Sizing Up General Practice Environments for Big-Bodied Patients: An Environmental Assessment of Three Facilities in Aotearoa New Zealand

OBJECTIVES

This research describes the physical environments of and equipment in Aotearoa New Zealand (NZ) general practices in relation to available standards for big-bodied people (BBP) seeking healthcare.

BACKGROUND

The prevalence of BBP both in NZ and globally has increased over the last 30 years and is expected to increase further. As the first and most utilized point of contact for patients in NZ and many countries, it is essential that general practices provide suitable environments to cater for and meet the needs of big-bodied patients seeking healthcare.

METHODS

An exploratory study utilizing an environmental investigation was undertaken in three diverse general practices. Data collection consisted of direct observation and physical measurements of practice layout and equipment. Findings were compared to the existing guidelines or standards for the healthcare of BBP.

RESULTS

The analysis identified most environmental facets and equipment in all three general practices did not meet published guidelines for the care of BBP.

CONCLUSIONS

In the global context of increasing and sustained prevalence of BBP, this exploratory study highlights it is crucial that general practices and similar community-based facilities review their physical environments and equipment and consider modifications to improve accessibility, inclusivity, and comfort for BBP.

Developing a transgender and non-binary inclusive obstetrics and gynaecology undergraduate medical curriculum in Aotearoa/New Zealand: Where are we at, and where do we need to be?

Internationally, undergraduate medical education is not currently enabling early career doctors to meet the needs of trans and gender diverse (TGD) people as healthcare consumers. This review outlines inclusion of TGD education in undergraduate medical education more broadly to contextualise curriculum development needs in obstetrics, gynaecology and reproductive medicine in Aotearoa/New Zealand. Limited, and lack of integrated content, teaching capability and current absence of TGD health knowledge as graduate outcomes, compounded by pedagogy (biomedical/binary framing) and more appropriate learning resources are indicators for curricula, and workforce, development.

New Zealand hospice staff perspectives on 'Xcellent Gowns' for big bodied palliative care patients: a qualitative study

Introduction A handful of reports detail efforts to redesign traditional hospital gowns to address common concerns related to patient comfort and privacy for big bodied patients. Results suggest that improving gown design has the potential to improve both the patient and carer experience and satisfaction of care. Aim This study aimed to ascertain the utility of gowns purposely designed for big bodied patients (named Xcellent Gowns) from a staff perspective. Methods Qualitative semi-structured interviews were conducted in 2022 with 14 hospice staff members. Interview transcripts were uploaded to DedooseTM . Data were analysed utilising reflexive thematic analysis according to a six-phase process including data familiarisation, iterative data coding, and theme development and refinement. Results The qualitative analysis of the interview data identified four main themes: (1) the gown experience, (2) fit-for-purpose, (3) love and dignity, (4) design principles. Each theme is presented and discussed with illustrative quotes from participants' interview transcripts. Discussion The perspectives of the staff participants in this study confirm research findings from other healthcare settings, that the patient and carer experience may be improved through focused redesign of this vital item of patient clothing.

Mental health, psychological distress and burnout in Australian dental practitioners

BACKGROUND

Dental practitioners are known to experience a high level of stress, but little is known about the mental health of Australian dental practitioners. The aim of this study was to investigate the prevalence of mental health conditions among Australian dental practitioners.

METHODS

A cross sectional survey of 1483 Australian dental practitioners was carried out from October to December 2021. Participants reported aspects of mental health including depression, anxiety disorder, burnout (Sydney Burnout Measure) and psychological distress (Kessler Psychological Distress Scale and General Health Questionnaire 12).

RESULTS

Self-reported psychological distress was high, with 32.0% rated as having moderate or severe psychological distress and 59.4% a high likelihood of minor (or more severe) psychological distress. One in four participants (24.8%) were classified as likely to be experiencing burnout, with 25.9% reporting ever having a diagnosis of depression, 11.4% a current diagnosis of depression, 23.1% ever having a diagnosis of anxiety disorder and 12.9% a current diagnosis of anxiety disorder.

CONCLUSION

Australian dental practitioners reported a high burden of psychological distress, burnout and mental health issues, suggesting a need for education and programmes to support their mental health and wellbeing. © 2023 Australian Dental Association.

Australian dental practitioners experience of burnout

BACKGROUND

The aim of this study was to investigate factors associated with burnout in Australian dental practitioners.

METHODS

A cross-sectional survey of 1483 Australian dental practitioners was conducted from Oct to Dec 2021. Participants reported burnout using the Sydney Burnout Measure, and aspects of mental health including psychological distress, depression, and anxiety disorders. Predictors of burnout were explored using a generalized linear model with a stepped approach including demographic, health and risk factor variables.

