Publications by authors named "Mary Joyce"

36 Publications

Fugitive aerosols in the intensive care unit: a narrative review.

Ann Transl Med 2021 Apr;9(7):592

Aerogen, IDA Business Park, Dangan, Galway, Ireland.

The risk of unintended inhalation of fugitive aerosols is becoming a topic of increasing interest in the healthcare arena. These fugitive aerosols may be bioaerosols, generated by the patient themselves through cough or sneeze, or they may be therapeutic medical aerosols, generated by therapeutic medical aerosol generators with the intent of delivery to a specific patient's respiratory tract. This review focus' on therapeutic aerosols in the intensive care unit (ICU) only, those typically generated by nebulisers. In the intensive care environment, patients are generally in receipt of ventilatory support, and the literature suggests that these different support interventions influence fugitive therapeutic medical aerosol emissions in a variety of ways. Predominant ventilatory support interventions include, but are not limited to, invasive mechanical ventilation (MV), non-invasive mechanical ventilation (NIV), high flow nasal therapy (HFNT), and supplemental oxygen delivery in spontaneously breathing patients. Further, factors such as nebuliser type, patient interface, patient breathing pattern, nebuliser position in the patient breathing circuit and medication formulation characteristics also have been shown to exert influence on aerosol concentrations and distance from the source. Here we present the state of the art knowledge in this, as yet, poorly described field of research, and identify the key risks, and subsequently, opportunities to mitigate the risks of unintended exposure of both patients and bystanders during and for periods following the administration of therapeutic aerosols.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/atm-20-2280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105852PMC
April 2021

Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis.

Antibiotics (Basel) 2021 Apr 21;10(5). Epub 2021 Apr 21.

Research and Development, Science and Emerging Technologies, Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland.

Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/antibiotics10050472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142975PMC
April 2021

In vitro evaluation of disposable transport ventilators with combination aerosol therapy.

BMJ Open Respir Res 2021 Mar;8(1)

R&D Science and Emerging Technologies, Aerogen Ltd, Galway, Ireland

Background: The COVID-19 pandemic has highlighted the need for alternative short-term, reliable means to aid in the treatment of patients requiring ventilatory support. Concurrent aerosol drug delivery is often prescribed to such patients. As such, this study examines one such short-term option, the disposable gas-powered transport ventilator to effectively deliver aerosol therapy. Factors such as aerosol generator type, patient breathing pattern, humidification and nebuliser position within the respiratory circuit were also examined.

Methods: Aerosol drug delivery characterisation was undertaken using two different disposable transport ventilators (DTVs). Two different nebuliser types, a closed circuit vibrating mesh nebuliser (VMN) and an open circuit jet nebuliser (JN), at different locations in a respiratory circuit, proximal and distal to an endotracheal tube (ETT), with and without passive humidification, were evaluated in simulated adult and paediatric patients.

Results: Placement of a nebuliser proximal to the ETT (VMN: 25.19%-34.15% and JN: 3.14%-8.92%), and the addition of a heat and moisture exchange filter (VMN: 32.37%-40.43% and JN: 5.60%-9.91%) resulted in the largest potential lung dose in the adult patient model. Irrespective of nebuliser position and humidification in the respiratory circuit, use of the VMN resulted in the largest potential lung dose (%). A similar trend was recorded in the paediatric model data, where the largest potential lung dose was recorded with both nebuliser types placed proximal to the ETT (VMN: 8.12%-10.89% and JN: 2.15%-3.82%). However, the addition of a heat and moisture exchange filter had no statistically significant effect on the potential lung dose (%) a paediatric patient would receive (p>0.05).

Conclusions: This study demonstrates that transport ventilators, such as DTVs, can be used concurrently with aerosol generators to effectively deliver aerosolised medication in both adult and paediatric patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjresp-2020-000739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006849PMC
March 2021

Dialectical behaviour therapy: Implementation of an evidence-based intervention for borderline personality disorder in public health systems.

Curr Opin Psychol 2021 Feb 7;37:152-157. Epub 2021 Jan 7.

National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland. Electronic address:

Dialectical behaviour therapy (DBT) is an intervention with demonstrated efficacy and effectiveness for individuals with borderline personality disorder. In recent years, research has shifted focus to the evaluation of DBT implementation in routine clinical settings. In this article, we consider the empirical evidence that guides clinicians and managers in health services with local implementation of DBT in community settings. Research on this topic has most recently advanced to the evaluation of coordinated implementation efforts. Although coordinated implementation has merit, it does not mitigate all implementation challenges. Consideration of implementation facilitators and barriers in DBT can also be applied to other evidence-based interventions for BPD and for adaptations for individuals with early-stage symptomatology. Ongoing research and evaluation in these areas is recommended.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.copsyc.2021.01.002DOI Listing
February 2021

Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation.

Pharmaceutics 2021 Feb 2;13(2). Epub 2021 Feb 2.

Aerogen Limited, Galway Business Park, H91 HE94 Galway, Ireland.

COVID-19 may lead to serious respiratory complications which may necessitate ventilatory support. There is concern surrounding potential release of patient-derived bioaerosol during nebuliser drug refill, which could impact the health of caregivers. Consequently, mesh nebulisers have been recommended by various clinical practice guidelines. Currently, there is a lack of empirical data describing the potential for release of patient-derived bioaerosol during drug refill. This study examined the release of simulated patient-derived bioaerosol, and the effect on positive end expiratory pressure during nebuliser refill during mechanical ventilation of a simulated patient. During jet nebuliser refill, the positive end expiratory pressure decreased from 4.5 to 0 cm HO. No loss in pressure was noted during vibrating mesh nebuliser refill. A median particle number concentration of 710 particles cm above ambient was detected when refilling the jet nebuliser in comparison to no increase above ambient detected when using the vibrating mesh nebuliser. The jet nebuliser with the endotracheal tube clamped resulted in 60 particles cm above ambient levels. This study confirms that choice of nebuliser impacts both the potential for patient-derived bioaerosol release and the ability to maintain ventilator circuit pressures and validates the recommended use of mesh nebulisers during mechanical ventilation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/pharmaceutics13020199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912998PMC
February 2021

Distribution of Droplets and Immune Responses After Aerosol and Intra-Nasal Delivery of Influenza Virus to the Respiratory Tract of Pigs.

Front Immunol 2020 27;11:594470. Epub 2020 Oct 27.

Department of Enhanced Host Responses, The Pirbright Institute, Pirbright, United Kingdom.

Recent evidence indicates that local immune responses and tissue resident memory T cells (T) are critical for protection against respiratory infections but there is little information on the contributions of upper and lower respiratory tract (URT and LRT) immunity. To provide a rational basis for designing methods for optimal delivery of vaccines to the respiratory tract in a large animal model, we investigated the distribution of droplets generated by a mucosal atomization device (MAD) and two vibrating mesh nebulizers (VMNs) and the immune responses induced by delivery of influenza virus by MAD in pigs. We showed that droplets containing the drug albuterol, a radiolabel (Tc-DTPA), or a model influenza virus vaccine (S-FLU) have similar aerosol characteristics. Tc-DTPA scintigraphy showed that VMNs deliver droplets with uniform distribution throughout the lungs as well as the URT. Surprisingly MAD administration (1ml/nostril) also delivered a high proportion of the dose to the lungs, albeit concentrated in a small area. After MAD administration of influenza virus, antigen specific T cells were found at high frequency in nasal turbinates, trachea, broncho-alveolar lavage, lungs, tracheobronchial nodes, and blood. Anti-influenza antibodies were detected in serum, BAL and nasal swabs. We conclude that the pig is useful for investigating optimal targeting of vaccines to the respiratory tract.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fimmu.2020.594470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653178PMC
October 2020

Distribution of Droplets and Immune Responses After Aerosol and Intra-Nasal Delivery of Influenza Virus to the Respiratory Tract of Pigs.

Front Immunol 2020 27;11:594470. Epub 2020 Oct 27.

Department of Enhanced Host Responses, The Pirbright Institute, Pirbright, United Kingdom.

Recent evidence indicates that local immune responses and tissue resident memory T cells (T) are critical for protection against respiratory infections but there is little information on the contributions of upper and lower respiratory tract (URT and LRT) immunity. To provide a rational basis for designing methods for optimal delivery of vaccines to the respiratory tract in a large animal model, we investigated the distribution of droplets generated by a mucosal atomization device (MAD) and two vibrating mesh nebulizers (VMNs) and the immune responses induced by delivery of influenza virus by MAD in pigs. We showed that droplets containing the drug albuterol, a radiolabel (Tc-DTPA), or a model influenza virus vaccine (S-FLU) have similar aerosol characteristics. Tc-DTPA scintigraphy showed that VMNs deliver droplets with uniform distribution throughout the lungs as well as the URT. Surprisingly MAD administration (1ml/nostril) also delivered a high proportion of the dose to the lungs, albeit concentrated in a small area. After MAD administration of influenza virus, antigen specific T cells were found at high frequency in nasal turbinates, trachea, broncho-alveolar lavage, lungs, tracheobronchial nodes, and blood. Anti-influenza antibodies were detected in serum, BAL and nasal swabs. We conclude that the pig is useful for investigating optimal targeting of vaccines to the respiratory tract.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fimmu.2020.594470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653178PMC
October 2020

Serial Prefrontal Pathways Are Positioned to Balance Cognition and Emotion in Primates.

J Neurosci 2020 10 28;40(43):8306-8328. Epub 2020 Sep 28.

Neural Systems Laboratory, Department of Health Sciences, Boston University, Boston, Massachusetts 02215

The delicate balance among primate prefrontal networks is necessary for homeostasis and behavioral flexibility. Dorsolateral prefrontal cortex (dlPFC) is associated with cognition, while the most ventromedial subgenual cingulate area 25 (A25) is associated with emotion and emotional expression. Yet A25 is weakly connected with dlPFC, and it is unknown how the two regions communicate. In rhesus monkeys of both sexes, we investigated how these functionally distinct areas may interact through pregenual anterior cingulate area 32 (A32), which is strongly connected with both. We found that dlPFC innervated the deep layers of A32, while A32 innervated all layers of A25, mostly targeting spines of excitatory neurons. Approximately 20% of A32 terminations formed synapses on inhibitory neurons in A25, notably the powerful parvalbumin inhibitory neurons in the deep layers, and the disinhibitory calretinin neurons in the superficial layers. By innervating distinct inhibitory microenvironments in laminar compartments, A32 is positioned to tune activity in columns of A25. The circuitry of the sequential pathway indicates that when dlPFC is engaged, A32 can dampen A25 output through the parvalbumin inhibitory microsystem in the deep layers of A25. A32 thus may flexibly recruit or reduce activity in A25 to maintain emotional equilibrium, a process that is disrupted in depression. Moreover, pyramidal neurons in A25 had a heightened density of NMDARs, which are the targets of novel rapid-acting antidepressants. Pharmacologic antagonism of NMDARs in patients with depression may reduce excitability in A25, mimicking the effects of the neurotypical serial pathway identified here. The anterior cingulate is a critical hub in prefrontal networks through connections with functionally distinct areas. Dorsolateral and polar prefrontal areas that are associated with complex cognition are connected with the anterior cingulate in a pattern that allows them to indirectly control downstream activity from the anterior cingulate to the subgenual cingulate, which is associated with heightened activity and negative affect in depression. This set of pathways provides a circuit mechanism for emotional regulation, with the anterior cingulate playing a balancing role for integration of cognitive and emotional processes. Disruption of these pathways may perturb network function and the ability to regulate cognitive and affective processes based on context.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1523/JNEUROSCI.0860-20.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577604PMC
October 2020

Dialectical behaviour therapy for adolescents: a comparison of 16-week and 24-week programmes delivered in a public community setting.

Child Adolesc Ment Health 2019 Sep 28;24(3):266-273. Epub 2019 Feb 28.

National Suicide Research Foundation, University College Cork, Cork, Ireland.

Background: Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. Previous studies have reported on varying lengths of treatment, however, and optimal treatment duration has not yet been identified. While the treatment developers initially proposed a 16-week programme, they have more recently recommended an extension to 24 weeks. This study compares outcomes for adolescents and parent/guardians who participated in 16- and 24-week DBT-A programmes in a community setting.

Methods: Eighty-four adolescents and 100 parent/guardians participated in 16-week DBT-A, while 68 adolescents and 67 parent/guardians participated in the 24-week programme. Outcome measures for adolescents included the presence and frequency of self-harm, suicidal ideation and depression; and for parents were burden, grief and parental stress. Outcomes were assessed at pre- and postintervention. Linear mixed-effects models were used to estimate the treatment duration effect (24-week vs. 16-week) utilising all available data at pre- and postintervention.

Results: Data analyses showed a reduction in the presence and frequency of self-harm at postintervention for adolescents in both programmes. Both adolescent and parent participants in the 16- and 24-week programmes also showed changes indicating significant improvement on all self-report outcome measures (p < .05). A treatment duration effect was identified with adolescents in the 24-week programme reporting greater gains on measures of suicidal ideation and depression (p < .05). However, drop-out rates were higher for the 24-week programme.

Conclusions: The findings of the current study indicate that 24-week DBT-A may have additional benefits in comparison to 16-week DBT-A in terms of further reductions in suicidal ideation and depression. Given the nature of this study, it was not possible to explore a potential time effect, however, so these results should be interpreted with caution. Further research will assist in determining an optimal programme duration of DBT-A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/camh.12325DOI Listing
September 2019

Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach.

BMC Psychiatry 2020 05 14;20(1):235. Epub 2020 May 14.

National Suicide Research Foundation, University College Cork, Western Gateway Building, Cork, Ireland.

Background: The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation.

Methods: A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis.

Results: Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management.

Conclusions: The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service.

Trial Registration: ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12888-020-02610-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227064PMC
May 2020

In Vitro Study of the Effect of Breathing Pattern on Aerosol Delivery During High-Flow Nasal Therapy.

Pulm Ther 2019 Jun 6;5(1):43-54. Epub 2019 Feb 6.

Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland.

Introduction: The use of concurrent aerosol delivery during high-flow nasal therapy (HFNT) may be exploited to facilitate delivery of a variety of prescribed medications for inhalation. The study assessed the effect of tidal volume, breath rate, and inspiratory:expiratory (I:E) ratio on the quantity of aerosol captured at the level of the trachea during simulated HFNT.

Methods: Testing was completed according to a factorial statistical design of experiments (DOE) approach. Tracheal dose was characterized with a vibrating mesh nebulizer (Aerogen Solo, Aerogen Ltd) using simulated adult, small child, and infant HFNT models. Furthermore, aerosol delivery was evaluated across a range of adult patient profiles with clinically representative test setups.

Results: Aerosol delivery increased with a large tidal volume, a rapid breath rate, and a long inspiratory time. Tidal volume, breath rate, and I:E ratio each had a significant effect on tracheal dose across simulated adult, small child, and infant breathing.

Conclusion: The main trends that were identified in the statistical DOE predicted aerosol delivery across adult patient breathing profiles, in terms of tidal volume, breath rate, and I:E ratio. Therefore, patients with distressed breathing profiles may be expected to receive a larger aerosol dose than those with normal breathing rates.

Funding: Aerogen Limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41030-019-0086-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6967176PMC
June 2019

In Vitro Study of the Effect of Breathing Pattern on Aerosol Delivery During High-Flow Nasal Therapy.

Pulm Ther 2019 Jun 6;5(1):43-54. Epub 2019 Feb 6.

Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland.

Introduction: The use of concurrent aerosol delivery during high-flow nasal therapy (HFNT) may be exploited to facilitate delivery of a variety of prescribed medications for inhalation. The study assessed the effect of tidal volume, breath rate, and inspiratory:expiratory (I:E) ratio on the quantity of aerosol captured at the level of the trachea during simulated HFNT.

Methods: Testing was completed according to a factorial statistical design of experiments (DOE) approach. Tracheal dose was characterized with a vibrating mesh nebulizer (Aerogen Solo, Aerogen Ltd) using simulated adult, small child, and infant HFNT models. Furthermore, aerosol delivery was evaluated across a range of adult patient profiles with clinically representative test setups.

Results: Aerosol delivery increased with a large tidal volume, a rapid breath rate, and a long inspiratory time. Tidal volume, breath rate, and I:E ratio each had a significant effect on tracheal dose across simulated adult, small child, and infant breathing.

Conclusion: The main trends that were identified in the statistical DOE predicted aerosol delivery across adult patient breathing profiles, in terms of tidal volume, breath rate, and I:E ratio. Therefore, patients with distressed breathing profiles may be expected to receive a larger aerosol dose than those with normal breathing rates.

Funding: Aerogen Limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41030-019-0086-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6967176PMC
June 2019

In Vitro Study of the Effect of Breathing Pattern on Aerosol Delivery During High-Flow Nasal Therapy.

Pulm Ther 2019 Jun 6;5(1):43-54. Epub 2019 Feb 6.

Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland.

Introduction: The use of concurrent aerosol delivery during high-flow nasal therapy (HFNT) may be exploited to facilitate delivery of a variety of prescribed medications for inhalation. The study assessed the effect of tidal volume, breath rate, and inspiratory:expiratory (I:E) ratio on the quantity of aerosol captured at the level of the trachea during simulated HFNT.

Methods: Testing was completed according to a factorial statistical design of experiments (DOE) approach. Tracheal dose was characterized with a vibrating mesh nebulizer (Aerogen Solo, Aerogen Ltd) using simulated adult, small child, and infant HFNT models. Furthermore, aerosol delivery was evaluated across a range of adult patient profiles with clinically representative test setups.

Results: Aerosol delivery increased with a large tidal volume, a rapid breath rate, and a long inspiratory time. Tidal volume, breath rate, and I:E ratio each had a significant effect on tracheal dose across simulated adult, small child, and infant breathing.

Conclusion: The main trends that were identified in the statistical DOE predicted aerosol delivery across adult patient breathing profiles, in terms of tidal volume, breath rate, and I:E ratio. Therefore, patients with distressed breathing profiles may be expected to receive a larger aerosol dose than those with normal breathing rates.

Funding: Aerogen Limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41030-019-0086-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6967176PMC
June 2019

A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community.

Ir J Med Sci 2020 May 3;189(2):415-423. Epub 2019 Sep 3.

National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.

