Trends in Mental Health Presentations to a Paediatric Emergency Department.

Aims This study aimed to analyse trends in mental health presentations to the Emergency Department (ED), which anecdotally had increased over the past decade. Methods The ED's electronic 'Symphony' system was used to identify the annual number of presentations categorised as having a mental health complaint from 2006-2017. A detailed analysis was performed on presentations over a one-year period. Results The number of presentations increased from 69 in 2006 to a peak of 432 in 2016 (526% increase). The overall admission rate was 33.3%(n=99), while 52.5%(n=156) of presentations occurred outside of standard working hours. Similar increases were documented by other ED's worldwide, and the WHO estimate that neuropsychiatric disorders will become one of the top five causes of morbidity, mortality and disability among children by 2020. Conclusion With the number of mental health presentations dramatically increasing, carefully designed and integrated strategies are required to pro-actively tackle this growing epidemic.

Anorexia nervosa (AN) in inpatients at a children's hospital (2005-2011).

AN is a serious mental illness best treated in the community. Those with critically low weight require hospitalisation. There is little published research on AN in Ireland. The aim of this audit was to evaluate the Irish experience. The mean age on admission was 13.5 yrs which is 6 mo earlier than 2002 figures. Boys represented 6/20 (30%) of admissions. On admission girls were more underweight than boys (0.4th centile V 9th centile for BMI). This was despite girls presenting to hospital sooner than boys post onset of symptoms. Aside from low weight, over-exercising and food restricting were the most common presenting features. Inpatient weight restoration is successful with a mean weekly weight gain of 930g which is within the recommended range of 500-1000g/wk. Mean hospital stay was 38 days.

A megavoltage scatter correction technique for cone-beam CT images acquired during VMAT delivery.

Kilovoltage cone-beam CT (kV CBCT) can be acquired during the delivery of volumetric modulated arc therapy (VMAT), in order to obtain an image of the patient during treatment. However, the quality of such CBCTs is degraded by megavoltage (MV) scatter from the treatment beam onto the imaging panel. The objective of this paper is to introduce a novel MV scatter correction method for simultaneous CBCT during VMAT, and to investigate its effectiveness when compared to other techniques. The correction requires the acquisition of a separate set of images taken during VMAT delivery, while the kV beam is off. These images--which contain only the MV scatter contribution on the imaging panel--are then used to correct the corresponding kV/MV projections. To test this method, CBCTs were taken of an image quality phantom during VMAT delivery and measurements of contrast to noise ratio were made. Additionally, the correction was applied to the datasets of three VMAT prostate patients, who also received simultaneous CBCTs. The clinical image quality was assessed using a validated scoring system, comparing standard CBCTs to the uncorrected simultaneous CBCTs and a variety of correction methods. Results show that the correction is able to recover some of the low and high-contrast signal to noise ratio lost due to MV scatter. From the patient study, the corrected CBCT scored significantly higher than the uncorrected images in terms of the ability to identify the boundary between the prostate and surrounding soft tissue. In summary, a simple MV scatter correction method has been developed and, using both phantom and patient data, is shown to improve the image quality of simultaneous CBCTs taken during VMAT delivery.

The use of a realistic VMAT delivery emulator to optimize dynamic machine parameters for improved treatment efficiency.

The delivery of volumetric modulated arc therapy (VMAT) requires the simultaneous movement of the linear accelerator gantry, multi-leaf collimators and jaws while the dose rate is varied. In this study, a VMAT delivery emulator was developed to accurately predict the characteristics of a given treatment plan, incorporating realistic parameters for gantry inertia and the variation in leaf speed with respect to gravity. The emulator was used to assess the impact of dynamic machine parameters on the delivery efficiency, using a set of prostate and head and neck VMAT plans. Initially, assuming a VMAT system with fixed dose rate bins, the allowable leaf and jaw speeds were increased and a significant improvement in treatment time and average dose rate was observed. The software was then adapted to simulate a VMAT system with continuously varying dose rate, and the increase in delivery efficiency was quantified, along with the impact of an increased leaf and jaw speed. Finally, a set of optimal dynamic machine parameters was derived assuming an idealized scenario in which the treatment is delivered in a single arc at constant maximum gantry speed.

