IgG in cervicovaginal mucus traps HSV and prevents vaginal herpes infections.

IgG is the predominant immunoglobulin in cervicovaginal mucus (CVM), yet how immunoglobulin G (IgG) in mucus can protect against infections is not fully understood. IgG diffuses rapidly through cervical mucus, slowed only slightly by transient adhesive interactions with mucins. We hypothesize that this almost unhindered diffusion allows IgG to accumulate rapidly on pathogen surfaces, and the resulting IgG array forms multiple weak adhesive crosslinks to mucus gel that effectively trap (immobilize) pathogens, preventing them from initiating infections. Here, we report that herpes simplex virus serotype 1 (HSV-1) readily penetrated fresh, pH-neutralized ex vivo samples of CVM with low or no detectable levels of anti-HSV-1 IgG but was trapped in samples with even modest levels of anti-HSV-1 IgG. In samples with little or no endogenous anti-HSV-1 IgG, addition of exogenous anti-HSV-1 IgG, affinity-purified from intravenous immunoglobulin, trapped virions at concentrations below those needed for neutralization and with similar potency as endogenous IgG. Deglycosylating purified anti-HSV-1 IgG, or removing its Fc component, markedly reduced trapping potency. Finally, a non-neutralizing IgG against HSV-gG significantly protected mice against vaginal infection, and removing vaginal mucus by gentle lavage abolished protection. These observations suggest that IgG-Fc has a glycan-dependent "muco-trapping" effector function that may provide exceptionally potent protection at mucosal surfaces.

All I want for coagulation.

Evidence-based medicine underpins modern practice of medicine. This paper describes a fictional consultation between Santa Claus and a doctor regarding deep vein thrombosis (DVT) prophylaxis, giving a review of the evidence for DVT prophylaxis in travellers while exposing the difficulty in applying evidence to atypical clinical encounters. Medline and the Cochrane Library were searched, and guidelines reviewed. Keywords used were DVT, thromboembolism, deep vein thrombosis and air travel-related venous thromboembolism. All relevant studies found, have been included in this review, with additional studies identified from the references in these articles. In conclusion, compression stockings, with or without a one-off dose of either aspirin or heparin, are the most evidence-based approaches for prophylaxis in someone with established risk factors for DVT prior to a long-haul flight. Simple exercises should also be encouraged.

An example of psychological adjustment in chronic illness: Hirschsprung's disease.

The aim of this study was to investigate the outcomes after definitive surgical correction for children with Hirschsprung's disease (HD) and the psychosocial impact of HD on the child and family. The total sample comprised 72 children with HD along with their families. The development of a condition-specific questionnaire measured the functional and psychosocial outcomes for children with HD with parental perception of their child's condition. Psychiatric measures were also examined to assess psychiatric morbidity. The greatest functional problem after definitive surgery for HD was faecal soiling (76%). The principle findings of the study were that (1) HD did not have a significant impact on the child's rate of psychiatric morbidity and levels of hopefulness in comparison to the normal population, (2) surgical and psychosocial functioning improved with increasing age and, (3) families remain troubled about their future with HD and dealing with psychosocial difficulties related to the condition (such as distress because of faecal soiling). Specifically, faecal soiling was found to be physically, emotionally and psychosocially distressing complication. Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Despite the significant impairment of faecal continence, we found that children/young adults with HD have minimal psychiatric morbidity, yet experience condition-specific psychosocial problems (e.g. embarrassment and distress/discomfort). HD does not increase the rate of clinical psychiatric morbidity in children and families with HD, but does determine the context of their daily distress and concern.

Life after definitive treatment for children with Hirschsprung's disease.

