Crisis care for children and young people with mental health problems: national mapping, models of delivery, sustainability and experience (CAMH-Crisis2). A study protocol.

Background: One in six five 16-year-olds have a probable mental health difficulty. Of these, almost half of older teenagers and a quarter of 11-16-year-olds report having self-harmed or attempted suicide. Currently, there is little research into mental health crisis services for young people, with little understanding of what services exist, who uses them, or what works best. Question: 'How are mental health crisis responses for children and young people up to the age of 25 sustained, experienced and integrated within their local systems of services'? Objectives:     1.    To describe National Health Service (NHS), local authority, education and third sector approaches to the implementation and organisation of crisis care for children and young people across England and Wales.    2.   To identify eight contrasting case studies in which to evaluate how crisis services have developed and are currently organised, sustained, experienced and integrated within the context of their local systems of services.    3.   To compare and contrast these services in the context of the available international evidence, drawing out and disseminating clear implications for the design and delivery of future crisis responses for children and young people and their families. Methods: A sequential mixed methods approach, underpinned by normalisation process theory will be employed. A survey will create a detailed record of how crisis responses across England and Wales are organised, implemented and used. Subsequently, eight contrasting services in relation to geographic and socioeconomic setting, populations served, and service configuration will be identified as case studies. Interviews will be conducted with children, young people and parents/carers who have used the service, as well as commissioners, managers and practitioners. Operational policies and service usage data will also be examined. Analysis of how each service is provided, experienced, implemented and sustained will be conducted both inductively and deductively, reflecting normalisation process theory constructs.

BACKGROUND: There has been a sharp increase in children and young people experiencing extreme emotional distress and/or self-harm, which is also known as 'crisis'. Services for young people in crisis are a priority in the UK but little is currently known about what crisis services exist, who uses them, or what type of service works best. AIM AND OBJECTIVES: This project aims to explore the types of mental health crisis services currently available to children and young people up to the age of 25 in England and Wales, and to examine how they are organised, perceived and integrated within other local care systems. The objectives are to: 1. Find out what NHS, local authority, education and charity sector crisis services exist for children and young people across England and Wales, to describe the services and to create a database of them. 2. Identify eight contrasting services from the database and evaluate how these services are organised, perceived and integrated within local care systems. 3. Compare and contrast these services with the available international evidence, drawing out clear implications for the design and delivery of future crisis responses for children and young people and their families. METHODS: We will use a survey to create a database of crisis response services across England and Wales. From the database we will identify eight contrasting services and we will conduct interviews with children, young people and parents/carers who have used the service as well as managers and staff. We will look at how the services work and explore how they are used and by whom. We will compare and contrast each case study and consider findings of other research studies from around the world to draw clear, actionable, lessons for the future provision of high-quality crisis services for children and young people.

Glucose concentration in capillary blood of dairy cows obtained by a minimally invasive lancet technique and determined with three different hand-held devices.

BACKGROUND: Dairy cows have a massive demand for glucose at the onset of lactation. A poor adaption to this period leads to an excessive negative energy balance with an increased risk for ketosis and impaired animal health and production. Besides the measurement of ketones, analysing the glucose concentration in blood is reported as helpful instrument for diagnosis and differentiation of ketosis. Monitoring metabolic parameters requires multiple blood sampling. In other species, new blood sampling techniques have been introduced in which small amounts of blood are rapidly analysed using electronic hand-held devices. The objective of this study was to evaluate the suitability of capillary blood for blood glucose measurement in dairy cows using the hand-held devices FreeStyle Precision (FSP, Abbott), GlucoMen LX Plus (GLX, A. Menarini) and the WellionVet GLUCO CALEA, (WGC, MED TRUST). In total, 240 capillary blood samples were obtained from dry and fresh lactating Holstein-Friesian cows. Blood was collected from the skin of the exterior vulva by using a lancet. For method comparison, additional blood samples were taken from a coccygeal vessel and analyzed in a laboratory. Glucose concentrations measured by a standard laboratory method were defined as the criterion standard. RESULTS: The Pearson correlation coefficients between the glucose concentrations analyzed in capillary blood with the devices and the reference were 73% for the FSP, 81% for the GLX and 41% for the WGC. Bland-Altman plots showed biases of -18.8 mg/dL for the FSP, -11.2 mg/dL for the GLX and +20.82 mg/dL for the WGC. The optimized threshold determined by a Receiver Operating Characteristics analysis to detect hyperglycemia using the FSP was 43 mg/dL with a sensitivity (Se) and specificity (Sp) of 76 and 80%. Using the GLX and WGC optimized thresholds were 49 mg/dL (Se = 92%, Sp = 85%) and 95 mg/dL (Se = 39%, Sp = 92%). CONCLUSIONS: The results of this study demonstrate good performance characteristics for the GLX and moderate for the FSP to detect hyperglycemia in dairy cows using capillary blood. With the study settings, the WGC was not suitable for determination of glucose concentrations.

