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Acute clinical deterioration in hospital inpatients can be caused by a range of factors including dementia, delirium, substance withdrawal and psychiatric disturbance, creating challenges in diagnosis, often requiring a management plan with input from multiple disciplines. Staff forums and broader literature have confirmed that healthcare staff working in non-mental health settings, may not be as skilled in recognising and managing early signs of emerging and/or escalating clinical agitation. The BoC RRT is a consultation service within the Division of Medicine and CL Psychiatry. Staffed by Medical Registrars and Mental Health Nurses, the collaboration provides a unique healthcare response to acute general wards. The BoC RRT has been implemented to address the rising number of incidences whereby staff and patient safety are compromised. Using evidence-based skills the team aimed to: respond to episodes of clinical agitation that require an internal security response, assist ward referrals by exploring biopsychosocial contributants to behaviour, develop individual patient support plans and review and reduce restrictive intervention practices.
Objectives
To determine if the rapid response model has influenced:
- The impact on staff/patient safety
- Frequency of emergency responses for aggression
- Frequency of restrictive intervention use
Methods
This project was approved as a quality assurance project (QA2022018). The patients within scope of the BoC RRT include inpatients in medical and surgical wards. It excludes patients in Emergency Departments, mental health units, outpatient clinics, and visitors. The evaluation of the pilot has used a PDSA (Plan, Do, Study, Act) cycle when implementing new improvements. A mixed methods approach explored the impact of the BoC RRT. Staff consultation will identify challenges in responding to scenarios whereby there is risk of harm to staff and patients. Staff feedback and the emergency response data was monitored.
Results
In 2021, there was approx. 720 code greys per month, requiring a security response. Since the implementation of BoC RRT, these numbers have reduced to 527. Reviewing restrictive intrvention practices has identified areas for policy review and need for education. Staff consultation found that nurses were confident caring for those patients exhibiting clinical agitation associated with delirium and dementia. However, caring for people with mental health or substance use disorders were more challenging.
Conclusions
These interim results indicate that BoC RRT has been generally well received by clinical staff. The decline in code grey responses indicates that it is likely having a positive impact in early identification and management of clinical agitation for hospital inpatients. There is support for this response model to continue beyond the pilot phase and further area for research.
Background: Rituximab is a B-cell-depleting monoclonal antibody whose off-label use is funded in Alberta by the Short-Term Exceptional Drug Therapy (STEDT) program. This study describes the use of rituximab for pediatric central nervous system (CNS) inflammatory disorders in Alberta. Methods: Rituximab applications for CNS inflammatory indications in patients < 18 years of age were identified from the STEDT database between January 1, 2012 – December 31, 2019. Patient information was linked to other provincial datasets, including the Discharge Abstract Database, Pharmaceutical Information Network, and provincial laboratory data. Analysis was descriptive. Results: 51 unique rituximab applications were identified, of which 50 were approved. New applications increased from one in 2012 to a high of 12 in 2018. The most common indication was autoimmune encephalitis (other than anti-NMDA receptor encephalitis; n=20, 39%). Most children were approved for a two-dose (n=33, 66%) or four-dose (n=16, 32%) induction regimen. Physician-reported outcomes were available for 24 patients, of whom 14 (58%) were felt to have fully met outcome targets. Conclusions: The use of rituximab for pediatric CNS inflammatory disorders has increased, particularly for the indication of autoimmune encephalitis. This study identified significant heterogeneity in dosing practices and laboratory monitoring, as well as regional disparities in use.
Adolescents with substance use disorders (SUDs) exhibit high rates of comorbid psychological problems. This study aimed to examine the impact of an outpatient substance use treatment programme upon the psychological wellbeing of adolescents.
Methods:
A prospective study was carried out examining psychological symptoms in a group of adolescents attending the Youth Drug and Alcohol (YoDA) Addiction Service in Dublin. Participants were treated with evidenced based psychological models such as cognitive behavioural therapy, motivational interviewing and systemic family therapy. The Becks Youth Inventory was utilised to assess psychological symptoms at treatment entry and repeated three months later at follow up.
Results:
Among 36 adolescents who were included in this study, poly-substance misuse was the norm. Almost three-quarter had a cannabis use disorder (CUD). There were significant reductions in mean subscale scores of depression (56.0 to 50.8, p = 0.003), anger (55.2 to 49.5, p < 0.001) and disruptive behaviour (61.6 to 56.5, p = 0.002) at follow up. Although there wasn’t a statistically significant reduction in mean scores for anxiety, we observed a significant proportion of participants (p = 0.008) improving and moving out of a moderate to severe symptom range when examined by category. This was also the case for self-concept (p = 0.04). Furthermore this study revealed a positive correlation between the reduction in days of cannabis use and reduction in depressive scores (Pearson correlation 0.49, p = 0.01) among those with a CUD.
Conclusion:
The findings indicate that substance use treatment for adolescents is associated with important psychological and behavioural improvements.
