Presepsin (PSEP) is released during infectious diseases and can be detected in the blood. PSEP has shown promising results as sepsis marker. We examined the diagnostic and prognostic validity of PSEP in patients suspicious of sepsis on admission in the emergency department (ED). Methods One hundred twenty three patients with signs of SIRS and/or sepsis and 123 healthy individuals were enrolled. PSEP was determined on admission, after 8, 24 and 72 h. Results Mean PSEP concentrations of the control group and the patient group were 130 and 1945 pg/ml. PSEP differed between SIRS, sepsis, severe sepsis and septic shock and showed strong association with 30-day mortality ranging from 10.3% in the 1st to 32.1% in the 4th quartile. The ROC curve analyses revealed an AUC value of 0.743. Combined assessment of PSEP and MEDS score increased the AUC up to 0.878 demonstrating the close relationship with outcome. Based on the PSEP values in the different severity degrees, decision thresholds for risk stratification were established. The course of PSEP during the first 72 h was associated with effectiveness of treatment and outcome. Conclusions PSEP allowed outcome prediction already on admission to a similar degree as the clinical scores MEDS and APACHE II. Combination of PSEP with MEDS score improved the discriminatory power for outcome prediction. / Our study has been supported by Mitsubishi Chemical Europe through providing the PSEP reagents free of charge. Dr. Carpio has received speaker honoraria from Mitsubishi Chemical Europe. DIAneering – Diagnostics Engineering & Research consulted to Axis Shield Diagnostics, Mitsubishi Chemical Europe, Radiometer, Roche Diagnostics, Shanghai Kehua Bio-engineering. No potential conflict of interest to this paper was reported / Peer review

Introduction: Digital ulcers (DUs) are responsible for much of the pain and disability associated with systemic sclerosis (SSc), and are a biomarker of internal organ involvement and poor prognosis. DUs are often used as the primary end-point in SSc clinical trials, although the reliability of rheumatologists in grading DUs is poor to moderate at best. Fingertip DUs are believed to be ischaemic in aetiology, whereas, extensor DUs are thought to occur due to mechanical factors and recurrent microtrauma. Treatments for DUs are often poorly tolerated due to systemic vasodilation. The overarching aim was to investigate the definition and objective measurement of SSc-related DUs, their pathophysiology, and a new light treatment. Method: Five studies were undertaken. (1) A web-based study in which photographs of digital lesions were graded, all either with or without clinical context. (2) A pilot study to assess the feasibility and tolerability of high-frequency ultrasound (HFUS) imaging to measure DUs. (3) A retrospective study examining whether thermographic abnormalities are associated with DUs. (4) A double-blind, randomised, crossover, controlled study of glyceryl trinitrate (GTN) to explore the pathophysiology of DUs in SSc. (5). A feasibility study of a novel light (red, infrared and blue) device to treat SSc-related DUs. Results: (1) 51 rheumatologists graded ≥ 4500 images. The clinical context (without vs with, weighted kappa statistic) did not significantly improve the intra- (0.32,0.36) or inter-rater (0.64,0.71) reliability. (2) HFUS was performed on 15 DUs and was well tolerated and feasible in the majority. DU measurement was possible in most (n=13) DUs, the mean DU depth and width were 0.99mm and 5.74mm, respectively. (3) Patients (n=138) with abnormal (compared to normal) thermography were more likely (adjusted odds ratio = 2.84) to develop future DUs, including multiple episodes. (4) 16 DUs were studied; the microvessels of the DU centre were responsive to GTN, with an increase in perfusion, with a similar effect in both fingertip and extensor DUs. There was less of a clear signal in the DU periphery. (5) Light treatment was safe, feasible and well tolerated (46 light treatments administered in 8 patients, one studied on three separate occasions). There was a significant improvement (change in visual analogue score per visit) in DUs as assessed by both patient (-7.1, P = < 0.001) and clinician opinion (-5.2, P = < 0.001). DU perfusion (measured by LDI) significantly increased post-treatment. Conclusion: The reliability of DU grading did not improve with clinical context. HFUS was feasible and well tolerated, and measurement was possible in most DUs. Our data suggests that many DUs might have an ischaemic drive, including extensor DUs. A novel light treatment was safe, feasible and well tolerated, with a tentative suggestion of treatment efficacy.

