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Coordinated specialty care (CSC) is widely accepted as an evidence-based treatment for first episode psychosis (FEP). The NAVIGATE intervention from the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study is a CSC intervention which offers a suite of evidence-based treatments shown to improve engagement and clinical outcomes, especially in those with shorter duration of untreated psychosis (DUP). Coincident with the publication of this study, legislation was passed by the United States Congress in 2014–15 to fund CSC for FEP via a Substance Abuse and Mental Health Services Administration (SAMHSA) block grant set-aside for each state. In Michigan (MI) the management of this grant was delegated to Network180, the community mental health authority in Kent County, with the goal of making CSC more widely available to the 10 million people in MI. Limited research describes the outcomes of implementation of CSC into community practices with no published accounts evaluating the use of the NAVIGATE intervention in a naturalistic setting. We describe the outcomes of NAVIGATE implementation in the state of MI.
In 2014, 3 centers in MI were selected and trained to provide NAVIGATE CSC for FEP. In 2016 a 4th center was added, and 2 existing centers were expanded to provide additional access to NAVIGATE. Inclusion: age 18–31, served in 1 of 4 FEP centers in MI. Data collection began in 2015 for basic demographics, global illness (CGI q3 mo), hospital/ED use and work/school (SURF q3 mo) and was expanded in 2016 to include further demographics, diagnosis, DUP, vital signs; and in 2018 for clinical symptoms with the modified Colorado Symptom Inventory (mCSI q6 mo), reported via an online portal. This analysis used data until 12/31/19. Mixed effects models adjusted by age, sex and race were used to account for correlated data within patients.
N=283 had useable demographic information and were included in the analysis. Age at enrollment was 21.6 ± 3.0 yrs; 74.2% male; 53.4% Caucasian, 34.6% African American; 12.9 ± 1.7 yrs of education (N=195). 18 mo retention was 67% with no difference by sex or race. CGI scores decreased 20% from baseline (BL) to 18 mo (BL=3.5, N=134; 15–18 mo=2.8, N=60). Service utilization via the SURF was measured at BL (N=172) and 18 mo (N=72): psychiatric hospitalizations occurred in 37% at BL and 6% at 18 mo (p<0.01); ER visits occurred in 40% at BL and 13% at 18 mo (p<0.01). 44% were working or in school at BL and 68% at 18 mo (p<0.01). 21% were on antipsychotics (AP) at BL (N=178) and 85% at 18 mo (N=13) with 8% and 54% on long acting injectable-AP at BL and 18 mo, respectively. Limitations include missing data and lack of a control group.
The implementation of the NAVIGATE CSC program for FEP in MI resulted in meaningful clinical improvement for enrollees. Further support could make this evidence-based intervention available to more people with FEP.
Supported by funds from the SAMHSA Medicaid State Block Grant set-aside awarded to Network180 (Achtyes, Kempema). The funders had no role in the design of the study, the analysis or the decision to publish the results.
Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p < 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p < 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p < 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p < 0.01). PIA time at SITE1 was decreased by 15 min vs control (p < 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p < 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.
The existence of a frontotemporal dementia phenocopy (phFTD) syndrome remains controversial. Opinions differ on whether the phenocopy presentation represents the neuropsychological manifestation of a mid-life decompensation in vulnerable pre-morbid personalities or an indolent prodrome of behavioral-variant FTD (bvFTD). Literature on this topic is sparse and clinicians and patients have little guidance around prognosis and management.
To describe the demographic, neuropsychological and biomarker profiles of a case series of phFTD patients, attending the memory clinic and review relevant literature.
Retrospective review of all cases diagnosed with phFTD.
Eleven cases were identified (male = 9, female = 2). Mean age 55.8 years. Subjective complaints comprised memory and language difficulties. Collateral reports described apathy, aggression, impulsivity, disinhibition, hyperorality. Function was relatively preserved though motivation or supervision for higher-level tasks was sometimes required. All had non-neurodegenerative MRI and PET scans. Neuropsychological test (NPT) findings predominantly showed executive dysfunction and fluency impairment. A total of 3/11 had non-amnestic memory impairment. Follow-up imaging and NPT were invariably unchanged; 1/11 had a pre-morbid psychiatric diagnosis; 5/11 had unusual personality traits pre-morbidly. Major psychosocial stressors were documented in 7/11. Management consisted of psychosocial interventions to support function and interpersonal relationships.
