Association between continuity of care and attendance of post-discharge follow-up after psychiatric emergency presentation.

The number of accident and emergency (A&E) hospital attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition more than tripled between 2010 and 2022. After discharge from the hospital, attendance at follow-up appointments in the community is critical to ensure the safety of young people and optimise the use of clinical resources. A retrospective cohort study was conducted to evaluate the association between follow-up attendance and the continuity of clinicians and clinical teams, using electronic clinical record data from East London NHS Foundation Trust (ELFT), between April 2019 and March 2022. Multi-level mixed effects logistic regression was performed to model the follow-up attendance odds based on whether the same or different clinician and clinical team offered the initial A&E and the community follow-up appointment or whether a crisis team was involved. 3134 A&E presentations by 2368 young people were identified within the study period. Following these presentations, 2091 follow-up appointments in the community were offered. The attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in A&E (odds ratio (OR) = 3.66; 95% CI 1.65-8.13). Whether the same clinical team provided the community follow-up appointment, or whether a crisis team was involved before discharge made no difference to the likelihood of follow-up attendance. The findings support the importance of the continuity of clinicians in the care of young people in crisis.

Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase.

BACKGROUND: Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies. METHODS: This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers. DISCUSSION: This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain. TRIAL REGISTRATION: ISRCTN ISRCTN42999542, Registration on April 29, 2020.

Intensive community care services for children and young people in psychiatric crisis: an expert opinion.

BACKGROUND: Children and young people's (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails. METHODS: A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up. RESULTS: ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children's Global Assessment Scale were agreed. CONCLUSIONS: This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Self-Harm in Children and Adolescents Who Presented at Emergency Units During the COVID-19 Pandemic: An International Retrospective Cohort Study.

OBJECTIVE: To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations. METHOD: This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed. RESULTS: Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58). CONCLUSION: Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs. DIVERSITY & INCLUSION STATEMENT: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Clean clothes or dirty clothes? Outbreak investigation of carbapenem-resistant Acinetobacter baumannii related to laundry contamination through multilocus sequence typing (MLST).

OBJECTIVE: To investigate the source in an outbreak of carbapenem-resistant Acinetobacter baumannii (CRA) in a general hospital due to contamination of a laundry evaporative cooler and the laundry environment using multilocus sequence typing (MLST). METHODS: For CRA culture, clinical samples were collected from infected patients and close contacts, and environmental sampling was performed in patient surroundings and laundry facilities. MLST was used for the molecular typing of representative CRA isolates. Bacterial isolates with identical sequence types were considered epidemiologically linked and attributable to the same source. OXA genes in Acinetobacter baumannii were detected using polymerase chain reaction (PCR). RESULTS: In total, 58 patients were affected in this outbreak. The mean patient age was 75.3, and 50% were female. The most common diagnoses at admission were skin and soft-tissue infection (n = 12, 20.7%) and pneumonia (n = 12, 20.7%). OXA-23 was positive in 64.7% of isolates. A CRA isolate from the evaporative cooler in the laundry was identical to that of 11 patients across 3 wards, belonging to ST345. Isolates from 3 laundry linen racks were identical to those of 7 patients from 3 wards, classified as ST1145. Isolates found on another linen rack and a pajama shelf were identical to isolates from 3 other patients from 2 wards, belonging to ST2207. There was no significant difference between sequence type distributions of clinical and environmental isolates (P = .12), indicating high likelihood of CRA originating from the same source. CONCLUSIONS: MLST confirmed that contamination of the laundry evaporative cooler and surrounding environment caused a polyclonal CRA hospital outbreak. Hospital laundry is an important area for infection control and outbreak investigations of CRA.

Topical application of the plant extract SDTL-E in ovariectomized rats: A potential new approach for treating osteoporosis.

