The clinical impact of a crisis resolution home treatment team.

OBJECTIVES: To evaluate the impact of treatment provided by a Crisis Resolution Home Treatment Team (CRHTT) in terms of preventing hospital admission, impact on service user's symptoms and overall functioning, as well as service user's satisfaction with the service. Secondary objectives were to evaluate the patient characteristics of those attending the CRHTT. METHODS: All the service users treated by the CRHTT between 2016 and 2020 were included. Service users completed the Brief Psychiatric Rating Scale (BPRS), the Health of the Nation Outcome Scale (HoNOS), and the Client Satisfaction Questionnaire-version 8 (CSQ-8) before and after treatment by the CRHTT. Admission rates were compared between areas served by the CRHTT and control, before and after the introduction of the CRHTT, using two-way ANOVA. RESULTS: Between 2016 and 2020, 1041 service users were treated by the service. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. There was a statistically significant interaction between CRHTT availability and time on admission rate, F (1,28) = 8.4, p = .007. BPRS scores were reduced significantly (p < .001), from a mean score of 32.01 before treatment to 24.64 after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p < .001). Of the 1041 service users receiving the CSQ-8, only 180 returned it (17.3%). Service users' median responses were "very positive" to all eight items on the CSQ-8. CONCLUSIONS: Although our study design has limitations this paper provides some support that CRHTT might be effective for the prevention of inpatient admission. The study also supports that CRHTT might be an effective option for the treatment of acute mental illness and crisis, although further research is needed in this area.

The influence of protein concentration on key quality attributes of chickpea-based alternatives to cheese.

In response to consumer demands, plant protein ingredients are increasingly being used in the formulation of plant-based alternatives to cheese. The aim of this study was to determine the influence of protein concentration on key quality attributes of chickpea-based alternatives to cheese. Moreover, the age-induced changes in such attributes were assessed, with samples analysed after 1 month of storage. After characterisation of the ingredients, the chickpea-based formulations were prepared by blending chickpea flour and protein concentrate in different proportions to obtain four samples of increasing protein content (i.e., 8.68-21.5%). Formulations were developed at pH ∼4.5, and a moisture content of 50%, with shea butter used to obtain 15% fat content. The differential scanning calorimetry thermograms of the samples showed a main peak around 30 °C, corresponding to transition of the shea butter, and a smaller peak around 70 °C related to starch gelatinisation. Analysis of microstructure showed formation of a protein matrix with more extensive protein structure at high protein concentration. Furthermore, none of the chickpea-based samples melted under the testing conditions and all samples showed increasing values for adhesiveness, springiness and cohesiveness with increasing protein content. However, hardness was the highest for the sample with the lowest protein content, likely due to starch retrogradation. After storage, hardness increased further for all samples. This work improves our understanding of the role of chickpea protein in developing plant-based alternatives to cheese and the challenges therein.

The Efficacy and Tolerability of Levetiracetam as a First Line Monotherapy in Childhood Epilepsy.

Introduction To examine efficacy and tolerability of Levetiracetam monotherapy as a first line agent in a national cohort of children with epilepsy, naïve to anti-epileptic medication. Methods A retrospective analysis of children with epilepsy who attended 4 Irish tertiary Paediatric Neurology Clinics (2009-2015) started on Levetiracetam as a first line monotherapy. Results 182 children were identified aged one month to 16 years (mean 6.2 years (SD=5.1) Retention at 6 and 12 months was 88% (n=161) and 83% (n=145) respectively. 75% (n=104) achieved seizure freedom or > 50% improvement in seizure control at 12 months. 30% (n=55) experienced ≥1 adverse effect with aggression (12%; n=21) the most frequent. Treatment was discontinued in 16% (n=29) because of intolerance. Underlying conditions and epilepsy type were not found to influence efficacy or tolerability. Conclusion Levetiracetam monotherapy was observed as effective and safe for children with epilepsy although side effects limit tolerance in a sizeable minority.

Nurses, age, job demands and physical activity at work and at leisure: A cross-sectional study.

