Characterizing the features and course of psychiatric symptoms in children and adolescents with autoimmune encephalitis

Autoimmune encephalitis (AE) can present like a psychiatric disorder. We aimed to illustrate the psychiatric manifestations, course and management of AE in a paediatric cohort. Neuropsychiatric symptoms, investigations and treatment were retrospectively retrieved in 16 patients (mean age 11.31, SD 2.98) with an AE diagnosis at the liaison psychiatry services in two UK tertiary paediatric centres. Psychiatric presentation was characterised by an acute polysymptomatic (predominantly agitation, anger outbursts/aggressiveness, hallucinations, and emotional lability) onset. Antipsychotics produced side effects and significant worsening of symptoms in four cases, and benzodiazepines were commonly used. This psychiatric phenotype should make clinicians suspect the diagnosis of AE and carefully consider use of treatments.

The Effects of Cumulative and Noncumulative Exams Within the Context of Interteaching

Interteaching is a behavioral teaching method that has been empirically shown to increase student learning outcomes. The present study investigated the effect of combining interteaching with cumulative versus noncumulative exams in two sections of an online asynchronous class. Interteaching was used in both sections of the course. The noncumulative exam section experienced weekly exams with test questions that only covered material learned in that week of class. The cumulative exam section was given weekly exams in which half of the questions were from material learned that current week and the other half were cumulative up to that point in the class. This was followed by a cumulative final exam given to both groups. All exam questions were multiple choice. On average, students in the cumulative exam group scored 4.91% higher on the final exam than students in the noncumulative exam group. Students exposed to weekly cumulative exams also earned more As and Bs on the final compared to the noncumulative exam group. Overall, our experiment provides evidence that interteaching may be further improved when combined with cumulative weekly exams.

Mycobacterium avium infection associated with sterile polyarthritis in a dog

A 1-year-old male neutered Portuguese Podengo dog was presented for lameness, inappetence, pyrexia, diarrhoea and abdominal moderate to severe lymphadenomegaly. Cytology of synovial fluid revealed neutrophilic inflammation in multiple joints suggestive of immune-mediated polyarthritis. Cytology of fine-needle-aspiration material obtained from lymph nodes revealed macrophages with intracytoplasmic, rod-like Ziehl-Neelsen positive staining structures, indicative of mycobacteria. Four-month treatment with enrofloxacin, rifampicin and clarithromycin resulted in clinical improvement and resolution of polyarthritis as evidenced on repeat synoviocentesis, but diarrhoea recurred, Ziehl-Neelsen positive organisms were again found on lymph node cytology and analysis of the 16S rRNA-gene using the Basic Local Alignment Search Tool facility resulted in a match to Mycobacterium avium with 100% sequence identity. Treatment was adjusted to include pradofloxacin, doxycycline, rifampicin and ethambutol and 3 months later the dog is clinically normal. Based on the literature search, this is the first time canine Mycobacterium avium infection associated with immune-mediated polyarthritis is reported. Based on scoping searches, this is the first report of canine Mycobacterium avium infection associated with immune-mediated polyarthritis.

489 The Role of Sentinel Lymph Node Biopsy in Cutaneous Head and Neck Melanoma: A Systematic Review and Meta-Analysis

Introduction

and

Aims

Method

This review follows the PRISMA guidelines. Database searches for MEDLINE and EMBASE were constructed to retrieve human studies published between 1st January 2010 and 1st July 2020 assessing the role and accuracy of sentinel lymph node biopsy in cutaneous malignant melanoma of the head and neck. Articles were independently screened by two reviewers and critically appraised using the MINORS criteria. The primary outcomes consisted of the sentinel node identification rate and test-performance measures, including the false-negative rate and the posttest probability negative.

Results

A total of 27 studies, including 4688 patients, met the eligibility criteria. Statistical analysis produced weighted summary estimates for the sentinel node identification rate of 97.3% (95% CI, 95.9% to 98.6%), the false-negative rate of 21.3% (95% CI, 17.0% to 25.4%) and the posttest probability negative of 4.8% (95% CI, 3.9% to 5.8%).