PURPOSE: The aim of this study was to investigate the long-term outcomes after definitive surgical correction for children with Hirschsprung's Disease (HD) and the psychosocial impact HD has on the child and family. METHODS: A clinical-based database of seventy-two children and young people aged between one to twenty-four years with HD, along with their families were investigated. This study involved the development of a condition-specific questionnaire in order to assess the functional and psychosocial outcomes for children with HD at different age groups, combined with parental perception of their child's condition in the long-term. RESULTS: The greatest functional problem after definitive surgery for HD was faecal soiling (n = 29/38: 76.3%). Children < or = 12 years experienced more embarrassment, distress/discomfort and family difficulties (n = 53/72; 73.6%) due to bowel dysfunctioning (such as faecal soiling) in comparison to children 12 years (n = 19/72; 26.3%) (p < 0.05). Young adults with HD (> 12 years) remained confident and 62.5% hopeful about their future with HD. Nine (12.5%) of the parents reported that HD had a negative impact on their marital relationship due to the daily stressors. Yet, 58.3% (n = 42) families remain confident and 70.8% (n = 42) hopeful about their child's future with HD. CONCLUSION: Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Psychosocial difficulties found in the child and family with HD are condition-specific--thus improving complications such as faecal soiling will further enhance better psychosocial adjustment.

The presentation of aggressive children and adolescents to emergency departments in Western Sydney.

AIM: To examine the utilization characteristics of children and adolescents with aggression presenting to emergency departments (ED) in Western Sydney. METHODS: Retrospective chart review of children and adolescents who presented with aggression to five non-psychiatric emergency departments over a 5-year period. Data were linked with the National Coroner's Information System Database. RESULTS: There were 279 index presentations by children and adolescents (66% male) with aggression. One hundred and seventeen (42%) were 14 years or under. The majority presented after working hours and/or on weekends (62%). Fifty-three percent of presentations had a self-harm component. In 26% of presentations, there was no documentation of mental health involvement. Children were discharged in 62% of presentations. Sixty-eight (24%) children and adolescents subsequently re-presented on 135 occasions with self-harm and/or aggression over the 5-year period. Four (1%) adolescents died. CONCLUSION: A presentation to an ED with aggression by a child or adolescent is an indicator of significant psychosocial dysfunction. These children and adolescents present when services are least accessible and are at risk of re-presentation and death. To address this issue, systems need to be developed that facilitate collaboration between EDs and child and adolescent mental health services.

Use of risperidone in a paediatric population: an observational study.

OBJECTIVE: To evaluate the impact of risperidone on functional impairment in a paediatric sample and to document the range of adverse drug reactions. METHODS: Risperidone treatment in children and adolescents (n = 51) with severe behavioural disturbances was assessed retrospectively to determine clinical response and adverse events. The change in patient functional performance during treatment was assessed using the Royal Alexandra Hospital for Children Measure of Function (MOF) score. Changes in target behaviours (such as severe aggression) were also assessed. RESULTS: The average duration of follow up was 9 months. Clinical improvement was demonstrated in 76% of the sample. There was a statistically significant improvement in the mean MOF with risperidone therapy (10.61 with 99% confidence interval 6.6-14.6). Risperidone appeared to be particularly useful in patients with autistic spectrum disorders. Twenty-five of the 51 patients (49%) experienced side-effects including sedation (27%), weight gain (20%), anticholinergic (10%) and extrapyramidal (8%) side-effects. CONCLUSIONS: This study suggests that risperidone is an effective agent in severely behaviourally disturbed paediatric patients. However, risperidone use is limited by the high frequency of side-effects. Randomized controlled trial data are required to determine the safety and efficacy of risperidone.

Anorexia nervosa (restrictive subtype) is associated with a polymorphism in the novel norepinephrine transporter gene promoter polymorphic region.

