Child and adolescent psychiatry training and mental health care in Southeast Europe.

There is very limited information available on child and adolescent psychiatry (CAP) training in the Southeast European (SEE) region. The objective of this study was to fill in this gap by presenting descriptive data on CAP training and national mental health services for children and adolescent in 11 SEE countries. On the initiative of World Psychiatric Association-CAP section, national CAP association boards from each SEE country allocated one member to the Consortium on Academic Child and Adolescent Psychiatry in SEE (CACAP SEE) in 2018. Using an internally distributed questionnaire, CACAP SEE members provided information on the CAP training structure and mental health care. Ten out of eleven SEE countries recognized CAP as a separate specialty. Duration of training did not differ much between the SEE countries. Other components were more variable (availability of rotations, overseas electives, and inclusion of psychotherapy). Ten countries were familiar with the CAP requirements of the European Union of Medical Specialists (UEMS-CAP) and five provided the training in accordance with it. Nine countries had less than 36 board-certified child and adolescent psychiatrists practicing in the country. The number of general psychiatrists treating children and adolescents with mental disorders was higher than the number of CAP specialists in five of the countries. Although CAP was recognized as a separate specialty in the vast majority of SEE countries, there was a substantial variation among them in available CAP training. In most of the countries, there is a considerable lack of CAP specialists for several reasons, including loss of trained specialists to other countries.

Effects of White Mulberry (Morus alba) Heartwood Extract Against Reticulitermes flavipes (Blattodea: Rhinotermitidae).

Heartwood extract from white mulberry (Morus alba L.) (Rosales: Moraceae) were investigated for antitermitic activity against Reticulitermes flavipes (Kollar) (Blattodea: Rhinotermitidae) in laboratory experiments. An ethanol:toluene (2:1) solvent system was used to remove extract from heartwood shavings. A concentration-dependent feeding response and mortality were observed for termites exposed to a concentration series range of 1.25 to 10 mg/ml of extract based on their dry weight. Results showed that maximum termite mortality occurred at 10 mg/ml. Based on the concentration series data, LC50 was calculated at 1.71 mg/ml. In filter paper feeding and repellency assays, extract significantly decreased the total number of gut protozoa compared with untreated and solvent controls. After feeding on filter paper treated at 10 mg/ml for 2 wk, protozoan populations were reduced by >55%. In choice and no-choice tests with mulberry heartwood, greater wood loss from termite feeding was found on solvent extracted blocks compared with nonextracted. Complete (100%) mortality was observed after feeding on nonextracted blocks compared with extracted blocks. Heartwood extract from white mulberry imparted resistance to vacuum pressure treated, nondurable southern pine and cottonwood. At every concentration tested, 100% mortality was observed after feeding on extract-treated southern pine or cottonwood. GC-MS analysis of extract showed high levels of the phenol compound, resorcinol. Results indicated that heartwood extract from white mulberry have antitermitic properties and might be potentially valuable in the development of environmentally benign termiticides.

Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity. Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management. 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management. WHAT THIS STUDY ADDS: This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting. Results show that the tool facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and caused a statistically significant increase in the perceived follow-up/coordination efforts (self-reported Patient Assessment of Chronic Illness Care components, 45 ± 22 vs. 67 ± 12 points, P = 0.002), as well as two components of the 5As framework: Assess (50 ± 29 vs. 66 ± 15 points, P = 0.03) and Assist (54 ± 26 vs. 72 ± 13 points, P = 0.01). Our results suggest that using the 5As of Obesity Management facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care.

Effect of prenatal hypoxia in transgenic mouse models of preeclampsia and fetal growth restriction.

