Particle and vapor emissions from vat polymerization desktop-scale 3-dimensional printers.

Little is known about emissions and exposure potential from vat polymerization additive manufacturing, a process that uses light-activated polymerization of a resin to build an object. Five vat polymerization printers (three stereolithography (SLA) and two digital light processing (DLP) were evaluated individually in a 12.85 m3 chamber. Aerosols (number, size) and total volatile organic compounds (TVOC) were measured using real-time monitors. Carbonyl vapors and particulate matter were collected for offline analysis using impingers and filters, respectively. During printing, particle emission yields (#/g printed) ranged from 1.3 ± 0.3 to 2.8 ± 2.6 x 108 (SLA printers) and from 3.3 ± 1.5 to 9.2 ± 3.0 x 108 (DLP printers). Yields for number of particles with sizes 5.6 to 560 nm (#/g printed) were 0.8 ± 0.1 to 2.1 ± 0.9 x 1010 and from 1.1 ± 0.3 to 4.0 ± 1.2 x 1010 for SLA and DLP printers, respectively. TVOC yield values (µg/g printed) ranged from 161 ± 47 to 322 ± 229 (SLA printers) and from 1281 ± 313 to 1931 ± 234 (DLP printers). Geometric mean mobility particle sizes were 41.1-45.1 nm for SLA printers and 15.3-28.8 nm for DLP printers. Mean particle and TVOC yields were statistically significantly higher and mean particle sizes were significantly smaller for DLP printers compared with SLA printers (p < 0.05). Energy dispersive X-ray analysis of individual particles qualitatively identified potential occupational carcinogens (chromium, nickel) as well as reactive metals implicated in generation of reactive oxygen species (iron, zinc). Lung deposition modeling indicates that about 15-37% of emitted particles would deposit in the pulmonary region (alveoli). Benzaldehyde (1.0-2.3 ppb) and acetone (0.7-18.0 ppb) were quantified in emissions from four of the printers and 4-oxopentanal (0.07 ppb) was detectable in the emissions from one printer. Vat polymerization printers emitted nanoscale particles that contained potential carcinogens, sensitizers, and reactive metals as well as carbonyl compound vapors. Differences in emissions between SLA and DLP printers indicate that the underlying technology is an important factor when considering exposure reduction strategies such as engineering controls.

Oral candidiasis following steroid therapy for oral lichen planus.

OBJECTIVES: The purpose of this multicentre study was to determine the incidence of oral candidiasis in patients treated with topical steroids for oral lichen planus (OLP) and to determine whether the application of a concurrent antifungal therapy prevented the development of an oral candidiasis in these patients. MATERIALS AND METHODS: Records of 315 patients with OLP seen at four Oral Medicine practices treated for at least 2 weeks with steroids with and without the use of an antifungal regimen were retrospectively reviewed. RESULTS: The overall incidence of oral fungal infection in those treated with steroid therapy for OLP was 13.6%. There was no statistically significant difference in the rate of oral candidiasis development in those treated with an antifungal regimen vs those not treated prophylactically (14.3% vs 12.6%) (P = 0.68). CONCLUSIONS: Despite the use of various regimens, none of the preventive antifungal strategies used in this study resulted in a significant difference in the rate of development of an oral candidiasis in patients with OLP treated with steroids.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression.

OBJECTIVE: To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour. METHOD: A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings. RESULTS: Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse. CONCLUSION: By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Differences in seclusion rates between admission wards: does patient compilation explain?

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

The antecedents of violence and aggression within psychiatric in-patient settings.

OBJECTIVE: To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings. METHOD: Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data. RESULTS: Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall. CONCLUSION: This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

Botulinum neurotoxin A blocks synaptic vesicle exocytosis but not endocytosis at the nerve terminal.

The supply of synaptic vesicles in the nerve terminal is maintained by a temporally linked balance of exo- and endocytosis. Tetanus and botulinum neurotoxins block neurotransmitter release by the enzymatic cleavage of proteins identified as critical for synaptic vesicle exocytosis. We show here that botulinum neurotoxin A is unique in that the toxin-induced block in exocytosis does not arrest vesicle membrane endocytosis. In the murine spinal cord, cell cultures exposed to botulinum neurotoxin A, neither K(+)-evoked neurotransmitter release nor synaptic currents can be detected, twice the ordinary number of synaptic vesicles are docked at the synaptic active zone, and its protein substrate is cleaved, which is similar to observations with tetanus and other botulinal neurotoxins. In marked contrast, K(+) depolarization, in the presence of Ca(2+), triggers the endocytosis of the vesicle membrane in botulinum neurotoxin A-blocked cultures as evidenced by FM1-43 staining of synaptic terminals and uptake of HRP into synaptic vesicles. These experiments are the first demonstration that botulinum neurotoxin A uncouples vesicle exo- from endocytosis, and provide evidence that Ca(2+) is required for synaptic vesicle membrane retrieval.

