Evaluation of a new Perinatal Mental Health Service in a University Maternity Hospital.

OBJECTIVES: Specialist Perinatal Mental Health Services (SPMHS) are a new development in Ireland. This service evaluation examined the impact of the introduction of a SPMHS multidisciplinary team (MDT) on prescribing practices and treatment pathways in an Irish maternity hospital. METHODS: Clinical charts were reviewed to collect data on all referrals, diagnoses, pharmacological and non-pharmacological interventions delivered in a SPMHS over a 3-week period in 2019. The findings were compared to the same 3-week period in 2020 following the expansion of the SPMHS MDT. RESULTS: In 2019 (n = 32) and 2020 (n = 47), most (75 and 79%, respectively) assessments were antenatal. The proportion of patients prescribed psychotropic medication within the SPMHS was not significantly different from 2019 (31%) to 2020 (23%), though more patients were already prescribed psychotropic medications at the time of referral (22% in 2019 v. 36% in 2020). There was an increase in MDT interventions in 2020 with more input from psychology, clinical nurse specialist (CNS), and social work intervention. Adherence to prescribing standards improved from 2019 to 2020. CONCLUSION: Prescribing patterns remained unchanged between 2019 and 2020. Improvement was observed in adherence to prescribing standards and there was increased provision of MDT interventions in 2020. Broader diagnostic categories were also used in 2020, possibly suggesting that the service is now providing more individualized care.

Vocally disruptive behaviour in nursing home residents in Ireland: a descriptive study.

BACKGROUND: Vocally disruptive behaviour (VDB) is relatively common in nursing home residents but difficult to treat. There is limited study on prevalence and treatment of VDB. We hypothesise that VDB is a result of complex interaction between patient factors and environmental contributors. METHODS: Residents of nursing homes in south Dublin were the target population for this study. Inclusion criteria were that the residents were 65 years or over and exhibited VDB significant enough for consideration in the resident's care plan. Information on typology and frequency of VDB, Interventions employed and their efficacy, diagnoses, Cohen-Mansfield Agitation Inventory scores, Mini-Mental State Examination scores, and Barthel Index scores were obtained. RESULTS: Eight percent of nursing home residents were reported to display VDB, most commonly screaming (in 39.4% of vocally disruptive residents). VDB was associated with physical agitation and dementia; together, these two factors accounted for almost two-thirds of the variation in VDB between residents. One-to-one attention, engaging in conversation, redirecting behaviour, and use of psychotropic medication were reported by nurses as the most useful interventions. Analgesics were the medications most commonly used (65.7%) followed by quetiapine (62.9%), and these were reportedly effective in 82.6% and 77.2% of residents respectively. CONCLUSIONS: VDB is common, challenging, and difficult to manage. The study of VDB is limited by a variety of factors that both contribute to this behaviour and make its treatment challenging. Issues relating to capacity and ethics make it difficult to conduct randomised controlled trials of treatments for VDB in the population affected.

Clozapine-induced interstitial nephritis in a patient with schizoaffective disorder in the forensic setting: a case report and review of the literature.

We present a rare case of Acute Interstitial Nephritis (AIN) that occurred following a re-trial of clozapine in a 56-year-old lady with schizoaffective disorder. On initial trial of clozapine, this patient felt generally unwell with respiratory symptoms. Her inflammatory markers were raised and her renal function showed a mild, transient deterioration which normalised on the day of cessation of clozapine. Two years later, clozapine was re-trialled due the refractory nature of her psychiatric symptoms. She subsequently developed renal failure and AIN was confirmed by renal biopsy. Renal function improved after cessation of clozapine; however, she never fully regained normal renal function.

The signature of competition in ecomorphological traits across the avian radiation.

Competition for shared resources represents a fundamental driver of biological diversity. However, the tempo and mode of phenotypic evolution in deep-time has been predominantly investigated using trait evolutionary models which assume that lineages evolve independently from each other. Consequently, the role of species interactions in driving macroevolutionary dynamics remains poorly understood. Here, we quantify the prevalence for signatures of competition between related species in the evolution of ecomorphological traits across the bird radiation. We find that mechanistic trait models accounting for the effect of species interactions on phenotypic divergence provide the best fit for the data on at least one trait axis in 27 out of 59 clades ranging between 21 and 195 species. Where it occurs, the signature of competition generally coincides with positive species diversity-dependence, driven by the accumulation of lineages with similar ecologies, and we find scarce evidence for trait-dependent or negative diversity-dependent phenotypic evolution. Overall, our results suggest that the footprint of interspecific competition is often eroded in long-term patterns of phenotypic diversification, and that other selection pressures may predominantly shape ecomorphological diversity among extant species at macroevolutionary scales.

