, lassitude, depression, and a perceived inability to function effectively. Several studies have shown that patients exhibit low quality-of-life scores that are independent of disease severity. We therefore considered whether HCV infection has a direct effect on the central nervous system, resulting in cognitive and cerebral metabolite abnormalities. Twenty-seven viremic patients with biopsy-proven mild hepatitis due to HCV and 16 patients with cleared HCV were tested with a computer-based cognitive assessment battery and also completed depression, fatigue, and quality-of-life questionnaires. The HCV-infected patients were impaired on more cognitive tasks than the HCV-cleared group (mean [SD]: HCV-infected, 2.15 [1.56]; HCV-cleared, 1.06 [1.24]; P =.02). A factor analysis showed impairments in power of concentration and speed of working memory, independent of a history of intravenous drug usage (IVDU), depression, fatigue, or symptom severity. A subgroup of 17 HCV-infected patients also underwent cerebral proton magnetic resonance spectroscopy (1H MRS). The choline/creatine ratio was elevated in the basal ganglia and white matter in this group. Patients who were impaired on 2 or more tasks in the battery had a higher mean choline/creatine ratio compared with the unimpaired patients. In conclusion, these preliminary results demonstrate cognitive impairment that is unaccounted for by depression, fatigue, or a history of IVDU in patients with histologically mild HCV infection. The findings on MRS suggest that a biological cause underlies this abnormality.