Insights Into Emissions and Exposures From Use of Industrial-Scale Additive Manufacturing Machines.

BACKGROUND: Emerging reports suggest the potential for adverse health effects from exposure to emissions from some additive manufacturing (AM) processes. There is a paucity of real-world data on emissions from AM machines in industrial workplaces and personal exposures among AM operators. METHODS: Airborne particle and organic chemical emissions and personal exposures were characterized using real-time and time-integrated sampling techniques in four manufacturing facilities using industrial-scale material extrusion and material jetting AM processes. RESULTS: Using a condensation nuclei counter, number-based particle emission rates (ERs) (number/min) from material extrusion AM machines ranged from 4.1 × 1010 (Ultem filament) to 2.2 × 1011 [acrylonitrile butadiene styrene and polycarbonate filaments). For these same machines, total volatile organic compound ERs (µg/min) ranged from 1.9 × 104 (acrylonitrile butadiene styrene and polycarbonate) to 9.4 × 104 (Ultem). For the material jetting machines, the number-based particle ER was higher when the lid was open (2.3 × 1010 number/min) than when the lid was closed (1.5-5.5 × 109 number/min); total volatile organic compound ERs were similar regardless of the lid position. Low levels of acetone, benzene, toluene, and m,p-xylene were common to both AM processes. Carbonyl compounds were detected; however, none were specifically attributed to the AM processes. Personal exposures to metals (aluminum and iron) and eight volatile organic compounds were all below National Institute for Occupational Safety and Health (NIOSH)-recommended exposure levels. CONCLUSION: Industrial-scale AM machines using thermoplastics and resins released particles and organic vapors into workplace air. More research is needed to understand factors influencing real-world industrial-scale AM process emissions and exposures.

Evaluation of emissions and exposures at workplaces using desktop 3-dimensional printer.

There is a paucity of data on additive manufacturing process emissions and personal exposures in real-world workplaces. Hence, we evaluated atmospheres in four workplaces utilizing desktop "3-dimensional" (3-d) printers [fused filament fabrication (FFF) and sheer] for production, prototyping, or research. Airborne particle diameter and number concentration and total volatile organic compound concentrations were measured using real-time instruments. Airborne particles and volatile organic compounds were collected using time-integrated sampling techniques for off-line analysis. Personal exposures for metals and volatile organic compounds were measured in the breathing zone of operators. All 3-d printers that were monitored released ultrafine and fine particles and organic vapors into workplace air. Particle number-based emission rates (#/min) ranged from 9.4 × 109 to 4.4 × 1011 (n = 9samples) for FFF3-d printers and from 1.9 to 3.8 × 109 (n = 2 samples) for a sheer 3-d printer. The large variability in emission rate values reflected variability from the printers as well as differences in printer design, operating conditions, and feedstock materials among printers. A custom-built ventilated enclosure evaluated at one facility was capable of reducing particle number and total organic chemical concentrations by 99.7% and 53.2%, respectively. Carbonyl compounds were detected in room air; however, none were specifically attributed to the 3-d printing process. Personal exposure to metals (aluminum, iron) and 12 different organic chemicals were all below applicable NIOSH Recommended Exposure Limit values, but results are not reflective of all possible exposure scenarios. More research is needed to understand 3-d printer emissions, exposures, and efficacy of engineering controls in occupational settings.

Patient ethnicity and three psychiatric intensive care units compared: the Tompkins Acute Ward Study.

Psychiatric care units provide care to disturbed patients in a context of higher security and staffing levels. Although such units are numerous, few systematic comparisons have been made, and there are indications that ethnic minority groups may be over-represented. The aim of this study was to compare the rates of adverse incidents and patterns of usage of three psychiatric intensive care units. The study used a triangulation or multi-method design, bringing together data from official statistics, local audit and interviews conducted with staff. Intensive care patients were more likely to be young, male and suffering a psychotic disorder, as compared with general acute ward patients. Caribbean patients were twice as likely, and Asian patients half as likely, to receive intensive care (age, gender and diagnosis controlled). There were large differences in service levels, staffing, team functioning and adverse incidents between the three units. Various aspects of physical security were important in preventing absconds. More evaluative research is required in order to define effective service levels, and to explore the nature of the interaction between ethnicity and inpatient care provision during acute illness.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services.

AIMS: Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion. METHODS: Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors. RESULTS: PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting. CONCLUSIONS: Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

An analysis of nurses' post-incident manual restraint reports.

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

Constraints and blocks to change and improvement on acute psychiatric wards--lessons from the City Nurses project.