The equation of state of Fo90 hydrous ringwoodite has been measured using X-ray powder diffraction to 45 GPa at the GSECARS beam line at the Advanced Photon Source synchrotron at Argonne National Laboratory. The sample was synthesized at 1400°C and 20 GPa in the 5000 ton multi anvil press at Bayerisches Geoinstitut in Bayreuth. The sample has the formula Mg1.70Fe0.192+ Fe0.023+H0.13- Si1.00O4 as determined by electron microprobe, Fourier transform infrared and Mössbauer spectroscopies, and contains ~0.79% H2O by weight. Compression of the sample had been been measured previously to 11 GPa by single crystal X-ray diffraction. A third-order Birch-Murnaghan equation of state fit to all of the data gives V0 = 530.49±0.07 Å3, K0 = 174.6±2.7 GPa and K' = 6.2±0.6. The effect of 1% H incorporation in the structure on the bulk modulus is large and roughly equivalent to an increase in the temperature of ∼600°C at low pressure. The large value of K' indicates significant stiffening of the sample with pressure so that the effect of hydration decreases with pressure.
Background: Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, spinal cord injury, or multiple sclerosis. These syndromes are much less common than peripheral etiologies, with less known regarding optimal treatment. The objective of this study was to determine the long-term clinical effectiveness of the management of central relative to peripheral neuropathic pain at tertiary pain centers. Methods: Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified from a prospective observational cohort from seven Canadian tertiary centers. Data regarding patient -characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome was the composite of reduced average pain intensity and pain interference. Secondary outcomes included assessments of function, mood, and quality-of-life. Results: At 12-month follow-up, 13.5% (95%CI,5.6-25.8) of patients achieved ≥30% reduction in pain, whereas 38.5% (95%CI,25.3-53.0) achieved a ≥1 point reduction in pain interference; 9.6% (95%CI,3.2-21.0) of patients achieving both these measures. Patients with peripheral neuropathic pain were more likely to achieve this primary outcome at 12-months (25.3% of patients; 95%CI,21.4-29.5) (p=.012). Conclusions: Patients with central neuropathic pain were less likely to achieve a meaningful improvement in pain and function compared to patients with peripheral neuropathic pain at 12-month follow-up.
Fertilization success will determine the rate at which a population can expand and is especially important when considering small, establishing or enduring communities. Introduced species frequently fail to establish reproductively functional populations due to strong Allee effects associated with low densities. The native European oyster, Ostrea edulis broods its fertilized eggs in the pallial cavity for a period of 8–10 days before releasing the larvae. It is considered a partial broadcast spawner and was used as a model species to assess the importance of Allee effects such as inter-individual distance on reproductive success. Distances between individual oysters within test plots in areas of known oyster density were used in conjunction with standardized brood size (n larvae g−1 total wet weight) to assess fertilization success. A significant, positive relationship was observed between brood size and oyster density. Oysters with a nearest neighbour ≤1.5 m were found to brood significantly more larvae than individuals with nearest neighbours ≥1.5 m. Therefore, high density sites need to be maintained to ensure the recovery and enhancement of this OSPAR Convention recognized species in decline.
Background: Painful diabetic neuropathy (PDN) is a frequent complication of diabetes mellitus. Current treatment recommendations are based on short-term trials, generally of duration ≤3 months. Limited data are available on the long-term outcomes of this chronic disease. This study aims to determine the long-term clinical effectiveness of the management of chronic PDN at tertiary pain centres. Methods: From a prospective observational cohort study of patients with chronic neuropathic non-cancer pain recruited from seven Canadian tertiary pain centres, 43 patients diagnosed with PDN were identified for analysis. Data were collected according to Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) guidelines including Brief Pain Inventory (BPI). Results: At 12-month follow-up, 37.2% of 43 patients achieved pain reduction of ≥30%, 51.2% achieved functional improvement with a reduction of ≥1 on the Pain Interference Scale (0-10, BPI), and 30.2% (95% CI: 17.2% to 46.1%) had achieved both these measures. Symptom management included at least 2 medication classes in 55.3%, and 3 medications classes (opioids, antidepressants, anticonvulsants) in 25.5%. Conclusions: A sizable minority of patients being managed for PDN in a tertiary care setting achieve meaningful improvement. Polypharmacy, including analgesic antidepressants, anticonvulsants and opioids, is often necessary to attain symptom management.
Social context has a major influence on the detection and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas, particularly where gang culture, community violence, normalisation of drug use and repetitive maladaptive family structures prevail. This paper aims to examine how social context influences the development, identification and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas from the perspectives of health care workers.
Method
Semi-structured interviews were conducted with health care workers (n=37) from clinical settings including: primary care, secondary care and community agencies and analysed thematically using Bronfenbrenner’s Ecological Theory to guide analysis.
