Art therapy masks reflect emotional changes in military personnel with PTSS

Among disabling post-traumatic stress symptoms (PTSS) are irritability, aggressive behavior, distressing memories and general impaired cognition and negative mood. Art therapy interventions, including mask-making, can potentially alleviate these symptoms. We tested the hypothesis that art conveys emotions and predicted that blinded viewers would be able to perceive changes in theoretically derived emotional profiles expressed in art made by military personnel with PTSS from the onset to the end of therapy. Five service members and veterans exhibiting PTSS were enrolled in an 8-session art therapy protocol, during which they artistically transformed papier-mâché masks at the beginning and end of the protocol. We found that blinded viewers without knowledge of the masks' creation stage (onset or end of therapy) read initial masks as conveying more negative emotions (e.g., angry, upset, and challenged) and later masks as conveying more positive emotions (calm and pleasure). Based on the assessments from the blinded evaluators, we infer the emotional transition experienced by the participants was expressed in the masks. In an exploratory arm of the study, we also found that viewers were better able to empathize with the negative emotions experienced by participants with PTSS when asked to explicitly take their perspective.

Electronic stripe patterns near the fermi level of tetragonal Fe(Se,S)

FeSe1-xSx remains one of the most enigmatic systems of Fe-based superconductors. While much is known about the orthorhombic parent compound, FeSe, the tetragonal samples, FeSe1-xSx with x > 0.17, remain relatively unexplored. Here, we provide an in-depth investigation of the electronic states of tetragonal FeSe0.81S0.19, using scanning tunneling microscopy and spectroscopy (STM/S) measurements, supported by angle-resolved photoemission spectroscopy (ARPES) and theoretical modeling. We analyze modulations of the local density of states (LDOS) near and away from Fe vacancy defects separately and identify quasiparticle interference (QPI) signals originating from multiple regions of the Brillouin zone, including the bands at the zone corners. We also observe that QPI signals coexist with a much stronger LDOS modulation for states near the Fermi level whose period is independent of energy. Our measurements further reveal that this strong pattern appears in the STS measurements as short range stripe patterns that are locally two-fold symmetric. Since these stripe patterns coexist with four-fold symmetric QPI around Fe-vacancies, the origin of their local two-fold symmetry must be distinct from that of nematic states in orthorhombic samples. We explore several aspects related to the stripes, such as the role of S and Fe-vacancy defects, and whether they can be explained by QPI. We consider the possibility that the observed stripe patterns may represent incipient charge order correlations, similar to those observed in the cuprates.

Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

Validity and reliability of the behavioral signs of respiratory instability (BSRI) © scale during activity for infants with bronchopulmonary dysplasia

OBJECTIVE

There is no reliable evidence on how best to evaluate the overall status of infants with severe forms of bronchopulmonary dysplasia (BPD). The Behavioral Signs of Respiratory Instability (BSRI) scale was developed as an objective measure of developmental capacity during occupational and physical therapy sessions. The purpose of this study was to determine the psychometric properties of the BSRI Scale.

STUDY DESIGN

The BSRI and Respiratory Severity Score (RSS) were compared for 25 infants with BPD and 15 infants without BPD. A cross-sectional design was used to test inter-rater reliability among 10 NICU occupational and physical therapists. A prospective cohort design was used to evaluate validity.

RESULTS

The BSRI demonstrated good to excellent inter-rater reliability (ρ = 0.47-0.91) and was strongly correlated with RSS (ρ = -0.77, p < 0.001; concurrent validity).

CONCLUSION

The BSRI Scale has preliminary psychometric support. Standardized measures like the BSRI may provide accurate, objective data that can improve care planning within interdisciplinary teams that supports brain growth and potentially improves neurodevelopment.

