Monthly engagement with EIP keyworkers was associated with a five-fold increase in the odds of engagement with psychosocial interventions.

BACKGROUND: Early intervention in psychosis (EIP) supports people who are experiencing their first episode of psychosis (FEP). A new Model of Care (MoC) for EIP services was launched in Ireland in 2019. Three EIP demonstration sites were chosen to test this MoC through a 'hub and spoke' approach. These services were a new way of organising care for people experiencing FEP, based upon a recovery model of care, and which sought to standardise care, improve access by clinically led multidisciplinary teams. This included newly created EIP keyworker roles whereby keyworkers assumed responsibilities regarding assessment, comprehensive individual care planning and coordination of care. METHODS: A mixed methods design utilising the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were utilised. Descriptive analyses and logistic regression were performed to examine how increased keyworker engagement influenced the use of other psychosocial interventions within the EIP demonstration sites. Thematic analyses was used for qualitative data. RESULTS: There was a strong positive relationship between keyworker contacts and psychosocial interventions offered. Specifically, the odds of achieving at least monthly engagement with cognitive behavioural therapy for psychosis (CBTp; (5.76 (2.43-13.64), p < 0.001), and behavioural family therapy (BFT; (5.52(1.63-18.69, p < 0.006)) increased by fivefold with each additional monthly keyworker contact. For individual placement support (IPS) each additional monthly keyworker contact was associated with a three-fold increase in the odds of achieving monthly attendance with IPS (3.73 (1.64-8.48), p < 0.002). Qualitative results found that the EIP keyworker role as viewed by both service users and staff as a valuable nodal point, with a particular emphasis on care coordination and effective communication. CONCLUSIONS: This study advances the understanding of keyworker effects through qualitative evidence of keyworkers functioning as a "linchpin" to the service, while the positive response association between keyworker contacts and engagement with other services provides quantitative support for keyworkers reducing the organisational or structural barriers to service access. Given the importance of these positions, health systems should ensure that EIP programmes identify qualified and experienced staff to fill these roles, as well as allocate the appropriate funding and protected time to support keyworker engagement and impact.

Barriers and facilitators to the implementation of an early intervention in psychosis service in three demonstration sites in Ireland.

BACKGROUND: Programmes for early intervention (EIP) in psychosis for people experiencing a first episode of psychosis (FEP) have been found to be both clinically and cost effective. Following the publication of a new EIP model of care (MoC) in Ireland, the aim of this research is to describe how people participated in and responded to the MoC including service users, family members, HSE clinical staff and HSE management. METHODS: Qualitative design using the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were used. A total of N = 40 key informant semi-structured interviews were completed which included clinical staff (N = 22), health service managers and administrators (N = 9), service users (N = 8) and a family member (N = 1). Thematic analyses were conducted. RESULTS: Unique features of the EIP service (e.g., speed of referral/assessment, multidisciplinary approach, a range of evidence-based interventions and assertive MDT follow up) and enthusiasm for EIP were identified as two key factors that facilitated implementation. In contrast, obstacles to staff recruitment and budget challenges emerged as two primary barriers to implementation. CONCLUSIONS: The findings from this research provide real world insights into the complexity of implementing an innovative service within an existing health system. Clear and committed financial and human resource processes which allow new innovations to thrive and be protected during their initiation and early implementation phase are paramount. These elements should be considered in the planning and implementation of EIP services both nationally in Ireland and internationally.

Improvements in Clinical Outcomes in Children with Cystic Fibrosis aged Six and 16 years.

