Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture.

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client's evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.

Residual strain mapping through pair distribution function analysis of the porcelain veneer within a yttria partially stabilised zirconia dental prosthesis.

OBJECTIVE: Residually strained porcelain is influential in the early onset of failure in Yttria Partially Stabilised Zirconia (YPSZ) - porcelain dental prosthesis. In order to improve current understanding it is necessary to increase the spatial resolution of residual strain analysis in these veneers. METHODS: Few techniques exist which can resolve residual stress in amorphous materials at the microscale resolution required. For this reason, recent developments in Pair Distribution Function (PDF) analysis of X-ray diffraction data of dental porcelain have been exploited. This approach has facilitated high-resolution (70µm) quantification of residual strain in a YPSZ-porcelain dental prosthesis. In order to cross-validate this technique, the sequential ring-core focused ion beam and digital image correlation approach was implemented at a step size of 50µm. This semi-destructive technique exploits microscale strain relief to provide quantitative estimates of the near-surface residual strain. RESULTS: The two techniques were found to show highly comparable results. The residual strain within the veneer was found to be primarily tensile, with the highest magnitude stresses located at the YPSZ-porcelain interface where failure is known to originate. Oscillatory tensile and compressive stresses were also found in a direction parallel to the interface, likely to be induced by the multiple layering used during fabrication. SIGNIFICANCE: This study provides the insights required to improve prosthesis modelling, to develop new processing routes that minimise residual stress and ultimately to reduce prosthesis failure rates. The PDF approach also offers a powerful new technique for microscale strain quantification in amorphous materials.

Ventricular Assist Device-Associated Infection.

Heart transplant remain the definitive therapy for end-stage heart failure but is limited by the availability of suitable donors. Ventricular assist devices (VAD) are designed as mechanical pumps to supplement or replace the function of damaged ventricles and maintain appropriate blood flow in patients with end-stage heart failure. Survival rates continue to increase in patient with VAD but infection remains a major cause of morbidity and mortality in VAD patients. The authors describe the current concepts regarding definitions, diagnosis, microbiology and principles of management in VAD-associated infections. The authors have also summarised the prevention strategies for infections in VAD patients.

Ministry of Health Clinical Practice Guidelines: Chronic Obstructive Pulmonary Disease.

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Chronic Obstructive Pulmonary Disease (COPD) to provide doctors and patients in Singapore with evidence-based treatment for COPD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on COPD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: https://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Taeniasis and neurocysticercosis among Malaysians.

Taeniasis, endemic in Southeast Asia, is caused by Taenia saginata (for beef) or Taenia solium and Taenia asiatica (for pork). T. solium also causes cysticercosis which can affect various organs. Taeniasis and cysticercosis cases are rarely reported in Malaysia. We report here two separate cases of beef taeniasis, and an interesting case of neurocysticercosis in a Malay Muslim. The taeniasis cases involved a Malaysian Chinese and a native Sabahan. Proglottids were recovered from them, and identification of the tapeworm done either from the microscopic examination of the egg or using PCR-based molecular diagnosis. Upon confirmation of taeniasis, both cases were given praziquantel and had been asymptomatic since. The neurocysticercosis case involving a Muslim who presented with seizure, was confirmed by histopathological examination of tissue sections taken from craniotomy excision of the brain lesion. He was given one month course of albendazole 400 mg bid and dexamethasone, and had been well and seizure free since. The two cases of taeniasis documented here had acquired the disease through eating raw or undercooked contaminated beef. For the neurocyticercosis case, it is suspected that he might have acquired the infection in one of his travels through human to human transmission via contaminated food or water consumption, given that Malaysia is not T. solium endemic area. Lastly praziquantel is an effective drug for beef taeniasis, while a combination of albendazole and dexamethasone work well for neurocysticercosis.

A scaffoldless technique for self-generation of three-dimensional keratinospheroids on liquid crystal surfaces.

We describe a new scaffold-free three-dimensional (3D) cell culture model using cholesteryl ester based lyotropic liquid crystal (LC) substrates. Keratinocytes were deposited randomly on the LC surface where they self-assembled into 3D microtissues or keratinospheroids. The cell density required to form spheroids was optimized. We investigated cell viability using dead/live cell assays. The adhesion characteristics of cells within the microtissues were determined using histological sectioning and immunofluorescence staining. Fourier transform infrared spectroscopy (FTIR) was used to characterize the biochemistry of the keratinospheroids. We found that both cells and microtissues could migrate on the LC surface. The viability study indicated approximately 80% viability of cells in the microtissues up to 20 days of culture. Strong intercellular adhesion was observed in the stratification of the multi-layered microspheroids using field emission-scanning electron microscopy (FE-SEM) and histochemical staining. The cytoskeleton and vinculins of the cells in the microtissues were expressed diffusely, but the microtissues were enriched with lipids and nucleic acids, which indicates close resemblance to the conditions in vivo. The basic 3D culture model based on LC may be used for cell and microtissue migration studies in response to cytochemical treatment.