Current osteoporosis medications have drawbacks of causing side effects and having slow onset, therefore developing osteoporosis drugs with faster onset and less side effects is essential. This study investigated the effects of the natural plant extract, SDTL-E, in ovariectomized (OVX)-induced osteoporosis rats. Rats were randomly assigned to sham operation control group (Control Group); OVX rat model group (Model Group) or OVX rat SDTL-E treatment group (SDTL-E Group). All groups underwent ovariectomy, but the Control Group did not have the ovaries removed. SDTL-E Group was treated with SDTL-E, Model and Control Groups were treated with vegetable oil, treatments were topically applied twice daily for 20 days. Results showed when compared with Model Group, SDTL-E Group significantly restored serum estradiol back to near Control Group level, serum ALP activity, serum and urinary calcium were significantly decreased, bone mechanics indicators increased and trabecular bone numbers slightly increased. These results demonstrated 20 days of SDTL-E topical treatment improved bone strength and trabecular bone structure in OVX-induced osteoporosis rats. The underlying mechanisms include restoring estradiol level, reducing bone turnover, net bone resorption, bone calcium loss, and calcium excretion through kidney. These findings suggest topical application of plant extract is a potential new approach with quick efficacy for treating osteoporosis.

Lockdown stringency and paediatric self-harm presentations during COVID-19 pandemic: retrospective cohort study.

BACKGROUND: Lockdown during the pandemic has had significant impacts on public mental health. Previous studies suggest an increase in self-harm and suicide in children and adolescents. There has been little research on the roles of stringent lockdown. AIMS: To investigate the mediating and predictive roles of lockdown policy stringency measures in self-harm and emergency psychiatric presentations. METHOD: This was a retrospective cohort study. We analysed data of 2073 psychiatric emergency presentations of children and adolescents from 23 hospital catchment areas in ten countries, in March to April 2019 and 2020. RESULTS: Lockdown measure stringency mediated the reduction in psychiatric emergency presentations (incidence rate ratio of the natural indirect effect [IRRNIE] = 0.41, 95% CI [0.35, 0.48]) and self-harm presentations (IRRNIE = 0.49, 95% CI [0.39, 0.60]) in 2020 compared with 2019. Self-harm presentations among male and looked after children were likely to increase in parallel with lockdown stringency. Self-harm presentations precipitated by social isolation increased with stringency, whereas school pressure and rows with a friend became less likely precipitants. Children from more deprived neighbourhoods were less likely to present to emergency departments when lockdown became more stringent. CONCLUSIONS: Lockdown may produce differential effects among children and adolescents who self-harm. Development in community or remote mental health services is crucial to offset potential barriers to access to emergency psychiatric care, especially for the most deprived youths. Governments should aim to reduce unnecessary fear of help-seeking and keep lockdown as short as possible. Underlying mediation mechanisms of stringent measures and potential psychosocial inequalities warrant further research.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study.

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Invasive Burkholderia cepacia Complex Infections among Persons Who Inject Drugs, Hong Kong, China, 2016-2019.

During March 2016-January 2019, Burkholderia cepacia complex (BCC) infection developed in 13 persons who inject drugs (PWID) in Kowloon West Region, Hong Kong, China. Seven cases were infective spondylitis, 2 endocarditis, 2 septic arthritis, 1 intramuscular abscess and bacteremia, and 1 necrotizing fasciitis. Pulsed-field gel electrophoresis revealed that the isolates from 9 patients were clonally related. This clone caused major illness, and 11 of the 13 patients required surgical treatment. Clinicians should be aware of this pathogen and the appropriate broad-spectrum antimicrobial drugs to empirically prescribe for PWID with this life-threatening infection. Close collaboration among public health authorities, outreach social workers, and methadone clinics is essential for timely prevention and control of outbreaks in the PWID population.

Colloidal stability as a determinant of nanoparticle behavior in the brain.