RESULTS

One in four participants were classified as likely to be experiencing burnout. Burnout was associated with working in a regional/rural location (β = 2.82, p < 0.001), an academic/non-clinical role (β = 5.01, p = 0.037), more years of experience as a dental practitioner (β = 0.08, p = 0.022), a current diagnosis of depression (β = 2.38, p = 0.049), moderate/severe psychological distress (β = 7.16, p < 0.001), poor self-rated physical health (β = 5.84, p < 0.001) and increasing alcohol consumption (β = 0.17, p = 0.020). Participants who scored high on resilience (β = -0.23, p = 0.002) or perfectionism (β = -0.24, p < 0.001) had lower burnout scores.

CONCLUSION

Australian dental practitioners appear to be at high risk of burnout which may impact on their health and wellbeing and ability to deliver patient care. There is a need for support services to manage burnout and education to address workplace and environmental factors that may contribute to burnout.

Features of Congenital Arthrogryposis Due to Abnormalities in Collagen Homeostasis, a Scoping Review

Congenital arthrogryposis (CA) refers to the presence of multiple contractures at birth. It is a feature of several inherited syndromes, notable amongst them are disorders of collagen formation. This review aims to characterize disorders that directly or indirectly impact collagen structure and function leading to CA in search for common phenotypic or pathophysiological features, possible genotype-phenotype correlation, and potential novel treatment approaches based on a better understanding of the underlying pathomechanism. Nine genes, corresponding to five clinical phenotypes, were identified after a literature search. The most notable trend was the extreme phenotype variability. Clinical features across all syndromes ranged from subtle with minimal congenital contractures, to severe with multiple congenital contractures and extra-articular features including skin, respiratory, or other manifestations. Five of the identified genes were involved in the function of the Lysyl Hydroxylase 2 or 3 enzymes, which enable the hydroxylation and/or glycosylation of lysyl residues to allow the formation of the collagen superstructure. Whilst current treatment approaches are post-natal surgical correction, there are also potential in-utero therapies being developed. Cyclosporin A showed promise in treating collagen VI disorders although there is an associated risk of immunosuppression. The treatments that could be in the clinical trials soon are the splice correction therapies in collagen VI-related disorders.

Development of a robust induced pluripotent stem cell atrial cardiomyocyte differentiation protocol to model atrial arrhythmia

BACKGROUND

Atrial fibrillation is the most common arrhythmia syndrome and causes significant morbidity and mortality. Current therapeutics, however, have limited efficacy. Notably, many therapeutics shown to be efficacious in animal models have not proved effective in humans. Thus, there is a need for a drug screening platform based on human tissue. The aim of this study was to develop a robust protocol for generating atrial cardiomyocytes from human-induced pluripotent stem cells.

METHODS

A novel protocol for atrial differentiation, with optimized timing of retinoic acid during mesoderm formation, was compared to two previously published methods. Each differentiation method was assessed for successful formation of a contractile syncytium, electrical properties assayed by optical action potential recordings and multi-electrode array electrophysiology, and response to the G-protein-gated potassium channel activator, carbamylcholine. Atrial myocyte monolayers, derived using the new differentiation protocol, were further assessed for cardiomyocyte purity, gene expression, and the ability to form arrhythmic rotors in response to burst pacing.

RESULTS

Application of retinoic acid at day 1 of mesoderm formation resulted in a robust differentiation of atrial myocytes with contractile syncytium forming in 16/18 differentiations across two cell lines. Atrial-like myocytes produced have shortened action potentials and field potentials, when compared to standard application of retinoic acid at the cardiac mesoderm stage. Day 1 retinoic acid produced atrial cardiomyocytes are also carbamylcholine sensitive, indicative of active I_kach currents, which was distinct from ventricular myocytes and standard retinoic addition in matched differentiations. A current protocol utilizing reduced Activin A and BMP4 can produce atrial cardiomyocytes with equivalent functionality but with reduced robustness of differentiation; only 8/17 differentiations produced a contractile syncytium. The day 1 retinoic acid protocol was successfully applied to 6 iPSC lines (3 male and 3 female) without additional optimization or modification. Atrial myocytes produced could also generate syncytia with rapid conduction velocities, > 40 cm s^-1, and form rotor style arrhythmia in response to burst pacing.

CONCLUSIONS

This method combines an enhanced atrial-like phenotype with robustness of differentiation, which will facilitate further research in human atrial arrhythmia and myopathies, while being economically viable for larger anti-arrhythmic drug screens.