Discussion

Application of the PRECEDE-PROCEED model for the development of a community pharmacy ear health intervention for rural populations

Introduction

The World Health Organisation has identified ear disease to be a major public health problem in rural and remote communities, with access to services an identified barrier. (1) Rural community pharmacists are recognised as highly skilled, accessible and trusted health professionals. An innovative service “LISTEN UP” (Locally Integrated Screening and Testing Ear aNd aUral Program) has been implemented in two remote community pharmacies in Australia. The service involves patients with an ear complaint self-presenting to a participating pharmacy and receiving a clinical examination by a pharmacist, who has completed accredited training in ear health, otoscopy and tympanometry. “LISTEN UP” has been developed using the PRECEDE-PROCEED planning model.(2) The PRECEDE component of the model assesses social, epidemiological, behavioural, environmental, educational and ecological factors to inform the development of an intervention.(2) The PROCEED-component consists of pilot testing and evaluation.

Aim

To describe an ecological approach to health promotion via the application of the PRECEDE-PROCEED planning model to develop a rural community pharmacy-based ear health intervention.

Methods

PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis) provided a framework to plan and develop a locally relevant and community focused program. This included research and engagement via meetings, surveys and interviews of consumers, pharmacists, health professionals and stakeholders. PROCEED (Policy, Regulatory, and Organisational Constructs in Educational and Environmental Development) outlined the structure for implementing and evaluating the intervention that was developed in the PRECEDE process. A pilot study has been included in PROCEED segment to allow improvement before implementing and evaluating the final model. Data will be collected in the pilot study via semi-structured interviews and surveys. This will be analysed using descriptive statistics and thematic analysis of qualitative data.

Results

As part of the PRECEDE segment a social assessment was undertaken via mixed method studies of rural consumers, pharmacists and health professionals. Hearing testing was ranked as the seventh (from twenty-six) most important expanded pharmacy service by both consumer and health professional groups. An epidemiological assessment found extensive ear disease in rural and remote locations resulting in complications and hearing loss. Behavioural and environment assessments identified eleven ear health interventions which include hearing screening [3], otoscopy pilot studies [2], audiometry services [1], specific education for undergraduate pharmacy students [2] and a pharmacy-based clinic [3]. However none of the interventions described a framework for continued service provision. Policy and regulation assessment was undertaken to align the intervention within the regulatory framework. The application of this model is partially complete with the study protocol for the intervention developed and the initial pilot study in progress. This study’s strengths include its applicability to rural populations and the limited evidence base that currently exists. It is however limited by the small size of the pilot study and application of this model to a national intervention would be useful for future.

Conclusions

The application of the PRECEDE-PROCEED model demonstrates the applicability of this planning model for developing and evaluating an ear health intervention with a particular focus on community pharmacies in rural and remote locations.

References

1. World Health Organisation. Deafness and hearing loss; 2020. Available from: https://www.who.int/health-topics/hearing-loss#tab=tab_1 [Accessed: 15/9/2020]

2. Binkley CJ, Johnson KW. Application of the PRECEDE-PROCEED Planning Model in Designing an Oral Health Strategy. J Theory Pract Dent Public Health. 2013;1(3):http://www.sharmilachatterjee.com/ojs-2.3.8/index.php/JTPDPH/article/view/89

Sweet Corn Sentinel Monitoring for Lepidopteran Field-Evolved Resistance to Bt Toxins

As part of an insect resistance management plan to preserve Bt transgenic technology, annual monitoring of target pests is mandated to detect susceptibility changes to Bt toxins. Currently Helicoverpa zea (Boddie) monitoring involves investigating unexpected injury in Bt crop fields and collecting larvae from non-Bt host plants for laboratory diet bioassays to determine mortality responses to diagnostic concentrations of Bt toxins. To date, this monitoring approach has not detected any significant change from the known range of baseline susceptibility to Bt toxins, yet practical field-evolved resistance in H. zea populations and numerous occurrences of unexpected injury occur in Bt crops. In this study, we implemented a network of 73 sentinel sweet corn trials, spanning 16 U.S. states and 4 Canadian provinces, for monitoring changes in H. zea susceptibility to Cry and Vip3A toxins by measuring differences in ear damage and larval infestations between isogenic pairs of non-Bt and Bt hybrids over three years. This approach can monitor susceptibility changes and regional differences in other ear-feeding lepidopteran pests. Temporal changes in the field efficacy of each toxin were evidenced by comparing our current results with earlier published studies, including baseline data for each Bt trait when first commercialized. Changes in amount of ear damage showed significant increases in H. zea resistance to Cry toxins and possibly lower susceptibility to Vip3a. Our findings demonstrate that the sentinel plot approach as an in-field screen can effectively monitor phenotypic resistance and document field-evolved resistance in target pest populations, improving resistance monitoring for Bt crops.