Proximal forearm fractures account for over 10% of all upper limb fractures. There is limited epidemiological data available and much of the literature focuses on the more complex fracture patterns, with the role of non-operative management for the isolated proximal forearm fracture still to be defined. Prospective short and long-term patient reported outcome data for simple isolated fractures of the radial head and olecranon would help define the indications for the non-operative management of these injuries. This thesis aims to test the hypothesis that non-operative management provides a comparable outcome to operative intervention for defined fractures of the proximal forearm. A large prospective database of 6872 fractures collected over a one-year period was used to define the epidemiology of proximal forearm fractures. A separate large prospective study carried out over an eighteen-month period using a pre-defined management protocol for all isolated radial head and neck fractures was analysed to determine the short and long-term outcome. Additional retrospective databases were collected and analysed to determine the short and long-term outcome for the non-operative and operative management of olecranon fractures, as well as the operative management of complex radial head fractures. Finally, two prospective randomised controlled trials (PRCTs) of isolated displaced fractures of the olecranon were carried out to compare 1) tension band wire (TBW) versus plate fixation in younger patients (< 75 years) and 2) operative versus non-operative management in elderly patients (≥75 years). The primary outcome measure for these studies was the upper limb specific patient reported Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcome measures included surgeon reported outcome scores, complication rates and cost. The incidence of proximal forearm fractures was 68 per 100,000. Radial head fractures fit a type D distribution curve (unimodal young man, bimodal woman) and radial neck type A (unimodal young man, unimodal older woman). Proximal ulna and olecranon fractures were both a type F (unimodal older man, unimodal older woman), with an increasing incidence after the 6th decade. Over 90% of proximal radial fractures were isolated stable fractures. Prospective analysis of 201 isolated proximal radius fractures found that the patient and surgeon reported outcome following primary non-operative management for Mason type 1 and type 2 (n=185) fractures was excellent in the short and long-term, with < 2% of patients undergoing secondary surgical intervention. At a mean of 10 years post injury (n=100), the mean DASH score was 5.8 and 92% of patients were satisfied. Factors associated with a poorer short and long-term patient reported outcome included increasing fracture displacement (≥5mm) and socio-economic deprivation. Retrospective analysis of 105 acute unstable complex radial head fractures found that the mean short-term functional outcome was good (mean Broberg and Morrey Score 80) following radial head replacement. In the long-term (mean 7 years), 28% of patients required removal or revision of the prosthesis, with younger patients and silastic implants independent risk factors (both p < 0.05). Retrospective analysis of 36 operatively managed isolated displaced olecranon fractures found satisfactory short and long-term outcomes, with the symptomatic metalwork removal rate 47% and the mean DASH 2.5 at a mean of seven years post injury. In the PRCT of plate (n=34) versus TBW (n=33) fixation, comparable functional and patient reported outcomes (DASH 8.5 vs 13.5; p=0.252) were found at one year following injury. Complication rates were significantly higher in the TBW group (63.3% vs 37.5%; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50.0% vs 21.9%; p=0.021), resulting in equivocal costs for both techniques (p=0.131). In older lower-demand patients, short and long-term retrospective analysis found very satisfactory outcomes following non-operative management of isolated displaced fractures of the olecranon, with patient satisfaction 91% and no patients requiring surgery for a symptomatic non-union. The preliminary results of the PRCT of non-operative (n=8) versus operative (n=11) management demonstrated comparable functional and patient reported outcomes at all points over the one-year following injury (all p≥0.05), with a higher rate of complications (81.8% vs 14.3%; p=0.013) and cost (p=0.01) following surgical intervention. The association found between fragility and the epidemiology of proximal forearm fractures highlighted the importance of considering non-operative management for these injuries. These findings support non-operative management for isolated stable radial head and neck fractures. For more complex injuries when radial head replacement is indicated, there is a high rate of removal or revision, with younger patients most at risk. In younger active patients with an isolated displaced fracture of the olecranon, TBW and plate fixation provide comparable short-term results, with TBW fixation as cost effective despite an increased rate of metalwork removal. In older lower demand patients, this data provides strong evidence for the non-operative management of isolated displaced olecranon fractures.

