Disparities in access to ear and hearing care in Cambodia: a mixed methods study on patient experiences.

OBJECTIVE: Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders. METHOD: In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews. RESULTS: Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment. CONCLUSION: This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.

The impact of attention deficit hyperactivity disorder (ADHD) in adulthood: a qualitative study.

OBJECTIVES: There is limited evidence of the unmet needs and experiences of adults with attention deficit hyperactivity disorder (ADHD). Previous research in this area is predominantly quantitative by nature, few studies employing qualitative approaches. This study seeks to provide a deeper insight into the lived experiences of adults with ADHD within Western Ireland. METHODS: A qualitative design, consisting of semi-structured face-to-face interviews with a clinical sample in the Sligo/Leitrim area. Participants were eligible for this study if they screened positive for symptoms of ADHD, and diagnosed with ADHD with the Conners' Adult ADHD Diagnostic Interview for DSM-IV. In total, 11 participants completed this research. The interviews were open ended and exploratory, adopting a phenomenological approach. RESULTS: Thematic analysis was used to explore three main themes; The Burden of symptoms of ADHD, Perceived Positive and Negative Effects of ADHD and Challenge of Accessing Services, each with several subthemes. CONCLUSION: This research highlights the experiences of adults with ADHD. It is important for practitioners to be aware of the perceived positive and negative effects of the disorder, and how it can impact on their patient's lives. In addition, becoming aware of the stigma associated with ADHD can help clinicians improve upon individual treatment plans to meet their patient's needs. It is important to note that this sample experienced co-morbid diagnoses and so this may limit the interpretation of the findings. Further research in this area could explore patient's attitudes towards receiving a formal diagnosis of ADHD.

Host Responses to Biofilm.

From birth to death the human host immune system interacts with bacterial cells. Biofilms are communities of microbes embedded in matrices composed of extracellular polymeric substance (EPS), and have been implicated in both the healthy microbiome and disease states. The immune system recognizes many different bacterial patterns, molecules, and antigens, but these components can be camouflaged in the biofilm mode of growth. Instead, immune cells come into contact with components of the EPS matrix, a diverse, hydrated mixture of extracellular DNA (bacterial and host), proteins, polysaccharides, and lipids. As bacterial cells transition from planktonic to biofilm-associated they produce small molecules, which can increase inflammation, induce cell death, and even cause necrosis. To survive, invading bacteria must overcome the epithelial barrier, host microbiome, complement, and a variety of leukocytes. If bacteria can evade these initial cell populations they have an increased chance at surviving and causing ongoing disease in the host. Planktonic cells are readily cleared, but biofilms reduce the effectiveness of both polymorphonuclear neutrophils and macrophages. In addition, in the presence of these cells, biofilm formation is actively enhanced, and components of host immune cells are assimilated into the EPS matrix. While pathogenic biofilms contribute to states of chronic inflammation, probiotic Lactobacillus biofilms cause a negligible immune response and, in states of inflammation, exhibit robust antiinflammatory properties. These probiotic biofilms colonize and protect the gut and vagina, and have been implicated in improved healing of damaged skin. Overall, biofilms stimulate a unique immune response that we are only beginning to understand.

Biofilm maturity studies indicate sharp debridement opens a time- dependent therapeutic window.

OBJECTIVE: To investigate the hypothesis that newly formed wound biofilms (or bioburdens) are more susceptible to antimicrobial treatment. METHOD: Four separate and distinct models were performed by four separate biofilm research laboratories to evaluate the resistance of biofilms to antimicrobial treatments over time. These included a drip-flow biofilm model along with a hydrodebridement study, a porcine skin punch biopsy ex vivo model, a mouse chronic wound model and clinical longitudinal debridement study. RESULTS: All four models showed that, within the first 24 hours, the biofilm community was more susceptible to the selected antibiotics, and after maturing for up to 48 hours became increasingly tolerant. In each model, there was at least a 24-hour period in which the biofilms were more resistant to antibiotics. Each of the models utilised showed a significant decrease in the resistance of the biofilm/ burden to gentamicin for up to 24 hours with a confidence interval of at least 95%. The resistance increased in each of the models by 48 hours and reached original resistance levels by 72 hours. CONCLUSION: These data suggest the principles of biofilm-based wound care, along with the use of serial debridement to continually remove mature biofilm, followed by biofilm wound management strategies, including topical antibiotics while the bioburden is still immature and more susceptible, are valid.