The literature describes the phFTD syndrome as predominantly affecting males though we include 2 females who meet the criteria. In keeping with our findings, personality traits and psychosocial stressors may be more common in phFTD than bvFTD. More severe symptoms, memory impairment at presentation and C9ORF72 gene mutation may predict eventual progression. Those who do not progress have minimal long-term functional impairment though behavioral symptoms persist.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The aim of this study was to test the hypotheses that differences in residual feed intake (RFI) of beef steers are related to diet sorting, diet nutrient composition, energy intake and apparent digestibility. To phenotype steers for RFI, 69 weaned Angus × Hereford steers were fed individually for 56 days. A finishing diet was fed twice daily on an ad libitum basis to maintain approximately 0.5 to 1.0 kg refusals. Diet offered and refused was measured daily, and DM intakes (DMI) were calculated by difference. Body weights were recorded at 14-day intervals following an 18-h solid feed withdrawal. The residual feed intake was determined as the residual of the regression of DMI versus mid-test metabolic BW (BW0.75) and average daily gain (ADG). Particle size distributions of diet and refusals were determined using the Penn State Particle Separator to quantify diet sorting. Sampling of diet, refusals and feces were repeated in four sampling periods which occurred during weeks 2, 4, 6 and 8 of the study. Particle size distributions of refusals and diet were analyzed in weeks 2, 4 and 6, and sampling for chemical analysis of refusals and feces occurred in all four periods. Indigestible neutral detergent fiber (288 h in situ) was used as an internal marker of apparent digestibility. We conclude that preference for the intakes of particles > 19 mm and 4 to 8 mm were negatively correlated to RFI and ADG, respectively. Although steers did sort to consume a different diet composition than offered, diet sorting did not impact intake energy, digestible energy or DM digestibility.
Provision of critical care and resuscitation was not practical during early missions into space. Given likely advancements in commercial spaceflight and increased human presence in low Earth orbit (LEO) in the coming decades, development of these capabilities should be considered as the likelihood of emergent medical evacuation increases.
PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration (NASA) Technical Server, and Defense Technical Information Center were searched from inception to December 2018. Articles specifically addressing critical care and resuscitation during emergency medical evacuation from LEO were selected. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.
The search resulted in 109 articles included in the review with a total of 2,177 subjects. There were two Level I systematic reviews, 33 Level II prospective studies with 647 subjects, seven Level III retrospective studies with 1,455 subjects, and two Level IV case series with four subjects. There were two Level V case reports and 63 pertinent review articles.
The development of a medical evacuation capability is an important consideration for future missions. This review revealed potential hurdles in the design of a dedicated LEO evacuation spacecraft. The ability to provide critical care and resuscitation during transport is likely to be limited by mass, volume, cost, and re-entry forces. Stabilization and treatment of the patient should be performed prior to departure, if possible, and emphasis should be on a rapid and safe return to Earth for definitive care.
Extensively drug-resistant (XDR) tuberculosis (TB) poses a threat to public health due to its complicated, expensive and often unsuccessful treatment. A cluster of three XDR TB cases was detected among foreign medical students of a Romanian university. The contact investigations included tuberculin skin testing or interferon gamma release assay, chest X-ray, sputum smear microscopy, culture, drug susceptibility testing, genotyping and whole-genome sequencing (WGS), and were addressed to students, personnel of the university, family members or other close contacts of the cases. These investigations increased the total number of cases to seven. All confirmed cases shared a very similar WGS profile. Two more cases were epidemiologically linked, but no laboratory confirmation exists. Despite all the efforts done, the source of the outbreak was not identified, but the transmission was controlled. The investigation was conducted by a team including epidemiologists and microbiologists from five countries (Finland, Israel, Romania, Sweden and the UK) and from the European Centre for Disease Prevention and Control. Our report shows how countries can collaborate to control the spread of XDR TB by exchanging information about cases and their contacts to enable identification of additional cases and transmission and to perform the source investigation.
Many novel therapeutic options for depression exist that are either not mentioned in clinical guidelines or recommended only for use in highly specialist services. The challenge faced by clinicians is when it might be appropriate to consider such ‘non-standard’ interventions. This analysis proposes a framework to aid this decision.
Declaration of interest
In the past 3 years R.H.M.W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, LivaNova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. D.M.B.C. has received fees from LivaNova for attending an advisory board. In the past 3 years A.J.C. has received fees for lecturing from Astra Zeneca and Lundbeck; fees for consulting from LivaNova, Janssen and Allergan; and research grant support from Lundbeck.
