Review: Mitigating the risks posed by intensification in livestock production: the examples of antimicrobial resistance and zoonoses.

Major shifts in how animals are bred, raised and slaughtered are involved in the intensification of livestock systems. Globally, these changes have produced major increases in access to protein-rich foods with high levels of micronutrients. Yet the intensification of livestock systems generates numerous externalities including environmental degradation, zoonotic disease transmission and the emergence of antimicrobial resistance (AMR) genes. Where the process of intensification is most advanced, the expertise, institutions and regulations required to manage these externalities have developed over time, often in response to hard lessons, crises and challenges to public health. By exploring the drivers of intensification, the foci of future intensification can be identified. Low- and middle-income (LMICs) countries are likely to experience significant intensification in livestock production in the near future; however, the lessons learned elsewhere are not being transferred rapidly enough to develop risk mitigation capacity in these settings. At present, fragmentary approaches to address these problems present an incomplete picture of livestock populations, antimicrobial use, and disease risks in LMIC settings. A worldwide improvement in evidence-based zoonotic disease and AMR management within intensifying livestock production systems demands better information on the burden of livestock-associated disease, antimicrobial use and resistance and resources allocated to mitigation.

Antimicrobial use practices, attitudes and responsibilities in UK farm animal veterinary surgeons.

Increasing levels of antimicrobial resistance in human and veterinary medicine have raised concerns around the issue of overprescribing and the indiscriminate use of antimicrobials. Their use in food producing animals is under scrutiny due to the perceived risk from the zoonotic transfer of resistant pathogens from animals to humans. This study aimed to explore UK veterinary surgeons antimicrobial prescribing behaviours, their attitudes to antimicrobial resistance and their perceptions of responsibility of antimicrobial use in pigs through a questionnaire study on a census sample of 261 veterinary surgeons in England, Wales and Scotland who had a clinical caseload which included commercial pigs. The questionnaire had a useable response rate of 34.1% (n = 61/179) in eligible veterinary surgeons. Overall, veterinary surgeons reported personal confidence that their prescribing decisions were responsible however, there was concern that the prescribing behaviours of other veterinary surgeons and physicians in human medicine may be less responsible; a sociological concept known as 'othering'. In parallel, veterinary surgeons seldom identified that treatment failure was a consequence of antimicrobial resistance in their own clinical caseload, however they considered it an issue for other veterinary surgeons and for human prescribers. Veterinary surgeons consulted a wide spectrum of resources on antimicrobial use in pigs which, on occasion, contained conflicting guidance on what was defined as responsible prescribing. The decision over whether or not to prescribe an antimicrobial was influenced by numerous factors relating to the veterinary surgeons' experience and the clinical situation presented, but maintaining pig welfare was a high priority. There was a shared desire to seek alternative methods to prevent disease to antimicrobial use, however the use of diagnostics to support prescribing decisions was an infrequently reported behaviour and could play a more significant role in prescriber decisions if more cost effective and rapid tests were available. Future interventions to optimise antimicrobial use in pigs needs to focus on the evolution of antimicrobial use practices in a changing political and scientific landscape whilst also considering individual motivations and justifications for use.

Understanding the culture of antimicrobial prescribing in agriculture: a qualitative study of UK pig veterinary surgeons.

