Clinical Management Procedures Research Articles

Aktuelles Management des Basalzellkarzinoms

We present the current standard in diagnosis and treatment of basal cell carcinoma. Useful procedures for clinical management should be derived from this. A systematic literature search was carried out in the PubMed online database. The collected information was analyzed and evaluated. An overall concept was created from the gained knowledge. Basal cell carcinoma is the most common tumor in humans and its incidence is expected to increase in the future. When managing the disease, a one-dimensional orientation towards the clinical or histological subtype is not sufficient because of the heterogeneity of the tumor. The primary implementation of risk stratification, which is decisive for the further diagnostic and therapeutic steps, is becoming increasingly important. The gold standard in treatment continues to be the surgical procedure, which should be carried out using micrographically controlled surgery if possible. In addition, there are other therapeutic methods such as radiotherapy or a number of topical therapy options (photodynamic therapy, cryotherapy, application of 5-fluorouracil or imiquimod), which can be used in certain cases. Hedgehog inhibitors are also effective drugs for advanced or metastatic basal cell carcinoma. Practitioners have gained several years of experience with regard to effectiveness and handling of adverse events. With the PD-1 inhibitor cemiplimab, another therapeutic option for inoperable or metastatic tumors has been available since June 2021. Basal cell carcinoma will continue to gain in relevance in daily dermatological practice in the coming years. A structured approach to the assessment of the existing risk category of the tumor and the subsequent determination of the optimal therapy regimen are of central importance. Advanced or metastatic tumors no longer represent a hopeless situation for the patient. With long-termhedgehog therapy, an adapted dosage scheme can avoid discontinuation of therapy due to side effects. The therapeutic potential of the PD-1 inhibitor cemiplimab can also be used with the side effect profile known from other types of skin cancer.

Factorial Review Design Analysis of Different Types of Lymphadenopathy and Causative Factor

Lymphadenopathy is considered as chronic infection in which individuals are incompetent to follow up about stepwise clinical management procedures such as factorial design of different types of microorganisms and related infections, control measurements of preventive care, detoxification procedures, immune-stimulant merits and demerits and immuno suppressant action merits and demerits. This infection can be managed via stepwise clinical procedures such as SOP for cleaning of washing hands and WHO SAFE handling system procedures, controlling of antimicrobial resistance, Dosing errors such as over use and under use medications, Obesity related factors, Enzymatic inhibition and stimulation activity, systematic ADME modification, Vaccination procedures in different races and culture intake of foods, pharmacodynamics variation, Genetic and Heredictary disorders and drug addiction. This paper describe about different plants are categorized to manage stepwise infection on the basis of toxicological data pertaining to Idio-syncratic response reaction factors such as form and innate chemical activity, exposure route,presence of other chemicals in form of toxins, Psychological changes, role of circadian rhythum with gut toxicity, toxin rich intake nutrition packed and unpacked foods.

Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care

Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. ClinicalTrials.gov Identifier: NCT02700009.

Burden of Pediatric Central Nervous System Infection and Cost-Benefit Simulation of Multiplex Polymerase Chain Reaction in Japan.

To investigate the clinical use of multiplex polymerase chain reaction (mPCR) in Japan, epidemiological and clinical data for central nervous infections are needed. Here, we report on the epidemiology and economic burden of central nervous system infections and a simulation of the cost-benefit analysis of the Filmarray® Meningitis/Encephalitis (FAME) test for possible clinical use in Japan. We performed FAME tests on samples from 27 patients with pleocytosis aged between 0 and 20 years seen in six community hospitals in Nara and Osaka prefectures. All clinical management procedures were performed without knowledge of the mPCR test results. We analyzed the clinical data and calculated the required reduction in average length of stay for the FAME test to be cost-beneficial. Among the 27 cases, the FAME test revealed causal pathogens in 13 cases (48.1%). The average medical and social costs per case were ¥299,118 ($2,719.2) and ¥171,768 ($1,561.5), respectively. The minimal needed reduction in average length of stay for the FAME test to be cost-beneficial was 0.32- 0.86 days per meningitis case. The result can be informative for evaluating the cost-effectiveness of the clinical use of the FAME test in Japan.