In the past 3 years A.C. has received fees for lecturing from pharmaceutical companies namely Lundbeck and Sunovion. In the past 3 years A.L.M. has received support for attending seminars and fees for consultancy work (including advisory board) from Medtronic Inc and LivaNova. R.M. holds joint research grants with a number of digital companies that investigate devices for depression including Alpha-stim, Big White Wall, P1vital, Intel, Johnson and Johnson and Lundbeck through his mindTech and CLAHRC EM roles. M.S. is an associate at Blueriver Consulting providing intelligence to NHS organisations, pharmaceutical and devices companies. He has received honoraria for presentations and advisory boards with Lundbeck, Eli Lilly, URGO, AstraZeneca, Phillips and Sanofi and holds shares in Johnson and Johnson. In the past 3 years P.R.A.S. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending an advisory board) from life sciences companies including Corcept Therapeutics, Indivior and LivaNova. In the past 3 years P.S.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has received funding for investigator initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth.
Hippocampal dysfunction is considered central to many neurobiological models of schizophrenia, yet there are few longitudinal in vivo neuroimaging studies that have investigated the relationship between antipsychotic treatment and morphologic changes within specific hippocampal subregions among patients with psychosis.
A total of 29 patients experiencing a first episode of psychosis with little or no prior antipsychotic exposure received structural neuroimaging examinations at illness onset and then following 12 weeks of treatment with either risperidone or aripiprazole in a double-blind randomized clinical trial. In addition, 29 healthy volunteers received structural neuroimaging examinations at baseline and 12-week time points. We manually delineated six hippocampal subregions [i.e. anterior cornu ammonis (CA) 1–3, posterior CA1–3, subiculum, dentate gyrus/CA4, entorhinal cortex, and fimbria] from 3T magnetic resonance images using an established method with high inter- and intra-rater reliability.
Following antipsychotic treatment patients demonstrated significant reductions in dentate gyrus/CA4 volume and increases in subiculum volume. Healthy volunteers demonstrated non-significant volumetric changes in these subregions across the two time points. We observed a significant quadratic (i.e. inverted U) association between changes in dentate gyrus/CA4 volume and cumulative antipsychotic dosage between the scans.
This study provides the first evidence to our knowledge regarding longitudinal in vivo volumetric changes within specific hippocampal subregions in patients with psychosis following antipsychotic treatment. The finding of a non-linear relationship between changes in dentate gyrus/CA4 subregion volume and antipsychotic exposure may provide new avenues into understanding dosing strategies for therapeutic interventions relevant to neurobiological models of hippocampal dysfunction in psychosis.
Prior studies have suggested a relationship between atopy and mental health, although methodological barriers have limited the generalizability of these findings. The objective of this study was to investigate the relationship between early-life atopy and vulnerability to mental health problems among youth in the community.
Data were drawn from the Raine Study (N = 2868), a population-based birth cohort study in Western Australia. Logistic regression and generalized estimating equations were used to examine the relationship between atopy at ages 1–5 years [using parent report and objective biological confirmation (sera IgE)], and the range of internalizing and externalizing mental health problems at ages 5–17 years.
Atopy appears to be associated with increased vulnerability to affective and anxiety problems, compared to youth without atopy. These associations remained significant after adjusting for a range of potential confounders. No relationship was evident between atopy and attention deficit hyperactivity disorder or externalizing problems.
Findings are the first linking atopy (measured by both parent report and objective verification) with increased vulnerability to affective and anxiety problems. Therefore, replication is required. If replicated, future research aimed at understanding the possible biological and/or social and environmental pathways underlying these links is needed. Such information could shed light on shared pathways that could lead to more effective treatments for both atopy and internalizing mental health problems.
We present a catalogue of 668 major metre-wavelength radio events. The data was collected from dynamic spectra (taken at Dapto, N.S.W. until 1966 and at Culgoora, N.S.W. thereafter) by means of a radio spectrograph, which records the intensity of radio emission as a function of both frequency and time. A description of the major types of metre-wavelength phenomena can be found in Wild et al. (1963), Kundu (1965), Wild and Smerd (1972) and Kruger (1979), and details of the radio spectrograph in Sheridan (1963, 1967) and Labrum (1972).
Photoelectric B and V light curves and high dispersion spectroscopic observations were obtained in 1985 February for the rapidly rotating spotted star HD 36705. The visual light range was about 0.09 magnitude, with a well correlated B-V change of approximately 0.04 magnitude, the star being redder when faintest. There is evidence for a broadband flare of ~0.05 magnitude in V and 0.07 magnitude in B. This occurred near maximum light.
Spectroscopic observations show a variation in the equivalent width of the Ca K emission by a factor of about two in antiphase with the photometric variations, maximum emission corresponding to minimum brightness. This is probably due to bright plages and enhanced chromospheric heating associated with the photospheric starspots.
High dispersion, high signal-to-noise spectroscopic observations confirm the presence of lithium λ 6708 as reported by Rucinski (1982, 1985).
