Newborn Pulse Oximetry Screening at a Community Hospital: An 8-Year Experience.

OBJECTIVES: To evaluate newborn pulse oximetry screening (POS) outcomes at a large community hospital and the impact of the recommended revised POS algorithm. METHODS: A retrospective cohort study was performed to evaluate the results of POS in the well-infant nursery between 2012 and 2020. The POS results were obtained from an electronic platform. Chart review was completed for newborns with failed screens. The recommended revision to POS, no second rescreen, was applied to the data to evaluate screening outcomes. RESULTS: Of the total 65 414 infants admitted to the well-infant nursery during this 8-year period, >99% (n = 64 780) received POS. Thirty-one infants failed POS (4.6 per 10 000 screened). All infants who failed POS were found to have a disorder, with 12 (39%) having critical congenital heart disease (CCHD), 9 (29%) having non-CCHD requiring further follow-up, and 10 (32%) having noncardiac conditions. One false-negative screen result was identified through the Maryland Department of Health Newborn Screening Follow-up Program. The positive predictive value of POS for those screened was 39% for CCHD, with a specificity of 99.97%. Eliminating the second rescreen in the POS algorithm would have resulted in an additional 5 newborns without CCHD failing POS, increasing the false-positive rate from 0.03% to 0.04%. CONCLUSIONS: POS is an effective tool for identifying CCHD and secondary conditions. POS was successfully implemented with few missed screens and was highly specific. Elimination of the second rescreen in the pulse oximetry algorithm would have resulted in a minimal increase in false-positive results and faster evaluation of newborns with CCHD.

Development and Evaluation of Acceptance and Commitment Therapy Delivered by Psychologists and Non-Psychologists in an NHS Community Adult Mental Health Service: a Preliminary Analysis.

BACKGROUND: Previous studies have demonstrated that acceptance and commitment therapy (ACT) is effective for depression and may be useful for complex transdiagnostic clients. AIMS: To conduct a preliminary evaluation of whether ACT is feasible and effective when delivered by psychologists and non-psychologists for complex clients in a National Health Service (NHS) community mental health service for adults. METHOD: Staff were trained in ACT and conducted one-to-one therapy with clients. Measures on general mental health, depression, fusion and values were given pre-therapy, post-therapy and at 3-month follow-up. RESULTS: Standardized measures showed significant improvements post-therapy for global mental health, depression, cognitive fusion and values post-treatment. These were partially maintained at follow-up and remained after an intent-to-treat analysis. There were no differences in outcomes between psychologists and non-psychologists. CONCLUSIONS: ACT may be delivered effectively with limited training for complex cases in secondary care, though further research is needed.

A preliminary investigation into the effectiveness of a group-delivered sleep management intervention for parents of children with intellectual disabilities.

Sleep problems are more prevalent and severe among children with intellectual disabilities and autism compared to typically developing children. Training parents in behavioural approaches to manage sleep problems is advocated. However, delivering such interventions via groups is novel. This article reports the findings from a preliminary evaluation of a group-delivered intervention routinely delivered by a Child and Adolescent Mental Health Service Learning Disability team in England. For this purpose, parents (n = 23) of children with intellectual disabilities were recruited. The Children's Sleep Habits Questionnaire, Parents' Sense of Competence Scale and parent-set goals captured outcomes at pre-intervention, post-intervention and 3- and 6-month follow-up. Intervention delivery costs were collected. Take-up was high (86%), and no parent dropped out. Statistically significant improvements in night wakings, parent-set goals and parents' sense of efficacy were observed. The estimated mean cost of delivering each intervention was British (GBP) £1570. Findings suggest the intervention is a low-cost, acceptable service warranting further evaluation.

Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training.

BACKGROUND: Patients diagnosed with a personality disorder (PD) are often stigmatized by the healthcare staff who treat them. AIMS: This study aimed to compare the impact on front-line staff of a self-management Acceptance and Commitment Therapy-based training intervention (ACTr) with a knowledge- and skills-based Dialectical Behaviour Training intervention (DBTr). METHOD: A service-based randomized controlled trial was conducted comparing the effects of 2-day ACTr (N = 53) and DBTr (N = 47) staff workshops over 6 months. Primary outcome measures were staff attitudes towards patients and staff-patient relationships. RESULTS: For both interventions, staff attitudes, therapeutic relationship, and social distancing all improved pre- to postintervention, and these changes were maintained at 6-month follow-up. CONCLUSIONS: Although offering different resources to staff, both ACTr and DBTr were associated with an improved disposition towards PD patients. Future research could evaluate a combined approach, both for staff working with PD patients and those working with other stigmatized groups.