Knowledge and management of low back pain as running-related injuries among Italian physical therapists: findings from a national survey

ABSTRACT Objectives To investigate the beliefs, knowledge, attitudes, behavior, and the clinical management procedures of the Italian physical therapists specialized in orthopedic manipulative physical therapy (OMPT) toward running and its correlation with low back pain (LBP). Design: A cross-sectional online survey was conducted in 2019, according to the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Setting: Italy. Participants: One thousand two hundred and eighteen Italian OMPTs. Methods Survey Monkey software was used to administer the survey. The questionnaire was self-reported and included 26 questions. Descriptive statistics were used and related to the effective respondents for each question. Results One thousand two hundred and eighteen questionnaires (60.9%) were included in the analysis. A considerable cohort of OMPTs working in private practice clinical settings (n = 845; 69.4%; 95% CI 66.7–71.9) has indicated running not to be a relevant risk factor for the onset of LBP (n = 806; 66.2%; 95% CI 63.4–68.8). Moreover, most of the participants (n = 679; 55.7%; 95% CI 52.9–58.5) adopted a combination of manual therapy techniques and therapeutic exercise for the management of runners with LBP. Conclusions Widespread knowledge of clinical and theoretical management of LBP in runners-patients has emerged among Italian OMPTs. The OMPTs’ academic background agrees with the recent literature and therefore highlights the paucity of studies related to LBP as running-related injuries.

Effect of auditory temporal processing training on behavioral and electrophysiological functions in central presbycusis

ObjectiveAge-related changes in the central auditory system, particularly auditory temporal processing abilities, were considered among most important factors affecting speech understanding performance in older adults. Once these factors are identified, clinical management procedures could be developed for prevention and treatment. The aim of this study was to determine the effects of short-term auditory training on the behavioral and electrophysiological measurements of auditory function in individuals with age-related temporal processing deficit.Participants and methodsA prospective study of 20 individuals aged 60–67 years with either normal or bilateral symmetric high-frequency hearing loss was conducted. Evaluations of auditory temporal processing using behavioral tests (Pitch Discrimination Test, Pitch Pattern Sequence Test, Auditory Fusion Test-Revised, and Time Compressed Speech Test), P300 potential, and the administration of ‘Amsterdam inventory for auditory disability and handicap’ were performed before and after short-term auditory training.ResultsAll participants demonstrated poor pretraining Pitch Pattern Sequence Test results which were significantly improved after remediation. All patients showed normal pretraining performance on Pitch Discrimination Test, Auditory Fusion Test-Revised, and Time Compressed Speech Test tests. There was a statistically significant increase in P300 amplitude and shortening in latency after remediation.ConclusionShort-term auditory training in older adults with auditory temporal processing deficit led to improvements in temporal sequencing skills and communication in noisy environments. P300 potential has been proved to be an objective indicator of neurophysiologic changes in the central auditory system resulting from auditory experience.RecommendationShort-term auditory training is an efficient rehabilitative tool for elderly people with auditory temporal processing deficit. However, maintenance of treatment effects over time should be evaluated.

