Monthly engagement with EIP keyworkers was associated with a five-fold increase in the odds of engagement with psychosocial interventions.

BACKGROUND: Early intervention in psychosis (EIP) supports people who are experiencing their first episode of psychosis (FEP). A new Model of Care (MoC) for EIP services was launched in Ireland in 2019. Three EIP demonstration sites were chosen to test this MoC through a 'hub and spoke' approach. These services were a new way of organising care for people experiencing FEP, based upon a recovery model of care, and which sought to standardise care, improve access by clinically led multidisciplinary teams. This included newly created EIP keyworker roles whereby keyworkers assumed responsibilities regarding assessment, comprehensive individual care planning and coordination of care. METHODS: A mixed methods design utilising the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were utilised. Descriptive analyses and logistic regression were performed to examine how increased keyworker engagement influenced the use of other psychosocial interventions within the EIP demonstration sites. Thematic analyses was used for qualitative data. RESULTS: There was a strong positive relationship between keyworker contacts and psychosocial interventions offered. Specifically, the odds of achieving at least monthly engagement with cognitive behavioural therapy for psychosis (CBTp; (5.76 (2.43-13.64), p < 0.001), and behavioural family therapy (BFT; (5.52(1.63-18.69, p < 0.006)) increased by fivefold with each additional monthly keyworker contact. For individual placement support (IPS) each additional monthly keyworker contact was associated with a three-fold increase in the odds of achieving monthly attendance with IPS (3.73 (1.64-8.48), p < 0.002). Qualitative results found that the EIP keyworker role as viewed by both service users and staff as a valuable nodal point, with a particular emphasis on care coordination and effective communication. CONCLUSIONS: This study advances the understanding of keyworker effects through qualitative evidence of keyworkers functioning as a "linchpin" to the service, while the positive response association between keyworker contacts and engagement with other services provides quantitative support for keyworkers reducing the organisational or structural barriers to service access. Given the importance of these positions, health systems should ensure that EIP programmes identify qualified and experienced staff to fill these roles, as well as allocate the appropriate funding and protected time to support keyworker engagement and impact.

Barriers and facilitators to the implementation of an early intervention in psychosis service in three demonstration sites in Ireland.

BACKGROUND: Programmes for early intervention (EIP) in psychosis for people experiencing a first episode of psychosis (FEP) have been found to be both clinically and cost effective. Following the publication of a new EIP model of care (MoC) in Ireland, the aim of this research is to describe how people participated in and responded to the MoC including service users, family members, HSE clinical staff and HSE management. METHODS: Qualitative design using the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were used. A total of N = 40 key informant semi-structured interviews were completed which included clinical staff (N = 22), health service managers and administrators (N = 9), service users (N = 8) and a family member (N = 1). Thematic analyses were conducted. RESULTS: Unique features of the EIP service (e.g., speed of referral/assessment, multidisciplinary approach, a range of evidence-based interventions and assertive MDT follow up) and enthusiasm for EIP were identified as two key factors that facilitated implementation. In contrast, obstacles to staff recruitment and budget challenges emerged as two primary barriers to implementation. CONCLUSIONS: The findings from this research provide real world insights into the complexity of implementing an innovative service within an existing health system. Clear and committed financial and human resource processes which allow new innovations to thrive and be protected during their initiation and early implementation phase are paramount. These elements should be considered in the planning and implementation of EIP services both nationally in Ireland and internationally.

An audit of assessment rooms for mental health assessments in Ireland's emergency departments.

OBJECTIVES: To audit compliance of mental health assessment rooms in Irish adult emergency departments (EDs) which are open 24 hours on 7 days a week with standards identified by the Psychiatric Liaison Accreditation Network (PLAN). METHODS: A self-audit tool was sent via email to Clinical Nurse Specialists and Consultant Psychiatrists in Ireland's 26 Adult EDs that are open 24 hours on seven days a week. Results were collated and are presented ensuring anonymity. RESULTS: A response rate of 100% was achieved. Full or substantial compliance with PLAN standards was recorded in 73% of services. In seven services, the rooms used for mental health assessments were unsuitable when measured against the PLAN standards. A number of services identified the presence of ligature points within the rooms. CONCLUSION: The Health Service Executive (HSE) National Clinical Programme for the Assessment and Management of patients presenting to the ED following self-harm is committed to achieving 100% compliance with PLAN standards in all services. Recommendations include introducing formal ligature risk assessments and risk assessments of the use of the assessment rooms. The Chief Executive Officers of all hospital groups were informed of the results of the audits and advised on recommendations for each hospital ED.

