What are Canadian emergency physicians' attitudes and self-perceived competence toward patients who present with suicidal ideation?

INTRODUCTION: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) attitudes toward and understanding of individuals with suicidal ideation. METHODS: We developed a web-based survey on suicide knowledge, which was pilot tested by two EPs and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. The Understanding of Suicidal Patients (USP) Scale is an 11-point questionnaire to assess healthcare providers' attitudes toward individuals with suicidal ideation. Other questions pertaining to suicidal ideation, self-perceptions on ability to treat suicidal patients, and personal experiences with suicide were asked in Likert format. RESULTS: One hundred eighty-eight Canadian EPs responded to the survey (15% response rate), with a median age of 49 (IQR 39-55), academic practice reported by 55% of respondents, and 65% of respondents identified as male. The mean USP score was 21.8 (95% CI 21.1-22.5), which indicates a generally positive attitude and willingness to provide care for suicidal patients. Only 17% of respondents had participated in specific training for treatment of suicidal patients in the last five years, while the majority of respondents estimate treating 5-15 patients with suicidal ideation a month. Sixty four percent of respondents indicated they had the skills to screen patients for suicidal ideation, but less than one-third felt they could create a personalized safety plan for patients. CONCLUSIONS: Respondents have a generally positive attitude toward treating individuals with suicidal ideation. Respondents scored highly on the USP scale that measured willingness to provide care for and empathize with suicidal patients. Respondents felt they had the skills to adequately screen patients for suicidal ideation. Key gaps in knowledge were identified suggesting improved residency and ongoing medical education opportunities are needed to better improve care for this vulnerable population.

RéSUMé: INTRODUCTION: Le suicide est la 9e principale cause de décès au Canada et une raison courante pour laquelle les patients se présentent aux services d'urgence (SU) canadiens. Il existe peu de connaissances sur les attitudes et la compréhension des médecins d'urgence canadiens à l'égard des personnes ayant des idées suicidaires. MéTHODES: Nous avons développé une enquête en ligne sur la connaissance du suicide, qui a été testée par deux médecins d'urgence et un psychiatre pour en vérifier la clarté et le contenu. Le sondage a été distribué par courriel aux médecins traitants membres de l'Association canadienne des médecins d'urgence. Les données ont été décrites à l'aide de chiffres, de moyennes, de médianes et d'intervalles interquartiles. L'échelle de compréhension des patients suicidaires (USP) est un questionnaire en 11 points visant à évaluer l'attitude des prestataires de soins de santé envers les personnes ayant des idées suicidaires. D'autres questions portant sur les idées suicidaires, les perceptions de soi sur la capacité de traiter les patients suicidaires et les expériences personnelles de suicide ont été posées en format Likert. RéSULTATS: Cent quatre-vingt-huit médecins d'urgence canadiens ont répondu à l'enquête (taux de réponse de 15 %), avec un âge médian de 49 ans (IQR 39-55), une pratique universitaire déclarée par 55 % des répondants, et 65 % des répondants se sont identifiés comme des hommes. Le score USP moyen était de 21,8 (IC à 95 % 21,1-22,5), ce qui indique une attitude généralement positive et une volonté de fournir des soins aux patients suicidaires. Seuls 17 % des répondants ont participé à une formation spécifique pour le traitement des patients suicidaires au cours des cinq dernières années, tandis que la majorité des répondants estiment traiter 5 à 15 patients ayant des idées suicidaires par mois. Soixante-quatre pour cent des répondants ont indiqué qu'ils possédaient les compétences nécessaires pour dépister les idées suicidaires chez les patients, mais moins d'un tiers estimaient qu'ils pouvaient créer un plan de sécurité personnalisé pour les patients. CONCLUSIONS: Les répondants ont une attitude généralement positive à l'égard du traitement des personnes ayant des idées suicidaires. Les répondants ont obtenu un score élevé sur l'échelle USP qui mesurait la volonté de fournir des soins et de l'empathie envers les patients suicidaires. Les répondants estimaient avoir les compétences nécessaires pour dépister adéquatement les idées suicidaires chez les patients. Des lacunes importantes dans les connaissances ont été identifiées, ce qui suggère que de meilleures possibilités de formation en résidence et de formation médicale continue sont nécessaires pour améliorer les soins offerts à cette population vulnérable.

Nasal Reconstruction: Current Overview.

The nose, with its conspicuous location, intricate convexities, and delicate 3-dimensional structure, continues to challenge the reconstructive surgeon. Today, there are a myriad of options available for reconstruction. The practitioner must take into account the location of the defect as well as the components needed to be restored. This article addresses the current practices in nasal reconstruction, including the different strategies for skin coverage, nasal lining, and structural support. We discuss both the newest techniques as well as basic principles of this long-standing procedure.

Prevention of vein graft intimal hyperplasia with photochemical tissue passivation.

OBJECTIVE: Saphenous vein is the conduit of choice for bypass grafting. Saphenous vein grafts have poor long-term patency rates because of intimal hyperplasia (IH) and subsequent accelerated atherosclerosis. One of the primary triggers of IH is endothelial injury resulting from excessive dilation of the vein after exposure to arterial pressures. Photochemical tissue passivation (PTP) is a technology that cross-links adventitial collagen by a light-activated process, which limits dilation by improving vessel compliance. The objective of this study was to investigate whether PTP limits the development of IH in a rodent venous interposition graft model. METHODS: PTP is accomplished by coating venous adventitia with a photosensitizing dye and exposing it to light. To assess the degree of collagen cross-linking after PTP treatment, a biodegradation assay was performed. Venous interposition grafts were placed in the femoral artery of Sprague-Dawley rats. Rats were euthanized after 4 weeks, and intimal thickness was measured histologically. Vein dilation at the time of the initial procedure was also measured. RESULTS: Time to digestion was 63 ± 7 minutes for controls, 101 ± 2.4 minutes for rose bengal (RB), and 300 ± 0 minutes for PTP (P < .001 PTP vs control). A total of 37 animals underwent the procedure: 12 PTP, 12 RB only, and 13 untreated controls. Dilation of the graft after clamp release was 99% for control, 65% for RB only, and 19% for PTP-treated (P < .001 PTP vs control). Intimal thickness was 77 ± 59 µm in controls, 60 ± 27 µm in RB only, and 33 ± 28 µm in PTP-treated grafts. There was a statistically significant 57% reduction in intimal thickness after treatment with PTP compared with untreated controls (P = .03). CONCLUSIONS: PTP treatment of venous interposition grafts in a rat model resulted in significant collagen cross-linking, decreased vessel compliance, and significant reduction in IH.

Burn Ear Reconstruction Using Porous Polyethylene Implants and Tissue Expansion.

Reconstruction of the external ear after a burn is particularly challenging. The nature of the injury poses many problems including excessive scar tissue, poor blood supply, and the lack of adequate and appropriate materials for a framework. The use of costochondral grafts often leads to marginal outcomes which do not justify the morbidity. Children under the age of 10 years commonly have insufficient cartilage for a graft. Medpor (Stryker, Kalamazoo, MI) offers minimal morbidity and a very effective result. In this series, the authors describe the experience using Medpor and scalp tissue expansion to reconstruct severely burned ears. A total of 16 pediatric patients underwent 18 reconstructions, with two patients receiving bilateral procedures. All patients received Medpor implants. Thirteen patients were tissue expanded under the subgaleal plane before reconstruction, for concomitant scalp alopecia reconstruction. Eleven temporoparietal fascial flaps were performed. In the remaining patients, coverage of the implant was achieved by local advancement flaps. Only two patients had complications, with exposure of the construct after several years. In these two cases, the implants were removed. The experience has shown porous polyethylene reconstruction to be very efficient, with low morbidity and good cosmetic outcomes. Medpor is an excellent option for the reconstruction of both fully and partially burned ears as you may implant only the helical rim, base, or both pieces. The best results were achieved after tissue expansion and the use of the alopecic skin overlying a temporoparietal fascial flap. This has become the preferred method.

Comparative analysis of processing methods in fat grafting.

BACKGROUND: Centrifugation is a popular processing method, with an unclear mechanism of action. Hypotheses include fat concentration, reduced inflammatory response by removal of blood, and concentration of adipose-derived stem cells. The authors performed multiple experiments to determine the role of centrifugation and compared it with a different processing method (mesh/gauze technique). METHODS: Lipoaspirate components were quantified after centrifugation at increasing speed to determine concentration efficacy. For comparison, the authors quantified the concentration efficacy of mesh/gauze. They also compared the number of adipose-derived stem cells isolated by either method. To determine the effects of each component, they compared fat alone to fat mixed with various spinoff components in a mouse model. They also compared centrifugation to mesh/gauze. RESULTS: The adipocyte fraction remains constant above 5000 g, whereas 1200 g results in 91 percent concentrated fat. Mesh/gauze also results in 90 percent concentrated fat. The number of adipose-derived stem cells in 1 g of fat was 1603 ± 2020 and 1857 ± 1832 in the centrifuge and mesh/gauze groups, respectively (p = 0.86). Five "add-back" groups were created: fat plus oil, fat plus surgical tumescence, fat plus fresh tumescence, fat plus cell pellets and fresh tumescence, and fat plus cell pellets. The fat-only group had better retention than the groups mixed with tumescence, regardless of whether it was surgical, fresh, or had cell pellets. Oil did not affect grafts. Centrifugation at 1200 g was equivalent to mesh/gauze (0.73 ± 0.12 g and 0.72 ± 0.13 g, respectively). CONCLUSIONS: Centrifugation improves graft retention by concentration of the adipocyte fraction. The concentration efficacy of mesh/gauze is equivalent to centrifugation at 1200 g, with equivalent in vivo outcomes.

Prevention of capsular contracture with photochemical tissue passivation.

BACKGROUND: Capsular contracture is the most common complication following the insertion of breast implants. Within a decade, half of patients will develop capsular contracture, leading to significant morbidity and need for reoperation. There is no preventative treatment available and the recurrence rate remains high. Photochemical tissue passivation is a novel tissue-stabilization technique that results in collagen cross-linking. It can rapidly link collagen fibers in situ, preserving normal tissue architecture. By using this therapy to passivate the collagenous tissues of the implant pocket, the authors hope to prevent the development of pathogenic collagen bundles and subsequent capsule contracture. METHODS: Six-cubic centimeter tissue expanders were placed below the panniculus carnosus muscle along the dorsum of New Zealand white rabbits. Fibrin glue was instilled into each implant pocket to induce contracture. Treated pockets received photochemical tissue passivation by coating them with a photosensitizing dye and exposing the area to a 532-nm light. After 8 weeks, capsule tissue was harvested for histologic evaluation. RESULTS: Implant capsule thickness is the number one prognostic factor for contracture development. The authors demonstrated a 52 percent decrease in capsule thickness in the passivated group compared with controls. Photochemical tissue passivation resulted in fewer fibrohistiocytic cells and macrophages and in reduced synovial metaplasia and smooth muscle actin deposition. CONCLUSIONS: Photochemical tissue passivation significantly decreased both capsule thickness and smooth muscle actin deposition. It is a promising technique for preventing capsular contracture that can be performed at the time of initial surgery without a significant increase in procedure time.

Tissue-resident Sca1+ PDGFRα+ mesenchymal progenitors are the cellular source of fibrofatty infiltration in arrhythmogenic cardiomyopathy.

Arrhythmogenic cardiomyopathy (AC) is a disease of the heart involving myocardial dystrophy leading to fibrofatty scarring of the myocardium and is associated with an increased risk of both ventricular arrhythmias and sudden cardiac death. It often affects the right ventricle but may also involve the left. Although there has been significant progress in understanding the role of underlying desmosomal genetic defects in AC, there is still a lack of data regarding the cellular processes involved in its progression. The development of cardiac fibrofatty scarring is known to be a principal pathological process associated with ventricular arrhythmias, and it is vital that we elucidate the role of various cell populations involved in the disease if targeted therapeutics are to be developed. The known role of mesenchymal progenitor cells in the reparative process of both the heart and skeletal muscle has provided inspiration for the identification of the cellular basis of fibrofatty infiltration in AC. Here we hypothesize that reparative processes triggered by myocardial degeneration lead to the differentiation of tissue-resident Sca1+ PDGFRα+ mesenchymal progenitors into adipocytes and fibroblasts, which compose the fibrofatty lesions characteristic of AC.

Micro-mechanical fractional skin rejuvenation.

BACKGROUND: The most commonly performed skin rejuvenation procedure, laser resurfacing, is associated with adverse events and significant expense. The authors have developed a novel device that uses micro-coring needles to remove tissue in a fractional pattern and avoid the side effects of laser therapy. The authors compare the efficacy of these needles to standard needles in a pig model. METHODS: One swine was treated with three needle types: standard hypodermic, solid hypodermic, and the authors' novel coring needles. Thirty-two 1 × 1-inch sites per flank received either 20 or 40 percent treatment coverage. Photographs were taken and punch biopsies were performed at days 0, 7, 28, 56, and 84. Biopsy specimens were evaluated for histology and collagen content. RESULTS: All treatment sites healed quickly, with no evidence of scarring or infection. Coring sites were easily identified and contained increased fibroblast activity and newly synthesized collagen. At 1 month, the papillary dermis and epidermis of the coring sites were up to 196 percent thicker compared with controls (p < 0.001). The coring sites had enhanced undulating rete ridges-consistent with regeneration. At 3 months, a pronounced increase in collagen fibers and newly organized and augmented elastic fibers was seen. Enzyme-linked immunosorbent assay confirmed an 89 percent increase in collagen content in these coring sites (p < 0.001). CONCLUSIONS: This novel approach to skin rejuvenation was found to effectively induce the microscopic and biological endpoints of skin rejuvenation. This may provide a new modality for the safe and cost-effective treatment of age-related rhytides, skin laxity, photodamage, scarring, and striae.