Suitability of capillary blood obtained by a minimally invasive lancet technique to detect subclinical ketosis in dairy cows by using 3 different electronic hand-held devices.

The objective of this study was to evaluate the suitability of capillary blood obtained by a minimally invasive lancet technique to detect subclinical ketosis in 49 prepartum and 191 postpartum Holstein-Friesian cows using 3 different electronic hand-held devices [FreeStyle Precision (FSP, Abbott), GlucoMen LX Plus (GLX, A. Menarini), NovaVet (NOV, Nova Biomedical)]. The ß-hydroxybutyrate (BHBA) concentration in serum harvested from coccygeal blood samples was analyzed in a laboratory and used as a reference value. Capillary samples were obtained from the skin of the exterior vulva by using 1 of 3 different lancets. In all samples, the concentration of BHBA was immediately analyzed with all 3 hand-held devices used in random order. All lancets used in the study were eligible for capillary blood collection but differed in the total number of incisions needed. Spearman correlation coefficients between the BHBA concentrations in capillary blood and the reference test were highly significant with 83% for the FSP, 73% for the NOV, and 63% for the GLX. Using capillary blood, the FSP overestimated the mean BHBA concentration compared with the reference test (+0.08 mmol/L), whereas the GLX and NOV underestimated the mean concentration (-0.07 and -0.01 mmol/L). When a BHBA concentration of 1.2 mmol/L in serum was used to define subclinical ketosis, the corresponding analyses of receiver operating characteristics resulted in optimized thresholds for capillary blood of 1.1 mmol/L for the NOV and GLX devices, and of 1.0 mmol/L for the FSP. Based on these thresholds, sensitivities (Se) and specificities (Sp) were 89 and 84% for the NOV, 80 and 89% for the GLX, and 100 and 76% for the FSP. Based on a serum BHBA concentration of 1.4 mmol/L, analyses of receiver operating characteristics resulted in optimized cut-offs of 1.4 mmol/L for the FSP (Se 100%, Sp 92%), 1.3 mmol/L for the NOV (Se 80%, Sp 95%), and 1.1 mmol/L (Se 90%, Sp 85%) for the GLX. Using these optimized thresholds for the specific hand-held meters, no significant differences between the devices in Se and Sp to detect subclinical ketosis in coccygeal blood were observed. Calculated test characteristics for analyzing capillary blood using the hand-held devices were numerically smaller compared with blood obtained from a coccygeal vessel, but overlapping confidence intervals indicate no statistical difference between the origin of the sample. Hence, this procedure seems to be suitable for ketosis monitoring in dairy cows, but further validation with more data from different farms is recommended.

Deployment of a dental treatment facility during Operation Gritrock - lessons for future maritime contingency operations.

Following the largest outbreak of Ebola in history, Royal Fleet Auxiliary Argus deployed to Sierra Leone in October 2014 as part of the UK Armed Forces response to the Ebola crisis. Integral to the Primary Casualty Receiving Facility deployment was a dental capability, which was one of the busiest departments on board during the deployment. This paper describes the deployment and unique challenges of conducting dental treatment in an environment where there is an infectious disease epidemic.

Motion estimation for cardiac emission tomography by optical flow methods.

This paper describes a new method for estimating the 3D, non-rigid object motion in a time sequence of images. The method is a generalization of a standard optical flow algorithm that is incorporated into a successive quadratic approximation framework. The method was evaluated for gated cardiac emission tomography using images obtained from a mathematical, 4D phantom and a physical, dynamic phantom. The results showed that the proposed method offers improved motion estimation accuracy relative to the standard optical flow method. Convergence of the proposed algorithm was evidenced with a monotonically decreasing objective function value with iteration. Practical application of the motion estimation method in cardiac emission tomography includes quantitative myocardial motion estimation and 4D, motion-compensated image reconstruction.

Estimation of images and nonrigid deformations in gated emission CT.

In this paper, we propose and test a new iterative algorithm to simultaneously estimate the nonrigid motion vector fields and the emission images for a complete cardiac cycle in gated cardiac emission tomography. We model the myocardium as an elastic material whose motion does not generate large amounts of strain. As a result, our method is based on minimizing an objective function consisting of the negative logarithm of a maximum likelihood image reconstruction term, the standard biomechanical model of strain energy, and an image matching term that ensures a measure of agreement of intensities between frames. Simulations are obtained using data for the four-dimensional (4-D) NCAT phantom. The data models realistic noise levels in a typical gated myocardial perfusion SPECT study. We show that our simultaneous algorithm produces images with improved spatial resolution characteristics and noise properties compared with those obtained from postsmoothed 4-D maximum likelihood methods. The simulations also demonstrate improved motion estimates over motion estimation using independently reconstructed images.