Drug delivery to the brain is challenging due to a highly regulated blood-brain barrier (BBB) and a complex brain microenvironment. Nanoparticles, due to their tailorability, provide promising platforms to enhance therapeutic delivery and achieve controlled release and disease-specific localization in the brain. However, we have yet to fully understand the complex interactions between nanoparticles and the biological environments in which they operate. It is important to perform a systematic study to characterize nanoparticle behavior as a function of ion composition, concentration, and pH in cerebrospinal fluid (CSF). These could alter nanoparticle biological identity and influence diffusive capability and cellular uptake. In this study, poly(ethylene glycol) (PEG)-coated and carboxyl-coated polystyrene (PS-PEG and PS-COOH respectively) nanoparticles (NPs) were used to evaluate the aggregation kinetics, colloidal stability, and diffusive capability of nanoparticles in conditions relevant to the brain microenvironment. Size, surface charge, and surface coating were varied in a range of CSF ion concentrations and compositions, pH conditions, and temperatures. Small changes in calcium concentration and pH destabilize nanoparticles in CSF. However, PS-PEG NPs remain stable over a wider variety of conditions than PS-COOH NPs, and have higher diffusion capabilities in both agarose gels, an in vitro model of the brain microenvironment, and an organotypic brain tissue slice model. These results demonstrate the need for steric stabilization to maintain nanoparticle colloidal stability in a wide range of conditions. Importantly, colloidal stabilization allows for increased diffusive capability and can be used to predict diffusive behavior in the brain microenvironment.

Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities.

BACKGROUND: Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and had completed a multidisciplinary modality assessment. PREDICTOR: HD or PD. OUTCOMES: Mortality from any cause. RESULTS: Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time. LIMITATIONS: The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center. CONCLUSIONS: HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.

Multi-functional bis(alkynyl)gold(iii) N⁁C complexes with distinct mechanochromic luminescence and electroluminescence properties.

A new class of donor-acceptor type luminescent bis(alkynyl)gold(iii) N⁁C complexes has been synthesized and characterized. These gold(iii) complexes not only exhibit high photoluminescence quantum yields of up to 0.81, but also interesting mechanochromic luminescence behaviors that are reversible. Upon grinding, a dramatic luminescence color change from green to red can be observed in solid samples of the gold(iii) complexes, and the mechanochromic luminescence can be readily tuned via a judicious selection of substituents on the pyridine ring. In addition, solution-processable OLEDs based on this class of complexes with EQE values of up to 4.0% have been realized, representing the first demonstration of bis(alkynyl)gold(iii) N⁁C complexes as emissive materials in solution-processable OLEDs.

In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence.

BACKGROUND: Owing to its longer treatment duration-up to 8 hours per dialysis treatment-in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes. STUDY DESIGN: We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016. SETTING & POPULATION: Adults receiving in-center nocturnal HD compared with those receiving conventional HD. SELECTION CRITERIA FOR STUDIES: All quasi-experimental and observational studies were considered; randomized trials were sought but not found. PREDICTOR: Nocturnal vs conventional in-center HD. OUTCOMES: Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality. RESULTS: Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (-3.18 [95% CI, -5.58 to -0.78) mm Hg, increased hemoglobin levels (0.53 [95% CI, 0.11-0.94] g/dL), and lower serum phosphate levels (-0.97 [95% CI, -1.48 to -0.46] mg/dL). LIMITATIONS: No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities. CONCLUSIONS: Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.

Selection of peritoneal dialysis among older eligible patients with end-stage renal disease.

Background: Older patients with end-stage renal disease (ESRD) are less likely to choose peritoneal dialysis (PD) over hemodialysis (HD). The reasons behind their choice of dialysis modality are not clear. This study seeks to determine the patient-perceived factors that influence ESRD patients' choice of dialysis modality among older ESRD patients who are deemed eligible for both PD and HD. Methods: All patients had completed a multidisciplinary modality assessment, were deemed eligible for both PD and HD, and had received modality education. Semi-structured interviews were conducted and transcripts were read repeatedly to derive potential codes using line-by-line textual analysis. The Capability, Opportunity, Motivation ­ Behaviour (COM-B) and Theoretical Domain Framework (TDF), validated tools that were developed for designing behavioral change interventions, were used to help guide the coding framework. Results: Among older ESRD patients who are deemed eligible for both PD and HD, factors relevant to their modality decision-making were identified with respect to physical strength/dexterity and having a sound mind (capability), external forces and constraints (opportunity), and values and beliefs (motivation). Often a combination of factors led to an individual's choice of a particular dialysis modality. However, preferences for PD were primarily based around convenience and maintaining a normal life, while a heightened sense of security was the primary reason for those who selected HD. Conclusions: We have identified patient-perceived factors that influence choice of dialysis modality in older individuals with ESRD who are eligible for PD and HD. These factors should be considered and/or addressed within PD programs seeking to promote PD.

