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Learning from a case of a 13 year old patient with auditory hallucinations for 2 months, admitted to the hospital due to suicidal ideation. Her mother had been diagnosed with Lupus and OCD. Her mood had been low for several months, probable mild intellectual disability.
Objectives
Learn how to assess auditory hallucinations and possible new onset psychotic symptoms in teenagers. Learn about different levels of care involved. Discuss differential diagnosis and future directions and treatment.
Methods
Description of the case. Differential diagnosis: Obsessive compulsive disorder, Major depressive disorder with Psychotic features, schizophrenia spectrum disorder, epilepsy or other neurologic disease, autoimmune disease, post-traumatic stress disorder… Tests and consults conducted by Neurology team Psychopharmacology description.
Results
Differential diagnosis: Obsessive compulsive disorder, Major depressive disorder with Psychotic features, schizophrenia spectrum disorder, epilepsy, autoimmune diseases like Lupus, post-traumatic stress disorder etc. Video EEG: normal. Brain MRI: normal Blood work unremarkable with positive ANA (titer 1:80). Work up, including lumbar puncture with autoimmune encephalitis and MS panels was negative. Psychopharmacology: Fluoxetine up to 40mg, and Aripiprazol up to 20mg without a good response. Possible sexual trauma was disclosed in a second hospitalization, months later.
Conclusions
Recommendation of assessing new onset of psychotic symptoms in detail to get a good diagnosis. Psychotic symptoms in young teenagers may occur as part of different presentations and it is important to provide a good follow up of the patient in order to provide the most accurate treatment.
A developing application of laser-driven currents is the generation of magnetic fields of picosecond–nanosecond duration with magnitudes exceeding $B=10~\text{T}$. Single-loop and helical coil targets can direct laser-driven discharge currents along wires to generate spatially uniform, quasi-static magnetic fields on the millimetre scale. Here, we present proton deflectometry across two axes of a single-loop coil ranging from 1 to 2 mm in diameter. Comparison with proton tracking simulations shows that measured magnetic fields are the result of kiloampere currents in the coil and electric charges distributed around the coil target. Using this dual-axis platform for proton deflectometry, robust measurements can be made of the evolution of magnetic fields in a capacitor coil target.
Filamentary structures can form within the beam of protons accelerated during the interaction of an intense laser pulse with an ultrathin foil target. Such behaviour is shown to be dependent upon the formation time of quasi-static magnetic field structures throughout the target volume and the extent of the rear surface proton expansion over the same period. This is observed via both numerical and experimental investigations. By controlling the intensity profile of the laser drive, via the use of two temporally separated pulses, both the initial rear surface proton expansion and magnetic field formation time can be varied, resulting in modification to the degree of filamentary structure present within the laser-driven proton beam.
Neighboring tidewater glaciers often exhibit asynchronous dynamic behavior, despite relatively uniform regional atmospheric and oceanic forcings. This variability may be controlled by a combination of local factors, including glacier and fjord geometry, fjord heat content and circulation, and glacier surface melt. In order to characterize and understand contrasts in adjacent tidewater glacier and fjord dynamics, we made coincident ice-ocean-atmosphere observations at high temporal resolution (minutes to weeks) within a 10 000 km2 area near Uummannaq, Greenland. Water column velocity, temperature and salinity measurements reveal systematic differences in neighboring fjords that imply contrasting circulation patterns. The observed ocean velocity and hydrography, combined with numerical modeling, suggest that subglacial discharge plays a major role in setting fjord conditions. In addition, satellite remote sensing of seasonal ice flow speed and terminus position reveal both speedup and slow-down in response to melt, as well as differences in calving style among the neighboring glaciers. Glacier force budgets and modeling also point toward subglacial discharge as a key factor in glacier behavior. For the studied region, individual glacier and fjord geometry modulate subglacial discharge, which leads to contrasts in both fjord and glacier dynamics.
To determine the prevalence and acquisition of extended-spectrum β-lactamases (ESBLs), plasmid-mediated AmpCs (pAmpCs), and carbapenemases (“MDR Enterobacteriaceae”) colonizing children admitted to a pediatric intensive care unit (PICU).
DESIGN
Prospective study.
SETTING
40-bed PICU.
METHODS
Admission and weekly thereafter rectal surveillance swabs were collected on all pediatric patients during a 6-month study period. Routine phenotypic identification and antibiotic susceptibility testing were performed. Enterobacteriaceae displaying characteristic resistance profiles underwent further molecular characterization to identify genetic determinants of resistance likely to be transmitted on mobile genetic elements and to evaluate relatedness of strains including DNA microarray, multilocus sequence typing, repetitive sequence-based PCR, and hsp60 sequencing typing.
RESULTS
Evaluating 854 swabs from unique children, the overall prevalence of colonization with an MDR Enterobacteriaceae upon admission to the PICU based on β-lactamase gene identification was 4.3% (n=37), including 2.8% ESBLs (n=24), 1.3% pAmpCs (n=11), and 0.2% carbapenemases (n=2). Among 157 pediatric patients contributing 603 subsequent weekly swabs, 6 children (3.8%) acquired an incident MDR Enterobacteriaceae during their PICU stay. One child acquired a pAmpC (E. coli containing blaDHA) related to an isolate from another patient.