Aims Our aim was to assess if outcomes for cystic fibrosis (CF) patients at six & sixteen years of age have improved in the last 17 years looking at FEV1, BMI and death. Methods A retrospective observational study using a prospectively maintained database of CF patients at Cork University Hospital. Results 84 patients were included in the 16-year-old data and 89 patients were included in the six-year-old data. The mean FEV1 and BMI (16 years) for the 2002-2007 group was 72.9±21.0% and 18.9±2.53 respectively, 2008-2013 group was 75.4±27.2% and 19.8±2.7 and for the 2014-2018 group was 95.2±16.0% and 22.9±4.1. The percentage of patients (16 years) with chronic pseudomonas status was 37.9% (11/30) in the 2002-2007 group, 51.6 % (16/31) in the 2008-2013 group and 4.2% (1/24) in the 2014-2018 group. The relationship between FEV1 and FVC with BMI remained significant in multivariate analysis (P <0.001). The mean FEV1 (six years) for the 2002-2007 group was 90.7±16.1%, 2008-2013 group was 99.3±17.9% and for the 2014-2018 group was 100.9±15.8%. Conclusions Improvements in FEV1 and BMI aged six and 16 years are notable as well as a significant decline in the number of patients with chronic pseudomonas.

Antenatal Ultrasound Detection of Cleft in Western Australia from 2003 to 2012: A Follow-Up Study.

AIM: To investigate trends in the rate of antenatal detection of cleft lip and palate (CLP) patients referred to the CLP Unit at Princess Margaret Hospital for Children in Perth, Western Australia during the period 2003-2012 and compare data with a previously published report covering the years 1996-2003. METHODS: This is a single-center, retrospective survey of antenatal transabdominal ultrasound screenings of mothers of infants born between July 1, 2003 and June 30, 2012 that were referred to the CLP Unit at Princess Margaret Hospital. RESULTS: Detection rates of oral clefts increased significantly when compared with outcomes reported in the same population between 1996 and 2003 (P < .05). An overall detection rate of 71.7% (165/230) was achieved for clefts involving lip and palate. Detection of isolated cleft palate (1/99) and microform (0/8) remained elusive. Most detections (76.5%) were achieved at 15 to 20 weeks of gestational age, corresponding with routine anatomical screening. A further 16.8% were detected post-20 weeks of gestation. Scans were performed by specialist obstetricians, and sonography clinics reported a detection rate of 84.6% (55/65), whereas nonspecialist clinics reported a detection rate of only 67.1% (110/164). CONCLUSION: The antenatal detection rates of oral clefts involving the lip have improved to the extent that the majority of mothers are now being referred to a cleft unit in Western Australia prior to the births of their children. As a result of this improvement, antenatal counseling is now a common facet of cleft management.

Predominant Acidilobus-like populations from geothermal environments in yellowstone national park exhibit similar metabolic potential in different hypoxic microbial communities.

High-temperature (>70°C) ecosystems in Yellowstone National Park (YNP) provide an unparalleled opportunity to study chemotrophic archaea and their role in microbial community structure and function under highly constrained geochemical conditions. Acidilobus spp. (order Desulfurococcales) comprise one of the dominant phylotypes in hypoxic geothermal sulfur sediment and Fe(III)-oxide environments along with members of the Thermoproteales and Sulfolobales. Consequently, the primary goals of the current study were to analyze and compare replicate de novo sequence assemblies of Acidilobus-like populations from four different mildly acidic (pH 3.3 to 6.1) high-temperature (72°C to 82°C) environments and to identify metabolic pathways and/or protein-encoding genes that provide a detailed foundation of the potential functional role of these populations in situ. De novo assemblies of the highly similar Acidilobus-like populations (>99% 16S rRNA gene identity) represent near-complete consensus genomes based on an inventory of single-copy genes, deduced metabolic potential, and assembly statistics generated across sites. Functional analysis of coding sequences and confirmation of gene transcription by Acidilobus-like populations provide evidence that they are primarily chemoorganoheterotrophs, generating acetyl coenzyme A (acetyl-CoA) via the degradation of carbohydrates, lipids, and proteins, and auxotrophic with respect to several external vitamins, cofactors, and metabolites. No obvious pathways or protein-encoding genes responsible for the dissimilatory reduction of sulfur were identified. The presence of a formate dehydrogenase (Fdh) and other protein-encoding genes involved in mixed-acid fermentation supports the hypothesis that Acidilobus spp. function as degraders of complex organic constituents in high-temperature, mildly acidic, hypoxic geothermal systems.

[The Carnot efficiency and plant photosystems].