OBJECTIVES: The use of antimicrobials in food-producing animals has been linked with the emergence of antimicrobial resistance in bacterial populations, with consequences for animal and public health. This study explored the underpinning drivers, motivators and reasoning behind prescribing decisions made by veterinary surgeons working in the UK pig industry. METHODS: A qualitative interview study was conducted with 21 veterinary surgeons purposively selected from all UK pig veterinary surgeons. Thematic analysis was used to analyse transcripts. RESULTS: Ensuring optimum pig health and welfare was described as a driver for antimicrobial use by many veterinary surgeons and was considered a professional and moral obligation. Veterinary surgeons also exhibited a strong sense of social responsibility over the need to ensure that antimicrobial use was responsible. A close relationship between management practices, health and economics was evident, with improvements in management commonly identified as being potential routes to reduce antimicrobial usage; however, these were not always considered economically viable. The relationship with clients was identified as being a source of professional stress for practitioners due to pressure from farmers requesting antimicrobial prescriptions, and concern over poor compliance of antimicrobial administration by some farmers. CONCLUSIONS: The drivers behind prescribing decisions by veterinary surgeons were complex and diverse. A combination of education, improving communication between veterinary surgeons and farmers, and changes in regulations, in farm management and in consumer/retailer demands may all be needed to ensure that antimicrobial prescribing is optimal and to achieve significant reductions in use.

ESTABLISHMENT OF A NATIONAL DOSE REGISTER AND A DOSIMETRY SERVICE APPROVAL SYSTEM IN IRELAND.

Until the end of 2012, the Radiological Protection Institute of Ireland (RPII) operated a personal dosimetry service for workers in the medical, industrial, education and research sectors in Ireland. The data recorded by the RPII service were used to generate national dose statistics and as such acted as a National Dose Register (NDR). In preparation for the closure of the RPII dosimetry service in 2012, a formal NDR was introduced for the first time in Ireland and data on all monitored workers are now supplied to it annually by Approved Dosimetry Services. A new system for approving dosimetry services operating in Ireland was also introduced in 2012. The criteria for approval are based on the recommendations given in the European Commission's publication, 'Radiation Protection No. 160'. This paper describes the steps involved and the operational experience gained in establishing both the NDR and the system for approval of dosimetry services.

Understanding antimicrobial use and prescribing behaviours by pig veterinary surgeons and farmers: a qualitative study.

Increasing awareness of bacterial antimicrobial resistance in human beings and veterinary medicine has raised concerns over the issue of overprescribing and the indiscriminate use of antimicrobials. Their use in food-producing animals is under scrutiny due to the perceived risk from the zoonotic transfer of resistant pathogens from animals to human beings. This study used focus groups to explore the drivers and motivators behind antimicrobial use and prescribing by veterinary surgeons and farmers in the pig industry in the UK. Studies of two veterinary and four farmer focus groups were undertaken, each with between three and six participants, in three geographically distinct regions of low, moderate and high pig density in England. Thematic analysis of the focus group transcriptions revealed convergent themes, both within and across, the veterinary and farmer focus groups. Veterinary opinion was such that 'external pressures', such as pressure from clients, legislation and public perception, were considered to strongly influence prescribing behaviour, whereas, farmers considered issues surrounding farming systems and management to be greater drivers towards antimicrobial use. Acquiring such in-depth insight into the antimicrobial prescribing behaviours in veterinary medicine provides more detailed understanding of prescribing practice and will aid the development of interventions to promote the responsible use of antimicrobials.

The analgesic effect of odour and music upon dressing change.

Vascular wounds may require frequent dressing changes over a long period of time, often involving pain, which may not be adequately controlled with conventional analgesia. Complementary analgesia may be beneficial as an adjunctive therapy. This pilot study presented eight patients with two odour therapies, lavender and lemon, two music therapies, relaxing and preferred music and a control condition, during vascular wound dressing changes. Although the therapies did not reduce the pain intensity during the dressing change there was a significant reduction in pain intensity for the lavender therapy and a reduction in pain intensity for the relaxing music therapy after the dressing change. This supports the use of these complementary therapies, which are inexpensive, easy to administer and have no known side effects, as adjunctive analgesia in this patient population. Earlier administration before dressing change may enhance these effects. Further research is required to ascertain why certain complementary therapies are more effective than others at relieving pain.

Human embryonal carcinoma stem cells expressing green fluorescent protein form functioning neurons in vitro: a research tool for co-culture studies.

