Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

OBJECTIVE

The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS

Narrative literature review.

RESULTS

Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS

There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Writing in the European Annals of Otorhinolaryngology Head & Neck Diseases. Dos and Don'ts!

Too many articles are still rejected by scientific medical journals due to lack of preparation of the manuscript and of knowledge of the modern editorial rules that govern scientific medical writing. Therefore, the editorial board of the European Annals of Otorhinolaryngology Heads & Neck Diseases summarized studies published by its members since 2020 in the columns of the scientific journal of the French Society of Otorhinolaryngology and the International Francophone Society of Otorhinolaryngology and data from the PubMed indexed literature dedicated to scientific medical writing in otolaryngology in the 21st century. The authors hope that this review, in the form of a list of "Dos and Don'ts", will provide authors with a practical guide facilitating publication of rigorous, reproducible and transparent scientific studies, in accordance with the movement toward better science that society as a whole has been fighting for since the beginning of this century.

Management of a large outbreak of COVID-19 at a British Army training centre: lessons for the future

INTRODUCTION

The COVID-19 pandemic has posed major challenges for infection control within training centres, both civilian and military. Here we present a narrative review of an outbreak that occurred at the Royal Military Academy Sandhurst (RMAS) in January-March 2021, in the context of the circulating, highly transmissible SARS-CoV-2 variant B.1.1.7.

METHODS

Testing for SARS-CoV-2 was performed using a combination of reverse transcriptase PCR and Lateral Flow Devices (LFDs). Testing and isolation procedures were conducted in line with a pre-established symptom stratification system. Genomic sequencing was performed on 10 sample isolates.

RESULTS

By the end of the outbreak, 185 cases (153 Officer Cadets, 32 permanent staff) had contracted confirmed COVID-19. This represented 15% of the total RMAS population. This resulted in 0 deaths and 0 hospitalisations, but due to necessary isolation procedures did represent an estimated 12 959 person-days of lost training. 9 of 10 (90%) of sequenced isolates had a reportable lineage. All of those reported were found to be the Alpha lineage B.1.1.7.

CONCLUSIONS

We discuss the key lessons learnt from the after-action review by the Incident Management Team. These include the importance of multidisciplinary working, the utility of sync matrices to monitor outbreaks in real time, issues around Officer Cadets reporting symptoms, timing of high-risk training activities, infrastructure and use of LFDs. COVID-19 represents a vital learning opportunity to minimise the impact of potential future pandemics, which may produce considerably higher morbidity and mortality in military populations.

A44 A 1000 PATIENT CANADIAN NETWORK FOR AUTOIMMUNE LIVER DISEASE EVALUATION OF CLINICAL AND DEMOGRAPHIC PATTERNS OF AUTOIMMUNE HEPATITIS

Background

We sought to understand how the demographics of autoimmune hepatitis (AIH) have changed over time in Canada.

Purpose

Using a large multi-centre Canadian cohort of patients with AIH, we describe the trends in patient and disease characteristics at presentation across 30 years of clinical practice.

Method

Patients from the Canadian Network for Autoimmune Liver Disease with a confirmed diagnosis of AIH (simplified score ≥6) were included for analysis. Patients were grouped into five cohorts according to the year of diagnosis (i.e., <2000, 2000-2004, 2005-2009, 2010-2014, ≥2015). Patient demographics and baseline clinical and biochemistry features of disease activity were investigated using Chi-square tests and Kruskal-Wallis tests adjusted for multiple comparisons. Logistic and linear regression models with estimated means were utilized to further investigate relationships with time and to adjust for confounding.

Result(s)

1016 patients followed across 10 Canadian health centres with AIH were diagnosed between November 1965 and December 2021. Overall, 76.4% (n=776) of patients were female, and the median age at diagnosis was 46 years (IQR 28.2 - 58.3). Cirrhosis at presentation was seen in 20.6% of patients (n=209). The median age at diagnosis increased significantly from 31.8 years [IQR 17.9 - 46.8] pre-2000 to 54 years [IQR 9.0 - 95.2] after 2014 (p<0.001; Figure 1a). This effect of time persisted after adjusting for sex and cirrhosis status at diagnosis. Female sex and the presence of cirrhosis at diagnosis were factors independently associated with older age at presentation (p<0.0001).

The proportion of patients that presented with cirrhosis at diagnosis increased significantly over calendar time, from 13.7% (n=23) pre-2000 to 30.8% (n=69) after 2014 (p=0.003; Figure 1b). Male sex was independently associated with an increased odds of having cirrhosis at presentation (OR= 1.46, CI 1.02 - 2.07) and higher baseline ALT levels compared to females (p=0.036). The proportion of patients that identified as non-white ethnicity increased significantly from 15.2% (n= 24) pre-2000, to 32% (n= 86) after 2014 (p<0.001, Figure 1b). This effect of time on ethnicity was most pronounced after the year 2010 (OR= 2.32, CI 1.39 - 3.98) and persisted after adjusting for sex. There was no significant pattern of change in sex over calendar time.

Image

Conclusion(s)

In Canada, patients with AIH at presentation are now older, have more advanced disease, and are more ethnically diverse than when compared to 30 years ago.

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A82 PREVALENCE AND NON-INVASIVE SCREENING FOR CYSTIC FIBROSIS RELATED LIVER DISEASE IN A COHORT FOLLOWED AT A CYSTIC FIBROSIS REFERENCE CENTER

Background

The reported prevalence of cystic fibrosis (CF) related liver disease (CFLD) varies widely based on diagnostic criteria but reaches up to 40% in some cohorts. Furthermore, its clinical impact is significant as hepatic involvement is the 3^rd leading cause of mortality in CF patients and is associated with a lower life expectancy. Due to the heterogeneous clinical presentation of CFLD, clear diagnostic criteria and non-invasive assessment methods are lacking.

Purpose

This study aimed to measure the prevalence of CFLD in a cohort of patients followed at a tertiary CF center.

Method

The files of all patients followed at the CF clinic of the Centre hospitalier de l’Université de Montréal in 2021 were retrospectively reviewed. Imaging reports, histopathology, laboratory values and transient elastography results were assessed. The NIH criteria were used to define CFLD through either presence of one major criteria (abnormal imaging) or two minor criteria (persistently abnormal lab values, hepatosplenomegaly, or transient elastography ≥ 7 kPa).