CONCLUSIONS
Approximately 4% of children admitted to a PICU were colonized with MDR Enterobacteriaceae (based on β-lactamase gene identification) and an additional 4% of children who remained in the PICU for at least 1 week acquired 1 of these organisms during their PICU stay. The acquired MDR Enterobacteriaceae were relatively heterogeneous, suggesting that a single source was not responsible for the introduction of these resistance mechanisms into the PICU setting.
The collective response of electrons in an ultrathin foil target irradiated by an ultraintense (${\sim}6\times 10^{20}~\text{W}~\text{cm}^{-2}$) laser pulse is investigated experimentally and via 3D particle-in-cell simulations. It is shown that if the target is sufficiently thin that the laser induces significant radiation pressure, but not thin enough to become relativistically transparent to the laser light, the resulting relativistic electron beam is elliptical, with the major axis of the ellipse directed along the laser polarization axis. When the target thickness is decreased such that it becomes relativistically transparent early in the interaction with the laser pulse, diffraction of the transmitted laser light occurs through a so called ‘relativistic plasma aperture’, inducing structure in the spatial-intensity profile of the beam of energetic electrons. It is shown that the electron beam profile can be modified by variation of the target thickness and degree of ellipticity in the laser polarization.
Combination antibiograms can be used to evaluate organism cross-resistance among multiple antibiotics. As combination therapy is generally favored for the treatment of carbapenemase-producing Enterobacteriaceae (CPE), combination antibiograms provide valuable information about the combination of antibiotics that achieve the highest likelihood of adequate antibiotic coverage against CPE.
Infect. Control Hosp. Epidemiol. 2015;36(12):1458–1460
Clostridium difficile infection (CDI) in hospitalized patients is generally attributed to the current stay, but recent studies reveal high C. difficile colonization rates on admission.
OBJECTIVE
To determine the rate of colonization with toxigenic C. difficile among intensive care unit patients upon admission as well as acquired during hospitalization, and the risk of subsequent CDI.
METHODS
Prospective cohort study from April 15 through July 8, 2013. Adults admitted to an intensive care unit within 48 hours of admission to the Johns Hopkins Hospital, Baltimore, Maryland, were screened for colonization with toxigenic C. difficile. The primary outcome was risk of developing CDI.
RESULTS
Among 542 patients, 17 (3.1%) were colonized with toxigenic C. difficile on admission and an additional 3 patients were found to be colonized during hospitalization. Both colonization with toxigenic C. difficile on admission and colonization during hospitalization were associated with an increased risk for development of CDI (relative risk, 10.29 [95% CI, 2.24–47.40], P=.003; and 15.66 [4.01–61.08], P<.001, respectively). Using multivariable analysis, colonization on admission and colonization during hospitalization were independent predictors of CDI (relative risk, 8.62 [95% CI, 1.48–50.25], P=.017; and 10.93 [1.49–80.20], P=.019, respectively), while adjusting for potential confounders.
CONCLUSIONS
In intensive care unit patients, colonization with toxigenic C. difficile is an independent risk factor for development of subsequent CDI. Further studies are needed to identify populations with higher toxigenic C. difficile colonization rates possibly benefiting from screening or avoidance of agents known to promote CDI.
Infect. Control Hosp. Epidemiol. 2015;36(11):1324–1329
The Murchison Widefield Array is a new low-frequency interferometric radio telescope built in Western Australia at one of the locations of the future Square Kilometre Array. We describe the automated radio-frequency interference detection strategy implemented for the Murchison Widefield Array, which is based on the aoflagger platform, and present 72–231 MHz radio-frequency interference statistics from 10 observing nights. Radio-frequency interference detection removes 1.1% of the data. Radio-frequency interference from digital TV is observed 3% of the time due to occasional ionospheric or atmospheric propagation. After radio-frequency interference detection and excision, almost all data can be calibrated and imaged without further radio-frequency interference mitigation efforts, including observations within the FM and digital TV bands. The results are compared to a previously published Low-Frequency Array radio-frequency interference survey. The remote location of the Murchison Widefield Array results in a substantially cleaner radio-frequency interference environment compared to Low-Frequency Array’s radio environment, but adequate detection of radio-frequency interference is still required before data can be analysed. We include specific recommendations designed to make the Square Kilometre Array more robust to radio-frequency interference, including: the availability of sufficient computing power for radio-frequency interference detection; accounting for radio-frequency interference in the receiver design; a smooth band-pass response; and the capability of radio-frequency interference detection at high time and frequency resolution (second and kHz-scale respectively).
