Electroconvulsive Therapy Credentialing for Psychiatrists-Review of Required Standards Across States and Territories in Australia.

ABSTRACT: Electroconvulsive therapy (ECT) is a complex medical procedure, the delivery of which requires specialist knowledge and skills. We reviewed the standards required for ECT credentialing in different jurisdictions in Australia. We reviewed the Chief Psychiatrist guidelines and statewide policy standards on ECT and focused on standards required for initial credentialing and ongoing privileging in ECT. We compared the credentialing requirements within these documents with the standards specified in the Royal Australian and New Zealand College of Psychiatrists professional practice guideline for ECT. Most of the jurisdictions had specific standards for initial credentialing and maintenance of this credentialing; however, there was significant variance in the credentialing process and standards required. It would be useful to have a minimum standard for credentialing for ECT psychiatrists and prescribers. This standard would be relevant for practice of ECT internationally. States and territories would have the responsibility for implementation of these standards. Appropriate training and establishing good clinical governance processes are essential to the provision of high quality ECT.

Prescribing electroconvulsive therapy for depression: Not as simple as it used to be.

In the last century, prescribing electroconvulsive therapy usually involved considering the relative merits of unilateral versus bilateral electroconvulsive therapy, with most other parameters fixed. However, research over the last 30 years has discovered that several parameters of the electroconvulsive therapy stimulus can have a significant impact on efficacy and cognitive side effects. The stimulus dose relative to seizure threshold was shown to significantly affect efficacy, especially for right unilateral electroconvulsive therapy, where suprathreshold doses in the vicinity of 5-6 times seizure threshold were far more efficacious than doses closer to threshold. However, this did not hold for bitemporal electroconvulsive therapy, where near-threshold stimuli were equally effective as suprathreshold stimuli. Then, changes in stimulus pulse width were found to also have a significant impact on both efficacy and side effects, with ultrabrief pulse widths of 0.3 ms having significantly fewer cognitive side effects in unilateral electroconvulsive therapy than standard brief pulse widths of 1.0 ms, with only slightly reduced efficacy. Therefore, choosing the optimum electroconvulsive therapy prescription for an individual patient now requires consideration of placement, pulse width and stimulus dose relative to seizure threshold, and how these three interact with each other. This viewpoint aims to raise awareness of these issues for psychiatrists involved in electroconvulsive therapy practice.

The place of non-invasive brain stimulation in the RANZCP clinical practice guidelines for mood disorders.

Clinical practice guidelines are important documents as they have the capacity to significantly influence and shape clinical practice in important areas of therapeutics. As such, they need to be developed informed by comprehensive and quality-based systematic reviews, involve consensus deliberations representative of the appropriate experts in the field and be subject to thorough critical review. A revised clinical practice guideline for the management of patients with mood disorders was recently published under the auspices of the Royal Australian and New Zealand College of Psychiatrists. However, this clinical practice guideline was not developed in a manner that reflects the appropriate standards that should apply to clinical practice guideline development and it has critical flaws, especially as it pertains to the use of repetitive transcranial magnetic stimulation treatment for patients with depression. The revision of the college clinical practice guideline has explicitly removed clear and unequivocal evidence-based recommendations that were found in a previous version of the clinical practice guideline and replaced these with consensus-based recommendations. However, the consensus-based recommendations were developed without consultation of the appropriate expert body within the college and contradict the scientific literature. There is substantive and unequivocal evidence supporting the antidepressant use of repetitive transcranial magnetic stimulation in the treatment of patients with depression and its use after a patient with depression has failed a limited number (typically around two) of antidepressant medication trials. Readers should refer to the college Professional Practice Guidelines for repetitive transcranial magnetic stimulation published in 2018 for thorough information about the use of this important new treatment.

A Nutritional Profile of the Trap-Nesting Wasp Trypoxylon lactitarse (Hymenoptera: Crabronidae): Comparison of Sexes and Overwintering and Non-Overwintering Generations.

