Transitioning Youth into Adult Mental Health and Addiction Services: An Outcomes Evaluation of the Youth Transition Project.

The Youth Transition Project was designed to provide youth with mental health and addiction issues with individualized transitional care plans as they transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). Over an 18-month period, a total of 127 (59.1%) youth were transitioned and seen by an AMHS provider, 41 (19.1%) remained on a waitlist for services and 47 (21.8%) canceled services. The average time to transition was 110 days (SD = 100). Youth exhibited a wide range of diagnoses; 100% of the population was identified as having serious psychiatric problems. Findings demonstrate that the Youth Transition Project has been successful in promoting continuity of care by transitioning youth seamlessly from youth to adult services. Inconsistencies in wait times and service delivery suggest that further model development is needed to enhance the long-term sustainability of the Youth Transition Project.

Acute gastrointestinal illness following a prolonged community-wide water emergency.

The drinking water infrastructure in the United States is ageing; extreme weather events place additional stress on water systems that can lead to interruptions in the delivery of safe drinking water. We investigated the association between household exposures to water service problems and acute gastrointestinal illness (AGI) and acute respiratory illness (ARI) in Alabama communities that experienced a freeze-related community-wide water emergency. Following the water emergency, investigators conducted a household survey. Logistic regression models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for self-reported AGI and ARI by water exposures. AGI was higher in households that lost water service for ⩾7 days (aPR 2·4, 95% CI 1·1-5·2) and experienced low water pressure for ⩾7 days (aPR 3·6, 95% CI 1·4-9·0) compared to households that experienced normal service and pressure; prevalence of AGI increased with increasing duration of water service interruptions. Investments in the ageing drinking water infrastructure are needed to prevent future low-pressure events and to maintain uninterrupted access to the fundamental public health protection provided by safe water supplies. Households and communities need to increase their awareness of and preparedness for water emergencies to mitigate adverse health impacts.

Mcm2 deficiency results in short deletions allowing high resolution identification of genes contributing to lymphoblastic lymphoma.

Mini-chromosome maintenance (Mcm) proteins are part of the replication-licensing complex that is loaded onto chromatin during the G1-phase of the cell cycle and required for initiation of DNA replication in the subsequent S-phase. Mcm proteins are typically loaded in excess of the number of locations that are used during S-phase. Nonetheless, partial depletion of Mcm proteins leads to cancers and stem cell deficiencies. Mcm2 deficient mice, on a 129Sv genetic background, display a high rate of thymic lymphoblastic lymphoma. Here array comparative genomic hybridization is used to characterize the genetic damage accruing in these tumors. The predominant events are deletions averaging less than 0.5 Mbp, considerably shorter than observed in prior studies using alternative mouse lymphoma models or human tumors. Such deletions facilitate identification of specific genes and pathways responsible for the tumors. Mutations in many genes that have been implicated in human lymphomas are recapitulated in this mouse model. These features, and the fact that the mutation underlying the accelerated genetic damage does not target a specific gene or pathway a priori, are valuable features of this mouse model for identification of tumor suppressor genes. Genes affected in all tumors include Pten, Tcfe2a, Mbd3 and Setd1b. Notch1 and additional genes are affected in subsets of tumors. The high frequency of relatively short deletions is consistent with elevated recombination between nearby stalled replication forks in Mcm2-deficient mice.

DNA damage response and tumorigenesis in Mcm2-deficient mice.