Early Intervention in Psychosis services: A systematic review and narrative synthesis of the barriers and facilitators to implementation.

BACKGROUND: Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation. METHODS: We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool. RESULTS: Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35 years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services. CONCLUSIONS: A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.

Idiopathic pulmonary arterial hypertension in a pot-bellied pig (Sus scrofa domesticus) with right-sided congestive heart failure.

Idiopathic pulmonary arterial hypertension is a rare disease reported in humans and dogs diagnosed as persistent elevation of pulmonary arterial blood pressure without predisposing or associated diseases. A four-month-old pot-bellied pig (Sus scrofa domesticus) was presented for decreased appetite, lethargy, respiratory distress, and occasional syncope. On physical examination, the pig was tachypneic with labored breathing, with a distended abdomen and a bilateral grade 4-5/6 parasternal systolic heart murmur. Systolic pulmonary arterial pressure was estimated at 95 mmHg by Doppler echocardiography, consistent with severe pulmonary hypertension. At autopsy, there was dilation of the main pulmonary artery and right ventricle. The lungs were diffusely rubbery, and there was tricavitary effusion. Microscopically, there was severe widespread pulmonary arterial concentric medial hypertrophy with rare plexiform lesions. The clinical history and gross and microscopic findings supported a diagnosis of idiopathic pulmonary arterial hypertension with subsequent right-sided congestive heart failure. Primary (idiopathic) pulmonary arterial hypertension should be considered as a differential diagnosis in young pigs with right-sided congestive heart failure.

Improvements in Clinical Outcomes in Children with Cystic Fibrosis aged Six and 16 years.

Aims Our aim was to assess if outcomes for cystic fibrosis (CF) patients at six & sixteen years of age have improved in the last 17 years looking at FEV1, BMI and death. Methods A retrospective observational study using a prospectively maintained database of CF patients at Cork University Hospital. Results 84 patients were included in the 16-year-old data and 89 patients were included in the six-year-old data. The mean FEV1 and BMI (16 years) for the 2002-2007 group was 72.9±21.0% and 18.9±2.53 respectively, 2008-2013 group was 75.4±27.2% and 19.8±2.7 and for the 2014-2018 group was 95.2±16.0% and 22.9±4.1. The percentage of patients (16 years) with chronic pseudomonas status was 37.9% (11/30) in the 2002-2007 group, 51.6 % (16/31) in the 2008-2013 group and 4.2% (1/24) in the 2014-2018 group. The relationship between FEV1 and FVC with BMI remained significant in multivariate analysis (P <0.001). The mean FEV1 (six years) for the 2002-2007 group was 90.7±16.1%, 2008-2013 group was 99.3±17.9% and for the 2014-2018 group was 100.9±15.8%. Conclusions Improvements in FEV1 and BMI aged six and 16 years are notable as well as a significant decline in the number of patients with chronic pseudomonas.

Antenatal Ultrasound Detection of Cleft in Western Australia from 2003 to 2012: A Follow-Up Study.

AIM: To investigate trends in the rate of antenatal detection of cleft lip and palate (CLP) patients referred to the CLP Unit at Princess Margaret Hospital for Children in Perth, Western Australia during the period 2003-2012 and compare data with a previously published report covering the years 1996-2003. METHODS: This is a single-center, retrospective survey of antenatal transabdominal ultrasound screenings of mothers of infants born between July 1, 2003 and June 30, 2012 that were referred to the CLP Unit at Princess Margaret Hospital. RESULTS: Detection rates of oral clefts increased significantly when compared with outcomes reported in the same population between 1996 and 2003 (P < .05). An overall detection rate of 71.7% (165/230) was achieved for clefts involving lip and palate. Detection of isolated cleft palate (1/99) and microform (0/8) remained elusive. Most detections (76.5%) were achieved at 15 to 20 weeks of gestational age, corresponding with routine anatomical screening. A further 16.8% were detected post-20 weeks of gestation. Scans were performed by specialist obstetricians, and sonography clinics reported a detection rate of 84.6% (55/65), whereas nonspecialist clinics reported a detection rate of only 67.1% (110/164). CONCLUSION: The antenatal detection rates of oral clefts involving the lip have improved to the extent that the majority of mothers are now being referred to a cleft unit in Western Australia prior to the births of their children. As a result of this improvement, antenatal counseling is now a common facet of cleft management.

Management of orbital fractures: challenges and solutions.