BACKGROUND: The nursing workforce is ageing and increased age and demands at work, can impact on physical activity levels in the workplace and at leisure. Research has shown that work physical activity, without activity at leisure, is insufficient to prolong well-being. This study investigated the physical activity levels of a sample of nurses and aimed to determine if age and job demands are associated with engaging in recommended physical activity levels at work and at leisure. METHODS: A cross-sectional study was conducted with data collected during 2016. Two-hundred and ten nurses participated in the study. Two validated instruments were used: the Copenhagen Psychosocial Questionnaire (quantitative and cognitive demands) and the International Physical Activity Questionnaire. RESULTS: Older nurses (≥40-years) were significantly less likely to report engaging in recommended physical activity levels at work than younger nurses [OR 0.47, 95% CI (0.25-0.88) p = 0.02]. Nurses with high quantitative demands were over twice as likely to engage in recommended levels of physical activity at work and at leisure. Engaging in recommended levels of physical activity at work was not associated with leisure-time physical activity reports. CONCLUSION: Initiatives need to be put in place to ensure older nurses can fulfil their nursing role within their capabilities. These could include offering personal physical activity education to both on and off-duty nurses. Assessment of ability and patient acuity may be necessary.

Is the Current BST ePortfolio fulfilling its Role in the Training of Clinical Medicine SHOs?

While the objective recording of clinical competencies in an electronic portfolio (ePortfolio) has become a key aspect of basic specialist training (BST), it continues to divide opinion. We surveyed medical trainees and their supervisors in the Dublin region examining their views of the ePortfolio and workplace-based assessments (WPBAs). Responses were received from 27 of 149 (18.1%) SHOs and 24 of 307 (7.9%) consultants. Our results highlight significant dissatisfaction amongst trainees with 20 (74.1%) stating that the ePortfolio is not an effective educational tool. Consultants had more mixed views. While 16 (66.7%) reported that feedback sessions were useful for trainee development, only 4 (16.7%) found the ePortfolio to be useful in highlighting trainees' strengths and weaknesses. Although other studies have emphasised its educational potential, our results suggest that practical barriers, such as time constraints and a lack of training, lead to poor engagement and a negative view of the ePortfolio.

Efficient expression of stabilized mRNA PEG-peptide polyplexes in liver.

The expression efficiency in liver following hydrodynamic delivery of in vitro transcribed mRNA was improved 2000-fold using a codon-optimized mRNA luciferase construct with flanking 3' and 5' human ß-globin untranslated regions (UTR mRNA) over an unoptimized mRNA without ß-globin UTRs. Nanoparticle UTR mRNA polyplexes were formed using a novel polyacridine polyethylene glycol (PEG) peptide, resulting in an additional 15-fold increase in expression efficiency in the liver. The combined increase in expression for UTR mRNA PEG-peptide polyplexes was 3500-fold over mRNA lacking UTRs and PEG-peptide. The expression efficiency of UTR mRNA polyplex was 10-fold greater than the expression from an equivalent 1 µg dose of pGL3. Maximal expression was maintained from 4 to 24 h. Serum incubation established the unique ability of the polyacridine PEG-peptide to protect UTR mRNA polyplexes from RNase metabolism by binding to double-stranded regions. UTR mRNA PEG-peptide polyplexes are efficient nonviral vectors that circumvent the need for a nuclear uptake, representing an advancement toward the development of a targeted gene delivery system to transfect liver hepatocytes.

The uptake mechanism of PEGylated DNA polyplexes by the liver influences gene expression.

Two uptake mechanisms were identified for PEGylated DNA polyplex biodistribution to the liver. At a low polyplex dose, a rapid-uptake mechanism dominates, resulting in 60% capture by liver in 5 min, due to a saturable receptor-mediated process. Rapid-uptake led to the fast metabolism of polyplexes by liver (t1/2 = 2.1 h), correlating with a 1-µg pGL3 polyplex dose losing full transfection competency after 4 h in the liver. Dose escalation of either polyplex or poly(ethylene glycol) (PEG) peptide led to the saturation of rapid-uptake and revealed a delayed-uptake mechanism for polyplexes by liver. Delayed-uptake was characterized by the slower liver accumulation of 40% of the polyplex dose over 40 min, followed by slow metabolism (t1/2 = 15 h) and an extended time (12 h) for a 1-µg pGL3 polyplex dose, remaining fully transfection competent in the liver. The delayed-uptake mechanism is consistent with polyplexes crossing liver fenestrated endothelial cells to reach steady state in the space of Disse. The results describe how to control polyplex biodistribution to liver to avoid rapid-uptake and metabolism, in favor of delayed-uptake, to preserve polyplex transfection competency in the liver for up to 12 h.

