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Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance.
We have developed ultra-high risk criteria for bipolar affective disorder (bipolar at-risk - BAR) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania, depressive symptoms, cyclothymic features and genetic risk. In the current study, the predictive and discriminant validity of these criteria were tested in help seeking adolescents and young adults.
This medical file-audit study was conducted at ORYGEN Youth Health (OYH), a public mental health program for young people aged between 15 and 24 years and living in metropolitan Melbourne, Australia. BAR criteria were applied to the intake assessments of all non-psychotic patients who were being treated in OYH on 31 January.08. All entries were then checked for conversion criteria. Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania.
The BAR criteria were applied to 173 intake assessments. Of these, 22 patients (12.7%) met BAR criteria. The follow-up period of the sample was 265.5 days on average (SD 214.7). There were significantly more cases in the BAR group (22.7%, n = 5) than in the non-BAR group (0.7%, n = 1) who met conversion criteria (p < .001).
These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase. The proposed criteria need further evaluation in prospective clinical trials.
Alcohol induced liver disease (ALD) is the predominant cause of alcohol-related mortality in the UK. Therefore helping patients with ALD to quit is a primary treatment goal.
The primary aim of this study was to measure the effectiveness and tolerability of Baclofen in maintaining abstinence, and to determine if this resulted in a reduction in standard measures of liver damage.
An observational prospective clinical audit was performed. Patients with ALD were commenced on Baclofen titrated according to tolerability and response up to 30 mg TDS. Primary outcome measures were severity of physical dependence (SADQ score) and biochemical markers of liver damage GGT, ALT, Bilirubin fibroelastography. These were compared at baseline, and 1 year.
Of the 243 patients commenced on Baclofen, 151 (85 female 66 male) have completed 1 year follow-up (F/U) of which 130 (86%) have remained engaged. 10 have died. Comparison of baseline (B/L) and 1 year biochemical markers showed a reduction in GGT (c2= 66.8 P < 0.0001) and Bil (c2= 82.6 P < 0.0001). There was a significant reduction in alcohol consumption (P < 0.0001 95% CI = 10 to 22). And the presence of physical dependence (c<sup>2</sup> = 77.4 P < 0.0001) as categorised by SADQ.
Baclofen is well tolerated in this very difficult to treat, high risk patient group. It has a positive impact on alcohol consumption, and overall measures of liver function and harm. A RCT is needed to confirm the benefit of Baclofen in this patient group.</div>
Abnormal brain connectivity has recently been reported in obsessive compulsive disorder (OCD). However, structural differences in the corpus callosum (CC), the primary structure connecting the two hemispheres, have not been extensively studied. In this case-control study, we recruited 30 patients with OCD and 30 healthy control subjects carefully matched for age, sex and handedness. Combining surface-based mesh-modeling and voxel-based morphometry (VBM), we compared callosal thickness and white matter (WM) density in patients and controls. We investigated associations between callosal structure and cortical gray matter (GM) density, and we related CC measures to neuropsychological performance in OCD. OCD patients showed small anterior and posterior callosal regions compared to healthy control subjects. In the OCD group, anterior callosal thickness was positively correlated with GM density of the right mid-dorso-lateral prefrontal (BA 9/46) area, while posterior callosal thickness was positively correlated with GM density in the left supramarginal gyrus (BA 40). Moreover, posterior callosal WM density was positively correlated with verbal memory, visuo-spatial memory, verbal fluency, and visuo-spatial reasoning performances. Callosal attributes were related to GM density in cortical areas innervated by the CC, and were also related to performance in cognitive domains impaired in the disorder. The CC may therefore be integrally involved in OCD.
There are increasing concerns regarding long-term psychotropic polypharmacy prescribed for foster care youth 3.5 to 5 times more often than in at-home youth (Kreider et al., 2014). Polypharmacy risks include weight gain, glucose intolerance and type 2 diabetes. (De Hert et al., 2011). In view of these risks, novel interventions are essential to safeguard foster care youth from overmedication.
To present guidelines for identification and management of polypharmacy in foster care youth.
To demonstrate a novel intervention to monitor and diminish polypharmacy and enhance psychiatric care in foster care children.
Polypharmacy is identified using LA County Juvenile Court Mental Health Service (JCMHS) Psychotropic Parameters* to review medication consent forms from treating psychiatrists. Polypharmacy triggers an in-person JCHMS consultation. *(Parameters 3.9 for JCMHS PMAF Review, Revised May 2015).