Acceptance and commitment therapy-based self-management versus psychoeducation training for staff caring for clients with a personality disorder: a randomized controlled trial.

People diagnosed with a personality disorder (PD) are often a stigmatized patient group. This can affect the care they receive, their progression, and the well-being of staff caring for them. Interventions targeted at health care professionals that aim to improve attitudes toward these patients and improve staff well-being do exist; however, evidence for their effectiveness is limited. The present study compared a self-management, Acceptance and Commitment Therapy-based training intervention (ACTr) with a Psychoeducation Training (PETr) intervention in their effectiveness in improving attitudes toward PD patients, staff-patient relations, and staff well-being. Both interventions were successful at improving attitudes and measures of staff-patient relations up to 6 months after training; however, staff well-being did not change for either group. The implications for staff training and future research are discussed.

Diagnosis and assessment of food allergy in children and young people.

Food allergies are recognised as a major paediatric health problem in Western countries, affecting 6% to 8% of children up to the age of three years. Food allergy symptoms can be very severe or subtle and sometimes overlooked. Following a Department of Health review of allergy services in 2006, the National Institute for Health and Clinical Excellence (NICE) was commissioned to produce a guideline to support GPs and other healthcare professionals in primary care and community settings in recognising the signs and symptoms of food allergy in order to bring about consistency in diagnosis and assessment. This paper has been written by a member of the guideline development group to provide an overview of the guidance. The guidance addresses six key clinical questions about taking an allergy-focused clinical history, signs and symptoms of IgE-mediated and non-lgE mediated allergy, information and support that should be offered during the assessment process, when to refer on to secondary or specialist services, and the value of alternative allergy tests.

Developing and validating the "composite measure of problem behaviors".

Clinicians frequently encounter problem behaviors such as self-harm, restrictive eating, binge eating, alcohol misuse, drug misuse, smoking, sexual promiscuity, internet addiction, excessive exercise, and aggression. Although these behaviors commonly co-occur, no scale exists to measure them concurrently. Based on data from two opportunity samples (N = 691 and N = 53), this study designed and validated a composite measure of the problem behaviors noted above. The Composite Measure of Problem Behaviors, developed using exploratory factor analysis, demonstrated good psychometric properties. Subsequent confirmatory factor analysis, using both the first (N = 691) and a third sample (N = 740), identified a common higher order factor that accounted for covariance between behaviors. Findings thus suggest that despite the formal dissimilarity of behaviors assessed, a common function may explain their covariation.

An experimental investigation of emotional willingness and physical pain tolerance in deliberate self-harm: the moderating role of interpersonal distress.

Although theoretical and clinical literature emphasize the role of both an unwillingness to experience emotional distress and physical pain tolerance in deliberate self-harm (DSH), research on their associations with DSH remains limited. This study sought to examine the relationships between DSH and the willingness to experience emotional distress and tolerate physical pain, including the moderating role of interpersonal distress in these relationships. To this end, young adults with recent DSH (n = 43) and controls without any DSH (n = 52) were randomly assigned to 1 of 2 emotion-induction conditions (distressing or neutral), after which behavioral measures of both the willingness to experience distress and physical pain tolerance were obtained. Consistent with hypotheses, findings indicated heightened physical pain tolerance among self-harming individuals only under conditions of interpersonal distress. Furthermore, findings provided some support for the hypothesized association between DSH and the unwillingness to experience emotional distress, suggesting that self-harming women evidence less willingness to experience emotional distress only under conditions of depleted regulatory capacity (eg, following an interpersonal stressor).

The differences of anaesthetic care in paediatrics compared to adults.

In the study of holistic perspectives in perioperative care the following article focuses on the care required for paediatric patients through the perioperative period. This incorporates an understanding of the anatomical, physiological and pharmacological differences from adult practice, acknowledging the most important principles of patient safety. The planning, implementation, equipment adaptations and psychological challenges associated with this group will be discussed in relation to improving the overall perioperative experience.

Referrers' use and views of specialist mental health services for deaf children and young people in England.

