Consultant psychiatrists' experience of the impact of the COVID-19 pandemic on mental health services.

OBJECTIVES: The novel coronavirus 2019 (COVID-19) has spread worldwide threatening human health. To reduce transmission, a 'lockdown' was introduced in Ireland between March and May 2020. The aim of this study is to capture the experiences of consultant psychiatrists during lockdown and their perception of it's impact on mental health services. METHODS: A questionnaire designed by the Royal College of Psychiatrists was adapted and circulated to consultant members of the College of Psychiatrists of Ireland following the easing of restrictions. The questionnaire assessed the perceived impact on referral rates, mental health act provision, availability of information technology (IT), consultant well-being and availability of personal protective equipment (PPE). Thematic analysis was employed to analyse free-text sections. RESULTS: Response rate was 32% (n = 197/623). Consultants reported an initial decrease/significant decrease in referrals in the first month of lockdown (68%, n = 95/140) followed by an increase/significant increase in the second month for both new (83%, n = 100/137) and previously attending patients (65%, n = 88/136). Social isolation and reduced face-to-face mental health supports were among the main reasons identified. The needs of children and older adults were highlighted. Most consultants (76%, n = 98/129) felt their working day was affected and their well-being reduced (52%, n = 61/119). The majority felt IT equipment availability was inadequate (67%, n = 88/132). Main themes identified from free-text sections were service management, relationship between patients and healthcare service and effects on consultants' lives. CONCLUSIONS: The COVID-19 pandemic has placed increased pressure on service provision and consultant wellness. This further supports the longstanding need to increase mental health service investment.

Psychiatrists and COVID-19: what is our role during this unprecedented time?

The declaration of a COVID-19 (Severe Acute Respiratory Syndrome - CoronaVirus2) pandemic by the World Health Organization in March 2020 has vastly changed the landscape in which mental health services function. Consideration is required to adapt services during this unusual time, ensuring continued provision of care for current patients, availability of care for patients with new-onset mental health difficulties and delivery of evidence-based support for healthcare professionals working with affected patients. Lessons can be learned from research carried out during the severe acute respiratory syndrome, Middle East respiratory syndrome and Ebola epidemics to ensure the delivery of efficient and effective mental health services both now and into the future.

Thalamic projection fiber integrity in de novo Parkinson disease.

BACKGROUND AND PURPOSE: Postmortem studies of advanced PD have revealed disease-related pathology in the thalamus with an apparent predilection for specific thalamic nuclei. In the present study, we used DTI to investigate in vivo the microstructural integrity of 6 thalamic regions in de novo patients with PD relative to healthy controls. MATERIALS AND METHODS: Forty subjects (20 with early stage untreated PD and 20 age- and sex-matched controls) were studied with a high-resolution DTI protocol at 3T to investigate the integrity of thalamic nuclei projection fibers. Two blinded, independent raters drew ROIs in the following 6 thalamic regions: AN, VA, VL, DM, VPL/VPM, and PU. FA values were then calculated from the projection fibers in each region. RESULTS: FA values were reduced significantly in the fibers projecting from the AN, VA, and DM, but not the VPL/VPM and PU, in the PD group compared with the control group. In addition, there was a reduction in FA values that approached significance in the VL of patients with PD. These findings were consistent across both raters. CONCLUSIONS: The present study provides preliminary in vivo evidence of thalamic projection fiber degeneration in de novo PD and sheds light on the extent of disrupted thalamic circuitry as a result of the disease itself.

Thalamic integrity underlies executive dysfunction in traumatic brain injury.

OBJECTIVE: To quantify the effects of traumatic brain injury on integrity of thalamocortical projection fibers and to evaluate whether damage to these fibers accounts for impairments in executive function in chronic traumatic brain injury. METHODS: High-resolution (voxel size: 0.78 mm x 0.78 mm x 3 mm(3)) diffusion tensor MRI of the thalamus was conducted on 24 patients with a history of single, closed-head traumatic brain injury (TBI) (12 each of mild TBI and moderate to severe TBI) and 12 age- and education-matched controls. Detailed neuropsychological testing with an emphasis on executive function was also conducted. Fractional anisotropy was extracted from 12 regions of interest in cortical and corpus callosum structures and 7 subcortical regions of interest (anterior, ventral anterior, ventral lateral, dorsomedial, ventral posterior lateral, ventral posterior medial, and pulvinar thalamic nuclei). RESULTS: Relative to controls, patients with a history of brain injury showed reductions in fractional anisotropy in both the anterior and posterior corona radiata, forceps major, the body of the corpus callosum, and fibers identified from seed voxels in the anterior and ventral anterior thalamic nuclei. Fractional anisotropy from cortico-cortico and corpus callosum regions of interest did not account for significant variance in neuropsychological function. However, fractional anisotropy from the thalamic seed voxels did account for variance in executive function, attention, and memory. CONCLUSIONS: The data provide preliminary evidence that traumatic brain injury and resulting diffuse axonal injury results in damage to the thalamic projection fibers and is of clinical relevance to cognition.