Reported rationales for HPV vaccination vs. Non-vaccination among undergraduate and medical students in South Carolina

Objective: We sought to identify factors that influence Human Papillomavirus (HPV) vaccination rates in individuals at two higher education institutions in South Carolina (SC).Participants: We surveyed 1007 students with a mean age and standard deviation of 20.3 ± 3.3 from September 2018 to December 2018.Methods: Participants answered 13 questions, assessing HPV vaccination rates, demographics, and rationales for vaccination vs. non-vaccination.Results: Of 1007 respondents, 700 received HPV vaccination, 165 were unvaccinated, 75 received partial vaccination and 138 were uncertain. Commonalities in HPV vaccination existed between females (p = 0.037), individuals who received standard childhood vaccinations (p = 0.04), and those not native-born in SC (p < 0.001). Of non-vaccinated individuals, 37% "never thought about vaccination," 32% did not perceive a need for vaccination, and 31% reported vaccine safety as reasons for not receiving the vaccine.Conclusions: Promotion of HPV vaccination may benefit from targeting SC natives, males, and individuals who are under-vaccinated or unvaccinated.

The Canadian Neuromuscular Disease Registry 2010-2019: A Decade of Facilitating Clinical Research Througha Nationwide, Pan-NeuromuscularDisease Registry

We report the recruitment activities and outcomes of a multi-disease neuromuscular patient registry in Canada. The Canadian Neuromuscular Disease Registry (CNDR) registers individuals across Canada with a confirmed diagnosis of a neuromuscular disease. Diagnosis and contact information are collected across all diseases and detailed prospective data is collected for 5 specific diseases: Amyotrophic Lateral Sclerosis (ALS), Duchenne Muscular Dystrophy (DMD), Myotonic Dystrophy (DM), Limb Girdle Muscular Dystrophy (LGMD), and Spinal Muscular Atrophy (SMA). Since 2010, the CNDR has registered 4306 patients (1154 pediatric and 3148 adult) with 91 different neuromuscular diagnoses and has facilitated 125 projects (73 academic, 3 not-for-profit, 3 government, and 46 commercial) using registry data. In conclusion, the CNDR is an effective and productive pan-neuromuscular registry that has successfully facilitated a substantial number of studies over the past 10 years.

Sub-national structures matter when evaluating physical activity promotion: Lessons from Germany

Background

Public policies are increasingly acknowledged as important part of promoting physical activity (PA). However, especially in states with sub-national administrative structures such as Germany, national and sub-national approaches differ considerably. In Germany, sport for all (SfA) promotion is mostly organized at sub-national level, which is usually not covered in national evaluations. Knowledge of these structures helps to understand national outcomes, enables comparisons and learning within and between countries, and assists in identifying support structures for effective PA promotion.

Methods

Data were collected in the PEN Policy Evaluation Network project. In addition to the WHO HEPA PAT, a questionnaire was sent to the sports representatives of the 16 federal states. Responses of 11 state representatives were included and overarching issues were identified using inductive thematic analysis.

Results

PA promotion in Germany is organized in three areas: SfA, professional sports and school sports. SfA promotion at sub-national level is assigned to different administrative bodies (ministries, senate administration, state chancellery) and policy areas: culture, health and care, home affairs with various aspects, education, social affairs and family. The priorities of the federal states are more diverse and specific compared to the national level. There is an overlap in the topics: urban planning, cycling, health prevention and targeting children. Cooperation mechanisms and partners vary between federal states, but some partners are active at sub-national and national level.

Conclusions

The results provide an insight into the complexity of PA and especially SfA promotion at sub-national level in Germany. Our results suggest that a broader range of approaches is used in the 16 German states than national overviews would suggest. These particularities must be taken into account when assessing and comparing the results from different countries.

Key messages

The promotion of SfA at German sub-national level is much more diverse than represented at national level evaluations. Knowledge of sub-national structures enables the understanding of national outcomes, the promotion of cross-national learning and the identification of supportive structures for effective PA promotion.

"Always Events® "… just another quality improvement tool … or is it?

INTRODUCTION

Always Events® are defined as "those aspects of the care experience that should always occur when patients, their family members or other care partners, and service users interact with health care professionals and the health care system". It is a quality improvement methodology that starts by asking our patients the simple question "what matters to you?" and then through coproduction, works out a way to achieve this.

