In psychiatric clinics with an exclusively open-door policy, the risk of patients committing suicide or absconding from treatment is no higher than in clinics with locked wards. This has been demonstrated in a large study by the University of Basel and the University Psychiatric Clinics of Basel (UPK), in which around 350,000 cases were analysed over a period of 15 years.

Self-endangering behaviour by patients, suicidality and absconding from treatment represent great challenges for all medical institutions. In many psychiatric clinics, therefore, high-risk patients are accommodated in locked wards. This is done on the grounds that patients can only receive adequate protection and appropriate therapy if they are prevented from attempting suicide or absconding, but there is no evidence that locked wards actually prevent self-endangering behaviour. It is, however, known that such wards create a treatment climate that is not conducive to successful therapy and tends to increase motivation to escape.

In their naturalistic observational study, PD Dr. Christian Huber and Prof. Dr. Undine Lang of the UPK and the University of Basel, together with colleagues, studied 349,574 cases in 21 German clinics over the period from 1998 to 2012. Some of these clinics practiced an open door policy, making do without any locked wards. Sixteen clinics also maintained intermittently or permanently locked wards in addition to open wards. All of the clinics were legally obliged to admit all individuals from a certain area, regardless of the severity of their illness or of self-endangering behaviour on the part of the patient.

One of the study’s findings is that the rate of suicide attempts and suicides is no lower in clinics with locked departments. Furthermore, institutions with open doors did not record a higher rate of absconding. ‘The effect of locked doors in clinics is overestimated,’ says first author Christian Huber. ‘According to our study, being locked in does not improve patient safety and, in some cases, actually hinders the prevention of suicide and absconding. An atmosphere of control, restricted personal freedoms and sanctions is more likely to be a risk factor impeding successful therapy.’

University of Basel www.unibas.ch/en/News-Events/News/Uni-Research/Psychiatry-on-Closed-and-Open-Wards-The-Suicide-Risk-Remains-the-Same.html

Older people are particularly at risk of water-loss dehydration – which is caused by not drinking enough fluid. It can lead to poor health outcomes such as disability and even death.
The best test for diagnosing dehydration, known as a serum osmolality test, is expensive and not currently viable for wide-scale NHS screening.
But new research published recently reveals how routine blood tests for sodium, potassium, urea and glucose could be used to screen for dehydration.
By putting the results of these tests through an osmolarity equation’, health professionals can tell whether an older person is drinking enough fluid.
Lead researcher Dr Lee Hooper from UEA’s Norwich Medical School said: ‘Around 20 per cent of older people living in residential care are dehydrated, and that figure rises to around 40 per cent among those admitted to hospital.
‘Older people often drink less than younger people for a variety of reasons. Loss of routine and fewer social contacts can reduce drinking. In some cases older people choose to drink less as getting to the toilet can be more difficult and take longer. It can be physically difficult to make, carry and drink a cup of tea when you get older – especially if you need a zimmer frame to walk about. And older people tend not to feel thirsty when they drink too little so their bodies don’t warn them to start drinking.
‘On top of all that – as our kidneys get older we are less able to concentrate our urine to preserve fluid, so the body’s ability to regulate its fluid balance slowly reduces.
‘Dehydration often goes unnoticed by carers, but it can lead to increased risk of hospital admission, urinary tract infections, disability and even death.
‘A serum osmolality test measures the freezing point of blood serum to show how concentrated a sample of blood is. People’s blood becomes more concentrated as they become dehydrated.
‘But it is an expensive and time consuming procedure – and clinical laboratories would not be able to handle routine screening. Simpler tests such as urine measurements, which appear to work well in children and young adults, do not work in older adults.
‘When our blood becomes more concentrated, as we become dehydrated, concentrations of serum sodium, potassium, urea and glucose rise. Many blood tests routinely measured in older people already check for all of these, and assess them independently.
‘We wanted to test whether results from routine tests for sodium, potassium, urea and glucose could be used together to accurately screen for dehydration by using a simple mathematical equation.
‘There are a number of different equations already being used, but they vary considerably from each other, and it wasn’t known which were most useful for elderly people. We wanted to find a universal equation which would be accurate for a broad range of elderly people including people with conditions such as diabetes.’
The research team studied 595 people over age 65 – including those who were healthy and lived independently, frail people living in residential care, and those in hospital. The group also spanned several European countries and took into account those with poor renal function and diabetes.
They assessed the diagnostic accuracy of 39 different equations, and compared the results to directly measured serum osmolality.
They found that an osmolarity equation described by Khajuria and Krahn had greatest universal accuracy – across healthy and frail older people, those in and out of hospital, with and without diabetes, with and without poor renal function, at all levels of dehydration and in men and women.
Dr Hooper said: ‘We propose that clinical laboratories use this equation to report on hydration status of older people when reporting blood test results that include sodium, potassium, urea and glucose. We hope our findings will lead to pragmatic screening in older people to allow early identification of dehydration. This would help doctors, nurses and carers support older people to increase their fluid intake.’