Taking up the challenge of trans and non-binary inclusion in midwifery education: Reflections from educators in Aotearoa and Ontario Canada

Perinatal services are being challenged to acknowledge that not all pregnant and birthing people are women and to ensure the design and delivery of services that are inclusive of, and deliver equitable outcomes for, trans, non-binary, and other gender diverse people. This is posing unique challenges for midwifery with its women-centred philosophy and professional frameworks. This paper presents the critical reflections of midwifery educators located in two midwifery programmes in Aotearoa¹ and Ontario Canada, who are engaged in taking up the challenge of trans and non-binary inclusion in their local contexts. The need to progress trans and non-binary inclusion in midwifery education to secure the human rights of gender diverse people to safe midwifery care and equitable perinatal outcomes is affirmed. We respond to an existing lack of research or guidance on how to progress trans and non-binary inclusion in midwifery education. We offer our insights and reflections organised as four themes located within the frameworks of cultural humility and safety. These themes address midwifery leadership for inclusion, inclusive language, a broader holistic approach, and the importance of positioning this work intersectionally. We conclude by affirming the critical role of midwifery education/educators in taking up the challenge of trans and non-binary inclusion to ensure a future midwifery workforce skilled and supported in the provision of care to the growing gender diverse population.

875 Use of Oriented Priors Through Magnetic Tractography (MAGNET) In Deliniation Of Meyer's Loop and Correlation with Visual Field Deficit In Temporal Lobe Epilepsy (TLE) Surgery: A Pilot Study

Introduction

Pre-operative white matter tract reconstruction of the Meyer’s loop (ML) of the optic radiation using diffusion MRI (tractography) can be used to prevent post-operative visual-field deficit. Due to its complex anatomy, precise reconstruction of the ML is challenging and often underestimated. Previous work has suggested that an innovative tractography technique using oriented priors called MAGNET better approximates reconstruction to reported histological prosections. This proof-of-context study validates the MAGNET methodology in predicting visual-field deficits in patients undergoing TLE surgery.

Method

Diffusion MRI datasets were used to reconstruct pre-operative ML using MAGNET in five patients. These were overlaid on post-operative T2-MRI series demonstrating the surgically resected area to measure overlap between resection and reconstructed ML. A correlation with post-operative visual-field defects was established.

Results

There was no evidence of visual field deficit in the cases where there was no overlap between the reconstructed ML and the resected region. In the cases with overlap with reconstructed ML and resection, there was visual deficit found. There was no correlation between proportion of resected ML and visual deficit.

Conclusions

This pilot demonstrates that MAGNET accurately reconstructs ML in pre-surgical TLE cases compared to standard tractography techniques and can be used to augment neurosurgical planning and resection.

Resisting the problematisation of fatness in COVID-19: In pursuit of health justice

The purpose of this paper is to explore the problematisation of fatness in contemporary responses to the COVID-19 pandemic. This paper draws from the catalogue of reports from journalists informed largely by an array of non-peer reviewed scientific literature documenting the relationship between fatness and COVID-19. Our method of enquiry is to examine fatness and COVID-19 through a problematisation lens that enables us to interrogate the scientific, political, and economic processes implicated in the production of fat bodies as problems. Fatness has been problematised in the COVID-19 pandemic. This has diverted responsibility for preparedness and well-being away from health systems and governments and onto the back of fat people and communities. This is unjust and unethical. In juxtaposition, fat activists around the world have challenged the problematisation of fatness and its effects, finding ways for fat people to subvert fat phobic institutions in the midst of the COVID-19 pandemic by collectively organising to support one another. The ways in which fatness is being taken up in current COVID-19 pandemic responses diverts responsibility for health system preparedness and community resiliency to fat individuals. This is both unjust and also obstructs meaningful action to address the health inequities laid bare by COVID-19. This paper is believed to be the first to analyse the problematisation of fatness in COVID-19, highlighting that lessons can be learned about health justice in disasters from the work of fat activists during this COVID-19 pandemic.

Acoustic shock: an update review

BACKGROUND

This paper discusses the concept of acoustic shock based on a literature review and the results of our own research into cases seen in both clinical and medicolegal practice. With the demise of traditional 'metal bashing' and 'smoke stack' heavy industries, there has been a decline in the incidence of noise-induced hearing loss and tinnitus in this form of employment. However, with the increasing establishment of call centre work, the emergence of acoustic shock has been noted. Acoustic shock is recognised as a clinical entity distinct from noise-induced hearing loss and acoustic trauma.

OBJECTIVE

This article discusses clinical implications, medicolegal considerations in light of a recent high-profile court case and proposed criteria for diagnosis.

Refined diagnostic criteria for the bipolar disorders: phase two of the AREDOC project

OBJECTIVE

As limitations exist across DSM criteria sets for defining and differentiating the bipolar disorders generally and their component bipolar I (BP-1) and bipolar II (BP-II) sub-types, we sought to generate empirically based criteria.

METHOD

We formed an international Task Force (TF) comprising members with bipolar disorder expertise, and who recruited 74 patients with a TF-diagnosed bipolar I and 104 with a bipolar II condition (with patients responding to definitional queries and symptom questionnaires), while 33 unipolar depressed patients recruited by the first author also completed the symptom questionnaire. A factor analysis sought to determine granular hypo/manic constructs.