The wasp Trypoxylon lactitarse Saussure is a bivoltine trap-nesting species that possesses a non-overwintering generation (G1) and a generation that overwinters as a prepupa (G2). Thus, the nutritional needs of the G1 individuals were predicted to be different than the G2 because the latter generation needs to store energy prior to diapause. Trap-nesting Trypoxylon are also of interest because, unlike most Hymenoptera, the males guard the nest while females forage. Thus, males may lose nutrients as they stay and guard the nest. In this study, a nutritional profile was created for T. lactitarse to compare the macronutrient (protein, carbohydrates, and lipids) and micronutrient (Ca, Cu, Fe, K, Mg, Mn, Na, and Zn) levels of the different life stages of the wasp and compare individuals of the G1 and G2 generations. There were distinct changes in the nutrient levels relative to the original food source as individuals metamorphosed into larvae, pupae, and adults. G1 larvae had higher levels of carbohydrates than G2 larvae. G2 larvae had higher levels of lipids and K than G1 larvae, indicating possible differences in energy storage. In adults, there was an increase in levels of carbohydrates and Mn. Parental males, which stay and guard the nest, were found to have higher levels of carbohydrates at the end of the nesting period than females and emerging adults. One possible implication is that females may feed males during the nesting period, as the females are the only individuals to forage.

A nutritional profile of the social wasp Polistes metricus: differences in nutrient levels between castes and changes within castes during the annual life cycle.

In wasps, nutrition plays a vital role for colony cohesion and caste determination. However, there is no baseline data set for the nutritional levels of wasps during the different stages of the colony cycle. Here we examined the levels of carbohydrates, lipids, protein, Ca, Cu, Fe, K, Mg, Mn, Na, and Zn in the wasp Polistes metricus at different stages of the wasp's lifecycle. Individuals were collected at the following stages (1) spring gynes, (2) foundress colonies, (3) early worker colonies, (4) late worker colonies, (5) emerging reproductives (gynes and males), (6) early fall reproductives, and (7) late fall reproductives. All eggs, larvae, pupae and adults were analyzed for their nutritional content to determine if there were any differences between the nutrient levels in the different castes and how these nutrients changed within a caste during its lifetime. The results show there are differences in macro and micronutrient levels between the reproductive females and workers during development. Gynes showed changes in nutrient levels during their lifetime especially as they changed roles from a solitary individual to a nesting queen. Males also showed distinct nutritional changes during their lifetime. The implications for these nutritional differences are discussed.

Mechanisms of the aqueous photodegradation of polycyclic aromatic hydrocarbons.

The role of O2 and photoionization as well as the involvement of polycyclic aromatic hydrocarbon (PAH) cation radicals (P+) in the photodegradation of nine PAHs was examined. Photodegradation quantum yields for all PAHs increased with increasing O2 concentration, illustrating the key role of O2 in the photodegradation mechanism. In the presence of a series of electron donors (to P+), the photodegradation rate constants of most PAHs were largely unaffected at low O2 concentrations (< or = 250 microM), indicating that P+ is not extensively produced. However, at higher O2 concentrations (up to 1.2 mM), the presence of the donors substantially lowered photodegradation rates for most PAHs, indicating that P+ is produced and is arising from O2 reaction with the excited singlet state. Because little P+ was detected at low O2 concentrations and, further, because degradation rates were not enhanced in the presence of N2O, we conclude that photoionization is unimportant. With some exceptions, photodegradation can proceed through reaction of O2 with both excited singlet and triplet states of the PAHs. Our results indicate that photodegradation via the excited singlet state occurs primarily through electron transfer to O2, whereas degradation via the triplet occurs predominately through a direct reaction of O2 with the PAH within the collision complex.

Aqueous photodegradation of polycyclic aromatic hydrocarbons.

Photodegradation of 12 polycyclic aromatic hydrocarbons was studied in aerated pure water, solutions of Suwannee River fulvic acid, and natural waters using polychromatic light (>290 nm). Quantum yields in pure water varied from 3.2 x 10(-5) to 9.2 x 10(-3). No obvious relationships were evident among the quantum yields and molecular properties. Photodegradation rate constants in solutions of Suwannee River fulvic acid or natural waters were largely unchanged compared to rate constants in pure water. Estimates of PAH photodegradation rates in natural waters can thus be obtained employing the quantum yields in pure water, PAH absorption, and solar irradiance. Calculated rate constants for photodegradation in surface waters during the summertime at mid-latitude varied from 3.2 x 10(-3) to 7.6 h(-1).