Accelerated penalized weighted least-squares and maximum likelihood algorithms for reconstructing transmission images from PET transmission data.

We present penalized weighted least-squares (PWLS) and penalized maximum-likelihood (PML) methods for reconstructing transmission images from positron emission tomography transmission data. First, we view the problem of minimizing the weighted least-squares (WLS) and maximum likelihood objective functions as a sequence of nonnegative least-squares minimization problems. This viewpoint follows from using certain quadratic functions as surrogate functions for the WLS and maximum likelihood objective functions. Second, we construct surrogate functions for a class of penalty functions that yield closed form expressions for the iterates of the PWLS and PML algorithms. Due to the slow convergence of the PWLS and PML algorithms, accelerated versions of them are developed that are theoretically guaranteed to monotonically decrease their respective objective functions. In experiments using real phantom data, the PML images produced the most accurate attenuation correction factors. On the other hand, the PWLS images produced images with the highest levels of contrast for low-count data.

Hypotensive reactions associated with platelet transfusions and angiotensin-converting enzyme inhibitors.

BACKGROUND AND OBJECTIVES: To determine the cause of hypotensive reactions associated with platelet transfusions in coronary artery bypass surgery patients. MATERIALS AND METHODS: Platelet transfusion reactions that occurred during a 3-month period were retrospectively reviewed. RESULTS: Eighteen transfusion reactions occurred in 16 patients. Sixteen of the reactions were hypotensive and occurred in 14 patients transfused with platelets through negatively charged bedside leukocyte reduction filters. All 14 patients had received angiotensin-converting enzyme (ACE) inhibitors prior to transfusion. CONCLUSION: Preliminary findings suggest a new type of transfusion reaction associated with the use of negatively charged leukocyte reduction filters during platelet transfusions to patients on ACE inhibitors.

Evaluation of changes in hemoglobin levels associated with ABO-incompatible plasma in apheresis platelets.

BACKGROUND: Hemolytic transfusion reaction is considered a rare complication of platelet transfusion. If minor ABO incompatibility exists (donor antibody directed against recipient's red cells [plasma-incompatible platelets]), however, the antibodies present in the plasma of platelets may cause acute hemolysis. A retrospective study was performed to identify possible hemolysis related to the transfusion of plasma-incompatible apheresis platelets. STUDY DESIGN AND METHODS: Acute hemolysis due to low-titer anti-A present in group O apheresis platelets transfused to a group A patient is reported. Pretransfusion and posttransfusion hemoglobin levels were evaluated in 16 non-group O autologous bone marrow transplant patients receiving apheresis platelets. All patients received, within 24 hours, both ABO-identical and plasma-incompatible platelet transfusions. No red cells were transfused during the time between the collection of the pretransfusion and posttransfusion hemoglobin samples. RESULTS: A total of 24 evaluable paired platelet transfusions in the 16 patients were compared. The mean change in hemoglobin following transfusion of the ABO-identical and plasma-incompatible platelets was -0.50 g per dL and -0.11 g per dL, respectively (p = 0.193). CONCLUSION: There was no significant change in the hemoglobin concentration associated with the transfusion of plasma-incompatible apheresis platelets (minor ABO incompatibility) in our study group. The case reported here represents the only hemolytic transfusion reaction identified among 46,176 platelet transfusions performed at this hospital, despite approximately 21 percent of all platelet transfusions being plasma incompatible. The risk of such a reaction remains low.

Effects of topical skin protectant on heat exchange in humans.

BACKGROUND: The application of a Topical Skin Protectant (TSP) under chemical protective clothing may impair heat exchange and/or decrease tolerance time during exercise. HYPOTHESIS: The extent to which TSP might act as a barrier to heat transfer was unknown. Since TSP may be permeable to water vapor, we hypothesized that there would be no significant differences between treatments on variables effecting heat exchange. METHODS: There were 10 subjects who walked (3.5 mph, 3% grade) until volitional exhaustion in an environmental chamber (TA = 36.0 +/- 0.5 degrees C; TDP = 27.0 +/- 1.0 degrees C) in two conditions: no TSP application (CON) and TSP application (TSP). TSP was applied to 21% of body surface area on six specific areas. Esophageal temperature, skin temperature (8 sites), heart rate, and pre- and post-experimental weights were measured. Mean skin temperature, mean body temperature, changes in esophageal temperature per min of exercise, evaporative heat loss, and sweating rate were calculated. RESULTS: There was no effect (p < 0.05) of TSP on esophageal temperature, mean skin temperature, heart rate, tolerance time (CON: 139.3 +/- 32.5 vs. TSP: 132.3 +/- 37.0 min), sweating rate (CON: 9.5 +/- 1.9 vs. TSP: 9.4 +/- 3.03 g.min-1) and evaporative heat loss (CON: 200.9 +/- 31.6 vs. TSP: 215.9 +/- 25.9 W.m-2). The change in TES per min of exercise averaged 0.014 +/- 0.003 degree C during TSP and 0.012 +/- 0.003 degree C during CON, and was higher (p = 0.024) in TSP. At this rate, the difference between treatments for 4 h would be 0.48 degree C. There were no adverse local or systemic reactions to TSP application. CONCLUSIONS: TSP application minimally affected heat exchange under the conditions of this study.