M.Med., Orthopaedic Surgery, Faculty of Health Sciences, University of the Witwatersrand, 2010

The Clinical Support Tools (CST) was developed to help therapists organize and target potential problems that might account for negative outcomes in psychotherapy. The core of CST feedback is The Assessment for Signal Clients (ASC). The purpose of this study was to describe and identify patterns of problems that typically characterize off-track cases. A cluster analysis of 107 off-track clients revealed three client types: those whose problems were characterized by alliance and motivational difficulties; those characterized by social support and life event difficulties; and those whose problems had an indistinguishable pattern. Loglinear modeling showed that if patients had less therapeutic alliance problems they were also less likely to have motivational problems. Findings were also consistent with the cluster analysis, which showed that a relatively higher percentage of not-on-track participants received signal alerts for the social support items and scale. Individuals whose progress goes off-track appear to have their greatest difficulty with social support, losses, and therapy task agreement.

Discrepancy in reporting is a frequent phenomenon in psychotherapy research and its presence indicates added information to take into account when assessing youth functioning (De Los Reyes, 2011; Hawley & Weisz, 2003). There is a need to further understand patterns in youth psychotherapy to protect from risk of treatment failure or deterioration. Our study aimed to explore informant discrepancy and its relation to key therapeutic constructs as well as youth functionality over time within youth outpatient mental health populations who use the Y-OQ and TSM in routine outcome monitoring and as clinical support measures. Using an outpatient mental health sample, regular Y-OQ and TSM data from n=157 youth ages 12-18 and their primary caregivers was assessed. Informant discrepancy was measured using initial total Y-OQ scores from both the youth and primary caregiver. Therapeutic constructs were measured using the TSM domains of primary caregiver distress, therapeutic alliance, and youth motivation. Change in functioning throughout the course of treatment was measured by the primary caregiver and youth Y-OQ total scores at each session. Results indicated that informant discrepancy predicted primary caregiver distress as well as change in youth functioning over time as perceived by the primary caregiver. Consistent with previous research, higher discrepancy between was associated with higher primary caregiver distress and predicted poorer youth functioning throughout the course of treatment. Implications and conclusions are discussed.

This study examined the relationship between perceived parenting skills and youth externalizing symptoms throughout the course of routine treatment of youth receiving services in a community mental health setting. Specifically, this study investigated whether changes in parenting skills were associated with changes in three dimensions of youth externalizing behaviors (behavioral dysfunction, interpersonal relations, social problems). Participants were 401 youth (aged 4-17, mean aged 10.7, 48% female) and their parents/guardians. At regular intervals throughout treatment, parents completed the Treatment Support Measure (TSM) to assess perceived parenting skills along with the Youth Outcome Questionnaire (Y-OQ) to assess youth externalizing symptoms. Hierarchical linear modeling analyses revealed that changes in perceived parenting skills were not significantly related to changes youth behavioral dysfunction, interpersonal relations, or social problems. However, parenting skills and all facets of externalizing significantly changed throughout the course of therapy and higher parenting skills were associated with lower levels of youth externalizing throughout therapy. Parenting skill appears to require further study as a key factor involved in youth psychotherapy outcomes in real world settings, especially in relation to youth externalizing symptoms.

