Effect of managed transition on mental health outcomes for young people at the child-adult mental health service boundary: a randomised clinical trial.

BACKGROUND: Poor transition planning contributes to discontinuity of care at the child-adult mental health service boundary (SB), adversely affecting mental health outcomes in young people (YP). The aim of the study was to determine whether managed transition (MT) improves mental health outcomes of YP reaching the child/adolescent mental health service (CAMHS) boundary compared with usual care (UC). METHODS: A two-arm cluster-randomised trial (ISRCTN83240263 and NCT03013595) with clusters allocated 1:2 between MT and UC. Recruitment took place in 40 CAMHS (eight European countries) between October 2015 and December 2016. Eligible participants were CAMHS service users who were receiving treatment or had a diagnosed mental disorder, had an IQ ⩾ 70 and were within 1 year of reaching the SB. MT was a multi-component intervention that included CAMHS training, systematic identification of YP approaching SB, a structured assessment (Transition Readiness and Appropriateness Measure) and sharing of information between CAMHS and adult mental health services. The primary outcome was HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents) score 15-months post-entry to the trial. RESULTS: The mean difference in HoNOSCA scores between the MT and UC arms at 15 months was -1.11 points (95% confidence interval -2.07 to -0.14, p = 0.03). The cost of delivering the intervention was relatively modest (€17-€65 per service user). CONCLUSIONS: MT led to improved mental health of YP after the SB but the magnitude of the effect was small. The intervention can be implemented at low cost and form part of planned and purposeful transitional care.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services.

PURPOSE: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS. METHODS: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations. RESULTS: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. CONCLUSION: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Transition from child and adolescent mental health care to adult services for young people with Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) in Europe: Barriers and recommendations.

Transition in mental health care is the process ensuring continuity of care of a young patient arriving at the CAMHS (Child and Adolescent Mental Health Service) age boundary within mental health services. Transition refers to a transfer to an adult mental health service (AMHS), to private care or other mental health community services. A transition plan can also lead to a managed end of specialized care with involvement of a general practitioner or social services. For young people with a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) or ASD (Autism Spectrum Disorder), two disorders that persist into adulthood, an optimal transition would ensure continuity of care or facilitate access to specialized care in the case of a discharge. Transition typically occurs during adolescence, a known sensitive period when young people may experience major changes at several levels: physiological, psychological and social. Any barrier in the transition process resulting in discontinuity of care may worsen the symptoms of ADHD or ASD and can ultimately adversely affect the global mental health of young people with such neurodevelopmental disorders. The objectives of this narrative review are: 1/to identify the barriers in the transition process in mental health services often faced by young people with these two disorders; 2/to highlight specific recommendations for strengthening the CAMHS-AMHS interface that have been proposed by various countries in Europe.

Protocol for the development and validation procedure of the managing the link and strengthening transition from child to adult mental health care (MILESTONE) suite of measures.

BACKGROUND: Mental health disorders in the child and adolescent population are a pressing public health concern. Despite the high prevalence of psychopathology in this vulnerable population, the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) has many obstacles such as deficiencies in planning, organisational readiness and policy gaps. All these factors contribute to an inadequate and suboptimal transition process. A suite of measures is required that would allow young people to be assessed in a structured and standardised way to determine the on-going need for care and to improve communication across clinicians at CAMHS and AMHS. This will have the potential to reduce the overall health economic burden and could also improve the quality of life for patients travelling across the transition boundary. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Health Care) project aims to address the significant socioeconomic and societal challenge related to the transition process. This protocol paper describes the development of two MILESTONE transition-related measures: The Transition Readiness and Appropriateness Measure (TRAM), designed to be a decision-making aide for clinicians, and the Transition Related Outcome Measure (TROM), for examining the outcome of transition. METHODS: The TRAM and TROM have been developed and were validated following the US FDA Guidance for Patient-reported Outcome Measures which follows an incremental stepwise framework. The study gathers information from service users, parents, families and mental health care professionals who have experience working with young people undergoing the transition process from eight European countries. DISCUSSION: There is an urgent need for comprehensive measures that can assess transition across the CAMHS/AMHS boundary. This study protocol describes the process of development of two new transition measures: the TRAM and TROM. The TRAM has the potential to nurture better transitions as the findings can be summarised and provided to clinicians as a clinician-decision making support tool for identifying cases who need to transition and the TROM can be used to examine the outcomes of the transition process. TRIAL REGISTRATION: MILESTONE study registration: ISRCTN83240263 Registered 23-July-2015 - ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Correction to: Managing the link and strengthening transition from child to adult mental health Care in Europe (MILESTONE): background, rationale and methodology.