Mice lacking endothelial nitric oxide synthase (eNOS(-)(/-)) or catechol-O-methyl transferase (COMT(-/-)) exhibit a preeclampsia-like phenotype and fetal growth restriction. We hypothesized that a hypoxic insult would result in a more severe phenotype. Pregnant eNOS(-/-), COMT(-/-) and control (C57BL/6J) mice were randomized to hypoxic (10.5% O(2)) or normal conditions (20.9% O(2)) from gestational day 10.5 to 18.5. Hypoxia increased the blood pressure in all genotypes and proteinuria in C57BL/6J and eNOS(-/-) mice. Fetal survival was significantly reduced following hypoxia, particularly in eNOS(-/-) mice. Birth weight was decreased in both C57BL/6J and COMT(-/-) mice. Placentas from COMT(-/-) mice demonstrated increased peroxynitrite. Despite similar hypoxia-induced effects on maternal blood pressure and proteinuria, eNOS(-/-) embryos have a decreased tolerance to hypoxia. Compared to C57BL/6J, COMT(-/-) mice exhibited less severe changes in proteinuria and fetal growth when exposed to prenatal hypoxia. This relative resistance to prenatal hypoxia was associated with a significant increase in placental levels of peroxynitrite.

Efficacy and safety of long-term low-calorie diet in severely obese patients non-eligible for surgery.

The aim of this study was to describe the long-term efficacy and safety of low-calorie diets (LCDs; providing 900 kcal day(-1) ) in obese patients who have failed to achieve adequate weight loss with standard medical management and are non-eligible for surgical therapeutic options. Charts from a regional hospital-based outpatient bariatric programme were reviewed. Eight patients (75% male, age 60.1 ± 7.8 years) with severe obesity (body mass index 57.1 ± 8.8 kg m(-2) ) and undergoing long-term LCD (33 ± 10 months) were identified. Variables of interest included anthropometric, cardiovascular risk and nutritional parameters, thyroid, renal and liver function, changes in medications, side effects and adverse events. Average weight loss was 44 ± 15 kg (27 ± 13% of initial weight) at 24 months. Long-term management with LCD resulted in substantial and sustained improvements in glucose homeostasis, blood pressure and lipid profile. LCD was well tolerated with minor self-limited side effects. Over the follow-up period, two subjects underwent coronary revascularization and one patient underwent knee replacement surgery - all recovered without complications. These findings suggest that in selected obese patients (non-eligible for surgery), long-term management with LCD may provide an alternative option for substantial and sustainable weight loss with significant improvements in metabolic and cardiovascular health.

Increased plasma levels of total homocysteine but not asymmetric dimethylarginine in Hispanic subjects with ischemic stroke FREC-VI sub-study.

BACKGROUND AND PURPOSE: Despite sharing some metabolic and pathological mechanisms, the reported association between total homocysteine (tHcy), asymmetric dimethylarginine (ADMA) and stroke remains controversial, particularly in Hispanic populations from developing countries in which genetic, socioeconomic, and nutritional factors are different to those described in developed countries. Our objectives were to determine the relationships of these factors to stroke and to each other independent of other cardiovascular risk factors, and to explore potential sex differences. METHODS: This national (Colombia) multicenter case-control study included 238 cases and 238 controls to evaluate traditional and emerging risk factors for ischemic stroke including tHcy and ADMA plasma levels. RESULTS: The median plasma levels of tHcy were 8.48 µM for controls and 10.01 µM for cases (P<0.0001). Plasma levels of tHcy between 12 and 50µM were considered moderate hyperhomocysteinemia (HtHcy). There were no differences in plasma ADMA concentration between groups (P=0.40). Plasma levels of ADMA and creatinine were not correlated (P=0.47). After adjusting for confounding factors, the presence of HtHcy was strongly associated with stroke (OR 8.97; P<0.0001). The adjusted association between HtHcy and stroke in men (OR 9.98) was comparable to that in women (OR 8.98) (P=0.41). CONCLUSIONS: In this Hispanic population, with relatively normal renal function, plasma levels of tHcy but not ADMA were associated with stroke independent of other cardiovascular risk factors.

SU-E-T-598: Clinical Experience of Configuration, Commission and Implementation for SmartArc with MOSAIQ R&V System.

