An initial evaluation of the safety of a disposable oscillating positive expiratory pressure device in patients with chronic obstructive pulmonary disease: a sort-term pilot study.

BACKGROUND: Handheld oscillating positive expiratory pressure (OPEP) devices have been a mainstay of treatment for patients with hypersecretory conditions such as cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD) since the 1970s. Current devices are reusable and require regular cleaning and disinfection to prevent harbouring potentially pathogenic organisms. Adherence to cleaning regimens for respiratory devices is often poor and in response to this, a prototype disposable OPEP device-the 'UL-OPEP' (University of Limerick-Oscillating Positive Expiratory Pressure device)-was developed to mitigate the risk of contamination by pathogens. The device was previously evaluated successfully in a group of paediatric CF patients. The aim of the current study was to initially evaluate the safety of the prototype in patients with COPD over a period of 1 month to ensure no adverse events, negative impacts on lung function, exercise tolerance, or quality of life. Data on user experience of the device were also collected during post-study follow-up. METHODS: A sample of 50 volunteer participants were recruited from pulmonary rehabilitation clinics within the local hospital network. The patients were clinically stable, productive, and not current or previous users of OPEP devices. Participants were invited to use a prototype disposable OPEP device daily for a period of 1 month. Pre- and post-study lung function was assessed with standard spirometry, and exercise tolerance with the 6-min-walk-test (6MWT). Quality of life was assessed using the St. George's Respiratory Questionnaire (SGRQ), and user experience of the prototype device evaluated using a post-study questionnaire. RESULTS: 24 Participants completed the study: 9 were female. Overall median age was 67.5 years, range 53-85 years. Lung function, 6-min walk test, and SGRQ scores showed no significant change post-study. User feedback was positive overall. CONCLUSIONS: The results indicate that the UL-OPEP is safe to use in patients with COPD. No adverse events were recorded during the study or in the follow-up period of 2 weeks. The device did not negatively impact patients' lung function, exercise tolerance, or quality of life during short term use (1 month), and usability feedback received was generally positive. Larger, longer duration studies will be required to evaluate efficacy. Registration The study was approved as a Clinical Investigation by the Irish Health Products Regulatory Authority (CRN-2209025-CI0085).

Experience of using electromyography of the genioglossus in the investigation of paediatric dysphagia.

AIM: The aim of the study was to assess, retrospectively, the utility of genioglossus electromyography (gEMG) in evaluating children with suspected neurogenic feeding and swallowing difficulties. METHOD: Children who were evaluated using gEMG at a tertiary paediatric neurology dysphagia service were reviewed. Data were analysed by the presence/absence of neurogenic changes on gEMG and the method of feeding at their most recent follow-up. RESULTS: The study group comprised 59 individuals (36 males, 23 females; median age 20 mo; range 1 mo-15 y). The study cohort included individuals with heterogeneous neurological phenotypes (n=40), craniofacial syndrome (n=10), and congenital bulbar palsy (n=9). gEMG identified 35 out of 59 (60%) with neurogenic changes. At follow-up, 24 individuals were on oral feeds and 35 were on alternative methods of feeding (nasogastric /gastrostomy). Eight out of 24 children on oral feeds showed neurogenic changes compared with 27 out of 35 on alternative feeds. χ(2) analysis of feeding method at follow-up and the presence or absence of neurogenic change on EMG was highly significant (p≤0.002). When confounding factors for alternative feeds were accounted for on univariate analysis, the neurogenic changes, severe gastro-oesophageal reflux disease, and respiratory comorbidities were statistically significant in predicting the alternative feeding, whereas growth failure and behavioural difficulties were not significant confounders. Moreover, multiple logistic regression analysis revealed that the neurogenic changes were independently predictive of an alternative method of feeding after adjusting for other confounders with an odds ratio of 29.6 (95% confidence interval 3.97-220; p<0.007). CONCLUSION: gEMG is a valuable complementary tool in the evaluation of children with neurogenic dysphagia as the degree of severity is independently correlated with long-term feeding outcomes.

Patient satisfaction with an emergency department psychiatric service.