Result(s)

358 patients were included in our study, 56% male with a median age of 36 years. While mean liver tests were within normal limits (ALT 24 U/L, AST 26 U/L, ALP 96 U/L, GGT 29 U/L), 182 patients (51%) had at least one episode of abnormal liver function tests (LFTs), and 85 patients (24%) had persistently abnormal LFTs. CFLD was present in 42 patients (12%), with 39 patients presenting major criteria and 3 patients presenting minor criteria. In addition, 67 patients (19%) had solely hepatic steatosis. Furthermore, clinically significant portal hypertension and esophageal varices were detected in 50% of patients with CFLD who underwent upper endoscopy (n=20). Median transient elastography value was 5.4 kPa (interquartile range 4.25 kPa) in the 51 patients with exam results, and 32% had values ≥ 7 kPa. Fibroscan values correlated well with the presence of major criteria, with an area under the curve (AUROC) of 0.80 (0.68-0.92, p=0.0007), while non-invasive serological markers did not perform as well (Fib4: AUROC 0.70 (0.59-0.81) and APRI: AUROC 0.69 (0.59-0.80)).

Conclusion(s)

The overall prevalence of CFLD, including hepatic steatosis, was 31% in this cohort. Prompt recognition is important in clinical care in order to prevent hepatic complications from cirrhosis and portal hypertension. The use of Fibroscan seems promising for detecting CFLD.

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None

Disclosure of Interest

None Declared

The representation of authors of color in schizophrenia research articles published in high-impact psychiatric journals

OBJECTIVE

We evaluate how often scholars of color publish papers on schizophrenia in high-impact psychiatric journals, and whether they are more likely than white authors to prioritize race/ethnicity as a primary variable of interest in analyses.

METHODS

Prior work categorized the types of ethnoracial analyses reported in 474 papers about schizophrenia published in high-impact psychiatric journals between 2014 and 2016. In this study, the photographs of the first and last author for each paper were coded as "person of color" (POC) or "white". Additionally, each author was asked to self-report their race and ethnicity. The percentage of papers published by white versus POC authors was calculated. Chi-square analyses tested the hypotheses that (a) white scholars are more likely than POC scholars to conduct any sort of racial analysis; (b) POC scholars are more likely to conduct primary analyses by race/ethnicity; and (c) white scholars are more likely to analyze race/ethnicity as extraneous variables.

RESULTS

Eighteen percent of papers were published by POC first authors, and 17% were published by POC last authors. There were minimal differences in the types of analyses conducted by POC and white authors. Self-reported race/ethnicity showed that Asian scholars were the most highly represented within POC authors (9% of respondents), but only 3% of authors identified as Hispanic/Latinx and none identified as Black or Indigenous American.

CONCLUSIONS

People of color are underrepresented as authors in US-based schizophrenia research published in high-impact journals. Culturally-informed mentorship as well as prioritization of race/ethnicity in funding structures are important to increase representation of POC authors.

User-centered development process of an operating interface to couple a robotic glove with a virtual environment to optimize hand rehabilitation following a stroke

Introduction

Task-specific neurorehabilitation is crucial to optimize hand recovery shortly after a stroke, but intensive neurorehabilitation remains limited in resource-constrained healthcare systems. This has led to a growing interest in the use of robotic gloves as an adjunct intervention to intensify hand-specific neurorehabilitation. This study aims to develop and assess the usability of an operating interface supporting such a technology coupled with a virtual environment through a user-centered design approach.

Methods

Fourteen participants with hand hemiparesis following a stroke were invited to don the robotic glove before browsing through the operating interface and its functionalities, and perform two mobility exercises in a virtual environment. Feedback was collected for improving technology usability. Participants completed the System Usability Scale and ABILHAND questionnaires and their recommendations were gathered and prioritized in a Pugh Matrix.

Results

The System Usability Scale (SUS) score for the operating interface was excellent (M = 87.0 SD = 11.6). A total of 74 recommendations to improve the user interface, calibration process, and exercise usability were identified.

Conclusion

The application of a full cycle of user-centred design approach confirms the high level of usability of the system which is perceived by end users as acceptable and useful for intensifying neurorehabilitation.

Keys for successful publication in Eur Ann Otorhinolaryngol Head Neck Dis: A STROBE analysis of peer reviews of articles submitted in 2020-2021

OBJECTIVE

To evaluate reviewing and editorial decision for articles submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases.

MATERIALS AND METHODS

A retrospective analysis was made of reviewers' comments on 1,133 scientific articles (700 original articles, 96 literature reviews, and 337 case reports), originating from 69 countries, consecutively submitted on-line between January 1st, 2020 and December 31st, 2021. The main objective was to document the acceptance rate and decision time. Accessory objectives were to synthesize the main comments and to screen for correlations between acceptance and the main characteristics of first authors, articles and reviewers' comments.

RESULTS

In total, 4.1% of submitted articles were accepted. Median decision time differed significantly (P<0.0001), at 1 month in case of refusal and 4 months in case of acceptance. Reviewers mentioned failure to adhere to the journal's authors' guide, to use the appropriate EQUATOR guidelines and to adopt the recommended P<0.005 significance threshold in 94.8%, 54.2%, and 39.9% of cases, respectively. On multivariate analysis, 3 variables significantly impacted acceptance, which increased from 1.3% to 44.6% (P<0.0001) when an appropriate EQUATOR guideline was used and from 0.3% to 57.4% (P<0.0001) when the significance threshold was set at P<0.005, and decreased from 10.5% to 1.1% (P=0.0001) when the article did not originate from a French-speaking country (member of the Francophonie organization).

CONCLUSION

Adhesion to modern scientific medical writing rules increased acceptance rates for articles in the European Annals of Otorhinolaryngology Head & Neck Diseases. Teaching modern scientific medical writing needs to be enhanced in otorhinolaryngology.