Minichromosome maintenance proteins (Mcm's) are components of the DNA replication licensing complex. In vivo, reduced expression or activity of Mcm's has been shown to result in highly penetrant early onset cancers (Shima et al., 2007; Pruitt et al., 2007) and stem cell deficiencies (Pruitt et al., 2007). Here we use mouse embryonic fibroblasts from an Mcm2-deficient strain of mice to show by DNA fiber analysis that origin usage is decreased in Mcm2-deficient cells under conditions of hydroxyurea (HU)-mediated replication stress. DNA damage responses (DDRs) resulting from HU and additional replication-dependent and replication-independent genotoxic agents were also examined and shown to function at wild-type (wt) levels. Further, basal levels of many components of the DDR were expressed at wt levels, showing that there is no acute replicative stress under normal growth conditions. Only very modest, 1.5- to 2-fold increases in the basal levels of gamma-H2AX, p21(cip1) and 53bp foci were found, consistent with a slight chronic elevation in DDR pathways. The one condition in which a larger difference between wt- and Mcm2-deficient cells was found occurred after ultraviolet irradiation and may reflect the role of Chk1-mediated suppression of dormant origins. In vivo, abrogating p53-mediated DDR in Mcm2-deficient mice results in increased embryonic lethality and accelerated cancer formation in surviving mice. Further, p53 mutation rescues the negative effect of Mcm2 deficiency on the survival of neural stem cells in vitro; however, the enhanced survival correlates with increased genetic damage relative to Mcm2 wt cells carrying the p53 mutation. Together these results show that even relatively minor perturbations to primary or dormant replication origin usage contribute to accelerated genetic damage in vivo. In addition, these studies show that tumor types resulting from Mcm2 deficiency are strongly affected by interaction with both genetic background and p53.

B-cell lymphoma of the larynx in a patient with rheumatoid arthritis.

We report a case of B-cell lymphoma with the larynx as the primary site of presentation in a rheumatoid arthritis patient previously treated with methotrexate. Primary non-Hodgkin's lymphoma (NHL) of the larynx is rare. There may be an increased risk of lymphoma in patients with rheumatoid arthritis, with an even higher risk in those patients treated with methotrexate. The diagnostic and treatment options are discussed.

Compression of the median nerve in CTS is mediated by periods of acute synovial swelling.

Tolerance of neural tissue to external compression has been shown to depend on several factors. The mechanism by which acute compression alters peripheral nerve conduction is not completely understood. Ischemic and mechanical factors have alternatively been implicated as the primary causes of nerve dysfunction in compression syndromes. An ischemic etiology for acute nerve compression would be favored if there were changes in pressure within the carpal canal. Upon excision of the synovial tissue from within the canal it has been recognized that the tissue can absorb media and swell to three times it original size. This investigation compares the synovial tissue obtained during carpal tunnel surgeries with synovial tissue collected from control patients presenting with injuries not related to carpal tunnel syndrome. A total of twenty-seven carpal patients and six control patients were included within the study. The synovial tissue was obtained, weighed and placed in a 2 ml of sterile phosphate buffer saline (pH 7.3). The rate of fluid up take was determined at intervals of 15 minutes for the first two hours and then hourly for an additional four hours. The results indicate an increase in fluid uptake ranging between 0.004 mg/min to 0.011 mg/min for the first hour in the CTS patients. The rate of fluid uptake subsides after 4 hours. Control patients exhibited less of an increase in fluid uptake ranging between 0.003 to 0.007 over the first three hours. These differences in fluid retention of the different tissues may suggest a tendency for increased fluid pressure within the carpal canal, which may cause compression of the neural tissues.

Traumatic combined radial and ulnar axial wrist dislocation.

In axial wrist dislocation, the proximal and distal transverse arches are disrupted and the carpus and metacarpal bases are split longitudinally. Early reduction and stabilization of the dislocation combined with exploration and decompression provide the best results.

Training residents for community psychiatric practice: the resident perspective.

