Ventromedial prefrontal cortex activation and neurofeedback modulation during episodic future thinking for individuals with suicidal thoughts and behaviors.

Individuals experiencing suicidal thoughts and behaviors (STBs) show less specificity and positivity during episodic future thinking (EFT). Here, we present findings from two studies aiming to (1) further our understanding of how STBs may relate to neural responsivity during EFT and (2) examine the feasibility of modulating EFT-related activation using real-time fMRI neurofeedback (rtfMRI-nf). Study 1 involved 30 individuals with major depressive disorder (MDD; half with STBs) who performed an EFT task during fMRI, for which they imagined personally-relevant future positive, negative, or neutral events. Positive EFT elicited greater ventromedial prefrontal cortex (vmPFC) activation compared to negative EFT. Importantly, the MDD + STB group exhibited reduced vmPFC activation across all EFT conditions compared to MDD-STB; although EFT fluency and subjective experience remained consistent across groups. Study 2 included rtfMRI-nf focused on vmPFC modulation during positive EFT for six participants with MDD + STBs. Results support the feasibility and acceptability of the rtfMRI-nf protocol and quantitative and qualitative observations are provided to help inform future, larger studies aiming to examine similar neurofeedback protocols. Results implicate vmPFC blunting as a promising treatment target for MDD + STBs and suggest rtfMRI-nf as one potential technique to explore for enhancing vmPFC engagement.

Protocol for a randomized controlled trial examining multilevel prediction of response to behavioral activation and exposure-based therapy for generalized anxiety disorder.

BACKGROUND: Only 40-60% of patients with generalized anxiety disorder experience long-lasting improvement with gold standard psychosocial interventions. Identifying neurobehavioral factors that predict treatment success might provide specific targets for more individualized interventions, fostering more optimal outcomes and bringing us closer to the goal of "personalized medicine." Research suggests that reward and threat processing (approach/avoidance behavior) and cognitive control may be important for understanding anxiety and comorbid depressive disorders and may have relevance to treatment outcomes. This study was designed to determine whether approach-avoidance behaviors and associated neural responses moderate treatment response to exposure-based versus behavioral activation therapy for generalized anxiety disorder. METHODS/DESIGN: We are conducting a randomized controlled trial involving two 10-week group-based interventions: exposure-based therapy or behavioral activation therapy. These interventions focus on specific and unique aspects of threat and reward processing, respectively. Prior to and after treatment, participants are interviewed and undergo behavioral, biomarker, and neuroimaging assessments, with a focus on approach and avoidance processing and decision-making. Primary analyses will use mixed models to examine whether hypothesized approach, avoidance, and conflict arbitration behaviors and associated neural responses at baseline moderate symptom change with treatment, as assessed using the Generalized Anxiety Disorder-7 item scale. Exploratory analyses will examine additional potential treatment moderators and use data reduction and machine learning methods. DISCUSSION: This protocol provides a framework for how studies may be designed to move the field toward neuroscience-informed and personalized psychosocial treatments. The results of this trial will have implications for approach-avoidance processing in generalized anxiety disorder, relationships between levels of analysis (i.e., behavioral, neural), and predictors of behavioral therapy outcome. TRIAL REGISTRATION: The study was retrospectively registered within 21 days of first participant enrollment in accordance with FDAAA 801 with ClinicalTrials.gov, NCT02807480. Registered on June 21, 2016, before results.

How normative interpretations of climate risk assessment affect local decision-making: an exploratory study at the city scale in Cork, Ireland.

Urban areas already suffer substantial losses in both economic and human terms from climate-related disasters. These losses are anticipated to grow substantially, in part as a result of the impacts of climate change. In this paper, we investigate the process of translating climate risk data into action for the city level. We apply a commonly used decision-framework as our backdrop and explore where in this process climate risk assessment and normative political judgements intersect. We use the case of flood risk management in Cork city in Ireland to investigate what is needed for translating risk assessment into action at the local city level. Evidence presented is based on focus group discussions at two stakeholder workshops, and a series of individual meetings and phone-discussions with stakeholders involved in local decision-making related to flood risk management and adaptation to climate change, in Ireland. Respondents were chosen on the basis of their expertise or involvement in the decision-making processes locally and nationally. Representatives of groups affected by flood risk and flood risk management and climate adaptation efforts were also included. The Cork example highlights that, despite ever more accurate data and an increasing range of theoretical approaches available to local decision-makers, it is the normative interpretation of this information that determines what action is taken. The use of risk assessments for decision-making is a process that requires normative decisions, such as setting 'acceptable risk levels' and identifying 'adequate' protection levels, which will not succeed without broader buy-in and stakeholder participation. Identifying and embracing those normative views up-front could strengthen the urban adaptation process-this may, in fact, turn out to be the biggest advantage of climate risk assessment: it offers an opportunity to create a shared understanding of the problem and enables an informed evaluation and discussion of remedial action.This article is part of the theme issue 'Advances in risk assessment for climate change adaptation policy'.