Recurrence of cystic echinococcosis in an endemic area: a retrospective study

BackgroundCystic echinococcosis (CE) is a chronic, complex and neglected zoonotic disease. CE occurs worldwide. In humans, it may result in a wide spectrum of clinical manifestations, ranging from asymptomatic infection to fatal disease. Clinical management procedures have evolved over decades without adequate evaluation. Despite advances in surgical techniques and the use of chemotherapy, recurrence remains one of the major problems in the management of hydatid disease. The aim of this study was to determine the frequency of CE recurrence and the risk factors involved in recurrence.MethodsA descriptive longitudinal-retrospective study was designed. We reviewed all patients diagnosed with CE according to ICD-9 (code 122–0 to 122–9) criteria admitted at Complejo Asistencial Universitario de Salamanca, Spain, between January 1998 and December 2015.ResultsAmong the 217 patients studied, 25 (11.5%) had a hydatid recurrence after curative intention treatment. Median duration of recurrence’s diagnosis was 12.35 years (SD: ±9.31). The likelihood of recurrence was higher [OR = 2.7; 95% CI, 1.1–7.1; p < 0.05] when the cyst was located in organs other than liver and lung, 22.6% (7/31) vs 14.2% (31/217) in the cohort. We detected a chance of recurrence [OR = 2.3; 95% CI, 1.4–6.5; p > 0.05] that was two times higher in those patients treated with a combination of antihelminthic treatments and surgical intervention (20/141, 14.2%) than in patients treated with surgical intervention alone (5/76, 6.6%).ConclusionsDespite advances in diagnosis and therapeutic techniques in hydatid disease, recurrence remains one of the major problems in the management of hydatid disease. The current management and treatment of recurrences is still largely based on expert opinion and moderate-to-poor quality of evidence. Consequently, large prospective and multicenter studies will be needed to provide definitive recommendations for its clinical management.

Potential drug-drug interactions in older adults: A population-based study.

To evaluate the potential drug-drug interactions (PDDI) between drugs used by older adults, any associated factors and recommended clinical management. A cross-sectional, population-based study was carried out through a home survey of 934 older adults (from December 2009 to April 2010). A questionnaire was applied, and the participants were asked to show all the drugs used and their respective prescriptions, thus providing data to identify polypharmacy, self-medication and PDDI. PDDI, their consequences, severity and clinical management were identified using Micromedex. Overall, 2846 drugs and 665 PDDI were identified, 71.0% of which were moderate and 22.4% serious. The prevalence of PDDI was 36.9%. Drugs with a narrow therapeutic index were involved in 17.0% of the PDDI. The variables female sex (PR=1.11, 95% CI 1.02-1.20), age ≥80years (PR=1.15, 95% CI 1.03-1.28), no polypharmacy (PR=0.72, 95% CI 0.67-0.78) and no hospitalization in the past year (PR=0.90, 95% CI 0.82-0.97) remained associated with the presence of three or more PDDI in the final multivariate analysis model. Most PDDI were related to routinely used drugs (enalapril, hydrochlorothiazide, calcium, captopril, levothyroxine and simvastatin), and more than one-third of the older adults were exposed to PDDI with the possible risk of serious health consequences. Drugs with a narrow therapeutic index were involved in several PDDI, with increased risk of toxicity. The clinical management procedures most recommended are dose adjustment and dosing changes, control of the drugs' serum levels, and monitoring of the clinical conditions. Geriatr Gerontol Int 2017; 17: 2336-2346.

Risk factors for Clostridium difficile infections - an overview of the evidence base and challenges in data synthesis.

BackgroundRecognition of a broad spectrum of disease and development of Clostridium difficile infection (CDI) and recurrent CDI (rCDI) in populations previously considered to be at low risk has renewed attention on differences in the risk profile of patients. In the absence of primary prevention for CDI and limited treatment options, it is important to achieve a deep understanding of the multiple factors that influence the risk of developing CDI and rCDI.MethodsWe conducted a review of systematic reviews and meta–analyses on risk factors for CDI and rCDI published between 1990 and October 2016.Results22 systematic reviews assessing risk factors for CDI (n = 19) and rCDI (n = 6) were included. Meta–analyses were conducted in 17 of the systematic reviews. Over 40 risk factors have been associated with CDI and rCDI and can be classified into three categories: pharmacological risk factors, host–related risk factors, and clinical characteristics or interventions. Most systematic reviews and meta–analyses have focused on antibiotic use (n = 8 for CDI, 3 for rCDI), proton pump inhibitors (n = 8 for CDI, 4 for rCDI), and histamine 2 receptor antagonists (n = 4 for CDI) and chronic kidney disease (n = 4 for rCDI). However, other risk factors have been assessed. We discuss the state of the evidence, methods, and challenges for data synthesis.ConclusionSeveral studies, synthesized in different systematic review, provide valuable insights into the role of different risk factors for CDI. Meta–analytic evidence of association has been reported for factors such as antibiotics, gastric acid suppressants, non–selective NSAID, and some co–morbidities. However, despite statistical significance, issues of high heterogeneity, bias and confounding remain to be addressed effectively to improve overall risk estimates. Large, prospective primary studies on risk factors for CDI with standardised case definitions and stratified analyses are required to develop more accurate and robust estimates of risk effects that can inform targeted–CDI clinical management procedures, prevention, and research.

