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Age-related incidence of desaturation events and the cardiac responses on stroke index, cardiac index, and heart rate measured by continuous bioimpedance noninvasive cardiac output monitoring in infants and children undergoing general anesthesia. - Journal of clinical anesthesia
To assess the effects of desaturation on stroke index (SI), cardiac index (CI), and heart rate (HR) using the ICON continuous noninvasive cardiac output monitor in children undergoing general anesthesia.Retrospective analysis of a prospectively collected data set.Pediatric operating rooms in a tertiary academic medical center.Children younger than 20 years who experienced desaturation while undergoing general anesthesia.All records were retrospectively searched for desaturation events defined as a recorded Spo2 â‰¤ 90%. We compared the data from the prior 4 minutes (baseline) with mild, moderate, and severe levels of desaturation.The relationship between Spo2 and percent change in SI, CI, and HR from baseline was assessed using a generalized linear model with repeated measures and the least-squares method.Data from 446 patients were reviewed; 38 events were eligible for analysis after exclusions. There were significant decreases in SI at all saturation ranges below 95%: -6.5% (P < .001) for 85%-95%, -8.9% (P = .002) for 71%-84%, and -11% (P < .001) for â‰¤70%. Based on the result from the regression, Spo2 was associated with change in SI with borderline significance (P = .053) but not that of HR and CI. There was a strong relationship to desaturation events with young age (P < .001), particularly infants younger than 6 months.Events associated with desaturation in children under general anesthesia were significantly associated with decreased SI with a greater effect with lower saturation nadirs. It is unclear if other concurrent events could have also contributed to adverse hemodynamic responses during desaturation. In most children, a compensatory increase in HR generally offsets concurrent decreases in CI. It would appear that bradycardia is a late manifestation of hypoxemia.Copyright Â© 2016 Elsevier Inc. All rights reserved.
Prevalence and treatment of common mental disorders in the English national population, 1993-2007. - The British journal of psychiatry : the journal of mental science
The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007.To evaluate frequency of common mental disorders (CMDs), service contact and treatment.Common mental disorders were identified with the Clinical Interview Schedule - Revised (CIS-R). Service contact and treatment were established in structured interviews.There were 8615, 6126 and 5385 participants aged 16-64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment.Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions.Â© The Royal College of Psychiatrists 2016.
LROC Investigation of Three Strategies for Reducing the Impact of Respiratory Motion on the Detection of Solitary Pulmonary Nodules in SPECT. - IEEE transactions on nuclear science
The objective of this investigation was to determine the effectiveness of three motion reducing strategies in diminishing the degrading impact of respiratory motion on the detection of small solitary pulmonary nodules (SPN) in single photon emission computed tomographic (SPECT) imaging in comparison to a standard clinical acquisition and the ideal case of imaging in the absence of respiratory motion. To do this non-uniform rational B-spline cardiac-torso (NCAT) phantoms based on human-volunteer CT studies were generated spanning the respiratory cycle for a normal background distribution of Tc-99m NeoTect. Similarly, spherical phantoms of 1.0 cm diameter were generated to model small SPN for each of 150 uniquely located sites within the lungs whose respiratory motion was based on the motion of normal structures in the volunteer CT studies. The SIMIND Monte Carlo program was used to produce SPECT projection data from these. Normal and single-lesion containing SPECT projection sets with a clinically realistic Poisson noise level were created for the cases of: 1) the end-expiration (EE) frame with all counts, 2) respiration-averaged motion with all counts, 3) one-fourth of the 32 frames centered around EE (Quarter-Binning), 4) one-half of the 32 frames centered around EE (Half-Binning), and 5) eight temporally binned frames spanning the respiratory cycle. Each of the sets of combined projection data were reconstructed with RBI-EM with system spatial-resolution compensation (RC). Based on the known motion for each of the 150 different lesions, the reconstructed volumes of respiratory bins were shifted so as to superimpose the locations of the SPN onto that in the first bin (Reconstruct and Shift). Five human-observers performed localization receiver operating characteristics (LROC) studies of SPN detection. The observer results were analyzed for statistical significance differences in SPN detection accuracy among the three correction strategies, the standard acquisition, and the ideal case of the absence of respiratory motion. Our human-observer LROC determined that Quarter-Binning and Half-Binning strategies resulted in SPN detection accuracy statistically significantly below (P < 0.05) that of standard clinical acquisition, whereas the Reconstruct and Shift strategy resulted in a detection accuracy not statistically significantly different from that of the ideal case. This investigation demonstrates that tumor detection based on acquisitions associated with less than all the counts which could potentially be employed may result in poorer detection despite limiting the motion of the lesion. The Reconstruct and Shift method results in tumor detection that is equivalent to ideal motion correction.