Is transcutaneous electrical nerve stimulation an effective analgesia during colonoscopy?

OBJECTIVES: To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) as analgesia during colonoscopy. DESIGN: In a randomised controlled trial, patients undergoing diagnostic colonoscopy were assigned to one of three groups: standard medication only (midazolam); active TENS plus standard medication; or non-functioning TENS and standard medication. Efficacy of TENS was determined using numerical rating scores for pain and the post-procedural evaluation questionnaire. SETTING: Patients undergoing diagnostic colonoscopy in a teaching hospital. MAIN OUTCOME: There was no statistically significant differences between the three groups. However in the active TENS group there was a greater variation in "physical discomfort" and "psychological distress", suggesting TENS may be effective in subgroup of patients.

Emerging paradigms in the mental health care of refugees.

Over the past decade the approaches adopted towards the mental health care of refugees by a range of national and international healthcare organisations have been the subject of a sustained and growing critique. Much of this critique has focused on the way in which Western psychiatric categories have been ascribed to refugee populations in ways which, critics argue, pay scant attention to the social, political and economic factors that play a pivotal role in refugees' experience. Rather than portraying refugees as "passive victims" suffering mental health problems, critics have argued that attention should be given to the resistance of refugees and the ways in which they interpret and respond to experiences, challenging the external forces bearing upon them. In this paper a range of issues concerning the mental health care of refugees will be examined. These include the role of psychiatric diagnosis in relation to refugees' own perceptions of their need and within the context of general health and social care provision. In examining services the emergence of new paradigms in mental health care is identified. These include the growth of holistic approaches that take account of refugees' own experiences and expressed needs and which address the broader social policy contexts in which refugees are placed. A three-dimensional model for the analysis of the interrelationship between "macro" level institutional factors in the mental health of refugees and the individual treatment of refugees within mental health services is proposed.

Policies of deterrence and the mental health of asylum seekers.

In the past, most refugees who permanently resettled in the traditional recipient countries of North America, Europe, and Australasia were screened prior to arrival in a host country. In the last decade, increasing numbers of unauthorized refugees or asylum seekers, those who formally lodge application for refugee status in the country in which they are residing, have applied for protection after crossing the borders of these countries. Concerns about uncontrolled migration have encouraged host countries to adopt policies of deterrence in which increasingly restrictive measures are being imposed on persons seeking asylum. These measures include, variously, confinement in detention centers, enforced dispersal within the community, the implementation of more stringent refugee determination procedures, and temporary forms of asylum. In several countries, asylum seekers living in the community face restricted access to work, education, housing, welfare, and, in some situations, to basic health care services. Allegations of abuse, untreated medical and psychiatric illnesses, suicidal behavior, hunger strikes, and outbreaks of violence among asylum seekers in detention centers have been reported. Although systematic research into the mental health of asylum seekers is in its infancy, and methods are limited by sampling difficulties, there is growing evidence that salient postmigration stress facing asylum seekers adds to the effect of previous trauma in creating risk of ongoing posttraumatic stress disorder and other psychiatric symptoms. The medical profession has a role in educating governments and the public about the potential risks of imposing excessively harsh policies of deterrence on the mental health of asylum seekers. JAMA. 2000;284:604-611

Assessment of health locus of control in the use of nonconventional remedies by patients with rheumatic diseases.