A novel tool to quantify in vivo lumbar spine kinematics and 3D intervertebral disc strains using clinical MRI

Medical imaging modalities that calculate tissue morphology alone cannot provide direct information regarding the mechanical behaviour of load-bearing musculoskeletal organs. Accurate in vivo measurement of spine kinematics and intervertebral disc (IVD) strains can provide important information regarding the mechanical behaviour of the spine, help to investigate the effects of injuries on the mechanics of the spine, and assess the effectiveness of treatments. Additionally, strains can serve as a functional biomechanical marker for detecting normal and pathologic tissues. We hypothesised that combining digital volume correlation (DVC) with 3T clinical MRI can provide direct information regarding the mechanics of the spine. Here, we have developed a novel non-invasive tool for in vivo displacement and strain measurement within the human lumbar spine and we used this tool to calculate lumbar kinematics and IVD strains in six healthy subjects during lumbar extension. The proposed tool enabled spine kinematics and IVD strains to be measured with errors that did not exceed 0.17 mm and 0.5%, respectively. The findings of the kinematics study identified that during extension the lumbar spine of healthy subjects experiences total 3D translations ranging from 1 mm to 4.5 mm for different vertebral levels. The findings of strain analysis identified that the average of the maximum tensile, compressive, and shear strains for different lumbar levels during extension ranged from 3.5% to 7.2%. This tool can provide base-line data that can be used to describe the mechanical environment of healthy lumbar spine, which can help clinicians manage preventative treatments, define patient-specific treatments, and to monitor the effectiveness of surgical and non-surgical interventions.

An Extremely Rare Variant of Pancreatic Ductal Adenocarcinoma Masquerading as Chronic Pancreatitis

Introduction/Objective

Primary Pancreatic signet-ring cell carcinoma (PPSRCC) is an extremely rare histologic variant with sparse literature. Herein, we describe a case of PPSRCC in a 75-year-old female with positive family history of pancreatic cancer (47y/o brother). The diagnosis was delayed secondary to diagnostic challenges on initial fine-needle aspiration (FNA).

Methods/Case Report

Diagnosing PPSRCC on FNA can be extremely difficult. Primary, and metastatic neoplasms to the pancreas may exhibit cytomorphological similarities to signet-ring cells, posing diagnostic challenges. Further, sampling of abundant background inflammatory cells during a biopsy can result in incorrect diagnosis of pancreatitis. Given the strong clinical suspicion based on imaging findings, a second FNA was performed which showed few atypical cells suspicious for carcinoma. Subsequently, the patient underwent neoadjuvant chemotherapy and Whipple resection. The tumor morphology is characterized by infiltrating cells with large mucin vacuoles and peripheric nucleus comprising &gt; 50% of the mass lesion with perineural invasion, in a background of chronic inflammation and pancreatic intraepithelial neoplasia, grade III. A diagnosis of PPSRCC was rendered. Notably, lymph nodes (LN) showed no evidence of metastasis.

Results (if a Case Study enter NA)

NA.

Conclusion

Based on limited literature, PPSRCC is considered an aggressive malignancy with low survival rate, because of a high rate of metastasis. However, our case was rather unique given the lack of LN metastasis and the neodjuvant treatment strategy. As of February 2022, &lt;10 cases have been reported with ill-defined characteristics and treatment guidelines.

Is the Primary Tumor Site of Ampullary Carcinoma Distinct in the Setting of Morphology Subtype?

Introduction/Objective

Ampullary cancer (AC) are rare and represents only 6% of the malignant periampullary tumors. Two main histologic subtypes of AC are pancreatobiliary (Pb-AC), and intestinal (In-AC). The data on the influencing role of several characteristics associated with AC subtypes on long term outcome is still emerging. Our study aimed to analyze the two subtypes Pb-AC and In-AC regarding their primary tumor site, median overall survival, and associated precursor lesion.

Methods/Case Report

Using the cBioPortal platform and systematic bioinformatical analysis of the Cancer Genome Atlas Baylor College of Medicine Cell Reports, 2016, 133 AC patients were included and analyzed based on their morphology subtype. Of which 62 patients had the intestinal subtype, and 71 had the pancreaticobiliary morphological subtype.

Results (if a Case Study enter NA)

The role of primary tumor site was statistically significant (p-value = 0.01) among subtypes Pb-AC and In-AC (See Figure). Remarkably, the primary tumor site most associated with the pancreaticobiliary subtype was the distal bile duct, and the intestinal subtype was intra-ampullary. Additionally, the precursor lesion identification (absent vs present) was statistically significant among the subtypes (p-value = 0.01). Further, the median overall survival in ampullary carcinoma varied among the morphology of the two subtypes: In-AC (75.56 months, (95% CI: 57.04-NA)) and Pb-AC (27.04 months, (95% CI: 18.29-NA)).