Research on the effects of progress feedback and clinician problem-solving tools on patient outcome has been limited to a few clinical problems and settings (Shimowaka, Lambert & Smart, 2010). Only one randomized clinical trial has examined feedback-assisted treatment in an inpatient eating-disordered population. Results from this study suggested that those who received feedback-assisted (Fb) treatment were more likely to meet Jacobson and Truax's (1991) criteria for recovery than participants in the treatment-as-usual (TAU) condition; however, while these interventions appear to have worked well in the inpatient setting, the long-term effects of this treatment have not been investigated. This is especially pertinent in an eating disorder population, where outcomes tend to be poor and course of illness tends to be chronic. In this study, the effect of feedback interventions on long-term outcome was investigated. Fifty-three of the individuals from the aforementioned original study were contacted by mail, email, or telephone three to four years after leaving the inpatient facility to assess their current level of distress (as measured by the OQ-45) and overall psychological functioning. Comparisons were made between the outcomes of patients assigned to the experimental feedback condition and the TAU condition. Results suggested that both treatment conditions were nearly indistinguishable from one another and did not significantly differ at follow-up; however, the study was significantly underpowered. Our effect size suggested that the Fb group slightly deteriorated over time, while the TAU group slightly improved; however, effect sizes were minimal and did not meet criteria for "small" change according to Cohen's d. Patients’ Body Mass Index (BMI) largely remained the same since leaving the hospital, with a small portion deteriorating. The vast majority of women sought out multiple forms of treatment over the follow-up period, regardless of treatment condition. This is consistent with past research that suggests women with more severe pathology, and who thus require inpatient treatment, tend to experience a more chronic pattern of symptoms even after receiving intensive treatment. Overall, the superiority of feedback-assisted treatment that was found post-treatment appeared to diminish over time and was not detected at follow-up. Suggestions for further research are delineated.

The purpose of this project was to identify the standards for the American Association of Critical Care Nurses (AACN). The employees of a 39-bed medical surgical unit within a 697-bed metropolitan medical center were selected through collaboration with the practicum site. Out of 68 allocated positions for this unit, only permanent employees were selected to participate. An employee presented the purpose of the project, the survey process, and inferred consent represented by online login to complete the survey. Following the online assessment, the employee explained the AACN healthy work environment standards in a subsequent presentation. The online healthy work environment assessment measured the AACN healthy work environment standards, which included skilled communication, collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. A mean score was generated by the healthy work environment online assessment tool on a scale ranging from 1 (Needs Improvement) to 5 (Excellent). Data from the online assessment were analyzed by comparing mean pre- (3.03) and post- (2.17) project results, which revealed a need for greater understanding of AACN healthy work environment standards. Increased education of the AACN healthy work environment standards and implementation of a formal program would impact nursing turnover rates, improve employee engagement, and ultimately improve the care and outcome of patients, thereby promoting positive social change.

Diabetes mellitus is one of the leading causes of death and disability in the United Sates. Certain Native American groups have been harder hit than the mainstream population, both in prevalence of the disease and in rates of related complications. The highest known prevalence in the world is found among a Southwestern U.S. Tribe, and other Native American Tribes have demonstrated similar prevalence rates. It has been shown that certain psychological factors such as depression and hostility impact both the occurrence and outcome of certain diseases, including diabetes. This study examined whether those individuals who have not met the criteria for diabetes mellitus were more prone to develop diabetes mellitus if they reported signs of depression, cynical hostility, or anger that is either expressed or not expressed. It also examined the impact of depression, cynical hostility, and anger on glucose control among individuals who were diagnosed with diabetes mellitus. Finally, an aim was to determine if "psychological distress, " rather than specific psychosocial variables, was related to poorer diabetic outcomes among a specific Native American population. Participants for this study were part of the Strong Heart Study and were examined at two different points in time (1992-1994 and 1997-1999). The current study found that psychosocial variables did not predict the incidence of diabetes mellitus. Depression was found to impact glucose control among individuals without diabetes or impaired glucose tolerance, but psychosocial variables did not appear to have any measurable influence on glucose control among those individuals with diabetes mellitus or impaired glucose tolerance. Overall, it appears that psychosocial variables do not play as large of role in both incidence and outcome among certain Native American tribes as has been shown among the mainstream population.