Effect of Combined versus Monotherapy with Deferoxamine and Deferiprone in Iron Overloaded Thalassemia Patients: a Randomized Clinical Trial

Background: Patients with transfusional iron overload have depended on iron chelation therapy and improving chelation regimens have been of the highest priority. The aim of this study was to compare effect of combined versus monotherapy with Deferoxamine (DFO) and Deferiprone (DFP) in iron overloaded beta thalassemia (BT) major patients Materials and Methods We studied 36 BT major patients (mean age 7.6±4.6; range 3–16 years) attending the Ormieh Motahari hospital for regular transfusional support. Patients were randomly allocated to receive one of the following two treatments: DFO in combination with DFP (n=12), DFO alone (n=12) and DFP alone (n=12). Serum ferritin level, liver enzymes, blood urea nitrogen, and creatinine and side effects were monitored over a 12 months period. Results: After one year, serum ferritin decreased more significantly in patients on DFO+DFP therapy compared to patients who only received DFO or DFP alone (P<0.01). Side effects of DFP, including gastrointestinal upset (nausea, vomiting and abdominal pain) and mild agranulocytosis occurred in five (41.7%) and two (8.3%) patients, respectively but none led to discontinuation of the treatment. Conclusion: In comparison to the standard chelation monotherapy of DFO, combination treatment with additional DFP reduced serum ferritin and is effective procedure in clinical management of iron overload in patients with BT major.

Management of Ocular Diseases Using Lutein and Zeaxanthin: What Have We Learned from Experimental Animal Studies?

Zeaxanthin and lutein are two carotenoid pigments that concentrated in the retina, especially in the macula. The effects of lutein and zeaxanthin on the prevention and treatment of various eye diseases, including age-related macular degeneration, diabetic retinopathy and cataract, ischemic/hypoxia induced retinopathy, light damage of the retina, retinitis pigmentosa, retinal detachment, and uveitis, have been studied in different experimental animal models. In these animal models, lutein and zeaxanthin have been reported to have beneficial effects in protecting ocular tissues and cells (especially the retinal neurons) against damage caused by different etiological factors. The mechanisms responsible for these effects of lutein and zeaxanthin include prevention of phototoxic damage by absorption of blue light, reduction of oxidative stress through antioxidant activity and free radical scavenging, and their anti-inflammatory and antiangiogenic properties. The results of these experimental animal studies may provide new preventive and therapeutic procedures for clinical management of various vision-threatening diseases.