Versatile Synthesis of Luminescent Tetradentate Cyclometalated Alkynylgold(III) Complexes and Their Application in Solution-Processable Organic Light-Emitting Devices.

A new class of cyclometalated tetradentate alkynylgold(III) complexes has been successfully synthesized by post-synthetic modification. Through the judicious design and choice of pincer ligands, post-synthetic cyclization could be achieved to produce the robust and structurally rigid class of tetradentate gold(III) C^N^C^C complexes with high photoluminescence quantum yields of up to 0.49 in solution and 0.78 in doped thin films at room temperature, at least an order of magnitude higher than those of the structurally related uncyclized tridentate alkynylgold(III) analogues. High-performance yellow to orange-red emitting solution-processable organic light-emitting devices have also been achieved with external quantum efficiency of 11.1 %. This work describes for the first time of the use of post-synthetic ligand modification approach to overcome the synthetic challenge for tetradentate alkynylgold(III) complexes.

Air-Stable Spirofluorene-Containing Ladder-Type Bis(alkynyl)borane Compounds with Readily Tunable Full Color Emission Properties.

A series of air-stable spiro-fused ladder-type boron(III) compounds has been designed, synthesized, and the electrochemistry and photophysical behavior have been characterized. By simply varying the substituents on the pyridine ring and extending the π-conjugation of the spiro framework, the emission color of these compounds can be easily fine-tuned spanning the visible spectrum from blue to red. All compounds exhibit a broad and structureless emission band across the entire visible region, assigned as an intramolecular charge-transfer transition originating from the thiophene of the spiro framework to the pyridine-borane moieties. In addition, these compounds demonstrate high photoluminescence quantum yields of up to 0.81 in dichloromethane solution and 0.86 in doped thin films. Some of the compounds have also been employed as emissive materials, in which solution-processed organic light-emitting devices (OLEDs) with tunable emission colors spanning the visible spectrum from blue, green to red have been realized, demonstrating the potential applications of these boron compounds in OLEDs.

Patient Education and Peritoneal Dialysis Modality Selection: A Systematic Review and Meta-analysis.

BACKGROUND: Educational interventions are increasingly used to promote peritoneal dialysis (PD), the most common form of home therapy for end-stage renal disease. A systematic review of the evidence in support of dialysis modality education is needed to inform the design of patient-targeted interventions to increase selection of PD. We performed a systematic review and meta-analysis to characterize the relationship between patient-targeted educational interventions and choosing and receiving PD. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Published original studies and abstracts. SELECTION CRITERIA FOR STUDIES: We searched MEDLINE, EMBASE, CINAHL and EBMR. We included controlled observational studies and randomized trials of educational interventions designed to increase PD selection. INTERVENTION: Predialysis educational interventions. OUTCOMES: The primary outcome was choosing PD, defined as intention to use PD regardless of whether PD was ever used. The secondary outcome, receiving PD, was defined as an individual receiving PD as his or her treatment. RESULTS: Of 3,540 citations, 15 studies met our inclusion criteria, including 1 randomized trial. In the single randomized trial (N=70), receipt of an educational intervention was associated with a more than 4-fold increase in the odds of choosing PD (OR, 4.60; 95% CI, 1.19-17.74). Based on results from 4 observational studies (N=7,653), patient-targeted educational interventions were associated with a 2-fold increase in the odds of choosing PD (pooled OR, 2.15; 95% CI, 1.07-4.32; I(2)=76.7%). Based on results from 9 observational studies (N=8,229), patient-targeted educational intervention was associated with a 3-fold increase in the odds of receiving PD as the initial treatment modality (OR, 3.50; 95% CI, 2.82-4.35; I(2)=24.9%). LIMITATIONS: Most studies were observational studies, which can establish an association between education and choosing PD or receiving PD, but does not establish causality. CONCLUSIONS: This systematic review demonstrates a strong association between patient-targeted education interventions and the subsequent choice and receipt of PD.

Magnetic resonance imaging arthrography following type II superior labrum from anterior to posterior repair: interobserver and intraobserver reliability.