Conclusion

The findings in this study highlight the complex multifactorial role of the two morphological subtypes in AC. Further studies are essential for understanding the underlying tumor site specific molecular signatures leading to subtyping and their impact on prognosis.

Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula

BACKGROUND

Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula.

METHODS

The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary.

RESULTS

Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments.

CONCLUSIONS

This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

A wearable multi-sensor system for real world gait analysis

Gait analysis is commonly performed in standardized environments, but there is a growing interest in assessing gait also in ecological conditions. In this regard, an important limitation is the lack of an accurate mobile gold standard for validating any wearable system, such as continuous monitoring devices mounted on the trunk or wrist. This study therefore deals with the development and validation of a new wearable multi-sensor-based system for digital gait assessment in free-living conditions. In particular, results obtained from five healthy subjects during lab-based and real-world experiments were presented and discussed. The in-lab validation, which assessed the accuracy and reliability of the proposed system, shows median percentage errors smaller than 2% in the estimation of spatio-temporal parameters. The system also proved to be easy to use, comfortable to wear and robust during the out-of-lab acquisitions, showing its feasibility for free-living applications.

The devil is in the detail: reflections on the value and application of cognitive interviewing to strengthen quantitative surveys in global health

Cognitive interviewing is a qualitative research method for improving the validity of quantitative surveys, which has been underused by academic researchers and monitoring and evaluation teams in global health. Draft survey questions are administered to participants drawn from the same population as the respondent group for the survey itself. The interviewer facilitates a detailed discussion with the participant to assess how the participant interpreted each question and how they formulated their response. Draft survey questions are revised and undergo additional rounds of cognitive interviewing until they achieve high comprehension and cognitive match between the research team's intent and the target population's interpretation. This methodology is particularly important in global health when surveys involve translation or are developed by researchers who differ from the population being surveyed in terms of socio-demographic characteristics, worldview, or other aspects of identity. Without cognitive interviewing, surveys risk measurement error by including questions that respondents find incomprehensible, that respondents are unable to accurately answer, or that respondents interpret in unintended ways. This methodological musing seeks to encourage a wider uptake of cognitive interviewing in global public health research, provide practical guidance on its application, and prompt discussion on its value and practice. To this end, we define cognitive interviewing, discuss how cognitive interviewing compares to other forms of survey tool development and validation, and present practical steps for its application. These steps cover defining the scope of cognitive interviews, selecting and training researchers to conduct cognitive interviews, sampling participants, collecting data, debriefing, analysing the emerging findings, and ultimately generating revised, validated survey questions. We close by presenting recommendations to ensure quality in cognitive interviewing.

A traditional Ugandan Ficus natalensis bark cloth exhibits antimicrobial activity against methicillin-resistant Staphylococcus aureus

AIMS

Surgical site, soft tissue and wound infections are some of the most prominent causes of healthcare-associated infections (HCAIs). Developing novel antimicrobial textiles and wound dressings may help alleviate the risk of developing HCAIs. We aimed to determine the antimicrobial efficacy of natural Ugandan bark cloth derived exclusively from the Ficus natalensis tree.

METHODS AND RESULTS

Antimicrobial contact and disc diffusion assays, coupled with time-kill kinetic assays, demonstrated that bark cloth inhibited the growth of a clinically relevant methicillin-resistant Staphylococcus aureus (MRSA) strain and acted as a bactericidal agent causing a seven-log reduction in bacterial viability. Scanning electron microscopy was used to reveal morphological changes in the bacterial cell ultrastructure when exposed to bark cloth, which supported a proposed mechanism of antimicrobial activity.

CONCLUSIONS

The observed antimicrobial properties, combined with the physical characteristics elicited by bark cloth, suggest this product is ideally suited for wound and other skin care applications.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report where a whole bark cloth product made by traditional methods has been employed as an antimicrobial fabric against MRSA. Bark cloth is a highly sustainable and renewable product and this study presents a major advance in the search for natural fabrics which could be deployed for healthcare applications.

