Incorporando un plan de Vida Saludable en la Terapia Familiar Conductual: Ejemplificando un Caso Clínico de una Mujer con historial de Violencia Doméstica, Negligencia Infantil, Abuso de Drogas y Obesidad

Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems. This research was supported by a grant from the National Institute on Drug Abuse (1R01DA020548-01A1) awarded to Brad Donohue. The authors wish to thank Sally K. Miller, PhD, APN, FAANP and Associate Professor, UNLV School of Nursing for her work in completing the initial in-home health evaluation/physical for the current project.Las mujeres reportadas a las agencias de servicios de protección infantil, con frecuencia presentan problemas que interfieren con la salud y el bienestar de ellas y de sus hijos. Los programas de intervención conductual parecen ser eficaces en el manejo de problemas coexistentes como: la violencia doméstica y el abuso de drogas. Sin embargo, los tratamientos cuya eficacia ya ha sido demostrada en ocasiones anteriores, rara vez se han puesto en práctica en casos clínicos complicados, sobre todo en los centros de asistencia a menores. Por lo tanto, en este caso clínico, se describe el proceso de adaptación de un tratamiento eficaz para ayudar a controlar los problemas coexistentes de salud de una mujer acusada de negligencia infantil y abuso de drogas. Al finalizar el tratamiento, la participante informó sobre la mejoría en sus relaciones familiares, sobre su consumo de drogas y la negligencia infantil; aunque otros resultados relacionados con su salud no quedaron completamente claros. Gran parte de las mejorías se mantuvieron hasta 4 meses  después de haber concluido el tratamiento. Antes de implementar cada fase del tratamiento, discutimos los  contextos de la comunidad, aumentando así la probabilidad de obtener resultados positivos y respetando la integridad y el ajuste del tratamiento estándar para evitar que se presenten problemas en un futuro.Esta investigación se financió gracias a una subvención del Instituto Nacional de Drogodependencia (1R01DA020548-01A1) otorgada a Brad Donohue. Los autores desean agradecer a Sally K. Miller, PhD, APN, FAANP y Profesora Asociada de la Escuela de Enfermería de La Universidad de Nevada Las Vegas, por el examen físico inicial que se llevó a cabo en el domicilio de la participante de este proyecto

Incorporating a Healthy Living Curriculum within Family Behavior Therapy: A Clinical Case Example in a Woman with a History of Domestic Violence, Child Neglect, Drug Abuse, and Obesity

Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems. This research was supported by a grant from the National Institute on Drug Abuse (1R01DA020548-01A1) awarded to Brad Donohue. The authors wish to thank Sally K. Miller, PhD, APN, FAANP and Associate Professor, UNLV School of Nursing for her work in completing the initial in-home health evaluation/physical for the current project

Incorporando un plan de Vida Saludable en la Terapia Familiar Conductual: Ejemplificando un Caso Clínico de una Mujer con historial de Violencia Doméstica, Negligencia Infantil, Abuso de Drogas y Obesidad

