Suicide risk assessment in the emergency department: Are there any tools in the pipeline?

Background

It is estimated that as many as 1 in 10 individuals who complete suicide had been seen in emergency departments within the prior 2 months. However, very little evidence underlies the current recommendations on managing patients with suicidal ideation presenting to the emergency department. The American College of Emergency Physicians (ACEP) and Veterans Affairs/Department of Defense (VA/DoD) have developed clinical practice guidelines for the screening and treatment of patients with suicidal ideation who present to emergency departments. In this study we investigated the extent to which new and ongoing studies are being conducted to address the current limitations in suicide screening in emergency departments.

Umbilical venous blood pH: a useful aid in the diagnosis of asphyxia at birth.

Umbilical venous blood, and umbilical arterial blood pH, PO2, PCO2, and base excess were determined in 453 term infants at birth. The results indicate that umbilical venous blood pH, and umbilical arterial blood pH are significantly related to each another. Acidosis, as defined by an umbilical venous blood pH less than 7 X 27, is associated with a lower PO2, a raised PCO2, and a reduced buffer base when compared with PO2, PCO2, and buffer base associated with a normal pH (7 X 27-7 X 42), or alkalosis (pH greater than 7 X 42). The infant''s condition at birth was recorded using modified Apgar scores, in which the gradings were vigorous (5-6), intermediate (3-4), or depressed (0-2). In the neonatal period, neurological abnormalities occurred in infants who had been in a depressed condition at birth in the presence of acidosis. Other infants, who had been in a depressed condition with a normal pH or alkalosis and the remaining infants who had an intermediate or a vigorous condition at birth, did not manifest neurological abnormalities in the neonatal period. Our findings suggest that measurement of umbilical venous blood pH, whose values correlate well with those of umbilical arterial blood pH, in infants who are in a depressed condition at birth improves the clinical assessment of the severity of asphyxia.     

Dosimetric considerations for validation of a sequential IMRT process with a commercial treatment planning system

Commercial multileaf collimator (MLC) systems can employ leaves with rounded ends. Treatment planning beam modelling should consider the effects of transmission through rounded leaf ends to provide accurate dosimetry for IMRT treatments delivered with segmented MLC. We determined that an MLC leaf gap reduction of 1.4 mm is required to obtain an agreement between calculated and measured profile 50% dose points. A head and neck dosimetry phantom, supplied by the Radiological Physics Center (RPC), was planned and irradiated as a necessary credentialing requirement for the RTOG H-0022 protocol. The agreement between the RPC TLD measurements and treatment planning calculations was within experimental error for the primary and secondary planning target volumes (PTVs); however, the calculated mean dose for the critical structure was approximately 9% lower than the RPC TLD measurements. RPC radiochromic film profile measurements also indicated significant discrepancies (>5%) with calculated values especially in the high dose gradient region in the vicinity of the critical structure. These results substantiate our own in-house phantom measurements, performed with the same IMRT fields as for the RPC phantom experiment, using Kodak EDR2 film to measure absolute dose. Our results indicate a maximum underestimate of calculated dose of 12% with no leaf gap reduction. The discrepancy between measured and calculated phantom values is reduced to +/- 5% when a leaf gap reduction of 1.4 mm is used. A further improvement in the accuracy of dose calculation is not possible without a more accurate modelling of the leaf end transmission by the planning system. In the absence of published dosimetric criteria for IMRT our results stress the need for stringent in-house dosimetric QA and validation for IMRT treatments. We found the dosimetric validation service provided by the RPC to be a valuable component of our IMRT validation efforts.     

An unusual appearance of renal lymphoma

The kidney is a relatively common site of extranodal involvement by lymphoma and various patterns have been documented (Richmond et al., 1962). We describe a patient in whom renal involvement by non-Hodgkin's lymphoma produced unusual appearances on ultrasound and computed tomography (CT). The possible causes and relevance of these findings are discussed.     

Factors Associated with Incarceration in Older Adults Experiencing Homelessness: Results from the HOPE HOME Study

BackgroundIn the US, the median age of adults experiencing homelessness and incarceration is increasing. Little is known about risk factors for incarceration among older adults experiencing homelessness. To develop targeted interventions, there is a need to understand their risk factors for incarceration.ObjectiveTo examine the prevalence and risk factors associated with incarceration in a cohort of older adults experiencing homelessness.DesignProspective, longitudinal cohort study with interviews every 6 months for a median of 5.8 years.ParticipantsWe recruited adults ≥50 years old and homeless at baseline (n=433) via population-based sampling.Main MeasuresOur dependent variable was incident incarceration, defined as one night in jail or prison per 6-month follow-up period after study enrollment. Independent variables included socioeconomic status, social, health, housing, and prior criminal justice involvement.Key ResultsParticipants had a median age of 58 years and were predominantly men (75%) and Black (80%). Seventy percent had at least one chronic medical condition, 12% reported heavy drinking, and 38% endorsed moderate-severe use of cocaine, 8% of amphetamines, and 7% of opioids. At baseline, 84% reported a lifetime history of jail stays; 37% reported prior prison stays. During follow-up, 23% spent time in jail or prison. In multivariable models, factors associated with a higher risk of incarceration included the following: having 6 or more confidants (HR=2.13, 95% CI=1.2–3.7, p=0.007), remaining homeless (HR=1.72, 95% CI=1.1–2.8, p=0.02), heavy drinking (HR=2.05, 95% CI=1.4–3.0, p<0.001), moderate-severe amphetamine use (HR=1.89, 95% CI=1.2–3.0, p=0.006), and being on probation (HR=3.61, 95% CI=2.4–5.4, p<0.001) or parole (HR=3.02, 95% CI=1.5–5.9, p=0.001).ConclusionsOlder adults experiencing homelessness have a high risk of incarceration. There is a need for targeted interventions addressing substance use, homelessness, and reforming parole and probation in order to abate the high ongoing risk of incarceration among older adults experiencing homelessness.KEY WORDS: incarceration, homelessness, vulnerable populations     

Issues in measuring change in motor function in children with cerebral palsy: a special communication

Assessing clinical change in motor function in children with cerebral palsy is a complex measurement task. Whereas a variety of methods have been developed to quantify specific aspects of gross motor behavior (eg, gait analysis, electrophysiological tests, energy-consumption techniques), systematic measurement of overall gross motor function is a more difficult problem. This special communication reviews the structural and performance characteristics required of a well-developed, valid, and responsive clinically based evaluative measure. We discuss several recent approaches used to assess responsiveness and critically examine clinical measures used in randomized controlled trials of physical therapy for children with cerebral palsy. It is argued that the creation and validation of responsive evaluative measures is essential if we are to assess accurately whether our treatments do more good than harm.     

Comparative study of three prostaglandin analogues in the treatment of newly diagnosed cases of ocular hypertension,open‐angle and normal tension glaucoma

Background: To compare the efficacy and tolerance of three prostaglandin analogues, bimatoprost, latanoprost and travoprost in patients with previously untreated open‐angle glaucoma and ocular hypertension. Methods: Prospective randomized single (investigator) masked comparative clinical trial at the Taunton and Somerset NHS Hospital, Taunton, UK. Newly diagnosed, treatment naïve glaucoma/ocular hypertension patients were recruited. Patients were randomized into three groups to receive one of the three prostaglandin analogues. Intraocular pressure (IOP) was measured before starting treatment and after 2 and 6 months of treatment. The IOP reduction and the tolerance profile of each drug were compared. The data were analysed on the basis of intention to treat, using analysis of covariance comparing IOP in the three groups at 2 and 6 months, adjusting for baseline IOP. Tolerance levels were compared using Kruskal–Wallis test. Results: Of the 122 patients, 40 patients were given bimatoprost, 42 received latanoprost and 40 had travoprost. At 2 months, there was a significant difference between the three treatment groups (P = 0.013) with bimatoprost achieving a greater reduction in IOP than the other two drops. However, at 6 months, the difference was not statistically significant (P = 0.13). There was no significant difference in the tolerance profile. Conclusion: All the three topical prostaglandin analogues are effective at lowering IOP, but bimatoprost was found to be most effective in the initial phase of the trial, and there was no statistically significant difference in the efficacy, among the three prostaglandin analogue eye drops after 6 months of treatment.