Correlates of rate heterogeneity in avian ecomorphological traits.

Heterogeneity in rates of trait evolution is widespread, but it remains unclear which processes drive fast and slow character divergence across global radiations. Here, we test multiple hypotheses for explaining rate variation in an ecomorphological trait (beak shape) across a globally distributed group (birds). We find low support that variation in evolutionary rates of species is correlated with life history, environmental mutagenic factors, range size, number of competitors, or living on islands. Indeed, after controlling for the negative effect of species' age, 80% of variation in species-specific evolutionary rates remains unexplained. At the clade level, high evolutionary rates are associated with unusual phenotypes or high species richness. Taken together, these results imply that macroevolutionary rates of ecomorphological traits are governed by both ecological opportunity in distinct adaptive zones and niche differentiation among closely related species.

Ventral hernia repair in patients with abdominal loss of domain: an observational study of one institution's experience.

PURPOSE: Abdominal wall hernias are a common problem. The success of abdominal wall reconstruction decreases with increasing hernia size. This study summarizes the outcomes of one surgeon's experience using a "sandwich" technique for hernia repair in patients with loss of abdominal domain. METHODS: We reviewed our ventral hernia repair (VHR) experience from 2008 to 2015 among patients with loss of domain, as defined by a hernia defect greater than 300 cm2. The percent of herniation through the defect, defined by a hernia sac-to-abdominal cavity volume ratio, was measured on preoperative CT scans by four independent reviewers and averaged. Outcomes were compared among those with giant ventral hernias (hernia sac-to-abdominal cavity volume >30%) and those with smaller defect ratios. RESULTS: Over the study period, 21 patients underwent VHR. In 17 patients (81%), a "sandwich" technique was utilized. Ten patients had hernia sac-to-abdominal cavity defects less than 30%, and 11 had defects greater than 30%. Preoperative characteristics were similar in both groups with the exception of a higher ASA score in those with giant ventral hernias and more Ventral Hernia Working Group Grade 3 hernias in those without giant ventral hernias. Postoperative outcomes were similar in both groups. There were no mortalities. There were two recurrences (18%) in the giant VHR group and none in the smaller defect group (p = 0.16). Surgical site occurrences were noted in 48% of patients and did not differ between giant and non-giant VHR groups (50 vs 45%, p = 0.84). Average postoperative length of stay was significantly longer in the giant VHR group (31 vs. 17 days, p = 0.03). CONCLUSIONS: Our results suggest that the "sandwich" technique for VHR is a safe and durable method to restore abdominal wall integrity in those with LOD, even in patients with giant ventral hernias.

Creation of a novel risk score for surgical site infection and occurrence after ventral hernia repair.

BACKGROUND: Complex ventral hernia repair (VHR) is a common surgical operation but carries a risk of complications from surgical site infections (SSI) and occurrences (SSO). We aimed to create a predictive risk score to identify patients at increased risk for SSO or SSI within 30 days of surgery. METHODS: Data were prospectively collected on all patients undergoing VHR between January 2008 and February 2015 by a single surgeon. Multivariable logistic regression was used to identify independent factors predictive of SSO and SSI. Significant predictors of SSO and SSI were assigned point values based on their odds ratios to create a novel risk score, the Hopkins ventral hernia repair SSO/SSI risk score; predicted and actual rates of outcomes were then compared using weighted regression. RESULTS: During the study period, 362 patients underwent open VHR. Thirty-day SSO and SSI occurred in 18.5 and 10% of patients, respectively. After risk adjustment, ASA class ≥3 (1 point), operative time ≥4 h (2 points), and the absence of a postoperative wound vacuum dressing (1 point) were predictive of 30-day SSO. Predicted risk of SSO utilizing this scoring system was 9.7, 19.4, 29.1, and 38.8% for 1, 2, 3, and 4 points (AUC = 0.73). For SSI, operative time ≥4 h (1 point) and the lack of a wound vacuum dressing (1 point) were predictive. Predicted risk of SSI based on this scoring system was 12.5% for 1 point and 25% for 2 points (AUC = 0.71). Actual vs. predicted rates of SSO and SSI correlated strongly for risk model with a coefficient of determination (R 2) of 0.92 and 0.91, respectively. CONCLUSION: The novel Hopkins ventral hernia repair risk score accurately predicts risk of SSO and SSI after complex VHR. Further studies using a prospective randomized controlled trial will be needed to further validate our findings.