BACKGROUND: Deaf children are at greater risk of mental health problems than hearing children. Generic child and adolescent mental health services cannot be expected to have the expertise to work with these children. Three teams in England currently provide specialist mental health services to deaf children. AIMS: The research sought to explore referrers' views of these specialist services. METHODS: Interviews and a postal survey were used. RESULTS: Referrers were very satisfied with the service and identified the features of the service which supported positive outcomes for users. Access was, however, a significant problem. Referrers suggested developments to the service should incorporate preventive work and cascading of skills to other professional groups. CONCLUSIONS: Deaf children require services which are expert in deafness and mental health, and the findings suggest the specialist services are achieving this. Resolving issues of access and widening its remit are desirable ways forward in any future development of the service.

Experiential avoidance and problem behavior: a mediational analysis.

Despite their formal dissimilarity, problem behaviors (e.g., substance misuse, binge eating, self-harm) may share a common function. According to Acceptance and Commitment Therapy (ACT), this shared function is Experiential Avoidance, the process of avoiding, escaping or otherwise altering unwanted private events (e.g., thoughts, feelings, memories) and the contexts that elicit them. Structural Equation Modeling was used cross-sectionally with data from a clinical opportunity sample ( N = 290) to test (a) whether problem behavior covariance was associated with experiential avoidance, and (b) whether experiential avoidance mediated the relationships between historical and dispositional risk factors (childhood trauma and negative affect intensity, respectively) and the tendency to engage in problem behaviors. Analysis showed that experiential avoidance contributed to the covariation of problem behaviors, and that it fully mediated the relationships between both risk factors and problem behavior. Thus, experiential avoidance may be a key process to target in the management of individuals with behavior problems.

Emergency treatment of anaphylactic reactions--guidelines for healthcare providers.

*The UK incidence of anaphylactic reactions is increasing. *Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. *Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. *Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. *The exact treatment will depend on the patient's location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. *Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. *Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline. *Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. *All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. *Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use. *There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.

Making informed choices in social care: the importance of accessible information.

The current policy trend is to encourage greater choice in the use of welfare services. To make informed choices, people need information. The process of finding and using information has costs for individuals in terms of effort, time and material resources. These costs are different for different people and impact on their use of information in different ways. Thus, the accessibility of information is important in ensuring those people who need to make choices can do so in an informed way. This paper discusses the importance of information in making informed choices about social support by drawing on the findings of a scoping review of government research and development activity on the accessibility of information about adult social care services. The scoping review was carried out in spring 2006. Details of recent, current and planned projects were obtained through discussions with staff in government departments, government agencies and other related organisations identified using a snowballing technique. Forty-two contacts were made. Eleven research and 36 development projects were identified that aimed to investigate or improve the accessibility of information about social care services. A limited literature search was undertaken on information needs in areas not already under investigation by government. Eighteen articles were identified. Information and helpline staff from six voluntary organisations gave their views on the accessibility of information about social care services. Our findings show that there is no government-related or other recent research evidence on the specific information access needs for some user groups and services, for example, people from ethnic minority groups. For other user groups, such as people with chaotic lifestyles, there is evidence on information needs but no current or planned development projects to address these needs. The implications for the costs of finding and processing information to aid informed choices are discussed.

RET is constitutively activated by novel tandem mutations that alter the active site resulting in multiple endocrine neoplasia type 2B.

Constitutive activation of the RET receptor tyrosine kinase underlies the genesis and progression of multiple endocrine neoplasia type 2 (MEN 2), a dominantly inherited cancer predisposition. Importantly, although kinase activation represents a common theme in neoplasias, not all activating mutations are functionally equivalent. Consistent with this, we ascertained a patient with classical features of MEN 2B, but lacking either of the classical mutations in RET (M918T or A883F). Instead, the patient harbors a novel pair of germ line missense mutations in cis at codons 804 and 805. We evaluated the potential physiochemical effects of these substitutions in silico, predicting both to be moderately deleterious in isolation, but severely deleterious in combination. Consistent with this postulate, we show that the identified tandem mutations (V804M/E805K) are biologically active, transforming cells in culture and that their transforming capacity in combination is distinctly synergistic. Furthermore, the V804M/E805K tandem lesion confers resistance to the small molecule receptor tyrosine kinase inhibitor, PP1, suggesting a mode of action distinct from that known for classical MEN 2B mutations. To address this question, we used homology molecular modeling in silico to model the active site of RET. We predict that RET804 constitutes a critical gatekeeper residue that, when mutated in combination with RET805, induces a conformational change in the hinge region that locks the active site in a position permissive for ATP hydrolysis. Our findings have implications both in the clinic and in the successful development of novel kinase-targeted anticancer drugs.

