Intensive community care services for children and young people in psychiatric crisis: an expert opinion.

BACKGROUND: Children and young people's (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails. METHODS: A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up. RESULTS: ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children's Global Assessment Scale were agreed. CONCLUSIONS: This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Invasive Burkholderia cepacia Complex Infections among Persons Who Inject Drugs, Hong Kong, China, 2016-2019.

During March 2016-January 2019, Burkholderia cepacia complex (BCC) infection developed in 13 persons who inject drugs (PWID) in Kowloon West Region, Hong Kong, China. Seven cases were infective spondylitis, 2 endocarditis, 2 septic arthritis, 1 intramuscular abscess and bacteremia, and 1 necrotizing fasciitis. Pulsed-field gel electrophoresis revealed that the isolates from 9 patients were clonally related. This clone caused major illness, and 11 of the 13 patients required surgical treatment. Clinicians should be aware of this pathogen and the appropriate broad-spectrum antimicrobial drugs to empirically prescribe for PWID with this life-threatening infection. Close collaboration among public health authorities, outreach social workers, and methadone clinics is essential for timely prevention and control of outbreaks in the PWID population.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study.

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities.

BACKGROUND: Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and had completed a multidisciplinary modality assessment. PREDICTOR: HD or PD. OUTCOMES: Mortality from any cause. RESULTS: Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time. LIMITATIONS: The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center. CONCLUSIONS: HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.

In-Center Nocturnal Hemodialysis Versus Conventional Hemodialysis: A Systematic Review of the Evidence.

BACKGROUND: Owing to its longer treatment duration-up to 8 hours per dialysis treatment-in-center thrice-weekly nocturnal hemodialysis (HD) is receiving greater attention. To better understand the evidence for in-center nocturnal HD, we sought to systematically review the literature to determine the effects of in-center nocturnal HD versus conventional HD on clinically relevant outcomes. STUDY DESIGN: We searched MEDLINE, Embase, Evidence-Based Medicine Reviews (EBMR), Web of Science, and Scopus from the earliest date in the database to November 2016. SETTING & POPULATION: Adults receiving in-center nocturnal HD compared with those receiving conventional HD. SELECTION CRITERIA FOR STUDIES: All quasi-experimental and observational studies were considered; randomized trials were sought but not found. PREDICTOR: Nocturnal vs conventional in-center HD. OUTCOMES: Indexes of blood pressure and left ventricular hypertrophy, markers of anemia, measures of bone mineral metabolism, nutrition, quality of life, sleep quality, episodes of intradialytic hypotension, hospitalization, and mortality. RESULTS: Of 2,086 identified citations, 21 met the inclusion criteria, comprising a total of 1,165 in-center nocturnal HD patients and 15,865 conventional HD patients. Although there was substantial heterogeneity in reporting of outcomes, we pooled data for measures of blood pressure, anemia, and mineral metabolism. Though heterogeneity was generally high, in-center nocturnal HD was associated with improved systolic blood pressure (-3.18 [95% CI, -5.58 to -0.78) mm Hg, increased hemoglobin levels (0.53 [95% CI, 0.11-0.94] g/dL), and lower serum phosphate levels (-0.97 [95% CI, -1.48 to -0.46] mg/dL). LIMITATIONS: No randomized trials have been conducted to address the clinical effects of in-center nocturnal HD. The quality of the observational literature contributing to the results of this review was generally poor to moderate. Confounded outcomes are a significant concern. Publication bias and outcome reporting bias remain possibilities. CONCLUSIONS: Relative to conventional HD, in-center nocturnal HD was associated with improvements in several clinically relevant outcomes. Other benefits may not have been detected due to small sample sizes of included studies; no prespecified outcome was worse with in-center nocturnal HD.

Selection of peritoneal dialysis among older eligible patients with end-stage renal disease.

Background: Older patients with end-stage renal disease (ESRD) are less likely to choose peritoneal dialysis (PD) over hemodialysis (HD). The reasons behind their choice of dialysis modality are not clear. This study seeks to determine the patient-perceived factors that influence ESRD patients' choice of dialysis modality among older ESRD patients who are deemed eligible for both PD and HD. Methods: All patients had completed a multidisciplinary modality assessment, were deemed eligible for both PD and HD, and had received modality education. Semi-structured interviews were conducted and transcripts were read repeatedly to derive potential codes using line-by-line textual analysis. The Capability, Opportunity, Motivation ­ Behaviour (COM-B) and Theoretical Domain Framework (TDF), validated tools that were developed for designing behavioral change interventions, were used to help guide the coding framework. Results: Among older ESRD patients who are deemed eligible for both PD and HD, factors relevant to their modality decision-making were identified with respect to physical strength/dexterity and having a sound mind (capability), external forces and constraints (opportunity), and values and beliefs (motivation). Often a combination of factors led to an individual's choice of a particular dialysis modality. However, preferences for PD were primarily based around convenience and maintaining a normal life, while a heightened sense of security was the primary reason for those who selected HD. Conclusions: We have identified patient-perceived factors that influence choice of dialysis modality in older individuals with ESRD who are eligible for PD and HD. These factors should be considered and/or addressed within PD programs seeking to promote PD.

Versatile Synthesis of Luminescent Tetradentate Cyclometalated Alkynylgold(III) Complexes and Their Application in Solution-Processable Organic Light-Emitting Devices.

A new class of cyclometalated tetradentate alkynylgold(III) complexes has been successfully synthesized by post-synthetic modification. Through the judicious design and choice of pincer ligands, post-synthetic cyclization could be achieved to produce the robust and structurally rigid class of tetradentate gold(III) C^N^C^C complexes with high photoluminescence quantum yields of up to 0.49 in solution and 0.78 in doped thin films at room temperature, at least an order of magnitude higher than those of the structurally related uncyclized tridentate alkynylgold(III) analogues. High-performance yellow to orange-red emitting solution-processable organic light-emitting devices have also been achieved with external quantum efficiency of 11.1 %. This work describes for the first time of the use of post-synthetic ligand modification approach to overcome the synthetic challenge for tetradentate alkynylgold(III) complexes.

Patient Education and Peritoneal Dialysis Modality Selection: A Systematic Review and Meta-analysis.

BACKGROUND: Educational interventions are increasingly used to promote peritoneal dialysis (PD), the most common form of home therapy for end-stage renal disease. A systematic review of the evidence in support of dialysis modality education is needed to inform the design of patient-targeted interventions to increase selection of PD. We performed a systematic review and meta-analysis to characterize the relationship between patient-targeted educational interventions and choosing and receiving PD. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Published original studies and abstracts. SELECTION CRITERIA FOR STUDIES: We searched MEDLINE, EMBASE, CINAHL and EBMR. We included controlled observational studies and randomized trials of educational interventions designed to increase PD selection. INTERVENTION: Predialysis educational interventions. OUTCOMES: The primary outcome was choosing PD, defined as intention to use PD regardless of whether PD was ever used. The secondary outcome, receiving PD, was defined as an individual receiving PD as his or her treatment. RESULTS: Of 3,540 citations, 15 studies met our inclusion criteria, including 1 randomized trial. In the single randomized trial (N=70), receipt of an educational intervention was associated with a more than 4-fold increase in the odds of choosing PD (OR, 4.60; 95% CI, 1.19-17.74). Based on results from 4 observational studies (N=7,653), patient-targeted educational interventions were associated with a 2-fold increase in the odds of choosing PD (pooled OR, 2.15; 95% CI, 1.07-4.32; I(2)=76.7%). Based on results from 9 observational studies (N=8,229), patient-targeted educational intervention was associated with a 3-fold increase in the odds of receiving PD as the initial treatment modality (OR, 3.50; 95% CI, 2.82-4.35; I(2)=24.9%). LIMITATIONS: Most studies were observational studies, which can establish an association between education and choosing PD or receiving PD, but does not establish causality. CONCLUSIONS: This systematic review demonstrates a strong association between patient-targeted education interventions and the subsequent choice and receipt of PD.

Air-Stable Spirofluorene-Containing Ladder-Type Bis(alkynyl)borane Compounds with Readily Tunable Full Color Emission Properties.

A series of air-stable spiro-fused ladder-type boron(III) compounds has been designed, synthesized, and the electrochemistry and photophysical behavior have been characterized. By simply varying the substituents on the pyridine ring and extending the π-conjugation of the spiro framework, the emission color of these compounds can be easily fine-tuned spanning the visible spectrum from blue to red. All compounds exhibit a broad and structureless emission band across the entire visible region, assigned as an intramolecular charge-transfer transition originating from the thiophene of the spiro framework to the pyridine-borane moieties. In addition, these compounds demonstrate high photoluminescence quantum yields of up to 0.81 in dichloromethane solution and 0.86 in doped thin films. Some of the compounds have also been employed as emissive materials, in which solution-processed organic light-emitting devices (OLEDs) with tunable emission colors spanning the visible spectrum from blue, green to red have been realized, demonstrating the potential applications of these boron compounds in OLEDs.

Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective.

BACKGROUND: There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic. STUDY DESIGN: Quality improvement report. SETTING & PARTICIPANTS: We present the experience of 2 adult home HD programs in Canada from 2001 to 2012, including a total of 190 patients and approximately 500 patient-years of treatments. QUALITY IMPROVEMENT PLAN: We retrospectively reviewed all life-threatening adverse events occurring in our programs and re-examined our approach to patient training, retraining, and safety monitoring. RESULTS: We report 1 death and 6 potentially fatal adverse events, yielding a crude rate of 0.060 events/1,000 dialysis treatments. Six of 7 events involved significant blood loss (including 1 exsanguination); 5 of 7 events involved human error with lapses in protocol adherence. Because such events are rare, evaluation of specific intervention strategies will require much longer follow-up. LIMITATIONS: Retrospective identification of cases. A specific quality improvement initiative was not undertaken. CONCLUSIONS: Life-threatening adverse events in home HD are uncommon; however, when one does occur, this should prompt review of home HD-related policies and procedures to make this therapy even safer.

Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review.

BACKGROUND: The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain. STUDY DESIGN: A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded). SETTING & POPULATION: HD patients (both in-center conventional HD and home HD) using an AVF for vascular access. SELECTION CRITERIA FOR STUDIES: We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique. INTERVENTION: Buttonhole versus rope-ladder cannulation technique. OUTCOMES: The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality. RESULTS: Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, -0.76 [95%CI, -1.38 to -0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI, -0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections. LIMITATIONS: Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes. CONCLUSIONS: Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.

Association between continuity of care and attendance of post-discharge follow-up after psychiatric emergency presentation.

The number of accident and emergency (A&E) hospital attendances by young people aged 18 or under with a recorded diagnosis of a psychiatric condition more than tripled between 2010 and 2022. After discharge from the hospital, attendance at follow-up appointments in the community is critical to ensure the safety of young people and optimise the use of clinical resources. A retrospective cohort study was conducted to evaluate the association between follow-up attendance and the continuity of clinicians and clinical teams, using electronic clinical record data from East London NHS Foundation Trust (ELFT), between April 2019 and March 2022. Multi-level mixed effects logistic regression was performed to model the follow-up attendance odds based on whether the same or different clinician and clinical team offered the initial A&E and the community follow-up appointment or whether a crisis team was involved. 3134 A&E presentations by 2368 young people were identified within the study period. Following these presentations, 2091 follow-up appointments in the community were offered. The attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in A&E (odds ratio (OR) = 3.66; 95% CI 1.65-8.13). Whether the same clinical team provided the community follow-up appointment, or whether a crisis team was involved before discharge made no difference to the likelihood of follow-up attendance. The findings support the importance of the continuity of clinicians in the care of young people in crisis.

Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase.

BACKGROUND: Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies. METHODS: This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers. DISCUSSION: This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain. TRIAL REGISTRATION: ISRCTN ISRCTN42999542, Registration on April 29, 2020.

Adrenomedullin enhances invasion of human extravillous cytotrophoblast-derived cell lines by regulation of urokinase plasminogen activator expression and s-nitrosylation.

Extravillous cytotrophoblast (EVCT) is responsible for trophoblast invasion, which is an important process during placentation. Dysregulation of the process is associated with a wide range of pregnancy complications. Adrenomedullin (ADM) is a polypeptide expressed most abundantly in first-trimester placentas. We hypothesized that ADM modulated the invasion of human EVCT. Our results showed that ADM enhanced invasion and migration but not proliferation in two EVCT cell lines, JEG-3 and TEV-1. Similar observation can also be obtained in primary EVCTs. JEG-3 and TEV-1 cells expressed ADM receptor components as demonstrated by immunostaining, Western blotting, and RT-PCR. The ADM antagonist ADM(22-52) (ADM C-terminal 22-52 amino acid fragment) suppressed ADM-induced invasion and migration, confirming that ADM exerted its biological effects through its classical receptors. The stimulatory effect of ADM on EVCT invasiveness was associated with induction (P < 0.05) of urokinase plasminogen activator (uPA) and nitric oxide synthase (NOS) expression and activity. Silencing of uPA by siRNA transfection abolished the stimulatory effect of ADM, suggesting that uPA is the key mediator for ADM-induced invasion. The involvement of NO in enhancing the invasion and biosynthesis of uPA in EVCT cell lines was confirmed by using pharmacological inhibitors of NOS and NO donors. ADM-mediated NO production also increased protein S-nitrosylation of JEG-3 cells. S-nitrosylation activated uPA in vitro and induced a higher proteinase activity. These findings provide indications that ADM and its downstream NO signaling may play an important role in modulating human EVCT functions.