PURPOSE: Clinical experience for configuration, commission and implementation of SmartArc with MOSAIQ R&V system. METHODS: SmartArc is Pinnacle's solution for VMAT. On July 2011 we updated to Pinnacle 9.0 and purchased SmartArc. A standalone Eclipse workstation has been used 3 years for VMAT planning. Our clinical setting: Mosaiq 2.2; Varian Trilogy driven by 4DiTC and Varian 21ex driven by sequencer. Some key physics parameters have been studied: machine dose rate; MLC leaf speed; Leaf motion per gantry rotation. Tabletop was created by user to improve the dose accuracy for planning. In-house sandwich phantom was used with MapCheck for planner dose verification. A PTW 0.6cc ion chamber was included for absolute dose comparison. RESULTS: A copy of current machine data with default highest dose rate is recommended. It is due to after 10th iteration of optimization, the default dose rate will kick in. 2.5cm/s is the constraint for Varian Millennium 120 MLC; a buffer zone of 10% is suggested to reduce the MLC error on treatment. 2.25cm/s is used in our configuration. This results in MLC interlock if not configured correct. Maximum leaf motion per gantry rotation of 0.46cm/degree has to be checked for planning with Mosaiq R&V. Otherwise, undeliverable plan will show up sometimes on 4DiTC.Tabletop was exported as a DICOM structure from Eclipse to Pinnacle; we created a ROI template based on the matched tabletop.QA using in-house phantom for different sites were tested. Results for both planner dose and absolute chamber measurement are satisfactory. CONCLUSIONS: Special attentions need to be paid for dose rate, MLC leaf speed, leaf motion per gantry rotation when configuring SmartArc. Varian 21ex is supported but is slow for clinical delivery. Users need to create your own tabletop to improve planning accuracy. Conventional commission procedures for RapidArc also apply for SmartArc.

The effect of hypoxia-induced intrauterine growth restriction on renal artery function.

The risk of developing cardiovascular diseases is known to begin before birth and the impact of the intrauterine environment on subsequent adult health is currently being investigated from many quarters. Following our studies demonstrating the impact of hypoxia in utero and consequent intrauterine growth restriction (IUGR) on the rat cardiovascular system, we hypothesized that changes extend throughout the vasculature and alter function of the renal artery. In addition, we hypothesized that hypoxia induces renal senescence as a potential mediator of altered vascular function. We demonstrated that IUGR females had decreased responses to the adrenergic agonist phenylephrine (PE; pEC50 6.50 ± 0.05 control v. 6.17 ± 0.09 IUGR, P < 0.05) and the endothelium-dependent vasodilator methylcholine (MCh; E max 89.8 ± 7.0% control v. 41.0 ± 6.5% IUGR, P < 0.001). In IUGR females, this was characterised by increased basal nitric oxide (NO) modulation of vasoconstriction (PE pEC50 6.17 ± 0.09 IUGR v. 6.42 ± 0.08 in the presence of the NO synthase inhibitor N-nitro-l-arginine methyl ester hydrochloride (l-NAME; P < 0.01) but decreased activated NO modulation (no change in MCh responses in the presence of l-NAME), respectively. In contrast, IUGR males had no changes in PE or MCh responses but demonstrated increased basal NO (PE pEC50 6.29 ± 0.06 IUGR v. 6.42 ± 0.12 plus l-NAME, P < 0.01) and activated NO (E max 37.8 ± 9.4% control v. -0.8 ± 13.0% plus l-NAME, P < 0.05) modulation. No significant changes were found in gross kidney morphology, proteinuria or markers of cellular senescence in either sex. In summary, renal vascular function was altered by hypoxia in utero in a sex-dependent manner but was unlikely to be mediated by premature renal senescence.

Effects of hypoxia-induced intrauterine growth restriction on cardiac siderosis and oxidative stress.