Many specialists encounter and treat orbital fractures. The management of these fractures is often challenging due to the impact that they can have on vision. Acute treatment involves a thorough clinical examination and management of concomitant ocular injuries. The clinical and radiographic findings for each individual patient must then be analyzed for the need for surgical intervention. Deformity and vision impairment can occur from these injuries, and while surgery is intended to prevent these problems, it can also create them. Therefore, surgical approach and implant selection should be carefully considered. Accurate anatomic reconstruction requires complete assessment of fracture margins and proper implant contouring and positioning. The implementation of new technologies for implant shaping and intraoperative assessment of reconstruction will hopefully lead to improved patient outcomes.

Facial fractures in children.

Facial trauma in children differs from adults. The growing facial skeleton presents several challenges to the reconstructive surgeon. A thorough understanding of the patterns of facial growth and development is needed to form an individualized treatment strategy. A proper diagnosis must be made and treatment options weighed against the risk of causing further harm to facial development. This article focuses on the management of facial fractures in children. Discussed are common fracture patterns based on the development of the facial structure, initial management, diagnostic strategies, new concepts and old controversies regarding radiologic examinations, conservative versus operative intervention, risks of growth impairment, and resorbable fixation.

African American rhinoplasty.

Rhinoplasty in patients of African descent requires a patient-specific approach, because the goals and ideal proportions differ from the white nose. This article discusses approaches to surgical correction of common anatomic variations. In addition, common pitfalls are outlined.

Prospective quality of life assessment in congenital laryngomalacia.

PURPOSE OF STUDY: Disturbances in breathing or feeding may profoundly affect parental perceptions of a newborn's health. Previous research into quality of life for patients with laryngomalacia is limited to retrospective analysis. The purpose of this study is to prospectively evaluate the quality of life of families of infants with laryngomalacia and the impact of surgical and non-surgical treatments. DESIGN AND METHOD: Pilot prospective analysis using the laryngomalacia quality of life (QOL) survey in families of infants with newly diagnosed laryngomalacia under age one year. A 29-question survey regarding severity of symptoms related to overall health, airway, and swallowing is completed at initial and post-treatment visits. Responses are quantified over a range from 1 to 5 (1 never to 5 always). RESULTS: Twenty-six families were enrolled in the study. Eleven patients were managed medically and fifteen underwent supraglottoplasty. The overall mean QOL score for patients treated medically was 2.57 (standard error, SE 0.16) on initial visit and 1.67 (SE 0.16) post-treatment (mean 3.9 months). Patients undergoing supraglottoplasty had an overall mean QOL score of 3.59 (SE 0.14) on initial visit and 2.22 (SE 0.22) post-treatment (mean 3.5 months). Analysis of variance (ANOVA) and post hoc testing revealed significant improvement between initial and follow-up visits in both treatment groups (p < 0.01). Patients who underwent supraglottoplasty had significantly higher scores at initial visit (p < 0.01). No statistically significant difference was noted between patient groups post-treatment (p > 0.05). CONCLUSIONS: Prospective QOL assessment of children with laryngomalacia and their families reveals a significant burden of disease. Quality of life improves in all patients but may improve more significantly in patients managed surgically.

Predominant Acidilobus-like populations from geothermal environments in yellowstone national park exhibit similar metabolic potential in different hypoxic microbial communities.

High-temperature (>70°C) ecosystems in Yellowstone National Park (YNP) provide an unparalleled opportunity to study chemotrophic archaea and their role in microbial community structure and function under highly constrained geochemical conditions. Acidilobus spp. (order Desulfurococcales) comprise one of the dominant phylotypes in hypoxic geothermal sulfur sediment and Fe(III)-oxide environments along with members of the Thermoproteales and Sulfolobales. Consequently, the primary goals of the current study were to analyze and compare replicate de novo sequence assemblies of Acidilobus-like populations from four different mildly acidic (pH 3.3 to 6.1) high-temperature (72°C to 82°C) environments and to identify metabolic pathways and/or protein-encoding genes that provide a detailed foundation of the potential functional role of these populations in situ. De novo assemblies of the highly similar Acidilobus-like populations (>99% 16S rRNA gene identity) represent near-complete consensus genomes based on an inventory of single-copy genes, deduced metabolic potential, and assembly statistics generated across sites. Functional analysis of coding sequences and confirmation of gene transcription by Acidilobus-like populations provide evidence that they are primarily chemoorganoheterotrophs, generating acetyl coenzyme A (acetyl-CoA) via the degradation of carbohydrates, lipids, and proteins, and auxotrophic with respect to several external vitamins, cofactors, and metabolites. No obvious pathways or protein-encoding genes responsible for the dissimilatory reduction of sulfur were identified. The presence of a formate dehydrogenase (Fdh) and other protein-encoding genes involved in mixed-acid fermentation supports the hypothesis that Acidilobus spp. function as degraders of complex organic constituents in high-temperature, mildly acidic, hypoxic geothermal systems.

