Previous Violent Events and Mental Health Outcomes in Guatemala

Objectives. We analyzed a probability sample of Guatemalans to determine if a relationship exists between previous violent events and development of mental health outcomes in various sociodemographic groups, as well as during and after the Guatemalan Civil War.Methods. We used regression modeling, an interaction test, and complex survey design adjustments to estimate prevalences and test potential relationships between previous violent events and mental health.Results. Many (20.6%) participants experienced at least 1 previous serious violent event. Witnessing someone severely injured or killed was the most common event. Depression was experienced by 4.2% of participants, with 6.5% experiencing anxiety, 6.4% an alcohol-related disorder, and 1.9% posttraumatic stress disorder (PTSD). Persons who experienced violence during the war had 4.3 times the adjusted odds of alcohol-related disorders (P < .05) and 4.0 times the adjusted odds of PTSD (P < .05) compared with the postwar period. Women, indigenous Maya, and urban dwellers had greater odds of experiencing postviolence mental health outcomes.Conclusions. Violence that began during the civil war and continues today has had a significant effect on the mental health of Guatemalans. However, mental health outcomes resulting from violent events decreased in the postwar period, suggesting a nation in recovery.For 36 years Guatemala experienced a violent civil war in which over 200 000 civilians were killed, 440 villages destroyed, and more than 1 million Guatemalans displaced, both internally and into southern Mexico.1–3 Those killed included indigenous persons, laborers, academics, religious leaders, and others who were clearly noncombatants.3,4 In 1996, peace accords were signed between a number of rurally based guerrilla forces and Guatemala’s national army.Nearly three quarters of the people in the world’s poorest societies have recently been through a civil war or are still in one. The average civil war lasts approximately 5 years and can be embedded in a societal context that fuels the longevity of the conflict itself by marking it as culturally “normal.”5–7 Because of cultural normalization and numerous other factors, both within and outside of Guatemala, the Guatemalan Civil War far exceeded the length of the average national civil war and might have long-standing implications for the safety and health of Guatemalans today.Civil wars produce a legacy of postconflict violence and disease,7–12 and Guatemala is no exception. Today, the northern triangle of Central America, which includes Guatemala, Honduras, and El Salvador, is described as the most violent area of the world outside of active theaters of war.3,13 Less than a decade after the civil war peace accords were signed in Guatemala, persistent violence reportedly resulted in the second highest rates of fear from armed crime in the world and the proliferation of more private security personnel than members of the regular army.3,14 Approximately at the same time, some 1500 Guatemalan Civil War refugees living in Mexico reported alarmingly high levels of depression, anxiety, and posttraumatic stress disorder (PTSD).15 The World Health Organization (WHO) also reported elevated alcohol use disorders in Guatemala in the years following the civil war.16 These indicators occurred alongside reports that 40% of the country continued to have no mental health services, leaving many Guatemalans, repatriated refugees, and affected citizens, who remained throughout the civil war without a key aspect of care on the road to national recovery.17In dealing with the effects of civil conflicts, such as recurring violence, PTSD, depression, anxiety, alcohol abuse, and other mental health issues, postconflict societies like Guatemala face difficult decisions between enacting extraordinary military spending3,5 or provisions of enhanced social and public health services.7,18 However, policymakers in Guatemala (and internationally) have limited population-level and epidemiologic evidence19 with which to make such decisions. With this in mind, we completed the first national probability sample of the mental health of Guatemalans still living in Guatemala. We analyzed these survey data to obtain nationally representative estimates of the prevalence of select mental health problems in Guatemala,9,11,15 and to determine if a relationship existed between previous violent events and the development of subsequent mental health outcomes. We compared different sociodemographic groups,20–25 as well as the periods before and after the signing of the 1996 civil war peace accords.     