Normal relationship of beta- and non-beta-cells not needed for successful islet transplantation.

Islets are composed mostly of beta-cells, and therefore stem cell research has concentrated on generating purified beta-cells, neglecting the other endocrine cell types in the islet. We investigated the presence of endocrine non-beta-cells after islet transplantation. In addition, we studied whether the transplantation of pure beta-cells, in volumes similar to that used in islet transplantation, would suffice to reverse hyperglycemia in diabetic mice. Rat islets were dispersed and beta-cells were purified by fluorescence-activated cell sorting according to their endogenous fluorescence. After reaggregation, 600 islet equivalents of the purified beta-cell aggregates were implanted into diabetic SCID mice. In mice implanted with beta-cell-enriched aggregates, the hyperglycemia was reversed and good graft function over a 12-week period was observed with regard to glucose and insulin levels, glucose tolerance tests, and graft insulin content. The endocrine cell composition of the beta-cell-enriched aggregates remained constant; before and 12 weeks after transplantation, the beta-cell-enriched aggregates comprised 95% beta-cells and 5% endocrine non-beta-cells. However, islet grafts, despite originally having comprised 75% beta-cells and 25% endocrine non-beta-cells, comprised just 5% endocrine non-beta-cells after transplantation, indicating a loss of these cells. beta-Cell-enriched aggregates can effectively reverse hyperglycemia in mice, and transplanted intact islets are depleted in non-beta-cells. It is therefore likely that islet non-beta-cells are not essential for successful islet transplantation.

Long-term normoglycemia in rats receiving transplants with encapsulated islets.

BACKGROUND: To follow up on previously successful transplantation of encapsulated islets in mice, the present study was performed in rats to determine the effects of several factors, including alginate composition and concentration of cross-linking agent and capsule size on the effectiveness of encapsulated islets. METHODS: Highly purified alginate of either high guluronic acid or high mannuronic acid (M) with low endotoxin content was used. Regular-size (0.8-1.1 mm) or small microcapsules (0.5-0.7 mm) were produced by cross-linking with BaCl2 without additional poly-L-lysine coating and were transplanted into abdominal cavity of normoglycemic (empty capsules) or streptozotocin induced diabetic Lewis rats (islet containing capsules). RESULTS: Empty regular-size capsules made of different alginate compositions had similar biocompatibility and stability results. Compared with empty capsules, regular-size capsules made of high-M alginate containing syngeneic islets had inferior stability indicated with lower fractional volume retrieved. Islet-containing smaller-size microcapsules made of high-M alginate were more stable and had less cellular attachment compared with the regular-size capsules, although the normoglycemic period was comparable between two groups of rats receiving transplants with smaller-size microcapsules (48+/-8 days, n=8) or regular-size capsules (59+/-11 days, n=4) in allogeneic experiments. In syngeneic experiments, all of the rats (n=4) maintained normoglycemia up to 210 days after transplantation. CONCLUSION: These results indicate that regular-size alginate capsules do less well in rats than in our previous experiments with mice. Smaller capsules made of alginate cross-linked with barium appear to provide better stability and may be a useful strategy for use in larger recipients.

Transplantation of islets transduced with CTLA4-Ig and TGFbeta using adenovirus and lentivirus vectors.

BACKGROUND: A major problem facing islet transplantation is immune destruction of grafts by transplant rejection and autoimmunity. Some success in prolonging graft rejection has been obtained by transducing islets prior to transplantation with adenoviral (Ad) vectors containing CTLA4-Ig and TGFbeta. The purpose of this study was to see if lentiviral (LV) vectors would provide superior results compared with adenoviral vectors. METHODS: Islets were isolated from Sprague-Dawley rats and transduced with Ad or LV vectors containing LacZ, CTLA4-Ig, CTLA4, and TGFbeta1 using various MOIs. Islets transduced with LV were healthy as judged by DNA and insulin content, and insulin secretion. Using the kidney capsule transplant site, 500 transduced rat islets were transplanted into streptozotocin diabetic B6AF1 mice. RESULTS: Maintenance of normoglycemia was prolonged in recipient mice carrying islets transduced with Ad vectors containing CTLA4-Ig, CTLA4, and TGFbeta1. Return of hyperglycemia in controls was 17-18 days while loss of function for the experimental groups occurred at 20-27 days. For the lentivirus transduced islets, rejection of controls was 20+/-1.6 days, for CTLA4-Ig was 42+/-21 days and for TGFbeta was 28+/-3.2 days. CONCLUSIONS: Although islets transduced with either adenovirus or lentivirus containing CTLA4-Ig, CTLA4, and TGFbeta1 could prolong graft survival in a rat to mouse transplantation model, with the conditions of this study lentivirus provided no advantage over adenovirus vectors.