[The Carnot efficiency and plant photosystems].

The concept that the Carnot efficiency places an upper limit of 0.60-0.75 on the thermodynamic efficiency of photosynthetic primary photochemistry is examined using the PSI-LHCI preparation. The maximal quantum efficiency was determined approximately 0.99 which yielded a thermodynamic efficiency of 0.96, a value far above that predicted on the basis of the Carnot efficiency. The commonly presented reasoning leading to the Carnot efficiency idea was therefore critically examined. It is concluded that the crucial assumption that the pigment system, under illumination, is in equilibrium with the incident light field, at a black body temperature of Tr, is erroneous, as the temperature of the excited state pigments was experimentally shown to be that of the sample solvent (thermal bath), 280 K in this case. It is concluded that the classical reasoning used to describe the thermodynamics of heat systems is not applicable to "photonic" systems such as plant photosystems.

Selectin blockade decreases postischemic recruitment of bone marrow stromal cells.

OBJECTIVES/HYPOTHESIS: Investigate the localization mechanisms of bone marrow stromal cells following transient ischemia-reperfusion injury in a murine flap model. STUDY DESIGN: Controlled laboratory study. METHODS: A cutaneous flap based on the inferior epigastric artery was elevated, and transient ischemia of 3.5 hours using a microvascular clamp was achieved. Fucoidan was injected intravenously 24 hours before the ischemic period. Following the period of ischemia, radiolabeled bone marrow stromal cells were injected intravenously, and radioactivity was determined postoperatively. RESULTS: Attenuation of the uptake of bone marrow stromal cells into postischemic tissue was observed in those mice treated with fucoidan as indicated by gamma counts measured in the flaps when compared with controls (P < . 001). CONCLUSIONS: Decreased uptake of radiolabeled bone marrow stromal cells into postischemic tissues pretreated with fucoidan indicates selectin-mediated bone-marrow stromal cell recruitment in a murine cutaneous flap model.

Recurrent multifocal diabetic myonecrosis: a cause of severe extremity pain in a diabetic patient.

We detail the unusual occurrence of successive episodes of diabetic myonecrosis in both lower and upper limbs in a young woman with diabetic end organ dysfunction. We highlight the importance of recognising this as a differential diagnosis for acute limb pain in diabetic patients and advocate conservative measures for successful treatment and return to function.

Immediate pain response to interlaminar lumbar epidural steroid administration: response characteristics and effects of anesthetic concentration.

BACKGROUND AND PURPOSE: Interlaminar LESIs are commonly used to treat LBP or radiculopathy. Most studies focus on the long-term outcomes of LESI. The purpose of this study is to evaluate the immediate effects of fluoroscopically guided LESI on LBP/radiculopathy including low- or high-strength anesthetic response. MATERIALS AND METHODS: The procedure notes, post-procedure records, and imaging records dedicated spine nurse assessments, and imaging records were retrospectively evaluated in 392 fluoroscopically guided LESIs performed in 276 patients (nonrandomized, nonblinded; 131 males, 145 females; average age, 56 years) with LBP/radiculopathy using either low- or high-strength anesthetic (80 mg of methylprednisilone mixed with bupivacaine [0.25% or 0.5%]). Post-procedure documentation of the patient's pre- and postprocedure VAS pain-scale level were tabulated. RESULTS: Single LESI was performed in 199 patients, with multiple LESIs in 77 (193 injections). Low-strength bupivacaine (0.25%) was used in 237 injections, with high-strength (0.5%) in 155. Complete to near-complete immediate pain relief (<20% residual pain) was reported after 197 of 392 (50.3%) injections. No pain relief was reported after 60 (15.4%) injections (>80% residual), with partial relief in the remainder. No statistical difference was noted between low- and high-anesthetic strength or between single- and multiple-injection patients. In multiple-LESI patients, consistent pain relief response was noted in 39 of 77 (50.6%) patients, with improving LESI response in 20.8%, deteriorating LESI response in 19.5%, and variable response in 9.1%. CONCLUSIONS: An immediate pain-extinction response is identified after LESI, which appears independent of anesthetic strength. This observation may relate to pain origin and/or pain nociceptor afferent pathway in an individual patient and potentially relate to treatment response.