Background/aims: This paper investigates the cost-effectiveness of dialectical behaviour therapy (DBT) for treating individuals with borderline personality disorder (BPD) in a community setting in Ireland, in the short term.

Methods: Resource utilisation and effectiveness data were collected as part of the National DBT Project, Ireland, and are incorporated into a cost-effectiveness analysis. The perspective taken was that of the service provider and payer. Direct health resources were included and effectiveness was measured using the EQ-5D-5L questionnaire. To examine cost-effectiveness, incremental costs are compared with incremental quality-adjusted life years, to estimate an incremental cost-effectiveness ratio. A probabilistic sensitivity analysis was employed to investigate parameter uncertainty. Scenario analyses are employed to investigate cost-effectiveness of DBT with varying assumptions around effectiveness and costs.

Results: The baseline analysis reveals that DBT is more expensive and more effective than routine clinical care (without DBT). The low incremental cost-effectiveness ratio suggests DBT can be considered cost effective in the short term. In each scenario analyses considered, the probability that DBT is cost effective is greater than 50%.

Conclusions: Mental health care provision, including that of DBT, varies across jurisdictions, necessitating economic evaluations of current practice in community-based services, on a country-by-country basis, to inform resource allocation decisions. In line with previous research, the analysis here indicates DBT can be considered cost effective in the short term. Future data collection on alternative comparators and long-term outcomes associated with DBT is warranted to investigate the longer term cost-effectiveness of DBT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11845-019-02091-8DOI Listing
May 2020

Does an adapted Dialectical Behaviour Therapy skills training programme result in positive outcomes for participants with a dual diagnosis? A mixed methods study.

Addict Sci Clin Pract 2019 08 15;14(1):28. Epub 2019 Aug 15.

Cork Kerry Community Healthcare Addiction Service, Arbour House, St Finbarr's Hospital, Douglas Rd., Cork, Ireland.

Background: Treating severe emotional dysregulation and co-occurring substance misuse is challenging. Dialectical behaviour therapy (DBT) is a comprehensive and evidence-based treatment for borderline personality disorder (BPD). It has been hypothesised that the skills training, which is a facet of the full DBT programme, might be effective for people with severe emotional dysregulation and other co-occurring conditions, but who do not meet the criteria for BPD. However, there is limited research on standalone DBT skills training for people with substance misuse and emotional dysregulation.

Methods: A mixed methods study employing an explanatory sequential design was conducted where participants with a dual diagnosis (n = 64) were recruited from a community-based public addiction treatment service in Ireland between March 2015 and January 2018. DBT therapists screened potential participants against the study eligibility criteria. Quantitative self-report measures examining emotion regulation, mindfulness, adaptive and maladaptive coping responses including substance misuse, and qualitative feedback from participants were collected. Quantitative data were summarised by their mean and standard deviation and multilevel linear mixed effects models were used to estimate the mean change from baseline to post-intervention and the 6-month follow-up period. Thematic analysis was used to analyse the qualitative data.

Results: Quantitative results indicated reductions in binge drinking and use of Class A, B and C drug use from pre-intervention (T1) to the 6-month follow-up (T3). Additionally, significant improvements were noted for mindfulness practice and DBT skills use from T1 to T3 (p < 0.001). There were also significant reductions in dysfunctional coping and emotional dysregulation from T1 to T3 (p < 0.001). Significant differences were identified from pre to post intervention in reported substance use, p = 0.002. However, there were no significant differences between pre-intervention and 6-month follow up reports of substance use or at post-intervention to 6 month follow up. Qualitative findings indicated three superordinate themes in relation to participants' experiences of a DBT skills training programme, adapted from standard DBT: (1) new lease of life; (2) need for continued formal aftercare and (3) programme improvements. Participants described reductions in substance misuse, while having increased confidence to use the DBT skills they had learned in the programme to deal with difficult emotions and life stressors.

Conclusions: This DBT skills training programme, adapted from standard DBT, showed positive results for participants and appears effective in treating people with co-occurring disorders. Qualitative results of this mixed methods study corroborate the quantitative results indicating that the experiences of participants have been positive. The study indicates that a DBT skills programme may provide a useful therapeutic approach to managing co-occurring symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13722-019-0156-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694661PMC
August 2019

Exploring staff perceptions of the utility of clinician connections when working with emotionally dysregulated clients.

Borderline Personal Disord Emot Dysregul 2019 26;6:12. Epub 2019 Jul 26.

3National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.

Background: Borderline personality disorder (BPD) is considered to be a challenging condition for clinicians to treat. Clinicians routinely working with individuals who experience severe emotional dysregulation often do not receive appropriate training and support to work with this client group. This article describes an intervention, Clinician Connections (CC), which was developed to support practitioners who work with individuals with BPD. CC aims to increase practitioner's knowledge of BPD, develop a skillset to work with emotionally dysregulated individuals and enhance practitioner's self-efficacy with regard to working effectively with this client group. The aim of this study is to investigate the perceived utility and acceptability of CC, and identify areas for further development of the intervention.

Method: A seven-hour CC workshop was provided to Emergency Department and community mental health clinicians. Three focus groups were completed following completion of the intervention with 13 clinicians (12 female; 1 male) and were audio recorded. The study utilised a thematic analysis framework.

Results: Six master themes emerged from the focus group data which included 10 subordinate themes. The master themes identified were: the need for training; a new understanding; validation; barriers to applying new skills; overcoming barriers to skill application; and future direction: practical application of skills. Participants reflected on how their new understanding of transactions and their own experiences affects their practice. They also noted improved client interactions and client relationships resulting from the use of validation. While there was an increase in participants' self-efficacy in working with individuals with BPD, a need for further skills and practice was also highlighted.

Conclusion: The evidence presented here suggests that CC is both beneficial and feasible. Qualitative feedback suggests there is a need for further support in the strengthening and generalisation of skills. Suggestions were made by practitioners regarding potential improvements to the delivery of the workshop. Future research could evaluate the changes made to CC and focus on a quantitative approach to quantify the impact of CC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40479-019-0109-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660965PMC
July 2019

Investigation of Fugitive Aerosols Released into the Environment during High-Flow Therapy.

Pharmaceutics 2019 Jun 1;11(6). Epub 2019 Jun 1.