Women reported to child protective service agencies frequently report problems that significantly interfere with the health and well-being of their children and themselves. Behavioral treatment programs appear to be effective in managing these co-existing problems, such as domestic violence and substance abuse. However, evidence-supported interventions are rarely exemplified in complicated clinical cases, especially within child welfare settings. Therefore, in this case example, we describe the process of adapting an evidence-supported treatment to assist in managing significant co-existing health-related problems in a mother who was referred due to child neglect and drug abuse. At the conclusion of therapy, the participant reported improvements in perceived family relationships, illicit drug use, child maltreatment potential, whereas other health-related outcomes were mixed. Most improvements were maintained at 4-month follow-up. Issues relevant to implementing evidence-based treatments within community contexts are discussed, including methods of increasing the likelihood of valid outcome assessment, managing treatment integrity, and adjusting standardized treatments to accommodate co-occurring problems. This research was supported by a grant from the National Institute on Drug Abuse (1R01DA020548-01A1) awarded to Brad Donohue. The authors wish to thank Sally K. Miller, PhD, APN, FAANP and Associate Professor, UNLV School of Nursing for her work in completing the initial in-home health evaluation/physical for the current project.Las mujeres reportadas a las agencias de servicios de protección infantil, con frecuencia presentan problemas que interfieren con la salud y el bienestar de ellas y de sus hijos. Los programas de intervención conductual parecen ser eficaces en el manejo de problemas coexistentes como: la violencia doméstica y el abuso de drogas. Sin embargo, los tratamientos cuya eficacia ya ha sido demostrada en ocasiones anteriores, rara vez se han puesto en práctica en casos clínicos complicados, sobre todo en los centros de asistencia a menores. Por lo tanto, en este caso clínico, se describe el proceso de adaptación de un tratamiento eficaz para ayudar a controlar los problemas coexistentes de salud de una mujer acusada de negligencia infantil y abuso de drogas. Al finalizar el tratamiento, la participante informó sobre la mejoría en sus relaciones familiares, sobre su consumo de drogas y la negligencia infantil; aunque otros resultados relacionados con su salud no quedaron completamente claros. Gran parte de las mejorías se mantuvieron hasta 4 meses  después de haber concluido el tratamiento. Antes de implementar cada fase del tratamiento, discutimos los  contextos de la comunidad, aumentando así la probabilidad de obtener resultados positivos y respetando la integridad y el ajuste del tratamiento estándar para evitar que se presenten problemas en un futuro.Esta investigación se financió gracias a una subvención del Instituto Nacional de Drogodependencia (1R01DA020548-01A1) otorgada a Brad Donohue. Los autores desean agradecer a Sally K. Miller, PhD, APN, FAANP y Profesora Asociada de la Escuela de Enfermería de La Universidad de Nevada Las Vegas, por el examen físico inicial que se llevó a cabo en el domicilio de la participante de este proyecto

Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

BackgroundWe previously reported that impaired type I IFN activity, due to inborn errors of TLR3- and TLR7-dependent type I interferon (IFN) immunity or to autoantibodies against type I IFN, account for 15-20% of cases of life-threatening COVID-19 in unvaccinated patients. Therefore, the determinants of life-threatening COVID-19 remain to be identified in similar to 80% of cases.MethodsWe report here a genome-wide rare variant burden association analysis in 3269 unvaccinated patients with life-threatening COVID-19, and 1373 unvaccinated SARS-CoV-2-infected individuals without pneumonia. Among the 928 patients tested for autoantibodies against type I IFN, a quarter (234) were positive and were excluded.ResultsNo gene reached genome-wide significance. Under a recessive model, the most significant gene with at-risk variants was TLR7, with an OR of 27.68 (95%CI 1.5-528.7, P=1.1x10(-4)) for biochemically loss-of-function (bLOF) variants. We replicated the enrichment in rare predicted LOF (pLOF) variants at 13 influenza susceptibility loci involved in TLR3-dependent type I IFN immunity (OR=3.70[95%CI 1.3-8.2], P=2.1x10(-4)). This enrichment was further strengthened by (1) adding the recently reported TYK2 and TLR7 COVID-19 loci, particularly under a recessive model (OR=19.65[95%CI 2.1-2635.4], P=3.4x10(-3)), and (2) considering as pLOF branchpoint variants with potentially strong impacts on splicing among the 15 loci (OR=4.40[9%CI 2.3-8.4], P=7.7x10(-8)). Finally, the patients with pLOF/bLOF variants at these 15 loci were significantly younger (mean age [SD]=43.3 [20.3] years) than the other patients (56.0 [17.3] years; P=1.68x10(-5)).ConclusionsRare variants of TLR3- and TLR7-dependent type I IFN immunity genes can underlie life-threatening COVID-19, particularly with recessive inheritance, in patients under 60 years old

Correction: Rare predicted loss-of-function variants of type I IFN immunity genes are associated with life-threatening COVID-19

International audienc

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially