Cross-Sectional Comparison of Treatment Provided Under the Clinical, Integrated, and Partnership Staffing Models for Community-Based Residential Mental Health Rehabilitation.

In Queensland (Australia), community-based residential mental health rehabilitation services have three distinct staffing profiles. The traditional 'clinical' staffing model has nursing staff occupying most staff roles. The 'partnership' approach involves collaboration between the health service and a Non-Government Organisation. Under the 'integrated' staffing approach, Peer Support Workers reflect the majority staffing component. This study compares the treatment received by consumers (N = 172) under these staffing models using cross-sectional administrative data. Staffing models were generally comparable on demographic, diagnostic, and symptomatic/impairment measures. However, statistically significant differences were present on a range of treatment variables. Differences mainly occurred between the clinical and integrated approaches, with the integrated staffing model having lower rates of involuntary treatment, antipsychotic polypharmacy, depot use, and chlorpromazine dose equivalence levels. These findings indicate the need to carefully examine the impact of staffing configuration on rehabilitation processes to understand whether differences in approaches are likely to impact rehabilitation outcomes.

Real-time sonoelastography evaluation of the Achilles tendon following ultrasound-guided platelet-rich plasma injection and eccentric exercise for the treatment of refractory Achilles tendinopathy.

The objective of this study was to investigate the feasibility of using sonoelastography to depict Achilles tendon stiffness after platelet-rich plasma injection and eccentric exercise for chronic Achilles tendinopathy, and to correlate sonoelastography findings with clinical outcome up to 12 months after treatment. Forty-five Achilles tendons from 45 patients (33 males, 12 females; mean age 51 years) were examined using sonoelastography and ultrasound at baseline, 4-6 weeks, 6 months and 12 months post-treatment. The strain ratio (between Achilles tendon and Kager's fat) during sonoelastography was obtained. The proportion of tendons with hypoechogenicity and neovascularity were documented. Clinical outcomes were assessed by the Victorian Institute of Sport Assessment-Achilles questionnaire and correlated with sonographic findings. The Victorian Institute of Sport Assessment-Achilles improved significantly from 38.4 (±14.1) at baseline, 77.2 (±12.5) at 6 months (p < 0.001) to 81.2 (±10.8) at 12 months (p < 0.001). The strain ratio values were 2.16 (±1.02) at baseline, 2.03 (±0.67) at 4-6 weeks, 1.81 (±0.62) at 6 months and 1.19 (±0.34) at 12 months with a significant reduction observed at 6 months (p = 0.006) and 12 months (p < 0.001). At 12-month evaluation, none of the tendons regained a normal echotexture. Strain ratio demonstrated a moderately good inverse correlation with Victorian Institute of Sport Assessment-Achilles (r = -0.610, p<0.001) while B-mode and Doppler ultrasound did not show a significant correlation (r = -0.041, p = 0.817, and r = -0.116, p = 0.514). Achilles tendon stiffness shows moderately good correlation with clinical symptom at 12-month post-treatment. Sonoelastography using strain ratio could be a promising ancillary tool for monitoring Achilles tendon healing after treatment.

Metabolic risk in patients participating in residential rehabilitation programs: how are we doing?

OBJECTIVES: To examine the prevalence of metabolic syndrome and its association with clinical, demographic and lifestyle factors in patients with mental illness participating in residential rehabilitation. METHODS: A physical health audit of all consumers ( n = 364) in publicly funded residential rehabilitation programs in Queensland was carried out in late 2016. Data collection focused on clinical, demographic and lifestyle factors associated with physical health. RESULTS: Central obesity was identified in 80% of males and 89% of females and half of the patients (49.4%) met criteria for metabolic syndrome (MetS). The prevalence of MetS in Indigenous patients (66.1%) was 20% higher than the rate found in non-Indigenous patients (46.1%). Smoking, substance abuse, gender, Indigenous background, length of stay and rarely eating fruit and vegetables were individually associated with MetS. CONCLUSIONS: The prevalence of MetS in this cohort is almost double that of the general population, while the rate in Indigenous patients is among the highest reported for those with mental illness. Rehabilitation staff are encouraged to engage more fully in the monitoring of physical health status, sharing this information with consumers and primary care providers, and encouraging consumers to play a greater role in managing their physical health.