Aerogen, IDA Business Park, Dangan, H91 HE94 Galway, Ireland.

Background: Nebulised medical aerosols are designed to deliver drugs to the lungs to aid in the treatment of respiratory diseases. However, an unintended consequence is the potential for fugitive emissions during patient treatment, which may pose a risk factor in both clinical and homecare settings.

Methods: The current study examined the potential for fugitive emissions, using albuterol sulphate as a tracer aerosol during high-flow therapy. A nasal cannula was connected to a head model or alternatively, a interface was connected to a tracheostomy tube in combination with a simulated adult and paediatric breathing profile. Two aerodynamic particle sizers (APS) recorded time-series aerosol concentrations and size distributions at two different distances relative to the simulated patient.

Results: The results showed that the quantity and characteristics of the fugitive emissions were influenced by the interface type, patient type and supplemental gas-flow rate. There was a trend in the adult scenarios; as the flow rate increased, the fugitive emissions and the mass median aerodynamic diameter (MMAD) of the aerosol both decreased. The fugitive emissions were comparable when using the adult breathing profiles for the nasal cannula and tracheostomy interfaces; however, there was a noticeable distinction between the two interfaces when compared for the paediatric breathing profiles. The highest recorded aerosol concentration was 0.370 ± 0.046 mg m from the tracheostomy interface during simulated paediatric breathing with a gas-flow rate of 20 L/min. The averaged MMAD across all combinations ranged from 1.248 to 1.793 µm by the APS at a distance of 0.8 m away from the patient interface.

Conclusions: Overall, the results highlight the potential for secondary inhalation of fugitive emissions released during simulated aerosol treatment with concurrent high-flow therapy. The findings will help in developing policy and best practice for risk mitigation from fugitive emissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/pharmaceutics11060254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6630289PMC
June 2019

Comparison of aerosol delivery across combinations of drug delivery interfaces with and without concurrent high-flow nasal therapy.

Intensive Care Med Exp 2019 Apr 3;7(1):20. Epub 2019 Apr 3.

Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland.

Background: Current clinical practice during high-flow nasal therapy (HFNT) involves utilization of a nasal cannula to provide humidification, with a facemask placed over the cannula to deliver aerosol. Few studies have compared aerosol delivery across various delivery interfaces during HFNT. The objective of this study was to address this gap in the literature and evaluate aerosol delivery using two nebulizer types across different drug delivery interfaces, nasal cannula, facemask, and mouthpiece, during simulated adult HFNT.

Methods: A facemask or mouthpiece and/or a nasal cannula were positioned on an anatomically correct adult head model. The head model was connected to a breathing simulator via a collection filter. Both healthy breathing pattern and distressed breathing patterns were utilized. Aerosol dose was determined by quantifying the mass of drug captured on a filter positioned distal to the trachea.

Results: During simulated healthy breathing, a significantly greater aerosol dose was observed when the vibrating mesh nebulizer (VMN) was integrated with HFNT alone, supplying aerosol and humidified air simultaneously (2.88 ± 0.15%), as opposed to using with a facemask (0.33 ± 0.07%, 1.62 ± 0.46%, and 1.07 ± 0.25% at 0 L/min (LPM), 2LPM, and 6LPM, respectively) or mouthpiece (0.56 ± 0.13%, 2.16 ± 0.06%, and 1.82 ± 0.41% at 0LPM, 2LPM, and 6LPM). In addition, aerosol delivery was also significantly greater when the VMN was integrated into simulated HFNT (2.88 ± 0.15%), in comparison with using the jet nebulizer (JN) with a facemask (0.82 ± 0.16%) or a mouthpiece (0.86 ± 0.11%). During simulated distressed breathing, a significantly greater aerosol dose was observed when the VMN was integrated with HFNT, supplying aerosol and humidified air simultaneously (6.81 ± 0.45%), compared with using a facemask (0.86 ± 0.04%, 2.96 ± 0.26%, and 4.23 ± 0.93% at 0LPM, 2LPM, and 6LPM) or mouthpiece (0.73 ± 0.37%, 0.97 ± 0.20%, and 3.11 ± 0.53% at 0LPM, 2LPM, and 6LPM, respectively). Aerosol delivery was also greater when the VMN was integrated into HFNT (6.81 ± 0.45%), in comparison with using the JN with a facemask (5.72 ± 0.71%) or a mouthpiece (0.69 ± 0.53%). Furthermore, across all drug delivery interfaces, and in line with previous reports, aerosol delivery was greater during simulated distressed breathing, in comparison with simulated healthy adult breathing.

Conclusions: This article will be of considerable benefit in enhancing the understanding of aerosol delivery during HFNT, an increasingly adopted therapeutic intervention by healthcare professionals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40635-019-0245-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447636PMC
April 2019

Investigation of the Quantity of Exhaled Aerosols Released into the Environment during Nebulisation.

Pharmaceutics 2019 Feb 12;11(2). Epub 2019 Feb 12.

Aerogen, IDA Business Park, Dangan, Galway, H91 HE94, Ireland.

Background: Secondary inhalation of medical aerosols is a significant occupational hazard in both clinical and homecare settings. Exposure to fugitive emissions generated during aerosol therapy increases the risk of the unnecessary inhalation of medication, as well as toxic side effects.

Methods: This study examines fugitively-emitted aerosol emissions when nebulising albuterol sulphate, as a tracer aerosol, using two commercially available nebulisers in combination with an open or valved facemask or using a mouthpiece with and without a filter on the exhalation port. Each combination was connected to a breathing simulator during simulated adult breathing. The inhaled dose and residual mass were quantified using UV spectrophotometry. Time-varying fugitively-emitted aerosol concentrations and size distributions during nebulisation were recorded using aerodynamic particle sizers at two distances relative to the simulated patient. Different aerosol concentrations and size distributions were observed depending on the interface.

Results: Within each nebuliser, the facemask combination had the highest time-averaged fugitively-emitted aerosol concentration, and values up to 0.072 ± 0.001 mg m were recorded. The placement of a filter on the exhalation port of the mouthpiece yielded the lowest recorded concentrations. The mass median aerodynamic diameter of the fugitively-emitted aerosol was recorded as 0.890 ± 0.044 µm, lower the initially generated medical aerosol in the range of 2⁻5 µm.