PURPOSE: The purpose of this paper is to measure the rate of satisfaction of the sample population with an emergency department psychiatric service and to explore in open-ended questions, factors which contributed to these satisfaction ratings. DESIGN/METHODOLOGY/APPROACH: All psychiatric patients who attended the service and fulfilled the eligibility criteria during the study timeframe received the postal questionnaire (n = 55). The Client Satisfaction Questionnaire-8 was used, which is a brief, eight-item instrument designed to assess post-service satisfaction. It has good psychometric properties and has been validated for use in a psychiatric patient population. FINDINGS: It is found that 35 per cent of respondents scored a low level of satisfaction, 29 per cent a medium level and 36 per cent a high level of satisfaction. The qualitative data, completed by 73 per cent of respondents, provided a more in-depth view from the patient's perspective. RESEARCH LIMITATIONS/IMPLICATIONS: The response rate was low as predicted for this population. PRACTICAL IMPLICATIONS: The qualitative findings reveal positive feedback regarding the staff, but patients expressed dissatisfaction about the availability of beds, waiting times for assessment, communication by staff, deficiency of crisis services in the home and inadequate provision of information regarding services. This study identifies factors which contribute to the low satisfaction ratings and identify ways to improve the service. ORIGINALITY/VALUE: This mail patient survey provides valuable information for those planning and improving services for patients in the setting of the emergency department. The paper contributes to the limited number of studies of psychiatric services in this setting and identifies ways to improve patient satisfaction as supported by international evidence.

Audit of an inpatient liaison psychiatry consultation service.

PURPOSE: The purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence-based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards. DESIGN/METHODOLOGY/APPROACH: All inpatient referrals to a liaison psychiatry service were recorded over a six-month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards. FINDINGS: A total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol-related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence-based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day. PRACTICAL IMPLICATIONS: Use of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence-based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards. ORIGINALITY/VALUE: This paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.

Swallow Prognosis and Follow-Up Protocol in Infantile Onset Pompe Disease.

Oro-pharyngeal dysphagia commonly occurs in patients with infantile onset Pompe disease (IOPD), which is a rare recessive neuromuscular disorder caused by deficiency of the lysosomal enzyme acid alpha-glucosidase. Without treatment, death occurs by 1 year of age from cardiorespiratory failure. Enzyme replacement therapy (ERT) has been used to increase life expectancy, however emerging developmental and medical morbidities have become apparent. A case file review of the feeding outcomes of 12 patients with IOPD, managed at a single tertiary centre, was undertaken. Two types of assessment had been completed: clinical feeding assessment (CFA) and instrumental videofluoroscopy swallow study (VFSS). A rating of functional oral intake at every Speech and Language Therapy feeding assessment from initial diagnosis to the most recent assessment was applied using the functional oral intake scale (FOIS).Results indicate, initial diagnosis VFSS predicts long-term feeding outcomes. Even if a patient had an improvement in oral feeding after diagnosis, over a period of time their oral intake returned to the initial diagnosis VFSS level or below. All patients (8/8) who required non-oral feeding support under 6 months of age went on to require non-oral feeding support, even if they had periods of full oral feeding. CRIM negative status predicted significant oral feeding difficulties. An evidence-based follow-up protocol was developed. The information is used at diagnosis to counsel families regarding feeding prognosis and consideration of early gastrostomy when cardiac status allows safe anaesthesia. The results reinforce that feeding changes over time and patients require on-going dysphagia monitoring.

Elevated expression of integrin alpha(IIb) beta(IIIa) in drug-naïve, first-episode schizophrenic patients.

BACKGROUND: Patients with schizophrenia have an increased risk over the general public of developing cardiovascular illness. It is unknown if there are functional changes in platelet surface receptors in schizophrenia. We therefore analyzed the surface expression of glycoprotein (GP)Ib, the integrin receptor alpha(IIb)beta(IIIa), CD62 (P-selectin), and CD63, and investigated platelet function in schizophrenic patients compared with healthy volunteers. METHODS: Nineteen drug-naive, first-episode patients with a DSM IV diagnosis of paranoid schizophrenia were compared with matched healthy controls. Flow cytometry was used to assess platelet surface expression levels of GPIb, alpha(IIb)beta(IIIa), CD62, and CD63. Adenosine diphosphate-induced platelet aggregation was assayed. RESULTS: The schizophrenic patients had a significantly (p < .0001) increased number of 68,145 +/- 8,260.1 alpha(IIb)beta(IIIa) receptors, platelet compared with 56,235 +/- 8,079.4 receptors, platelet in healthy controls. CONCLUSIONS: Patients with schizophrenia have increased platelet expression of alpha(IIb)beta(IIIa), which may contribute to their increased risk of cardiovascular illness compared with the general population.

Impaired fasting glucose tolerance in first-episode, drug-naive patients with schizophrenia.