JCMHS Psychotropic Parameters (summary):
– age 0–5 years:
– 2 or > psychotropic medications,
– Any antipsychotic (*except Risperidone in ASD);
– age 6–8 years:
– 3 or > psychotropic medications;
– age 9–17 years:
– 4 or > psychotropic medications;
– All age youth:
– 2 or > psychotropic medications in the same class (antipsychotics, antidepressants, stimulants, mood stabilizers, alpha agonists).
Psychotropic medication doses in excess of recommended (*LA County Department of Mental Health Parameters 3.8 for use of Psychotropic Medications for Children and Adolescents).
Approximately 25% of JCMHS annual psychiatric consultations were initiated by JCMHS parameters for polypharmacy. Corresponding consultations included education and recommendations discussed with treating psychiatrists regarding polypharmacy and optimal psychiatric management.
JCMHS Psychotropic Parameters is a useful tool to identify polypharmacy and enhance psychiatric care of foster care youth.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
It is well known that youth in foster care are at high risk for psychiatric disorders, recently reported in up to 89%, with over 55% exhibiting ADHD in one sample (Linares et al., 2013). Psychotropic medication use was reported in 59% of foster care youth within a 2-month period (Brenner et al., 2013). The psychotropic medication consent process in Los Angeles for dependent children is multidisciplinary, starting with the treating psychiatrist's written authorization request to Children's Dependency Court. Once received, it is distributed to the child's attorney, social worker, and Juvenile Court Mental Health Service (JCMHS). JCMHS reviews and provides recommendations to the judicial officer who ultimately approves, modifies, or denies consent.
To present the steps and reasoning in the process of review, consultation, recommendations and decisions in psychotropic medication consent for dependent youth.
To provide an understanding of the multidisciplinary review process involved in determining psychotropic medication consent in foster care youth.
Presentation of a timeline, forms and guidelines used in the process including the “Psychotropic Medication Authorization Form” (PMA) (Judicial Council of California, 2008).
Categories of recommendations and approvals provided to the judicial officer will be presented and rationales for in-person consultations.
The psychotropic medication consent process for foster care youth is a complex multidisciplinary process which includes a clinically significant set of recommendations from JCMHS to the judicial officer to aid in making informed decisions regarding psychotropic medication.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Total laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period.
A retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts.
A shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development.
Complications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.
Tuberous sclerosis complex is a rare genetic disorder leading to the growth of hamartomas in multiple organs, including cardiac rhabdomyomas. Children with symptomatic cardiac rhabdomyoma require frequent admissions to intensive care units, have major complications, namely, arrhythmias, cardiac outflow tract obstruction and heart failure, affecting the quality of life and taking on high healthcare cost. Currently, there is no standard pharmacological treatment for this condition, and the management includes a conservative approach and supportive care. Everolimus has shown positive effects on subependymal giant cell astrocytomas, renal angiomyolipoma and refractory seizures associated with tuberous sclerosis complex. However, evidence supporting efficacy in symptomatic cardiac rhabdomyoma is limited to case reports. The ORACLE trial is the first randomised clinical trial assessing the efficacy of everolimus as a specific therapy for symptomatic cardiac rhabdomyoma.
ORACLE is a phase II, prospective, randomised, placebo-controlled, double-blind, multicentre protocol trial. A total of 40 children with symptomatic cardiac rhabdomyoma secondary to tuberous sclerosis complex will be randomised to receive oral everolimus or placebo for 3 months. The primary outcome is 50% or more reduction in the tumour size related to baseline. As secondary outcomes we include the presence of arrhythmias, pericardial effusion, intracardiac obstruction, adverse events, progression of tumour reduction and effect on heart failure.
ORACLE protocol addresses a relevant unmet need in children with tuberous sclerosis complex and cardiac rhabdomyoma. The results of the trial will potentially support the first evidence-based therapy for this condition.
Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative respiratory support mode and timing affects outcomes.
We retrospectively collected data on children <18 years of age undergoing cardiac surgery at an academic tertiary care medical centre. Using multivariable regression, we examined the association between modes of preoperative respiratory support (nasal cannula, high-flow nasal cannula/noninvasive ventilation, or invasive mechanical ventilation), escalation of preoperative respiratory support, and invasive mechanical ventilation on the day of surgery for three outcomes: operative mortality, postoperative length of stay, and postoperative complications. We repeated our analysis in a subcohort of neonates.