We have previously shown that adult rat offspring born intrauterine growth restricted (IUGR) as a result of a prenatal hypoxic insult exhibit several cardiovascular characteristics that are compatible with common manifestations of chronic iron toxicity. As hypoxia is one of the major regulators of iron absorption and metabolism, we hypothesized that hypoxia-induced IUGR offspring will have long-term changes in their ability to regulate iron metabolism leading to myocardial iron deposition and induction of myocardial oxidative stress. Pregnant Sprague Dawley rats were randomized to control (n = 8) or maternal hypoxia (11.5% oxygen; n = 8) during the last 6 days of pregnancy. At birth, litters were reduced to eight pups (four male and four female). At 4 or 12 months of age, offspring were euthanatized and samples (blood and myocardium) were collected. In only the male offspring, IUGR and aging were associated with an increase in myocardial markers of oxidative stress such as oxidized/reduced glutathione ratio and malondialdehyde. Aged male IUGR offspring also exhibited interstitial myocardial remodeling characterized by myocyte loss and disrupted extracellular matrix.Contrary to our hypothesis, however, neither IUGR nor aging were associated with changes in any systemic or local markers of iron metabolism. Our results suggest that hypoxic insults leading to IUGR produce long-term effects on the levels of oxidative stress and connective tissue distribution in the myocardium of male but not female offspring.

Effect of gestational diabetes on maternal artery function.

Endothelial dysfunction has been observed systemically in women with gestational diabetes (GDM). Important cardiovascular adaptations occur during pregnancy, including enhanced endothelium-dependent vasodilation in systemic and uterine arteries, which are necessary to ensure the health of both mother and fetus. The effects of GDM, however, on uterine artery function and the possible mechanisms that mediate endothelial dysfunction remain unknown. The aim of this study was to utilize a mouse model of GDM to investigate (a) effects on uteroplacental flow, (b) endothelial function of uterine and mesenteric arteries, and (c) possible mechanisms of any dysfunction observed. Pregnant mice heterozygous for a leptin receptor mutation (Lepr(db) (/+); He) spontaneously develop GDM and were compared to wild-type (WT) mice at day 18.5 of gestation. Uterine artery flow was assessed using ultrasound biomicroscopy. Uterine and mesenteric artery function was assessed using wire myography. Arterial superoxide production was measured using oxidative fluorescence microphotography. In vivo uteroplacental perfusion was impaired in mice with GDM, indicated by a significant increase in uterine artery resistance index. Maximal endothelium-dependent relaxation to methacholine was significantly impaired in mesenteric arteries from mice with GDM, while sensitivity was significantly reduced in uterine arteries. Both uterine and mesenteric arteries from mice with GDM exhibited a greater dependence on nitric oxide and increased superoxide production compared with those from mice with a healthy pregnancy. A significant source of superoxide in GDM mice was uncoupled nitric oxide synthase. These changes may contribute to the development of some of the fetal and maternal complication associated with GDM.

Flow-mediated vasodilation is impaired in adult rat offspring exposed to prenatal hypoxia.

There is now a demonstrated association between low birth weight and increased mortality later in life. Changes in fetal development may program the cardiovascular system and lead to an increased risk of cardiovascular diseases later in life. In addition, aging is a risk factor for vascular endothelial-dependent dysfunction. However, the impact of being born intrauterine growth restricted (IUGR) on the normal aging mechanisms of vascular dysfunction is not clear. We hypothesized that IUGR would cause changes in vascular function that would affect the mechanisms of flow-induced vasodilation later in life in an age- or sex-dependent manner. To create an IUGR model, pregnant Sprague-Dawley rats were placed in a hypoxic (11.5% O2) or control (room air, 21% O2) environment from days 15 to 21 of pregnancy. Both male and female offspring were investigated at 4 or 12 mo of age. Vascular function was assessed in small mesenteric arteries using flow-induced vasodilation, a physiological stimuli of vasodilation, in a pressure myograph. Flow-induced vasodilation was unaffected at a young age, but was significantly reduced in aging IUGR compared with aging controls (P < 0.05). Underlying vasodilator mechanisms were altered such that nitric oxide-mediated vasodilation was abolished in both young adult and aging IUGR males and females and in aging control females (P > 0.05). Endothelium-derived hyperpolarizing factor-mediated vasodilation was maintained in all groups (P < 0.01). A change in the mechanisms of vasodilation occurring at an earlier age in IUGR offspring may predispose them to develop cardiovascular diseases as an aging adult.