OBJECTIVE: To capture the views and experiences of psychiatry residents in 5 Canadian training programs with respect to community psychiatric training. METHOD: We sent a questionnaire regarding respondent demography, career interests, and community psychiatry training experiences to psychiatry residents at 5 training programs in Ontario. We undertook descriptive analyses and frequency comparisons on the returned data. RESULTS: The overall response rate was 48%, with considerable variation between programs. With respect to career planning, respondents indicated highest interest in urban hospital-based practice. An interest in additional community psychiatry training was, however, expressed, particularly by junior residents. Residents' suggestions for improving community psychiatry training included better promotion of training opportunities, improved quality of supervision in community settings, and more didactic teaching. CONCLUSION: Psychiatry residents are obtaining training experiences in community psychiatry, but objectives and guidelines are quite variable, as is reflected in their understanding of the definition of "community psychiatry." Residents' career paths are still focused on urban hospital-based practice or solo private practice, which likely reflects their prevalent training experiences. There is, however, interest in community psychiatry training. Junior residents may be more open to this type of practice, and curricula should allow more exposure to community psychiatry at this stage of training.

First permanent implant of the Jarvik 2000 Heart.

BACKGROUND: Heart failure is a major public-health concern. Quality and duration of life on maximum medical therapy are poor. The availability of donor hearts is severely limited, therefore an alternative approach is necessary. We have explored the use of a new type of left-ventricular assist device intended as a long-term solution to end-stage heart failure. METHODS: As part of a prospective clinical trial, we implanted the first permanent Jarvik 2000 Heart--an intraventricular device with an innovative power delivery system--into a 61-year-old man (New York Heart Association functional class IV) with dilated cardiomyopathy. We assessed the effect of this left-ventricular assist device on both native heart function and the symptoms and systemic characteristics of heart failure. FINDINGS: The Jarvik 2000 Heart sustained the patient's circulation, and was practical and user-friendly. After 6 weeks, exercise tolerance, myocardial function, and end-organ function improved. Symptoms of heart failure have resolved, and continuous decreased pulse-pressure perfusion has had no adverse effects in the short term. There has been no significant haemolysis and no device-related complications. The skull-mounted pedestal is unobtrusive and has healed well. CONCLUSIONS: The initial success of this procedure raises the possibility of a new treatment for end-stage heart failure. In the longer term, its role will be determined by mechanical reliability.

Auras, seizure focus, and psychiatric disorders.

OBJECTIVE: The goal of this study was to assess the types of auras and their associations with the focus of seizures in 144 consecutive adult patients with partial epilepsy refractory to medical treatment. The association of frequency and type of aura with a psychiatric disorder was also studied. BACKGROUND: The nature of the aura, its association with the seizure focus, and its relation with emotions and behavioral dysfunction have received relatively little attention, and remain controversial. METHODS: Patients were admitted to an epilepsy investigation unit for detailed observation of their seizures and type of aura. Patients underwent standard electroencephalographic telemetry, including implanted subdural electrodes, if necessary, to delineate the seizure focus. The auras were classified into nine categories. All patients had an independent clinical psychiatric interview for a Diagnostic and Statistical Manual, Third Edition-Revised (DSM-III-R)-based diagnosis. RESULTS: Of the 144 patients studied, 111 (77.1%) had one or more symptoms during the aura and 33 (22.9%) had no aura. The most frequent aura types were viscerosensory (47 cases [32.6%]), experiential (44 cases [30.6%]), and cephalic (21 cases [14.6%]). A temporal lobe focus was present in 116 (80.5%) patients. Only experiential auras were significantly associated with a temporal lobe seizure focus (33 of 44 cases). A DSM-III-R psychiatric diagnosis was present in 74 (51.4%) patients. Of the 116 patients with a temporal lobe focus, 60 (50.2%) had a DSM-III-R psychiatric diagnosis. Patients with two or more auras were significantly more likely to have a psychiatric diagnosis (70.2%) compared with those with one aura (39.1%) or no aura (48.5%). A significant association between experiential auras and psychiatric morbidity was seen. CONCLUSIONS: Auras occurred in a majority of patients with a treatment-refractory partial epilepsy who were hospitalized for assessment of their seizure focus for possible surgical candidacy. Two or more auras were associated with a psychiatric diagnosis as was the presence of an experiential aura. Experiential auras were most common in temporal lobe epilepsy. Approximately half the patients, irrespective of seizure focus, had an associated psychiatric morbidity.

The arthroscopic management of intra-articular distal radius fractures.

