Introduction to project ECHO (extension for community heathcare outcomes)

Introduction:

Nationally and internationally, there is a gap between the need and availability of child mental health services. This gap stems from a lack of trained specialists, workforce misdistribution, variations in insurance and financing, and family concerns about the benefits of existing services. Of the possible solutions to these problems, expansion of the child mental health capacity of primary care providers (PCPs) has been proposed as a feasible and scalable approach. The Extension for Community Healthcare Outcomes (ECHO) model was originally conceived and executed by Dr. Sanjeev Arora at the University of New Mexico for Hepatitis C. It serves to de-monopolize medical expertise by extending knowledge from specialists to PCPs

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

KKI-NECT: Kennedy krieger institute’s network for early childhood tele-education (US)

Introduction

The Kennedy Krieger Institute Network for Early Childhood Tele-Education (KKI-NECT) is a federally funded ECHO project. Its hub consists of a child psychiatrist, developmental pediatricians and a behavioral psychologist. Its community partners are primary care providers(PCPs) in underserved areas. Its goal is to create local experts in early childhood behavioral, emotional and developmental disorders.

Objectives

After attendance at this session, the learner will be able to: 1. report the rates of co-occurring developmental, behavioral and emotional disorders presented by primary care participants 2. explain the efficacy of case based learning and a structured curriculum as a mechanism for expanding the workforce. The goal of this presentation is to build awareness of and interest in ECHOs specifically targeted to child behavioral, emotional and developmental issues.

Methods

Dr. Leppert will discuss KKI-NECT, particularly the process of procuring funding, setting up an ECHO, and getting institutional “buy-in". She will describe the use of case based learning and a structured curriculum in a longitudinal CME program, report the comorbidities in cases that participants present for discussion, and demonstrate the impact on participants’ practice.

Results

Data from four cohorts demonstrate that PCPs showed increased comfort levels, improved knowledge of behavioral, emotional and developmental disorders. PCPs expanded the scope issues they could address in their practice as a result of participation in KKI-NECT.

Conclusion

KKI-NECT is a viable response to the workforce shortage of child psychiatrists by confidently increasing the role of the PCP in treating childhood developmental and mental health disorders.

Disclosure

No significant relationships.

Snaps of a tiny amphipod push the boundary of ultrafast, repeatable movement

Surprisingly, the fastest motions are not produced by large animals or robots. Rather, small organisms or structures, including cnidarian stinging cells, fungal shooting spores, and mandible strikes of ants, termites, and spiders, hold the world acceleration records.^1-5 These diverse systems share common features: they rapidly convert potential energy - stored in deformed material or fluid - into kinetic energy when a latch is released.^4-6 However, the fastest of these are not repeatable, because mechanical components are broken or ejected.^5,6 Furthermore, some of these systems must overcome the added challenge of moving in water, where high density and viscosity constrain acceleration at small sizes. Here we report the kinematics of repeatable, ultrafast snaps by tiny marine amphipods (Dulichiella cf. appendiculata). Males use their enlarged major claw, which can exceed 30% of body mass, to snap a 1 mm-long dactyl with a diameter equivalent to a human hair (184 μm). The claw snaps closed extremely rapidly, averaging 93 μs, 17 m s^-1, and 2.4 x 10⁵ m s^-2. These snaps are among the smallest and fastest of any documented repeatable movement, and are sufficiently fast to operate in the inertial hydrodynamic regime (Reynolds number (Re) >10,000). They generate audible pops and rapid water jets, which occasionally yield cavitation, and may be used for defense. These amphipod snaps push the boundaries of acceleration and size for repeatable movements, particularly in water, and exemplify how new biomechanical insights can arise from unassuming animals. VIDEO ABSTRACT.

Verification and Validation of Digital Pathology (Whole Slide Imaging) for Primary Histopathological Diagnosis: All Wales Experience

Aims:

The study is aimed to verify Aperio AT2 scanner for reporting on the digital pathology platform (DP) and to validate the cohort of pathologists in the interpretation of DP for routine diagnostic histopathological services in Wales, United Kingdom.

Materials, Methods and Results:

This was a large multicenter study involving seven hospitals across Wales and unique with 22 (largest number) pathologists participating. 7491 slides from 3001 cases were scanned on Leica Aperio AT2 scanner and reported on digital workstations with Leica software of e-slide manager. A senior pathology fellow compared DP reports with authorized reports on glass slide (GS). A panel of expert pathologists reviewed the discrepant cases under multiheader microscope to establish ground truth. 2745 out of 3001 (91%) cases showed complete concordance between DP and GS reports. Two hundred and fifty-six cases showed discrepancies in diagnosis, of which 170 (5.6%) were deemed of no clinical significance by the review panel. There were 86 (2.9%) clinically significant discrepancies in the diagnosis between DP and GS. The concordance was raised to 97.1% after discounting clinically insignificant discrepancies. Ground truth lay with DP in 28 out of 86 clinically significant discrepancies and with GS in 58 cases. Sensitivity of DP was 98.07% (confidence interval [CI] 97.57–98.56%); for GS was 99.07% (CI 98.72–99.41%).

Conclusions:

We concluded that Leica Aperio AT2 scanner produces adequate quality of images for routine histopathologic diagnosis. Pathologists were able to diagnose in DP with good concordance as with GS.

Strengths and Limitations of this Study:

Strengths of this study – This was a prospective blind study. Different pathologists reported digital and glass arms at different times giving an ambience of real-time reporting. There was standardized use of software and hardware across Wales. A strong managerial support from efficiency through the technology group was a key factor for the implementation of the study.

Limitations:

This study did not include Cytopathology and in situ hybridization slides. Difficulty in achieving surgical pathology practise standardization across the whole country contributed to intra-observer variations.

Risk Factors for Relapsing Remitting Multiple Sclerosis

Relapsing remitting is the most common type of multiple sclerosis, affecting approximately 85% of all patients. Previous evidence has suggested that the risk factors for developing relapsing remitting multiple sclerosis is multifactorial. Similarly, it has been suggested that these factors also influence the risk of relapse. This article critically appraises and evaluates a systematic review that examined multiple factors associated with the risk of relapse for relapsing remitting multiple sclerosis.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background

Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs).

Objectives

To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone.

Methods

This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At‐risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) – pooled as the treatment group – and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites.

Results

In the intention‐to‐treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41–0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35–0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34–1·68, P = 0·49).

Conclusions

Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at‐risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

What is already known about this topic?

The incidence of hospital‐acquired pressure ulcers (PUs) remains high despite the implementation of best‐practice recommendations.

The concept of using silicone foam dressings as an additional prophylactic strategy in PU prevention has been investigated in previous studies but with some limitations.

Most RCTs were monocentric studies, restricted to either critically ill or acute care patients and did not observe more than two anatomical at‐risk skin sites, which limited the generalizability of the findings.

What does this study add?

This large pragmatic RCT suggests that it is beneficial to use silicone adhesive multilayer foam dressings on the sacrum, in addition to standard of care, to help prevent hospital‐acquired PUs.

Clinical decision making for heel dressings should be based on the clinical effectiveness of the intervention weighed against the potential risk of falling.

Linked Comment: F. Coyer. Br J Dermatol 2021; 185:4–5.

Adopting evidence-based guidelines for acute stroke care: barriers and enablers for health professionals

An evidence summary based on the systematic review: Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implement Sci. 2017;12:74. 10.1186/s13012-017-0599-3

Evidence-based practice is the keystone of clinical practice, policy and management. Despite this, a knowledge-to-practice gap still exists, and it is estimated to take 17 years for evidence to be translated into clinical practice. The reasons for slow translation in acute stroke care are not completely understood.

Filament identification in wide-angle high speed imaging of the mega amp spherical tokamak

A new tomographic inversion technique is presented for the identification of plasma filaments in wide-angle visible camera data. The technique works on the assumption that background subtracted images of filaments can be represented as a superposition of uniformly emitting magnetic equilibrium field lines. A large collection of equilibrium magnetic field lines is traced and projected onto the camera field of view and combined to form a geometry matrix describing the coordinate transformation from magnetic field aligned coordinates to image pixel coordinates. Inverting this matrix enables the reprojection of the emission in the camera images onto a field aligned basis, from which filaments are readily identifiable. The inversion is a poorly conditioned problem which is overcome using a least-squares approach with Laplacian regularization. Blobs are identified using the "watershed" algorithm and 2D Gaussians are fitted to get the positions, widths, and amplitudes of the filaments. A synthetic camera diagnostic generating images containing experimentally representative filaments is utilized to rigorously benchmark the accuracy and reliability of the technique. 74% of synthetic filaments above the detection amplitude threshold are successfully detected, with 98.8% of detected filaments being true positives. The accuracy with which filament properties and their probability density functions are recovered is discussed, along with sources of error and methods to minimize them.

Impact of Puberty and Age on Adolescent Inhibition Over Time

Objective

We measured how puberty impacted inhibition over three years. We hypothesized that age and puberty development would predict inhibition at each time point. Results revealed differential effects of puberty and age over time.

Method

Participants from Southern Idaho were 245 adolescents at Time 1 (T1) (M = 10.4, SD = 1.5, 50% female, 64% Caucasian), 196 adolescents at Time 2 (T2) (M = 11.8, SD = 1.5, 50% female, 81% Caucasian), and 87 adolescents at Time 3 (T3) (M = 13, SD = 1.5, 56% female, 82% Caucasian). Participants completed a physical exam with a registered nurse, which included the Tanner Scale (Apter & Hermanson, 2002; Tinggaard et. al., 2012) and the Puberty Development Scale (Petersen et al., 1988). Inhibition was assessed using stop-signal reaction time (SSRT) within the Stop-it Task (Logan, Cowan, & Davis, 1984).

Results

Using structural equation modeling, for T1, the overall model demonstrated a good fit, χ2(3) = 1.23, p = .75, RMSEA = .00, CFI = 1.00, TLI = 1.04. Puberty significantly predicted inhibition (β = -.21, p < .05), i.e., higher puberty scores predicted stronger inhibition. However, age was not a significant predictor. At T2, the model demonstrated a good fit, χ2(7) = 7.77, p = .35, RMSEA = .03, CFI = 1.00, TLI = .99. Age significantly predicted inhibition (β=-.39, p < .001). However, puberty was not a significant predictor. In T3, neither age nor puberty predicted inhibition.

Conclusions

Our results indicate that early adolescent increases in inhibition may be due to puberty development rather than age. As one ages, puberty has less effect, and chronological age becomes more significant. Finally, in mid-adolescence, neither age nor puberty significantly affects inhibition. These findings highlight the changing effects of age and puberty on inhibitory control across adolescence.

The digital mirror Langmuir probe: Field programmable gate array implementation of real-time Langmuir probe biasing

High bandwidth, high spatial resolution measurements of electron temperature, density, and plasma potential are valuable for resolving turbulence in the boundary plasma of tokamaks. While conventional Langmuir probes can provide such measurements, either their temporal or spatial resolution is limited: the former by the sweep rate necessary for obtaining I-V characteristics and the latter by the need to use multiple electrodes, as is the case in triple and double probe configurations. The Mirror Langmuir Probe (MLP) bias technique overcomes these limitations by rapidly switching the voltage on a single electrode cycling between three bias states, each dynamically optimized for the local plasma conditions. The MLP system on Alcator C-Mod used analog circuitry to perform this function, measuring T_e, V_F, and I_sat at 1.1 MSPS. Recently, a new prototype digital MLP controller has been implemented on a Red Pitaya Field Programmable Gate Array (FPGA) board which reproduces the functionality of the original controller and performs all data acquisition. There is also the potential to provide the plasma parameters externally for use with feedback control systems. The use of FPGA technology means the system is readily customizable at a fraction of the development time and implementation cost. A second Red Pitaya was used to test the MLP by simulating the current response of a physical probe using C-Mod experimental measurements. This project is available as a git repository to facilitate extensibility (e.g., real-time control outputs and more voltage states) and scalability through collaboration.