RESULTS

The bipolar disorder subjects strongly affirmed a new general definition of a bipolar disorder (capturing both manic and hypomanic episodes). While DSM-5 requires impaired functioning, we established that a high percentage of individuals with a BP-I or a BP-II disorder reported improved functioning and therefore modified this criterion. Analyses identified syptoms with differential high rates in individuals with bipolar disorder and its sub-types (and thus not simply capturing happiness), while a factor analysis generated seven symptom constructs both linked with and differing from DSM-5 bipolar symptom criteria.

CONCLUSION

This second-stage report details a new set of criteria for differentiating the bipolar disorders from unipolar depressive conditions, while arguing for BP-I and BP-II disorders being differentiated principally by the respective presence or absence of psychotic features. Future studies will evaluate whether further modifications are required and examine for differential treatment benefits for those with a BP-I versus a BP-II condition.

Differentiating clinical and non-clinical depression: a heuristic study offering a template for extension studies

OBJECTIVE

To differentiate clinical and non-clinical depression via a set of symptoms.

METHODS

A sample of 140 patients attending a clinical service for those with mood disorders together with 40 subjects denying ever experiencing a clinical episode of depression were compared, with participants completing a questionnaire capturing many symptoms of depression as well as illness correlates.

RESULTS

A latent class analysis of symptom data identified two classes and with class assignment corresponding strongly with initial clinical vs. non-clinical assignment. Univariate analyses identified the extent to which individual symptoms contributed to differentiation. Study data suggested DSM criteria that would benefit from re-writing or of reassignment. Two models for classifying clinical depression were generated. The first involved individuals feeling hopeless and also being suicidal or at risk of self-harm. The second involved a symptom set corresponding to DSM-5 criteria but with only five making significant independent contributions to diagnostic differentiation.

CONCLUSION

The study is heuristic in offering a strategy for more precisely differentiating clinical and non-clinical depression in more representative samples, so allowing resolution of key features, and determining whether a monothetic or polythetic diagnostic symptom criterion model is optimal.

Development of a Scale to Measure Interpersonal Sensitivity

We describe the development of a self-report measure (the Interpersonal Sensitivity Measure or IPSM). The IPSM generates a total score as well as five sub-scale scores: interpersonal awareness, need for approval, separation anxiety, timidity and fragile inner-self. Its reliability is demonstrated by high internal consistency in two separate groups, and by stability in scores over time in a non-clinical group. Studies of a clinical group of depressives showed change in scale scores following improvement in the depressive state, suggesting some sensitivity of the measure to mood state. The IPSM appears related to measures of neuroticism and to low self-esteem but not to a modified concept of neuroticism, emotional arousability. The constructs contributing to interpersonal sensitivity and their relevance to depression are considered. Some preliminary findings of higher scores in depressives compared to non-depressives are reported.

Productive but not constructive: The work of shame in the affective governance of fat Pregnancy

The productivity of shame as an affective-discursive practice implicated in the neoliberal governance of “healthy pregnancy” is examined in the narratives of 27 ethnically diverse, cis-gendered, self-identified fat pregnant people in Aotearoa New Zealand. Shame is identified as a dominant affective-discursive practice produced in response to the problematising medical discourses surrounding the fat pregnant body, leading to the constitution of shamed maternal subjectivities. Seeking reparation in order to restore their maternal identities, participants adopted a range of self-governance strategies. However, fat shaming, while productive in constituting self-governed maternal subjects, was not constructive. We demonstrate how shame induced self-governed action, rather than improving maternal and infant health, instead led to a range of unhealthful behaviours and negatively impacted how participants experienced their pregnancies, emerging maternal selves, and newly born children. We call for attention to affect in feminist governmentality studies of reproduction and fatness.

How to choose an antidepressant medication

OBJECTIVE

We consider how to choose an antidepressant (AD) medication for the treatment of clinical depression.

METHOD

A narrative review was undertaken addressing antidepressant 'choice' considering a range of parameters either weighted by patients and clinicians or suggested in the scientific literature. Findings were synthesised and incorporated with clinical experience into a model to assist AD choice.

RESULTS

Efficacy studies comparing ADs offer indicative guidance, while precision psychiatry prediction based on genetics, developmental trauma, neuroimaging, behavioural and cognitive biomarkers, currently has limited clinical utility. Our model offers guidance for AD choice by assessing first for the presence of a depressive subtype or symptom cluster and matching choice of AD class accordingly. Failing this, an AD can be chosen based on depression severity. Within-class choice can be determined by reference to personality style, patient preference, medical or psychiatric comorbidities and side-effect profile.

