45 research outputs found
Acute Kawasaki Disease: Not Just for Kids
Kawasaki Disease is a small-to-medium-vessel vasculitis that preferentially affects children. Kawasaki Disease can occur in adults, but the presentation may differ from that observed in children. Typical findings in both adults and children include fever, conjunctivitis, pharyngitis, and skin erythema progressing to a desquamating rash on the palms and soles. Adults more frequently present with cervical adenopathy (93% of adults vs. 15% of children), hepatitis (65% vs. 10%), and arthralgia (61% vs. 24â38%). In contrast, adults are less frequently affected by meningitis (10% vs. 34%), thrombocytosis (55% vs. 100%), and coronary artery aneurysms (5% vs. 18â25%). We report a case of acute Kawasaki Disease in a 24-year-old man who presented with rash, fever, and arthritis. He was successfully treated with high-dose aspirin and intravenous immunoglobulin (IVIG). Our case highlights the importance of considering Kawasaki Disease in adults presenting with symptoms commonly encountered in a general medical practice
A meta-analysis on the effect of corticosteroid therapy in Kawasaki disease
The current recommended therapy for Kawasaki disease (KD) is the combination of intravenous immunoglobulin (IVIG) and aspirin. However, the role of corticosteroid therapy in KD remains controversial. Using meta-analysis, this study aimed to investigate the efficacy of corticosteroid therapy in KD by comparing it with standard IVIG and aspirin therapy. We included all related randomized and quasi-randomized controlled trials by searching Medline, the Cochrane Central Register of Controlled Trials, EMBASE, Pub Med, Chinese BioMedical Literature Database, China National Knowledge Infrastructure, and the Japanese database (Japan Science and Technology) as well as hand searches of selected references. Data collection and meta-analysis were performed to evaluate the effect of corticosteroids. Our search yielded 11 studies; 7 of which evaluated the effect of corticosteroid for primary therapy in KD, and 4 investigated the effect of corticosteroid therapy in IVIG-resistant patients. Meta-analysis of these studies revealed a significant reduction in the rates of initial treatment failure among patients who received corticosteroid therapy in combination with IVIG compared to IVIG alone (odds ratio (OR)â=â0.50; 95% CI, 0.32~0.79; pâ=â0.003). Furthermore, the use of corticosteroids reduced the duration of fever and the time required for C-reactive protein to return to normal. Our data did not show any significant increase in the incidence of coronary artery lesions or coronary aneurysms (ORâ=â0.67; 95% CI, 0.35~1.28; pâ=â0.23) in the corticosteroid group. Conclusion. Corticosteroid combined with IVIG in primary treatment or as treatment of IVIG-resistant patients improved clinical course without increasing coronary artery lesions in children with acute KD
Interventions for drug-using offenders with co-occurring mental health problems
Background
This review represents one from a family of three reviews focusing on interventions for drugâusing offenders. Many people under the care of the criminal justice system have coâoccurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population.
Objectives
To assess the effectiveness of interventions for drugâusing offenders with coâoccurring mental health problems in reducing criminal activity or drug use, or both.
This review addresses the following questions.
⢠Does any treatment for drugâusing offenders with coâoccurring mental health problems reduce drug use?
⢠Does any treatment for drugâusing offenders with coâoccurring mental health problems reduce criminal activity?
⢠Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)?
⢠Does the type of treatment affect treatment outcome(s)?
Search methods
We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information.
Selection criteria
We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drugâusing offenders with coâoccurring mental health problems.
Data collection and analysis
We used standard methodological procedures as expected by Cochrane .
Main results
We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias.
Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderateâcertainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitiveâbehavioural therapy (one study; 314 participants), reporting no significant reduction in selfâreported drug use (RR 0.78, 95% CI 0.46 to 1.32), reâarrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drugârelated crime (RR 0.87, 95% CI 0.56 to 1.36), yielding lowâcertainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderateâcertainty evidence.
One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' followâup on an Addictive Severity Index (ASI) selfâreport of drug use (mean difference (MD) 0.00, 95% CI â0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or reâincarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing lowâcertainty evidence.
Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at threeâmonth followâup assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderateâcertainty evidence. In comparison to a waiting list control, one study reported no significant reduction in selfâreported drug use based on the ASI (MD â0.04, 95% CI â0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting lowâcertainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD â1.05, 95% CI â2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI â0.12 to 1.86), along with a small reduction in frequency of reâarrest (MD â0.66, 95% CI â1.31 to â0.01) up to 36 months, yielding lowâcertainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD â0.7, 95% CI â3.5 to 2.1), providing very lowâcertainty evidence.
Two studies reported on the use of multiâsystemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD â0.22, 95% CI â2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing lowâcertainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in reâarrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on lowâcertainty evidence.
One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in selfâreported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very lowâcertainty evidence. The final study (29 participants) compared legal defence service and wrapâaround social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very lowâcertainty evidence.
Authors' conclusions
Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multiâsystemic therapy, legal defence wrapâaround services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes