Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania.

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Sustained benefit of cognitive behaviour therapy for health anxiety in medical patients (CHAMP) over 8 years: a randomised-controlled trial.

BACKGROUND: Health anxiety is an under-recognised but a frequent cause of distress. It is particularly common in general hospitals. METHODS: We carried out an 8-year follow-up of medical out-patients with health anxiety (hypochondriasis) enrolled in a randomised-controlled trial in five general hospitals in London, Middlesex and Nottinghamshire. Randomisation was to a mean of six sessions of cognitive behaviour therapy adapted for health anxiety (CBT-HA) or to standard care in the clinics. The primary outcome was a change in score on the Short Health Anxiety Inventory, with generalised anxiety and depression as secondary outcomes. Of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics, 306 (68.9%) were followed-up 8 years after randomisation, including 36 who had died. The study is registered with controlled-trials.com, ISRCTN14565822. RESULTS: There was a significant difference in the HAI score in favour of CBT-HA over standard care after 8 years [1.83, 95% confidence interval (CI) 0.25-3.40, p = 0.023], between group differences in generalised anxiety were less (0.54, 95% CI -0.29 to 1.36), p = 0.20, ns), but those for depression were greater at 8 years (1.22, 95% CI 0.42-2.01, p < 0.003) in CBT-HA than in standard care, most in standard care satisfying the criteria for clinical depression. Those seen by nurse therapists and in cardiology and gastrointestinal clinics achieved the greatest gains with CBT-HA, with greater improvement in both symptoms and social function. CONCLUSIONS: CBT-HA is a highly long-term effective treatment for pathological health anxiety with long-term benefits. Standard care for health anxiety in medical clinics promotes depression. Nurse therapists are effective practitioners.

Quality of English inpatient mental health services for people with anxiety or depressive disorders: Findings and recommendations from the core audit of the National Clinical Audit of Anxiety and Depression.

BACKGROUND: Clinical audit is a sustained cyclical quality improvement process seeking to improve patient care and outcomes by evaluating services against explicit standards and implementing necessary changes. National audits aim to improve population-level clinical care by identifying unwarranted variations and making recommendations for clinicians, managers and service commissioners. The National Clinical Audit of Anxiety and Depression aimed to improve clinical care for people admitted to English hospitals for treatment of anxiety and depression, to provide comparative data on quality of care, and to support local quality improvement initiatives by identifying and sharing examples of best practice. PROCEDURES: Thirteen standards were developed based on NICE guidelines, literature review and feedback from a steering committee and reference group of service users and carers. All providers of NHS inpatient mental health services in England were asked to submit details of between 20 and 100 eligible service users/patients admitted between April 2017 and September 2018. To ascertain data reliability, participating services re-audited 5 sets of case-notes with a second auditor, and the coordinating team checked 10 randomly-selected sets of case-notes from 3 services, also selected at random. The reference group and steering committee identified key findings and developed a series of recommendations, which were discussed in regional quality improvement workshops and on-line webinars. FINDINGS: Data from 3795 case notes were analysed. A sizeable proportion of records indicated that at least one important aspect of initial assessment was not documented. Many service users/patients who could have benefited from an intervention targeted at optimising physical health did not receive it. Only a minority (39%) were referred for psychological therapy. Use of outcome measures varied considerably but no single outcome measure was being used routinely. Most individuals had a care plan recorded in the notes, but a review date was documented in only two-thirds, and almost half of individuals had not received a copy. CONCLUSIONS: There was considerable variation between English mental health services across many variables, and much scope for improvement. Clinicians should ensure that care plans are developed collaboratively with service users/patients and identified carers should be provided with information about support services. Health services should investigate the reasons for low referral rates for psychological therapies. Clinicians should ensure all service users have jointly developed crisis plans in place at discharge. Service managers should agree outcome measures to evaluate the treatment provided and clinicians should use these measures at initial assessment and review appointments. The implementation of such changes provides an opportunity for collaborative research into mental health service delivery and quality.

Patient-reported experience and quality of care for people with schizophrenia.