OBJECTIVE: To assess the prevalence and characteristics of the use of nonconventional remedies (NCR) and to determine the type of health locus of control that the users of NCR may have. METHODS: We conducted a cross sectional survey of 200 patients with rheumatic diseases at 3 outpatient rheumatic clinics in Edmonton, Canada. A face-to-face structured interview was administered by a trained assistant to evaluate the prevalence of use, and patient beliefs, perceptions, and expectations in relation to NCR. To assess locus of control the Multidimensional Health Locus of Control (MHLC) instrument was applied. RESULTS: One-hundred nineteen patients (60%) had used a total of 530 NCR (range 1-25) in the previous 12 months; 94 (79%) of these patients used 309 NCR (mean of 3, range 1-15 remedies). Forty-seven percent had received at least one NCR before the first rheumatology consultation, but an additional 8% initiated NCR after their initial contact with a rheumatologist at our clinics. Only 22 (18%) of the patients using NCR notified their rheumatologist about their use. The mean reported expenditures for the users of NCR in the past 12 months were $260.00 CDN per patient (range 0 to $3,520), and the mean reported expenditures for the ever users of NCR were $730.00 CDN (range 0 to $9,720). Patients who used NCR in the past 12 months were younger (52 +/- 14 vs 58 +/- 15 yrs; p = 0.003), slightly more disabled (1.26 vs 1.11, modified Health Assessment Questionnaire; p = 0.006), and in the middle income class (p < 0.001). Possible associations between MHLC and the use of NCR were assessed in different ways in the logistic regression models, including the entry of MHLC subscales as means or class intervals, and NCR as users versus no users, or as higher users (> 4 NCR) versus no users of NCR. The use of NCR, ever or in the past 12 months, did not have statistical association with any of the subscales of the MHLC. CONCLUSION: In this survey over one-half of patients used NCR for treatment of their rheumatic disease. NCR were costly and the MHLC scales scores alone did not explain all the variance in health behaviors. Other contributing factors such as perceived severity of the disease, health motivation, or previous behavior should be addressed in further research.

The benefits of providing chemotherapy at home.

Diagnosis of cancer and subsequent treatment can result in feelings of loss of control. Home treatment services are suitable for many people receiving chemotherapy. Clients should be enabled to take as much control as they want to and are able. Effective communication within the multidisciplinary team is essential to continuity of care.

Spatial performance correlates with in vitro potentiation in young and aged Fischer 344 rats.

Young adult (2-4 months old) and aged (24-26 months old) Fischer 344 (F344) rats were trained for spatial behavior (locating a hidden escape platform) in a circular water maze. The aged rats showed deficits in both the acquisition and retention of the learned response. Following the behavioral training, hippocampal slices from the rats were prepared. Potentiation of CA1 extracellular, somatic field potentials was studied in vitro following either a short stimulus train (4 pulses) or a longer train (50 pulses). Slices from the aged rats showed less short-term potentiation (124.8 +/- 4.9% baseline, mean +/- S.E.M.) at 1 min following the short train in comparison to slices from the young rats (151.8 +/- 7.5%, P less than 0.05). However, following the longer train, no differences were found between the groups in the degree of either short-term (measured at 1 min after stimulation) or long-term potentiation (measured at 60 min). The amount of potentiation seen at various time points after either train correlated with the behavioral measure of retention. These results indicate that F344 rats exhibit age-related behavioral deficits, and age-related synaptic potentiation deficits in response to short stimulation trains. The correlation between the degree of potentiation (both short-term and long-term) and retention of a behavioral task adds strength to the hypothesis that potentiation mechanisms may underlie memory processes.

Biliary response to glucagon in humans.

Glucagon has been demonstrated to have profound effect on biliary secretion in several species. Glucagon's biliary effects were studied in humans following biliary tract surgery. Nine patients underwent common bile duct exploration and insertion of a balloon-occludable t tube. An aliquot of the collected sample was kept and the enterohepatic circulation was maintained by reinfusion of the collected bile via the distal t-tube port. Glucagon increased bile flow and decreased cholesterol and phospholipid output during stable bile acid output. Furthermore high-performance liquid chromatographic analysis of bile acid profiles revealed no significant changes in bile salt species or conjugation after glucagon infusion. Glucagon is probably important in the physiologic regulation of biliary secretion in humans.

Factors that influence the induction dose of propofol.