Intra-operative arthroscopy and fluoroscopy provide improved visualisation and guide the restoration of intra-articular distal radial fractures while minimising the operative dissection required for their stabilisation. Radial styloid fractures, distal radial fractures with dorsal, palmar or combined ulnar-sided "die punch" fragments, palmar and dorsal Barton's fractures, and various three- and four-part intra-articular fractures without significant bone loss or defect are especially suited for this technique. The experienced arthroscopist may wish to apply the technique to more severely comminuted intra-articular fractures. Bone defects may be approached through a limited dorsal incision traversing the 3rd dorsal wrist compartment. Arthroscopy and fluoroscopy may be used adjunctively to assess fracture reduction and fixation. Arthoscopy further facilitates initial treatment by allowing direct joint visualisation, debridement, the removal of small free intra-articular fragments, and the recognition and early treatment of wrist ligament injuries, particularly those not appreciated by X-ray evaluation

Early wrist arthrodesis for irreparable intra-articular distal radial fractures.

When articular restoration and congruity cannot be accomplished in distal radial fractures owing to severe articular bone loss or comminution, early wrist arthrodesis should be considered. This procedure rapidly restores wrist alignment and stability and controls pain. Arthrodesis is a highly reliable and definitive procedure that optimises the opportunity for early functional and occupational recovery while minimising the risks of developing stiff digits or chronic pain in injuries otherwise doomed from the start of treatment to result in severe wrist stiffness and post-traumatic arthritis. Simultaneous proximal row carpectomy or the use of ipsilateral local bone graft donor sites, such as the distal radius or proximal ulna, decrease both initial treatment and hospital costs and morbidity. Wrist arthrodesis is also effective when polytrauma or multiple fractures co-exist. Successful early treatment may expedite return to work and reduce lost time and wages resulting from the injury.

Inference of blood glucose concentrations from subcutaneous glucose concentrations: applications to glucose biosensors.

An approach for inference of blood glucose concentrations in real time is considered. First, a model that predicts the subcutaneous glucose concentration from the blood glucose concentration is presented. The model includes diffusive transport from the blood to the subcutaneous tissue and reactive-like cellular uptake of glucose. Next, the Phillips-Tikhonov regularization method is considered to solve the real-time input estimation problem that determines the blood glucose concentration given the subcutaneous glucose concentration. The inverse problem is regularized by imposing a smoothing condition to obtain a stable solution. Three different penalization functionals were considered in evaluating the regularization method using a synthetic function that approximates the subcutaneous glucose response to an oral glucose tolerance test in a human subject. Various levels of either white noise or time-correlated noise were superimposed onto the synthetic response to evaluate the sensitivity of the inverse to measurement error. For inversion assuming only diffusive transport, the optimal time interval of integration of previous subcutaneous measurements was found to be about 1.5/alpha, where alpha(-1) is the dominant time constant for the exchange of glucose between the blood and subcutaneous tissue. The optimal sampling rate was found to be 54alpha. Linear regularizations based on minimization of first or second derivatives of the blood glucose concentration were found to be satisfactory, each yielding a minimum error that was about 50% greater than the measurement error. Including nonlinear, reactive-like uptake of glucose was found to decrease the error magnification factor slightly. Both the model and the inverse method relating blood and subcutaneous glucose concentrations are successfully applied to experimental measurements using glucose biosensors reported by Schmidtke et al. (Proc. Natl. Acad. Sci. USA 95:294-299, 1998).

Arthroscopic management of intra-articular distal radius fractures.

Wrist arthroscopy is increasingly becoming recognized as an important adjunct in the management of displaced intra-articular fractures of the distal radius. Anatomic restoration of the articular surface is possible under bright, magnified conditions. Osteochondral loose bodies and associated intracarpal soft tissue injuries that may not be apparent on plain radiographs are detected and simultaneously managed. A method of management for displaced distal radius fractures using wrist arthroscopy and a combination of percutaneous and limited open reduction techniques are described.