Best predictors of grayscale ultrasound combined with color Doppler in the diagnosis of retained products of conception.

OBJECTIVES: To determine the best predictors of the presence of retained products of conception (RPOC) on grayscale and color Doppler transvaginal sonographic examination. METHODS: This was a retrospective study of 91 consecutive patients who underwent transvaginal sonography (TVS) with color Doppler to evaluate for the presence of RPOC. The images of TVS studies were reviewed by two radiologists in consensus blinded to the final outcome. Data on a number of variables including endometrial measurable mass and focal increased color vascularity were collected as predictors of RPOC. The patients' ages ranged from 17 to 48 years (mean, 31.8 ± 6.8) and gestational age from 5 to 24 weeks (mean, 9.2 ± 3.8). Thirty-six were confirmed as RPOC by dilatation and curettage (D&C) and pathology. Fifty-five were considered negative, 9 based on D&C results and 46 on clinical grounds. RESULTS: Sensitivity, specificity, negative- and positive-predictive and accuracy values were 81% (CI: 68%-94%), 71% (CI: 59%-83%), 85% (CI: 74%-95%), 64% (CI: 50%-78%), and 75% (CI: 66%-84%) to detect RPOC when a mass was present. The corresponding numbers for the presence of focal color vascularity were 94% (CI: 87%-100%) (p = 0.07), 67% (CI: 55%-80%) (p > 0.05), 95% (CI: 88%-100%) (p = 0.1), 65% (CI: 52%-78%) (p > 0.05), and 78% (CI: 70%-87%) (p > 0.05). Of the patients with confirmed RPOC on pathology, five had focal increased vascularity and no massand none had a mass without focal increased vascularity. CONCLUSION: An area of focal increased vascularity with or without a mass is the best predictor of the presence of RPOC.

A VMAT planning solution for prostate patients using a commercial treatment planning system.

Volumetric modulated arc therapy (VMAT) is a rotational delivery technique which offers the potential of improved dose distributions and shorter treatment times when compared to fixed-beam intensity-modulated radiation therapy (IMRT). This note describes the use of an existing treatment planning system (Philips Pinnacle(3) v.8.0), supplemented by in-house software, to produce a single-arc VMAT prostate plan. While a number of planning systems for the Elekta VMAT platform are commercially available, the use of an in-house solution has allowed more detailed investigations of VMAT planning, as well as greater control over the optimization process. The solution presented here begins with a static step-and-shoot IMRT approach to provide initial segment shapes, which are then modified and sequenced into 60 equally spaced control points in a 360 degrees arc. Dose-volume histogram comparisons demonstrate that this VMAT planning method offers multiple dose level target coverage comparable to that from a standard IMRT approach. The VMAT plans also show superior sparing of critical structures such as the rectum and bladder. Delivery times are reduced with the VMAT method, and the results of dosimetric verification, resilience and repeatability tests indicate that the solution is robust.

Neither peripheral nerve input nor cortical NMDA receptor activity are necessary for recovery of a disrupted barrel pattern in rat somatosensory cortex.