Conclusions: The results highlight the potential secondary inhalation of exhaled aerosols from commercially available nebuliser facemask/mouthpiece combinations. The results will aid in developing approaches to inform policy and best practices for risk mitigation from fugitive emissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/pharmaceutics11020075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6409895PMC
February 2019

C-Metomidate PET/CT is a useful adjunct for lateralization of primary aldosteronism in routine clinical practice.

Clin Endocrinol (Oxf) 2019 05 18;90(5):670-679. Epub 2019 Mar 18.

Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland.

Objective: To describe clinical practice experience of C-Metomidate PET/CT as an adjunct to adrenal vein sampling (AVS) in the lateralization of aldosterone-producing adenomas (APA) in primary aldosteronism (PA).

Context: Accurate lateralization of APA in the setting of PA offers the potential for surgical cure and improved long-term cardiovascular outcomes. Challenges associated with AVS, the current gold standard lateralization modality, mean that only a small proportion of potentially eligible patients currently make it through to surgery. This has prompted consideration of alternative strategies for lateralization, including the application of novel molecular PET tracers such as C-Metomidate.

Design: Clinical Service Evaluation/Retrospective audit.

Patients: Fifteen individuals with a confirmed diagnosis of PA, undergoing lateralization with C-Metomidate PET/CT prior to final clinical decision on surgical vs medical management.

Measurements: All patients underwent screening aldosterone renin ratio (ARR), followed by confirmatory testing with the seated saline infusion test, according to Endocrine Society Clinical Practice Guidelines. Adrenal glands were imaged using dedicated adrenal CT. C-Metomidate PET/CT was undertaken due to equivocal or failed AVS. Management outcomes were assessed by longitudinal measurement of blood pressure, ARR, number of hypertensive medications following adrenalectomy or institution of medical therapy.

Results: We describe the individual lateralization and clinical outcomes for 15 patients with PA.

Conclusion: C-Metomidate PET/CT in conjunction with adrenal CT and AVS provided useful information which aided clinical decision-making for PA within a multidisciplinary hypertension clinic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/cen.13942DOI Listing
May 2019

Innovations in Practice: Dialectical behaviour therapy for adolescents: multisite implementation and evaluation of a 16-week programme in a public community mental health setting.

Child Adolesc Ment Health 2019 Feb 17;24(1):76-83. Epub 2018 Sep 17.

National Suicide Research Foundation, University College Cork, Cork, Ireland.

Background: Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. This study describes the implementation and effectiveness of 16-week DBT-A across multiple sites in publicly funded child/adolescent mental health services (CAMHS) in Ireland.

Method: The Consolidated Framework for Implementation Research was used to guide this national implementation. Fifty-four clinicians from seven CAMHS teams completed DBT training and delivered the 16-week DBT-A programme. Eighty-four adolescents with emotional and behavioural dysregulation participated in the intervention and outcome measures were administered at preintervention, postintervention and 16-week follow-up.

Results: Significant reductions on all outcome measures were observed for DBT-A participants including presence and frequency of self-harm, suicidal ideation and depression. Reductions in the number of acute inpatient admissions, bed days and emergency department visits were also reported.

Conclusions: DBT-A can be successfully implemented in CAMHS settings and yield positive outcomes for adolescents with emotional and behavioural dysregulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/camh.12298DOI Listing
February 2019

Evaluation of a virtual reality enhanced bullying prevention curriculum pilot trial.

J Adolesc 2019 02 10;71:72-83. Epub 2019 Jan 10.

Harmony Labs, USA.

Introduction: Bullying is a widely prevalent public health and safety issue that can have serious long-term consequences for youth. Given the limited efficacy of traditional bullying prevention programs, a need exists for novel, theoretically informed, prevention programming. Construal Level Theory provides a useful framework.

Methods: This study evaluated a pseudo-randomized pilot trial of a virtual reality enhanced bullying prevention program among middle school students (N = 118) in the Midwest United States. Two models were proposed. The first predicts reductions in bullying behavior (traditional bullying, cyberbullying, relational aggression) at post-test, mediated by changes in empathy in the virtual reality condition compared to the control condition. The second predicts increases in school belonging and willingness to intervene as an active bystander at post-test, mediated by changes in empathy in the virtual reality condition compared to the control condition.

Results: The virtual reality condition yielded increased empathy from pre-to post-intervention compared to the control condition. Through the mediating role of empathy, changes in the desirable directions were also observed for traditional bullying, sense of school belonging, and willingness to intervene as an active bystander, but not for cyberbullying or relational aggression.

Conclusions: The scope and practical limitations of the virtual reality trial prevented a larger scale and more rigorous evaluation; however, results justify an expanded examination of virtual reality as a youth violence prevention tool.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.adolescence.2018.12.006DOI Listing
February 2019

Innovations in Practice: Dialectical behaviour therapy - skills training for emotional problem solving for adolescents (DBT STEPS-A): evaluation of a pilot implementation in Irish post-primary schools.

Child Adolesc Ment Health 2018 Nov 13;23(4):376-380. Epub 2018 Jun 13.

Department of Epidemiology and Public Health, Western Gateway Building, University College Cork, Cork, Ireland.

Background: Whole school approaches to mental health are recommended where schools and community partners work together to support positive mental health for young people. Universal interventions which adopt this approach are limited however. This study evaluates the pilot implementation of DBT STEPS-A, a social-emotional learning programme for adolescents, in Ireland.

Method: Data were collected at the beginning and end of the academic year from students who participated in DBT STEPS-A and a control group. A matched comparison was conducted where a subset of the data was analysed consisting of 72 adolescents aged 15-16 years from two schools in the south of Ireland. Outcomes included emotion symptoms, dysfunctional coping and DBT skill use. Linear mixed-effects models were used to estimate the treatment effect (intervention vs. control).

Results: A statistically significant treatment effect was observed on two of four outcome measures (emotion symptom index: p = 0.011; internalising problems: p = 0.012). The effect sizes were large (Cohen's F squared = 0.65 and 0.83 respectively).