METHODS AND RESULTS

This article tells our story and highlights the value of undertaking an Always Event® within the Radiology department at Warrington and Halton Hospitals. It will demonstrate how this approach combines research, an evaluation of findings and implementation of those findings within a very short timeframe. Embedded within the article are comments from our staff, volunteers and patients which reflect upon their experiences, our limitations, the outcomes we achieved and the impact it has had upon our patients and staff.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It was important to our patients that they would be informed of how long they would wait for their examination once they booked in at x-ray reception. By undertaking an Always Event® this process is now embedded in our departments everyday activities with over 90% of our patients now being informed of their waiting time. This continued collaboration has really emphasised the value of listening to our patients, and the benefits this can lead to. It has also encouraged a positive research culture within our department (optimisation studies, working with industry, quality projects), helping to progress our profession and resulting in a quality service for our patients.

Polypharmacy and potential drug-drug interactions for people with HIV in the UK from the Climate-HIV database

Objectives

People with HIV (PWHIV) are likely to need therapies for comorbidities as they age. We assessed risk of drug–drug interactions (DDIs) in PWHIV.

Methods

The Climate‐HIV electronic recording system was used to cross‐sectionally analyse records from PWHIV aged ≥ 18 years attending four UK HIV units with a current antiretroviral (ARV) prescription in February 2018. Antiretroviral and non‐ARV medications were categorized by clinical significance of DDIs (University of Liverpool DDI tool). Potential DDIs were predicted using treatment guidelines for commonly recorded comorbidities.

Results

Among 4630 PWHIV (44% female), 41% were ≥ 50 years old. The average number of non‐ARV comedications increased from < 1 for patients aged ≤ 24 years to > 5 for patients aged ≥ 75 years; 65% were taking one or more non‐ARV comedications. The median (interquartile range) number of non‐ARVs was 1 (0–2) and 2 (1–5) for those aged < 50 and ≥ 50 years, respectively. Common comorbidities/concurrent health conditions occurred more frequently in patients aged ≥ 50 years vs. < 50 (53% vs. 34%). Boosted protease inhibitors were associated with the highest proportion of contraindicated comedications; dolutegravir and raltegravir had the fewest. For non‐ARVs, sildenafil and quetiapine were most likely to result in DDIs. Guideline‐recommended treatments for hepatitis C, hepatitis B, and tuberculosis had the highest proportions of contraindications when combined with ARV regimens, while treatments for hepatitis C, malignancy, and mental health conditions had the highest proportion of combinations potentially causing DDIs requiring dose monitoring or adjustment.

Conclusions

Non‐ARV use by PWHIV is high and increases with age. Treatment decisions for ageing PWHIV should consider guideline recommendations for comorbidities.

Introducing magnetic resonance imaging into the lung cancer radiotherapy workflow - An assessment of patient experience

INTRODUCTION

Magnetic resonance imaging (MRI) offers superior soft tissue contrast to computed tomography (CT), the current standard imaging modality for planning radiotherapy treatment. Improved soft tissue contrast could reduce uncertainties in identifying tumour and surrounding healthy tissues, potentially leading to improved outcomes in patients with lung cancer. This study explored patient experience of MR treatment planning scans in addition to a CT scan.

METHODS

Participants were recruited to the 'Magnetic Resonance Imaging for the Delineation of Organs At Risk and Target Volumes in Lung Cancer Patients (MR-Lung)' study at a UK specialist cancer centre. Participants completed their standard of care radiotherapy planning CT scan and two additional MRI scans. Baseline and post-scan questionnaires were completed assessing anxiety and claustrophobia. Motion artefact during MRI was assessed by a modified visual grading analysis. Sixteen participants completed semi-structured interviews; transcripts were analysed thematically.

RESULTS

29 people (66% female; aged 54-89 years) participated. Nineteen participants completed all imaging and 10 participants withdrew before completion. There was minimal adverse impact on state and scan-specific anxiety levels from completing the MRI scans. Completers experienced significantly less scan-specific anxiety during MRI 1 compared to non-completers (U = 33, z = -1.98, p < 0.05). 78% of those who withdrew during or post MRI 1 were positioned 'arms up'. Motion artefact negatively impacted image quality in 34% of scans. Participants commonly reported concerns during MRI; noise, claustrophobia and pain in upper limbs.