Neural differentiation is controlled by complex molecular mechanisms that determine cell fate and diversity within the nervous system. Interactions between developing tissues play an important role in regulating this process. In vitro co-culture experiments offer a method to study cell differentiation and function under controlled conditions, with the additional benefit of investigating how interactions between populations of cells influence cell growth and behavior. However, it can often be difficult to distinguish between populations of co-cultured cells. Here we report the development of a human embryonal carcinoma (EC) stem cell line (named TERA2.cl.SP12-GFP) that expresses the genetic marker, green fluorescent protein (GFP). Here, we demonstrate that TERA2.cl.SP12-GFP stem cells stably express GFP and that this remains detectable during retinoic acid-induced differentiation. Regulated expression of neural markers during cell development correlated with the formation of morphologically identifiable neurons. Populations of post-mitotic GFP-positive neurons were readily purified and electrophysiological characterization confirmed that such neurons were functionally active. Thus, cultured TERA2.cl.SP12-GFP cells can be readily distinguished from alternative cell types in vitro and provide an amenable system for live cell imaging to study the development and function of human neurons in isolation, and in co-culture with other tissue types.

Sodium channel inhibition by anandamide and synthetic cannabimimetics in brain.

Anandamide is a prominent member of the endocannabinoids, a group of diffusible lipid molecules which influences neuronal excitability. In this context, endocannabinoids are known to modulate certain presynaptic Ca(2+) and K(+) channels, either through cannabinoid (CB1) receptor stimulation and second messenger pathway activation or by direct action. We investigated the susceptibility of voltage-sensitive sodium channels to anandamide and other cannibimimetics using both biochemical and electrophysiological approaches. Here we report that anandamide, AM 404 and WIN 55,212-2 inhibit veratridine-dependent depolarization of synaptoneurosomes (IC(50)s, respectively 21.8, 9.3 and 21.1 microM) and veratridine-dependent release of L-glutamic acid and GABA from purified synaptosomes [IC(50)s: 5.1 microM (L-glu) and 16.5 microM (GABA) for anandamide; 1.6 microM (L-glu) and 3.3 microM (GABA) for AM 404, and 12.2 (L-glu) and 14.4 microM (GABA) for WIN 55,212-2]. The binding of [3H]batrachotoxinin A 20-alpha-benzoate to voltage-sensitive sodium channels was also inhibited by low to mid micromolar concentrations of anandamide, AM 404 and WIN 55,212-2. In addition, anandamide (10 microM), AM 404 (10 microM) and WIN 55,212-2 (1 microM) were found to markedly block TTX-sensitive sustained repetitive firing in cortical neurones without altering primary spikes, consistent with a state-dependent mechanism. None of the inhibitory effects we demonstrate on voltage-sensitive sodium channels are attenuated by the potent CB1 antagonist AM 251 (1-2 microM). Anandamide's action is reversible and its effects are enhanced by fatty acid amidohydrolase inhibition. We propose that voltage-sensitive sodium channels may participate in a novel signaling pathway involving anandamide. This mechanism has potential to depress synaptic transmission in brain by damping neuronal capacity to support action potentials and reducing evoked release of both excitatory and inhibitory transmitters.

Changing patterns of inpatient care for children and adolescents at the Menninger Clinic, 1988-1994.

The authors describe trends in inpatient psychiatric length of stay (LOS) and admissions for the population of children and adolescents (N = 784) at the Menninger Clinic from 1988 to 1994. During this period. median LOS declined dramatically from 7 months to 3 weeks, whereas admissions increased 4-fold. The diagnostic case mix changed substantially, with a crossover in modal principal diagnosis from personality disorder to affective disorder. Use of medications became almost universal. Diagnosis and medication use became less important determinants of LOS over time. The practical implications of these patterns include higher patient turnover, fewer inpatient clinical contact hours, and heightened importance of continuity with outpatient care. Research should center on the impact of declining LOS on clinical and functional outcomes for children and adolescents.