Fission chamber data acquisition system for neutron flux measurements on the Mega-Amp Spherical Tokamak Upgrade

Neutron flux measurements are important in fusion devices for both safety requirements and physics studies. A new system has been built for the Mega-Amp Spherical Tokamak Upgrade (MAST Upgrade) that provides neutron count, DC, and Campbell mode measurements for a 1 µs period at 1 MHz. The acquisition system uses a Red Pitaya board to sample current from two fission chambers mounted on the side of the MAST-U vessel. The system-on-chip design of the Zynq-7020 on the Red Pitaya also allows a web server implementation using Flask for data retrieval and diagnostic configuration over the MAST Upgrade network.

1011 CONTINUUM OF GERIATRIC CARE FOR OLDER ADULTS WITH DUAL SENSORY LOSS DURING THE COVID-19 PANDEMIC IN CANADA: LESSONS LEARNED

Introduction

Around 1.1 million older Canadians live with combined hearing and vision impairment (dual sensory loss/DSL). Evidence highlights that they are at a high risk of cognitive impairment, functional decline, social isolation, falls, depression, and mortality. Compared to their non-DSL peers, older adults with DSL experience various challenges in accessing healthcare, which were exacerbated during the COVID-19 pandemic. This study aimed to explore the continuum of geriatric care for older adults with DSL by integrating their perspectives, those of caregivers who accompany them on healthcare visits, and their healthcare providers in Canada during the pandemic.

Method

We conducted a qualitative study with 32 older Canadians with DSL and their caregivers, and an online survey with 228 healthcare providers across the country. Qualitative interviews were audio-recorded using Zoom and transcribed verbatim, while the survey data were collected using Lime Survey. Thematic analysis was used to analyse qualitative data, whereas descriptive statistics were used for quantitative survey data.

Results

The findings highlighted the gaps in the continuum of care for this population. The reported gaps were lack of training on DSL among healthcare providers, lack of time and comfort to go beyond one’s specialty, lack or limited support to overcome communication challenges while providing care to older adults with DSL, difficulty in using technologies for virtual/telehealth, presence of comorbidities such as cognitive impairment, and restrictions in caregiver accompaniment during the pandemic.

Conclusion

Our findings indicate that the continuum of care for this group is negatively affected due to the pandemic, in a disproportionate manner, and structural barriers are experienced by older adults with DSL and their caregivers for access to care. To ensure effective care, healthcare professionals need training on DSL-specific accessibility and communication. A collaborative, cross-disciplinary geriatric care approach with the active involvement of essential care partners is an utmost need.

Characterising the nature of the beast: Challenges associated with understanding patient safety within community-based mental health services

Introduction

Patient safety problems stemming from healthcare represent a significant cause of morbidity and mortality globally. The evidence base on safety in mental healthcare, particularly regarding community-based mental health services, has long fallen behind that of physical healthcare, with fewer research publications, developed primarily in isolation from the wider improvement science discipline. This disconnect both yields, and stems from, conceptual and practical challenges which must be surmounted in order to advance the science and improvement of safety in mental healthcare.

Objectives

The objectives of this research were to conduct a narrative review to provide an overview of conceptual issues in this area, their origins, and implications for patient safety science and clinical care. We also sought to identify approaches to overcoming these issues.

Methods

We examined theoretical and empirical evidence from the fields of patient safety, mental health, and improvement science to address this knowledge gap.

Results

We identified challenges with defining safety in the context of community mental healthcare, ascertaining what constitutes a ‘preventable’ safety problem requiring intervention, and in finding relevant research evidence. The research indicated that risk management has taken precedence over proactive safety promotion in mental healthcare. This positions service users as the origin of safety risks, with iatrogenic harm and latent system hazards associated with mental healthcare widely overlooked.

Conclusions

We propose a broader conceptualisation of safety to advance the field and outline potential next steps for the integration and uptake of different sources of ‘safety intelligence’ within community mental health services.

Disclosure

NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Patient safety in community-based mental healthcare: A systematic scoping review

Introduction

There is limited existing research about patient safety issues in mental healthcare. A lack of evidence is particularly pronounced in relation to safety in community-based mental health services, where the majority of care is provided. To date, reviews of mental health patient safety literature have focused primarily on inpatient care settings.

Objectives

This systematic scoping review will aim to identify and synthesise literature about the types of patient safety problems in adult community-based mental health settings, the causes of these problems, and evaluated safety interventions in this care context.

Methods

A systematic search was conducted on 19^th June 2020 and refreshed on 23^rd October 2021, across five databases: Medline, Embase, PsycINFO, Health Management Information Consortium, and Cumulative Index to Nursing and Allied Health Literature. The search strategy focused on three key elements: ‘mental health’, ‘patient safety’ and ‘community-based mental health services’. Retrieved articles were screened at title, abstract and subject heading level, followed by full-text screen of longlisted articles.

Results

In this presentation, the findings of this systematic scoping review will be described, based on synthesised literature about safety incidents, broader care delivery problems, their causes, and evaluated patient safety interventions to address these issues.

Conclusions

This study will offer learning opportunities about the safety problems, contributory factors, and safety interventions in adult community-based mental health services, as described in the evidence base. Review findings will also help to ascertain gaps in existing research, which should be addressed in future studies.

Disclosure

NS is the director of London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no competing interests.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) and the French Society of Audiology (SFA) for Speech-in-Noise Testing in Adults

OBJECTIVES

This document presents the fundamentals of speech audiometry in noise, general requirements for implementation and criteria for choice among the tests available in French according to the health-professional's needs.

MATERIAL AND METHODS

The recommendations are based on a systematic analysis of the literature carried out by a multidisciplinary group of doctors, audiologists and audioprosthetists from all over France. They are graded A, B, C or expert opinion according to decreasing level of scientific evidence.

RESULTS

Eight tests of speech audiometry in noise can be used in France.

CONCLUSION

To be complete, evaluation of hearing status requires testing understanding of speech in noise. The examination must begin with a minimum of two measurements familiarizing the subject with the test procedure. For initial diagnosis, adaptive procedures establishing the 50% speech reception threshold (SRT50) in noise are to be preferred in order to obtain a rapid and standardized measurement of perception of speech in noise. When the aim is to measure real-life speech comprehension, tests based on sentences, cocktail-party noise and free-field stimulation are to be preferred. Prosthetic gain is evaluated exclusively in free field. This is the only way to evaluate the contribution of binaurality and to measure perception in noise in an environment as close as possible to real life. In order to avoid acoustic interference in free field, at least five loudspeakers should be used, in particular for evaluating the effectiveness of directional microphones, CROS devices enabling sounds picked up in the damaged ear to be rerouted to the functional ear, or bimodal fitting (i.e., when hearing is enabled by two modalities: for example, hearing aid for one ear, cochlear implant for the other).

Can a brief training intervention on schizophrenia and depression improve knowledge, attitudes and practices of primary healthcare workers? The experience in Armenia

BACKGROUND

Although the World Health Organization has called for mental health services to be integrated into primary care, mental health remains in most countries, and especially in low- and middle-income countries, one of the most neglected topics in the training curriculum of frontline health workers. As a result, primary healthcare professionals leave medical and nursing schools with insufficient knowledge, and often with negative attitudes towards mental disorders.

AIM

We investigated the effect of a brief training intervention on schizophrenia and depression conducted among general practitioners and nurses in Armenia.

METHODS

Training interventions were one-day, face-to-face, interactive workshops, including didactic presentations and discussions of case studies. We used a quasi-experimental design of the before/after type, to compare data on knowledge, attitudes and practices collected before and after the training sessions.

RESULTS

Mean scores for knowledge, attitudes and practices increased significantly (p < 0.001) among both nurses and GPs for both schizophrenia (111 GPs and 167 nurses) and depression (459 GPs and 197 nurses).

CONCLUSIONS

Our experience suggests that a brief training intervention can result in significant improvements in knowledge, attitudes and practices among primary healthcare workers and could help improve mental health services.

First application of a digital mirror Langmuir probe for real-time plasma diagnosis

For the first time, a digital Mirror Langmuir Probe (MLP) has successfully sampled plasma temperature, ion saturation current, and floating potential together on a single probe tip in real time in a radio-frequency driven helicon linear plasma device. This is accomplished by feedback control of the bias sweep to ensure a good fit to I-V characteristics with a high frequency, high power digital amplifier, and field-programmable gate array controller. Measurements taken by the MLP were validated by a low speed I-V characteristic manually collected during static plasma conditions. Plasma fluctuations, induced by varying the axial magnetic field (f̃ = 10 Hz), were also successfully monitored with the MLP. Further refinement of the digital MLP pushes it toward a turn-key system that minimizes the time to deployment and lessens the learning curve, positioning the digital MLP as a capable diagnostic for the study of low radio-frequency plasma physics. These demonstrations bolster confidence in fielding such digital MLP diagnostics in magnetic confinement experiments with high spatial and adequate temporal resolution, such as edge plasma, scrape-off layer, and divertor probes.

Dexamethasone-loaded cochlear implants: How to provide a desired "burst release"

Cochlear implants containing iridium platinum electrodes are used to transmit electrical signals into the inner ear of patients suffering from severe or profound deafness without valuable benefit from conventional hearing aids. However, their placement is invasive and can cause trauma as well as local inflammation, harming remaining hair cells or other inner ear cells. As foreign bodies, the implants also induce fibrosis, resulting in a less efficient conduction of the electrical signals and, thus, potentially decreased system performance. To overcome these obstacles, dexamethasone has recently been embedded in this type of implants: into the silicone matrices separating the metal electrodes (to avoid short circuits). It has been shown that the resulting drug release can be controlled over several years. Importantly, the dexamethasone does not only act against the immediate consequences of trauma, inflammation and fibrosis, it can also be expected to be beneficial for remaining hair cells in the long term. However, the reported amounts of drug released at “early” time points (during the first days/weeks) are relatively low and the in vivo efficacy in animal models was reported to be non-optimal. The aim of this study was to increase the initial “burst release” from the implants, adding a freely water-soluble salt of a phosphate ester of dexamethasone. The idea was to facilitate water penetration into the highly hydrophobic system and, thus, to promote drug dissolution and diffusion. This approach was efficient: Adding up to 10% dexamethasone sodium phosphate to the silicone matrices substantially increased the resulting drug release rate at early time points. This can be expected to improve drug action and implant functionality. But at elevated dexamethasone sodium phosphate loadings device swelling became important. Since the cochlea is a tiny and sensitive organ, a potential increase in implant dimensions over time must be limited. Hence, a balance has to be found between drug release and implant swelling.

Effects of an educational comic book on epilepsy-related knowledge, attitudes and practices among schoolchildren in Madagascar

INTRODUCTION

Epilepsy is a chronic disease of the brain that affects approximately 50 million people globally, with over 80 % of them living in low- and middle-income countries (LMICs). In Madagascar, as in most LMICs, one of the main obstacles to treatment is the stigma and discrimination experienced by patients. Beliefs and prejudices regarding this disease are common, especially among children. "Ao Tsara" is an educational comic book regarding epilepsy, which has been translated in Malagasy from a French version, and which objective is to raise awareness and fight epilepsy related stigma and discrimination. Comic books have indeed been used successfully to raise awareness and change behaviors in several areas of public health.

METHODS

We conducted a study to evaluate the effect of a single reading of this comic book on epilepsy related knowledge, attitudes and practices (KAP) in schoolchildren in Madagascar. This quasi-experimental study compared data collected before and immediately after reading "Ao Tsara". It was conducted both in a school in an urban area and in a school in a rural area.

RESULTS

We recruited 244 children with a mean age of 11.4 (±1.5) in this study. We noted a significant improvement in the global KAP score after reading the comic book, overall as well as both in the urban school and the rural school. Out of a maximum score of twenty, the global KAP score increased from 9.4 to 11.2 (p < 0.001). Although the increase in knowledge was reasonable (from 10.2 to 12.9, p < 0.001) and the corresponding subscore after reading the comic book was at a satisfactory level, that was not the case for attitudes & practices, where the sub-score despite a significant increase remained low (from 8.7 to 9.5 out of a maximum score of twenty, p < 0.001). The comic book was much appreciated by the children with more than 50.0 % giving it the top rating, and 66.4 % stating they had learned a lot from it.