Impact of Preoperative Prealbumin on Outcomes After Cardiac Surgery

Background: Preoperative malnutrition is increasingly prevalent in patients undergoing cardiac surgery. Although prealbumin is a widely used indicator of nutrition status, its use in the preoperative assessment of patients undergoing cardiac surgery is not well defined. The purpose of this study is to determine the impact of preoperative prealbumin levels on outcomes after cardiac surgery. Materials and Methods: Data were prospectively gathered from February 2013 to July 2013 on 69 patients undergoing cardiac surgery. Prealbumin levels were obtained within 24 hours of surgery. Patients were divided into 2 groups based on a prealbumin cutoff value of 20 mg/dL. Results: Of the 69 patients, 32 (46.4%) had a preoperative prealbumin ≤20 mg/dL. There was no correlation between prealbumin levels and body mass index (r = ?0.13, P = .28). Likewise, there was no correlation between preoperative albumin and prealbumin levels (r = 0.09, P = .44). Nine of 32 (28.1%) patients with low preoperative prealbumin levels had postoperative infections compared with 2 of 37 (5.4%) patients with high prealbumin levels (P = .010). Patients with low prealbumin levels also had increased risk of postoperative intubation for >12 hours (P = .010). Conclusions: Patients undergoing cardiac surgery with preoperative prealbumin levels of ≤20 mg/dL have an increased risk for postoperative infections and the need for longer mechanical ventilation. If feasible, nutrition optimization of such patients may be considered prior to cardiac surgery.     

New anti-angiogenesis agents: review of the clinical experience with carboxyamido-triazole (CAI), thalidomide, TNP-470 and interleukin-12

Angiogenesis was postulated to be a critical prognostic factor and therapeutic focus for malignancy more than two decades ago. Recent studies indicate quantitative assessments of microvessel count to be an independent prognostic variable for disease-free and overall survival in a wide variety of tumors, and that angiogenesis may be a feasible target against which to intervene pharmacologically. Several new and old agents have been found to have anti-angiogenic activity and have reached clinical trial. This review will focus on four agents under investigation in the US: carboxyamido-triazole (CAI), thalidomide, TNP-470 and interleukin (IL)-12. CAI, originally identified for its anti-invasive capacity, has been shown to inhibit tumor and endothelial cell proliferation by inhibition of calcium uptake. It is administered orally, is generally well tolerated, and has been shown to induce disease stabilization and occasional reductions in tumor mass. Thalidomide was shown to inhibit growth factor-induced neovessel formation, a process that can also explain its earlier devastating clinical toxicity. It is administered orally, and is currently in phase II clinical trials for prostate cancer, glioblastoma multiforme and breast cancer. TNP-470 is a fumagillin analog that has been shown in in vivo models to be a potent inhibitor of angiogenesis at concentrations that are cytostatic to endothelial cells and tumor cells. Lastly, IL-12 may exert its anti-angiogenic effects through activation of interferon- to up-regulate interferon-inducible protein-10, an anti-angiogenic cytokine. Phase I clinical trials of IL-12 have shown disease stabilization in several tumor types in response to s.c. administration or using genetically engineered IL-12-expressing patient fibroblasts. These promising new agents join the matrix metalloproteinase inhibitors as important new drugs in the anti-cancer armamentarium.     

Scaffold attachment region-containing retrovirus vectors improve long-term proviral expression after transplantation of GFP-modified CD34+ baboon repopulating cells

Sustained high-level proviral expression is important for clinical applications of gene therapy. Genetic elements including the beta-interferon scaffold attachment region (SAR) have been shown to improve transgene expression in hematopoietic cells. We hypothesized that SAR elements might improve expression and allow the preselection of successfully transduced cells. Thus, we transplanted green fluorescent protein (GFP)-selected cells, half of which had been transduced with either SAR or non-SAR-containing retrovirus vectors, into 3 animals. All animals showed delayed engraftment compared with historic controls (28 vs 15.5 days). GFP marking was seen at levels up to 8% but declined over the first 6 weeks. Importantly, fluorescence intensity was 2- to 9-fold increased in progeny of SAR versus non-SAR vector-modified cells in all hematopoietic lineages for the duration of follow-up (6-12 months). In conclusion, the use of SAR-containing vectors improved transgene expression in hematopoietic repopulating cells, which may obviate the need for multicopy integration to achieve high-level expression and reduce the risk for insertional mutagenesis.     

Can Sonography Distinguish a Supraorbital Notch From a Foramen?