Conclusions: Significant reductions on measures which assess constructs including depression, anxiety and social stress were found for the intervention group. The results suggest that DBT STEPS-A may yield positive effects for adolescents who complete the intervention. Feedback from adolescents and teachers suggests that refinement of content, structure and implementation may make the programme more accessible to an adolescent population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/camh.12284DOI Listing
November 2018

Multisite Implementation and Evaluation of 12-Month Standard Dialectical Behavior Therapy in a Public Community Setting.

J Pers Disord 2020 06 11;34(3):377-393. Epub 2018 Oct 11.

School of Public Health, University College Cork, Cork, Ireland.

Dialectical behavior therapy (DBT) is an effective intervention for treating adults with emotional and behavioral dysregulation. The National DBT Project, Ireland was established in 2013 to coordinate the implementation of DBT across public community mental health settings at a national level. This study describes the implementation and evaluation of DBT across multiple independent sites in adult mental health services (AMHS). The Consolidated Framework for Implementation Research was used to guide this national implementation where barriers and facilitators to DBT implementation were considered. Nine AMHS teams completed DBT training and delivered the standard 12-month program. One hundred and ninety-six adults with borderline personality disorder participated in the program, and outcome measures were recorded at four time points. Significant reductions on outcome measures, including frequency of self-harm and suicidal ideation, were observed. This study highlights that DBT can be successfully implemented in community mental health settings as part of a coordinated implementation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1521/pedi_2018_32_402DOI Listing
June 2020

Pathway mechanism for excitatory and inhibitory control in working memory.

J Neurophysiol 2018 11 26;120(5):2659-2678. Epub 2018 Sep 26.

Neural Systems Laboratory, Boston University , Boston, Massachusetts.

Humans engage in many daily activities that rely on working memory, the ability to hold and sequence information temporarily to accomplish a task. We focus on the process of working memory, based on circuit mechanisms for attending to relevant signals and suppressing irrelevant stimuli. We discuss that connections critically depend on the systematic variation in laminar structure across all cortical systems. Laminar structure is used to group areas into types regardless of their placement in the cortex, ranging from low-type agranular areas that lack layer IV to high-type areas that have six well-delineated layers. Connections vary in laminar distribution and strength based on the difference in type between linked areas, according to the "structural model" (Barbas H, Rempel-Clower N. Cereb Cortex 7: 635-646, 1997). The many possible pathways thus vary systematically by laminar distribution and strength, and they interface with excitatory neurons to select relevant stimuli and with functionally distinct inhibitory neurons that suppress activity at the site of termination. Using prefrontal pathways, we discuss how systematic architectonic variation gives rise to diverse pathways that can be recruited, along with amygdalar and hippocampal pathways that provide sensory, affective, and contextual information. The prefrontal cortex is also connected with thalamic nuclei that receive the output of the basal ganglia and cerebellum, which may facilitate fast sequencing of information. The complement of connections and their interface with distinct inhibitory neurons allows dynamic recruitment of areas and shifts in cortical rhythms to meet rapidly changing demands of sequential components of working memory tasks.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1152/jn.00936.2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295541PMC
November 2018

In Vitro Determination of the Main Effects in the Design of High-Flow Nasal Therapy Systems with Respect to Aerosol Performance.

Pulm Ther 2018 Jun 18;4(1):73-86. Epub 2018 Apr 18.

Aerogen Limited, IDA Business Park, Dangan, Galway, Ireland.

Introduction: The use of concurrent aerosol delivery during high-flow nasal therapy (HFNT) may be exploited to facilitate the delivery of a variety of prescribed medications for inhalation. Until now, a systematic approach to determine the conditions required to yield an optimal emitted dose has not been reported. The aim of this study was to establish the effects of gas flow rate, input droplet size, and nebulizer position on the amount of aerosol exiting the nasal cannula during HFNT and thus becoming available for inhalation.

Methods: Testing was completed according to a factorial statistical design of experiments (DOE) approach. Emitted dose was characterized with a vibrating mesh nebulizer (Aerogen Solo, Aerogen Ltd) for an adult model of HFNT at three clinically relevant gas flow rates, using three nebulizers producing varying input droplet sizes and placed at two different nebulizer positions.

Results: Increasing the gas flow rate significantly lowered the emitted dose, with a dose of 7.10% obtained at 10 LPM, 2.67% at 25 LPM, and 1.30% at 40 LPM (p < 0.0001). There was a significant difference in emitted dose between nebulizers with different input droplet sizes, with increasing input droplet size associated with a reduced emitted dose (6.11% with an input droplet size of 3.22 µm, 2.76% with 4.05 µm, and 2.38% with 4.88 µm, p  = 0.0002, Pearson's r = - 0.2871). In addition, the droplet size exiting the nasal cannula interface was lower than that produced by the aerosol generator for all devices under test. Positioning the nebulizer immediately after the humidification chamber yielded a marginally greater emitted dose (3.79%) than when the nebulizer was placed immediately upstream of the nasal cannula (3.39%). Flow rate, input droplet size, and nebulizer position were at the 0.10 level of significance, indicating that all three factors had significant effects on emitted dose. According to the DOE model, flow rate had the greatest influence on emitted dose, followed by input droplet size and then nebulizer position.

Conclusion: Our findings indicate that in order to optimize the amount of aerosol exiting the nasal cannula interface during HFNT, it is necessary for gas flow rate to be low and the input droplet size to be small, while the nebulizer should be positioned immediately after the humidification chamber.

Funding: Aerogen Limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s41030-018-0054-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6967237PMC
June 2018

Correction to: Dialectical behaviour therapy for treating adults and adolescents with emotional and behavioural dysregulation: study protocol of a coordinated implementation in a publicly funded health service.

BMC Psychiatry 2018 05 7;18(1):123. Epub 2018 May 7.

National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.

Upon publication of the original article (1) it was highlighted by the authors that there was just one error in the manuscript in the 'Sample size' subsection of the Methods/Design.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12888-018-1694-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938812PMC
May 2018

Dialectical behaviour therapy for treating adults and adolescents with emotional and behavioural dysregulation: study protocol of a coordinated implementation in a publicly funded health service.

BMC Psychiatry 2018 02 26;18(1):51. Epub 2018 Feb 26.

National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.