CONCLUSION

A single reading of the comic book has demonstrated a positive effect on the knowledge, attitudes and practices of primary school children in Madagascar. This educational tool, which was much enjoyed by the children, could be of great value to raise awareness about epilepsy in Madagascar. By targeting a slightly older age group and adjusting the reading approach, the outcomes could be optimized especially in terms of attitudes and practices.

Mental health capacity building in Mali by training rural general practitioners and raising community awareness

Introduction

despite the high prevalence and significant burden of mental disorders, they remain grossly under-diagnosed and undertreated. In low-income countries, such as Mali, integrating mental health services into primary care is the most viable way of closing the treatment gap. This program aimed to provide a mental health training intervention to rural general practitioners (GPs), to organize community awareness activities, and to evaluate the impact on mental health knowledge and through the number of new patients diagnosed with mental disorders and managed by these general practitioners.

Methods

a pre-test/post-test design and the monthly monitoring of the number of new patients diagnosed with mental disorders by the trained GPs were used to evaluate the effect of the training interventions (two face-to-face group training workshops followed by individual follow-up supervisions) and of the community awareness activities.

Results

the mean knowledge score of the 19 GPs who completed the initial 12-day group training raised from 24.6/100 at baseline, to 61.5/100 after training (p<0.001), a 150% increase. Among them, sixteen completed the second 6-day group training with a mean score increasing from 50.2/100 to 70.1/100 (p<0.001), a 39.6% improvement. Between July 2018 and June 2020, 2,396 new patients were diagnosed with a mental disorder by the 19 GPs who took part in the program.

Conclusion

despite limited data regarding the effect of the community awareness component at this stage, the findings from this study suggest that the training intervention improved GPs' knowledge and skills, resulting in a significant number of new patients being identified and managed.

1 Quality of Care Transitions: Older Adults’ Experiences in An Integrated Care Trust

Introduction

The transition of care from hospital to home is a high-risk time for older adults. The Partners at Care Transitions (PACT) programme aims to improve safety and quality of care transitions. We aimed to test the feasibility of using the Partners at Care Transitions Measure (PACT-M) to evaluate older adults’ experiences of the transition from hospital to home in an Inner London Integrated Care Trust and to identify factors impacting transition quality.

Methods

The PACT-M, a validated patient-reported questionnaire designed to evaluate care transitions, was administered to patients ≥65 years at 7, 30 and 90 days post-discharge. Likert scores were analysed quantitatively and manual thematic analysis performed on free-text comments.

Results

101 participants were recruited. Mean age 77.8 years. 84, 70 and 65 participants completed follow-up at 7, 30 and 90 days, respectively.

Factors impacting patients’ experience of transition quality are shown in Table 1.

Conclusions

A206 EVOLUTION OF PEDIATRIC AUTOIMMUNE CHOLANGITIS AND PRIMARY SCLEROSING CHOLANGITIS INTO ADULTHOOD

Background

The natural history of primary sclerosing cholangitis (PSC) in children seems to differ from PSC in adults. However, studies on this matter have been limited by short follow-up periods and inconsistent classification of patients with autoimmune cholangitis (AIC) (or overlap syndrome). Consequently, it remains unclear if long-term outcomes are affected by the clinical phenotype.

Aims

The aims of this is study are to describe the long-term evolution of PSC and AIC in a pediatric cohort with extension of follow-up into adulthood and to evaluate the influence of phenotype on clinical outcomes.

Methods

This is a retrospective study of patients with AIC or PSC followed at CHU-Sainte-Justine, a pediatric referral center in Montreal. All charts between January 1998 and December 2019 were reviewed. Patients were classified as either AIC (duct disease on cholangiography with histological features of autoimmune hepatitis) or PSC (large or small duct disease on cholangiography and/or histology). Extension of follow-up after the age of 18 was done for patients followed at the Centre hospitalier de l’Université de Montréal. Clinical features at diagnosis, response to treatment at one year and liver-related outcomes were compared.

Results

40 patients (27 PSC and 13 AIC) were followed for a median time of 71 months (range 2 to 347), with 52.5% followed into adulthood. 70% (28/40) had associated inflammatory bowel disease (IBD) (78% PSC vs 54% AIC; p=0.15). A similar proportion of patients had biopsy-proven significant fibrosis at diagnosis (45% PSC vs 67% AIC; p=0.23). Baseline liver tests were similar in both groups.

At diagnosis, all patients were treated with ursodeoxycholic acid. Significantly more patients with AIC (77% AIC vs 30 % PSC; p=0.005) were initially treated with immunosuppressive drugs, without a significant difference in the use of Anti-TNF agents (0% AIC vs 15% PSC; p= 0.12). At one year, 55% (15/27) of patients in the PSC group had normal liver tests versus only 15% (2/13) in the AIC group (p=0.02).

During follow-up, more liver-related events (cholangitis, liver transplant and cirrhosis) were reported in the AIC group (HR=3.7 (95% CI: 1.4–10), p=0.01). Abnormal liver tests at one year were a strong predictor of liver-related events during follow-up (HR=8.9(95% CI: 1.2–67.4), p=0.03), while having IBD was not (HR=0.48 (95% CI: 0.15–1.5), p=0.22). 5 patients required liver transplantation with no difference between both groups (8% CAI vs 15% CSP; p=0.53).

Conclusions

Pediatric patients with AIC and PSC show, at onset, similar stage of liver disease with comparable clinical and biochemical characteristics. However, patients with AIC receive more often immunosuppressive therapy and treatment response is less frequent. AIC is associated with more liver-related events and abnormal liver tests at one year are predictor of bad outcomes.

Funding Agencies

None

Telemedicine in Audiology. Best practice recommendations from the French Society of Audiology (SFA) and the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL)

Objectives

Access to diagnosis and treatments for auditory disorders and related pathologies has regressed in France during the COVID-19 pandemic, posing a risk to the patient's chance of recovery. This best practice recommendations guide aims to list the existing technological solutions for the remote examination of a patient with hearing complaint, and to outline their benefits and, where applicable, their limitations.

Methods

The recommendations were developed both from the clinical experience of the medical experts who drafted the guide, and from an extensive review of the literature dealing with clinical practice recommendations for tele-audiology. Tele-audiometry solutions were identified on the basis of a search engine query carried out in April 2020, prior to verification of their availability on the European market.