Outcome of Standardized Case Management of Under-5 Children with Severe Acute Malnutrition in Three Hospitals of Dhaka City in Bangladesh

Objects: A hospital based descriptive study was carried out among under-5 children suffering from severe protein-energy-malnutrition (PEM) Methodology: This was a descriptive analytical study conducted during June 2002 to May 2003 in three purposively selected hospitals of Dhaka city, Bangladesh. Results: Mean±SD age of the children was 15.1±10.9 months, majority being under three years (91.5%), 47.2% were female, and 51% did not receive or complete immunization according to their age. No significant age and sex difference was found among the admitted children in different hospitals. Most of their parents were illiterate (mothers 71%, fathers 56%) with low family income and social status. Marasmus cases were 61%, followed by kwashiorkor 25% and marasmic kwashiorkor 14%. The children were managed broadly according to standard protocol based on the guideline of World Health Organization but adopted/modified by the individual hospitals. Overall outcome of the patients were: recovery 62.4%, default 21.4%, death 13.7% and transfer 2.6%. Mean duration of hospital stay was 14.2±9.9 (ranging from 0 to 59) days. Recovery rate was better among male (67.3%) than female (56.8%) children, p=0.033. Default rate was higher among female (27.3%) than male (16.1%) children, p=0.007. Case fatality rate was highest (40%, p=0.001) in children suffering from septicaemia. Conclusion: Evidences of faulty case management practices viz. over use of intravenous fluids and blood transfusion, inappropriate diets, less use of micronutrients, incorrect antibiotics were observed occasionally in all the three hospitals. Updated and comprehensive treatment guidelines need to be implemented, and every hospital should review its own clinical management procedures and performance with a view to improving practice. DOI: http://dx.doi.org/10.3329/bjch.v37i1.15345 BANGLADESH J CHILD HEALTH 2013; VOL 37 (1) : 5-13

The “dysplastic” nevus

Dysplastic nevi have become an increasing focus clinically, with evidence that they are associated with a higher risk of developing melanoma. However, there still is contention regarding the significance of dysplastic nevi. This contribution provides an overview of the history, epidemiology, genetics, clinical and histologic features, and procedures for clinical management of dysplastic nevi. Since dysplastic nevi were described originally in 1978, a great deal of research has examined the epidemiology of these lesions and the genetic factors related to the development of dysplastic nevi. However, there is disagreement regarding the clinical management of dysplastic nevi and the histologic definition of dysplastic nevi. Current recommendations include preventative measures, such as sun protection and careful surveillance and biopsies of suspicious lesions as needed. The advent of new technologies, such as computer-vision systems, have the potential to significantly change treatment of dysplastic nevi in the future.

Need for More Traumatic Brain Injury Research

We thank Dr. Agrawal and colleagues1 for providing a synopsis of the sleep and medical issues facing patients with traumatic brain injury (TBI), as were discussed in three companion articles on the topic published in the June 15, 2007, issue of this journal.2–4 Although these articles represent progress in our understanding of the intersection between TBI and sleep, they also serve as a potent reminder of how little is actually known on this topic. The Verma and Castriotta studies implement objective measures of sleep, but their populations are highly selected (rehabilitation centers or sleep clinics) and are therefore not representative of sleep dysfunction following TBI in the general population.2,3 Indeed, epidemiologic studies in highly selected populations often provide inflated prevalence estimates. Our study was population based, assessing consecutive subjects with a broad spectrum of TBI presenting to a level I trauma center, but we lacked objective measures of sleep and limited our analysis to hypersomnia.4 Other studies on the subject suffer from similar shortcomings.5–10 Therefore, a clear understanding of the scope of the problem remains outside our grasp. We still await a definitive population-based prospective cohort study of TBI and sleep with both objective and subjective measures to delineate the true incidence and prevalence of sleep disturbance in these patients. Despite the lack of reliable prevalence estimates, current evidence points to substantial sleep disturbance following TBI.2–4 As a result, exciting research avenues abound. It's likely that susceptibility to sleep disturbance following TBI is variable, influenced by gene-environment interactions. The APOE allele has been demonstrated to influence overall and rehabilitation outcome, coma recovery, risk of posttraumatic seizures, and cognitive and behavioral functions following TBI.11 The impact of APOE or other polymorphic alleles on TBI-induced sleep disturbance is unknown. Genome-wide association studies of TBI patients with similar injury severity with and without objective sleep disturbance are needed to provide a better understanding of the genetic underpinnings of variable susceptibility. In the future, this type of research has the potential to identify patients with TBI who are at greatest risk for developing sleep disturbance, providing opportunities for prevention through neuroprotection, if and when this becomes available.12 At the very least, symptomatic intervention could be undertaken earlier in efforts to increase patient participation in rehabilitation. Beyond genomics, there's also a need to research the impact of current treatment modalities on patients with TBI-related sleep disturbance. A pilot study of cognitive behavioral therapy for post-TBI insomnia in 11 subjects demonstrated encouraging results, with significant increases in sleep efficiency and reductions in Insomnia Severity Index scores.13 Regarding stimulants, a small study of 30 patients with TBI demonstrated no change in observational sleep-wake distribution, including total sleep time, in those receiving methylphenidate.14 These studies, although a good start, point to the need for larger, randomized, placebo-controlled trials investigating the impact of the treatment of TBI-associated sleep disorders on measures of rehabilitation outcome. Only in this manner can we confirm the clinical importance of identifying these patients following injury. In appreciation of this research challenge, the U.S. Department of Defense recently accepted proposals for their Congressionally Directed Medical Research Program in the area of TBI (http://cdmrp.army.mil/funding/ptsdtbirp.htm). These Concept Awards aim to, “spark new ideas, innovative technologies, and ground-breaking concepts that will drive the field of TBI research forward.”15 Proposal specifications overlap with many areas salient to post-TBI sleep disturbance, including the development of standardized diagnostic criteria and clinical management procedures and research into both the short- and long-term treatment of associated conditions.15 As sleep specialists and researchers, we can only hope that proposals addressing the sleep-related ramifications of TBI will be represented among the applications submitted for these Awards.