Elevating cortical serotonin (5-HT) in rats from postnatal day (P-) 0 to P-6 by administering the monoamine oxidase (MAO(A)) inhibitor, clorgyline, produces a dose-dependent spectrum of effects on rat somatosensory organization, ranging from enlarged with indistinct septa to a complete lack of vibrissae-related patterns. However, if clorgyline treatment is stopped on P-6, a qualitatively and quantitatively normal vibrissae-related pattern of thalamocortical afferents appears in somatosensory cortex (S-I) on P-10. We employed high performance liquid chromatography (HPLC), infraorbital nerve (ION) transection, N-methyl-D-aspartate (NMDA) receptor blockade, 1,1'-dioctadecyl-3,3,3"3'-tetramethylindocarbocyanine perchlorate (DiI) labeling of thalamic afferents, and CO histochemistry to determine whether peripheral nerve input and/or cortical NMDA receptor activity were required for the recovery of vibrissae-related patterns in clorgyline-treated animals. Clorgyline administration from P-0 to P-6 produced a 1589.4+/-53.3% increase in cortical 5-HT over control animals on P-6 and a 268.8+/-6.3% elevation over controls at P-10. Postnatal day 6 pups had significantly altered vibrissae-related patterns in S-I following 6 days of clorgyline treatment but by P-10, the characteristic vibrissae-related patterns were restored. Neither transection of the ION nor application of the NMDA antagonist, DL-2-amino-5-phosphonovaleric acid (APV), to the cortices of P-6 pups that were treated with clorgyline from birth had any significant effect on the recovery of the vibrissae-related patterns by P-10. These results indicate that neither peripheral nerve input nor cortical NMDA receptor activity are necessary for the restoration of cortical vibrissae-related patterns in rats that have sustained transient elevations of 5-HT.

Validation of a noninvasive, real-time imaging technology using bioluminescent Escherichia coli in the neutropenic mouse thigh model of infection.

A noninvasive, real-time detection technology was validated for qualitative and quantitative antimicrobial treatment applications. The lux gene cluster of Photorhabdus luminescens was introduced into an Escherichia coli clinical isolate, EC14, on a multicopy plasmid. This bioluminescent reporter bacterium was used to study antimicrobial effects in vitro and in vivo, using the neutropenic-mouse thigh model of infection. Bioluminescence was monitored and measured in vitro and in vivo with an intensified charge-coupled device (ICCD) camera system, and these results were compared to viable-cell determinations made using conventional plate counting methods. Statistical analysis demonstrated that in the presence or absence of antimicrobial agents (ceftazidime, tetracycline, or ciprofloxacin), a strong correlation existed between bioluminescence levels and viable cell counts in vitro and in vivo. Evaluation of antimicrobial agents in vivo could be reliably performed with either method, as each was a sound indicator of therapeutic success. Dose-dependent responses could also be detected in the neutropenic-mouse thigh model by using either bioluminescence or viable-cell counts as a marker. In addition, the ICCD technology was examined for the benefits of repeatedly monitoring the same animal during treatment studies. The ability to repeatedly measure the same animals reduced variability within the treatment experiments and allowed equal or greater confidence in determining treatment efficacy. This technology could reduce the number of animals used during such studies and has applications for the evaluation of test compounds during drug discovery.

Clorgyline treatment elevates cortical serotonin and temporarily disrupts the vibrissae-related pattern in rat somatosensory cortex.

Manipulation of cortical serotonin (5-HT) levels in perinatal rodents produces significant alterations in the development of the layer IV cortical representation of the mystacial vibrissae. Monoamine oxidase A (MAO(A)) knockout mice have highly elevated cortical 5-HT and completely lack barrels in somatosensory cortex (S-I). The present study was undertaken to determine whether the effects on thalamocortical development seen in MAO(A) knockout mice can be replicated in perinatal rats treated with an MAO(A) inhibitor and, second, to determine whether these effects persist with continued treatment or after discontinuation of the drug. Littermates were injected with either clorgyline (5 mg/kg) or sterile saline five times daily. Clorgyline administration from birth to postnatal day (P) 6, 8, or 10 produced increases of 1,589.4 +/- 53.3%, 1660.2 +/- 43.1% and 1,700.5 +/- 84.5 %, respectively, in cortical 5-HT as compared with controls. Serotonin immunocytochemistry, 1,1;-dioctadecyl-3,3,3", 3;-tetramethylindocarbocyanine perchlorate (DiI) labeling of thalamocortical afferents and Nissl and cytochrome oxidase staining of layer IV cellular aggregates demonstrated that clorgyline treatment from P0 to P6 produced a complete absence of any segmentation of vibrissae-related patches in S-I. However, continued treatment until P8 or P10 did not prevent the appearance of these patches. Animals treated with clorgyline from birth to P6 and killed on P8 or P10 had increases of 546.8 +/- 33.2% and 268.8 +/- 6.3% in cortical 5-HT and they had qualitatively normal vibrissae-related patterns in S-I. These results indicate that clorgyline treatment produces a transient disruption of vibrissae-related patterns, despite the continued presence of elevated cortical 5-HT.