Effect of hernia size on operative repair and post-operative outcomes after open ventral hernia repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed operation, but analysis of patient outcomes based upon hernia size is lacking. We sought to identify differences in operative repair and post-operative morbidity and mortality after open VHR based on hernia defect size. METHODS: Patient and operative data were retrospectively reviewed on all patients undergoing open incisional VHR between January 2008 and February 2015 by a single surgeon at the Johns Hopkins Hospital. Patient variables were described by means for continuous variables and percentages for discrete variables, with differences between groups calculated by Chi-squared analysis. RESULTS: During the study period, 228 patients underwent open VHR during which intraoperative defect size was measured. Patients were split into four groups based upon defect size: less than 200 cm2, 200-300 cm2, 301-400 cm2, and over 400 cm2. Patients with large defects were more likely to present with a recurrent hernia (P = 0.007) and trended towards a history of wound infections (P = 0.07). Operative time was significantly longer as defect size increased (P < 0.001). Component separation was most frequently used in patients with defects 200-300 cm2 in size (P = 0.001), in whom primary closure was most likely to occur. While mesh was used in almost all patients, the specific location (overlay only, underlay only, or overlay with underlay) depended on hernia size (P < 0.001). Mean length of stay increased with defect size (P < 0.001). Larger defect size was associated with increased 30-day morbidity (P = 0.03) but not readmission (P = 0.53), recurrence (P = 0.99), or mortality (P = 0.99). CONCLUSION: Hernia defect size affects operative time and surgical technique for repair of a ventral hernia. Larger defect size is associated with increased post-operative morbidity and length of stay but not readmission, recurrence, or mortality. Hernia size greater than 400 cm2 should not be a limitation to operative repair.

Leveraging Industry-Academia Collaborations in Adaptive Biomedical Innovation.

Despite the rapid pace of biomedical innovation, research and development (R&D) productivity in the pharmaceutical industry has not improved broadly. Increasingly, firms need to leverage new approaches to product development and commercial execution, while maintaining adaptability to rapid changes in the marketplace and in biomedical science. Firms are also seeking ways to capture some of the talent, infrastructure, and innovation that depends on federal R&D investment. As a result, a major transition to external innovation is taking place across the industry. One example of these external innovation initiatives is the Sanofi-MIT Partnership, which provided seed funding to MIT investigators to develop novel solutions and approaches in areas of interest to Sanofi. These projects were highly collaborative, with information and materials flowing both ways. The relatively small amount of funding and short time frame of the awards built an adaptable and flexible process to advance translational science.

A validated, risk assessment tool for predicting readmission after open ventral hernia repair.

BACKGROUND/PURPOSE: To present a validated model that reliably predicts unplanned readmission after open ventral hernia repair (open-VHR). STUDY DESIGN: A total of 17,789 open-VHR patients were identified using the 2011-2012 ACS-NSQIP databases. This cohort was subdivided into 70 and 30% random testing and validation samples, respectively. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the open-VHR procedure. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression on the testing sample (n = 12,452 patients). Subsequently, the predictors were weighted according to ß-coefficients to generate an integer-based Clinical Risk Score (CRS) predictive of readmission, which was validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 5337 patients). RESULTS: The rate of 30-day unplanned readmission was 4.7%. Independent risk factors included inpatient status at time of open-VHR, operation time, enterolysis, underweight, diabetes, preoperative anemia, length of stay, chronic obstructive pulmonary disease, history of bleeding disorders, hernia with gangrene, and panniculectomy (all P < 0.05). ROC analysis of the validation cohort rendered an area under the curve of 0.71, which demonstrates the accuracy of this prediction model. Predicted incidence within each 5 risk strata was statistically similar to the observed incidence in the validation sample (P = 0.18), further highlighting the accuracy of this model. CONCLUSION: We present a validated risk stratification tool for unplanned readmissions following open-VHR. Future studies should determine if implementation of our CRS optimizes safety and reduces readmission rates in open-VHR patients.