A prospective audit on the effect of training and educational workshops on the incidence of urethral catheterization injuries.

INTRODUCTION: The incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries. METHODS: A prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data. RESULTS: The incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100). CONCLUSIONS: Current forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design.

Veterans with post-traumatic stress disorder exhibit altered emotional processing and attentional control during an emotional Stroop task.

BACKGROUND: Post-traumatic stress disorder (PTSD) is often associated with attention allocation and emotional regulation difficulties, but the brain dynamics underlying these deficits are unknown. The emotional Stroop task (EST) is an ideal means to monitor these difficulties, because participants are asked to attend to non-emotional aspects of the stimuli. In this study, we used magnetoencephalography (MEG) and the EST to monitor attention allocation and emotional regulation during the processing of emotionally charged stimuli in combat veterans with and without PTSD. METHOD: A total of 31 veterans with PTSD and 20 without PTSD performed the EST during MEG. Three categories of stimuli were used, including combat-related, generally threatening and neutral words. MEG data were imaged in the time-frequency domain and the network dynamics were probed for differences in processing threatening and non-threatening words. RESULTS: Behaviorally, veterans with PTSD were significantly slower in responding to combat-related relative to neutral and generally threatening words. Veterans without PTSD exhibited no significant differences in responding to the three different word types. Neurophysiologically, we found a significant three-way interaction between group, word type and time period across multiple brain regions. Follow-up testing indicated stronger theta-frequency (4-8 Hz) responses in the right ventral prefrontal (0.4-0.8 s) and superior temporal cortices (0.6-0.8 s) of veterans without PTSD compared with those with PTSD during the processing of combat-related words. CONCLUSIONS: Our data indicated that veterans with PTSD exhibited deficits in attention allocation and emotional regulation when processing trauma cues, while those without PTSD were able to regulate emotion by directing attention away from threat.

Evaluating the cost of iatrogenic urethral catheterisation injuries.

INTRODUCTION: Technique is vital to prevent urethral trauma during urethral catheterisation (UC). Education programmes are helpful but are not compulsory and safe UC remains operator dependent. Traumatic UC is associated with increased morbidity, length of stay, resource utilisation and surgical intervention. AIM: To determine the cost of iatrogenic urethral injuries managed in a tertiary referral centre over a 6-month period. METHODS: A 6-month prospective study monitored iatrogenic urethral injuries secondary to traumatic UC. Included were referrals from district hospitals and inpatient consultations relating to urethral injury caused by traumatic UC. The added cost of management was estimated. RESULTS: Thirteen iatrogenic urethral injuries were recorded in 6 months. Management included open surgery for a ruptured bladder (n = 1), flexible cystourethroscopy (n = 10), suprapubic catherisation (n = 4), 3-way catheterisation (n = 4) and catheter re-insertion under direct vision (n = 6). The cost of acute management of these injuries was approximately €50,000 including theatre costs, ambulance transfer, hospital stay, procedural and equipment costs and short-term follow-up care. CONCLUSION: Iatrogenic injuries during UC represent a significant cost burden to the healthcare system. Training programmes should be compulsory for all healthcare professionals routinely involved in catheterisation procedures.

An Unusual Case Of Urinary Bladder Arteriovenous Malformation.

A 45-year-old male presented with haematuria and urinary frequency. Computed Tomography (CT) urogram revealed gross thickening of the left bladder wall. Histology showed large vessels cuffed by eosinophonilic material suggestive of urinary bladder arteriovenous malformation (AVM). No further intervention was carried out as symptoms resolve after the resection. Follow up rigid cystoscopy and CT at 3 months showed resolution of all visible pathology and no evidence of recurrence.

Transurethral resection of the prostate--"now and then".

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

Delayed contrast-enhanced MRI to localize Botox after cystoscopic intravesical injection.

PURPOSE: There is a lack of studies to show localization of botulinum toxins (BoNT) within bladder wall and/or absorption rates. Our study examined the later distribution of BoNTA/gadolinium within the bladder wall by performing a delayed MRI scan after intravesical injection. This potentially may help to explain the level and mechanism at which BoNT may be producing its effect. METHODS: A prospective study enrolled 20 consecutive patients with neuropathic or idiopathic overactive bladders. The Aim of the study was to perform MRI 3 h post procedure. Botox 100-200 IU was reconstituted with 19 ml saline and 1 ml of gadolinium contrast. Intradetrusor injections were administered using a rigid 21F cystoscope with a total of 20 injections into bladder wall, including two into the trigone. The depth of injection was approximately 2 mm, without raising a bleb. One radiologist reviewed films and reported on the number of bladder walls with contrast, location, the presence of extravesical extravasation, contrast in distal ureter(s), and bladder wall thickness. RESULTS: Ninety percentage of patients had contrast within bladder wall. There was a variation in the number of bladder walls involved; 85 % had contrast seen in at least two walls. Also, a variation was noted in the extent of extravasation; 80 % showed some evidence. CONCLUSIONS: Diffusion of BoNT after intravesical injection is very common once bladder wall is breeched. Precise injection localization into muscle layer may not be as relevant to outcome as previously assumed. The assumption in our study that localization and diffusion of contrast also represents the localization of BoNT is open to critique as BoNT diffusion is potentially slower (Mehnert et al. in World J Urol 27(3):397-403, 2009). The absence of systemic symptoms after the injection in our series supports guidelines concerning the safety of procedure.