Comparative analysis of two antifungal Lactobacillus plantarum isolates and their application as bioprotectants in refrigerated foods.

AIMS: To compare the technological robustness of two antifungal Lactobacillus plantarum isolates and to assess their ability to inhibit growth of the spoilage yeast Rhodotorula mucilaginosa in two different refrigerated foods. METHODS AND RESULTS: The effects of freeze-drying, thermal treatments and varying salt concentrations on the viability of two antifungal lactic acid bacteria (LAB) were examined. Antifungal compound(s) contained in the supernatant of both isolates were compared to commercially available food preservatives. Both isolates were used as dairy starter adjuncts in yoghurt and inoculants in orange juice to determine the antiyeast activity towards R. mucilaginosa. Yeast growth was retarded by the tested isolates in both food settings with one of the isolates, Lact. plantarum 16, being the most potent inhibitor. CONCLUSIONS: Both lactobacilli exhibited considerable robustness to withstand processing treatments commonly encountered in a food industrial setting. The isolates were shown to possess potent antifungal activity in both in vivo and in vitro food models. SIGNIFICANCE AND IMPACT OF THE STUDY: The studied antifungal lactobacilli may represent safer and consumer-friendly alternatives to the use of chemical preservatives. This is the first report of antifungal Lact. plantarum exerting protective potential in yoghurt and orange juice.

Protease inhibitor-containing antiretroviral treatment and tuberculosis: can rifabutin fill the breach?

OBJECTIVE: To assess how to best manage co-administration of rifabutin (RFB) and human immunodeficiency virus 1 (HIV-1) protease inhibitor (PI) containing antiretroviral treatment (ART). Recommended for initial anti-tuberculosis treatment, rifampicin (RMP) lowers PI concentrations below therapeutic levels, posing significant challenges for ART. As RFB has little effect on PI concentrations, it could be an alternative to RMP. METHODS: A review of the scientific literature on the safety and efficacy of RFB for adult tuberculosis (TB) treatment was conducted, focusing on ART-TB co-therapy. A cost comparison was performed between treatment regimens, and estimates of the burden of TB disease in patients on ART were used to model RFB demand in low- and middle-income countries (LMICs). RESULTS: Eleven clinical studies were identified, comprising 1543 TB patients treated with RFB; 980 (64%) were living with HIV. RFB was as safe and effective as RMP, including in 313 patients receiving co-administered ART (unboosted PIs included indinavir, nelfinavir or saquinavir; a minority received ritonavir [RTV] boosted amprenavir or saquinavir). The total cost for 6 months of all HIV and TB treatment containing RTV-boosted lopinavir (LPV) and RFB is US$410, compared to US$455 if RMP is used with LPV super-boosted with RTV. Our model suggests that demand for RFB in LMICs could be between 10,000 and 18,000 courses by 2012. CONCLUSION: RFB is effective and safe in combination with the PIs studied, cost-saving for co-therapy with currently recommended boosted PIs, and may have a pivotal role in the roll-out of ART. Further research into a daily dose of RFB to simplify dosing regimens and developing fixed-dose combinations can enhance the public sector roll-out of ART.