Modeling the respiratory motion of solitary pulmonary nodules and determining the impact of respiratory motion on their detection in SPECT imaging. - IEEE transactions on nuclear science
The objectives of this investigation were to model the respiratory motion of solitary pulmonary nodules (SPN) and then use this model to determine the impact of respiratory motion on the localization and detection of small SPN in SPECT imaging for four reconstruction strategies. The respiratory motion of SPN was based on that of normal anatomic structures in the lungs determined from breath-held CT images of a volunteer acquired at two different stages of respiration. End-expiration (EE) and time-averaged (Frame Av) non-uniform-B-spline cardiac torso (NCAT) digital-anthropomorphic phantoms were created using this information for respiratory motion within the lungs. SPN were represented as 1 cm diameter spheres which underwent linear motion during respiration between the EE and end-inspiration (EI) time points. The SIMIND Monte Carlo program was used to produce SPECT projection data simulating Tc-99m depreotide (NeoTect) imaging. The projections were reconstructed using 1) no correction (NC), 2) attenuation correction (AC), 3) resolution compensation (RC), and 4) attenuation correction, scatter correction, and resolution compensation (AC_SC_RC). A human-observer localization receiver operating characteristics (LROC) study was then performed to determine the difference in localization and detection accuracy with and without the presence of respiratory motion. The LROC comparison determined that respiratory motion degrades tumor detection for all four reconstruction strategies, thus correction for SPN motion would be expected to improve detection accuracy. The inclusion of RC in reconstruction improved detection accuracy for both EE and Frame Av over NC and AC. Also the magnitude of the impact of motion was least for AC_SC_RC.
Design of a Multi-Pinhole Collimator for I-123 DaTscan Imaging on Dual-Headed SPECT Systems in Combination with a Fan-Beam Collimator. - IEEE transactions on nuclear science
For the 2011 FDA approved Parkinson's Disease (PD) SPECT imaging agent I-123 labeled DaTscan, the volume of interest (VOI) is the interior portion of the brain. However imaging of the occipital lobe is also required with PD for calculation of the striatal binding ratio (SBR), a parameter of significance in early diagnosis, differentiation of PD from other disorders with similar clinical presentations, and monitoring progression. Thus we propose the usage of a combination of a multi-pinhole (MPH) collimator on one head of the SPECT system and a fan-beam on the other. The MPH would be designed to provide high resolution and sensitivity for imaging of the interior portion of the brain. The fan-beam collimator would provide lower resolution but complete sampling of the brain addressing data sufficiency and allowing a volume-of-interest to be defined over the occipital lobe for calculation of SBR's. Herein we focus on the design of the MPH component of the combined system. Combined reconstruction will be addressed in a subsequent publication. An analysis of 46 clinical DaTscan studies was performed to provide information to define the VOI, and design of a MPH collimator to image this VOI. The system spatial resolution for the MPH was set to 4.7 mm, which is comparable to that of clinical PET systems, and significantly smaller than that of fan-beam collimators employed in SPECT. With this set, we compared system sensitivities for three aperture array designs, and selected the 3 Ã— 3 array due to it being the highest of the three. The combined sensitivity of the apertures for it was similar to that of an ultra-high resolution fan-beam (LEUHRF) collimator, but smaller than that of a high-resolution fan-beam collimator (LEHRF). On the basis of these results we propose the further exploration of this design through simulations, and the development of combined MPH and fan-beam reconstruction.