A 30-year experience of Millin's retropubic prostatectomy: Has this classic operation derived by a President of the College in Ireland stood the test of time?

INTRODUCTION: In patients with large gland volume, open prostatectomy/adenoma enucleation remains a valuable surgical option in treating large obstructing prostates. We report our series of open prostatectomies spanning 32 years from a single institution. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent open prostatectomy between 1980 and 2012. Patient demographical, clinical, pre- and postoperative data and final histology were retrieved from hospital in-patient enquiry system and chart review. RESULTS: A total of 161 patients underwent Millin's prostatectomy by seven surgeons between 1980 and 2012. The mean blood loss was 1,381 mls (range 300-3,675 mls). One-third (34%) of patients (n = 55) received a blood transfusion. The mean weight of prostate tissue removed was 119 g (median 112 g, range 17-372 g). 6.6 % of pathological specimens revealed incidental prostate cancer, of which 78% were well differentiated (Gleason score ≤ 6). The mean weight of prostate tissue removed in patients who received a transfusion was 124 g. Trial of micturition (TOM) was performed at a mean of 9 days (median 9 days, range 5-25 days) with 94% of patients having a successful trial of voiding. 6% of cases early in the series failed to void initially, but did so at later removal of catheter while still in hospital. 45 patients (28%) of patients developed peri- or postoperative complications. There were three deaths (1.9%). CONCLUSION: Open Millin's prostatectomy popularized over half a century ago continues to be a valuable option for the surgical treatment of high-volume prostate glands with excellent outcomes for patients.

Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis.

A 44-year-old Indian national with a prostate-specific antigen of 5.4 ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum ß lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2 months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting.

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

The effect of a Rapid Access Prostate Cancer Clinic on prostate cancer patient and disease characteristics, primary treatment and surgical workload.

BACKGROUND: In 2009, Rapid Access Prostate Cancer Clinics (RAPC) were introduced to St. James's Hospital to improve the access and organisation of patients to prostate cancer investigations and treatment. AIMS: To observe the effects of the RAPC on prostate cancer diagnosis, primary treatment and overall workload. METHODS: Using a prospectively designed patient database, the records of all prostate cancer patients between 2007 and 2011 were retrieved and analysed. Data were obtained for age, PSA, biopsy Gleason score and primary treatment modality and charted for the observation and comparison of trends. RESULTS: Seven hundred and eighty-nine patients had a new diagnosis of prostate cancer between 2007 and 2011. The median PSA prior to the RAPC was 9.7-13.1 ng/ml, which decreased to 7.79-9 ng/ml after the RAPC. Prior to the RAPC, 77-81 biopsies were performed annually versus 149-271 in the post-RAPC era. Annual requirements for radical prostatectomy also increased from 12 to 27 in the post-RAPC era. Conversely, an initially increasing percentage of patients for radiotherapy was reversed in the post-RAPC period. An increasing trend for higher grade PCa (Gleason score 4 + 4 and higher) was also reversed. CONCLUSIONS: The introduction of a RAPC improves the overall pathological characteristics of patients with prostate cancer. However, RAPCs are also associated with a considerable increase in surgical workload. These are important considerations for units considering the incorporation of a similar facility in their institutions.

Cyanidiales diversity in Yellowstone National Park.

The Cyanidiales are unicellular red algae that are unique among phototrophs. They thrive in acidic, moderately high-temperature habitats typically associated with geothermally active regions, although much remains to be learned about their distribution and diversity within such extreme environments. We focused on Yellowstone National Park (YNP), using culture-dependent efforts in combination with a park-wide environmental polymerase chain reaction (PCR) survey to examine Cyanidiales diversity and distribution in aqueous (i.e. submerged), soil and endolithic environments. Phylogenetic reconstruction of Cyanidiales biodiversity demonstrated the presence of Cyanidioschyzon and Galdieria lineages exhibiting distinct habitat preferences. Cyanidioschyzon was the only phylotype detected in aqueous environments, but was also prominent in moist soil and endolithic habitats, environments where this genus was thought to be scarce. Galdieria was found in soil and endolithic samples, but absent in aqueous habitats. Interestingly, Cyanidium could not be found in the surveys, suggesting this genus may be absent or rare in YNP. Direct microscopic counts and viable counts from soil samples collected along a moisture gradient were positively correlated with moisture content, providing the first in situ evidence that gravimetric moisture is an important environmental parameter controlling distribution of these algae.