Congenital unilateral pulmonary venous atresia: definitive diagnosis and treatment.

Three cases of unilateral right-sided pulmonary venous atresia were evaluated over an 18-year period. These bring the total number of cases to 25 in the literature. The clinical presentation of all these patients was similar and consisted of recurrent pulmonary infections, asthma-like symptoms, and exercise intolerance. The patients presented in 1982 (patient 1, a 12-year-old boy), 1994 (patient 2, a 9-year-old girl), and 1999 (patient 3, a 13-year-old boy). All patients were evaluated with a chest roentgenogram, and patients 1 and 2 had a ventilation and perfusion scan. Patients 1 and 3 also had cardiac catheterization and pulmonary angiography. Patient 2 had a magnetic resonance imaging study of the chest. Only patient 3 had wedge pulmonary angiography. Although a rare congenital defect, this diagnosis should be strongly suspected based on the typical clinical presentation and the preliminary studies, such as the chest roentgenogram and ventilation and perfusion scan. However, for definitive diagnosis, cardiac catheterization with wedge pulmonary angiography is necessary. Anastomosis of the atretic pulmonary veins to the left atrium is a theoretical consideration. However, this may not be feasible due to pulmonary venous anatomy or significant pulmonary dysfunction with pulmonary vascular changes. In these circumstances, we recommend performing pneumonectomy to remove the nidus for repeated bouts of pulmonary infections, to eliminate the left-to-right shunt, and to eliminate the dead space contributing to exercise intolerance.

Medicaid's beta 2-agonist recipients and their treatment by national standards.

OBJECTIVE: To determine whether Connecticut's Medicaid high-dose beta 2-agonists (HDB) users (> 1 canister/mo) are receiving medications according to National Institutes of Health (NIH) asthma guidelines, and to compare healthcare utilization between HDB users and patients receiving no more than one canister of a short-acting beta 2-agonist per month. METHODS: All Connecticut Medicaid pharmacy claims from April to December 1998 were examined. Subjects were included if they had an asthma diagnosis and were excluded if they had chronic obstructive pulmonary disease. The percentage of HDB users not receiving long-term-control medication; receiving low doses of a long-term-control medication; and receiving oral, nebulized, or long-acting beta 2-agonists was determined. Healthcare utilization between HDB users and patients receiving no more than one canister of a short-acting beta 2-agonist per month was also compared. RESULTS: Of 1599 profiles included, 14% (n = 223) were HDB users. Twenty-five percent of these patients did not receive a long-term-control medication, and 35% received low doses of a long-term-control medication. Claims for oral, nebulized, and long-acting beta 2-agonists were submitted for 4%, 29%, and 22% of HDB users, respectively. More claims for short courses of oral corticosteroids were submitted for HDB users than for patients receiving no more than one canister of a short-acting beta 2-agonist per month (n = 1376) (1.99 +/- 3.60 vs. 0.39 +/- 1.07 mean +/- SD; p < 0.001). HDB users visited their physicians' offices an average of 4.72 +/- 24.08 times per month compared with an average of 2.40 +/- 14.4 office visits per month for patients receiving no more than one canister of a short-acting beta 2-agonist (p = 0.04). CONCLUSIONS: A high proportion of Connecticut's Medicaid HDB users are not receiving medications according to NIH guidelines. HDB users were significantly more likely to receive short courses of oral corticosteroids and required significantly more office visits than patients receiving no more than one canister of a short-acting beta 2-agonist per month. Intervention programs designed to improve adherence to the guidelines will be developed.

Pulmonary arteriovenous malformations after cavopulmonary connection.

We report the case of a child with hypoplastic left heart syndrome who developed pulmonary arteriovenous (AV) malformations after superior cavopulmonary anastomoses. Resolution of the pulmonary AV malformations occurred following a completion Fontan procedure. This phenomenon has been reported previously, but only in patients with heterotaxy and polysplenia.

Pathological characteristics and prognosis of nonpalpable and palpable prostate cancers with a Hybritech prostate specific antigen of 4 to 10 ng./ml.