Background: In the Republic of Ireland, borderline personality disorder (BPD) is a feature of approximately 11-20% of clinical presentations to outpatient clinics within mental health services. These estimates are similar to other countries including the UK and USA. Dialectical behaviour therapy (DBT) is an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with BPD. While a number of randomised controlled trials (RCTs) have demonstrated the efficacy of DBT, there is limited research which evaluates the effectiveness of this model when applied to real world settings. Funding was secured to co-ordinate DBT training in public community-based mental health services across Ireland. As no other study has evaluated a co-ordinated national implementation of DBT, the current study proposes to investigate the effectiveness of DBT in both adult and child/adolescent community mental health services across Ireland, evaluate the coordinated implementation of DBT at a national level, and complete a comprehensive economic evaluation comparing DBT versus treatment-as-usual.

Methods/ Design: This study takes the form of a quasi-experimental design. Individuals attending community mental health services who meet criteria for participation in the DBT programme will be allocated to the intervention group. Individuals who live in areas in Ireland where DBT is not yet available, and individuals who choose not to participate in the intervention, will be invited to participate in a treatment-as-usual comparison group. Self-report clinical measures and health service use questionnaires for DBT participants (and parent/guardians as appropriate) will be administered at pre-, mid- and post-intervention, as well as follow-up for participants who complete the intervention. Survey and interview data for DBT therapists will be gathered at three time points: prior to DBT training, 6 months after teams begin delivery of the intervention, and 2 years following training completion.

Discussion: It is anticipated that the results of this study will provide evidence for the effectiveness of DBT for patients, and report on recommendations regarding best practice guidelines for implementation of DBT and its economic merit in a publicly funded service.

Trial Registration: ClinicalTrials.gov ID: NCT03180541 ; Registered June 7th 2017 'retrospectively registered'.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12888-018-1627-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828478PMC
February 2018

Cortical Connections Position Primate Area 25 as a Keystone for Interoception, Emotion, and Memory.

J Neurosci 2018 02 22;38(7):1677-1698. Epub 2018 Jan 22.

Graduate Program in Neuroscience, Boston University and School of Medicine, Boston, Massachusetts 02215, and

The structural and functional integrity of subgenual cingulate area 25 (A25) is crucial for emotional expression and equilibrium. A25 has a key role in affective networks, and its disruption has been linked to mood disorders, but its cortical connections have yet to be systematically or fully studied. Using neural tracers in rhesus monkeys, we found that A25 was densely connected with other ventromedial and posterior orbitofrontal areas associated with emotions and homeostasis. A moderate pathway linked A25 with frontopolar area 10, an area associated with complex cognition, which may regulate emotions and dampen negative affect. Beyond the frontal lobe, A25 was connected with auditory association areas and memory-related medial temporal cortices, and with the interoceptive-related anterior insula. A25 mostly targeted the superficial cortical layers of other areas, where broadly dispersed terminations comingled with modulatory inhibitory or disinhibitory microsystems, suggesting a dominant excitatory effect. The architecture and connections suggest that A25 is the consummate feedback system in the PFC. Conversely, in the entorhinal cortex, A25 pathways terminated in the middle-deep layers amid a strong local inhibitory microenvironment, suggesting gating of hippocampal output to other cortices and memory storage. The graded cortical architecture and associated laminar patterns of connections suggest how areas, layers, and functionally distinct classes of inhibitory neurons can be recruited dynamically to meet task demands. The complement of cortical connections of A25 with areas associated with memory, emotion, and somatic homeostasis provide the circuit basis to understand its vulnerability in psychiatric and neurologic disorders. Integrity of the prefrontal subgenual cingulate cortex is crucial for healthy emotional function. Subgenual area 25 (A25) is mostly linked with other prefrontal areas associated with emotion in a dense network positioned to recruit large fields of cortex. In healthy states, A25 is associated with internal states, autonomic function, and transient negative affect. Constant hyperactivity in A25 is a biomarker for depression in humans and may trigger extensive activation in its dominant connections with areas associated with emotions and internal balance. A pathway between A25 and frontopolar area 10 may provide a critical link to regulate emotions and dampen persistent negative affect, which may be explored for therapeutic intervention in depression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1523/JNEUROSCI.2363-17.2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815452PMC
February 2018

Standard 12 month dialectical behaviour therapy for adults with borderline personality disorder in a public community mental health setting.

Borderline Personal Disord Emot Dysregul 2017 23;4:19. Epub 2017 Sep 23.

National Suicide Research Foundation, Western Gateway Building, University College Cork, Cork, Ireland.

Background: Dialectical behaviour therapy (DBT) is noted to be an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with borderline personality disorder (BPD). Evidence for the effectiveness of DBT in publicly funded community mental health settings is lacking however. No study to our knowledge has been published on the effectiveness of a 12 month standard DBT programme without adaptations for individuals with BPD in a publicly funded community mental health setting and no study has included data across multiple time-points. The main objective of the current study was to determine if completion of a 12 month DBT programme is associated with improved outcomes in terms of borderline symptoms, anxiety, hopelessness, suicidal ideation, depression and quality of life. A secondary objective includes assessing client progress across multiple time-points throughout the treatment.

Methods: Fifty-four adult participants with BPD completed the standard DBT programme across four sites in community mental health settings in the Republic of Ireland. Data was collected by the DBT therapists working with participants and took place at 8 week intervals across the 12 month programme. To explore the effects of the intervention for participants, linear mixed-effects models were used to estimate change utilising data available from all time-points.

Results: At the end of the 12 month programme, significant reductions in borderline symptoms, anxiety, hopelessness, suicidal ideation and depression were observed. Increases in overall quality of life were also noted. In particular, gains were made during the first 6 months of the programme. There was a tendency for scores to slightly regress after the six-month mark which marks the start of the second delivery of the group skills cycles.

Conclusions: The current study provides evidence for the effectiveness of standard DBT in publicly funded community mental health settings. As participants were assessed at the end of every module, it was possible to observe trends in symptom reduction during each stage of the intervention. Despite real-world limitations of applying DBT in community settings, the results of this study are comparable with more tightly controlled studies.

Trial Registration: ClinicalTrials.gov ID: NCT03166579; Registered May 24th 2017 'retrospectively registered'.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40479-017-0070-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610433PMC
September 2017