Following publication of the original article [1], the authors reported they wanted to reinstate a co-author, who previously declined his authorship due to a misinterpretation of authorship limitations per research center.

Managing the link and strengthening transition from child to adult mental health Care in Europe (MILESTONE): background, rationale and methodology.

BACKGROUND: Transition from distinct Child and Adolescent Mental Health (CAMHS) to Adult Mental Health Services (AMHS) is beset with multitude of problems affecting continuity of care for young people with mental health needs. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge globally. The overall aim of the Managing the Link and Strengthening Transition from Child to Adult Mental Health Care in Europe (MILESTONE) project (2014-19) is to improve transition from CAMHS to AMHS in diverse healthcare settings across Europe. MILESTONE focuses on current service provision in Europe, new transition-related measures, long term outcomes of young people leaving CAMHS, improving transitional care through 'managed transition', ethics of transitioning and the training of health care professionals. METHODS: Data will be collected via systematic literature reviews, pan-European surveys, and focus groups with service providers, users and carers, and members of youth advocacy and mental health advocacy groups. A prospective cohort study will be conducted with a nested cluster randomised controlled trial in eight European Union (EU) countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS users, their carers, and clinicians. DISCUSSION: Improving transitional care can facilitate not only recovery but also mental health promotion and mental illness prevention for young people. MILESTONE will provide evidence of the organisational structures and processes influencing transition at the service interface across differing healthcare models in Europe and longitudinal outcomes for young people leaving CAMHS, solutions for improving transitional care in a cost-effective manner, training modules for clinicians, and commissioning and policy guidelines for service providers and policy makers. TRIAL REGISTRATION: "MILESTONE study" registration: ISRCTN ISRCTN83240263 Registered 23 July 2015; ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Behavioral motor dysfunction in Kv3-type potassium channel-deficient mice.

The voltage-gated potassium channels Kv3.1 and Kv3.3 are expressed in several distinct neuronal subpopulations in brain areas known to be involved in motor control such as cortex, basal ganglia and cerebellum. Depending on the lack of Kv3.1 or Kv3.3 channel subunits, mutant mice show different Kv3-null allele-dependent behavioral alterations that include constitutive hyperactivity, sleep loss, impaired motor performance and, in the case of the Kv3.1/Kv3.3 double mutant, also severe ataxia, tremor and myoclonus (Espinosa et al. 2001, J Neurosci 21, 6657-6665, Genes, Brain Behav 3, 90-100). The lack of Kv3.1 channel subunits is mainly responsible for the constitutively increased locomotor activity and for sleep loss, whereas the absence of Kv3.3 subunits affects cerebellar function, in particular Purkinje cell discharges and olivocerebellar system properties (McMahon et al. 2004, Eur J Neurosci 19, 3317-3327). Here, we describe two sensitive and non-invasive tests to reliably quantify normal and abnormal motor functions, and we apply these tests to characterize motor dysfunction in Kv3-mutant mice. In contrast to wildtype and Kv3.1-single mutants, Kv3.3-single mutants and Kv3 mutants lacking three and four Kv3 alleles display Kv3-null allele-dependent gait alterations. Although the Kv3-null allele-dependent gait changes correlate with reduced motor performance, they appear to not affect the training-induced improvement of motor performance. These findings suggest that altered cerebellar physiology in the absence of Kv3.3 channels is responsible for impaired motor task execution but not motor task learning.