Comparison of CD34, CD31, and factor VIII-related antigen immunohistochemical expression in feline vascular neoplasms and CD34 expression in feline nonvascular neoplasms.

The diagnosis of vascular neoplasms is often facilitated by the use of immunohistochemical markers such as factor VIII-related antigen, CD31, and CD34. However, the relative sensitivity and specificity of these markers have not been compared in cat vascular neoplasms. In this study, these 3 immunohistochemical markers were evaluated in 61 endothelial neoplasms (50 hemangiosarcomas and 11 hemangiomas) in 59 cats. All neoplasms were labeled by all 3 markers. CD34 had the highest average immunolabeling intensity in neoplastic endothelial cells. CD31 had the lowest average background labeling, followed by CD34 and factor VIII-related antigen, respectively. CD34 expression was also examined in 130 nonvascular neoplasms of cats; 14 of 62 epithelial neoplasms, 39 of 43 mesenchymal neoplasms, 8 of 23 leukocytic neoplasms, and 2 of 2 melanomas were positive. Given the broad expression of CD34 in mesenchymal neoplasms, this marker has limited diagnostic relevance for vascular neoplasms of cats.

TU-E-217BCD-01: X-Ray Spectra for Breast CT.

PURPOSE: To study a range of x-ray spectra with regard to their suitability for dedicated breast CT, taking into account realistic tube loading limitations. METHODS: A simple theoretical model was used to get a preliminary indication of the best mono-energetic x-ray energy as a function of object size. That model was extended to poly-energetic spectra and used to study a range of object sizes, tube voltages, filter materials, and filter thicknesses. Spectra from IPEM Report 78 were used as input to the model. Initially we have looked at lanthanide filters (Z = 57-60) and tube voltages from 30 to 80 kVp. Outputs from the model included contrast, contrast-to-noise ratio (CNR), dose, dose efficiency (CNR̂2/dose), and tube loading. Dose was estimated as incident minus transmitted energy fluence. We have also started experiments to verify the computational results. Experiments are done using a bench-top cone beam CT and a 14 cm diameter cylindrical PMMA phantom filled with liquid mixtures equivalent to breast tissue of varying glandularity. We use reconstructed data to determine the CNR of a test block representing 100% glandular breast tissue, immersed in the liquid. Air kerma measurements are obtained at the center and periphery of the phantom, and used in the calculation of dose efficiency. Monte Carlo calculations are being done to get a more accurate dose estimate. RESULTS: For a constant CNR, computational results indicate that as filter thickness increases above 0.4 mm dose efficiency plateaus. However, the power required to maintain a constant CNR becomes prohibitively large for filter thicknesses greater than 0.3 mm. CONCLUSIONS: Spectra generated at tube voltages above 40 kVp are likely to provide the best trade-off between dose efficiency and tube loading. For lanthanide filters, there is little benefit from using thicknesses greater than 0.3 mm.

Cervicofacial advancement-rotation flap in midface reconstruction: forward or reverse?

OBJECTIVE: To present the authors' experience and outcomes in the reconstruction of midfacial defects using cervicofacial advancement-rotation flaps (CARFs) based on a method of determining forward or reverse design in relation to the proportions of the defect. STUDY DESIGN: Case series with retrospective chart review. SETTING: Tertiary care academic medical center. SUBJECTS AND METHODS: Patients who underwent CARF reconstruction and the subset of patients with midfacial defects medial to the lateral canthus were included. CARF was designed in a forward fashion with an anteromedial movement for the defects with a larger vertical dimension and in a reverse fashion with a posterosuperior movement for the defects with a larger horizontal dimension. RESULTS: Thirteen of 45 patients who underwent CARF reconstruction qualified for the analysis as a subset based on defect location. CARF was used in a forward fashion in 7 patients and in a reverse fashion in 6 patients. The largest defect in this subset was measured as 9 × 6 cm, while the smallest defect was 3 × 2 cm. Average follow-up was 11.5 months. None of the patients developed partial or total flap loss. Six patients had mild ectropion, which was managed with conservative measures only. The outcome of the reconstruction was satisfactory in all cases. CONCLUSION: Designing the CARF based on the proportion of the vertical and horizontal diameters of the selected midfacial defects as described allows for closure of the defects with minimal tension and minimizes the amount of discarded healthy skin overlapping at the suture lines.