A total of 701 children underwent 800 surgical procedures, and 40% received preoperative respiratory support. Among neonates, 243 patients underwent 253 surgical procedures, and 79% received preoperative respiratory support. In multivariable analysis, all modes of preoperative respiratory support, escalation in preoperative respiratory support, and invasive mechanical ventilation on the day of surgery were associated with increased odds of prolonged length of stay in children and neonates. Children (odds ratio = 3.69, 95% CI 1.2–11.4) and neonates (odds ratio = 8.97, 95% CI 1.31–61.14) on high-flow nasal cannula/noninvasive ventilation had increased odds of operative mortality compared to those on room air.
Preoperative respiratory support is associated with prolonged length of stay and mortality following CHD surgery. Knowing how preoperative respiratory support affects outcomes may help guide surgical timing, inform prognostic conversations, and improve risk stratification models.
To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.
A pre- and postintervention, quasi-experimental quality improvement study.
Setting and participants:
Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.
We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014–January 2015) and the intervention period (April 2015–October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.
Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06–0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).
The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.
To better understand hepatitis C virus (HCV) epidemiology in Punjab state, India, we estimated the distribution of HCV antibody positivity (anti-HCV+) using a 2013–2014 HCV household seroprevalence survey. Household anti-HCV+ clustering was investigated (a) by individual-level multivariable logistic regression, and (b) comparing the observed frequency of households with multiple anti-HCV+ persons against the expected, simulated frequency assuming anti-HCV+ persons are randomly distributed. Village/ward-level clustering was investigated similarly. We estimated household-level associations between exposures and the number of anti-HCV+ members in a household (N = 1593 households) using multivariable ordered logistic regression. Anti-HCV+ prevalence was 3.6% (95% confidence interval 3.0–4.2%). Individual-level regression (N = 5543 participants) found an odds ratio of 3.19 (2.25–4.50) for someone being anti-HCV+ if another household member was anti-HCV+. Thirty households surveyed had ⩾2 anti-HCV+ members, whereas 0/1000 (P < 0.001) simulations had ⩾30 such households. Excess village-level clustering was evident: 10 villages had ⩾6 anti-HCV+ members, occurring in 31/1000 simulations (P = 0.031). The household-level model indicated the number of household members, living in southern Punjab, lower socio-economic score, and a higher proportion having ever used opium/bhuki were associated with a household's number of anti-HCV+ members. Anti-HCV+ clusters within households and villages in Punjab, India. These data should be used to inform screening efforts.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
Normal and oblique drop impact on a solid surface is numerically analysed for yield stress fluids. A rich diversity of results are generated as a consequence of the exploration of the inertial, elastic, plastic and thixotropic features of the process, as well as the inclination of the solid surface. We show that drops of more thixotropic fluids have a higher tendency to bounce in the normal impact, and to roll or to bounce in the case of an oblique drop impact. Concerning elasticity, we found a critical value for the elastic Ohnesorge number above which no bouncing takes place. Experimental findings such as the fact that the stored energy due to the elasticity of the fluid drop plays a role similar to the stored energy of an interfacial nature in inelastic fluid drops are corroborated in the present study.
Space Infrared Telescope for Cosmology and Astrophysics (SPICA), the cryogenic infrared space telescope recently pre-selected for a ‘Phase A’ concept study as one of the three remaining candidates for European Space Agency (ESA's) fifth medium class (M5) mission, is foreseen to include a far-infrared polarimetric imager [SPICA-POL, now called B-fields with BOlometers and Polarizers (B-BOP)], which would offer a unique opportunity to resolve major issues in our understanding of the nearby, cold magnetised Universe. This paper presents an overview of the main science drivers for B-BOP, including high dynamic range polarimetric imaging of the cold interstellar medium (ISM) in both our Milky Way and nearby galaxies. Thanks to a cooled telescope, B-BOP will deliver wide-field 100–350
m images of linearly polarised dust emission in Stokes Q and U with a resolution, signal-to-noise ratio, and both intensity and spatial dynamic ranges comparable to those achieved by Herschel images of the cold ISM in total intensity (Stokes I). The B-BOP 200
m images will also have a factor
30 higher resolution than Planck polarisation data. This will make B-BOP a unique tool for characterising the statistical properties of the magnetised ISM and probing the role of magnetic fields in the formation and evolution of the interstellar web of dusty molecular filaments giving birth to most stars in our Galaxy. B-BOP will also be a powerful instrument for studying the magnetism of nearby galaxies and testing Galactic dynamo models, constraining the physics of dust grain alignment, informing the problem of the interaction of cosmic rays with molecular clouds, tracing magnetic fields in the inner layers of protoplanetary disks, and monitoring accretion bursts in embedded protostars.
Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.
To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).
We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).
A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1–9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9–11.3%) compared with LMICs (4.3%, 95% CI 2.6–6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).
Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.
Childhood maltreatment (CM) plays an important role in the development of major depressive disorder (MDD). The aim of this study was to examine whether CM severity and type are associated with MDD-related brain alterations, and how they interact with sex and age.
Within the ENIGMA-MDD network, severity and subtypes of CM using the Childhood Trauma Questionnaire were assessed and structural magnetic resonance imaging data from patients with MDD and healthy controls were analyzed in a mega-analysis comprising a total of 3872 participants aged between 13 and 89 years. Cortical thickness and surface area were extracted at each site using FreeSurfer.
CM severity was associated with reduced cortical thickness in the banks of the superior temporal sulcus and supramarginal gyrus as well as with reduced surface area of the middle temporal lobe. Participants reporting both childhood neglect and abuse had a lower cortical thickness in the inferior parietal lobe, middle temporal lobe, and precuneus compared to participants not exposed to CM. In males only, regardless of diagnosis, CM severity was associated with higher cortical thickness of the rostral anterior cingulate cortex. Finally, a significant interaction between CM and age in predicting thickness was seen across several prefrontal, temporal, and temporo-parietal regions.
Severity and type of CM may impact cortical thickness and surface area. Importantly, CM may influence age-dependent brain maturation, particularly in regions related to the default mode network, perception, and theory of mind.
Emotion dysregulation is defined as patterns of emotional experience or expression that interfere with goal-directed activity. This paper considers this functionalist definition from a developmental perspective with the goal of elaborating this approach with respect to its central questions. What are the goals that are impeded by emotionally dysregulated responding, and what alternative goals might motivate emotion dysregulation? What are the developmental processes by which these goals take shape, and what are the influences of the family context, and especially of central relationships in the family, in their emergence? How does this functionalist account address the complex interaction of experience and developing biological processes that also influence emotion regulation and dysregulation? Drawing on research literature concerning children at risk for affective psychopathology and considering relevant examples of the interaction of biology and context, this discussion offers a portrayal of emotion dysregulation as a biologically dynamic, experience-based aspect of adaptation to environments and relationships that, in conditions of risk for the emergence of developmental psychopathology, motivates patterns of emotional responding that serve immediate coping often at the cost of long-term maladaptation. Implications for emotions theory and the study of developmental psychopathology are also considered.
Dicamba-resistant (DR) kochia is an increasing concern for growers in the US Great Plains, including Kansas. Greenhouse and field experiments (Garden City and Tribune, KS, in the 2014 to 2015 growing season) were conducted to characterize the dicamba resistance levels in two recently evolved DR kochia accessions collected from fallow fields (wheat–sorghum–fallow rotation) near Hays, KS, and to determine the effectiveness of various PRE herbicide tank mixtures applied in fall or spring prior to the fallow year. Dicamba dose–response studies indicated that the KS-110 and KS-113 accessions had 5- to 8-fold resistance to dicamba, respectively, relative to a dicamba-susceptible (DS) accession. In separate field studies, atrazine-based PRE herbicide tank mixtures, dicamba + pendimethalin + sulfentrazone, and metribuzin + sulfentrazone when applied in the spring had excellent kochia control (85% to 95%) for 3 to 4 mo at the Garden City and Tribune sites. In contrast, kochia control with those PRE herbicide tank mixtures when applied in the fall did not exceed 79% at the later evaluation dates. In conclusion, the tested kochia accessions from western Kansas had evolved moderate to high levels of resistance to dicamba. Growers should utilize these effective PRE herbicide tank mixtures (multiple sites of action) in early spring to manage kochia seed bank during the summer fallow phase of this 3-yr crop rotation (wheat–corn/sorghum–fallow) in the Central Great Plains.