Diagnostic tools for evaluating the supraorbital rim in preparation for nerve decompression surgery in patients with chronic headaches are currently limited. We evaluated the use of sonography to diagnose the presence of a supraorbital notch or foramen in 11 cadaver orbits. Sonographic findings were assessed by dissecting cadaver orbits to determine whether a notch or foramen was present. Sonography correctly diagnosed the presence of a supraorbital notch in 7 of 7 cases and correctly diagnosed a supraorbital foramen in 4 of 4 cases. We found that sonography had 100% sensitivity in diagnosing a supraorbital notch and foramen. This tool may therefore be helpful in characterizing the supraorbital rim preoperatively and may influence the decision to use a transpalpebral or endoscopic approach for supraorbital nerve decompression as well as the decision to use local or general anesthesia.     

Comorbid Profile Rather than Age Determines Hip Fracture Mortality in a Nonagenarian Population

Background

In light of poor outcomes with nonoperative management of hip fractures, orthopedic surgeons are faced with difficult decisions about which patients are too ill or too old for surgical treatment.

Questions/Purposes

This study sought to investigate if patients over 90 years had different preoperative laboratory, clinical, and injury characteristics than younger patients with the same injury. We compared our cohort with previously published data. We wished to identify if there were pre-injury risk factors associated with 30-day mortality, which could be modified to enhance postoperative outcomes.

Methods

This is a retrospective review of 198 operatively managed hip fractures in patients 75 years or older. We collected data on demographics, select preoperative laboratory values, injury type, comorbidities, and 30-day mortality.

Results

Eleven (5.6%) of the cohort died within 30 days of surgery, 6.3% in the younger group, and 3.7% in the older group; the difference was not statistically significant. For baseline characteristics, there was no difference between the age groups for pre-injury comorbidities, hemoglobin, serum albumin, BUN, prevalence of UTI, or fracture type. A total of 67 (35.8%) patients had evidence of UTI on admission.

Conclusions

These findings reveal that in our dichotomized cohort, pre-injury characteristics were similar and age alone was not an independent predictor of mortality. These data may inform decision-making for orthopedic surgeons and the medical providers who consult to optimize these patients for surgery. We identified high rates of UTI in both age groups, a potentially remediable factor to optimize outcomes in hip fracture surgery in elderly patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9435-y) contains supplementary material, which is available to authorized users.     

Anogenital HIV RNA in Thai men who have sex with men in Bangkok during acute HIV infection and after randomization to standard vs. intensified antiretroviral regimens

Introduction

HIV transmission risk is highest during acute HIV infection (AHI). We evaluated HIV RNA in the anogenital compartment in men who have sex with men (MSM) during AHI and compared time to undetectable HIV RNA after three-drug versus five-drug antiretroviral therapy (ART) to understand risk for onward HIV transmission.

Methods

MSM with AHI (n=54) had blood, seminal plasma and anal lavage collected for HIV RNA at baseline, days 3 and 7, and weeks 2, 4, 12 and 24. Data were compared between AHI stages: 1 (fourth-generation antigen-antibody combo immunoassay [IA]–, third-generation IA–, n=15), 2 (fourth-generation IA+, third-generation IA–, n=9) and 3 (fourth-generation IA+, third-generation IA+, western blot–/indeterminate, n=30) by randomization to five-drug (tenofovir+emtricitabine+efavirenz+raltegravir+maraviroc, n=18) versus three-drug (tenofovir+emtricitabine+efavirenz, n=18) regimens.

Results

Mean age was 29 years and mean duration since HIV exposure was 15.4 days. Mean baseline HIV RNA was 5.5 in blood, 3.9 in seminal plasma and 2.6 log₁₀ copies/ml in anal lavage (p<0.001). Blood and seminal plasma HIV RNA were higher in AHI Stage 3 compared to Stage 1 (p<0.01). Median time from ART initiation to HIV RNA <50 copies/ml was 60 days in blood, 15 days in seminal plasma and three days in anal lavage. Compared with the three-drug ART, the five-drug ART had a shorter time to HIV RNA <1500 copies/ml in blood (15 vs. 29 days, p=0.005) and <50 copies/ml in seminal plasma (13 vs. 24 days, p=0.048).

Conclusions

Among MSM with AHI, HIV RNA was highest in blood, followed by seminal plasma and anal lavage. ART rapidly reduced HIV RNA in all compartments, with regimen intensified by raltegravir and maraviroc showing faster HIV RNA reductions in blood and seminal plasma.