Validation of mental health screening instruments in the Kashmir Valley, India.

The present study aimed to culturally adapt, translate, and validate the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire-Posttraumatic Stress Symptoms Checklist (HTQ-16) prior to use in a cross-sectional mental health population survey in the Kashmir Valley. Cultural adaptation and translation of the HSCL-25 and the HTQ-16 employed multiple forms of transcultural validity check. The HSCL-25 and HTQ-16 were compared against a "gold standard" structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Interviews were conducted with 290 respondents recruited using consecutive sampling from general medical outpatient departments in five districts of the Kashmir Valley. Receiver operating characteristics (ROC) analysis was used to estimate the cut point with optimal discriminatory power based on sensitivity and specificity. Internal reliability of the HSCL-25 was high, Cronbach's alpha (α) = .92, intraclass correlation coefficient (ICC) = 0.75, with an estimated optimal cut point of 1.50, lower than the conventional cut point of 1.75. Separation of the instruments into subscales demonstrated a difference in the estimated cut point for the anxiety subscale and the depression subscale, 1.75 and 1.57, respectively. Too few respondents were diagnosed with posttraumatic stress disorder (PTSD) during structured psychiatric interview, and therefore the HTQ-16 could not be validated despite the fact that high internal reliability was demonstrated (α = .90). This study verified the importance of culturally adapting and validating screening instruments in particular contexts. The use of the conventional cut point of 1.75 would likely have misclassified depression in our survey, leading to an underestimate of this condition.

Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley.

BACKGROUND: Following the partition of India in 1947, the Kashmir Valley has been subject to continual political insecurity and ongoing conflict, the region remains highly militarised. We conducted a representative cross-sectional population-based survey of adults to estimate the prevalence and predictors of anxiety, depression and post-traumatic stress disorder (PTSD) in the 10 districts of the Kashmir Valley. METHODS: Between October and December 2015, we interviewed 5519 out of 5600 invited participants, ≥18 years of age, randomly sampled using a probability proportional to size cluster sampling design. We estimated the prevalence of a probable psychological disorder using the Hopkins Symptom Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ-16). Both screening instruments had been culturally adapted and translated. Data were weighted to account for the sampling design and multivariate logistic regression analysis was conducted to identify risk factors for developing symptoms of psychological distress. FINDINGS: The estimated prevalence of mental distress in adults in the Kashmir Valley was 45% (95% CI 42.6 to 47.0). We identified 41% (95% CI 39.2 to 43.4) of adults with probable depression, 26% (95% CI 23.8 to 27.5) with probable anxiety and 19% (95% CI 17.5 to 21.2) with probable PTSD. The three disorders were associated with the following characteristics: being female, over 55 years of age, having had no formal education, living in a rural area and being widowed/divorced or separated. A dose-response association was found between the number of traumatic events experienced or witnessed and all three mental disorders. INTERPRETATION: The implementation of mental health awareness programmes, interventions aimed at high risk groups and addressing trauma-related symptoms from all causes are needed in the Kashmir Valley.

Heat induction of a novel Rad9 variant from a cryptic translation initiation site reduces mitotic commitment.

Exposure of human cells to heat switches the activating signal of the DNA damage checkpoint from genotoxic to temperature stress. This change reduces mitotic commitment at the expense of DNA break repair. The thermal alterations behind this switch remain elusive despite the successful use of heat to sensitise cancer cells to DNA breaks. Rad9 is a highly conserved subunit of the Rad9-Rad1-Hus1 (9-1-1) checkpoint-clamp that is loaded by Rad17 onto damaged chromatin. At the DNA, Rad9 activates the checkpoint kinases Rad3(ATR) and Chk1 to arrest cells in G2. Using Schizosaccharomyces pombe as a model eukaryote, we discovered a new variant of Rad9, Rad9-M50, whose expression is specifically induced by heat. High temperatures promote alternative translation from a cryptic initiation codon at methionine-50. This process is restricted to cycling cells and is independent of the temperature-sensing mitogen-activated protein kinase (MAPK) pathway. While full-length Rad9 delays mitosis in the presence of DNA lesions, Rad9-M50 functions in a remodelled checkpoint pathway to reduce mitotic commitment at elevated temperatures. This remodelled pathway still relies on Rad1 and Hus1, but acts independently of Rad17. Heat-induction of Rad9-M50 ensures that the kinase Chk1 remains in a hypo-phosphorylated state. Elevated temperatures specifically reverse the DNA-damage-induced modification of Chk1 in a manner dependent on Rad9-M50. Taken together, heat reprogrammes the DNA damage checkpoint at the level of Chk1 by inducing a Rad9 variant that can act outside of the canonical 9-1-1 complex.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature.

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age

Needle core biopsy for the assessment of unilateral breast masses in men.

Although unilateral male breast swelling is relatively common, a histological diagnosis is infrequently obtained. From 1998 to 2003 we routinely performed needle core biopsy on all men presenting with unilateral breast swelling in whom there was diagnostic uncertainty. Of 113 patients, 93% had gynaecomastia, two patients had primary breast cancer and one had metastatic lymphoma. One patient had chronic mastitis. Gamolenic acid treatment produced a 73% response rate amongst patients presenting with pain. Core biopsy is a safe and effective method of diagnosing unilateral male breast swelling, which allows either confident reassurance or definitive treatment of those with cancer or pain.

Cardio-pulmonary resuscitation training, knowledge and attitudes of newly-qualified doctors in New Zealand in 2003.