Heterogenous expression of nestin in human pancreatic tissue precludes its use as an islet precursor marker.

The discovery of a pancreatic adult stem cell would have significant implications for cell-based replacement therapies for type 1 diabetes mellitus. Nestin, a marker for neural precursor cells, has been suggested as a possible marker for islet progenitor cells. We have characterized the expression and localization of nestin in both the intact human pancreas and clinical human pancreatic islet grafts. Nestin was found to be expressed at different levels in the acinar component of human pancreatic biopsies depending on donor, as well as in ductal structures and islets to some degree. In islets, insulin-producing beta-cells rarely co-expressed the protein, and in the ducts a small percentage (1-2%) of cells co-expressed nestin and cytokeratin 19 (CK19) while most expressed only CK19 (90%) or nestin (5-10%) alone. Assessment of nestin expression in neonatal pancreatic sections revealed an increased number of islet-associated positive cells as compared with adult islets. Nestin immunoreactivity was also found in cells of the pancreatic vasculature and mesenchyme as evidenced by co-localization with smooth muscle actin and vimentin. Samples from post-islet isolation clinical islet grafts revealed a pronounced heterogeneity in the proportion of nestin-positive cells (<1-72%). Co-localization studies in these grafts showed that nestin is not co-expressed in endocrine cells and rarely (<5%) with cytokeratin-positive ductal cells. However, relatively high levels of co-expression were found with acinar cells and cells expressing the mesenchymal marker vimentin. In conclusion we have shown a diffuse and variable expression of nestin in human pancreas that may be due to a number of different processes, including post-mortem tissue remodeling and cellular differentiation. For this reason nestin may not be a suitable marker solely for the identification of endocrine precursor cells in the pancreas.

A simple microcomputer-based three-dimensional serial section reconstruction system (MICROS).

We have developed a computer system which enters and aligns serial sections and displays the completed reconstructions at different rotations in space. The system uses commercially available hardware, including a Hewlett-Packard 9845T microcomputer and an H-P 9874A digitizer. The software for the system is written in the BASIC language. The system consists of two programs, one for section digitization, the other for rotation and display of the reconstructions. Sections are digitized directly from micrographs or back-projected slides. The outlines of cells or other structures are traced from these media using a hand-held cursor on the digitizer. The positions of elements (inputs) which contact the structure and fiducials are also digitized. The sections are aligned by simultaneously displaying two consecutive sections on the graphics CRT screen. The sections are coarsely superimposed by centering around screen center using a centering algorithm. They are precisely aligned by rotating and translating the images with a reference cursor. Special functions for inserting and deleting sections and rapid section scanning are available for editing. The aligned sections are stored using a linked-list file structure on either floppy disks or tape cartridges. The rotation program replots the completed reconstructions on the graphics CRT or digital plotter. The program will reproduce the reconstructions at any scale and at any rotation in the x-, y- or z-planes. A hidden line algorithm removes hidden lines to give a 3-dimensional (3-D) perspective to the reconstructions. The positions of inputs and fiducials are represented by symbols. We use the system to reconstruct cells and neural processes. The 3-D reconstructions allow us to: (a) examine the spatial distribution and density of synaptic contacts on neurons; (b) study complex neuronal shapes; (c) examine the vectors of neural processes. The computer reconstruction system, which is moderately priced, should also prove useful for reconstructing many other types of biological profile.

Subchronic effects of gum arabic (Acacia) in the rat.

Young Wistar rats were fed gum arabic (GA) at dietary concentrations of 0% (two control groups), 1, 2, 4, 8 and 20% for 13 weeks. The criteria studied were body weights, food and water consumption, urinalysis, liver and kidney weights, clinical chemistry, haematology, and histology. No untoward effects were observed at dose levels below those which caused dietary imbalance. At the top dose, female rats showed a small reduction in kidney weight, caecal enlargement, and changes in serum urea and total CO2. Male rats showed no differences from the control groups at dietary concentrations up to approx. 8%, but food and water consumption, body weight, liver and kidney weights all decreased significantly and caecal enlargement was evident at the top dose tested. There were no histological changes and no significant changes in haematological parameters in male or female rats at the top dose tested. The no-untoward effect concentrations were 8.6% (5.2 g/kg/day) and 18.1% (13.8 g/kg/day) for male and female rats respectively.