The B fields in OB stars (BOB) survey is an ESO large programme collecting spectropolarimetric observations for a large number of early-type stars in order to study the occurrence rate, properties, and ultimately the origin of magnetic fields in massive stars. As of July 2014, a total of 98 objects were observed over 20 nights with FORS2 and HARPSpol. Our preliminary results indicate that the fraction of magnetic OB stars with an organised, detectable field is low. This conclusion, now independently reached by two different surveys, has profound implications for any theoretical model attempting to explain the field formation in these objects. We discuss in this contribution some important issues addressed by our observations (e.g., the lower bound of the field strength) and the discovery of some remarkable objects.
To compare direct laboratory costs of different methods for perirectal screening for carbapenemase-producing Enterobacteriaceae (CPE) colonization.
Design.
Cost-benefit analysis.
Setting.
A university hospital and affiliated long-term acute care hospital (LTACH).
Participants.
Inpatients from the hospital or LTACH.
Methods.
Perirectal samples were collected from inpatients at risk for exposure to CPE. In 2009, we compared the accuracy of the Centers for Disease Control and Prevention (CDC)-recommended CPE screening method with similar methods incorporating a chromogenic agar (CA). We then performed a cost projection analysis using 2012 screening results for the CA method, the CDC method, and a molecular assay with wholesale pricing based on the 2009 analysis. Comparisons of turnaround and personnel time were also performed.
Results.
A total of 185 (2.7%) of 6,860 samples were confirmed as CPE positive during 2012. We previously found that the CDC protocol had a lower sensitivity than the CA method and predicted that the CDC protocol would have missed 92 of the CPE-positive screening results, whereas the modified protocol using CA would have missed 26, assuming similar prevalence and performance. Turnaround time was 3 days using the CDC and CA-modified protocols compared with 1 day for molecular testing. The estimated annual total program cost and total technologist's hours would be the following: CA-modified protocol, $37,441 and 376 hours; CDC protocol, $22,818 and 482 hours; and molecular testing, $224,596 and 343 hours.
Conclusions.
The CDC screening protocol appeared to be the least expensive perirectal screening method. However, expense must be weighed against a lower sensitivity and extra labor needed for additional work-up of non-CPE isolates. The molecular test has the shortest turnaround time but the greatest expense.
The first experimental measurements of intense (${\sim }7\times 10^{19}~ {\rm W}~ {\rm cm}^{-2}$) laser-driven terahertz (THz) radiation from a solid target which is preheated by an intense pulse of laser-accelerated protons is reported. The total energy of the THz radiation is found to decrease by approximately a factor of 2 compared to a cold target reference. This is attributed to an increase in the scale length of the preformed plasma, driven by proton heating, at the front surface of the target, where the THz radiation is generated. The results show the importance of controlling the preplasma scale length for THz production.
Improving the interface between primary care and mental health services is a key target in current healthcare policy in Ireland. This study examines the content of referrals from primary care to a community mental health service for apparent depression.
Method
We retrospectively reviewed the clinical records of 100 patients with depression who consecutively attended a specialist mental health service in Ireland's midwest region. Records were reviewed for demographic and clinical information provided by the doctor at the time of referral, subsequent service engagement, diagnosis and treatment initiated.
Results
There was considerable variation in the content and presentation of information contained in referral letters. Eleven per cent used structured HSE mental health referral forms. Seventy-six per cent of referrals contained clear information regarding name, address, symptoms and treatment previously initiated. Specifically, low mood, biological symptoms of depression and illness severity were documented in 43%, 34% and 27%, respectively. Suicide risk was documented in 20%. More detail was significantly associated with more severe illness. At initial specialist assessment, 71% had commenced antidepressant treatment, with 11% having received an adequate trial of a first antidepressant and 3% an adequate trial of two antidepressants. Two-thirds were diagnosed with mild/moderate depression. Initiation of antidepressant treatment was linked to subsequent diagnosis of depressive illness by mental health services (p < 0.001).
Conclusions
Our findings indicate variable referral practices from general practice to mental health in our region. Most referrals were for mild to moderate depression. Poor access to psychological services locally may be a key factor in this phenomenon.
We evaluated 222 hospitalized patients whose clinical isolates were tested using standard methods and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF). MALDI-TOF could have reduced time to appropriate therapy for 28.8% and 44.6% patients based on the treating physician's choices and stewardship team recommendations, respectively. Clinicians should be aware of scenarios in which MALDI-TOF can optimize antibiotic therapy.
The scaling of the flux and maximum energy of laser-driven sheath-accelerated protons has been investigated as a function of laser pulse energy in the range of 15–380 mJ at intensities of 1016–1018 W/cm2. The pulse duration and target thickness were fixed at 40 fs and 25 nm, respectively, while the laser focal spot size and drive energy were varied. Our results indicate that while the maximum proton energy is dependent on the laser energy and laser spot diameter, the proton flux is primarily related to the laser pulse energy under the conditions studied here. Our measurements show that increasing the laser energy by an order of magnitude results in a more than 500-fold increase in the observed proton flux. Whereas, an order of magnitude increase in the laser intensity generated by decreasing the laser focal spot size, at constant laser energy, gives rise to less than a tenfold increase in observed proton flux.