Weighted least-squares reconstruction methods for positron emission tomography.

We present unpenalized and penalized weighted least-squares (WLS) reconstruction methods for positron emission tomography (PET), where the weights are based on the covariance of a model error and depend on the unknown parameters. The penalty function for the latter method is chosen so that certain a priori information is incorporated. The algorithms used to minimize the WLS objective functions guarantee nonnegative estimates and, experimentally, they converged faster than the maximum likelihood expectation-maximization (ML-EM) algorithm and produced images that had significantly better resolution and contrast. Although simulations suggest that the proposed algorithms are globally convergent, a proof of convergence has not yet been found. Nevertheless, we are able to show that the unpenalized method produces estimates that decrease the objective function monotonically with increasing iterations.

Monitoring for undertransfusion.

BACKGROUND: Most published reviews and audits of blood and blood component transfusion have focused on the issue of overtransfusion and on the inappropriate use of red cell components. There is growing concern that efforts to curb unnecessary transfusions may result in a trend toward undertransfusion of patients. There is little published information that addresses this issue or the magnitude of this practice. STUDY DESIGN AND METHODS: Undertransfusion was evaluated by examining the transfusion records from a 3-month period for 55 patients who met the study criteria of having either a hemoglobin level < 7 g per dL or a platelet count of < 10 x 10(9) per L. If the identified patient did not receive a transfusion within 24 hours of the reported hemoglobin level or platelet count, the medical record was reviewed by a resident physician. RESULTS: A total of 213 individual hemoglobin levels and platelet counts, representing the 55 patients, met our transfusion criteria. All except 8 of the identified patients received red cells and/or platelet transfusions. Reasons for not transfusing red cells included the patient's response to nutritional support and iron supplementation, refusal of blood, and noncompliance. Reasons for not transfusing platelets included falsely low platelet count because of platelet clumping in vitro, contraindication based on clinical diagnosis (e.g., immune thrombocytopenic purpura), and the patient's death before transfusion. CONCLUSION: Red cell and platelet transfusions were appropriately ordered for all patients who met the transfusion criteria. Undertransfusion is not a problem at this institution according to the criteria established. It is recommended that other institutions expand their blood utilization audits to include investigation for evidence of undertransfusion. Further research regarding the issue of undertransfusion is warranted and could be expanded to include other components.

Abnormally high values for direct bilirubin in the serum of newborns as measured with the DuPont aca.

To assess notably high measurements of direct bilirubin in the serum of newborns obtained on the DuPont aca analyzer, the authors compared results from the aca instrument with the results from the Technicon RA-1000 analyzer. Total and direct bilirubin values in 11 serum samples of newborn babies were measured in parallel on both instruments. There was good correspondence between the two instruments in determination of total bilirubins. However, the diazotized sulfanilic acid method (used by both instruments) yielded much higher direct bilirubin values on the aca analyzer than on the RA-1000. The possibly spuriously elevated direct bilirubin results produced by the aca may cause clinical confusion.

[A gradient in cold-resistance of ash bud sequences]. / Frosthärtegradienten entlang der Knospenfolge auf Eschentrieben.

UNLABELLED: Terminal buds of ash (Fraxinus ornus L.) twigs are more developed than the two additional subterminal buds and the axillary buds inserted lower on the twig. The lateral buds gradually decrease in size from the tip to the base of the twig.A gradient of cold-resistance was established in the bud sequence of ash twigs. The terminal bud is the most frost-sensitive, and the inactive substitutional buds are the most resistant. As soon as the trees become active at the beginning of spring, the high degree of cold-resistance achieved during winter is reduced first in those buds which are the earliest to burst. The subterminal and the most basal buds, which, as a rule, do not open, partially lose their cold-resistance in spring and summer, however they remain markedly more resistant during this time than growing buds. IN CONCLUSION: InFraxinus ornus the more a bud is developed, the less it becomes cold-resistant and the sooner it loses the resistance it had.

Terpenoid precursors of hydrocarbons from the gasoline range of petroleum.

2,6-Dimethyloctane and 2-methyl-3-ethylheptane were isolated from petroleum. These hydrocarbons which are present in relatively large amounts appear to be derived from the monoterpenoids.