"I can guess the month … but beyond that, I can't tell" an exploratory qualitative study of health care provider perspectives on gestational age estimation in Rajasthan, India

BACKGROUND

Accurately estimating gestational age is essential to the provision of time-sensitive maternal and neonatal interventions, including lifesaving measures for imminent preterm birth and trimester-specific health messaging.

METHODS

We explored healthcare provider perspectives on gestational age estimation in the state of Rajasthan, India, including the methods they use (last menstrual period [LMP] dating, ultrasound, or fundal height measurement); barriers to making accurate estimates; how gestational age estimates are documented and used for clinical decision-making; and what could help improve the accuracy and use of these estimates. We interviewed 20 frontline healthcare providers and 10 key informants. Thematic network analysis guided our coding and synthesis of findings.

RESULTS

Health care providers reported that they determined gestational age using some combination of LMP, fundal height, and ultrasound. Their description of their practices showed a lack of standard protocol, varying levels of confidence in their capacity to make accurate estimates, and differing strategies for managing inconsistencies between estimates derived from different methods. Many frontline healthcare providers valued gestational age estimation more to help women prepare for childbirth than as a tool for clinical decision making. Feedback on accuracy was rare. The providers sampled could not offer ultrasound directly, and instead could only refer women to ultrasound at higher level facilities, and usually only in the second or third trimesters because of late antenatal care-seeking. Low recall among pregnant women limited the accuracy of LMP. Fundal height was heavily relied upon, despite its lack of precision.

CONCLUSION

The accuracy of gestational age estimates is influenced by factors at four levels: 1. health system (protocols to guide frontline workers, interventions that make use of gestational age, work environment, and equipment); 2. healthcare provider (technical understanding of and capacity to apply the gestational age estimation methods, communication and rapport with clients, and value assessment of gestational age); 3. client (time of first antenatal care, migration status, language, education, cognitive approach to recalling dates, and experience with biomedical services); and, 4. the inherent limitations and ease of application of the methods themselves.

Short chain fatty acids in human gut and metabolic health

Evidence is accumulating that short chain fatty acids (SCFA) play an important role in the maintenance of gut and metabolic health. The SCFA acetate, propionate and butyrate are produced from the microbial fermentation of indigestible carbohydrates and appear to be key mediators of the beneficial effects elicited by the gut microbiome. Microbial SCFA production is essential for gut integrity by regulating the luminal pH, mucus production, providing fuel for epithelial cells and effects on mucosal immune function. SCFA also directly modulate host metabolic health through a range of tissue-specific mechanisms related to appetite regulation, energy expenditure, glucose homeostasis and immunomodulation. Therefore, an increased microbial SCFA production can be considered as a health benefit, but data are mainly based on animal studies, whereas well-controlled human studies are limited. In this review an expert group by ILSI Europe’s Prebiotics Task Force discussed the current scientific knowledge on SCFA to consider the relationship between SCFA and gut and metabolic health with a particular focus on human evidence. Overall, the available mechanistic data and limited human data on the metabolic consequences of elevated gut-derived SCFA production strongly suggest that increasing SCFA production could be a valuable strategy in the preventing gastro-intestinal dysfunction, obesity and type 2 diabetes mellitus. Nevertheless, there is an urgent need for well controlled longer term human SCFA intervention studies, including measurement of SCFA fluxes and kinetics, the heterogeneity in response based on metabolic phenotype, the type of dietary fibre and fermentation site in fibre intervention studies and the control for factors that could shape the microbiome like diet, physical activity and use of medication.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

A Brief Overview of Neurosurgical Management for Breast Cancer Metastasis

Despite advances in chemotherapy and radiation, stage IV breast cancer presents a serious challenge to clinicians in light of the continued poor outcomes for patients. Stage IV breast cancer frequently metastasizes to the brain often necessitating neurosurgical intervention. The goals of the neurosurgeon are to adequately address metastatic disease to the central nervous system, limit morbidity for the patients, while preserving as much neurologic function as possible, and to help guide next steps regarding need for radiation and immunotherapy. In this review, we provide a background overview of the role of neurosurgery in managing stage IV metastatic breast cancer involving the brain, discuss what is known about brain metastasis, and highlight avenues for future study and investigation.