Building Global Epidemiology and Response Capacity with Field Epidemiology Training Programs.

More than ever, competent field epidemiologists are needed worldwide. As known, new, and resurgent communicable diseases increase their global impact, the International Health Regulations and the Global Health Security Agenda call for sufficient field epidemiologic capacity in every country to rapidly detect, respond to, and contain public health emergencies, thereby ensuring global health security. To build this capacity, for >35 years the US Centers for Disease Control and Prevention has worked with countries around the globe to develop Field Epidemiology Training Programs (FETPs). FETP trainees conduct surveillance activities and outbreak investigations in service to ministry of health programs to prevent and control infectious diseases of global health importance such as polio, cholera, tuberculosis, HIV/AIDS, malaria, and emerging zoonotic infectious diseases. FETP graduates often rise to positions of leadership to direct such programs. By training competent epidemiologists to manage public health events locally and support public health systems nationally, health security is enhanced globally.

* Tissue Engineering Strategies to Improve Osteogenesis in the Juvenile Swine Alveolar Cleft Model.

Alveolar (gumline) clefts are the most common congenital bone defect in humans, affecting 1 in 700 live births. Treatment to repair these bony defects relies on autologous, cancellous bone transfer from the iliac crest. This harvest requires a second surgical site with increased surgical time associated with potential complications, while providing only limited cancellous bone. Improvements in treatment protocols that avoid these limitations would be beneficial to patients with clefts and other craniofacial bone defects. There have been steady advances in tissue-engineered (TE) solutions for long-bone defects and adult patients, but advances for the pediatric craniofacial skeleton have been slower to emerge. This study utilizes a previously established juvenile swine model with a surgically created, critical size alveolar defect to test the efficacy of umbilical cord (UC) mesenchymal stem cells (MSCs) treatments on nano-microfiber scaffolds. At 1 month after implanting our TE construct, mineralized tissue in the surgical gap was quantified through computed tomography (CT), and histology, and excised tissue was subjected to mechanical testing. Both undifferentiated and predifferentiated (toward an osteogenic lineage) UC MSCs generated bone within the cleft on a scale comparable to iliac crest cancellous bone, as evidenced by histology and CT scans. All of the pigs treated with scaffold/stem cell combinations had mineralized tissue within the defect, although without filling the entire defect. Several of the experimental animals exhibited poor and/or asymmetric maxillary growth 1 month after the initial surgery, especially if the surgical defect was located on the smaller side of an already asymmetric pig. Our results demonstrate that tissue engineering approaches using UC MSCs are a promising alternative for repair of the alveolar cleft. Data in the pig model demonstrate that implanted scaffolds are at least as good as the current gold standard treatment based on harvesting cancellous bone from the iliac crest, regardless of whether the cells seeded on the scaffold are precommitted to an osteogenic fate.

The physical health of Indigenous and non-Indigenous patients participating in residential rehabilitation programs: a comparison study.

OBJECTIVE: To examine the differences in the physical health of Indigenous and non-Indigenous patients with severe mental illness (SMI) undergoing psychiatric rehabilitation. METHODS: An audit of the physical health of patients ( n = 361) in all publicly funded residential rehabilitation programs in Queensland was carried out in late 2014. Data collection focused on clinical and lifestyle factors associated with physical health. RESULTS: The prevalence of smoking, substance use and type 2 diabetes in Indigenous patients was significantly higher than rates found in non-Indigenous patients. Metabolic syndrome was also significantly higher in indigenous patients, with 66% of Indigenous patients compared to 46% of non-Indigenous patients meeting criteria for metabolic syndrome. CONCLUSIONS: Patients with SMI in residential rehabilitation programs have poor physical health. Our findings underscore the need for clinicians to develop and evaluate interventions aimed at improving the metabolic profile of those with SMI in residential rehabilitation programs. Historical factors and cultural traditions need to be considered when designing lifestyle interventions for Indigenous patients.

Comparing clinical and demographic characteristics of people with mental illness in hospital- and community-based residential rehabilitation units in Queensland.

Objective The aim of the present study was to examine care pathways and characteristics of mental health consumers participating in both hospital- and community-based residential rehabilitation programs. Methods An audit of consumers (n=240) in all publicly funded residential rehabilitation units in Queensland was performed on the same day in 2013. Data collection focused on demographic characteristics, clinical information and measures of consumer functioning. Results Significant differences emerged for consumers in community- and hospital-based services with regard to age, length of stay, functioning, Mental Health Act status, guardianship status, family contact and risk of violence. Consumers in hospital-based programs have more severe and complex problems. Conclusions Consumers in residential rehabilitation units have high levels of disability, poor physical health and high levels of vulnerability. Nonetheless, it is likely that a sizeable proportion of consumers occupying rehabilitation beds in Queensland could be discharged if more 'step-down' options to move patients on were available. What is known about the topic? A small subgroup of people with severe and complex mental health problems is likely to require time in a residential rehabilitation program. This group is characterised by failure to respond to treatment, severe negative symptoms and some degree of cognitive impairment. What does this paper add? Patients currently occupying residential rehabilitation beds in Queensland have high levels of disability, poor physical health and high levels of vulnerability. Patients in hospital-based programs are more severely disabled than those in community-based programs. What are the implications for practitioners? It is likely that a sizeable proportion of patients occupying rehabilitation beds in Queensland could be discharged if more 'step-down' options were available. Future planning initiatives need to focus on developing a greater array of community support options to facilitate the discharge of people from residential services.

Application of strain and calibration of Förster Resonance Energy Transfer (FRET) emission for in vitro live cell response to cytoskeletal deformation.

Cellular mechanotransduction is an integral part of many crucial physiological processes, but non-invasive tools for quantifying intracellular strain in vivo are not available for complex tissues such as bone. As a first step to address this gap, we have utilized a novel, non-invasive approach to quantify cellular strain in vitro by employing a transfected alpha-actinin Förster Resonance Energy Transfer (FRET) sensor. Following validation experiments, mouse fibroblasts transfected to express FRET sensors were seeded to a silicone membrane and subjected to up to 10% tensile strain mounted on a multi-photon microscope. During tensile strain, fluorescent emission of acceptor (YFP) and donor (CFP) proteins was quantified. YFP/CFP ratio was normalized to the initial baseline (unstretched) ratio for each cell which demonstrates a negative linear correlation between the relative proximity ratio of emission spectra and cell strain, with a mean decrease of 1.017% normalized ratio for every percent strain experienced by the cell. The exciting implications of our findings are that the discovery of the stable correlation between loss of FRET and experimentally applied strain opens intriguing possibilities for future use of this technology with in vivo research, leading to discoveries improving disease treatments in mechanically sensitive tissues such as bone.

Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in Methicillin-Resistant Staphylococcus aureus Skin Abscesses after Surgical Drainage.

OBJECTIVE: To determine whether a 3-day vs 10-day course of antibiotics after surgical drainage of skin abscesses is associated with different failure and recurrence rates. STUDY DESIGN: Patients age 3 months to 17 years seeking care at a pediatric emergency department with an uncomplicated skin abscess that required surgical drainage were randomized to receive 3 or 10 days of oral trimethoprim-sulfamethoxazole therapy. Patients were evaluated 10-14 days later to assess clinical outcome. Patients were followed for 6 months to determine the cumulative rate of recurrent skin infections. RESULTS: Among the 249 patients who were enrolled, 87% of wound cultures grew Staphylococcus aureus (S aureus) (55% methicillin-resistant S aureus [MRSA], 32% methicillin-sensitive S aureus), 11% other organisms, and 2% no growth. Thirteen patients experienced treatment failure. Among all patients, no significant difference in failure rates between the 3- and 10-day treatment groups was found. After we stratified patients by the infecting organism, only patients with MRSA infection were more likely to experience treatment failure in the 3-day group than the 10-day group (P = .03, rate difference 10.1%, 95% CI 2.1%-18.2%) Recurrent infection within 1 month of surgical drainage was more likely in patients infected with MRSA who received 3 days of antibiotics. (P = .046, rate difference 10.3%, 95% CI 0.8%-19.9%). CONCLUSION: Patients with MRSA skin abscesses are more likely to experience treatment failure and recurrent skin infection if given 3 rather than 10 days of trimethoprim-sulfamethoxazole after surgical drainage. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02024867.

Sonoelastography of the Achilles Tendon: Prevalence and Prognostic Value Among Asymptomatic Elite Australian Rules Football Players.

OBJECTIVE: To investigate the prevalence of sonographic abnormalities at the mid-Achilles tendon among a cohort of asymptomatic professional football players and to determine whether these sonographic abnormalities predict midportion Achilles tendon symptoms. DESIGN: Longitudinal study. SETTING: A single competitive season in the Australian Rules Football League. PARTICIPANTS: Forty-two elite Australian Rules football players. MAIN OUTCOME MEASURES: Using ultrasound and sonoelastography, 42 players were examined at baseline and again 9 months later (postseason) for the existence of intratendinous hypoechogenicity, delamination, softening, and neovascularization. The anterio-posterior (AP) thickness and cross-sectional area (CSA) were measured. Players reporting Achilles tendon pain or with Victorian Institute of Sports Assessment-Achilles scores below 80 at the end of the season were classified as symptomatic. RESULTS: At preseason, ultrasound and/or sonoelastographic abnormalities were found in 22 (22/42, 52.4%) asymptomatic players. Baseline AP thickness and CSA were significantly greater in symptomatic players at the end season than those in asymptomatic players (0.57 ± 0.05 cm vs 0.50 ± 0.03 cm; P < 0.001 and 0.67 ± 0.07 cm vs 0.57 ± 0.06 cm; P < 0.001, respectively). The presence of intratendinous softening and delaminations at baseline was associated with pain onset during the season (P = 0.046; P = 0.048, respectively). CONCLUSIONS: Ultrasound and sonoelastography-detected abnormalities were relatively common among the asymptomatic footballers. Greater AP thickness and CSA and also the presence of intratendinous softening and delaminations were associated with the increased risk of developing symptoms. CLINICAL RELEVANCE: Conventional ultrasound supplement with sonoelastography may be able to identify elite athletes at risk of Achilles tendon injury, which may, in turn, impact therapeutic decisions.

Face Masks for Noninvasive Ventilation: Fit, Excess Skin Hydration, and Pressure Ulcers.

BACKGROUND: Pressure ulcers (stages III and IV) are serious safety events (ie, never events). Healthcare institutions are no longer reimbursed for costs to care for affected patients. Medical devices are the leading cause of pediatric pressure ulcers. Face masks for noninvasive ventilation were associated with a high percentage of pressure ulcers at our institution. METHODS: A prospective cohort study investigated factors contributing to pressure ulcer development in 50 subjects using face masks for noninvasive ventilation. Color imaging, 3-dimensional surface imaging, and skin hydration measurements were used to identify early skin compromise and evaluate 3 interventions to reduce trauma: (1) a silicone foam dressing, (2) a water/polyethylene oxide hydrogel dressing, and (3) a flexible cloth mask. A novel mask fit technique was used to examine the impact of fit on the potential for skin compromise. RESULTS: Fifty subjects age 10.4 ± 9.1 y participated with color images for 22, hydration for 34, and mask fit analysis for 16. Of these, 69% had diagnoses associated with craniofacial anomalies. Stage I pressure ulcers were the most common injury. Skin hydration difference was 317 ± 29 for sites with erythema versus 75 ± 28 for sites without erythema (P < .05) and smallest for the cloth mask (P < .05). Fit distance metrics differed for the nasal, oronasal, and face shield interfaces, with threshold distances being higher for the oronasal mask than the others (P < .05). Areas of high contact were associated with skin erythema and pressure ulcers. CONCLUSIONS: This fit method is currently being utilized to select best-fit masks from available options, to identify the potential areas of increased tissue pressure, and to prevent skin injuries and their complications. Improvement of mask fit is an important priority for improving respiratory outcomes. Strategies to maintain normal skin hydration are important for protecting tissue integrity.