University of East Angliahttp://tinyurl.com/hmefojk

For children with autism and a class of genetic disorders, exposure to diagnostic ultrasound in the first trimester of pregnancy is linked to increased autism severity, according to a study conducted by researchers at UW Medicine, University of Washington Bothell and Seattle Children’s Research Institute.
The study looked at the variability of symptoms among kids with autism, not what causes autism. The researchers found that exposure to diagnostic ultrasound in the first trimester is linked to increased autism symptom severity. The greatest link is among kids with certain genetic variations associated with autism; 7 percent of the children in the study had those variations.
Food and Drug Administration (FDA) guidelines recommend that diagnostic ultrasound be used only for medical necessity.
‘I believe the implications of our results are to bolster the FDA guidelines,’ said corresponding author Pierre D. Mourad, a UW professor of neurological surgery in Seattle. He is also a professor of engineering and mathematics at UW Bothell. As a UW Medicine scientist, he specializes in translational research on ultrasound and the brain.
Mourad said their results are related to the first trimester of pregnancy. Data from looking at the effect of ultrasound on the second and third trimester showed no link, he said.
Mourad said he and his colleagues now intend to look more closely into links between ultrasound and autism severity, as well as the possibility – thus far not shown – that ultrasound exposure could contribute to autism incidence.

UW Medicine http://tinyurl.com/hupd4oq

For medics on the battlefield and doctors in remote or developing parts of the world, getting rapid access to the drugs needed to treat patients can be challenging. Biopharmaceutical drugs, which are used in a wide range of therapies including vaccines and treatments for diabetes and cancer, are typically produced in large, centralized fermentation plants. This means they must be transported to the treatment site, which can be expensive, time-consuming, and challenging to execute in areas with poor supply chains.
Now a portable production system, designed to manufacture a range of biopharmaceuticals on demand, has been developed by researchers at MIT, with funding from the Defense Advanced Research Projects Agency (DARPA).
In a paper the researchers demonstrate that the system can be used to produce a single dose of treatment from a compact device containing a small droplet of cells in a liquid.

In this way, the system could ultimately be carried onto the battlefield and used to produce treatments at the point of care. It could also be used to manufacture a vaccine to prevent a disease outbreak in a remote village, according to senior author Tim Lu, an associate professor of biological engineering and electrical engineering and computer science, and head of the Synthetic Biology Group at MIT’s Research Laboratory of Electronics.
‘Imagine you were on Mars or in a remote desert, without access to a full formulary, you could program the yeast to produce drugs on demand locally,’ Lu says.

The system is based on a programmable strain of yeast, Pichia pastoris, which can be induced to express one of two therapeutic proteins when exposed to a particular chemical trigger. The researchers chose P. pastoris because it can grow to very high densities on simple and inexpensive carbon sources, and is able to express large amounts of protein.

‘We altered the yeast so it could be more easily genetically modified, and could include more than one therapeutic in its repertoire,’ Lu says.
When the researchers exposed the modified yeast to estrogen β-estradiol, the cells expressed recombinant human growth hormone (rHGH). In contrast, when they exposed the cells to methanol, the yeast expressed the protein interferon.
The cells are held within a millimeter-scale table-top microbioreactor, containing a microfluidic chip, which was originally developed by Rajeev Ram, a professor of electrical engineering at MIT, and his team, and then commercialized by Kevin Lee – an MIT graduate and co-author – through a spin-off company.
A liquid containing the desired chemical trigger is first fed into the reactor, to mix with the cells.

Inside the reactor, the cell-and-chemical mixture is surrounded on three sides by polycarbonate; on the fourth side is a flexible and gas-permeable silicone rubber membrane. By pressurizing the gas above this membrane, the researchers are able to gently massage the liquid droplet to ensure its contents are fully mixed together.
‘This makes sure that the one milliliter (of liquid) is homogenous, and that is important because diffusion at these small scales, where there is no turbulence, takes a surprisingly long time,’ says Ram, who was also a senior author of the paper.
Because the membrane is gas permeable, it allows oxygen to flow through to the cells, while any carbon dioxide they produce can be easily extracted.
The device continuously monitors conditions within the microfluidic chip, including oxygen levels, temperature, and pH, to ensure the optimum environment for cell growth. It also monitors cell density.
If the yeast is required to produce a different protein, the liquid is simply flushed through a filter, leaving the cells behind. Fresh liquid containing a new chemical trigger can then be added, to stimulate production of the next protein.
Although other research teams have previously attempted to build microbioreactors, these have not have not had the ability to retain the protein-producing cells while flushing out the liquid they are mixed with, Ram says. ‘You want to keep the cells because they are your factory,’ he says. ‘But you also want to rapidly change their chemical environment, in order to change the trigger for protein production.’

The researchers are now investigating the use of the system in combinatorial treatments, in which multiple therapeutics, such as antibodies, are used together.
Combining multiple therapeutics in this way can be expensive if each requires its own production line, Lu says.
‘But if you could engineer a single strain, or maybe even a consortia of strains that grow together, to manufacture combinations of biologics or antibodies, that could be a very powerful way of producing these drugs at a reasonable cost,’ he says.

MIT news.mit.edu/2016/portable-device-produces-biopharmaceuticals-on-demand-0729