Short communication: Risk factors identified at arrival associated with average daily gain at a grain-fed veal facility: A prospective single cohort study

The primary objective of this prospective cohort study was to identify factors evaluated upon arrival at a grain-fed veal facility that were associated with increased growth. A secondary objective was to determine if the factors associated with average daily gain (ADG) varied between the pre- and postweaning periods. Calves were visually assessed and scored using a standardized health scoring system immediately upon arrival. They were also weighed and vaccinated, and had blood drawn from their jugular vein to determine their serum total protein level. Weights were taken on d 49 and 78 after arrival and were used to calculate ADG. Three mixed linear regression models were created to determine factors associated with ADG from 0 to 49 d after arrival, 0 to 78 d after arrival, and 49 to 78 d after arrival. A total of 998 calves were evaluated and weighed upon arrival; 636 and 915 of those calves were weighed at d 49 and d 78, respectively. Mean ADG were 610 g/d from 0 to 49 d after arrival, 860 g/d from 0 to 78 d after arrival, and 1,240 g/d from 49 to 78 d after arrival. In the model evaluating growth from 0 to 49 d, calves arriving at the facility with a higher body mass index (BMI) gained more weight per day than calves that arrived with a lower BMI. If calves arrived in the spring, they gained 201 g/d more than calves that arrived in the winter. For the period following weaning (d 49 to 78), BMI was also associated with growth. For every additional 1 g/cm² increase in BMI at arrival, calves gained an additional 1.55 g/d from d 49 to 78. Growth from arrival to d 78 was affected solely by BMI. For every 1 g/cm² increase in BMI at arrival, calves gained 1.23 g/d more during the entire observation period. Body mass index and season at arrival affected growth through the initial period at a grain-fed veal facility. Producers should consider these factors, especially BMI, when purchasing calves to maximize the calves' growth potential.

Risk factors identified on arrival associated with morbidity and mortality at a grain-fed veal facility: A prospective, single-cohort study

High levels of morbidity, mortality, and antimicrobial use are common in the veal industry. For the sustainability of the industry, it is important to address these challenges and determine factors that can be used to improve animal health and welfare. The objectives of this prospective observational cohort study were to describe the health status of calves on arrival at a grain-fed veal facility and determine characteristics that were associated with morbidity and mortality. On arrival, the calves were assessed for health abnormalities, weighed, measured for hip height and length from withers to lumbosacral junction, and had blood collected to determine serum total protein level. Body mass index (BMI) was calculated using weight on arrival divided by the sum of the calf's length from withers to lumbosacral junction and hip height. The calves were observed for 77 d after arrival, during which the producer was responsible for recording all antibiotic treatments and mortality. We built Cox proportional hazard models for morbidity and mortality variables. We created 2 morbidity models: 1 for calves that were treated <21 d after arrival at the facility, and 1 for calves that were treated during the 11 wk at the facility. From January to December 2017, 998 calves were evaluated on arrival at the veal rearing facility. A large proportion (68%) were treated with antibiotics in the first 21 d after arrival. The only explanatory variable in the final <21 d morbidity model was BMI: calves with a higher BMI had a lower hazard of being treated for disease in the first 21 d after arrival. A total of 872 calves (87%) were treated at least once over the 11-wk housing period. A calf arriving with a BMI >371.46 g/cm or a serum total protein between 5.8 and 6.2 g/dL had a lower level of morbidity during the observation period. Over the 11-wk housing period, 74 calves (7.5%) died. Calves that arrived at the facility with a fecal score of 2 or a rectal temperature between 38.9 and 39.1°C had a higher hazard of dying; calves that had a BMI of >371 g/cm were less likely to die than calves that had a BMI <330 g/cm. These results point to the importance of assessing calves on arrival at a veal facility as a measure of identifying those at high risk for morbidity and mortality.