Enhanced pneumocystis carinii activity of new primaquine analogues.

New analogues of the venerable antimalarial drug primaquine have been synthesized and bioassayed in vivo against Pneumocystis carinii, a life-threatening infection common among immunosuppressed patients. Two of these new compounds are significantly more active than primaquine itself, and provide new information for future drug design and development in this area.

Time course of expression and function of the serotonin transporter in the neonatal rat's primary somatosensory cortex.

Immunocytochemical and autoradiographic techniques were employed to determine the time course of expression of the serotonin (5-HT) transporter (SERT) on thalamocortical afferents in the rat's primary somatosensory cortex (S-I), and to correlate this expression to the transient vibrissae-related patterning of 5-HT immunostaining previously described. In additional in vivo and in vitro experiments, 5-HT and 3H-5-HT were applied directly to the cortices of untreated and 5,7-dihydroxytryptamine-treated (5,7-DHT) rats in order to determine the period during which SERT functions on thalamocortical axons to take up 5-HT. In postnatal rats, SERT immunohistochemistry revealed a somatotopic patterning in S-I that persisted until P-15, which is 6 days after the disappearance of the vibrissae-related 5-HT immunostaining. 3H-citalopram autoradiography revealed a vibrissae-related pattern in layer IV of S-I until at least P-30. Following destruction of raphe-cortical afferents with 5,7-DHT on the day of birth, this binding pattern remained visible until at least P-25, indicating that SERT located on thalamocortical axons is responsible for the 3H-citalopram patterning observed in S-I. Tissue from 5,7-DHT-treated rats that had 5-HT applied directly to their cortices revealed a normal vibrissae-related pattern of 5-HT immunostaining in S-I at P-7 and P-11 but only a faint pattern at P-13 and none at P-14. In addition, 3H-5-HT injected directly into S-I labeled layer IV barrels at P-6 and P-12 but not at P-18. The results of these experiments demonstrate that SERT is expressed by thalamocortical afferents and remains functional long after the vibrissae-related 5-HT immunostaining in cortex disappears.

The cortical vibrissae representation is normal in transgenic mice lacking the 5-HT(1B) receptor.

Recent studies have suggested that 5-HT may modulate thalamocortical development in somatosensory cortex (S-I) of rats and mice, and that the 5-HT(1B) receptor may play a critical role in this process. Analysis of CO-stained sections through lamina IV of S-I in perinatal and adult 5-HT(1B) knockout mice revealed a normal vibrissae-related pattern, indicating that activation of the 5-HT(1B) receptor is not necessary for the normal development of the vibrissae representation in S-I.

Self-expanding oesophageal metal stents for the palliation of dysphagia due to extrinsic compression.