Long-term weight-restored patients with anorexia nervosa (AN) have lower norepinephrine levels than controls. Since this may reflect altered reuptake by the norepinephrine transporter (NET), we hypothesised that the NET gene was involved in the genetic component of AN. PCR-amplification of an AAGG repeat island (AAGG1) in the NET gene promoter region revealed a novel 343-bp sequence with five additional AAGG repeat islands (AAGG2-AAGG6). We named the sequence from AAGG1 to AAGG6 inclusive, the NET gene promoter polymorphic region (NETpPR). A 4-bp deletion (S4) or insertion (L4) in AAGG4 resulted in the net loss or gain, respectively, of a putative Elk-1 transcription factor site. The transmission disequilibrium test(TDT) with 87 Australian trios (patient plus parents) demonstrated significant preferential transmission of L4 (McNemar's chi(2) = 7.806, df = 1, P = 0.0052, odds ratio: 2.1) from parent to child with restricting AN (AN-R), suggesting that L4 or a DNA variant in linkage disequilibrium with it, doubles the risk for developing AN-R.

The Australian Childhood Dementia Study.

OBJECTIVES: To estimate the prevalence of childhood dementia, identify aetiological factors, and provide a brief survey of the psychosocial impact of childhood dementia. METHOD: The Australian Paediatric Surveillance Unit (APSU) was used to identify children with dementia. A total of 224 cases were notified about the dementia study and 141 (63%) questionnaires were completed and returned. Ascertainment was restricted to those most likely to have progressive neurocognitive decline because of practitioner bias against reporting non-progressive cases as dementia. RESULTS: Eighty children with dementia were identified. The estimated prevalence for dementia in childhood in Australian was 5.6/100,000. Thirteen cases (16%) were notified before the age of two years. Seventeen (21%) children were reported to have uncertain or unknown aetiology. Impact upon day to day family functioning was reported by clinicians to be 'marked' or 'extreme' in 50 (63%) families. Only four (6%) clinicians judged present services to be 'very adequate', while 16 (20%) clinicians judged current psychological support for the needs of the family to be 'very' or 'moderately inadequate'. Dementia as an overarching diagnostic concept offers integrative possibilities for research, management and service planning and provision. Childhood disintegrative disorder as a concept is criticised.

Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service.

A child and adolescent telepsychiatry service in rural New South Wales was evaluated. Part of the evaluation was to assess whether rural mental health workers and patients were satisfied with the videoconferencing services provided by child psychiatrists from the Children's Hospital at Westmead. During a 12-month study, information was collected using questionnaires on a total of 136 new patients who had been interviewed via videoconferencing. Satisfaction questionnaires were completed by 100 rural mental health workers, and 82 patients and their families/carers. Questionnaires about satisfaction with the technology were completed by 136 child psychiatrists, 101 rural mental health workers and 79 patients. Patients and their families/carers, as well as rural clinicians, expressed high overall satisfaction with the telepsychiatry service. The evaluation suggested that videoconferencing is a good method of providing child and adolescent psychiatry services to remote and rural communities.

Hoping and coping in young people who have been sexually abused.

BACKGROUND: Very little research has been conducted on the relationship between sexual abuse, reduced hopefulness and impaired coping. METHOD: The sample consisted of 22 abused young people (2 males (9%) and 20 females (91%)) and 29 nonabused young people (4 males (14%) and 25 females (86%)). Hopefulness, despair, depression, self-esteem, anxiety, number of negative life events and various parent, family and demographic variables were measured. The aim was to establish significant predictors of outcome, with outcome measured at the extreme end of the spectrum by self-injury and suicidal ideation and attempts. RESULTS: Depression predicted hopefulness and despair. Depression, anxiety, number of caregiver changes, despair and global personal hopefulness were significant predictors of outcome. Child sexual abuse itself was not a significant predictor of self-injury, suicidal ideation or suicide attempts in this sample. CONCLUSIONS: Each of the significant predictors of outcome, other than caregiver changes, has been linked to the learned helplessness paradigm. Depression and anxiety may be mediated by despair and hopefulness in their prediction of self-injury and suicidal attempts and ideation. To modify young people's long-term view of their futures and thereby reduce their vulnerability to depression and anxiety and in turn their tendency toward self-injury and suicide, something more than generic casework will be necessary. If self-injury, suicidal ideation and behaviour are to be effectively addressed, it is likely that anxiety and depression will need to be treated vigorously and attention will need to be paid to the perceived future.