The concept that the Carnot efficiency places an upper limit of 0.60-0.75 on the thermodynamic efficiency of photosynthetic primary photochemistry is examined using the PSI-LHCI preparation. The maximal quantum efficiency was determined approximately 0.99 which yielded a thermodynamic efficiency of 0.96, a value far above that predicted on the basis of the Carnot efficiency. The commonly presented reasoning leading to the Carnot efficiency idea was therefore critically examined. It is concluded that the crucial assumption that the pigment system, under illumination, is in equilibrium with the incident light field, at a black body temperature of Tr, is erroneous, as the temperature of the excited state pigments was experimentally shown to be that of the sample solvent (thermal bath), 280 K in this case. It is concluded that the classical reasoning used to describe the thermodynamics of heat systems is not applicable to "photonic" systems such as plant photosystems.

An audit of assessment rooms for mental health assessments in Ireland's emergency departments.

OBJECTIVES: To audit compliance of mental health assessment rooms in Irish adult emergency departments (EDs) which are open 24 hours on 7 days a week with standards identified by the Psychiatric Liaison Accreditation Network (PLAN). METHODS: A self-audit tool was sent via email to Clinical Nurse Specialists and Consultant Psychiatrists in Ireland's 26 Adult EDs that are open 24 hours on seven days a week. Results were collated and are presented ensuring anonymity. RESULTS: A response rate of 100% was achieved. Full or substantial compliance with PLAN standards was recorded in 73% of services. In seven services, the rooms used for mental health assessments were unsuitable when measured against the PLAN standards. A number of services identified the presence of ligature points within the rooms. CONCLUSION: The Health Service Executive (HSE) National Clinical Programme for the Assessment and Management of patients presenting to the ED following self-harm is committed to achieving 100% compliance with PLAN standards in all services. Recommendations include introducing formal ligature risk assessments and risk assessments of the use of the assessment rooms. The Chief Executive Officers of all hospital groups were informed of the results of the audits and advised on recommendations for each hospital ED.

Comparison of CD34, CD31, and factor VIII-related antigen immunohistochemical expression in feline vascular neoplasms and CD34 expression in feline nonvascular neoplasms.

The diagnosis of vascular neoplasms is often facilitated by the use of immunohistochemical markers such as factor VIII-related antigen, CD31, and CD34. However, the relative sensitivity and specificity of these markers have not been compared in cat vascular neoplasms. In this study, these 3 immunohistochemical markers were evaluated in 61 endothelial neoplasms (50 hemangiosarcomas and 11 hemangiomas) in 59 cats. All neoplasms were labeled by all 3 markers. CD34 had the highest average immunolabeling intensity in neoplastic endothelial cells. CD31 had the lowest average background labeling, followed by CD34 and factor VIII-related antigen, respectively. CD34 expression was also examined in 130 nonvascular neoplasms of cats; 14 of 62 epithelial neoplasms, 39 of 43 mesenchymal neoplasms, 8 of 23 leukocytic neoplasms, and 2 of 2 melanomas were positive. Given the broad expression of CD34 in mesenchymal neoplasms, this marker has limited diagnostic relevance for vascular neoplasms of cats.

Early Intervention in Psychosis services: A systematic review and narrative synthesis of the barriers and facilitators to implementation.

BACKGROUND: Early intervention in psychosis (EIP) services target the early manifestation of psychosis and provide multidisciplinary care. They demonstrate effectiveness and cost-effectiveness. Implementation of EIP services is inconsistent and piecemeal. This systematic review and narrative synthesis aims to identify barriers and facilitators to EIP service implementation. METHODS: We conducted an electronic search of databases (EMBASE, Medline, Web of Science, and PsychINFO) to detect papers reporting EIP service implementation findings and associated barriers and facilitators. The search occurred between June to August 2020, and again in January 2021. Articles meeting inclusion criteria were extracted and narratively synthesized. A quality assessment was conducted using the Mixed Methods Appraisal Tool. RESULTS: Twenty-three studies were selected. The most common study design was descriptive accounts of implementation. Patient age ranged varied from 14 to 35 years. We identified three barrier and facilitator domains: (a) system; (b) services; and (c) staff, and a range of subdomains. The most frequent subdomains were "funding" and "strength of collaboration and communication between EIP and outside groups and services". Associations between domains and subdomains were evident, particularly between systems and services. CONCLUSIONS: A range of barriers and facilitators to EIP implementation exist. Some of these are generic factors germane across health systems and services, while others are specific to EIP services. A thorough prior understanding of these challenges and enablers are necessary before implementation is attempted. Accounting for these issues within local and national contexts may help predict and increase the likelihood of services' success, stability, and longevity.