Impact of Lepeophtheirus salmonis infestations on migrating Atlantic salmon , Salmo salar L., smolts at eight locations in Ireland with an analysis of lice-induced marine mortality.

Sea lice infestation as a source of marine mortality of outwardly migrating Atlantic salmon smolts has been investigated by treating groups of ranched salmon, prior to release, with a prophylactic sea lice treatment conferring protection from sea lice infestation. A number of studies have been carried out in Ireland using both established ranched populations and groups of hatchery reared fish imprinted for 5-8 weeks in the sites of experimental releases. In this study, data on 352 142 migrating salmon from twenty-eight releases, at eight locations along Ireland's South and West coasts covering a 9-year period (2001 to 2009) are reviewed. Both published and new data are presented including a previously unpublished time series. The results of a meta-analysis of the combined data suggest that while sea lice-induced mortality on outwardly migrating smolts can be significant, it is a minor and irregular component of marine mortality in the stocks studied and is unlikely to be a significant factor influencing conservation status of salmon stocks.

An 11-year analysis of the prevalent uropathogens and the changing pattern of Escherichia coli antibiotic resistance in 38,530 community urinary tract infections, Dublin 1999-2009.

BACKGROUND: Knowledge of local antimicrobial resistance patterns is essential for evidence-based empirical antibiotic prescribing, and a cutoff point of 20% has been suggested as the level of resistance at which an agent should no longer be used empirically. We sought to identify the changing incidence of causative uropathogens over an 11-year period. We also examined the trends in antibiotic resistance encountered in both the pooled urine samples and those where the causative organism was Escherichia coli. PATIENT AND METHODS: A retrospective analysis of the antimicrobial resistance within the positive community urine isolates over the 11-year period, 1999 to 2009, in a single Dublin teaching hospital was performed. RESULTS: In total 38,530 positive urine samples processed at our laboratory originated in the community of which 23,838 (56.7%) had E. coli as the infecting organism. The prevalence of E. coli has been increasing in recent years in community UTIs with 70.4% of UTIs in the community caused by E.coli in 2009. Ampicillin and trimethoprim were the least-active agents against E. coli with mean 11-year resistance rates of 60.8 and 31.5%, respectively. Significant trends of increasing resistance over the 11-year period were identified for trimethoprim, co-amoxyclav, cefuroxime and gentamicin. Ciprofloxacin remains a reasonable empirical antibiotic choice in this community with an 11-year resistance rate of 10.6%. Higher antibiotic resistance rates were identified in the male population and in children. CONCLUSION: Resistance rates to commonly prescribed antibiotics are increasing significantly. This data will enable evidence-based empirical prescribing which will ensure more effective treatment and lessen the emergence of resistant uropathogens in the community.

Percutaneous nephrolithotomy in adult patients with spina bifida, severe spinal deformity and large renal stones.

AIMS: To present our experience in patients with spina bifida with severe spinal abnormality undergoing percutaneous nephrolithotomy (PCNL) for large stone burden. PATIENTS AND METHODS: A retrospective review identified five spina bifida patients with abnormal spinal curvature who had a PCNL for large kidney stones. The mean age was 28 years. In two patients, stones were on the concave side of the scoliotic spine further limiting percutaneous access. Mean stone burden was 940 mm2. All patients were paraplegic, three patients had symptomatic stone disease. We performed initial percutaneous renal access in radiology department and staged nephrolithotomy in operating room. Tract dilatation was accomplished using Amplatz dilators and a 24 Ch or 26 Ch nephroscope was used. Fragmentation and stone removal were accomplished in all patients using pneumatic and or ultrasound lithotripter and a retrieval grasper. RESULTS: No anaesthetic complications were recorded. One patient required multiple percutaneous tracts, four had single tract to access stones. Three patients were stone free after PCNL. One required second PCNL through the same tract and another patient had multiple adjunctive ESWL. All five patients were stone clear after the final procedure. Two patients required blood transfusion. No patient had major complication or admission to intensive care unit. CONCLUSIONS: Percutaneous nephrolithotomy in patients with spina bifida is challenging but safe. Detailed pre-operative anaesthetic assessment and precise uroradiological evaluation of renal anatomy is essential. Second-look PCNL and additional ESWL/URS treatment may be required to completely clear stones.

Management of recalcitrant urethral strictures with self-dilatation balloon catheter.

INTRODUCTION: Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE: To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS: Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS: Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS: Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.