HIV-1 Tat biosensor: Current development and trends for early detection strategies.

Human immunodeficiency virus (HIV) has infected almost 35 million people worldwide. Various tests have been developed to detect the presence of HIV during the early stages of the disease in order to reduce the risk of transmission to other humans. The HIV-1 Tat protein is one of the proteins present in HIV that are released abundantly approximately 2-4 weeks after infection. In this review, we have outlined various strategies for detecting the Tat protein, which helps transcribe the virus and enhances replication. Detection strategies presented include immunoassays, biosensors and gene expression, which utilize antibodies or aptamers as common probes to sense the presence of Tat. Alternatively, measuring the levels of gene transcription is a direct method of analysing the HIV gene to confirm the presence of Tat. By detection of the Tat protein, virus transmission can be detected in high-risk individuals in the early stages of the disease to reduce the risk of an HIV pandemic.

Stability and motor adaptation in human arm movements.

In control, stability captures the reproducibility of motions and the robustness to environmental and internal perturbations. This paper examines how stability can be evaluated in human movements, and possible mechanisms by which humans ensure stability. First, a measure of stability is introduced, which is simple to apply to human movements and corresponds to Lyapunov exponents. Its application to real data shows that it is able to distinguish effectively between stable and unstable dynamics. A computational model is then used to investigate stability in human arm movements, which takes into account motor output variability and computes the force to perform a task according to an inverse dynamics model. Simulation results suggest that even a large time delay does not affect movement stability as long as the reflex feedback is small relative to muscle elasticity. Simulations are also used to demonstrate that existing learning schemes, using a monotonic antisymmetric update law, cannot compensate for unstable dynamics. An impedance compensation algorithm is introduced to learn unstable dynamics, which produces similar adaptation responses to those found in experiments.

A model of force and impedance in human arm movements.

This paper describes a simple computational model of joint torque and impedance in human arm movements that can be used to simulate three-dimensional movements of the (redundant) arm or leg and to design the control of robots and human-machine interfaces. This model, based on recent physiological findings, assumes that (1) the central nervous system learns the force and impedance to perform a task successfully in a given stable or unstable dynamic environment and (2) stiffness is linearly related to the magnitude of the joint torque and increased to compensate for environment instability. Comparison with existing data shows that this simple model is able to predict impedance geometry well.

How are internal models of unstable tasks formed?

The results of recent studies suggest that humans can form internal models that they use in a feedforward manner to compensate for both stable and unstable dynamics. To examine how internal models are formed, we performed adaptation experiments in novel dynamics, and measured the endpoint force, trajectory and EMG during learning. Analysis of reflex feedback and change of feedforward commands between consecutive trials suggested a unified model of motor learning, which can coherently unify the learning processes observed in stable and unstable dynamics and reproduce available data on motor learning. To our knowledge, this algorithm, based on the concurrent minimization of (reflex) feedback and muscle activation, is also the first nonlinear adaptive controller able to stabilize unstable dynamics.

Advance directive: a study on the knowledge and attitudes among general practitioners in Singapore.

Recent calls for the Advance Directive (AD) to be implemented in Singapore have raised issues regarding the dearth of knowledge and attitude among local healthcare professionals. The present study aims to find out the attitudes and to assess the extent of knowledge regarding the AD among General Practitioners (GPs) in Singapore. This was a cross-sectional, descriptive survey with a sample size of 199 doctors randomly drawn from the Singapore Medical Council list, forming a sampling fraction of 16%. The response rate obtained was 78%. The results showed that while GPs generally supported the concept of the AD, their views were divided on the issue of legislation. They had a basic knowledge of the AD, such as the definition of the AD, that it could be revoked, and the continuity of care and pain relief even after withdrawal of life-sustaining measures. However, only half knew when it should be executed. Many GPs were concerned that the legislation of the AD would lead to the acceptance of euthanasia. They believed that they were in the best position to decide on the treatment of choice for their patients, although they would respect their patients' wishes.