Cáncer de pulmón y trasplante / Lung cancer and transplant

Resumen. El trasplante pulmonar constituye hoy en día una alternativa eficaz para muchos pacientes con enfermedades respiratorias en sus fases más avanzadas. La indicación actual más frecuente de trasplante pulmonar es el enfisema y, por lo tanto, son pacientes que de base presentan más riesgo que la población general de desarrollar una neoplasia pulmonar. Además, se trata de pacientes que reciben inmunosupresión, lo que condiciona, por diversos motivos, el comportamiento de este tipo de tumores. Por último, en algunos centros se ha indicado el trasplante pulmonar en casos seleccionados con adenocarcinoma bronquioalveolar. El objetivo de este trabajo es revisar nuestra experiencia y la evidencia disponible en cuanto a trasplante pulmonar y cáncer de pulmón (AU)

Abstract. Lung transplantation is a therapeutic alternative to patients with end stage pulmonary disease. Emphysema represents the most frequent indication for lung transplantation, these are patients with a higher risk to develop lung cancer than the normal population. Moreover, lung transplant recipients must receive immunosuppressive drugs, which maymodify the clinical course of these tumors. Finally, there have been reports concerning lung transplantation in selected cases of bronchioalveolar carcinoma. The aim of this work is to revise our experience and the scientific evidence regarding lung transplantation and lung cancer (AU)

Training in the private sector: what works and how do we increase opportunities?

In Australia 61% of elective surgery takes place in private hospitals where current opportunities for surgical education and training (SET) are limited. The situation will shortly be compounded because of the large increase in local medical graduates, many of whom will aspire to be surgeons. How and where to train these extra surgeons to meet the expanding needs of the community must be addressed. Two models of private sector training are reviewed both of which involved combined training in both private and public sectors. Two second-year (SET 2) positions were created from one public hospital SET position by using the private sector for 3.5 days per week for 3 months of a 6-month rotation. The second model was applicable to post-fellowship training with a fairly even split between public and private sector responsibilities. In the first year, four registrars shared the two 6-month rotations for the SET 2 position. Trainees did the required minimum procedures (range 109-139) with primary operating targets of 20-25% (range 21-32%). The post-fellowship position in colorectal surgery was greatly enhanced by the private sector involvement with regard to operating experience as well as meeting part of the remuneration of the trainee. Successful models for training within the private sector in Australia can be found. To expand training in the private sector there will need to be a cultural shift in the perceptions of surgeons, patients, administrators, and trainees. Funding for posts may be available to those private hospitals that can meet the Royal Australasian College of Surgeons' accreditation standards for posts and hospitals.

Role of the laboratory in ensuring global access to ARV treatment for HIV-infected children: consensus statement on the performance of laboratory assays for early infant diagnosis.

A two day meeting hosted by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) was held in May 2006 in Entebbe, Uganda to review the laboratory performance of virologic molecular methods, particularly the Roche Amplicor DNA PCR version 1.5 assay, in the diagnosis of HIV-1 infection in infants. The meeting was attended by approximately 60 participants from 17 countries. Data on the performance and limitations of the HIV-1 DNA PCR assay from 9 African countries with high-burdens of HIV/AIDS were shared with respect to different settings and HIV- subtypes. A consensus statement on the use of the assay for early infant diagnosis was developed and areas of needed operational research were identified. In addition, consensus was reached on the usefulness of dried blood spot (DBS) specimens in childhood as a means for ensuring greater accessibility to serologic and virologic HIV testing for the paediatric population.

Neonatal outcome of antenatally diagnosed congenital cystic adenomatoid malformations.

OBJECTIVE: To investigate the natural history and outcome of antenatally diagnosed congenital cystic adenomatoid malformation (CCAM) of the lung. METHODS: This was a retrospective study of all cases of fetal CCAM of the lung diagnosed antenatally. All cases were referred to a tertiary center for further management. A computer search identified all referred cases, and the records of these patients were examined to determine the pregnancy outcome. RESULTS: In a 4-year period, 34 cases of fetal CCAM were referred for further management. At presentation, all the cases were noted to be unilateral CCAMs and the majority (79%) were microcystic in nature. The CCAMs were complicated by varying degrees of mediastinal shift (79%) and hydrops fetalis (18%). During the course of the pregnancy, the lung lesion was seen to reduce in size or resolve spontaneously in 76% of cases without any prenatal intervention (including resolution of hydrops in three cases). The overall survival rate into infancy was 88%. One pregnancy was terminated for persisting hydrops fetalis and another resulted in infant death from complications of neonatal cardiac surgery for an associated aortic coarctation. CONCLUSION: The outcome of antenatally detected CCAM is much better than previously reported even when complicated by hydrops fetalis at presentation. The latter seems to be related to the high spontaneous regression rate of this tumor. Despite the antenatal resolution of CCAMs on ultrasound, postnatal follow-up is recommended in view of the long-term complications of this malformation.