Glucose response to abrupt initiation and discontinuation of total parenteral nutrition.

Plasma glucose was studied during the initiation of total parenteral nutrition (TPN) and the discontinuation of TPN without a tapering schedule. Blood was sampled every 5 minutes for 2 hours after the start of TPN and 1 week later as TPN was discontinued. A total of 14 initiations and 14 discontinuations were studied in 18 patients. Severity of illness in patients ranged from stable condition postoperatively to multiple-system failure; six patients had diabetes mellitus. The TPN solution was a 3:1 admixture that provided a caloric intake equal to 1.2 times the resting energy expenditure, with 40% fat and 60% carbohydrate calories. An average of 1963 kcal was provided per day (340 g of glucose, 79 g of fat). During the initiation phase, the mean increase in plasma glucose was 60 mg/dL. The increase for diabetic patients was 79 +/- 14 mg/dL compared with 52 +/- 23 mg/dL for the nondiabetics. During the discontinuation phase, the mean plasma glucose decreased 40 +/- 20 mg/dL; two patients with high concentrations of regular insulin (50 and 100 units) showed an increase in plasma glucose when the TPN was stopped. Plasma glucose returned to the preinfusion baseline after discontinuation. During both initiation and discontinuation, plasma glucose showed little change after the first 60 minutes. No clinical symptoms of hypoglycemia were observed. In conclusion, TPN as a 3:1 admixture can be safely started as full nutrition support and stopped abruptly without a tapering schedule. Plasma glucose response is rapid, predictable, and mostly complete within 60 minutes.

Pediatric sports injuries: when to refer or x-ray.

When any athlete presents for evaluation of an injury, the history and physical examination is of paramount importance in establishing a differential diagnosis. A radiograph is often used to confirm a diagnosis or to reassess an injury following treatment failure. There are certain drawbacks involved with getting a radiograph including cost, inconvenience, radiation exposure, and misinterpretation. Therefore, the radiographic evaluation of the injured athlete should be used only as clinically necessary. The benefits of getting a radiograph, to allow assessment of the severity of the injury, and thereby allow a more appropriate and aggressive treatment and rehabilitation program. The skills of history taking and physical examination presented in this article should make it easier to decide when the child athlete needs a more comprehensive and aggressive evaluation including radiographic studies.

Refinement of structures previously proposed for gum arabic and other acacia gum exudates.

In the light of advances in structural gum-chemistry, the analytical data available from earlier analytical and structural studies of gum arabic (Acacia Senegal Willd.), and of the gum exudates from Acacia laeta, A. campylacantha and A. seyal, have been re-interpreted. The structures originally suggested were based on random arbitrary assignments of substituent sugars without an attempt to establish regular structures. Modelling considerations and recalculations show that the data can also be interpreted in terms of more ordered structures. These are consistent with almost all of the available experimental data and give a much clearer insight into the nature and extent of the structural differences shown by the two Acacia gums of commercial importance. Acacia senegal (gum arabic, gum hashab) and Acacia seyal (gum talha).

The myosin filament. X. Observation of nine subfilaments in transverse sections.