BACKGROUND: Arthroscopic repair of type II superior labrum from anterior to posterior (SLAP) lesions is a common surgical procedure. However, anatomic healing following repair has rarely been investigated. The intraobserver and interobserver reliability of magnetic resonance imaging arthrography (MRA) following type II SLAP repair has not previously been investigated. This is of particular interest due to recent reports of poor clinical results following type II SLAP lesion repair. PURPOSE: To evaluate the MRA findings following arthroscopic type II SLAP lesion repair and determine its intraobserver and interobserver reliability. STUDY DESIGN: Cohort study (diagnosis), Level of Evidence, 2. METHODS: Twenty-five patients with an isolated type II SLAP lesion (confirmed via diagnostic arthroscopy) underwent standard suture anchor-based repair. At a mean of 25.2 months post-operatively, patients underwent a standardized MRA protocol to investigate the integrity of the repair. MRAs were independently reviewed by two radiologists and a fellowship trained shoulder surgeon. The outcomes were classified as healed SLAP repair or re-torn SLAP repair. RESULTS: On average, 54% of MRAs were interpreted as healed SLAP repairs while 46% of MRAs were interpreted as having a re-torn SLAP repair. Overall, only 43% of the studies had 100% agreement across all interpretations. The intraobserver reliability ranged from 0.71 to 0.81 while the interobserver reliability between readers ranged from 0.13 to 0.44 (Table 1). CONCLUSION: The intraobserver agreement of MRA in the evaluation of type II SLAP repair was substantial to excellent. However, the interobserver agreement of MRA was poor to fair. As a result, the routine use of MRA in the evaluation of type II SLAP lesion repair should be utilized with caution. A global evaluation of the patient, including detailed history and physical examination, is paramount in determining the cause of failure and one should not rely on MRA alone.

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up.

AIMS: The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions. MATERIALS AND METHODS: The senior author performed isolated repairs of 25 type II SLAP lesions in 25 patients with a mean age of 40.0 ± 12 years. All tears were repaired using standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by a blinded, independent observer, and using several shoulder outcome measures. Patients were evaluated by magnetic resonance imaging arthrogram at a minimum of 1-year postoperatively. STATISTICAL ANALYSIS USED: Two-tailed paired t-test were used to determine significant differences in preoperative and postoperative clinical outcomes scores. In addition, a Fisher's exact test was used. RESULTS: At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs. CONCLUSIONS: Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.

Haemodynamic and biochemical responses to fluid bolus therapy with human albumin solution, 4% versus 20%, in critically ill adults.

BACKGROUND: Fluid bolus therapy (FBT) is common in critically ill patients. With the exception of use in patients with traumatic brain injury, FBT with human albumin solution (HAS) appears safe and perhaps superior in severe sepsis. OBJECTIVE: To determine the physiological effects of FBT with 4% v 20% HAS. DESIGN, SETTING AND PARTICIPANTS: A retrospective observational study of 202 critically ill patients receiving FBT with HAS in a tertiary intensive care unit between April 2012 and March 2013. METHODS: FBT was instituted with 4% or 20% HAS, according to clinician preference. MAIN OUTCOME MEASURES: We compared biochemical and haemodynamic data between groups at baseline and at 1, 2 and 4 hours after FBT. RESULTS: Patients who had received 20% HAS had more liver disease, a greater need for renal replacement therapy and higher Acute Physiology and Chronic Health Evaluation III scores on admission. Patients who had received 4% HAS received a median volume of 500 mL (interquartile range [IQR], 350-500 mL), compared with 100mL (IQR, 100- 200 mL) in the 20% HAS group (P < 0.0001); a median of 70 mmol v 10 mmol of sodium (P < 0.0001); and a median of 64 mmol v 2 mmol of chloride (P < 0.0001). There was a trend toward higher mean arterial pressures in the 20% group after FBT (78.2 mmHg v 76.4 mmHg, P = 0.03). There were no significant differences in the absolute or percentage change for any haemodynamic parameters. Serum biochemical test results were comparable with a non-significant signal of higher serum chloride and more negative base excess in patients receiving 4% HAS. CONCLUSIONS: Haemodynamically, FBT with 100mL of 20% HAS performs in an equivalent way to 500 mL of 4% HAS but delivers much less fluid, sodium and chloride.