The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis.

PURPOSE: The authors evaluated the ability of a fibrin sealant (TISSEEL™: Baxter Healthcare Corp, Deerfield, IL, USA) to reduce the incidence of post-operative seroma following abdominal wall hernia repair. METHODS: We performed a 4-year retrospective review of patients undergoing abdominal wall hernia repair, with and without TISSEEL, by a single surgeon (FEE) at The Johns Hopkins Hospital. Demographics, surgical risk factors, operative data and 30-day outcomes, including wound complications and related interventions, were compared. The quantity and cost of Tisseel per case was reviewed. RESULTS: A total of 250 patients were evaluated: 127 in the TISSEEL group and 123 in the non-TISSEEL control group. The average age for both groups was 56.6 years (P = 0.97). The majority of patients were female (TISSEEL 52.8%, non-TISSEEL 56.1%, P = 0.59) and ASA Class III (TISSEEL 56.7%, non-TISSEEL 58.5%, P = 0.40). There was no difference in the average defect size for both groups (TISSEEL 217 ± 187.6 cm(2), non-TISSEEL 161.3 ± 141.5 cm(2), P = 0.36). Surgical site occurrences occurred in 18.1% of the TISSEEL and 13% of the non-TISSEEL group (P = 0.27). There was a trend towards an increased incidence of seroma in the TISSEEL group (TISSEEL 11%, non-TISSEEL 4.9%, P = 0.07). A total of $124,472.50 was spent on TISSEEL, at an average cost of $995.78 per case. CONCLUSIONS: In the largest study to date, TISSEEL™ application offered no advantage for the reduction of post-operative seroma formation following complex abdominal hernia repair. Moreover, the use of this sealant was associated with significant costs.

Psychotropic prescribing in the oldest old attending a geriatric psychiatry service: a retrospective, cross-sectional study.

OBJECTIVE: More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy. METHODS: Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria. RESULTS: A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0-5) psychotropics and 4.99 (S.D. 2.7, range 0-11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = -1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9-17.4)], anxiolytic [OR 13.5 (95% CI 1.7-110.4)] and antipsychotic [OR 3.4 (95% CI 1.1-10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%). CONCLUSIONS: Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.

46,X,del(X)(q13) Turner's syndrome women with systemic lupus erythematosus in a pedigree multiplex for SLE.

Systemic lupus erythematosus (SLE) disproportionately affects women. Recent work demonstrates that men with Klinefelter's syndrome (47,XXY men) have a similar risk of developing SLE as do women. We present an unusual African-American family with two SLE-affected individuals in which one of the patients with SLE also has Turner's syndrome (46,X,del(X)(q13)). Although not definitive, this family raises interesting questions regarding the function of genes located on the X chromosome in the development of SLE. The paucity of case reports documenting the overlap of SLE with Turner's syndrome while there is an association of male SLE with Klinefelter's syndrome suggests a lower risk of SLE in women with Turner's syndrome. These observations are consistent with a gene dose effect at X with two X chromosomes (46,XX or 47,XXY) conferring higher risk and one X chromosome (46,XY or 45,XO) conferring lower risk of SLE.

Contribution of de novo point mutations to the overall mutational burden in mitochondrial DNA of adult rats.

This study analyzed the incidence of point mutations in mitochondrial DNA of brain and muscle tissues from young (6-month) and old (24-month) male F344 rats. Coding sequence mutations in subunit 5 of the NADH dehydrogenase gene were detected after high-fidelity PCR amplification and cloning by denaturing gradient gel electrophoresis (DGGE) assay followed by sequencing of detected mutants. In total, almost a thousand individual clones were analyzed both in brain and muscle samples. On average, mtDNA from brain tissue showed a 66% increase with age in mutation frequencies (2.3+/-1.9 vs. 3.8+/-4.5 x 10(-4) mutations/bp, mean+/-SD), which failed to reach statistical significance (p=0.45). Muscle tissues yielded substantially fewer mutants with average mutant frequencies for both young and old rats almost 10 times lower than the corresponding values in the brain tissue (0.3+/-0.4 and 0.5+/-0.6 x 10(-4), respectively). The difference in mutation accumulation between muscle and brain was highly significant in both the younger group (Chi-squared=9.7, p < or = 0.01) and in older animals (Chi-squared=10.9, p < or = 0.001). Molecular analysis of the mutated sequences revealed that almost half were identical sequences recurring in different samples and tissues. Our findings indicate that the process of mutation accumulation in mitochondria begins in the germ-line and/or during earlier stages of life, contributing up to half of the total mutational burden, whereas de novo spontaneous formation of point mutations in adulthood is far less than was anticipated.