A child and adolescent psychiatric outreach service for rural New South Wales: a telemedicine pilot study.

OBJECTIVE: To examine the feasibility of a tertiary outreach service in child and adolescent psychiatry to two rural health centres in New South Wales, Australia. METHODS: Following a site visit to Dubbo Hospital and Bourke Hospital, telemedical videoconferencing was provided for 2 h/week for 32 weeks. Details of referrers, patients' diagnosis and outcome, and satisfaction with the service were obtained. RESULTS: Cases were triaged by a nominated rural adolescent mental health worker. The service provided detailed assessment and management of servere, complex, mental and neuropsychiatric disorders. Fifty-four young people were assessed and 72 joint consultative videoconferencing interviews were undertaken, including 26 initial consultations. Twenty-three initial consultations were undertaken on the visit to the rural centres. Clinical descriptions illustrate the flexibility and sensitivity of the service. CONCLUSION: Telepsychiatry provides access to a flexible, effective tertiary service for those with special, complex needs, including the disadvantaged or isolated. It makes a valuable economic contribution to supporting and educating rural health professionals, thereby enriching rural mental health services.

Training in psychiatry: an examination of trainee perceptions. Part 1.

OBJECTIVE: To look at the perceptions of New South Wales (NSW) psychiatric trainees in relation to their training experiences and the role and quality of the consultant-registrar relationship. METHODS: A self-report questionnaire was developed to probe trainee perceptions of the consultant-trainee relationship in all those who had completed at least 1 year of training in psychiatry (n = 138) in NSW, as well as all consultants who had completed their training in the last 5 years (n = 95). Test-retest reliability was assessed at 3 months for each of the subscales (r = 0.70-0.89) and found to be acceptable. Validity issues are discussed. RESULTS: The results are discussed with special reference to the perceived competence, availability, breadth of knowledge and willingness to accept responsibilities of the supervising consultant. Consultant competence as a clinician was consistently rated as more important than being emotionally supportive. CONCLUSION: In addressing these issues, we aim to increase the degree of self-consciousness and reflectiveness of the profession of psychiatry within the Australian context. If there is to be a substantial shift for the better in trainees' perceptions of consultants, it is likely that the general consultant experience will have to be improved rather than providing small amounts of exposure to high quality consultants.

Adverse experiences in psychiatric training. Part 2.

OBJECTIVE: To examine the perceptions of New South Wales (NSW) psychiatric trainees in relation to their training, the adverse events they experienced and the role and quality of the consultant-registrar relationship. METHOD: A self-report questionnaire was developed to probe trainee perceptions of the consultant-trainee relationship and adverse events during training in all those who had completed at least 1 year of training in psychiatry (n = 138) in NSW, as well as all consultants who had completed their training in the last 5 years (n = 95). All subjects were asked to rate the frequency and relative impact of 20 adverse experiences with the opportunity to proffer adversities not listed. They were also asked to rate their experience of their consultants in relation to the adversity. RESULTS: The results from The Training Impact Study exploring adverse events experienced by NSW trainees are presented. Assault by a patient and suicide of a patient are identified as the most stressfull adversities of training in psychiatry. However, more general concerns such as educational and emotional neglect by supervisors, observing consultant maltreatment of patients, exam failure and conflict between consultants were also identified and discussed. CONCLUSIONS: The high response rate of both trainees and consultants gives these results a level of representative validity. Recommendations in relation to future training and research are put forward. Specific training in the management of potentially assaultive patients and facilitating trainee recovery from assault or threat of assault should be a priority of the Royal Australian and New Zealand College of Psychiatrists. Support and education in relation to patient suicide is also important. Training and recognition of teachers within the College should be encouraged.