Can Psychiatry Prevent Suicide? Not Yet!

Let me begin by saying that I believe psychiatrists can and should play a significant role in the prevention of suicide in Canada. Whether this is currently the case is another question. Dr Lesage has advanced the “pro” opinion on this matter. It is my aim to examine these arguments in terms of scope, accuracy, and future planning. The “pro” part of this debate suggests that psychiatrists can prevent suicide in 3 ways: first, by adopting a shared care model that allows greater collaboration and thus better support for treatment of mental disorders (particularly depression) by general practitioners (GPs); second, by optimizing treatment of depression via the application of clinical management procedures as outlined by the Canadian Psychiatric Association; and third, by collaborating with addiction services, because alcohol and drugs are heavily involved in cases of completed suicide. Scope The merits of these points notwithstanding, they encompass an approach that falls far short of what might be considered comprehensive in regard to suicide prevention. In the first place, all the focus is on treatment of individuals who are actively suicidal and (or) suffer from mental illness. This approach has no room for early detection and intervention, no focus on healthy child development, and no emphasis on community development or ecologic interventions. To be fair, perhaps this is outside the purview of the In Debate section, since the topic refers to what psychiatrists can do, rather than to a comprehensive suicide prevention plan. Second, the focus seems to be on depression, but the evidence shows that virtually all mental disorders are associated with suicidal behaviour (for example, 1). In fact, schizophrenia and bipolar disorder show an equal or higher level of association with suicidal behaviour than does major depression (2,3). Third, it is important to consider suicide–substance abuse comorbidity, but suicide is related to any number of other social problems and conditions, including interpersonal violence, relationship difficulties, unintentional injuries, and being left out of the mainstream (4,5). This suggests that something causal underlies all these conditions, perhaps something social in nature. Finally, although it is reasonable, from the point of view of this journal’s readers, to conceive of a scheme with the medical profession at its centre, not everyone else sees it that way. Other professionals compete with psychiatry and general practice medicine to deliver treatment services—not as team members, but as primary care clinicians. It does not seem sensible either to ignore this or to compete. It should be noted, however, that the primacy of any mental health treatment specialist declines when we consider interventions at the societal level and when we engage in primary prevention with presuicidal children and youth.