The role of self-expanding metallic stents is well established in the palliation of oesophageal stenosis and dysphagia due to primary oesophageal malignancy. However, their role in palliation of dysphagia due to external compressive mediastinal malignancies is not well established. The purpose of this study was to assess the efficacy of self-expanding metallic stents in the palliation of dysphagia due to extrinsic oesophageal compression by mediastinal malignancy. Between January 1995 and January 1998, 21 patients with oesophageal compression due to malignant mediastinal tumours underwent oesophageal stent placement for palliation of dysphagia. Complete data were available in 17 patients (10 men and 7 women). The mean age was 63.5 years (range 46-89 years). A total of 19 stents were placed successfully. The dysphagia grade prior to and after oesophageal stent placement was assessed and the complications documented. Of the 17 patients, 16 reported an improvement in dysphagia. The mean dysphagia score improved from 3.1 prior to treatment to 1.3 after treatment. In 1 patient the stent slipped during placement and another stent was placed satisfactorily. Early complications (within 48 h) in the form of mild to moderate retrosternal chest pain occurred in 5 patients. This was treated symptomatically. Late complications (after 48 h) in the form of bolus impaction occurred in 2 patients. This was successfully treated with oesophagoscopy and removal of bolus. In 2 patients the stent was overgrown by tumour and in one of these an additional stent was placed. In 1 patient incomplete closure of a tracheo-oesophageal fistula was observed. There was no procedure- or stent-related mortality. The mean survival time of this group was 2. 1 months. Self-expanding metallic stents can be safely and effectively used in the palliation of dysphagia due to external mediastinal malignancies.

Meeting Joint Commission requirements for staff nurse competency.

Changes in the health care industry have created great challenges for leaders of acute care organizations. One of the greatest challenges is ensuring a competent nursing staff to care for patients within this changing environment. This article will describe how our organization uses Joint Commission standards to assess, maintain, and improve the competency of nursing staff.

Beyond restructuring. Futuristic rapid-cycle change to improve patient care.

Rapid changes in the healthcare environment provide an impetus to look closely at the way patient care is delivered. It is increasingly important to be both patient focused and cost effective in the delivery of care. No longer can tradition, organizational structures, or poor communication impede effective and efficient patient care. A rapid-cycle change process is one method that involves staff members in identifying and implementing needed change to improve patient care and to remove waste from the system.

Neonatal damage to the rat's infraorbital nerve upregulates both galanin and neuropeptide Y in individual vibrissae-related primary afferent axons.

Previous studies in adult animals have suggested that the peptides galanin and neuropeptide Y (NPY) may be upregulated in the same primary afferent neurons after peripheral axotomy. The present study was undertaken to determine whether such upregulation occurred in vibrissae-related primary afferent neurons and their axons after damage to the infraorbital nerve [ION; the trigeminal (V) branch that innervates the vibrissae follicles]. Double-labelling experiments demonstrated that approximately 75% of axotomized V ganglion cells and the central arbors of vibrissae-related primary afferents expressed both galanin and NPY after perinatal, but not adult, nerve damage. However, additional experiments demonstrated that the sensitive periods for lesion-induced upregulation of the two peptides and the period over which they were expressed after neonatal ION transection differed substantially. Staining for both peptides was increased after ION damage on P-0 through P-14, but only galanin staining was increased in vibrissae-related primary afferents after lesions on P-21. Galanin expression was elevated in vibrissae-related primary afferents in rats killed 3, 8, and 15 days after neonatal ION transection, while increased NPY was observed at only the middle time point. The lesion-induced increases in galanin and NPY in vibrissae-related ION primary afferents suggest that these peptides may modulate central V reorganization after such damage.

Semisynthetic echinocandins affect cell wall deposition of Pneumocystis carinii in vitro and in vivo.

Cyclic lipodepsipeptide compounds of the echinocandin class exhibit broad-spectrum antifungal activity and have been shown to be effective in the treatment of Pneumocystis carinii pneumonia in laboratory animal models. Previous studies have led investigators to propose that these compounds, active against fungal cell walls, are selectively active against the cyst forms of P. carinii. We demonstrate that a semisynthetic, water-soluble echinocandin analog, LY307853, is effective in reducing the number of all life cycle forms of P. carinii and is more effective in mice immunosuppressed with monoclonal antibody to L3T4+ cells than in mice immunosuppressed with dexamethasone. Treatment of P. carinii isolates with LY307853 in a short-term in vitro culture model resulted in cytoarchitectural alterations suggesting that this echinocandin may interfere with the export of surface glycoprotein and the formation of the tubular elements normally found on the surfaces of trophic forms. The cytoarchitectural changes in trophic forms treated in vitro with LY307853 were also observed in trophic forms in the lung tissue of rats treated with a closely related echinocandin analog, LY303366.