Association of a change in erythropoiesis-stimulating agent dose during hospitalization and subsequent hemoglobin levels and transfusions in hemodialysis patients.

BACKGROUND: Erythropoiesis-stimulating agent (ESA) doses are often increased in hospitalized dialysis patients in response to acute anemia with unknown consequences. We sought to determine whether increases in ESA dose during hospital admission were associated with changes in transfusion requirement and risk of exceeding recommended hemoglobin targets. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Linked administrative, laboratory, and blood transfusion data were used to identify a total of 700 hospitalizations involving 484 long-term hemodialysis patients between 2004 and 2008 in the Calgary Health Region, Canada. PREDICTOR: Change in ESA dose was determined by comparing the average weekly dose over the 6 weeks preceding admission to that administered during the 14 days following admission. OUTCOMES & MEASUREMENTS: Cox proportional hazards models adjusted for baseline patient characteristics were used to model the association between changes in ESA dose and outcomes, including exceeding recommended hemoglobin targets, receipt of blood transfusion, cardiovascular outcomes, and death. RESULTS: There was a significant increase in the risk of exceeding recommended hemoglobin targets as the ESA dose was increased by ≥40 µg/wk (equivalent darbepoetin alfa dose) above baseline (HR, 2.21; 95% CI, 1.19-4.10). However, an increase in ESA dose was not associated with reduced need for blood transfusion, risk of cardiovascular outcomes, or death. LIMITATIONS: Residual confounding by clinical events that may lead to changes in the management of patients and may have influenced the observed relationship between predictor and outcomes. CONCLUSIONS: Increasing the ESA dose at hospitalization in hemodialysis patients is associated with higher risk of exceeding recommended hemoglobin targets, but does not appear to be associated with the need for transfusion, risk of cardiovascular outcomes, or death.

Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction.

PURPOSE: To study the effect of bicanalicular silicone intubation on endonasal endoscopic mechanical dacryocystorhinostomy (EEM-DCR) for primary acquired nasolacrimal duct obstruction (PANDO). DESIGN: Randomized clinical trial. PARTICIPANTS: A total of 120 consecutive adults (103 females) with a presenting age of 64 ± 13.7 years (range, 39-92 years) underwent EEM-DCR for PANDO from November 2005 to May 2009 in a lacrimal referral center. METHODS: The EEM-DCR was performed by 2 lacrimal surgeons using standard techniques. Patients were randomly assigned to receive or not receive bicanalicular silicone intubation for 8 weeks. No antimetabolite was used. All patients received a course of oral antibiotics during nonabsorbable nasal packing for flaps tamponade, which was removed at the first postoperative visit. Patients were assessed at 1, 3, 6, 12, 26, and 52 weeks after the operation. MAIN OUTCOME MEASURES: Surgical success was defined by symptomatic relief of epiphora, reestablishment of nasolacrimal drainage confirmed by irrigation by 1 masked observer, and positive functional endoscopic dye test by the operative surgeon at 12 months postoperatively. Intraoperative and postoperative complications were recorded. RESULTS: A total of 118 of the 120 randomized cases completed 12 months of follow-up. Two patients died of unrelated medical illnesses during follow-up. At 12 months postoperatively, there was no statistical difference in the success rate between patients with (96.3%) and without (95.3%) intubation (P=0.79). The odds ratio of failure without silicone intubation was 1.28 (95% confidence interval, 0.21-7.95). There was no difference in the incidence (P=0.97) or the time to develop (P=0.12) granulation tissue between the 2 groups. No significant difference was found between successful and failed cases in terms of age (P=0.21), sex (P=0.37), laterality (P=0.46), mode of anesthesia (P=0.14), surgeon (P=0.26), use of stent (P=0.79), or presence of granulation tissue postoperatively (P=0.39). CONCLUSIONS: The current study design provided 90% statistical power to detect more than 21% difference in surgical outcome, and no such difference was found whether intubation was used or not used in EEM-DCR for PANDO at the 12-month follow-up. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Identification of CD44+ cancer stem cells in human gastric cancer.