Significance and outcome of left heart hypoplasia in fetal congenital diaphragmatic hernia.

OBJECTIVE: In patients with a left-sided congenital diaphragmatic hernia (CDH), the left ventricle (LV) is often compressed and smaller than normal. The objective of this study was to investigate whether small left heart dimensions prenatally normalize after birth in patients with CDH, or whether prenatal indices of left heart size and flow predict postnatal outcome. METHODS: Clinical and echocardiographic data were reviewed for patients diagnosed with left-sided CDH prenatally. Cardiac dimensions and flows were compared with normative data. Among liveborn patients, pre- and postnatal Z-scores of left heart structures were compared, and associations between prenatal indices and outcome were assessed. RESULTS: Of 125 patients diagnosed prenatally with CDH, 111 had a left-sided defect. Of these, 85 were liveborn, including 20 with congenital heart disease. Gestational age-adjusted dimensions of fetal left heart structures, including aortic valve diameter, mitral valve (MV) diameter, LV long-axis, LV short-axis and LV volume, were all smaller than normal (P < 0.001). On average, the LV contributed 33 +/- 8% of combined ventricular output, lower than the normal 40-50%. Z-scores of left heart structures increased from the prenatal echocardiogram to the postnatal study, with average changes ranging from 0.56 +/- 1.68 (aortic valve) to 1.39 +/- 1.85 (LV volume). Among liveborn patients, there was no association between prenatal left heart Z-scores and postnatal survival. CONCLUSIONS: Hypoplasia of and reduced flow through the left heart are common among fetuses with CDH. After birth and CDH repair, left heart dimensions generally normalize, with adequate size to support a biventricular circulation, even when there is very low flow through the left heart in mid- and late-gestation.

Idiopathic pulmonary arterial hypertension in a pot-bellied pig (Sus scrofa domesticus) with right-sided congestive heart failure.

Idiopathic pulmonary arterial hypertension is a rare disease reported in humans and dogs diagnosed as persistent elevation of pulmonary arterial blood pressure without predisposing or associated diseases. A four-month-old pot-bellied pig (Sus scrofa domesticus) was presented for decreased appetite, lethargy, respiratory distress, and occasional syncope. On physical examination, the pig was tachypneic with labored breathing, with a distended abdomen and a bilateral grade 4-5/6 parasternal systolic heart murmur. Systolic pulmonary arterial pressure was estimated at 95 mmHg by Doppler echocardiography, consistent with severe pulmonary hypertension. At autopsy, there was dilation of the main pulmonary artery and right ventricle. The lungs were diffusely rubbery, and there was tricavitary effusion. Microscopically, there was severe widespread pulmonary arterial concentric medial hypertrophy with rare plexiform lesions. The clinical history and gross and microscopic findings supported a diagnosis of idiopathic pulmonary arterial hypertension with subsequent right-sided congestive heart failure. Primary (idiopathic) pulmonary arterial hypertension should be considered as a differential diagnosis in young pigs with right-sided congestive heart failure.

Efficiency of human visual signal discrimination.

We have measured the overall statistical efficiency of human subjects discriminating the amplitude of visual pattern signals added to noisy backgrounds. By changing the noise amplitude, the amount of intrinsic noise can be estimated and allowed for. For a target containing a few cycles of a spatial sinusoid of about 5 cycles per degree, the overall statistical efficiency is as high as 0.7 +/- 0.07, and after correction for intrinsic noise, efficiency reaches 0.83 +/- 0.15. Such a high figure leaves little room for residual inefficiencies in the neural mechanisms that handle these patterns.