A novel activating mutation in the RET tyrosine kinase domain mediates neoplastic transformation.

We report the finding of a novel missense mutation at codon 833 in the tyrosine kinase of the RET proto-oncogene in a patient with a carcinoma of the thyroid. In vitro experiments demonstrate that the R833C mutation induces transformed foci only when present in the long 3' splice isoform and, in keeping with a model in which the receptor has to dimerize to be completely activated, glial cell line-derived neurotrophic factor stimulation leads the RET(R833C) receptor to a higher level of activation. Tyrosine kinase assays show that the RET(R833C) long isoform has weak intrinsic kinase activity and phosphorylation of an exogenous substrate is not elevated even in the presence of glial cell line-derived neurotrophic factor. Furthermore, the R833C mutation is capable of sustaining the transformed phenotype in vivo but does not confer upon the transformed cells the ability to degrade the basement membrane in a manner analogous to metastasis. Our functional characterization of the R833C substitution suggests that, like the V804M and S891A mutations, this tyrosine kinase mutation confers a weak activating potential upon RET. This is the first report demonstrating that the introduction of an intracellular cysteine can activate RET. However, this does not occur via dimerization in a manner analogous to the extracellular cysteine mutants.

Real-time quantitative PCR measurement of thyroglobulin mRNA in peripheral blood of thyroid cancer patients and healthy subjects.

Follow-up of recurrent differentiated thyroid carcinoma involves the measurement of serum thyroglobulin (Tg). However, Tg autoantibodies are present in a high proportion of thyroid carcinoma patients (up to 25%) and these can interfere with the Tg immunoassays. To overcome this obstacle, investigators have used real-time quantitative reverse transcriptase polymerase chain reaction (RT-PCR) to measure Tg mRNA in the blood of patients with differentiated thyroid cancer, with varying degrees of success. In the present study, we demonstrate the first reported use of the PAXgene Blood RNA collection tube and extraction kit method for the preparation of RT-PCR-quality RNA with subsequent deployment of the latter in the development of a specific, sensitive, and reproducible Taqman assay for the detection and quantification of thyroglobulin mRNA. Beta-actin mRNA was also assayed and results are expressed as a ratio of Tg to beta-actin mRNA. The intra-assay coefficient of variations (CVs) for Tg and beta-actin mRNA assay were 27.7% and 25.4%, respectively. Inter-assay CVs were 20.8% and 28.8%, respectively, for the two assays. Tg mRNA was detected in all cancer subjects (n = 42) and healthy individuals (n = 20). Tg mRNA was significantly higher in cancer patients than in the healthy subjects (0.00169 +/- 0.00013 vs. 0.00051 +/- 0.00015; P<0.0001). Fourteen cancer patients had detectable levels of serum Tg, and Tg mRNA levels tended to be higher in these than in cancer subjects with undetectable serum Tg (0.00188 +/- 0.00021 vs. 0.00157 +/- 0.000178; P = 0.08). Circulatory Tg mRNA measurement may serve a useful role in the assessment of thyroid cancer.

Towards a cognitive model and measure of dissociation.

Dissociation comprises a range of psychological processes, which have largely been the subject of psychodynamic discussion. Dissociative phenomena are for the most part unaddressed by cognitive theorists. Current measures are atheoretical and our understanding of dissociation has been hampered by the absence of clear psychological models. This paper describes a new cognitive model of dissociation and the development and validation of a theoretically based measure-the Wessex Dissociation Scale (WDS). The WDS has adequate internal consistency, shows convergent validity with the Dissociative Experiences Scale (DES-II), and is equivalent to the DES-II in its associations with severe psychopathology. However, the WDS has some advantages over the DES-II, in that it is sensitive to milder manifestations of dissociation, demonstrating links to less severe pathologies. The findings described here provide preliminary support for the usefulness of the cognitive model, and the varied consequences of dissociative processes. The clinical and research utility of the model and the scale are discussed.