Mechanisms of endothelium-dependent vasodilation in male and female, young and aged offspring born growth restricted.

Numerous epidemiological studies have shown that cardiovascular dysfunction in adult life may be programmed by compromised growth in utero. Aging is a risk factor for vascular endothelial-dependent dysfunction. After birth, the impact of intrauterine growth restriction (IUGR) on normal aging mechanisms of vascular dysfunction is not known. We hypothesized that IUGR would cause changes in vascular function that would affect the mechanisms of endothelium-dependent vasodilation later in life in an age- or sex-dependent manner. To create an IUGR model, pregnant Sprague-Dawley rats were placed in a hypoxic (12% O(2)) or control (room air, 21% O(2)) environment from days 15 to 21 of the pregnancy, and both male and female offspring were investigated at 4 or 12 mo of age. Endothelial function was assessed in small mesenteric arteries using methacholine (MCh)-induced vasodilation in a wire myograph system. The involvement of nitric oxide (NO), prostaglandins, and endothelium-derived hyperpolarizing factor (EDHF) was assessed using the inhibitors N(omega)-nitro-l-arginine methyl ester hydrochloride, meclofenamate, or a combination of apamin and TRAM-34 (SK(Ca) and IK(Ca) blockers), respectively. EDHF-induced vasodilation was further investigated by using inhibitors of P450 epoxygenases [N-methylsulfonyl-6-(2-propargyloxyphenyl) hexanamide] and gap junctions (18alpha-glycyrrhetinic acid). NO-mediated vasodilation was significantly reduced in aged controls and both young and aged IUGR females. EDHF-mediated vasodilation was maintained in all groups; however, an additional involvement of gap junctions was found in females exposed to hypoxia in utero, which may represent a compensatory mechanism. A change in the mechanisms of vasodilation occurring at an earlier age in IUGR offspring may predispose them to adult cardiovascular diseases.

Do referrals work? Responses of childbearing newcomers to referrals for care.

BACKGROUND: Health care post-birth may include referrals for additional care. Migrant (i.e., refugee, asylum-seeker, and immigrant) women frequently do not follow-up referrals for care and could be at increased health risk as a consequence. We sought to explore the inhibitors and facilitators of migrant women for following through with referrals for care. METHODS: Twenty-five women living in Montreal who had received a referral completed semi-structured interviews. RESULTS: Inhibitors included language barriers, transportation problems, scheduling appointments, absence of husband, absence of childcare, cold weather, perceived inappropriate referrals, and cultural practice differences. Facilitators included choice of follow-up facilitator, appropriate services, empathetic professionals, and early receipt of information. DISCUSSION: Results indicate that migrant women may not be receiving the care they and their newborns need once a concern is identified. This suggests conceiving of a different approach to the care of this population post-birth, which could include partnering with social or religious networks.

[Financing problems of capital goods. Part 2: procedure for investment appraisal]. / Finanzierungsproblematik von Investitionsgütern. Teil 2: Verfahren der Investitionsrechnung.

In part 1 of this series about problems of financing capital goods the multiple and partly diametric economic effects of financing instruments were presented using the leasing procedure as an example. The result indicated that due to the complexity of these effects the choice of a specific financing instrument requires an individual consideration. Therefore, part 2 of the series introduces the method of dynamic capital budgeting which allows the instruments discussed in part 1 to be compared with each other and helps to evaluate their economic benefits. More precisely this paper focuses on a comparative analysis of the most common alternatives, leasing, credit financing and investment financing by the state. In this context, after having identified the total costs of ownership of anesthesia devices, the final asset values of the three financing instruments can be compared with each other using the method of dynamic capital budgeting. In contrast to the prevailing opinion, the results show that from a purely fiscal perspective leasing anesthesia devices is the most expensive alternative. Given the fact that no financial support is available from the state, the option of credit financing turns out to be the most preferable alternative from a relatively limited pool of possibilities. However, it still remains to be answered whether credit financing can defend this position against further, innovative forms of debt financing (e.g., factoring, asset-backed securities, hedge funds, mezzanine capital, etc.).