A therapeutic nursery evaluation study.

The object of this prospective study was to evaluate the effectiveness of a therapeutic nursery program for troubled preschoolers attending the Preschool Day Treatment Center of The Menninger Clinic. Thirty-eight seriously disturbed preschoolers were assessed both at admission and at 9 months or at discharge (if before 9 months) in a pre-post design. Commonly used assessment instruments were collected by independent research clinicians. Significant gains were found in both internalizing and externalizing behaviors on the Child Behavior Checklist (CBCL). The Kohn Social Competence Scale showed significant improvement in learning, pleasurable play activities, and peer interactions. The socialization domain on the Vineland Adaptive Behavior Scale also indicated improvement beyond expectable maturation. In the Behavioral Observations test, both the capacities of the child and the qualities of the relationship were shown to be improved. As measured by the Epidemiologic Studies of Depression Scale (CES-D), mothers also became less depressed. Overall, the researchers conclude that a therapeutic nursery with a comprehensive program is an effective way to help seriously troubled preschoolers make gains in behavior, as well as in social and emotional growth.

Evaluation of intensive inpatient treatment of patients with severe personality disorders.

OBJECTIVE: The purpose of this study was to determine whether severe personality disorders improve or deteriorate with intensive inpatient treatment. METHODS: Overall 216 patients diagnosed as having personality disorders by DSM-III-R criteria were prospectively monitored at two private psychiatric hospitals from admission through discharge to one-year follow-up. RESULTS: Substantial positive change in the sample was recorded at discharge, and the improvements held up at one-year follow-up. The proportion of patients with scores of 50 or more on the Global Assessment Scale was 3.7 percent at the time of admission. By discharge the proportion had increased to 55.1 percent, and by one-year follow-up it had risen to 66.3 percent. CONCLUSIONS: These results suggest that patients with severe personality disorders benefit from intensive inpatient treatment. We found no evidence that hospitalization of such patients is associated with regression or deterioration of function.

Course of illness following specialized inpatient treatment for women with trauma-related psychopathology.

The authors report findings from repeated assessments of 101 women who received intensive inpatient treatment focused on trauma-related disorders. All patients were assessed at admission and discharge, and half were reassessed at 1-year follow-up. Measures included the Global Assessment Scale, Brief Psychiatric Rating Scale, Brief Symptom Inventory, Role Functioning Scales, Follow-up Adjustment Scale, and Client Satisfaction Questionnaire. As a group, patients improved substantially during hospitalization and maintained gains at follow-up, although they showed a trend toward relapse in some symptom areas. However, a substantial minority of patients continued to show severe impairment at follow-up. In light of continual need for changes in clinical programs in the face of declining reimbursement, there is a pressing need for future outcome research on specialized trauma programs to relate subsequent clinical course to specific treatment interventions.

Which treatments help? The patient's perspective.

In an effort to determine which specific aspects of treatment might account for patient satisfaction, the authors developed the Components of Treatment Questionnaire. This measure, which was administered to 500 adult inpatients along with the Client Satisfaction Questionnaire (CSQ-8; Larsen, Attkisson, Hargreaves, and Nguyen, 1979), asked patients to assess the helpfulness of their treatment. Convinced that patient input is pertinent to program design, the authors later surveyed 46 patients on treatments that they perceived as helpful and would like to receive. Respondents identified individual relationships and problem-focused therapies as the most helpful aspects of treatment.

Trauma pervasively elevates Brief Symptom Inventory profiles in inpatient women.