BACKGROUND: Evidence is mounting that patient-reported experience can provide a valuable indicator of the quality of healthcare services. However, little is known about the relationship between the experiences of people with severe mental illness and the quality of care they receive. We conducted a study to examine the relationship between patient-reported experience and the quality of care provided to people with schizophrenia. METHODS: We calculated a composite global rating of quality of care for people with schizophrenia using data from an audit of 64 mental health providers. We then examined associations between these ratings and mean patient satisfaction and patient-rated outcome using data from a survey of 5608 schizophrenic patients treated in these services. RESULTS: Global rating of quality of care was positively correlated with patient-rated outcome (r = 0.33; p = 0.01) but not with patient satisfaction (r = 0.21, p = 0.10). Patient-rated outcome was also positively correlated with patient involvement (r = 0.26, p = 0.04) and the quality of prescribing practice (r = 0.31, p = 0.02). High patient satisfaction scores were significantly associated with the extent of use of care plans within each organisation (r = 0.27, p = 0.03). CONCLUSIONS: Among people with schizophrenia, patient-rated outcome provides a better guide to the quality of care than patient-rated satisfaction. Greater use of patient-reported outcome measures should be made when assessing the quality of care provided to people with psychosis.

Classification of self-injurious behaviour across the continuum of relative environmental-biological influence.

Self-injurious behaviour (SIB) is generally considered to be the product of interactions between dysfunction stemming from the primary developmental disability and experiences that occasion and reinforce SIB. As a result of these complex interactions, SIB presents as a heterogeneous problem. Recent research delineating subtypes of SIB that are nonsocially mediated, including one that is amenable to change and one that is highly invariant, enables classification of SIB across a broader continuum of relative environmental-biological influence. Directly examining how the functional classes of SIB differ has the potential to structure research, will improve our understanding this problem, and lead to more targeted behavioural and pharmacological interventions. Recognising that SIB is not a single entity but is composed of distinct functional classes would better align research with conceptual models that view SIB as the product of interactions between environmental and biological variables.

Patterns of DNA Methylation Across the Leptin Core Promoter in Four Diverse Asian and North American Populations.

DNA methylation is the most widely studied of epigenetic mechanisms, with environmental effects recorded through patterned attachments of methyl groups along the DNA that are capable of modifying gene expression without altering the DNA sequencing. The degree to which these patterns of DNA methylation are heritable, the expected range of normality across populations, and the phenotypic relevance of pattern variation remain unclear. Genes regulating metabolic pathways appear to be vulnerable to ongoing nutritional programming over the life course, as dietary nutrients are significant environmental determinants of DNA methylation, supplying both the methyl groups and energy to generate the methylation process. Here we examine methylation patterns along a region of the metabolic gene leptin (LEP). LEP's putative functions include regulation of energy homeostasis, with its signals affecting energy intake and expenditure, adipogenesis and energy storage, lipid and glucose metabolism, bone metabolism, and reproductive endocrine function. A pattern of differential methylation across CpG sites of the LEP core promoter has been previously identified; however, any consistency of pattern or its phenotypic significance is not fully elucidated among populations. Using DNA extracted from unfractionated white blood cells of peripheral blood samples, our pilot study, divided into two parts, examined the significance of variation in DNA methylation patterns along the leptin core promoter in four populations (phase 1) and used biomarkers reflecting leptin's functional process in two of those populations, western Buryat of Siberia and the Mennonite of central Kansas, to investigate the relevance of the ethnic variation identified in the DNA methylation (phase 2). LEP's core promoter region contains both the binding site for C/EBPα (CCAAT/enhancer binding protein alpha), which tempers the final step in adipocyte maturity and capacity to synthesize leptin, and the TATA motif controlling leptin synthesis. Previous studies report that increased methylation in this region is correlated to decreased gene expression, suggesting tissue-specific methylation variation at this region ( Melzner et al. 2002 ). We hypothesized that evidence of nutritional epigenetic programming would be identified through variation in patterns of DNA methylation and that functional relevance of that variation among populations would be identified through biomarkers that reflect leptin's metabolic signals: serum leptin levels, lipoproteins of the lipid transport system, and anthropometric measures. In phase 1, our combined analyses of 313 individuals documented a distinct and consistent overall pattern of differential DNA methylation across seven CpG sites of LEP core promoter in all ethnicities and both sexes. This pattern replicates those identified in previous studies, suggesting a conserved core promoter region across populations. Phase 2 analyses of two of the four populations (n = 239), correlating methylation at the C/EBPα transcription binding site (TBS) with metabolic and anthropometric biomarkers reflecting LEP roles, showed that stature, which reflects bone growth and remodeling, was significantly and inversely correlated with the percentage of DNA methylation at this site in both sexes. We suggest that variation in DNA methylation along the LEP core promoter plays a substantial role in energy signals affecting both adipogenesis and bone metabolism.

Assessment of adult patients with chronic liver failure for liver transplantation in 2015: who and when?

In 2015, there are a few absolute contraindications to liver transplantation. In adult patients, survival post-liver transplant is excellent, with 1-year survival rate >90% and 5-year survival rates >80% and predicted median allograft survival beyond 20 years. Patients with a Child-Turcotte Pugh score ≥9 or a model for end-stage liver disease (MELD) score >15 should be referred for liver transplantation, with patients who have a MELD score >17 showing a 1-year survival benefit with liver transplantation. A careful selection of hepatocellular cancer patients results in excellent outcomes, while consideration of extra-hepatic disease (reversible vs irreversible) and social support structures are crucial to patient assessment. Alcoholic liver disease remains a challenge, and the potential to cure hepatitis C virus infection together with the emerging issue of non-alcoholic fatty liver disease-associated chronic liver failure will change the landscape of the who in the years ahead. The when will continue to be determined largely by the severity of liver disease based on the MELD score for the foreseeable future.

Percutaneous Retroperitoneal Splenorenal Shunt for Symptomatic Portal Vein Thrombosis After Liver Transplantation.

Acute or recurrent bleeding from ectopic varices is a potentially life-threatening condition in rare patients with extrahepatic complete portal vein thrombosis (PVT) after liver transplantation (LT). In this setting, the role of interventional radiology is very limited and surgical shunts, in particular splenorenal shunts are usually used, despite the high associated mortality. We present the first reports of the clinical use of a new minimally invasive technique, percutaneous retroperitoneal splenorenal shunt (PRESS), in two LT recipients with life-threatening variceal hemorrhage secondary to PVT. Both patients had a successful PRESS using a transplenic approach with resolution of bleeding, avoiding the need for a potentially complicated laparotomy. The PRESS procedure is a useful addition to the interventional armamentarium that can be used in cases unsuitable for surgical shunt, and refractory to endoscopic management. In the future, this technique may be an alternative to surgical shunts as the standard procedure in patients with extra-hepatic PVT, just as the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become for the management of portal hypertension in the absence of PVT. Longer-term follow-up will be needed to establish the long-term success of this procedure.

Brain imaging in lung cancer patients without symptoms of brain metastases: a national survey of current practice in England.

AIM: To determine current practice regarding brain imaging for newly diagnosed lung cancer patients without symptoms of brain metastases. MATERIALS AND METHODS: A survey questionnaire was sent by e-mail to all the lung cancer lead clinicians in England currently on the National Cancer Intelligence Network database. The survey asked whether brain imaging was used in new lung cancer patients without symptoms or signs to suggest brain metastases; and if so, which patient subgroups were imaged according to cell type, stage of disease, and intention to treat, and which techniques were used to image these patients. Responses were received between February and May 2014. RESULTS: Fifty-nine of 154 centres replied to the survey (38%). Thirty of the 59 centres (51%) did not image the brain in these patients. Twenty-nine of the 59 (49%) centres imaged the brain in at least certain subgroups. Of those centres that did image the brain 21 (72%) used CT as the first-line imaging technique and six (20%) used MRI. Twenty-five of 59 (42%) centres stated that the 2011 NICE guidelines had led to a change in their practice. CONCLUSION: There is wide variation in practice regarding brain imaging in this patient group in England, with no brain imaging at all in approximately half of centres and a spectrum of imaging in the other half. When the brain is imaged, CT is the technique most commonly used. The 2011 NICE guidelines have led to some change in practice but not to national uniformity.

Akinetic all-semiconductor programmable swept-source at 1550 nm and 1310 nm with centimeters coherence length.

We demonstrate, for the first time, OCT imaging capabilities of a novel, akinetic (without any form of movement in the tuning mechanism), all-semiconductor, all-electronic tunable, compact and flexible swept source laser technology at 1550 nm and 1310 nm. To investigate its OCT performance, 2D and 3D ex vivo and in vivo OCT imaging was performed at different sweep rates, from 20 kHz up to 200 kHz, with different axial resolutions, about 10 µm to 20 µm, and at different coherence gate displacements, from zero delay to >17 cm. Laser source phase linearity and phase repeatability standard deviation of <2 mrad (<160 pm) were observed without external phase referencing, indicating that the laser operated close to the shot noise limit (~2 × factor); constant percentile wavelengths variations of sliding RIN and ortho RIN <0.2% could be demonstrated, ~5 times better as compared to other swept laser technologies.

Ethnicity as a predictor of detention under the Mental Health Act.

BACKGROUND: There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for. METHOD: Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments - either resulting in 'detention' or 'no detention'. RESULTS: Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention. CONCLUSIONS: There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

Mind-body response and neurophysiological changes during stress and meditation: central role of homeostasis.

Stress profoundly impacts quality of life and may lead to various diseases and conditions. Understanding the underlying physiological and neurological processes that take place during stress and meditation techniques may be critical for effectively treating stress-related diseases. The article examines a hypothetical physiological homeostatic response that compares and contrasts changes in central and peripheral oscillations during stress and meditation, and relates these to changes in the autonomic system and neurological activity. The authors discuss how cardiorespiratory synchronization, which occurs during the parasympathetic response and meditation, influences and modulates activity and oscillations of the brain and autonomic nervous system. Evidence is presented on how synchronization of cardiac and respiratory rates during meditation may lead to a homeostatic increase in cellular membrane potentials in neurons and other cells throughout the body. These potential membrane changes may underlie the reduced activity in the amygdala, and other cortical areas during meditation, and research examining these changes may foster better understanding of the restorative properties and health benefits of meditation.

Chain conformation in polymer nanocomposites with uniformly dispersed nanoparticles.

The effect of nanoparticles (NP) on chain dimensions in polymer melts has been the source of considerable theoretical and experimental controversy. We exploit our ability to ensure a spatially uniform dispersion of 13 nm silica NPs miscible in polystyrene melts, together with neutron scattering, x-ray scattering, and transmission electron microscopy, to show that there is no measurable change in the polymer size in miscible mixtures, regardless of the relative sizes of the chains and the nanoparticles, and for NP loadings as high as 32.7 vol%. Our results provide a firm basis from which to understand the properties of polymer nanocomposites.

Prophylactic alpha-blockade for prevention of post-operative urinary retention after inguinal hernia repair: a systematic review and meta-analysis.

BACKGROUND: The rate of post-operative urinary retention (POUR) in inguinal hernia repairs (IHR) is estimated to be approximately 5.9% to 38% worldwide. Currently, there are minimal studies on the prophylaxis of POUR after IHR. Pre-operative administration of alpha-blockers such as (but not limited to) Tamsulosin, Prazosin and Alfuzosin has shown promising results in the prevention of POUR in patients undergoing IHR. This study aims to determine the effectiveness of prophylactic alpha-blockade in the prevention of POUR after IHR. METHODS: This study reports the findings of a systematic review and meta-analysis. Randomised controlled trials (RCTs) using prophylactic alpha-blockade for the prevention of POUR after open and/or laparoscopic IHR in patients aged more than 18 years in all sex groups were included. Multiple databases were searched from inception to October 2021 using the PRISMA flow diagram. Data were extracted and analysed to include eligibility criteria, comparator, intervention, study and participant characteristics. Studies excluded were non-RCT studies and patients with known urinary tract disorders such as benign prostate hypertrophy, urinary incontinence and cancer of the bladder or prostate. Subgroup analyses were also conducted. All effect measures of each data were odds ratio with 95% confidence interval. All studies were pooled using the dichotomous random effects Mantel-Haenszel statistical mode and I2 was used to assess heterogeneity. Publication bias was detected using the Cochrane risk-of-bias tool for randomised trials (RoB-2) involving two independent reviewers. RESULTS: A total of eight RCTs were identified which provided adequate numeric data for incorporation into the meta-analysis. Overall, administration of pre-operative alpha-blocker prior to IHR did not prevent POUR (95% CI 1.20 (0.96-1.49), I2: 34%). Subgroup analysis comparing pre-operative use of prophylactic alpha-blocker in open versus laparoscopic IHR has shown statistically significant reduction of POUR prevention in the laparoscopic group (95% CI 0.66 (0.47-0.92)), I2: 43%). The older age group benefited from pre-operative alpha-blocker use with reduced incidence of POUR post-IHR (95% CI 0.14 (0.08, 0.23), I2: 0%)). Gender did not affect the difference of incidence of POUR post-IHR despite pre-operative alpha-blockers (95% CI 0.62 (0.27, 1.44)), I2: 53%)). CONCLUSION: Overall, this meta-analysis has shown that administration of prophylactic alpha-blockers did not prevent POUR. However, there was statistically significant reduction of POUR in patients undergoing laparoscopic IHR as compared to open, as well as in older patients (age more than 60 years) after administration of pre-operative alpha-blocker. Hence, the use of pre-operative alpha-blocker especially in older patients should be considered and more RCTs should be undertaken.

Quantitative and depth-resolved deep level defect distributions in InGaN/GaN light emitting diodes.

Deep level defects in the multi-quantum well (MQW) region of InGaN/GaN light emitting diodes (LEDs) were investigated. InGaN quantum well and GaN quantum barrier defect states were distinguished using bias-dependent steady-state photocapacitance and deep level optical spectroscopy, and their possible physical origin and potential impact on LED performance is considered. Lighted capacitance-voltage measurements provided quantitative and nanoscale depth profiling of the deep level concentration within the MQW region. The concentration of every observed deep level varied strongly with depth in the MQW region, which indicates evolving mechanisms for defect incorporation during MQW growth.

Quantitative and depth-resolved deep level defect distributions in InGaN/GaN light emitting diodes.

Deep level defects in the multi-quantum well (MQW) region of InGaN/GaN light emitting diodes (LEDs) were investigated. InGaN quantum well and GaN quantum barrier defect states were distinguished using bias-dependent steady-state photocapacitance and deep level optical spectroscopy, and their possible physical origin and potential impact on LED performance is considered. Lighted capacitance-voltage measurements provided quantitative and nanoscale depth profiling of the deep level concentration within the MQW region. The concentration of every observed deep level varied strongly with depth in the MQW region, which indicates evolving mechanisms for defect incorporation during MQW growth.

Shifting effects in randomised controlled trials of complex interventions: a new kind of performance bias?

OBJECTIVE: Randomised controlled trials (RCTs) aim to provide unbiased estimates of treatment effects. However, the process of implementing trial procedures may have an impact on the performance of complex interventions that rely strongly on the intuition and confidence of therapists. We aimed to examine whether shifting effects over the recruitment period can be observed that might indicate such impact. METHOD: Three RCTs investigating music therapy vs. standard care were included. The intervention was performed by experienced therapists and based on established methods. We examined outcomes of participants graphically, analysed cumulative effects and tested for differences between first vs. later participants. We tested for potential confounding population shifts through multiple regression models. RESULTS: Cumulative differences suggested trends over the recruitment period. Effect sizes tended to be less favourable among the first participants than later participants. In one study, effects even changed direction. Age, gender and baseline severity did not account for these shifting effects. CONCLUSION: Some trials of complex interventions have shifting effects over the recruitment period that cannot be explained by therapist experience or shifting demographics. Replication and further research should aim to find out which interventions and trial designs are most vulnerable to this new kind of performance bias.

Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy.

STUDY PURPOSE: The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. METHODS: The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. RESULTS: Not applicable. CONCLUSION: DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).