Developing more participatory and accountable institutions for health: identifying health system research priorities for the Sustainable Development Goal-era

Health policy and systems research (HPSR) is vital to guiding global institutions, funders, policymakers, activists and implementers in developing and enacting strategies to achieve the Sustainable Development Goals. We undertook a multi-stage participatory process to identify priority research questions relevant to improving accountability within health systems. We conducted interviews (n = 54) and focus group discussions (n = 2) with policymakers from international and national bodies (ministries of health, other government agencies and technical support institutions) across the WHO regions. Respondents were asked to reflect on challenges and current policy discussions related to health systems accountability, and to identify their pressing research needs. We also conducted an overview of reviews (n = 34) to determine the current status of knowledge on health systems accountability and to identify any gaps. We extracted research questions from the policymaker interviews and focus groups (70 questions) and from the overview of reviews (112 questions), and synthesized these into 36 overarching questions. Using the online platform Co-Digital, we invited researchers from around the world to refine and then rank the questions according to research importance. The questions that emerged amongst the top priorities focused on political factors that mediate the adoption or effectiveness of accountability initiatives, processes and incentives that facilitate the acceptability of accountability mechanisms among frontline healthcare providers, and the national governance reforms and contexts that enhance provider accountability. The process revealed different underlying conceptions of social accountability and how best to promote it, with some researchers and policymakers focusing on specific interventions and others embracing a more systems-oriented approach to understanding accountability, the multiple forms that it can take, how these interact with each other and the importance of power and underlying social relations. The findings from this exercise identify HPSR funding priorities and future areas for evidence production and policy engagement.

How are gender inequalities facing India's one million ASHAs being addressed? Policy origins and adaptations for the world's largest all-female community health worker programme

BACKGROUND

India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations.

METHODS

We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens.

RESULTS

Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation.

CONCLUSIONS

Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Prescribing patterns for psychotic and behavioural symptoms in dementia: a national survey

Aims and Method

To compare current prescribing practice for psychotic and behavioural symptoms in dementia with the available research. An anonymous questionnaire was sent to all members of the Faculty of Old Age Psychiatry, enquiring about preferred drug treatments.

Results

Classical antipsychotics were chosen by 50% for psychotic symptoms over atypical antipsychotics (43%) and were preferred for aggression (48%) and sexual disinhibition (55%). Antidepressants were favoured in treating anxiety (41%) and lability (45%).

Clinical Implications

Alternatives to classical antipsychotics, especially for behavioural symptoms, have yet to be researched satisfactorily. In view of the continued widespread use of classical antipsychotics and recent concerns about their safety, we call for this to be addressed.

Medico-legal implications of drug treatment in dementia: prescribing out of licence

AIMS AND METHOD

There is increasing evidence-based knowledge in the drug treatment of psychotic and behavioural symptoms in dementia, but drugs do not possess a formal licence for these indications. Drug companies, health authorities, NHS trusts and medical defence unions were asked for their advice on the medico-legal implications for the prescribing clinician.

RESULTS

Drug companies, health authorities, medical defence unions and NHS trusts are aware of out-of-licence prescribing and leave ultimate accountability with the clinician. A suggested best practice is that of obtaining the patient's consent.

CLINICAL IMPLICATIONS

Out-of-licence prescribing for psychotic and behavioural symptoms in dementia is widespread. This patient group may be unable to grant consent. The accountability of individual clinicians should be supported by more adequate medico-legal frameworks.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS)

BACKGROUND

Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens.

METHODS

This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research.

DISCUSSION

This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG).

TRIAL REGISTRATION

NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.

Is Signature Size Associated With Organ Donor Designation on Driver's Licenses?

INTRODUCTION

Previous studies suggest that large signature size is associated with narcissistic characteristics. By contrast, organ donation is an indicator of altruism. Because altruism and narcissism may be viewed as opposites, we sought to determine if smaller signature size is associated with willingness to be an organ donor.

METHODS

Using a cross-sectional study design, we reviewed the health records of 571 randomly selected primary care patients at a large urban safety-net medical system to obtain their demographic and medical characteristics. We also examined driver's licenses that were scanned into electronic health records as part of the patient registration process. We measured signature sizes and obtained the organ donor designation from these driver's licenses.