PURPOSE: We compared the surgical pathological findings and postoperative course of patients with palpable and nonpalpable prostate cancers. MATERIALS AND METHODS: All patients with untreated prostate specific antigen (PSA) 4 to 10 ng./ml. who underwent radical prostatectomy between December 1984 and December 1993 were reviewed to select 61 with clinical stage T1c (nonpalpable) with stages T2a to c (palpable) disease. RESULTS: Nonpalpable cancers were smaller (2.99 versus 4.42 cc for palpable tumors), had smaller volumes of Gleason grade 4 to 5 cancer (0.66 versus 1.32 cc, respectively) and were less likely to have positive surgical margins (13 versus 22%, respectively) or significant (1 cm. or more) capsular penetration (10 versus 26%, respectively). Nonpalpable and palpable cancers had similar rates of seminal vesicle invasion (3.3 versus 4.3%, respectively) and positive lymph nodes (1.6 versus 0%, respectively). More than 90% of patients with nonpalpable cancer were biochemically cancer-free postoperatively, and the remainder were alive with disease after a mean followup of 25.1 months, compared to 69% disease-fee, 28% alive with disease and 2.5% dead of prostate cancer after mean followup of 43.8 months among those with palpable disease. CONCLUSIONS: We conclude that nonpalpable prostate cancers are pathologically more favorable than palpable prostate cancers with PSA 4 to 10 ng./ml. Our preliminary results also indicate that nonpalpable cancers are less likely to recur postoperatively than palpable cancers with a similar PSA range.

Testicular torsion with contralateral vanishing testis.

An infant with a left hydrocele and nonpalpable right testis had an antenatal ultrasonogram showing a left hydrocele and normal right testis. When left inguinal hydrocelectomy was performed, extravaginal torsion of the spermatic cord and a normal testis was discovered. The right spermatic cord ended in a testicular remnant. We propose that this was a case of bilateral antenatal torsion that would have resulted in bilateral vanishing testis syndrome had the left hydrocele not prevented vascular compromise when antenatal testicular torsion occurred. This case gives visible support to the theory that testicular remnants are the result of antenatal torsion.

Nerve sparing radical prostatectomy: a different view.

Erectile dysfunction was evaluated in 459 men with prostate cancer before and after radical prostatectomy. Potency was defined as the ability to achieve unassisted intercourse with vaginal penetration. Of the patients 51 were potent postoperatively, including 2 of 187 (1.1%) undergoing surgery without nerve sparing, and 27 of 203 (13.3%) undergoing unilateral and 22 of 69 (31.9%) undergoing bilateral nerve sparing prostatectomy. Less than half of the patients who were sexually active postoperatively were satisfied with the erections or achieved intercourse at least once a month. Postoperative potency was statistically related to the number of neurovascular bundles spared, frequency of intercourse preoperatively, absence of seminal vesicle or lymph node involvement with cancer, absence of postoperative incontinence or strictures, patient age and cancer volume.

Incontinence and vesical neck strictures following radical retropubic prostatectomy.

OBJECTIVES: To evaluate the incidence and severity of vesical neck strictures and urinary incontinence after radical retropubic prostatectomy (RRP) for prostate cancer. METHODS: Between August 1983 and December 1991, 481 consecutive patients underwent RRP by 1 of 2 senior surgeons. Strictures were treated by passing a urethral sound. Incontinence was measured by asking patients for a daily "pad count" of pads required to control urinary leakage. Results were compared to patient age, tumor volume, number of neurovascular bundles spared, preoperative urinary complaints, and previous transurethral resection of the prostate. RESULTS: Of 456 patients with adequate follow-up to determine stricture formation, 82.5% had no strictures, 6.8% required a single dilation, 3.7% required 2 dilations, 3.1% required 3 dilations, and 3.9% required more than 3 dilations. Risk of stricture formation was unrelated to every variable studied. Of 458 patients with adequate follow-up to determine recovery of continence, 80.1% required no pads, 8.1% required 1 to 2 pads a day, 6.6% required 3 to 5 pads a day, and 5.2% were totally incontinent 1 year or more after surgery. Incontinence was closely associated with postoperative urinary urgency. CONCLUSIONS: Strictures are a common but easily managed complication of RRP for prostate cancer. Despite substantial surgical experience, we report a somewhat higher rate of postoperative incontinence than other recently reported series. Our experience is more closely matched by published surveys of patient-reported complications after RRP.

Biology and treatment of pediatric genitourinary tumors.

Treatment of childhood genitourinary tumors continues to advance through the use of collaborative protocols and a multidisciplinary approach. This paper reviews the 1993 literature, with an emphasis on Wilms' tumor, rhabdomyosarcoma, and testicular intraepithelial neoplasia and its relationship to testicular maldescent.