OBJECTIVE: This study examined the prevalence of impaired fasting glucose tolerance in first-episode, drug-naive patients with schizophrenia. METHOD: In this cross-sectional study, fasting plasma levels of glucose, insulin, lipids, and cortisol were measured in 15 male and 11 female hospitalized Caucasian patients with DSM-IV schizophrenia (mean age=33.6 years) and age- and sex-matched healthy comparison subjects. The patients and comparison subjects were also matched in terms of various life-style and anthropometric measures. RESULTS: More than 15% of the drug-naive, first-episode patients with schizophrenia had impaired fasting glucose tolerance, compared to none of the healthy volunteers. Compared with the healthy subjects, the patients with schizophrenia had significantly higher fasting plasma levels of glucose (mean=88.2 mg/dl, SD=5.4, for the healthy subjects versus mean=95.8 mg/dl, SD=16.9, for the patients), insulin (mean=7.7 micro u/ml, SD=3.7, versus mean=9.8 micro u/ml, SD=3.9), and cortisol (mean=303.2 nmol/liter, SD=10.5, versus mean=499.4 nmol/liter, SD=161.4) and were more insulin resistant, as measured with homeostasis model assessment (mean=1.7, SD=0.7, for the healthy subjects versus mean=2.3, SD=1.0, for the patients). CONCLUSIONS: First-episode, drug-naive patients with schizophrenia have impaired fasting glucose tolerance and are more insulin resistant and have higher levels of plasma glucose, insulin, and cortisol than healthy comparison subjects.

Evidence of basal pituitary-adrenal overactivity in first episode, drug naïve patients with schizophrenia.

BACKGROUND: Evidence for basal hypothalamic-pituitary-adrenal (HPA) axis dysfunction in schizophrenia is less consistent than that seen in major depression. Potential reasons include sampling procedures and the use of patients on antipsychotic medications which may suppress the HPA axis. Therefore, the objective of this study was to determine whether first episode, drug naïve patients with schizophrenia have evidence of basal HPA axis dysfunction by measuring plasma levels of AVP, ACTH and cortisol from 13:00 to 16:00 h, a time frame which is believed to reflect 24 h concentrations of HPA axis activity. METHOD: In this cross-sectional study, plasma levels of AVP, ACTH and cortisol were measured in 12 (7 males and 5 females) (mean age +/-SD=33.6+/-12.6 years) patients with DSM-IV schizophrenia and compared with those found in age- and sex-matched healthy controls. RESULTS: Patients and controls did not differ in terms of their 13:00 h cortisol and AVP. However, patients with schizophrenia had higher levels of ACTH as compared to control subjects at 13:00 h (41.3+/-14.6 vs. 12.4+/-1.1 pg/ml respectively; t=1.99, df=11, p <0.05). In comparison to controls subjects, patients with schizophrenia, had higher mean (+/-SE) AUC of ACTH (26.3+/-6.2 vs. 13.9 nmol/l, respectively; t=2.86, df=11, p <0.02) and cortisol (279.4+/-26.0 vs. 213.1+/-18.4 nmol/l, respectively; t=3.72, df=11, p <0.01). Though, patients with schizophrenia, in comparison to control subjects, had lower mean (+/-SE) AUC of AVP (0.87+/-0.24 vs. 1.42+/-0.34 pmol/l, respectively; t=2.29, df=11, p <0.02). CONCLUSIONS: First episode, drug naïve patients with schizophrenia show evidence of basal overactivity of the pituitary-adrenal axis.

Physical consequences of schizophrenia and its treatment: the metabolic syndrome.

Schizophrenia is a life shortening illness. Unnatural causes and natural causes are put forward as reasons for this excess mortality. In terms of the latter, a host of different physical disorders occur with increased frequency in schizophrenia. When taken together, some of these illnesses such as type 2 diabetes mellitus and cardiovascular disorders constitute the Metabolic Syndrome; a characteristic phenotype of those with this syndrome is excessive visceral fat distribution. The exact reasons why this particular syndrome occurs in schizophrenia is as yet unclear though factors such as life style, poor diet and lack of exercise may contribute to it's development. Alternatively, overactivity of the hypothalamic-pituitary-adrenal axis leading to hypercortisolaemia can also result in excessive visceral fat accumulation. This minireview aims to explore the potential role of these issues and medication in terms of the increased morbidity and mortality observed in schizophrenia.

Depression is associated with an increase in the expression of the platelet adhesion receptor glycoprotein Ib.