RESULTS

Overall, 256 (45%) patients were designated as donors on their driver's licenses. Signature size averaged 113.3 mm(2) but varied greatly across patients (10th percentile 49.1 mm(2), 90th percentile 226.1 mm(2)). On multivariate analysis, donor designation was positively associated with age 18-34 years, non-black race, having private insurance, and not having any comorbid conditions. However, signature size was not associated with organ donor designation.

CONCLUSIONS

Signature size is not associated with verified organ donor designation. Further work is needed to understand the relationship between personality types and willingness to be an organ donor.

Mental disorders among college students in the World Health Organization World Mental Health Surveys

BACKGROUND

Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.

METHOD

The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).

RESULTS

One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.

CONCLUSIONS

Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

Effects of long term treatment with high doses of odanacatib on bone mass, bone strength, and remodeling/modeling in newly ovariectomized monkeys

The objectives here were to evaluate the effects of odanacatib (ODN) at doses exceeding the clinical exposure on biomechanical properties of lumbar vertebrae (LV), hip and central femur (CF), and compare ODN to alendronate (ALN) on bone remodeling/modeling in ovariectomized (OVX) monkeys. Ten days post-surgery, animals were treated with vehicle (VEH), ODN-L (2mg/kg/day, p.o.), ODN-H (8/4mg/kg/day), or ALN (30μg/kg/week, s.c.) for 20months. An intact group was also included. ODN-L provided systemic exposures of 1.8-fold of clinical exposure. ODN-H started at 20-fold for 5.5months, and then reduced to 7.8-fold of clinical exposure, compared to ALN at approximated clinical exposure. From cross sectional analyses, LV density and peak load in ODN at both doses or ALN were not different from VEH or Intact. However, cortical thickness of femoral neck (FN) and CF in ODN were higher (21-34%, p<0.05) than VEH, due to smaller endocortical (Ec) perimeter of FN (10-11%; p<0.05) and CF (9-12%; ODN-L, p<0.05), and larger CF periosteal (Ps) perimeter (2-12%; ODN-H, p<0.001) versus VEH. ODN groups also showed slightly higher cortical porosity and Ps non-lamellar bone in CF. ODN-H treatment resulted in higher CF peak load (p<0.05) versus VEH. For all bone sites analyzed, a positive, linear relationship (r(2)=0.46-0.69, p<0.0001) of peak load to density or structural parameters was demonstrated. No treatment-related differences in the derived intrinsic strength properties were evidenced as compared between groups. ALN reduced all remodeling surfaces without affecting Ps modeling. Trabecular and intracortical remodeling were reduced in ODN groups, similar to ALN. Ec mineralizing surface in ODN-H trended to be lower than VEH by month 20, but Ec bone formation indices in ODN groups generally were not different from VEH. Ps modeling in ODN groups was significantly higher than other treatment groups. This study overall demonstrated the bone safety profile of ODN and its unique mechanism on cortical bone supporting the clinical application for osteoporosis treatment.

DNA transfer through nonintimate social contact

The UK and Ireland Association of Forensic Science Providers' (AFSP) Body Fluid Forum (BFF) set out to assist in the interpretation of sexual offence cases where semen is absent on vaginal swabs but female DNA is present on penile swabs or male underwear, and the issue to be addressed is whether or not sexual intercourse occurred. This study aims to investigate the frequency and amount of female DNA transferred to the penis and underwear of males following staged nonintimate social contact with females and to compare the findings with the amount of female DNA transferred to the penis and subsequently to the underwear of a male who had engaged in unprotected sexual intercourse with a female. In this study, no matching female DNA was detected on the inside front of the 44 items of male underwear used in this research following staged contact of a nonintimate nature and subsequent secondary transfer to the penis. After sexual intercourse, full profiles matching the female participant were found on the inside front of the males underwear with maximum peak heights in the range between 1898 and 3157 rfu. It was possible to demonstrate that DNA can occasionally transfer to the waistband and outside front of underwear worn by a male following staged nonintimate social contact. Data obtained in this study suggest that a matching female DNA profile below a peak height of 1000 rfu on the waistband of a male's underwear might be explained by nonintimate social contact with secondary transfer of female DNA from the male's hands.