Self-harm, Unintentional Injury, and Suicide in Bipolar Disorder During Maintenance Mood Stabilizer Treatment: A UK Population-Based Electronic Health Records Study. - JAMA psychiatry
Self-harm is a prominent cause of morbidity in patients with bipolar disorder and is strongly associated with suicide. There is evolving evidence that lithium use may reduce suicidal behavior, in addition to concerns that the use of anticonvulsants may increase self-harm. Information is limited about the effects of antipsychotics when used as mood stabilizer treatment. Rates of unintentional injury are poorly defined in bipolar disorder, and understanding drug associations with this outcome may shed light on mechanisms for lithium's potential antisuicidal properties through reduction in impulsive aggression.To compare rates of self-harm, unintentional injury, and suicide in patients with bipolar disorder who were prescribed lithium, valproate sodium, olanzapine, or quetiapine fumarate.This investigation was a propensity score (PS)-adjusted and PS-matched longitudinal cohort study in a nationally representative UK sample using electronic health records data collected between January 1, 1995, and December 31, 2013. Participants included all patients diagnosed as having bipolar disorder who were prescribed lithium, valproate, olanzapine, or quetiapine as maintenance mood stabilizer treatment.The primary outcome was any form of self-harm. Secondary outcomes were unintentional injury and suicide.Of the 14â€¯396 individuals with a diagnosis of BPD, 6671 were included in the cohort, with 2148 prescribed lithium, 1670 prescribed valproate, 1477 prescribed olanzapine, and 1376 prescribed quetiapine as maintenance mood stabilizer treatment. Self-harm rates were lower in patients prescribed lithium (205; 95% CI, 175-241 per 10â€¯000 person-years at risk [PYAR]) compared with those prescribed valproate (392; 95% CI, 334-460 per 10â€¯000 PYAR), olanzapine (409; 95% CI, 345-483 per 10â€¯000 PYAR), or quetiapine (582; 95% CI, 489-692 per 10â€¯000 PYAR). This association was maintained after PS adjustment (hazard ratio [HR], 1.40; 95% CI, 1.12-1.74 for valproate, olanzapine, or quetiapine vs lithium) and PS matching (HR, 1.51; 95% CI, 1.21-1.88). After PS adjustment, unintentional injury rates were lower for lithium compared with valproate (HR, 1.32; 95% CI, 1.10-1.58) and quetiapine (HR, 1.34; 95% CI, 1.07-1.69) but not olanzapine. The suicide rate in the cohort was 14 (95% CI, 9-21) per 10â€¯000 PYAR. Although this rate was lower in the lithium group than for other treatments, there were too few events to allow accurate estimates.Patients taking lithium had reduced self-harm and unintentional injury rates. This finding augments limited trial and smaller observational study results. It supports the hypothesis that lithium use reduces impulsive aggression in addition to stabilizing mood.
Adaptation of the Quality Indicator for Rehabilitative Care (QuIRC) for use in mental health supported accommodation services (QuIRC-SA). - BMC psychiatry
No standardised tools for assessing the quality of specialist mental health supported accommodation services exist. To address this, we adapted the Quality Indicator for Rehabilitative care-QuIRC-that was originally developed to assess the quality of longer term inpatient and community based mental health facilities. The QuIRC, which is completed by the service manager and gives ratings of seven domains of care, has good psychometric properties.Focus groups with staff of the three main types of supported accommodation in the UK (residential care, supported housing and floating outreach services) were carried out to identify potential amendments to the QuIRC. Additional advice was gained from consultation with three expert panels, two of which comprised service users with lived experience of mental health and supported accommodation services. The amended QuIRC (QuIRC-SA) was piloted with a manager of each of the three service types. Item response variance, inter-rater reliability and internal consistency were assessed in a random sample of 52 services. Factorial structure and discriminant validity were assessed in a larger random sample of 87 services.The QuIRC-SA comprised 143 items of which only 18 items showed a narrow range of response and five items had poor inter-rater reliability. The tool showed good discriminant validity, with supported housing services generally scoring higher than the other two types of supported accommodation on most domains. Exploratory factor analysis showed that the QuIRC-SA items loaded onto the domains to which they had been allocated.The QuIRC-SA is the first standardised tool for quality assessment of specialist mental health supported accommodation services. Its psychometric properties mean that it has potential for use in research as well as audit and quality improvement programmes. A web based application is being developed to make it more accessible which will produce a printable report for the service manager about the performance of their service, comparison data for similar services and suggestions on how to improve service quality.
Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England. - BMC psychiatry
Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10-20Â % of all those with psychosis, they absorb 25-50Â % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome.Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12Â month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care.Across England, 50 units participated and 329 patients were followed over 12Â months (94Â % of those recruited). Service quality was not associated with patients' social function or length of admission (median 16Â months) at 12Â months but most patients were successfully discharged (56Â %) or ready for discharge (14Â %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95Â % CI 1.00-1.08), and patients' activity (OR 1.03, 95Â % CI 1.01-1.05) and social skills (OR 1.13, 95Â % CI 1.04-1.24) at recruitment.Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18Â months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients' social skills and activities may further enhance the effectiveness of these services.
Suicidality in primary care patients who present with sadness and anhedonia: a prospective European study. - BMC psychiatry
Sadness and anhedonia (loss of interest in activities) are central symptoms of major depression. However, not all people with these symptoms meet diagnostic criteria for major depression. We aimed to assess the importance of suicidality in the outcomes for primary care patients who present with sadness and anhedonia.Cohort study of 2,599 unselected primary care attenders in six European countries followed up at 6 and 12Â months.1) In patients with sadness and/or anhedonia who were not depressed at entry to the study, suicide plans (ORâ€‰=â€‰3.05; 95Â % CIâ€‰=â€‰1.50-6.24; pâ€‰=â€‰0.0022) and suicide attempts (ORâ€‰=â€‰9.08; 95Â % CIâ€‰=â€‰2.57-32.03; pâ€‰=â€‰0.0006) were significant predictors of developing new onset depression at 6 or 12Â months. 2) In patients with sadness and/or anhedonia who met CIDI criteria for major depression at entry, suicidal ideation (ORâ€‰=â€‰2.93; 95Â % CIâ€‰=â€‰1.70-5.07; pâ€‰=â€‰0.0001), suicide plans (ORâ€‰=â€‰3.70; 95Â % CIâ€‰=â€‰2.08-6.57; pâ€‰<â€‰0.0001), and suicide attempts (ORâ€‰=â€‰3.33; 95Â % CIâ€‰=â€‰1.47-7.54; pâ€‰=â€‰0.0040) were significant predictors of persistent depression at 6 or 12Â months.Three questions on suicidality could help primary care professionals to assess such patients more closely without necessarily establishing whether they meet criteria for major depression.
Effect of Pseudopod Extensions on Neutrophil Hemodynamic Transport Near a Wall. - Cellular and molecular bioengineering
During inflammation, circulating neutrophils roll on, and eventually tether to, the endothelial lining of blood vessels, allowing them to exit the bloodstream and enter the surrounding tissue to target pathogens. This process is mediated by the selectin family of adhesion proteins expressed by endothelial cells. Interestingly, only 10% of activated, migrating neutrophils transmigrate into the extravascular space; the other 90% detach from the wall and rejoin the blood flow. Neutrophils extrude pseudopods during the adhesion cascade; however, the transport behavior of this unique cell geometry has not been previously addressed. In this study, a three-dimensional computational model was applied to neutrophils with pseudopodial extensions to study the effect of cell shape on the hydrodynamic transport of neutrophils. The collision time, contact area, contact force, and collision frequency were analyzed as a function of pseudopod length. It was found that neutrophils experience more frequent collisions compared to prolate spheroids of equal volume and length. Longer pseudopods and lower shear rates increase the collision time integral contact area, a predictor of binding potential. Our results indicate that contact between the neutrophil and the vessel wall was found to be focused predominantly on the pseudopod tip.
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