There is a significant association between cardiovascular disease and depression. Previous studies have documented changes in platelets in depression. It is unknown if depression causes functional changes in platelet surface receptors. Therefore, we analyzed (1) the surface expression of glycoprotein (GP)Ib and the integrin receptor alpha(IIb)beta(IIIa), receptors involved in platelet adhesion and aggregation, (2) CD62 (P-selectin) and CD63, integral granule proteins translocated during platelet activation, (3) platelet aggregation in response to ADP and (4) plasma levels of glycocalicin and von Willebrand factor (vWF), in depressed patients compared to healthy volunteers. Fifteen depressed patients with a Hamilton depression score of at least 22 and fifteen control subjects were studied. Platelets were assessed for surface expression levels of GPIb, alpha(IIb)beta(IIIa), CD62 and CD63 by flow cytometry. Genomic DNA was isolated to investigate a recently described polymorphism in the 5' untranslated region of the GPIbalpha gene. The number of GPIb receptors was significantly increased on the surface of platelets from patients with depression compared to control subjects. Surface expression of CD62 was also significantly increased in the depressed patients versus control subjects. There was no significant difference between depressed patients and healthy volunteers in the surface expression of alpha(IIb)beta(IIIa) or CD63, or in glycocalicin or vWF plasma concentration, or ADP-induced aggregation. There was no difference in allele frequency of the Kozak region polymorphism of the GPIbalpha gene, which can affect GPIb expression. The results of this study demonstrate that the number of GPIb receptors on platelets are increased in depression and suggest a novel risk factor for thrombosis in patients with depression.

The effects of atypical antipsychotics on visceral fat distribution in first episode, drug-naive patients with schizophrenia.

The aim of this study was to determine the location of antipsychotic-induced weight gain in drug naïve, first episode patients with schizophrenia. Various fatness and fat distribution parameters (by Computerized Tomography scanning and anthropometry) and 1600 hr plasma cortisol were measured in 19 (15 men and 4 women) subjects with schizophrenia (mean age = 31.0 years; mean body mass index [BMI] = 24.6 kg/m2) and an equal number of age- and sex- matched controls (mean age = 32.6 yr; mean BMI = 23.0 kg/m2). Patients were then given either olanzapine or risperidone. Sixteen patients were re-tested following a treatment period lasting approximately 6 months. Patients with schizophrenia, had significantly more intra-abdominal fat [IAF] (116.8 +/- 20.2 cm2 vs. 38.0 +/- 4.8 cm2, respectively; t = 3.80, df = 18, p < 0.0001) and had higher levels of plasma cortisol (360.2 +/- 49.6 nmol/L vs. 192.7 +/- 19.7 nmol/L, respectively; t = 3.13, df = 18, p < 0.003) than appropriately matched control subjects. Treatment with atypical antipsychotics did not result in a significant increase in IAF (116.8 +/- 20.2 cm2 vs. 131.7 +/- 20.9 cm2; p = NS) though visceral fat stores still remained significantly higher than those seen in controls (38.0 +/- 4.8 cm2) (F = 9.34; df = 2, 51; p < 0.0003). However, plasma levels of cortisol did significantly decrease (360.2 +/- 49.6 nmol/L +/- vs. 316.2 +/- 48.4 nmol/L; p < 0.05). Pre-treatment levels of IAF did not differ between those who received risperidone and those who were given olanzapine (123.0 +/- 35.9 cm2 vs. 113.1 +/- 15.7 cm2, respectively; t = 0.20, df = 16, p < 0.84). The increase in IAF did not differ between those given risperidone and those who received olanzapine (26.9 +/- 12.1 cm2 vs. 18.24 +/- 11.44 cm2, respectively; t = 0.50, df = 16, p < 0.63). Patients with drug naïve, first episode, schizophrenia have higher levels of visceral fats stores as compared to matched control subjects. Treatment with atypical antipsychotics does not result in a significant increase in IAF distribution.

Platelet surface glycoprotein expression in post-stroke depression: a preliminary study.

Depression is a significant risk factor for and consequence of both cardiovascular disease and stroke. The pathophysiological processes underlying this association are poorly understood. This study utilised a technique for measurement of whole blood platelet surface glycoproteins involved in early adhesion and aggregation in sample populations of patients with depression and stroke, and healthy controls. We analysed the platelet surface glycoproteins GPIb and GPIIbIIIa using flow cytometry in eight depressed subjects (Hamilton depression score >17), 14 post-stroke subjects (seven depressed and seven non-depressed), and in eight healthy control subjects. The number of GPIb receptors was significantly increased in subjects with depression and in post-stroke subjects compared to control subjects. The number of GPIb receptors from post-stroke subjects was not significantly different from that of depressed subjects. There were no differences between any groups in measures of GPIIbIIIa receptor numbers. No additive effect of co-morbid depression on the surface expression level of either marker could be detected in the post-stroke subjects. Platelet dysfunction may be involved in the pathophysiological process underlying the association between depression and cerebrovascular disease.