The etiology of recurrent chordoma presenting as a neck mass: metastasis vs. surgical pathway seeding.

Chordomas are rare tumors of notochordal origin that arise along the vertebral axis. These slowly growing yet highly destructive tumors are associated with an alarming rate of recurrence, although surgical resection followed by proton, proton/photon, or conventional radiotherapy has been somewhat successful in terms of recurrence-free survival. Still, recurrent disease as a result of metastasis or surgical pathway seeding does occur. We retrospectively reviewed the case of a 64-year-old woman who presented with a left neck mass at level II. She had a history of recurrent chordomas involving the occipital portion of the clivus that had been treated with multiple resections and proton-beam irradiations over a period of several years. The new mass was found to have infiltrated the superior end of the sternocleidomastoid muscle. Neck dissection was performed. Pathology revealed no lymphoid tissue in the main specimen and no evidence of chordoma in any of the lymph nodes. We believe that this latest clival chordoma might have occurred as a result of surgical pathway seeding during a previous operation anterior to the sternocleidomastoid muscle, although metastasis cannot be ruled out. We also review the literature on clival and skull base chordomas as it relates to recurrence, metastasis, and seeding.

The "no-reflow" phenomenon after temporary coronary occlusion in the dog.

The role of microvascular damage in the genesis of the "no-reflow" phenomenon was investigated in the left ventricular myocardium of dogs subjected to temporary occlusions of a major coronary artery for 40 and 90 min. Intravenous carbon black or thioflavin S (a fluorescent vital stain for endothelium) were used to demonstrate the distribution of coronary arterial flow in control and damaged myocardium. These tracers were injected simultaneously with release of the coronary occlusion or after 5 or 20 min of reflow of coronary arterial blood. After 40 min of ischemia plus arterial reperfusion, usually the tracers were evenly distributed throughout the damaged tissue at each time of reperfusion. On the other hand, when reflow was allowed after 90 min of ischemia, portions of the inner half of damaged myocardium were not penetrated by the tracers. Electron microscopic study of this poorly perfused tissue revealed severe capillary damage; endothelial cells with large intraluminal protrusions and decreased pinocytic vesicles were common. Also, occasional intraluminal fibrin thrombi were noted, as well as extravascular fibrin deposits and erythrocytes. Myocardial cells were swollen in both poorly perfused and well-perfused irreversibly injured tissue. Contraction bands and mitochondrial Ca(2+) accumulation were prominent features of irreversible injury with reflow at 40 min but were not noted after 90 min of ischemia in areas with poor perfusion. These results suggest that 40 min of ischemia were tolerated by the capillary bed of the dog heart without serious capillary damage or perfusion defects, but that 90 min of ischemic injury was associated with the "no-reflow" phenomenon, i.e., failure to achieve uniform reperfusion. This failure of reflow was associated with extensive capillary damage and myocardial cell swelling. Death of severely ischemic myocardial cells in this model occurs before the onset of capillary damage and the no-reflow phenomenon.

Lower cervical nerve root block using CT fluoroscopy in patients with large body habitus: another benefit of the swimmer's position.

We describe a method of performing lower cervical nerve root block (CNRB) with CT fluoroscopy in patients with large body habitus using the swimmer's position. This approach reduces image noise with acceptable visualization of vital structures and improved foraminal/root access. Anticipated use of the swimmer's position coupled with minimally modified radiation exposure parameters can limit radiation dose to operator/patient and reduce procedure time to match that of CNRB using CT fluoroscopy in typical patients.

Regulation of the human transforming growth factor beta type II receptor gene promoter by novel Sp1 sites.