Results

Video otoscopy solutions allow for the teletransmission of images compatible with a high-quality diagnosis, either by connecting via internet to a tele-health platform or using a smartphone or a tablet with an iOS or Android operating system. Using the same telecommunication methods, it is possible to remotely conduct a pure-tone audiometry test in accordance with standard practice, a speech-in-quiet or a speech-in-noise audiometry test, as well as objective measures of hearing. Clinical and paraclinical examinations can be accessed by the physician to be interpreted on a deferred basis (asynchronous tele-audiology). Examinations can also be conducted in real time in a patient, at any age of life, as long as a caregiver can be present during the installation of the transducers or the acoumetry. Tele-audiology solutions also find application in the remote training of future healthcare professionals involved in the management of deafness and hearing impairment.

Conclusion

Under French law, tele-otoscopy is a medical procedure that is either a tele-expertise (asynchronous adive) or a teleconsultation act (synchronous advice). Subjective and objective evaluation of the patient's hearing functions can be done remotely provided that the listed precautions are respected.

The French Cochlear Implant Registry (EPIIC): General indicators

Cochlear and brainstem implants have been included on the list of reimbursable products (LPPR) in France since March of 2009. The implants were initially inscribed for 5 years, after which an application for renewal with the French National Commission for the Evaluation of Medical Devices and Health Technologies (Commission Nationale d'évaluation des dispositifs médicaux et des technologies de santé - CNEDiMTS) was required [Haute Autorité de santé, 2009]. Upon registration to the list of reimbursable products, the companies and the reference centers for cochlear and brainstem implants were asked to set up a post-registration registry called EPIIC. This article reports the evolution in the EPIIC registry of the general indicators for 5051 patients over the five years from 2012-2016.

The French Cochlear Implant Registry (EPIIC): Cochlear implantation complications

OBJECTIVES

The aim of this study was to evaluate peri- and post-operative complications related to cochlear implantations. We searched for risk factors predicting these complications and analyzed the complications in the youngest and most elderly.

STUDY DESIGN

Retrospective analysis of cochlear implant patients.

MATERIALS AND METHODS

All patients who underwent cochlear implantation in France between January 2012 and December 2016 were anonymized and registered in the EPIIC database. This population included 3483 adults and 2245 children. Their demographic and surgical data and their incidence of peri- or post-operative complications, including their severity, whether major or minor, were all indicated.

RESULTS

The global complication rate was 6.84%. The risk of complication was higher in initial implantation versus reimplantation (P<0.0001). The risk was also higher for bilateral implantation versus unilateral (P<0.0001). Complications were more frequent for patients with cochlear malformation (P=0.002). There was no difference in complication rates across age groups; babies under 1 year old, and the elderly over 80 and even over 90, did not have more complications than the rest of the population. Patients treated in the daily care unit had no more complications than those who were hospitalized for one night or more (P=0.64).

CONCLUSION

Cochlear implantation is a safe technique with a low incidence of complications. The absence of increased risk in patients at the extremes of the age spectrum justifies offering this solution to all, without age limitation.

Racing against stomatal attenuation: rapid CO2 response curves more reliably estimate photosynthetic capacity than steady state curves in a low conductance species.. [PMID: 0 DOI: 10.1101/2020.08.28.270785]

A/Ci curves are an important gas-exchange-based approach to understanding the regulation of photosynthesis, describing the response of net CO2 assimilation (A) to leaf internal concentration of CO2 (Ci). Low stomatal conductance species pose a challenge to the measurement of A/Ci curves by reducing the signal-to-noise ratio of gas exchange measures. Additionally, the stomatal attenuation effect of elevated ambient CO2 leads to further reduction of conductance and may lead to erroneous interpretation of high Ci responses of A. Rapid A/Ci response (RACiR) curves offer a potential practice to develop A/Ci curves faster than the stomatal closure response to elevated CO2. We used the moderately low conductance Citrus to compare traditional steady state (SS) A/Ci curves with RACiR curves. SS curves failed more often than RACiR curves. Overall parameter estimates were the same between SS and RACiR curves. When low stomatal conductance values were removed, triose-phosphate utilization (TPU) limitation estimates increased. Overall RACiR stomatal conductance values began and remained higher than SS values. Based on the comparable resulting parameter estimates, higher likelihood of success and reduced measurement time, we propose RACiR as a valuable tool to measure A/Ci responses in low conductance species.

The French Cochlear Implant Registry (EPIIC): Perception and language results in infants with cochlear implantation under the age of 24 months

OBJECTIVE

Multi-centre study of the National French Registry (EPIIC) of patients with cochlear implants, focusing on infants who were operated-on under the age of 24 months between 2012 and 2016.

PATIENTS AND METHODS

A total of 615 profoundly deaf infants, who received cochlear implants (CIs) before their second birthday, were included in the registry by different CI centers. Epidemiological, surgical, speech therapy and school, follow-up data were included in the registry, 12, 24, 36 and 48 months thereafter. The following parameters were studied: type of implantation (uni- or bilateral), complications, cause of deafness, category of auditory perception (CAP), Open-set word recognition score (OSW), speech intelligibility rating, lexical comprehension with EVIP (Peabody), communication mode and type of schooling. Bilateral simultaneous CI (BiCI) and unilateral CI (UniCI) groups were compared.

RESULTS

There were 744 implantations. The explantation-reimplantation rate, within the four-year follow-up, was just 3.6%. Mean implantation age was 16.0 months, and similar in the two groups (BiCI/UniCI). A total of 51% of children had their first implant between 12 and 18 months, and 15% before 12 months. Implantation was unilateral in 52% of cases. Fifty-six percent of the bilateral procedures were sequential, with a mean delay of 16.8 months for the second implantation. The cause of deafness was unknown in 52% of cases. Of the 48% (297/615) of attributed cases, 32% had clear genetic causes. The remaining deafness was due to cytomegalovirus (CMV, 8%), inner-ear malformation (5%) and meningitis (3%). The main complications were from infections (47%) and internal device failure (25%). Four years post-operation, 84% of the UniCI and 75% of BiCl groups had a CAP≥5, and 83% of UniCl and 100% BiCI had OSW≥80%. Furthermore 74% of UniCI and 77% of BiCI communicated orally and 85% of UniCI and 90% of BiCI integrated into mainstream schooling.