CONCLUSION

Two thirds of participants tolerated two additional MR scans with minimal adverse impact on anxiety levels.

IMPLICATIONS FOR PRACTICE

Patient arm positioning and comfort ought to be considered when introducing MR-Linac systems. A screening tool to identify those at high risk of non-completion should be developed.

Precision measurement of the neutral pion lifetime

The explicit breaking of the axial symmetry by quantum fluctuations gives rise to the so-called axial anomaly. This phenomenon is solely responsible for the decay of the neutral pion π⁰ into two photons (γγ), leading to its unusually short lifetime. We precisely measured the decay width Γ of the [Formula: see text] process. The differential cross sections for π⁰ photoproduction at forward angles were measured on two targets, carbon-12 and silicon-28, yielding [Formula: see text], where stat. denotes the statistical uncertainty and syst. the systematic uncertainty. We combined the results of this and an earlier experiment to generate a weighted average of [Formula: see text] Our final result has a total uncertainty of 1.50% and confirms the prediction based on the chiral anomaly in quantum chromodynamics.

Deep androgen receptor suppression in prostate cancer exploits sexually dimorphic renal expression for systemic glucocorticoid exposure

BACKGROUND

Enzalutamide and apalutamide are potent next-generation androgen receptor (AR) antagonists used in metastatic and non-metastatic prostate cancer. Metabolic, hormonal and immunologic effects of deep AR suppression are unknown. We hypothesized that enzalutamide and apalutamide suppress 11β-hydroxysteroid dehydrogenase-2 (11β-HSD2), which normally converts cortisol to cortisone, leading to elevated cortisol concentrations, increased ratio of active to inactive glucocorticoids and possibly suboptimal response to immunotherapy. On-treatment glucocorticoid changes might serve as an indicator of active glucocorticoid exposure and resultant adverse consequences.

PATIENTS AND METHODS

Human kidney tissues were stained for AR and 11β-HSD2 expression. Patients in three trials [neoadjuvant apalutamide plus leuprolide, enzalutamide ± PROSTVAC (recombinant poxvirus prostate-specific antigen vaccine) for metastatic castration-resistant prostate cancer (CRPC) and enzalutamide ± PROSTVAC for non-metastatic castration-sensitive prostate cancer] were analyzed for cortisol and its metabolites using liquid chromatography-mass spectrometry (LC-MS/MS). Progression-free survival was determined in the metastatic CRPC study of enzalutamide ± PROSTVAC for those with glucocorticoid changes above and below the median.

RESULTS

Concurrent AR and 11β-HSD2 expression occurs only in the kidneys of men. A statistically significant rise in cortisol concentration, cortisol/cortisone ratio and tetrahydrocortisol/tetrahydrocortisone ratio with AR antagonist treatment occurred uniformly across all three trials. In the trial of enzalutamide ± PROSTVAC for metastatic CRPC, high cortisol/cortisone ratio in the enzalutamide arm was associated with significantly improved progression-free survival. However, in the enzalutamide + PROSTVAC arm, the opposite trend was observed.

CONCLUSION

Enzalutamide and apalutamide treatment toggles renal 11β-HSD2 and significantly increases indicators of and exposure to biologically active glucocorticoids, which is associated with clinical outcomes.

The Effects of Previous Error and Success in Alzheimer's Disease and Mild Cognitive Impairment

This work investigated in Alzheimer’s disease dementia (AD), whether the probability of making an error on a task (or a correct response) was influenced by the outcome of the previous trials. We used the antisaccade task (AST) as a model task given the emerging consensus that it provides a promising sensitive and early biological test of cognitive impairment in AD. It can be employed equally well in healthy young and old adults, and in clinical populations. This study examined eye-movements in a sample of 202 participants (42 with dementia due to AD; 65 with mild cognitive impairment (MCI); 95 control participants). The findings revealed an overall increase in the frequency of AST errors in AD and MCI compared to the control group, as predicted. The errors on the current trial increased in proportion to the number of consecutive errors on the previous trials. Interestingly, the probability of errors was reduced on the trials that followed a previously corrected error, compared to the trials where the error remained uncorrected, revealing a level of adaptive control in participants with MCI or AD dementia. There was an earlier peak in the AST distribution of the saccadic reaction times for the inhibitory errors in comparison to the correct saccades. These findings revealed that the inhibitory errors of the past have a negative effect on the future performance of healthy adults as well as people with a neurodegenerative cognitive impairment.