Reasons for referral and consultation liaison psychiatry diagnoses.

OBJECTIVES: Focused management strategies, including effective distribution of available resources is dependent on ongoing analysis of referral type in any liaison psychiatry consultation service. This survey sought to measure rate of diagnoses in an Irish liaison psychiatry consultation service, and compare the results with other similar services. METHOD: A survey of referral reasons and diagnoses was performed on all patients presenting to a Dublin based inpatient liaison psychiatry consultation service over two six month periods. The results were subsequently compared with other similar international studies. RESULTS: Commonest referral reasons were for depressive disorders, while commonest diagnoses included alcohol related disorders, depressive disorders, and delirium, with notably higher rates of alcohol related disorders than in other similar international studies. CONCLUSIONS: This study provides valuable information for referral reasons and diagnoses present in an Irish liaison psychiatry consultation service. The differences noted between diagnoses in our study and other international studies, as well as some of the difficulties in establishing these diagnoses, are discussed.

Dysphagia and nutrition problems in infants with apert syndrome.

OBJECTIVE: The purpose of this study was to identify and describe the nature of dysphagia and nutrition difficulties in infants with Apert syndrome. DESIGN: The study comprised a review of the medical, nutrition, and feeding records of 13 consecutive infants still feeding by the bottle who had been referred to the Craniofacial Unit and analyses of swallow function from videofluoroscopic swallow investigations. MAIN OUTCOME MEASURES: Outcome measures included qualitative analyses of bottle-feeding and nutritional status and quantitative functional severity ratings of dysphagia based on videofluoroscopic swallow investigations using the O'Neil et al. (1999) Dysphagia Outcome Severity Scale. RESULTS: The main qualitative descriptors of oral feeding in this cohort included uncoordinated suck-swallow-breathe patterns, inability to maintain sucking bursts, and changes in respiratory patterns as the feed progressed. Videofluoroscopic evaluations (N = 7) showed silent laryngeal penetration or aspiration in more than half of the cohort. Failure to thrive was a frequent occurrence seen in seven infants, and 9 of the 10 required dietetic intervention and enteral supplements. (Nutritional records were not located for three infants.) CONCLUSIONS: In view of the small sample size and retrospective nature of the study, the results need to be interpreted with caution. However, the study adds to current limited knowledge on feeding and nutrition in Apert syndrome. Further prospective multidisciplinary and objective research is clearly warranted.

Pre and post-surgical dysphagia outcome associated with posterior fossa tumour in children.

BACKGROUND: Swallowing impairment (dysphagia) has been reported as a possible sequela following surgical removal of posterior fossa tumours (PFT). Dysphagia may result in aspiration of food/fluid leading to respiratory tract infection, placing the patient at considerable health risk. No prospective studies have investigated dysphagia pre and post-surgical removal of PFT. The present study aimed to document the presence, severity and characteristics of dysphagia pre and post-surgical resection of PFT, and to determine whether children were managing a normal oral diet (i.e. a measure of functional swallowing ability) at two months post-surgery. METHODS: Dysphagia was assessed using a clinical bedside evaluation in 11 participants (8 M; aged 3 years 6 months to 13 years 5 months) pre (within 3-5 days) and post-surgery (within 1-2 weeks). Return to normal oral feeding was documented at two months post-surgery via a parent telephone interview. RESULTS AND CONCLUSION: No participant had dysphagia pre-surgically. Seventy three percent (8/11) had dysphagia at 1-2 weeks post-surgery, primarily characterized by impaired lip closure (8/8), poor mastication (8/8), and inefficient oral transit (8/8). Whilst dysphagia severity was largely mild (6/8) in presentation, data suggest that assessment and monitoring of this disorder may be required in the acute phase post-surgery. Overall however, prognosis appeared positive, with 75% (6/8) of participants managing a full oral diet at 2 months post-surgery.

Current practice in paediatric videofluoroscopy.

Use of the videofluoroscopy swallow study (VFSS), also known as the modified barium swallow (MBS), continues to increase in children. This article reviews the scope and limitations of the examination, explores the current techniques and illustrates some of the main findings. As moving images are key to the understanding of the use of this technique short videos are available in the on-line version of this paper.