The cancer stem cell hypothesis suggests that tumors are initiated and maintained by cancer stem cells capable of self-renewal and differentiation into mature tumor cells. Recent studies have demonstrated the existence of cancer initiating cells in different solid tumors. In this study, we identified a subpopulation of CD44+ cells within the tumor of gastric cancer patients, which, upon treatment by chemotherapeutic agent 5-fluorouracil (5-FU), were markedly enriched. In vitro culture of isolated CD44+ subpopulation from gastric tumors by magnetic beads sorting led to formation of gastric spheroid colonies. These colonies retained CD44+ surface marker expression during culture, and were undifferentiated in nature. Subcutaneous injections of CD44+ gastric cancer cells conferred tumorigenicity in SCID mice. Moreover, implantation of CD44+ cells from these established tumors remained tumorigenic in successive passages. Using CD44+ cells isolated from the gastric cell lines AGS and SGC7901, similar results were obtained. Upon enrichment by 5-FU, CD44+ cells harbored increased ALDH expression as compared with CD44- cells. Our results demonstrated for the first time the existence of CD44+ cells within the tumors of gastric cancer patients that are endowed with stem cells properties, and also provide a plausible explanation for chemo-resistance frequently observed in gastric cancer patients. Such findings provide a basis for further studies on targeting this tumorigenic subpopulation for better treatment of gastric cancer patients.

Clean clothes or dirty clothes? Outbreak investigation of carbapenem-resistant Acinetobacter baumannii related to laundry contamination through multilocus sequence typing (MLST).

OBJECTIVE: To investigate the source in an outbreak of carbapenem-resistant Acinetobacter baumannii (CRA) in a general hospital due to contamination of a laundry evaporative cooler and the laundry environment using multilocus sequence typing (MLST). METHODS: For CRA culture, clinical samples were collected from infected patients and close contacts, and environmental sampling was performed in patient surroundings and laundry facilities. MLST was used for the molecular typing of representative CRA isolates. Bacterial isolates with identical sequence types were considered epidemiologically linked and attributable to the same source. OXA genes in Acinetobacter baumannii were detected using polymerase chain reaction (PCR). RESULTS: In total, 58 patients were affected in this outbreak. The mean patient age was 75.3, and 50% were female. The most common diagnoses at admission were skin and soft-tissue infection (n = 12, 20.7%) and pneumonia (n = 12, 20.7%). OXA-23 was positive in 64.7% of isolates. A CRA isolate from the evaporative cooler in the laundry was identical to that of 11 patients across 3 wards, belonging to ST345. Isolates from 3 laundry linen racks were identical to those of 7 patients from 3 wards, classified as ST1145. Isolates found on another linen rack and a pajama shelf were identical to isolates from 3 other patients from 2 wards, belonging to ST2207. There was no significant difference between sequence type distributions of clinical and environmental isolates (P = .12), indicating high likelihood of CRA originating from the same source. CONCLUSIONS: MLST confirmed that contamination of the laundry evaporative cooler and surrounding environment caused a polyclonal CRA hospital outbreak. Hospital laundry is an important area for infection control and outbreak investigations of CRA.

Self-Harm in Children and Adolescents Who Presented at Emergency Units During the COVID-19 Pandemic: An International Retrospective Cohort Study.

OBJECTIVE: To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations. METHOD: This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed. RESULTS: Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58). CONCLUSION: Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs. DIVERSITY & INCLUSION STATEMENT: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Topical application of the plant extract SDTL-E in ovariectomized rats: A potential new approach for treating osteoporosis.

Current osteoporosis medications have drawbacks of causing side effects and having slow onset, therefore developing osteoporosis drugs with faster onset and less side effects is essential. This study investigated the effects of the natural plant extract, SDTL-E, in ovariectomized (OVX)-induced osteoporosis rats. Rats were randomly assigned to sham operation control group (Control Group); OVX rat model group (Model Group) or OVX rat SDTL-E treatment group (SDTL-E Group). All groups underwent ovariectomy, but the Control Group did not have the ovaries removed. SDTL-E Group was treated with SDTL-E, Model and Control Groups were treated with vegetable oil, treatments were topically applied twice daily for 20 days. Results showed when compared with Model Group, SDTL-E Group significantly restored serum estradiol back to near Control Group level, serum ALP activity, serum and urinary calcium were significantly decreased, bone mechanics indicators increased and trabecular bone numbers slightly increased. These results demonstrated 20 days of SDTL-E topical treatment improved bone strength and trabecular bone structure in OVX-induced osteoporosis rats. The underlying mechanisms include restoring estradiol level, reducing bone turnover, net bone resorption, bone calcium loss, and calcium excretion through kidney. These findings suggest topical application of plant extract is a potential new approach with quick efficacy for treating osteoporosis.