Results
Health care workers’ engagement with young people was influenced by the multilevel ecological systems within the individual’s social context which included: the young person’s immediate environment/‘microsystem’ (e.g., family relationships), personal relationships in the ‘mesosystem’ (e.g., peer and school relationships), external factors in the young person’s local area context/‘exosystem’ (e.g., drug culture and criminality) and wider societal aspects in the ‘macrosystem’ (e.g., mental health policy, health care inequalities and stigma).
Conclusions
In socioeconomically disadvantaged urban areas, social context, specifically the micro-, meso-, exo-, and macro-system impact both on the young person’s experience of mental health or substance use problems and services, which endeavour to address these problems. Interventions that effectively identify and treat these problems should reflect the additional challenges posed by such settings.
The aim of the current study was to gain insight into the process of initiation and progression to problematic use among young people who reach clinically significant levels of substance use requiring treatment.
Method
Twenty young people, aged between 15 and 19 years from two different drug treatment centres in Ireland were interviewed regarding their views on their pathway into substance use, their progress to more problematic use, their perception of their parents’ role, if any, in their trajectory and their typical coping style before treatment. Content analysis was conducted on the resulting narratives.
Results
The use of substances to cope with life stressors emerged as a prominent theme at initial and problematic stages of use. Multiple maladaptive coping approaches were reported. Both direct and indirect influences from parents in their substance use problem were cited. However, some participants reported that parents had no causal role in their substance use trajectory, in particular regarding mothers.
Conclusions
The current findings suggest that substance misuse is a multi-determined problem and a number of intervention strategies are suggested to delay onset and related harms associated with adolescent substance use.
To investigate prognostic indicators in an aggressive Crooke's cell adenoma of the pituitary.
Methods:
The surgically removed tumor was studied by histology, immunohistochemistry and transmission electron microscopy.
Results:
An aggressive invasive sellar tumor removed by repeated surgeries from a 43-year-old woman with pituitary related Cushing's disease was classified as a Crooke's cell adenoma of the pituitary. The application of several cell proliferation markers confirmed the aggressive nature of the tumor.
Conclusions:
The investigation of the present case provides additional evidence that pituitary Crooke's cell adenomas may possess aggressive behavior.
Having observed variation in the breadth of surgeons' fingers whilst they are placing the incision for submandibular gland surgery, we aimed to examine this technique of incision siting, quantify the differences in fingerbreadths and consider any consequences of variability.
Methods:
Surgeons trained in salivary gland surgery were questioned on their method of incision placement for submandibular gland surgery. The breadth of index and middle fingers were subsequently measured using Vernier calipers.
Results:
The majority of surgeons use a measure of two fingerbreadths below the mandible in planning their approach to the submandibular gland. There is a significant difference in the size of surgeons' fingers, particularly between men and women (mean, 4.2 cm vs 3.6 cm).
Conclusion:
Fingerbreadth measurements are somewhat arbitrary, with significant inter-surgeon variability. However, based on the results of cadaveric studies, the findings indicate that the technique is safe for marking the incision in submandibular surgery.
General Practitioner consultation rates for influenza-like illness (ILI) are monitored through several geographically distinct schemes in the UK, providing early warning to government and health services of community circulation and intensity of activity each winter. Following on from the 2009 pandemic, there has been a harmonization initiative to allow comparison across the distinct existing surveillance schemes each season. The moving epidemic method (MEM), proposed by the European Centre for Disease Prevention and Control for standardizing reporting of ILI rates, was piloted in 2011/12 and 2012/13 along with the previously proposed UK method of empirical percentiles. The MEM resulted in thresholds that were lower than traditional thresholds but more appropriate as indicators of the start of influenza virus circulation. The intensity of the influenza season assessed with the MEM was similar to that reported through the percentile approach. The MEM pre-epidemic threshold has now been adopted for reporting by each country of the UK. Further work will continue to assess intensity of activity and apply standardized methods to other influenza-related data sources.
Cystic fibrosis (CF) is an inherited childhood-onset life-shortening disease. It is characterized by increased respiratory production, leading to airway obstruction, chronic lung infection and inflammatory reactions. The most common bacteria causing persisting infections in people with CF is Pseudomonas aeruginosa. Superparamagnetic Fe3O4 iron oxide nanoparticles (NPs) conjugated to the antibiotic (tobramycin), guided by a gradient of the magnetic field or subjected to an oscillating magnetic field, show promise in improving the drug delivery across the mucus and P. aeruginosa biofilm to the bacteria. The question remains whether tobramycin needs to be released from the NPs after the penetration of the mucus barrier in order to act upon the pathogenic bacteria. We used a zero-length 1-ethyl-3-[3-dimethylaminopropyl] carbodiimide hydrochloride (EDC) crosslinking agent to couple tobramycin, via its amine groups, to the carboxyl groups on Fe3O4 NPs capped with citric acid. The therapeutic efficiency of Fe3O4 NPs attached to the drug versus that of the free drug was investigated in P. aeruginosa culture.