Effective strategies for suicide prevention in New Zealand: a review of the evidence

A national suicide prevention strategy for New Zealand was developed in 2006. There is relatively little strong evidence for the efficacy of many existing suicide prevention initiatives, and this area has frequently been captured by strong claims about the effectiveness of programmes that have not been adequately evaluated. This paper provides a conceptual framework for classifying suicide prevention initiatives, reviews evidence for their effectiveness, and makes recommendations for initiatives to be undertaken as part of suicide prevention activities in New Zealand. The available evidence thus far suggests that the most promising interventions likely to be effective in reducing suicidal behaviours are medical practitioner and gatekeeper education, and restriction of access to lethal means of suicide. This evidence also suggests a clear agenda for research, which includes evaluating interventions and prevention programmes, developing model and demonstration projects, identifying meaningful outcome measures, and refining and identifying the critical elements of effective programmes.     

Ketotifen in asthma

Sixty children aged 5-13 years with moderately severe asthma took part in a double-blind, placebo-controlled trial of ketotifen. The design incorporated a 22 week study period, the addition of ketotifen or placebo to the current medication, and a controlled withdrawal of the regular therapy. Children receiving ketotifen showed significantly lower mean numbers of asthma attacks and less absence from school. The addition of ketotifen to existing treatment was associated with marginally significant changes in rates of day and night wheezing. In the second phase of study, additional therapy was withdrawn from both the ketotifen and placebo groups which resulted in a high (percentage) withdrawal. Children receiving ketotifen did not have a significantly lower failure rate than those given placebo.     

An educational intervention to update health workers about HIV and infant feeding

Clinical guidelines are used to translate research findings into evidence‐based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV‐exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team‐based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On‐site workshops and clinical mentoring used interactive participatory methods and a simple low‐tech approach, guided by participants' self‐reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1–2 hr. Evaluation data were collected using a self‐administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and “catch‐up” sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource‐constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.     

The effect of age and Alzheimer's disease on pyramidal neuron density in the individual fields of the hippocampal formation

Summary Pyramidal neuron density was determined at autopsy in the brains of 12 neurologically normal patients (age range 6–87 years) and 18 patients with histopathologically confirmed Alzheimer's disease (AD; age range 62–89 years). Paraffin wax sections were cut at the level of the central part of the cornu ammonis and stained with cresyl fast violet. Pyramidal neuron density was determined in the stratum pyramidale of the presubiculum, subiculum, prosubiculum and CA1–4. The width of the stratum pyramidale in these areas was also determined. There was no significant effect of age on pyramidal neuron density in any of the fields of the hippocampal formation. However, there was a significant decrease in pyramidal neuron density in the subiculum (44%), prosubiculum (28%) and CA1 (41%) of AD brains compared to controls. There was no significant effect of AD on pyramidal neuron density in the presubiculum, CA2 and CA3, but in CA4 it increased (23%) significantly. Pyramidal band width decreased significantly with age in the presubiculum but there was no effect of age on any other region of the hippocampal formation investigated. The width of the stratum pyramidale was significantly lower in the presubiculum (19%), subiculum (30%) and CA3 (17%) of AD compared with control brains. These data suggest that a reduction in pyramidal neuron density within the hippocampal formation does not occur in the absence of underlying pathology. In AD, pyramidal neuron loss predominantly occurs from that sector of the hippocampal formation which comprises the subiculum, prosubiculum and CA1.Supported in part by MRC intercalated awards to N. H. and S. L. I.     

Reasons for holding health insurance: a study of a group of Christchurch families

The reasons for holding private medical insurance were studied in a sample of 495 insured Christchurch families having school aged children. In one-third of these families health insurance was provided by an employer. Two major reasons for holding insurance were cited by those whose insurance was not provided by an employer: three-quarters of these families stated that health insurance helped them meet medical bills and nearly two-thirds claimed that insurance provided them with access to immediate health care if this was needed. A minority (24%) of those holding health insurance believed that public sector services were inadequate to provide health care but only 9% of families were able to cite some specific shortcoming of public sector services which had impelled them to take out insurance cover. It is concluded that the rapid rise of private health insurance in New Zealand is likely to have arisen from the net effects of the promotional activities of insurance companies, the declining real contribution of State health care funding and the effects of growing public uncertainty about the ability of public sector services to deliver health care.     

Interleukin-18 (Interferon-γ–inducing Factor) Is Produced by Osteoblasts and Acts Via Granulocyte/Macrophage Colony-stimulating Factor and Not Via Interferon-γ to Inhibit Osteoclast Formation

We have established by differential display polymerase chain reaction of mRNA that interleukin (IL)-18 is expressed by osteoblastic stromal cells. The stromal cell populations used for comparison differed in their ability to promote osteoclast-like multinucleated cell (OCL) formation. mRNA for IL-18 was found to be expressed in greater abundance in lines that were unable to support OCL formation than in supportive cells. Recombinant IL-18 was found to inhibit OCL formation in cocultures of osteoblasts and hemopoietic cells of spleen or bone marrow origin. IL-18 inhibited OCL formation in the presence of osteoclastogenic agents including 1α,25-dihydroxyvitamin D₃, prostaglandin E₂, parathyroid hormone, IL-1, and IL-11. The inhibitory effect of IL-18 was limited to the early phase of the cocultures, which coincides with proliferation of hemopoietic precursors. IL-18 has been reported to induce interferon-γ (IFN-γ) and granulocyte/macrophage colony-stimulating factor (GM–CSF) production in T cells, and both agents also inhibit OCL formation in vitro. Neutralizing antibodies to GM–CSF were able to rescue IL-18 inhibition of OCL formation, whereas neutralizing antibodies to IFN-γ did not. In cocultures with osteoblasts and spleen cells from IFN-γ receptor type II–deficient mice, IL-18 was found to inhibit OCL formation, indicating that IL-18 acted independently of IFN-γ production: IFN-γ had no effect in these cocultures. Additionally, in cocultures in which spleen cells were derived from receptor-deficient mice and osteoblasts were from wild-type mice and vice versa, we identified that the target cells for IFN-γ inhibition of OCL formation were the hemopoietic cells. The work provides evidence that IL-18 is expressed by osteoblasts and inhibits OCL formation via GM–CSF production and not via IFN-γ production.     

Elimination of paediatric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission

Objective

To report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal.

Methods

Mothers with infants aged ≤ 16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunization clinics in six districts of KwaZulu-Natal were included. The mothers’ uptake of interventions for the prevention of MTCT was explored. Blood samples from infants aged 4–8 weeks were tested for anti-HIV antibodies and, if antibody-positive, for HIV desoxyribonucleic acid (DNA).

Findings

Of the 19 494 mothers investigated, 89·9% reported having had an HIV test in their recent pregnancy. Of the 19 138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. Just 7.1% of the infants checked for HIV DNA (equating to 2.8% of the infants tested for anti-HIV antibodies) were found positive.

Conclusion

The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission. Sampling at immunization clinics appears to offer a robust method of estimating the impact of interventions designed to reduce such transmission. Large-scale elimination of paediatric HIV infections appears feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.