The molecular packing of the subfilaments in muscle thick filaments has been investigated by electron microscopy. Thin (80-100 nm) transverse sections of vertebrate skeletal muscle were cut, and 129 electron microscope images of thick filaments from 15 different areas including seven to ten images in each area were analyzed by computer image processing. The transverse sections were limited to the portion of the filaments between the bare zone and the C-protein bearing region. Of the 129 images, six were discarded because they were structurally disrupted, 17 did not show evidence for the presence of subfilaments from the autocorrelation function, and four did not show evidence for three-fold rotational symmetry from the power spectrum. The remaining 102 filaments all showed evidence for three-fold rotational symmetry, consistent with other available evidence (Pepe, 1982). From the analysis of these images by rotational filtering, we have found that the vertebrate skeletal myosin filament is made up of nine subfilaments and that the image appears to have trigonal symmetry. Of these subfilaments, six are arranged with a center-to-center spacing of about 4 nm and the other three on the surface of the filament are distorted from this arrangement. Three additional densities, which together with the other nine, correspond to the pattern of 12 densities previously observed in more highly selected images (Stewart et al., 1981; Pepe and Drucker, 1972) were observed in 5% of the images. Another pattern of nine subfilaments peripherally arranged around the circumference of the filament was observed occasionally. This latter image may represent the organization of the subfilaments in the bare zone region of the filament, resulting from sampling of individual filaments displaced longitudinally relative to the other filaments in the A-band.

Verb and noun morphology in the spoken and written language of children with language learning disabilities.

The purpose of this study was to investigate the use of verb and noun morphology in school-age children's spoken and written language. Sixty children, with and without language learning disabilities (LLD), each produced 2 spoken and 2 written language samples. The children's accuracy in using morphemes that mark verb finiteness (regular past tense, 3rd person singular present tense, copula, and auxiliary BE) was compared with their accuracy in using noun morphology (regular plural, possessive, articles). As would be expected, the typically achieving children, who were aged 7 to 12 years, had mastered the verb and noun morphology in spoken and written samples. The children with LLD, aged 10 to 12 years, also showed high accuracy in the spoken samples. On the other hand, they showed substantial difficulty in the written samples with the regular past tense, with errors in 26% of obligatory contexts. However, the children with LLD also had difficulty with the regular plural, with errors in 12% of obligatory contexts. For both the regular past tense and plural, all errors were errors of omission. These results indicate that finiteness marking remains an area of relative difficulty, but perhaps not the only grammatical difficulty, for children with language impairments in the school years.

Stress injury to the bone among women athletes.

Women's participation and recognition in sports have grown dramatically in the last 30 years, and this trend is expected to continue. In the last decade exciting research has centered on the unique medical and musculoskeletal aspects of the female athlete. Scientists have elucidated significant findings in the area of bone health, amenorrhea, disordered eating, osteoporosis, and stress fractures. Stress fractures are a common problem in female athletes and they appear to occur more commonly in the sacrum, pelvis, and femoral neck. Certain risk factors place women at a greater risk for stress injury to the bone, such as amenorrhea, low calcium intake, disordered eating, bone geometry, and leg length discrepancy. The best treatment for a stress fracture is prevention. Moreover, any woman with a stress fracture must be evaluated for the female athlete triad. Most stress fractures can be treated with relative rest and correction of the underlying factors that contributed to the injury. Certain stress fractures occur in areas of relative hypovascularity and are at risk for nonunion or avascular necrosis. In these cases surgery should be considered.

Traumatic osteochondral defect of the first metatarsal head: a case report.

Osteochondral injury of the first metatarsophalangeal joint is described in most literature as "osteochondritis dissecans" and an early stage of hallux rigidus. Traumatic osteochondral lesions of the knee and ankle are relatively common and well described. A case of a traumatic osteochondral defect of the first metatarsal head is presented.

Practice nursing: an evaluation of a training practice initiative.

Globally, health care is moving towards a primary care approach. In the UK initiatives for nurses wishing to gain experience in primary and community care may be crucial with the advent of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). This paper outlines an initiative in practice nursing, developed as a pilot study by a Health Authority. The training practice initiative was aimed at nurses returning to practice and offered them an experiential and supportive career pathway into primary care. The evaluation (carried out over 1 year), highlighted that those primarily involved in the initiative--the trainees, educators and general practitioners--felt it had been successful, especially in relation to professional development issues. The funding bodies for the initiative, who previously had concerns over the recruitment and retention of practice nurses, were also optimistic that the support networks which developed as a result of the initiative had raised morale. The paper suggests several educational, organizational and professional issues which arose from the evaluation exercise. Further, it suggests how this initiative, in an extended form, could provide an effective basis for the training and development of nursing staff in PCGs/PCTs.