The transforming growth factor-beta (TGF beta) type II receptor (T beta R-II) is responsible for transducing the growth inhibitory signals of TGF beta. The T beta R-II gene promoter lacks both a TATA box and a CAAT box near the transcription initiation site, and has been shown to contain binding sequences for several transcription factors (Sp1, AP1, NF-Y, Cut and ERT) which are important for T beta R-II gene promoter activity in vitro. However, it is still not clear which interactions are important for the regulation of T beta R-II gene promoter activity in vivo. Using in vivo genomic DNA footprinting of normal human epithelial cells (HaCaT), we have identified two novel identical and strongly protected sites (ggggctgg) at positions -59 and -102 of the T beta R-II gene promoter. Mutation of either site significantly reduced promoter activity in transient transfections. Protein binding to these sites, as determined by electrophoretic mobility shift assays (EMSA), was specifically competed with consensus Sp1 oligonucleotides. Furthermore, anti-Sp1/3 antibodies produced band shifts when incubated with the T beta R-II -59 and -102 DNA probes. Importantly, Sp1 protein binding was influenced by the presence of an intact NF-Y binding site at position -83. Our data suggests that both Sp1 and NF-Y may play an important role in regulating T beta R-II gene promoter basal activity in vivo.

Evidence for energy migration from photosystem I to photosystem II and the effect of magnesium.

1. With Euglena chloroplasts 7722 nm light excites a fluorescence induction pattern, measured at l,u nm, typical of the Photosystem II reduction of Q. 2. Both methylviologen and phenazine methosulfate partially quench this fluorescence rise in the absence of electron transport between Photosystem II and Photosystem I, and in a manner consistent with their known role of stimulating Photosystem I photochemistry. 3. The variable fluorescence excited with 22 nm light is reduced to a greater extent than that excited by 638 nm light upon chlorophyll dilution during division in the dark. 4. These observations are interpreted to indicate that in Euglena chloroplasts light absorbed by Photosystem I is transferred energetically "uphill" to Photosystem II, where it can perform Photosystem II photochemistry. 5. Magnesium ions stimulate the variable fluorescence with both 638 nm and 722 nm light to a similar extent, which argues against the concept of magnesium ion interrupting energy transfer between Photosystem II and Photosystem I.

Fluorescence induction in intact spinach chloroplasts.

Under conditions in which the Photosystem II quencher is rapidly reduced upon illumination, either after a preillumination or following treatment with dithionite, the fluorescence-induction curve of intact spinich chloroplasts (class I type) displays a pronounced dip. This dip is probably identical with that observed after prolonged anaerobic incubation of whole algal cells ("I-D dip"). It is inhibited by 3(3,4-dichlorophenyl)-1,1-dimethylurea and occurs in the presence of dithionite, sufficient to reduce the plastoquinone pool. It is influenced by far red light, methylviologen, anaerobiosis and uncouplers in a manner consistent with the interpretation that it represents a photochemical quenching of fluorescence by an electron transport component situated between the Photosystem II quencher and plastoquinone. Glutaraldehyde inhibition may indicate that protein structural changes are involved.

Studies on the slow fluorescence decline in isolated chloroplasts.

Data presented here indicate that the slow fluorescence decline in osmotically disrupted chloroplasts is not associated with the well known divalent cation effect on fluorescence yield. Thus the two phenomena have markedly different magnesium concentration requirements, magnesium addition after the fluorescence decline did not stimulate the dark reversal, and the characteristics of the fluorescence induction kinetics of the two processes are not similar. At pH 7.6 the slow fluorescence decline was stimulated by several uncouplers demonstrated to greatly reduce proton pumping, and at pH 9.2 it was stimulated by all uncouplers tested. Acid-base transition was strongly inhibitory, and this inhibition was relieved by coupling factor is suggested by experiments in which phosphorylation substrates were inhibitory, and this inhibition was prevented by uncoupler. These data are explained in terms of coupling factor structural changes which in an unknown manner influence Photosystem II fluorescence emission. Fluorescence induction curves indicate that the slow quenching decreased only the variable fluorescence. The half rise time was decreased along with the sigmoidicity of the rise curve. These data can be accomodated in terms of a model recently proposed by Butler and Kitajima (Biochim. Biophys Acta (1975) 376, 116-125), involving the transfer of energy from the excited, but closed, reaction centres II to the light harvesting chlorophyll system. The slow fluorescence decline is suggested to represent a decrease of this process.