CONCLUSION

Clarification of AD choice would occur if medications are trialled in specific depressive subtypes rather than using the generic diagnosis of major depressive disorder (MDD). Such 'top-down' methods could be enhanced by 'bottom-up' studies to classify individuals according to symptom clusters and biomarkers with AD efficacy tested in these categories. Both methods could be utilised for personalised AD choice.

Is gentrification all bad? Positive association between gentrification and individual's perceived neighborhood collective efficacy in Montreal, Canada

Background

Collective efficacy has been associated with many health benefits at the neighborhood level. Therefore, understanding why some communities have greater collective efficacy than others is important from a public health perspective. This study examined the relationship between gentrification and collective efficacy, in Montreal Canada.

Methods

A gentrification index was created using tract level median household income, proportion of the population with a bachelor’s degree, average rent, proportion of the population with low income, and proportion of the population aged 30–44. Multilevel linear regression analyses were conducted to measure the association between gentrification and individual level collective efficacy.

Results

Gentrification was positively associated with collective efficacy. Gentrifiers (individuals moving into gentrifying neighborhoods) had higher collective efficacy than individuals that lived in a neighborhood that did not gentrify. Perceptions of collective efficacy of the original residents of gentrifying neighborhoods were not significantly different from the perceptions of neighborhood collective efficacy of gentrifiers.

Conclusions

Our results indicate that gentrification was positively associated with perceived collective efficacy. This implies that gentrification could have beneficial health effects for individuals living in gentrifying neighborhoods.

Targeting and transforming major depression

OBJECTIVE

To detail limitations to the construct of 'major depression', argue for repositioning it as a proxy for 'clinical depression' and then operationalize it and its principal constituent depressive subtypes, while preserving the DSM criteria-based format.

METHOD

We summarize limitations to major depression being viewed as a diagnostic entity. Data from 391 clinically depressed patients were analysed to identify high-prevalence non-specific depressive symptoms to define 'clinical depression' as well as the features showing specificity to a melancholic depressive subtype.

RESULTS

We identified a set of high-prevalence and generalized symptoms for defining clinical depression and with many being current criteria for major depression. We also developed a refined set of melancholic features and with their underlying distributions generating two classes that correlated strongly with clinical diagnoses of a melancholic or non-melancholic depression, thus validating its capacity to so differentiate. We append criteria sets for diagnosing clinical depression and its principal diagnostic subtypes (psychotic, melancholic and non-melancholic).

CONCLUSION

This heuristic study reframes and modifies major depression's criteria set to define a domain of clinical depression with additional criteria and then allowing the delineation of three diagnostic subtypes. If this paradigm shift is accepted and further refined, greater precision in diagnosis, treatment and research would be anticipated.

AEOL 10150 Mitigates Radiation-Induced Lung Injury in the Nonhuman Primate: Morbidity and Mortality are Administration Schedule-Dependent

Pneumonitis and fibrosis are potentially lethal, delayed effects of acute radiation exposure. In this study, male rhesus macaques received whole-thorax lung irradiation (WTLI) with a target dose of 10.74 Gy prescribed to midplane at a dose rate of 0.80 ± 0.05 Gy/min using 6 MV linear accelerator-derived photons. The study design was comprised of four animal cohorts: one control and three treated with AEOL 10150 (n = 20 animals per cohort). AEOL 10150, a metalloporphyrin antioxidant, superoxide dismutase mimetic was administered by daily subcutaneous injection at 5 mg/kg in each of three schedules, beginning 24 ± 2 h postirradiation: from day 1 to day 28, day 1 to day 60 or a divided regimen from day 1 to day 28 plus day 60 to day 88. Control animals received 0.9% saline injections from day 1 to day 28. All animals received medical management and were followed for 180 days. Computed tomography (CT) scan and baseline hematology values were assessed prior to WTLI. Postirradiation monthly CT scans were collected, and images were analyzed for evidence of lung injury (pneumonitis, fibrosis, pleural and pericardial effusion) based on differences in radiodensity characteristics of the normal versus damaged lung. The primary end point was survival to 180 days based on all-cause mortality. The latency, incidence and severity of lung injury were assessed through clinical, radiographic and histological parameters. A clear survival relationship was observed with the AEOL 10150 treatment schedule and time after lethal WTLI. The day 1-60 administration schedule increased survival from 25 to 50%, mean survival time of decedents and the latency to nonsedated respiratory rate to >60 or >80 breaths/min and diminished quantitative radiographic lung injury as determined by CT scans. It did not affect incidence or severity of pneumonitis/fibrosis as determined by histological evaluation, pleural effusion or pericardial effusion as determined by CT scans. Analysis of the Kaplan-Meier survival curves suggested that treatment efficacy could be increased by extending the treatment schedule to 90 days or longer after WTLI. No survival improvement was noted in the AEOL 10150 cohorts treated from day 1-28 or using the divided schedule of day 1-28 plus day 60-88. These results suggest that AEOL 10150 may be an effective medical countermeasure against severe and lethal radiation-induced lung injury.