Solitary infantile myofibroma compromising the airway.

Infantile myofibromatosis is an uncommon and benign condition presenting in the neonatal period. It is self-limiting disease that may present as a localised or generalised process. Various examples of this entity have been reported in the literature. This report describes a neonate with a rapidly growing oropharyngeal lesion obstructing the airway that had the typical histological features of an infantile myofibroma. This case report highlights that a solitary myofibroma may be incredibly extensive making complete excision impossible and can be particularly challenging to manage in terms of airway stabilisation.

Exploring type I angiotensin (AT1) receptor functions through gene targeting.

The renin-angiotensin system (RAS) modulates a diverse set of physiological processes including development, blood pressure, renal function and inflammation. The principal effector molecule of this system, angiotensin II, mediates most of these actions. The classically recognized functions of the RAS are triggered via the type 1 (AT(1)) class of angiotensin receptors. Pharmacological blockade of the AT(1) receptor lowers blood pressure and slows the progression of cardiovascular and renal diseases. Gene-targeting technology provides an experimental approach for precisely dissecting the physiological functions of the RAS. Here, we review how gene-targeting experiments have elucidated AT(1) receptor functions.

Ion cycling in hemlock-northern hardwood forests of the southern Lake Superior region: a preliminary study.

Upland forests of the southern Lake Superior region are diverse and contain a shifting mosaic of eastern hemlock [Tsuga canadensis (L.) Carr.] and northern hardwood forests dominated by sugar maple (Acer saccharum Marsh.). In this study, we survey the relative effects of management practice (old growth vs. managed), forest cover type (hemlock vs. northern hardwood), and soil great group (Entic Haplorthod vs. Alfic Oxyaquic Fragiorthod) on ion cycling as a precursor to a longer-term, more detailed study. Bulk precipitation, throughfall, and soil leachates at three depths were collected for two growing seasons in eight stands on the Ottawa National Forest in the Upper Peninsula of Michigan. A total of 1210 solutions were analyzed for pH, Na, K, Mg, Ca, Cl, NO3, and SO4. Losses of base cations (Ca, Mg, K) and SO4 from the bottom of the rooting zone generally were greater in old-growth than in managed northern hardwoods on both fragic and nonfragic soils. Leaching losses of base cations and NO3 usually were greater beneath old-growth northern hardwoods than beneath old-growth hemlock on both soil types and for both forest cover types and management practices on fragic than nonfragic soils. Management practice, forest cover type, and soil type all appear to affect ion cycling within these forests. All of the stands featured striking losses of base cations that probably are influenced strongly by NO3 and SO4 in atmospheric deposition.

Prevalence of persistent asymptomatic proteinuria in HIV-infected outpatients and lack of correlation with viral load.

AIM: Human immunodeficiency virus-associated nephropathy (HIVAN) is projected to be a leading cause of end-stage renal disease (ESRD) in young African American men in the new millennium. Little is known about the early natural history of the disease, including the prevalence of asymptomatic nephropathy. The primary aim of this study was to define the prevalence of persistent asymptomatic proteinuria in a contemporary, ambulatory human immunodeficiency virus- (HIV) infected population. The secondary aim was to correlate the presence of persistent proteinuria with measures of HIV disease. METHODS: Using a readily available screening tool, the urine dipstick, we determined the prevalence of persistent asymptomatic proteinuria in the outpatient VA Connecticut (VA CT) Healthcare System West Haven HIV Clinic population. We compared the presence of persistent proteinuria with measures of HIV viral disease. RESULTS: The prevalence of persistent asymptomatic proteinuria was 14% (7 of 49 patients). The presence of persistent proteinuria was not correlated with viral load. CONCLUSIONS: A significant prevalence of occult renal disease exists in the asymptomatic HIV-seropositive outpatient population and is not correlated with viral load.