Pitfalls and artifacts in 18FDG PET and PET/CT oncologic imaging

It is estimated that in excess of one million positron emission tomography (PET) scans are performed each year and PET can now truly be regarded as a routine imaging procedure in clinical management. Many potential pitfalls and artifacts have previously been described with 18F-fluorodeoxyglucose PET imaging, but more continue to become apparent as worldwide experience increases. In addition, the advent of combined PET/CT scanners in clinical imaging practice has brought their own specific pitfalls and artifacts. It is essential that we learn these potential pitfalls so that patients can be optimally prepared for their scans and that accurate interpretation can be made.

Protein and energy requirements of children with burn trauma

The Sutherland Formula is widely used in the United Kingdom to determine protein and energy requirements of burned children. Achieving the target of this formula can be difficult because of the high levels of protein and energy intake that are inherent in the Sutherland formula calculation. An alternative formula was devised using new parameters, i.e., normal daily nitrogen requirements, wound nitrogen losses and urinary nitrogen losses, which may more closely match the requirements of children with burns. The aim of the study was to evaluate the new formula and to reappraise the Sutherland Formula using current liquid enteral feeds and feeding methods. The study was randomly controlled in design, the Sutherland Fed (SF) Group received enteral feeds according to the Sutherland Formula and East Grinstead Formula (EGF) Group received enteral feeds according to the new East Grinstead Formula. Subjects entered the study on day zero of burn injury. Burn size, using the method of Lund and Browder, was used, to indicate the percentage of body surface area burned. All nutritional intakes were recorded, nutritional parameters, clinical assessments, wound status, medication, body weight changes, serum and urine analysis were assessed. Nine subjects were recruited into the Sutherland Formula Group, mean age 3 years, (range 1-5 years) mean burn size 19% Body Surface Area (BSA), range 10-40%. Eight subjects were recruited into East Grinstead fed Group, mean age 4 years, range 1-13 years mean burn size 15% BSA, range 10-30%. The Sutherland Formula Group achieved 80% of energy targets and 85% of protein targets. The East Grinstead Group achieved 95% of energy targets and 90% of protein targets. Total serum protein and albumin remained within the normal ranges for both groups. Serum Retinol binding protein and thyroxine binding protein showed an upward trend for both groups. Serum IGF-1 and growth hormone remained within the normal range for both groups. A larger number of patients in Sutherland Formula Group required antibiotics than in East Grinstead Formula Group. The Sutherland Formula Group had a negligible weight change -1.3%, whilst the East Grinstead Formula group had a weight gain +2.4%. An intake of 3g/kg/day protein is adequate to meet the requirements of young burned children, as was supplied by the EGF formula. A target protein intake at 4g/kg/day as provided by the Sutherland Formula is probably too high and did not appear necessary in the group of children studied. Children can be successfully and comfortably sustained on enteral feeding for 1-3 week periods and this mode of feeding can be instigated within hours of injury. Enteral feeding may be the only way to achieve EGF targets due to the rigorous demands of the surgical and clinical management procedures endured by these patients. From this work the researcher concluded that the East Grinstead Formula is appropriate for feeding children with burn trauma from a clinical and practical point of view. This study supports the findings of other studies in burned adults in that early enteral feeding of burned children is beneficial in promoting good nutritional status. In addition the low volume, isotonic, high protein enteral feed, with a protein energy ratio of 2 0 %, used in this study, was tolerated by the children studied. Simplification of the East Grinstead Formula for burned children is: Protein 3g/kg BW/day with a protein energy ratio of 17-20%.

Stuttering and Spontaneous Recovery

In the present paper, the authors review and evaluate the prospective and retrospective studies relative to spontaneous recovery from stuttering in children. The authors conclude that the frequently cited 80% spontaneous recovery figure is too high. The authors propose that speech-language pathologists abandon the concept of spontaneous recovery when devising clinical management procedures for the stuttering child.