Geophysical Variables and Behavior: Xcix. Reductions in Numbers of Neurons within the Parasolitary Nucleus in Rats Exposed Perinatally to a Magnetic Pattern Designed to Imitate Geomagnetic Continuous Pulsations: Implications for Sudden Infant Death

Correlational analyses have shown a moderate strength association between the occurrence of continuous pulsations, a type of geomagnetic activity within the 0.2-Hz to 5-Hz range, and the occurrence of Sudden Infant Deaths. In the present study, rats were exposed continuously from two days before birth to seven days after birth to 0.5-Hz pulsed-square wave magnetic fields whose intensities were within either the nanoTesla or microTesla range. The magnetic fields were generated in either an east-west (E-W) or north-south (N-S) direction. At 21 days of age, the area of the parasolitary nucleus (but not the solitary nucleus) was significantly smaller, and the numbers of neurons were significantly less in rats that had been exposed to the nanoT fields generated in the east-west direction or to the microTesla fields generated within either E-W or N-S direction relative to those exposed to the N-S nanoTesla fields. These results suggest nanoTesla magnetic fields, when applied in a specific direction, might interact with the local geomagnetic field to affect cell migration in structures within the brain stem that modulate vestibular-related arousal and respiratory or cardiovascular stability.

The impact of climate on risk of mania

Introduction

Bipolar disorder varies with season: admissions for depression peak in winter and mania peak in summer. Sunlight presumably increases the risk of mania through suppression of melatonin. If so, we expect admissions for mania to vary in accordance with climate variations.

Objectives

To investigate how climate and climate changes affects admissions for mania.

Aims

To identify which climate variables – sunshine, ultraviolet radiation, rain and snow cover – affect admissions for mania.

To examine whether year-to-year weather variation as well as long-term climate changes reflects the variation in number of admissions for mania.

Methods

This register-based nationwide cohort study covers all patients admitted for mania (ICD-10 code F31 or F30.0–F30.2) between 1995 and 2012 in Denmark. Climate data, obtained from the Danish Meteorological Institute, were merged with admission data and correlated using an Unobserved Component Model regression model.

Preliminary results

In total, 8893 patients were admitted 24,313 times between 1995 and 2012: 6573 first-admissions and 17,740 readmissions. Linear regression shows significant association between admissions per day and hours of sunshine (P < 0.01) and ultraviolet radiation (UV) dose (P < 0.01). Average days with snow cover and rain were not significantly correlated with admissions. Analyses on year-to-year variation and long-term change are not yet available.

Preliminary conclusions

Admissions for mania are correlated with sunshine and UV, but not rain and snow cover. If more patients are admitted during very sunny summers compared with less sunny summers this implies a relation with light itself and not just season.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Quantification of sodium pentobarbital residues from equine mortality compost piles

Sodium pentobarbital, a euthanasia drug, can persist in animal carcasses following euthanasia and can cause secondary toxicosis to animals that consume the remains. This experiment was conducted to observe the effects of composting on euthanized horse carcass degradation and sodium pentobarbital residues in compost material up to 367 d. Six separate compost bins were constructed on pastureland. Three bins served as the control while 3 served as the treatment. The carbonaceous material, or bulking agent, consisted of hardwood chips mixed with yard waste wetted to approximately 50% moisture content. Bulking agent was added to each bin at a depth of 0.46 m, creating the pad. A licensed veterinarian provided 6 horse carcasses for use in the experiment. These horses had required euthanasia for health reasons. All horses were weighed and then sedated with an intravenous injection of 8 mL of xylazine. After sedation the 3 horses in the treatment group were euthanized by intravenous injection of 60 mL of sodium pentobarbital. The 3 control group horses were anesthetized by intravenous injection of 15 mL of ketamine hydrochloride and then humanely euthanized by precise gunshot to the temporal lobe. Following euthanasia, each carcass was placed on the center of the pad and surrounded with 0.6 m of additional bulking agent. Serum and liver samples were obtained immediately following death. Compost samples were obtained on d 7, 14, 28, 56, 84, 129, 233, and 367 while soil samples were obtained on d -1 and 367. Each sample was analyzed for sodium pentobarbital concentration. Compost pile and ambient temperatures were also recorded. Composting successfully degraded soft tissue with only large bones remaining. Data illustrate that sodium pentobarbital was detectable up to 367 d in compost piles with no clear trend of concentration reduction. Drug residues were detected in soil samples indicating that sodium pentobarbital leached from the carcass and through the pad. These findings confirm the persistence of sodium pentobarbital from equine mortality compost piles and emphasize the importance of proper carcass management of animals euthanized with a barbiturate to reduce environmental impact and secondary toxicosis.