[Financing problems of capital goods: part 1: leasing as a solution?]. / Finanzierungsproblematik von Investitionsgütern: Teil 1: Leasing als Ausweg?

The provision of financial support of hospitals by States for buying capital goods is becoming increasingly more limited. In order to still make investments, alternative forms of financing such as leasing must be considered in hospitals. However, the change from the classical form of dual financing and the decision to opt for a leasing model involves much more than just a question of costs. Leasing results in easily manageable expenditure, flexibility and adaptability for the choice of model but the leasing installments must be directly financed by the turnover from diagnosis-related groups and so lead to a reduction in the annual profit. In this article the authors try to give the reader an overview of the complex and sometimes counter-productive effect of financial instruments for investments in hospitals using leasing financing as an example. In the follow-up article the decision-making procedure using dynamic investment calculations will be demonstrated using a concrete example.

Ultrasound pretreatment of elemental iron: kinetic studies of dehalogenation reaction enhancement and surface effects.

This work presents data showing the kinetic improvement afforded by ultrasound pretreatment and illustrates the physical and chemical changes that take place at the iron surface. First-order rate constants improved as much as 78% with 2h of ultrasound pretreatment. Scanning electron microscopy (SEM) and surface area analysis were used for confirmation of the physical changes that take place after ultrasound was used on iron surfaces exposed to a variety of conditions. X-ray photoelectron spectroscopy was used to determine chemical surface characteristics before and after ultrasound use. SEM and surface area analysis showed that ultrasound use clears the iron surface of debris increasing the surface area up to 169%. In addition, exposure to ultrasound alters ratios of surface species, such as adventitious carbon to carbonyl carbon and iron to oxygen, and removed hydroxides thus making the iron more reactive to reductive dehalogenation.

[Optimizing image reconstruction timing for the RR interval in imaging coronary arteries with multi-slice computerized tomography]. / Optimierung des Bild-Rekonstruktionszeitpunktes im RR-Intervall für die Darstellung der Koronararterien mittels Mehrzeilen-Computertomographie.

PURPOSE: Multislice spiral CT is a newly developed technology that allows the non-invasive detection of coronary stenoses and plaques. The acquired raw data are reconstructed at a given time point in the RR interval of the heart cycle. Thus, determination of this time point is a key factor for picture quality and for reliable diagnostic results. This study was performed to investigate the optimal time point for reconstruction within the RR interval. MATERIALS AND METHODS: The coronary arteries of 13 patients were examined with CT. Raw data were reconstructed 250, 350, 450 and 550 ms before the following R wave (absolute reverse retrospective ECG gating) for each patient. Data were then analyzed with a volume rendering mode on a SIEMENS 3 D-Virtuoso workstation. A total of 91 segments (segments 1 and 2 of the RCA, segments 5, 6, 7 and proximal and distal parts of segment 11) were assessed and image quality was classified. RESULTS: Visualization of the left main coronary artery was of a good quality at all time points, segments 6 and 7 of the LAD as well as the proximal and distal parts of segment 11 of the RCX had the best quality at 450 ms absolute reverse retrospective ECG gating. The segments 1 and 2 of the RCA were of best quality 550% ms absolute reverse to the R peak. CONCLUSIONS: Classification of image quality of coronary artery CT scans after retrospectively ECG gated reconstruction is highly determined by the time point of reconstruction in the heart cycle. The optimization of this time point increases diagnostic accuracy and helps to avoid misinterpretation due to image artifacts.