Effects of BDNF and NT-4/5 on striatonigral neuropeptides or nigral GABA neurons in vivo.

Supranigral infusions of the TrkB-receptor-preferring neurotrophins BDNF or NT-4/5 augment locomotor behaviours, pars compacta firing rates and striatal dopamine metabolism. However these actions of BDNF or NT-4/5 may involve other neurotransmitter systems in addition to dopamine neurons in the substantia nigra. We thus investigated the effects of 2-week supranigral infusions of BDNF or NT-4/5 on rat peptidergic striatonigral neurons and nigral GABAergic neurons. Radioimmunoassay revealed that BDNF and NT-4/5 elevated substantia nigra levels of substance P (by 46 and 57% respectively) and substance K (by 64 and 81%). In addition, BDNF elevated substance K by 59% in a nigral projection area, the superior colliculus. NT-4/5 elevated dynorphin A in the substantia nigra (by 52%) and met-enkephalin in substantia nigra and globus pallidus (by 89%). None of these neuropeptides were altered in the striatum. Consistent with these findings, supranigral infusions of BDNF elevated the mRNA for preprotachykinin A in striatal neurons. In the same animals, glutamic acid decarboxylase (GAD)67 mRNA was increased by 48% in the substantia nigra. The cross-sectional area of GAD67-positive neuronal somata in the BDNF-infused nigra was increased by 59%, and 70% of nigral GABAergic neurons had a cross-sectional area > 550 microns2, whereas 95% of the neurons in vehicle-infused animals had cross-sectional areas < 550 microns2. Thus, supranigral infusions of BDNF or NT-4/5 increase tachykinin mRNA and protein levels within striatonigral neurons and increase the size and GAD67 mRNA expression levels of nigral GABAergic neurons. These results suggest that BDNF or NT-4/5 may modify the output of the basal ganglia not only through effects on dopamine neurons but also by increasing neurotransmission in striatonigral peptidergic and nigral GABAergic pathways.

A continuous striatal infusion of 6-hydroxydopamine produces a terminal axotomy and delayed behavioral effects.

Rat models of Parkinson's disease typically employ a rapid nigral injection of 6-hydroxydopamine (6-OHDA) to produce a near-complete loss of nigrostriatal dopamine neurons, and thus, model end stage disease. The present report describes the use of a continuous, low dose infusion of 6-OHDA into the striatum which produces a terminal axotomy of nigrostriatal dopamine neurons and protracted behavioral response. A solution of 6-OHDA in 0.4% ascorbate, delivered at 37 degrees C from osmotic minipumps, was stable for 8 days as determined by its retained toxicity to a dopaminergic neuroblastoma cell line. The continuous infusion of 0.2 mu g 6-OHDA per h did not affect the striatal uptake of [3H]%GABA, [3H]choline, or [3H]glutamate but reduced [3H]dopamine uptake by 55% within 1.5 days after the start of the infusion. The striatal infusion of 6-OHDA produced a dose-dependent reduction of striatal dopamine and DOPAC levels but did not alter HVA, 5-HT, or 5-HIAA. An increase in amphetamine-induced ipsiversive rotations occurred within 1.5 days after the acute striatal injection of 20 mu g or 30 mu g of 6-OHDA but required 4 days to develop with the continuous 6-OHDA infusion. The topography of the lesion mapped by [3H]mazindol binding showed that, beginning by 1.5 days, a diffuse depletion of terminals encompassed much of the striatum in the 30 mu g acute injection group, whereas in the continuously infused rats, the lesion was apparent only by 4 days and was restricted to a smaller and more completely lesioned area. Unlike acutely lesioned animals, continuously infused rats revealed no obvious loss of dopamine neurons in the pars compacta by 5 weeks after 6-OHDA. The continuous striatal infusion of 6-OHDA can produce a topographically limited terminal axotomy of dopamine neurons and a protracted behavioral impairment.