Several interpretations of the nature of HD 36705 are discussed; however at present none is completely satisfactory and further observations are required. As the star is probably at less than 100 pc, a parallax determination may be possible, and could help answer many of the questions concerning HD 36705.
Multi-frequency observations with the Culgoora radioheliograph (Wild 1967); Sheridan et al. 1973) of five solar bursts of spectral type II (Wild et al. 1954) have now been analysed. The spectra of all five bursts show split-banded harmonic structure. Each type II burst passed through only two of the heliograph’s three observing frequencies (160, 80 and 43.25 MHz). Relationships between the positions, sizes and brightness temperatures of the various sources in each burst are presented and summarized; their implications for the propagation of shock waves and radio waves in the solar corona are briefly discussed.
We present observations of Hα and CaII resonance lines in 4 stars having Hα features which place them intermediately between the non-(e) and (e) classifications of dK/dM stars. There is considerable variety in the shape of the Hα line, presumably due in part to differences in rotation rates. As expected, the energy fluxes in the CaII emission lines lie between those typical of non-(e) and (e) stars. There is some evidence (especially from the binary Gl 876A) that the energy fluxes in the CaII and Hα emission lines do not vary from star to star according to a simple proportionality. An intriguing result is the apparent detection of spatially displaced chromospheric emission in Gl 907.1 and Gl 890.
In an attempt to determine whether the lithium Une at 6707 Å cornes mainly from the quiet photosphere or from the cooler spots on spotted active stars we have measured Une équivalent widths due to Li and also due to Cal at 6717 Å at various rotation phases on three fast rotating stars, AB Doradus, PZ Telescopium and V 1005 Orionis. The results for AB Dor and PZ Tel show there might be some small rotational modulation which can be linked to the best estimate of the spot position from the available photometry. This moduation is less than that expected on the basis of Giampapa’s work on sunspot spectra. The Li and Cal line equivalent widths were found to anticorrelate.
We present an overview of the survey for radio emission from active stars that has been in progress for the last six years using the observatories at Fleurs, Molonglo, Parkes and Tidbinbilla. The role of complementary optical observations at the Anglo-Australian Observatory, Mount Burnett, Mount Stromlo and Siding Spring Observatories and Mount Tamborine are also outlined. We describe the different types of star that have been included in our survey and discuss some of the problems in making the radio observations.
During routine monitoring of active-chromosphere stars in August 1987 an intense radio flare on the FK Comae star HD 32918 was detected by the Parkes radiotelescope. Other observatories were notified, enabling data to be collected at 843 MHz, 1.4 GHz, 8.4 GHz and optical frequencies.
The flare at radio frequencies was largely similar to a previous event on this star, reaching a peak radio power of 5 < 1012 W Hz−1 at 8.4 GHz. During the flare the spectrum varied as ∼ v1.4 and later flattened as the flare progressed. Compared to the previous flare, circular polarization was higher.
Ca II and Hα optical spectra taken at the AAO 3.9-metre telescope show the star to have a highly active chromosphere and a strong wind, with a terminal velocity of ≈230 km s−1. While much of this activity appears to be long lived, there is good evidence for an increase in the strength of the chromospheric lines during the radio flare event.
Ultracompact H II regions are small, dense regions of ionised gas surrounding high-mass stars which are still embedded in their natal molecular clouds. A survey of such regions has been commenced in an attempt to improve our understanding of the processes of high-mass star formation. The initial stages of the survey have involved selection of likely candidates from the IRAS Point Source Catalogue, correlation with radio continuum emission at 4·85 GHz and subsequent observations of methanol maser emission at 6·668 GHz. Preliminary results of the methanol maser survey are given.
The star AB Dor (HD 36705) was first identified as an interesting object because of its strong Call H and K emission features (Bidelman and MacConnell 1973; Houk and Cowley 1975). It has a spectral class of G8 and appears to be a single star, since no radial velocity variations have thus far been detected, despite numerous attempts (e.g. Collier 1982; Innis et al. 1985a). Probably the most unusual and important feature about the star is its rapid rotational velocity, with a Vsini of 80 km s-1 (Collier 1982), which is more than 20 times that of a normal star of similar spectral class. AB Dor also shows a substantial photometric wave, commonly interpreted as indicating the presence of starspots. This wave has a typical amplitude of 0.05 to 0.15 magnitudes in V and a period of 0.514 days (e.g. Innis et al. 1985b). Combining this with the Vsini value gives a lower limit of 0.76 R⊙ for the stellar radius, while assuming the radius of a normal G8 dwarf yields an axial inclination of 60° ± 10°.