Chronic obstructive pulmonary disease part 2: non-pharmacological therapy.

Chronic obstructive pulmonary disease (COPD) is a common, progressive and disabling disease that causes significant burden to patients, their families, and the NHS. Research suggests that the complexity of factors contributing to the disease requires a deeper understanding of the patient experience and a more holistic approach to care provision. This, the second of two articles, discusses the non-pharmacological therapies for managing patients with COPD and explores the concept of mindfulness as a therapy in the management of breathlessness.

Chronic obstructive pulmonary disease part 1: smoking cessation.

Chronic obstructive pulmonary disease (COPD) is common in the UK and causes a significant burden to patients and the NHS. Healthcare provision for COPD is largely focused on biomedical treatment, yet research suggests the complexity of factors contributing to this disease requires a deeper understanding of the patient experience and a more holistic approach to the provision of care. Smoking cessation is the single most cost-effective and significant way to slow the disease progress and improve outcomes for patients. However, barriers to smoking cessation are higher in patients with COPD than in other groups, requiring different approaches. This is part one of a two-part article, which focuses on patients with COPD caused by smoking. The second part will focus on non-pharmacological therapy.

Establishing a field epidemiology elective for medical students in Kenya: a strategy for increasing public health awareness and workforce capacity.

Medical students have limited exposure to field epidemiology, even though will assume public health roles after graduation. We established a 10-week elective in field epidemiology during medical school. Students attended one-week didactic sessions on epidemiology, and nine weeks in field placement sites. We administered pre- and post-tests to evaluate the training. We enrolled 34 students in 2011 and 2012. In 2011, we enrolled five of 24 applicants from a class of 280 medical students. In 2012, we enrolled 18 of 81 applicants from a class of 360 students; plus 11 who participated in the didactic sessions only. Among the 34 students who completed the didactic sessions, 74% were male, and their median age was 24 years (range: 22-26). The median pre-test score was 64% (range: 47-88%) and the median post-test score was 82% (range: 72-100%). Successful completion of the field projects was 100%. Six (30%) students were not aware of public health as a career option before this elective, 56% rated the field experience as outstanding, and 100% reported it increased their understanding of epidemiology. Implementing an elective in field epidemiology within the medical training is a highly acceptable strategy to increase awareness for public health among medical students.

Evaluating Application of Knowledge and Skills: The Use of Consensus Expert Review to Assess Conference Abstracts of Field Epidemiology Training Participants.

BACKGROUND: Often evaluations of training programs are limited - with many focusing on the aspects that are easy to measure (e.g., reaction of trainees) without addressing the important outcomes of training, such as how trainees applied their new knowledge, skills, and attitudes. Numerous evaluations fail to measure training's effect on job performance because few effective methods are available to do so. Particularly difficult is the problem of evaluating multisite training programs that vary considerably in structure and implementation from one site to another. PURPOSE: NA. SETTING: NA. INTERVENTION: NA. RESEARCH DESIGN: We devised a method of a consensus expert review to evaluate the quality of conference abstracts submitted by participants in Field Epidemiology Training Programs - an approach that can provide useful information on how well trainees apply knowledge and skills gained in training, complementing data obtained from other sources and methods. This method is practical, minimally intrusive, and resource-efficient, and it may prove useful for evaluation practice in diverse fields that require training. DATA COLLECTION AND ANALYSIS: NA. FINDINGS: NA.

Pressure ulcer prevention in the community setting.

Pressure ulcers are associated with reduced quality of life, affecting individuals physically, socially and emotionally. The financial cost to the NHS of preventing and treating such ulcers is substantial. Although largely preventable, pressure ulcers are still common. The Department of Health is committed to eliminating all avoidable pressure ulcers in NHS-provided care. This article explores methods of preventing pressure ulcers, with particular focus on risk assessment, skin inspection, pressure-relieving measures, nutrition and hydration, and patient and carer education.

Anatomic study of full facial and scalp allografts without cutaneous facial scars.