OBJECTIVE: To assess the resuscitation knowledge and confidence of newly-qualified doctors in New Zealand (NZ) in 2003. DESIGN: Anonymous questionnaires were distributed to all newly-qualified doctors in NZ (n=279). PARTICIPANTS: Two hundred and thirty-three respondents from hospitals throughout NZ (84% response rate). MAIN OUTCOME MEASURES: Resuscitation training received during medical school and use of recommended text (Level 7 of NZ resuscitation manual), confidence in resuscitation skills and core knowledge of basic and advanced resuscitation. RESULTS: 98.3% of doctors received advanced resuscitation training during their final year of medical school, of these 64.6% had received training in the previous 6 months. The mean knowledge score was 56.6% and 45% of doctors made 'fatal errors'. Eighty-four percentage of doctors had read the Level 7 manual and 72.6% found it very or extremely useful. Those who had read the manual had higher scores and were less likely to make a 'fatal error'. Having attended a cardiac arrest and having received training within the last 6 months improved doctor confidence in resuscitation. CONCLUSIONS: The resuscitation knowledge and confidence of newly-qualified doctors in NZ are sub-optimal, with some doctors displaying dangerous deficiencies. Our results suggest mandatory attainment of an advanced resuscitation certificate, six-monthly practical resuscitation sessions and increased exposure to real resuscitation situations should be implemented to improve undergraduate resuscitation training.

Essential oil poisoning: N-acetylcysteine for eugenol-induced hepatic failure and analysis of a national database.

UNLABELLED: We present a 15-month-old boy who developed fulminant hepatic failure after ingesting 10 ml of clove oil. After 24 h, the ALT level was in excess of 13,000 U/l, with blood urea and creatinine of 11.8 mmol and 134 micromol/l respectively. The hepatic impairment resolved after intravenous administration of N-acetylcysteine so that 6 h later, the ALT level was approximately 10,000 U/l. His liver synthetic function and clinical status improved over the next 4 days. This is the first such case report of its kind in Europe. Analysis of a national database revealed a 14-fold increase in home accidents related to aromatherapy from 1994-1999. Clove oil has important hepatotoxic effects. CONCLUSION: Recent growth in aromatherapy sales has been accompanied by an unfortunate increase in accidental poisoning from these products. Clove oil warrants special attention. Ingesting as little as 10 ml causes hepatotoxicity which can be treated with N-acetylcysteine.

Custom-made nipple prosthesis: a long-term satisfaction survey.

BACKGROUND: Nipple-areola reconstruction or prosthesis completes the process of breast reconstruction. Although custom made nipple prosthesis (CNP) have been used for almost 10 years, little follow-up data on patient satisfaction is available. We assessed long-term patient satisfaction with CNP. MATERIALS AND METHODS: All patients undergoing CNP from 2000 to 2001 were sent anonymous postal questionnaires. Perceived benefit and satisfaction with size, colour, and projection, were assessed using a modified Likart scale (1 not satisfied, 5 very satisfied). Results are expressed as median and interquartile range (IQR). RESULTS: Of 52 patients who had CNP, 29 responded to the questionnaire (56% response rate), median age (IQR) 56.1 years (52-61). The median time since CNP was 2 years (0.6-3), 67% felt they had benefited from the prosthesis and 39% wore their CNP regularly. Most patients were highly satisfied with CNP size, colour and projection, median score 5 (4-5) for each variable. Patients with CNP Patients with CNP < 3 years were more likely to be satisfied with CNP than those with CNP for = 3 years, 60% vs 18%, p = 0.04. Patients who were satisfied with their CNP (median age 52.9 years, IQR 45.3-59.2 years), were younger than patients not satisfied with their CNP (median age 59 years, IQR 54.7-62 years), p = 0.031, Z = -2.16. Three patients had subsequent nipple reconstruction, a further 7 (24%) wanted nipple reconstruction. All respondents thought CNP should be offered at the time of initial surgery. CONCLUSIONS: Most patients are highly satisfied with CNP, with highest satisfaction in the first 3 years after CNP. CNP should be offered at the time of initial surgery.

Management of post cholecystectomy Mirizzi's syndrome.

Various strategies have been proposed for the management of retained calculi within the biliary tree following cholecystectomy. We present a unique case of a cystic duct remnant calculus causing Mirizzi syndrome, only the fourth such case of its kind. An open procedure was planned, however the calculus was eventually extracted endoscopically. The pathophysiology and management of Mirizzi syndrome and retained calculi within the cystic duct remnant are discussed along with the merits of a minimally invasive approach.

Hashimoto's encephalopathy: an unusual cause of seizures in the intensive care unit.

OBJECTIVE: To present a case study of Hashimoto's encephalopathy. DESIGN: Case report. SETTING: Paediatric Intensive Care Unit, Nottingham University Hospital, UK. PATIENTS: Two adolescent females presented with encephalopathy and raised venous lactate. Both had subtle signs of neurocognitive deterioration before initial presentation. Extensive investigation revealed elevated antithyroid antibody titer, suggesting Hashimoto's encephalopathy. INTERVENTIONS: Steroid administration. MEASUREMENTS AND MAIN RESULTS: Symptoms rapidly resolved in both cases after steroid treatment. CONCLUSION: Hashimoto's encephalopathy should be considered in cases of unexplained encephalopathy presenting to the intensive care unit. Teenage girls with an antecedent history suggestive of thyroid disease or progressive cognitive decline warrant special attention. Antithyroid antibody titers should be measured even if standard thyroid function tests are normal. Although the etiology is unknown, prompt steroid responsiveness suggests an inflammatory or autoimmune disorder, and patients should be treated accordingly.