Personal hopefulness: a conceptual review of the relevance of the perceived future to psychiatry.

Personal hopefulness, along with the perceived future, has been overlooked by psychiatry until relatively recently. There are cogent reasons why psychiatry should not ignore developments in relation to hope. Concepts related to hope are examined to delineate the components of the perceived future. Hope is defined in terms of its elements, its objects, its subject, its phenomenology and its relationship to despair and reality. The contribution of hope to our understanding of psychiatric and medical disorder and recovery from mental illness are also considered, with special reference to existing notions of depression and anxiety. Institutionalization is characterized as a disorder of personal hopefulness. Implications for potential shifts in current theoretical formulation and practice are anticipated. In particular, a critique of the learned helplessness/optimism formulation is outlined.

The construction and characteristics of an instrument to measure personal hopefulness.

This paper describes the construction, refinement and implementation of a self-administered measure of personal hopefulness, the Hunter Opinions and Personal Expectations Scale (HOPES). Initial state and trait versions of the HOPES instrument were utilized in three separate studies, comprising a medical student sample (N = 211), an adolescent male sample (N = 280) and a psychiatric hospital staff sample (N = 318). A revised 20-item, two factor, trait version of the scale was then utilized in a prospective, longitudinal investigation (N = 753) of the psychosocial sequelae of the earthquake which struck Newcastle (Australia) in December, 1989. Data from all four studies provide strong support for the HOPES instrument's construct, concurrent and predictive validity. Global personal hopefulness (GPH) was shown to be an enduring characteristic of individuals, with a test-retest correlation of r = + 0.71 (over 64 weeks). The association between GPH and trait anxiety (r = -0.64) raised the possibility of redefining anxiety as hope under threat. The hope subscale (HS) and the despair subscale (DS) were moderately negatively correlated (r = -0.32), suggesting that hope and despair are not simply polar opposites. There were no gender differences in GPH scores, however, there were relatively clear age effects, with those aged 70 years and over reporting the lowest levels of personal hopefulness. GPH was negatively correlated with post-earthquake scores on the General Health Questionnaire (r = -0.33), the Impact of Event Scale (r = -0.33), the Beck Depression Inventory (r = -0.54) and the global symptom index from the SCL-90-R (r = -0.43). Overall, the contribution made by personal hopefulness to post-earthquake morbidity was equal to the contributions made by initial exposure to disruption and threat experiences.

Comparison of three methods of assessing strength imbalances at the knee.

Three strength measurement methods for determining muscle imbalances at the knee were compared in 24 male athletes. Peak quadriceps extensions and hamstring flexions were measured isotonically, isometrically, and isokinetically. Isokinetic measurement was performed at 60, 180, and 300 degrees /sec. Repeated measures ANOVA revealed no significant difference among the three methods for bilateral imbalance ratio measurement. However, hamstring/quadricep ratios were significantly greater when measured isokinetically than when measured by the other methods. It was concluded that strength measurement methods may be used interchangeably when determining bilateral strength imbalance ratios at the knee but they may not be used interchangeably when assessing hamstring/quadricep ratios. Determinations of excess imbalance ratios (>10%) showed no consistent pattern across methods and may indicate problems associated with attempts to identify safety limits from muscle testing.J Orthop Sports Phys Ther 1988;10(4):134-137.

Viruses, neurodevelopmental disorder and childhood psychosis.

Four cases are described of prepubertal boys in whom the convergence of neurodevelopmental disorder, viral infection and psychosis seemed more than coincidental. Review of the literature highlights the possibility that viral infection of the central nervous system may play a contributory role in childhood psychosis. Whilst it is essential to avoid a reductionist stance when investigating these difficult conditions, the emergence of potent anti-viral treatments and sophisticated methods of identifying the presence of viral infection should encourage us to consider more carefully the relevance of viruses in childhood psychosis.