Recent years have seen sustained criticism and inspection of acute inpatient psychiatric wards, with the publication of reports and research leading to policy developments and a variety of efforts to improve perceived deficits. The City Nurses project seeks to reduce levels of conflict and containment on acute wards through the placement of expert nurses on wards to assist with the implementation of changes according to a working model of conflict and containment generation, based on previous research. Evaluation has shown significant decreases in aggression, absconding and self-harm by patients. However, in the course of working with the wards, various constraints and blocks to change have been identified and we describe these in detail in this paper. Analysis of the fieldwork diaries of the two City Nurses identified that change was hindered by limited staffing resources, problems with the physical environment and other resources, insufficient beds and the process of bed management, hierarchical ambiguity and multidisciplinary issues, the overdemanding role of the ward manager, and pervasive anxiety about the potential for serious untoward incidents and their implications for staff. We argue that sustained positive change in acute inpatient psychiatry requires these underlying structural issues to be both acknowledged and, if possible, resolved.

Reflections on the process of change on acute psychiatric wards during the City Nurse Project.

The intention of this paper is to discuss the process of therapeutic change on two acute psychiatric wards during a research project that aimed to reduce conflict and containment. Analysis of fieldwork notes, reflection, team discussion and supervision. The City Nurse Project successfully reduced patient aggression, self-harm and absconding. This paper reports on the reflections made over the course of the year as changes and developments to acute wards took place. Specifically discussed are the beneficial effects of an action research approach, the role of the City Nurse, support for ward managers, education and training, clinical supervision as well as difficulties and barriers to the overall process of change. At an interim stage of the project, the staff have shown a willingness to engage in efforts to change and improve two acute wards. This paper shows the potential to improve acute wards and produce positive outcomes using a working model.

Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses.

Acute psychiatric wards experience high levels of conflict behaviours (violence, absconding, self-harm, rule breaking and medication refusal) by patients. These events cause stress and injury to staff and patients. Their management through containment methods (e.g. sedation, restraint, seclusion) is contentious, and nurses are ambivalent about their use. The aim of this study was to reduce conflict and containment on two acute psychiatric wards through changes in nurses' beliefs, attitudes and practices. Two 'City Nurses' were employed to work with two acute wards for 1 year, assisting with the implementation of changes according to a working model of conflict and containment generation, itself based on previous research. Evaluation was via before-and-after measures. Statistically and clinically significant decreases in conflict occurred, with falls in aggression, absconding and self-harm. Ward atmosphere improved and nurse-patient interaction rates increased. There was no significant change in containment method use. Significant reductions in aggression, absconding and self-harm can be achieved on acute psychiatric wards. However, it does not appear that containment can be reduced, even through large reductions in conflict.

Encephalitozoon hellem infection in aviary passerine and psittacine birds in Spain.

A European goldfinch (Carduelis carduelis), a canary (Serinus canaria), and a lovebird (Agapornis roseicollis) captive-bred at three different private aviaries in Spain were submitted for necropsy with a history of weakness and ruffled feathers, weight loss associated with glossitis, and respiratory disease, respectively. Microscopically, enterocytes in the jejunum and ileum contained colonies of gram- and Stamp-positive, oval to elliptical microorganisms within parasitophorous vacuoles in the apical cytoplasm. Nested PCR using MSP primers that target microsporidian RNA genes produced amplicons of expected size for Encephalitozoon species, and analysis of forward and reverse DNA sequences confirmed the presence of Encephalitozoon hellem in all cases. The main cause of death of all three birds consisted of concurrent infections. However, intestinal encephalitozoonosis may have contributed to exacerbated catabolism. Encephalitozoonosis (or microsporidiosis) has been rarely described in passerine birds.

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing.

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Training in cognitive behavioural interventions on acute psychiatric inpatient wards.

There has been a drive towards addressing the types of care and therapeutic interventions available to people with serious mental illness, which is reflected in the latest government mental health policy initiatives. Recent evidence strongly supports the implementation of psychological and social interventions for people with psychosis, and in particular the use of cognitive behavioural techniques. Until now, the main focus has been on people living in the community. This study examines the delivery of psychosocial interventions training to qualified psychiatric nurses and unqualified staff on seven acute psychiatric admission wards in London, UK. The approach had the strength of on-site delivery, follow-up role modelling of the interventions and clinical supervision. Despite this, in some cases the training was less successful, mainly because of staffing and leadership weaknesses. The impact of training in these methods and the implications for mental health education and practice development are discussed.

Coercive manoeuvres in a psychiatric intensive care unit.

Coercive manoeuvres in a psychiatric intensive care unit The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry.

Real world application of an intervention to reduce absconding.

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.