The 'disconnect' between initial judgments of lamotrigine vs. its real-world effectiveness in managing bipolar disorder. A tale with wider ramifications

OBJECTIVE

To detail the disconnect between the quantified efficacy of the mood stabilizer lamotrigine in its registration controlled trials and its later judged clinical effectiveness and consider some determinants of disconnects between some efficacy trial findings and 'real-world' clinical effectiveness judgments.

METHOD

Published articles considering lamotrigine as a treatment for the bipolar I or II disorders were selected for review. While randomized controlled trials were weighted, we also consider open trials and effectiveness observations from clinician researchers and demonstrate that lamotrigine has been quite variably judged over time.

RESULTS

We suggest that the early trials evaluating lamotrigine for acute bipolar disorder depression focused on a suboptimal clinical target, and in so doing, ensured less lamotrigine efficacy compared with trials of bipolar disorder preventative treatment. Moreover, a number of additional methodological limitations compromised analyses. We also detail variable reporting of actual study results. The initial sharp disconnect (between efficacy and effectiveness judgments) has narrowed as lamotrigine has been evaluated and progressively taken up as a maintenance mood stabilizer.

CONCLUSION

The lamotrigine disconnect story provides a number of salutary lessons that are salient to evaluating the effectiveness and ecological niche of any psychotropic medication. The lamotrigine story presented here argues strongly for the wisdom of encouraging an iterative process between efficacy studies and clinical observation.

The utility of a classificatory decision tree approach to assist clinical differentiation of melancholic and non-melancholic depression

BACKGROUND

Studies suggest that differentiating melancholic from non-melancholic depressive disorders is advanced by use of illness course as well as symptom variables but, in practice, potentially differentiating variables are generally positioned as having equal value. Judging that differentiating features are more likely to vary in their signal intensity, we sought to determine the number of features required to effect differentiation and their hierarchical order.

METHODS

The 24-item clinician-rated Sydney Melancholia Prototype Index (SMPI-CR) was completed for 364 unipolar depressed patients. The sample was divided into two cohorts according to the recruitment period. An RPART classification tree analysis identified the most discriminating SMPI items in the development sample of 197 patients, and examined the sensitivity and specificity of the diagnostic decisions, then sought to replicate findings in a validation sample of 169 patients.

RESULTS

Independent analyses of putative SMPI items identified only seven items as required to discriminate those with clinically-diagnosed melancholic or non-melancholic depression when the conditions were examined separately. An RPART analysis considering differentiation of melancholic and non-melancholic depression in the total samples retained five of those items in the classification tree, three of which were non-symptom items, and with 92% sensitivity and 80% specificity in the development sample. This reduced item set showed 93% sensitivity and 82% specificity in the validation sample.

LIMITATIONS

Our clinical judgment of melancholic or non-melancholic depression may not correspond with the clinical logic employed by other clinicians.

CONCLUSION

Only five SMPI items were required to derive a succinct and efficient decision tree, comprising high sensitivity and specificity in differentiating melancholic and non-melancholic depression. Current study findings provide an empirical model that could enrich clinicians׳ approach to differentiating melancholic and non-melancholic depression.

Differentiating 'clinical' and 'non-clinical' depression

OBJECTIVE

There has been increasing concern about extensions to the definition of 'clinical' depression, but little evident investigation as to how clinical and non-clinical depressive states might best be differentiated. This review considers the potential of many candidate symptom and non-symptom parameters.

METHOD

We overview representative concerns and theories about the nature of psychiatric disorders before reviewing the potential utility of candidate parameters for differentiating clinical and non-clinical depressive states.

RESULTS

While we detail limitations to all candidate parameters designed to distinguish between clinical and non-clinical depression, their actual utility may only be able to be judged by empirical testing across appropriate comparison groups.

CONCLUSION

We argue for initial comparisons being made between prototypically defined categorical (i.e. psychotic, melancholic and bipolar) depressive disease states and residual non-melancholic clinical depressive states, before considering how each of those two clinical subsets might differ from non-clinical depressive mood states.

Cleaving depressive diseases from depressive disorders and non-clinical states

OBJECTIVE

We sought to determine whether putative depressive diseases could be differentiated categorically from clinical depressive disorders and non-clinical mood states.

METHOD

We interviewed volunteers who reported or denied any lifetime depressive mood state and analyzed data from the former group reporting on their 'most severe' depressive episode. We employed latent class analysis (LCA) to determine whether a two-class solution was supported and the contribution of individual variables to class allocations.

RESULTS

All variables were significant predictors of class allocation. LCA-assigned Class I participants reported more depressive symptoms, had more distressing episodes and more lasting consequences, were more likely to view their depression as 'like a disease', and as being both disproportionately more severe and persistent in relation to any antecedent stressor. Validation involved comparison of LCA assignment with DSM-IV diagnosis for their most severe depressive episode. Of those assigned to Class I, 89% had a DSM diagnosis of melancholic, psychotic or bipolar depression. Class II had all those failing to meet criteria for a depressive episode and the majority of those with a non-melancholic depressive condition.