Conventional reconstructive procedures for face and scalp reconstruction fall short of aesthetic and functional goals because of the unique quality and quantity of facial and scalp soft tissue. The purpose of this cadaver study was to demonstrate the feasibility of a flap design for full face and scalp composite tissue allotransplantation, without cutaneous facial scars. Six fresh human cadavers were dissected with sagittal scalp and mucosal incisions for full face and scalp harvest without cutaneous facial incisions. Sub-galeal and sub-SMAS dissection allowed for inclusion of the external carotid and internal jugular systems. Time of facial-scalp flap harvesting, length of the arterial and venous pedicles, length of sensory nerves (that were included in the facial flaps) and approximate surface area of the flaps were measured. Three of six flaps were transferred to recipient cadavers and the time of transfer was recorded. As a proof of concept, the external carotid arteries of one of six cadavers was flushed to remove clots and perfused with a radio-opaque latex polymer, Microfil (Flow Tech Inc.), to study flap perfusion by X-ray imaging. In the donor cadaver, the mean harvesting time of the total facial-scalp flap was 105 ± 19 minutes. The mean length of the supraorbital, infraorbital, mental and great auricular nerves were 1.3 ± 0.2, 1.3 ± 0.1, 1.3 ± 0.1, and 4.8 ± 0.6 cm, respectively. The mean length of the external carotid artery and external jugular vein were 8.7 ± 0.3 and 9.2 ± 0.4 cm, respectively. The approximate area of the harvested flap was 1063 ± 60 cm(2). In preparation for full face and scalp allotransplantation in humans, this study has demonstrated the feasibility of a full face and scalp flap without visible facial incisions.

Dissection in the subgaleal and subperiosteal plane: implications on scalp wound healing.

Craniofacial reconstruction often involves the use of dissection in the subperiosteal or subgaleal plane to access the cranial vault and facial skeleton. Clinically, physical changes to the periosteal layer and underlying cortex were observed in the re-operative field. This article compares aspects of wound healing, structural integrity of the progenitor periosteal layer, and underlying bony changes when elevating a subgaleal or subperiosteal flap in a Lewis rat calvarial model. Cranial dissection in the subperiosteal or subgaleal plane was performed on 14 Lewis rats. En bloc resection of the calvarium and overlying soft tissue was harvested at days 0, 1, 3, 7, 14, 28, and 56. Samples underwent SEM imaging and were analysed histologically after trichrome and haematoxylin and eosin staining. One sample of native periosteum underwent cellular expansion to determine periosteal cell regenerative capability. Up to 56 days, subperiosteal dissection results in diffuse hypercellularity within the cambial layer (p < 0.001). There are irregular cortical changes at the periosteal interface and increased disorganised bone remodelling at the temporal ridges. Subgaleal dissection did not reveal any underlying bony changes, and cell counts were not significantly different from controls (p < 0.001). Subperiosteal dissection causes structural and cellular changes to the periosteum and underlying bone composition with a possible influence on its regenerative capability.

Variation in Protein and Calorie Consumption Following Protein Malnutrition in Rattus norvegicus.

Catch-up growth rates, following protein malnutrition, vary with timing and duration of insult, despite unlimited access to calories. Understanding changing patterns of post-insult consumption, relative rehabilitation timing, can provide insight into the mechanisms driving those differences. We hypothesize that higher catch-up growth rates will be correlated with increased protein consumption, while calorie consumption could remain stable. As catch-up growth rates decrease with age/malnutrition duration, we predict a dose effect in protein consumption with rehabilitation timing. We measured total and protein consumption, body mass, and long bone length, following an increase of dietary protein at 40, 60 and 90 days, with two control groups (chronic reduced protein or standard protein) for 150+ days. Immediately following rehabilitation, rats' food consumption decreased significantly, implying that elevated protein intake is sufficient to fuel catch-up growth rates that eventually result in body weights and long bone lengths greater or equal to final measures of chronically fed standard (CT) animals. The duration of protein restriction affected consumption: rats rehabilitated at younger ages had more drastic alterations in consumption of both calories and protein. While rehabilitated animals did compensate with greater protein consumption, variable responses in different ages and sex highlight the plasticity of growth and how nutrition affects body form.