CONCLUSION

The French Registry of cochlear implants (EPIIC) is the only such national registry in the world. Our analysis illustrates the immediate benefits of, either single or double, cochlear implantation for language, perception skills and schooling.

The French National Cochlear Implant Registry (EPIIC): Cochlear explantation and reimplantation

This study aims to determine the frequency and causes of cochlear explants with re-implantation (ERI) after 5 years' follow up of the patients included in the French national EPIIC (étude post-inscription des implants cochléaires) registry tracking patients with cochlear implantation. This multicenter, descriptive prospective study was conducted on 5051 patients enrolled in the EPIIC database between January 2012 and December 2016. Ninety-five patients (1.9%) received a primary implant and an ERI during the study. Of these, four benefitted from two ERIs. The number of ERIs was significantly higher in the pediatric population than among adults. The explantation and reimplantation were performed simultaneously in 86% of cases. The reasons for explantation were: in 46.4% of cases linked to a malfunction of the implant, and in 39.3% of cases for medical or surgical reasons. The number of electrodes inserted was significantly higher after the ERI than after the first implantation. There was just one post-ERI infection for these 95 explanted and re-implanted patients. As well as explantation with reimplantation rarely being necessary, it generally presents no major surgical difficulty and in most cases it allows a better integration than in the first implantation.

The French National Cochlear Implant Registry (EPIIC): Results, quality of life, questionnaires, academic and professional life

This study concerns the results of cochlear implantation in children and adults from French cochlear implantation centers, monitored at one, two and three years by the Cochlear Implant French Registry EPIIC. This multicenter study enrolled 2603 subjects (1667 adults and 936 children) implanted in one ear. The following parameters were studied: hearing overall performances, monosyllabic or dissyllabic word perception, speech intelligibility, self-assessment questionnaire of Cochlear Implant (CI) benefits (Abbreviated profile of Hearing aid Benefit); professional activity and schooling. This study confirms the ceiling effect in adults' performances after the 1^st year and the progressive growth in children's performances. It also shows that the contralateral hearing aid enhances performances compared to the CI alone condition, in all follow-up sessions. The French register of CIs is the only worldwide register of systematic follow-up on a period of three years and more of all adults and children implanted in a country.

The French National Cochlear Implant Registry (EPIIC): Cochlear implantation in adults over 65years old

OBJECTIVES

To analyze the performance of cochlear implants in French patients aged 65 and over, implanted between 2012 and 2016, using data from the French national registry for cochlear implants (EPIIC).

MATERIALS AND METHODS

The French national registry incorporates patient data from before implantation and for three years after implantation, stratified in different age groups (18-39, 40-64years, 65-74years and>75years). Here, we assessed the latter two categories. Hearing was assessed using mono- and disyllabic words in a silent background. The Category of Auditory Performance (CAP) scale was also implemented and subjects took the Abbreviated Profile of Hearing Aid Benefit (Aphab) questionnaire.

RESULTS

The population aged over 65 accounted for 38% (n=1193) of the 3178 adult implanted patients. The performance for mono- and disyllabic words in silence, the CAP scores and the APHAB questionnaire answers for ease of communication, background noise and reverberation were dramatically improved at one year post-implantation (P<0.0001 for each score) and remained stable between one and three years thereafter. The percentage improvement was similar across all age groups. The scores for loud-noise intolerance did not change after cochlear implantation in any age group.

CONCLUSION

Cochlear implants improve hearing and communication in subjects aged 65 and over, with comparable efficiency to that achieved in younger subjects. Cochlear implantation should thus be proposed whenever hearing aids provide only limited benefit. However, between 2012 and 2016, cochlear implantation was given to less than 1% of the French population aged 65 and over with profound deafness.

French Society of ENT (SFORL) guidelines. Management of acute Bell's palsy

AQFThe authors present the guidelines of the French Society of ENT and Head and Neck Surgery (SFORL) regarding the management of Bell's palsy in adults. After a literature review by a multidisciplinary workgroup, guidelines were drawn up based on retrieved articles and group-members' experience, then read over by an independent group to edit the final version. Guidelines were graded A, B, C or "expert opinion" according to decreasing level of evidence. Thorough ENT and neurological clinical examination is recommended in all patients presenting with peripheral facial palsy to confirm diagnosis of Bell's palsy. MRI with gadolinium enhancement should explore the entire course of the facial nerve, if possible within the first month. ENMG should be performed to assess prognosis for recovery. In confirmed Bell's palsy, corticosteroid therapy should be implemented as early as possible (ideally within 72h) at a dose of 1mg/kg/day for 7-10 days. Antiviral therapy should be associated to steroids in patients with severe and early-onset disease and in Ramsay-Hunt syndrome. Isolated antiviral therapy is not recommended. To date, there is no evidence that surgical facial nerve decompression provides benefit.

Optimised immunofluorescence method on cleared intact Mongolian gerbil cochlea

Immunofluorescence on cleared intact cochlea allows detailed analysis of the cochlear ultrastructure, while avoiding the problems of dissection and serial sections. Protocols have been developed for mice and Mongolian gerbils. This technical note proposes a detailed and optimised immunofluorescence protocol in the Mongolian gerbil comprising significant quantitative and qualitative improvements. This protocol sequentially comprises: fixation (1 day), decalcification (6 days), pre-treatment (7.5hours), immunolabelling (42hours), dehydration and clearing (23hours), followed by mounting and laser scanning confocal microscopy acquisition. This protocol has been optimised in terms of duration (10 days versus 13 days) with a reduction of the number of steps, improvement of the specificity of immunolabelling and optimisation of the quality of the results obtained. This technical note provides a detailed description of this protocol.

Use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases

OBJECTIVES

To evaluate the use of P-values and the terms "significant", "non-significant" and "suggestive" in Abstracts in the European Annals of Otorhinolaryngology, Head & Neck Diseases.