Insulin-like growth factor-I is internalized after binding to the type I insulin-like growth factor receptor.

Receptor-mediated endocytosis may represent an important mechanism whereby peptide hormones exert their biological effects. The ability of recombinant insulin-like growth factor (IGF)-I to be internalized by cultured cells was evaluated in BRL-3A2 cells, a rat liver-derived cell line which lacks insulin receptors. Since recombinant IGF-I does not bind to the Type II IGF receptor, all specific binding of 125I-IGF-I in BRL-3A2 cells represents binding to the Type I receptor. Exposure of BRL-3A2 cells to IGF-I resulted in a rapid 50% downregulation of Type I IGF receptors. Only one-half of these binding sites were sensitive to treatment with trypsin, a phenomenon which indicates that the peptide and its receptor were internalized after the cells were exposed to IGF-I. In conclusion, these experiments demonstrate that IGF-I can be internalized by cultured cells via the Type I IGF receptor, and suggest that IGF hormone action may be exerted by receptor-mediated endocytosis.

Triiodothyronine regulates insulin-like growth factor-I binding to cultured rat pituitary cells.

Abstract Triiodothyronine (T(3)) stimulates the synthesis of growth hormone and enhances the growth of neoplastic rat pituitary somatomam-motrophs (GH cells) in culture. Moreover, T(3) has been shown to stimulate the production and secretion of an autocrine growth factor by these cells. We have previously demonstrated the presence of specific receptors for insulin-like growth factors (IGF) on GH cells. Since GH(3) cells contain mRNA encoding IGF-I, it has been suggested that IGF-I might act in an autocrine fashion in these cells. Therefore, it was of interest to learn how T(3) affects IGF-I binding to GH(3) cells. T(3) increased [(125)I]IGF-I binding in a time - and dose-dependent manner. After 48 h of exposure to T(3), an increase in IGF-I binding was seen with 10(-11)M T(3), maximizing with 10(-8)M T(3). When cells were exposed to 10(-8) T(3), [(125)I]IGF-I binding reached a maximum of 218 +/- 20.8% of control (+/-SEM, P < 0.002) after 72 h of incubation. Scatchard analysis indicated that T(3) did not alter the K(d) of IGF-I for its receptor, but that the total receptor number was increased. Dexamethasone (10(-7)M) inhibited the T(3)-induced increase in IGF-I binding, but glucocorticoid alone did not substantially alter receptor number. No significant change in insulin or IGF-II binding was seen after hormone treatment. 10(-8) M T(3) or IGF-I increased the growth of the GH(3) cells by >/=30%. Our data indicate that T(3) upregulates IGF-I binding in GH(3) cells without altering insulin binding and thereby provides a means for enhancing potential autocrine regulation in this cell line.

Aberrant regulation of the metabolism of the insulin receptor in Swarm rat chondrosarcoma chondrocytes.

Treatment of Swarm rat chondrosarcoma chondrocytes for 3 days in media containing either non-recombinant pig or recombinant human insulin (1 micrograms/ml) increased the rate of proteoglycan synthesis approximately 6-fold compared with cells cultured in the absence of insulin. The concentrations of human and pig insulin that stimulated the cells to double their rate of proteoglycan synthesis were approximately 1 ng/ml and approximately 2 ng/ml respectively. Because physiological concentrations of insulin do not influence proteoglycan synthesis in non-transformed chondrocytes, the findings indicated a possible abnormality in the insulin-dependent regulation of the insulin receptor in these tumour cells. Like most cells, chondrosarcoma chondrocytes down-regulated their insulin receptors when incubated with insulin for 30 min. However, the number of plasma-membrane and intracellular insulin receptors did not decrease when the chondrocytes were exposed to insulin chronically for 4 days. Chondrocytes were cultured in media containing 2H-, 13C- and 15N-labelled amino acids, and the heavy-isotope density-shift method was used to investigate both the rate of degradation and the rate of synthesis of the insulin receptor. Although the rate of synthesis of the receptor was slightly faster in the insulin-treated cultures, as assessed by a slightly faster rate of appearance of the 'heavy' receptor, the rate of degradation of the receptor was slower in the insulin-treated cultures. The half-lives for the 'light' receptors were approx. 18 h and 10 h for chondrocytes cultured in insulin-containing and insulin-free media respectively. These studies in vitro indicate that the apparent up-regulation of insulin receptors that occurs in this transformed cell upon long-term exposure to insulin is primarily the result of a decreased rate of receptor degradation.