Evaluation of microfluidic blood gas sensors that combine microdialysis and optical monitoring.

It is shown that microdialysis-based blood gas (pH, pCO2 and pO2) optical sensors are stable for durations of several hours in blood. This performance is uncommon with many types of membrane sensor. Microdialysis techniques can be designed to ensure that the sweep microflow samples are in biochemical equilibrium with the bulk media, even after hours of exposure to the complex composition of blood. The rate of diffusion through the membrane is not the determining factor in sensor reading, as it is with other sensor techniques that consume the analyte. The sweep fluid 95% equilibration times for microdialysis fibres were approximately double in blood compared with buffer, reflecting slower diffusion of ions. This is in contrast to the equilibration of gases through silicone hollow-fibre membranes in blood, which showed unchanged equilibration times between blood and buffer. Sensor measurements correlate well with a blood gas analyser for up to 9 h in blood, with correlation coefficients of 0.973 for the pO2 sensor 0.974 for the pCO2 sensor and 0.947 for the pH sensor. In blood, the sensors have precisions of 1.7 mmHg, 3.7 mmHg and 0.019 pH units and bias levels of -0.7 mmHg, 1.2 mmHg and 0.002 pH units, for pO2, pCO2 and pH, respectively.

Comparison of the effects of two intrathecal anaesthetic techniques for transurethral prostatectomy on haemodynamic and pulmonary function.

BACKGROUND AND OBJECTIVE: Transurethral prostatectomy is routinely performed under spinal anaesthesia. This technique can cause hypotension, which is particularly undesirable in the elderly. The objective was to compare spinal anaesthesia for transurethral prostatectomy using hyperbaric bupivacaine 15 mg (control group) and hyperbaric bupivacaine 10 mg (limiting spread by maintaining the upright position for 15 min) and fentanyl 25 microg (fentanyl group) in terms of haemodynamic and pulmonary function. METHODS: Thirty ASA I-III patients were randomly selected and underwent spinal anaesthesia with either hyperbaric bupivacaine 15 mg (immediately positioned supine) or hyperbaric bupivacaine 10 mg (upright for 15 min) and fentanyl 25 microg. RESULTS: The greatest changes in mean arterial pressure (P = 0.9), ephedrine requirements (P = 0.8) and mean maximum change in forced vital capacity (P = 0.5) were similar in both groups. CONCLUSIONS: The addition of fentanyl 25 microg to bupivacaine 10 mg and limiting the spread of the block does not improve either haemodynamic or pulmonary function compared with bupivacaine 15 mg in patients undergoing transurethral prostatectomy.

Use of drugs by Old Age Psychiatrists in the treatment of psychotic and behavioural symptoms in patients with dementia.

The objective was to elicit the prescribing practises of Old Age Psychiatrists in the UK in the treatment of psychotic and behavioural symptoms in patients with dementia. A structured questionnaire was sent to all Old Age Psychiatrists in the United Kingdom. Respondents were questioned regarding their use of both typical and atypical antipsychotics and the most common dosages prescribed. Information was sought about usage of depot medication and dosages; use of alternative or adjunctive medications to antipsychotics and use of parenteral medication for acute management of agitation. The most commonly used antipsychotic to treat psychotic symptoms was haloperidol, and thioridazine to treat behavioural symptoms. A wide range of dosages was used. Use of depot medication was common, with flupenthixol decanoate being the most frequently used. Most respondents use at least one of the atypical antipsychotics, risperidone being most popular. Use of other psychotropic medication used as alternatives to antipsychotics or adjunctives in the treatment of behavioural symptoms was common, the most popular being trazodone. Of the respondents, 62.7% use parenteral medication for the acute management of agitation, the most popular drug being haloperidol. The typical antipsychotics are still the most commonly used despite the reputed better safety profile of the atypicals. There was wide variation in the dosages prescribed. Use of psychotropics other than phenothiazines was common. More research is needed into the use of psychotropic medication for dementia and there is need for consensus in this area. Forming an expert group may be the best way to create uniformity of prescription.