The Brief Symptom Inventory was administered to 228 women (M age: 37) consecutively admitted to specialized inpatient treatment for trauma-related disorders. Subsamples of patients were administered different posttraumatic stress disorder scales, the Impact of Events Scale-Revised, the Posttraumatic Stress Diagnostic Scale, and the PTSD scale of the Millon Clinical Multiaxial Inventory-III, as well as a measure of child abuse and neglect, the Childhood Trauma Questionnaire. In this severely traumatized group, every scale of the Brief Symptom Inventory was significantly more elevated than the inpatient female norms, with the five most highly elevated scales being Depression, Obsessive-Compulsive, Anxiety, Interpersonal Sensitivity, and Psychoticism. Different indicators of trauma (Childhood Trauma Questionnaire, PTSD scales, and PTSD diagnosis) show different patterns of relationships with the individual scales of the Brief Symptom Inventory. There is no simple relationship between trauma and BSI symptoms, but clinicians should consider severe interpersonal trauma to be one pathway to pervasively elevated profiles of the Brief Symptom Inventory.

Complex posttraumatic stress disorder in women from a psychometric perspective.

Herman's (1992a) formulation of complex PTSD was not incorporated into the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994), but finds ample confirmation in personality assessment of women in inpatient treatment for trauma-related disorders. This study relates MCMI-III and Adult Attachment Scale scores to a self-report measure of childhood abuse and neglect, the Childhood Trauma Questionnaire. Consistent with Herman's formulation, the data reveal a wide array of symptoms coupled with two facets of relationship disturbance: (a) enmeshment in ambivalence (depressive, dependent, and self-defeating personality as well as ambivalent attachment), and (b) more profound isolation (avoidant and schizoid personality coupled with profoundly insecure attachment). We present a model for using such psychometric findings in patient education and diagnostic evaluations.

Dissociative detachment relates to psychotic symptoms and personality decompensation.

Previous studies have addressed the prominence of psychotic symptoms in conjunction with multiple personality disorder (now dissociative identity disorder). The present study examines the relation between psychotic symptoms and a more pervasive form of dissociative disturbance, namely dissociative detachment. Two hundred sixty-six women in inpatient treatment for severe trauma-related disorders completed the Dissociative Experiences Scale (DES), and 102 of these patients also completed the Millon Clinical Multiaxial Inventory (MCMI-III). A factor analysis of the DES yielded two dimensions of dissociative detachment: detachment from one's own actions and detachment from the self and the environment. Each of these DES dimensions relates strongly to the thought disorder and schizotypal personality disorder scales of the MCMI-III. We propose that severe dissociative detachment, by virtue of loosening the moorings in inner and outer reality, is conducive to psychotic symptoms and personality decompensation.

Patterns of utilization of medical care and perceptions of the relationship between doctor and patient with chronic illness including chronic fatigue syndrome.

To what extent do personal constructs affect the relationship between doctor and patient when the ill patient does not readily recover with treatment? Questionnaires were returned anonymously by 609 patients with a self-reported diagnosis of chronic fatigue syndrome, who were considered chronically ill. Findings were compared with those of an earlier study of a population of 397 general medical patients. The chronically ill patients lost an average of 65 days of work per year due to illness compared to general medical patients who missed six or fewer days per year because they were ill. The chronically ill patients also reported a 66% higher frequency of iatrogenic illness, spent more money on health care, took more medication, saw more specialists, and were more litigious than the general medical population. Research suggested several patterns of relationships between doctors and patients, and attitudes to health and illness, which may alert doctors to patients' perceptions, beliefs, encoded constructs, and patterns of relating that affect responses to treatment. More attention by doctors to patients who are experiencing the stress of chronic illness is indicated.

Tailoring the psychotherapy to the borderline patient.

Views still differ as to the optimal psychodynamic treatment of borderline patients. Recommendations range from psychoanalysis and exploratory psychotherapy to an explicitly supportive treatment aimed at strengthening adaptive defenses. The authors contend that no single approach is appropriate for all patients in this wide-ranging diagnostic category, which spans a continuum from close-to-neurotic to close-to-psychotic levels of functioning. Careful differentiations based on developmental considerations, ego structures, and relationship patterns provide the basis for the optimal treatment approach.