MATERIALS AND METHODS

Consecutive articles accepted for publication during the period January 2016 - February 2019 were systematically reviewed. Main goal: descriptive analysis of the citation of P-values and use of the terms "significant", "non-significant" and "suggestive" in Abstracts. Secondary goal: analytic study of: (i) correlations between citation of a P-value and the main characteristics of authors and topics; and (ii) misuse of the terms "significant", "non-significant" and "suggestive" with respect to cited P-values, and correlations with author and topic characteristics.

RESULTS

In all, 91 articles were included. P-values and the terms "significant", "non-significant" and "suggestive" were cited in 35.1%, 41.7%, 10.9% and 0% of Abstracts, respectively. Citing a P-value did not significantly correlate with author or topic characteristics. There were discrepancies between the terms "non-significant", "significant" and "suggestive" and P-values given in the body of the article in 57.1% of Abstracts, with 30.7% overestimation and 25.2% underestimation of results, without significant correlation with author or topic characteristics.

CONCLUSION

Authors, editors and reviewers must pay particular attention to the spin resulting from inappropriate use of the terms "significant", "non-significant" and "suggestive" in Abstracts of articles submitted to the European Annals of Otorhinolaryngology, Head & Neck Diseases, to improve the rigor, quality and value of the scientific message delivered to the reader.

Azimuthal sound source localization of various sound stimuli under different conditions

AIM

To evaluate azimuthal sound-source localization performance under different conditions, with a view to optimizing a routine sound localization protocol.

MATERIAL AND METHOD

Two groups of healthy, normal-hearing subjects were tested identically, except that one had to keep their head still while the other was allowed to turn it. Sound localization was tested without and then with a right ear plug (acute auditory asymmetry) for each of the following sound stimuli: pulsed narrow-band centered on 250Hz, continuous narrowband centered on 2000Hz, 4000Hz and 8000Hz, continuous 4000Hz warble, pulsed white noise, and word ("lac" (lake)). Root mean square error was used to calculate sound-source localization accuracy.

RESULTS

With fixed head, localization was significantly disturbed by the earplug for all stimuli (P<0.05). The most discriminating stimulus was continuous 4000Hz narrow-band: area under the ROC curve (AUC), 0.99 [95% CI, 0.95-1.01] for screening and 0.85 [0.82-0.89] for diagnosis. With mobile head, localization was significantly better than with fixed head for 4000 and 8000Hz stimuli (P<0.05). The most discriminating stimulus was continuous 2000Hz narrow-band: AUC, 0.90 [0.83-0.97] for screening and 0.75 [0.71-0.79] for diagnosis. In both conditions, pulsed noise (250Hz narrow-band, white noise or word) was less difficult to localize than continuous noise.

CONCLUSION

The test was more sensitive with the head immobile. Continuous narrow-band stimulation centered on 4000Hz most effectively explored interaural level difference. Pulsed narrow-band stimulation centered on 250Hz most effectively explored interaural time difference. Testing with mobile head, closer to real-life conditions, was most effective with continuous narrow-band stimulation centered on 2000Hz.

The digital mirror Langmuir probe: Field programmable gate array implementation of real-time Langmuir probe biasing

High bandwidth, high spatial resolution measurements of electron temperature, density, and plasma potential are valuable for resolving turbulence in the boundary plasma of tokamaks. While conventional Langmuir probes can provide such measurements, either their temporal or spatial resolution is limited: the former by the sweep rate necessary for obtaining I-V characteristics and the latter by the need to use multiple electrodes, as is the case in triple and double probe configurations. The Mirror Langmuir Probe (MLP) bias technique overcomes these limitations by rapidly switching the voltage on a single electrode cycling between three bias states, each dynamically optimized for the local plasma conditions. The MLP system on Alcator C-Mod used analog circuitry to perform this function, measuring T_e, V_F, and I_sat at 1.1 MSPS. Recently, a new prototype digital MLP controller has been implemented on a Red Pitaya Field Programmable Gate Array (FPGA) board which reproduces the functionality of the original controller and performs all data acquisition. There is also the potential to provide the plasma parameters externally for use with feedback control systems. The use of FPGA technology means the system is readily customizable at a fraction of the development time and implementation cost. A second Red Pitaya was used to test the MLP by simulating the current response of a physical probe using C-Mod experimental measurements. This project is available as a git repository to facilitate extensibility (e.g., real-time control outputs and more voltage states) and scalability through collaboration.

Honeybees forage more successfully without the "dance language" in challenging environments

Honeybees use the waggle dance to share information about food-site locations with nestmates. However, the importance of this behavior in colony foraging success remains unclear. We tested whether spatial dance information affects colony foraging success in a human-modified temperate environment by comparing colonies with oriented and disoriented dances. Notably, colonies with disoriented dances had greater foraging success. Over time, bees exposed to disoriented dances showed reduced interest in dancing nestmates. This may explain why disoriented colonies had a higher foraging rate than oriented colonies, as bees did not waste time waiting for information. This change in information-use strategy suggests bees learn about the value of dance information. An agent-based model confirmed that, under challenging conditions, waiting for dance information reduces colony foraging success compared to foraging without social information. Our results raise the possibility that humans have created environments to which the waggle dance language is not well adapted.

Lithium as a disease-modifying agent for prion diseases

Prion diseases still remain incurable despite multiple efforts to develop a treatment. Therefore, it is important to find strategies to at least reduce the symptoms. Lithium has been considered as a neuroprotective agent for years, and the objective of this preclinical study was to evaluate the efficacy of lithium delivered as a water-in-oil microemulsion (Aonys^®). This delivery system allows using low doses of lithium and to avoid the toxicity observed in chronic treatments. C57BL/6J mice were intracranially inoculated with ME7 prion-infected brain homogenates and then were treated with lithium from day 90 post inoculation until their death. Lithium was administered at traditional doses (16 mg/kg/day) by the gavage route and at lower doses (40 or 160 µg/kg/day; Aonys^®) by the rectal mucosa route. Low doses of lithium (Aonys^®) improved the survival of prion-inoculated mice, and also decreased vacuolization, astrogliosis, and neuronal loss compared with controls (vehicle alone). The extent of the protective effects in mice treated with low-dose lithium was comparable or even higher than what was observed in mice that received lithium at the traditional dose. These results indicate that lithium administered using this innovative delivery system could represent a potential therapeutic approach not only for prion diseases but also for other neurodegenerative diseases.