Factors that influence the induction of anaesthesia with propofol were investigated in a prospective study of 1000 patients. Pre-operative albumin and urea concentrations correlated with the minimum induction dose of propofol, but less strong correlations were found with haemoglobin, globulin and total protein concentrations. Age was an important influence on the induction dose of propofol (r = -0.34) which was also closely related to ASA grade. Induction of anaesthesia with propofol is dependent on a number of variables, and this study suggests that pre-operative albumin and urea concentrations are important.

The Engström Elsa anaesthetic machine. An electronic system for anaesthesia.

Six Engström Elsa anaesthetic machines have been in regular use for 18-24 months. The machine incorporates a number of new concepts for anaesthetic delivery and monitoring. At flows below 1000 ml/minute, each machine delivered 20% more than the indicated value; at higher flows, the indicated value was within 10% of the flow delivered. Minute volume, tidal volumes and oxygen concentrations were within the manufacturer's specifications. However, vaporizer and vapour monitor performance was outside the (SD) 5% accuracy claimed by the manufacturers. It was noted that the bistable valve requires user familiarity for the change from controlled to spontaneous ventilation to be accomplished with ease. It was also possible to misconnect the breathing system and so isolate the excess pressure escape valve and high-pressure alarm. Nevertheless, once familiarisation was achieved, the machines have proved easy to operate and are particularly satisfactory when used with low fresh gas flows.

Biliary response to glucagon and insulin following hepatic transplantation in humans.

Glucagon and insulin are postulated to be physiologic regulators of hepatic biliary secretion. Effects of these hormones were studied following orthotopic transplantation. Five adult hepatic graft recipients had triple lumen t-tubes placed at the time of surgery and were studied 3 months after surgery. Experiments were performed after cholangiographic confirmation of t-tube placement and function. After overnight fast, t-tubes were inflated and bile was collected. A small quantity was saved for analysis and the remainder was reinfused to maintain enterohepatic circulation. After 1 hr of observation, the patients received a 2-hr infusion of insulin (0.125 U kg-1 hr-1), glucagon (2 micrograms kg-1 hr-1), or 0.9% saline. During saline infusions, all parameters remained stable. As has been previously demonstrated in the canine model and intact patients, bile salt outputs were constant under all experimental conditions. Glucagon stimulated bile secretion by 30% (6.7 +/- 1.5 to 8.7 +/- 1.2 ml/15 min) and inhibited biliary cholesterol output by 47% (16.4 +/- 3.2 to 8.7 +/- 1.5 mg/15 min). Bile flow and lipid secretion were not affected by insulin. Glucagon had profound effects on bile flow and lipid secretion, suggesting effects independent of innervation, while insulin at this dose had no statistically significant effects.

Pre-operative anxiety and serum potassium.

Small decreases in serum potassium in a study of 200 pre-operative patients were demonstrated in those who had an increase in anxiety, as measured on a linear analogue anxiety scale, in the 24 hours before anaesthesia. The possible aetiology and implications of this change are discussed. The combination of temazepam and a pre-operative visit by the anaesthetist effectively reduced pre-anaesthetic anxiety in 60% of patients.

Clinical significance of ultrasonographically detected coincidental gallstones.

The clinical profiles of 139 patients with gallstones found coincidentally during ultrasonography were reviewed and the patients followed prospectively for five years. Indications for ultrasonography included follow-up of abdominal malignancy (33%), evaluation of abdominal aortic aneurysm or other arteriosclerotic vascular disease (22%), renal insufficiency (12%), and lower abdominal pain (7%). At the time of gallstone detection, 14 patients (10%) had symptoms attributable to cholelithiasis. Over the next five years, only 15 patients (11%) developed episodes resembling biliary pain. Nine patients underwent cholecystectomy during this period. Three of the cholecystectomies were incidental to other abdominal procedures. Two cholecystectomies were performed as emergencies for gallstone complications with no perioperative mortality. Interestingly, 54 patients (40%) with coincidental gallstones died during the follow-up period. All the deaths were unrelated to gallstones. These data indicate that ultrasonographically detected coincidental gallstones rarely have clinical significance, leading strong support to the expectant management of most patients with purely coincidental gallstones.