CONCLUSION

Despite not including individual depressive symptoms, study variables strongly differentiated putative depressive diseases from a composite of clinical depressive conditions and subclinical depressive states.

Is essential fatty acid status in late pregnancy predictive of post-natal depression?

OBJECTIVE

We tested the hypothesis that abnormal levels of omega-3 and omega-6 polyunsaturated fatty acids (PUFAs) during late pregnancy are associated with antenatal and post-natal depression.

METHOD

We interviewed a sample of more than 900 women in late pregnancy. We assessed whether they met criteria for depression on a standardized measure of post-natal depression [the Edinburgh Post-natal Depression Scale (EPDS)] and met DSM-IV criteria for major depression and/or were in receipt of antidepressant medication. Blood was collected at that time to generate data on nine PUFA variables. Sample members were re-interviewed post-natally to determine depressive experience in the 3 months following the birth of their baby.

RESULTS

Univariate associations were demonstrated between pre-natal depression categorized using DSM criteria and measures of blood fatty acids including total omega-3, the ratio of omega-6 to omega-3, docosahexaenoic acid (DHA) omega-3 and DHA plus eicosapentaenoic acid (EPA) omega-3. Such associations were not found post-natally, but different associations were quantified between EPDS-diagnosed depression and total omega-6, total omega-3 and EPA omega-3. In multivariate analyses, slight associations were maintained between EPDS and lower omega-3, lower EPA and higher omega-6 when neuroticism, stress during pregnancy, a lifetime episode of depression and older age were included in the analysis.

CONCLUSION

Findings in such a large sample indicate that PUFA status in late pregnancy is only slightly linked with the risk of post-natal depression when depression was quantified by the EPDS. There were no associations between post-natal depression diagnosed by DSM criteria and any fatty acid variables.

Computational hemodynamics analysis of intracranial aneurysms treated with flow diverters: correlation with clinical outcomes

BACKGROUND AND PURPOSE

Recent studies have shown promising results regarding intracranial aneurysms treated with flow diverters. However, these have had adverse effects, including delayed aneurysm occlusion, posttreatment symptoms, and rupture. The hemodynamic profiles of aneurysms treated with flow diverters were analyzed to determine the ones associated with successful and failed treatments.

MATERIALS AND METHODS

Patient-specific computational fluid dynamics were used to simulate hemodynamic profiles, including the presence of jet flow, energy loss, volume flow, and wall shear stress in 4 successful occlusions of aneurysms and 4 failed cases after flow-diverter deployment. In these 4 failed cases, hemodynamic profiles were examined again after a hypothetic second intervention. This involved replacing the failed flow diverter with a hypothetic optimally deployed flow diverter or simulated placement of a second flow diverter within the first (double hypothetic optimally deployed).

RESULTS

Where successful occlusions were achieved, a marked obliteration of jet flow was observed. Flow entering the aneurysm sac was diverted via the center of the flow diverter and joined smoothly with the continuation of flow leaving the aneurysm sac into the parent arteries. These observations were supplemented by a reduction in the other hemodynamic profiles. Aneurysm neck geometry might influence the efficacy of the flow diverter.

CONCLUSIONS

Hemodynamic indices, as calculated by using computational fluid dynamics techniques, have close correlation with flow-diverter treatment outcome. Computational fluid dynamics could be potentially useful as a planning tool for neurointerventionists by simulating an optimized flow-diverter deployment strategy before the procedure and evaluating posttreatment outcome.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study

OBJECTIVE

To pursue the previously long-standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone.

METHOD

We sought to recruit a large sample of participants with melancholic depression for a 12-week trial but inclusion criteria compromised recruitment and testing the second hypothesis. The first hypothesis was evaluated by comparing 18 participants receiving antidepressant medication to 11 receiving CBT. Primary study measures were the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Endogenous Subscale (HES), rated blindly, while several secondary measures also evaluated outcome.

RESULTS

Participants receiving medication had a superior 12-week outcome to those receiving CBT, with significant differences present on primary measures as early as 4 weeks. At trial conclusion, the percentage improvement in HAM-D scores was 61.1% vs. 34.4%, respectively [Number Needed to Treat (NNT) = 3.7] and with those in receipt of medication returning non-significantly higher HAM-D responder (66.6% vs. 36.4%, NNT = 2.8) and remission (66.7% vs. 45.4%, NNT = 4.7) rates.

CONCLUSION

As the sample size was small and participants evidenced only moderate levels of depression severity, the study risked being underpowered and idiosyncratic. Despite the small sample, the superiority of antidepressant medication to CBT in those with a melancholic depression was distinctive in this pilot study.